In our study, the non-urgent visit rate was found as 9.9%. Various studies report rates ranging from 4.8–90.0%, as the definition of non-urgent or inappropriate emergency room visits differs worldwide (1, 13, 14). In addition to those patients in critical condition, patients who should usually be treated in ambulatory tend to go to emergency services to accelerate their treatment process (15). Certain hospital-level factors such as the availability of acute beds and emergency department admission procedures have been shown to drive geographical variation in potentially avoidable emergency department visits (16).
According to the per capita ED acceptance rate (1.31 per person) in Turkey, the total ED visit number is expected to be 1,720,017 annually in Samsun. Thus, there would be expected roughly 63,704 ED visits per hospital in 2017. However, as determined in this study, the number of visits to ED of HPRC (total of child and adult ED) was 124,871. Despite fifteen hospitals in the city center, it is considered that the number of ED visits in HPRC that is 17 km away from centrum is very high. There are no incentives for the care layers (primary-secondary and tertiary) to work together in Turkey. The pay system for performance in hospitals has created competition between the levels of care (17). Care coordination is a foundational element of an effective and efficient integrated care delivery system involved in a patient’s care to facilitate the appropriate delivery of health care services (18). The essential element of integrated care and transition between the care layers is the reinforced primary care, particularly critical for patients with complex or urgent needs (12). Therefore, effective care requires establishing a relationship between primary care health personnel and key specialists, hospitals, and community-based organizations.
In the literature, similar to our study, analysis of the demographic characteristics predictive of non-urgent patients showed that age, sex, and arrival to the ED has found related to non-urgent ED visits (3, 13, 14). The fact that non-urgent patients were younger than urgent patients and significantly in the 18–44 age group was consistent with other studies in the literature (1, 5, 13, 19). The non-urgent visit rate was significantly higher in patients arriving with their means than patients who arrived with ambulances. This difference may be because ambulance patients are pre-evaluated before arrival. Whether the patient’s medical condition is an emergency or not is evaluated both at initial request to the emergency call center and when the emergency ambulance team reaches the patient. Therefore, both occasions prevent non-urgent visits from approaching the ED. While patients do not pay any expense for diagnosis or treatment in urgent or very-urgent triage codes in the ED, they do pay a contribution fee for non-urgent visits. However, it is far from being a deterrent because the amount of the contribution payment is taken from green zone patients is very low (3–5 US dollars) (20). Otherwise, all primary care services are provided free of charge.
Along with publications that state that EDs are preferred even with costs concerns, this may not be the case for our study. The fact that the rate of recurrent admissions in patients with previous non-urgent visits was 14.8% also supports this theory. In addition, the data was not obtained from a national database, and it is unknown whether patients visited different EDs within the same year. Our study determined that there were patients with 13, 16, even 20 non-urgent visits.
The high number of urgent and non-urgent visits in the first days of the week may be related to patients who cannot get an outpatient appointment immediately after the weekend are referred to the ED. As in another study conducted in Turkey, non-urgent visits were found significantly higher during working hours. The most common diagnostic codes recorded in non-urgent visits were pain, upper respiratory tract infection, soft tissue disorder affecting the person’s quality of life (21). This kind of non-urgent visit may be related to the fact that EDs can be accessed quickly without waiting queues, yield rapid test results, and promptly provide service. Studies conducted using surveys or hospital records also support this theory (1, 5, 21–23). In Samsun, the population number per physician of FHC was above the average for Turkey (Turkey average 3124 vs. Samsun 3266) (10). In the year following this study’s data collection, the Ministry of Health of Turkey initiated an out-of-hours service in FHC to decrease non-urgent visits to EDs and outpatient clinics. In many studies, it was found that reasonable access to primary care providers such as GPs and continuity of care measured by seeing the same family doctor were essential factors in reducing non-emergency ED visits (24, 25). In the current health system, while it may seem that patients being unable to access immediate health service leads them to prefer EDs (23), many studies have shown that the level of service, working hours, and increased professionalism do not decrease the use of EDs (5, 19, 26–28).
Our study has some limitations. We did not have some basic data that could elucidate the cause-effect relationship because of being record-based research. The records of patients who visited the ED did not include essential data such as distance to hospital, number of visits, education level, and marital status. Even data was collected from a large district hospital, conducting the study in only one hospital might limit the generalizability of our findings.