Emergency Department Nonurgent Visits in Iran: Prevalence and Associated Factors
Published Online: January 17, 2013
Mohammad Jalili, MD; Farzaneh Shirani, MD; Mohamad Hosseininejad, MD; and Hossein Asl-e-Soleimani, MD
Emergency departments (EDs) across the world have turned into a safety net for healthcare systems. Therefore, the number of people presenting to an ED has been increasing worldwide. As a result, overcrowding has been a major concern of healthcare administrators for the past 3 decades.1
According to published statistics, the overall ED utilization in the United States increased from 93.4 million to 110.2 million visits from 1994 through 2004. That is an increase of more than 1.5 million visits annually.2
Not all visits to the EDs are for urgent problems.3 In fact, as EDs are supposed to provide care to all people requesting their service, patients with nonurgent problems make up a substantive proportion of those visiting the ED. Utilization of ED services by patients with nonurgent health problems has frequently been referred to as “inappropriate” in the literature and constitutes a worldwide problem.4,5 As patients’ and physicians’ perspectives on the appropriateness of the visit vary considerably, it is fundamentally difficult to assign this attribute to an ED visit. However, EDs are generally regarded as sources of care for patients with emergent and urgent problems; therefore, most definitions of the appropriateness of the ED use are based on urgency6-8 and nonurgent visits may intuitively be considered as inappropriate.
Although estimates of the magnitude of the problem vary among different studies, according to the data published in 2006 in the United States 12.5% of ED visits were classified as nonurgent.2 Other studies have noted that 16% of the patients visit the ED as “a regular source of care”9 and as “a substitute for a general practitioner to treat minor or unexpected illnesses.”10 Studies in the pediatric population have gone even further and noted that between one-third and one-half of the visits to the ED are for nonurgent conditions.11,12
In Iran, national laws ensure access to emergency care. ED staff are supposed to screen all people who present, regardless of their ability to pay or their insurance status. EDs are not allowed to withhold their services from any patient on the basis of their problem being nonurgent. Nonurgent ED use may adversely affect the quality of emergency services and contribute to overcrowding. Overcrowding may lead to prolonged patient wait time and delay in diagnosis and treatment of seriously ill patients, potentially increasing the risk of poor outcomes and patient dissatisfaction.13,14 Nonurgent ED use can be frustrating for ED staff who consider this use as unproductive because they are providing nonurgent care available in lower acuity settings.15,16
Several studies have addressed the reasons why patients use the ED for nonurgent problems.17-21 A multitude of factors have been suggested as reasons why patients choose to visit the ED instead of primary or specialty health services. These include “their desire to receive care on the same day,”4,5 the possibility of “being attended to in a setting where it is possible to do laboratory and other tests,”5,22 and the belief that the ED provides a better quality of service for complicated health problems.23 There have also been several attempts to identify populations with a higher prevalence of nonurgent ED utilization. Young age,10,24 female sex,10,25 homelessness, and lack of health insurance26 have been suggested in different studies to be associated with nonurgent ED visits.
Despite the publication of numerous studies, the prevalence of and reasons for choosing the ED instead of primary care for nonurgent medical complaints are not fully understood. To the best of our knowledge, few published studies from Asia have addressed the prevalence of ED visits for nonurgent problems and patients’ reasons for making these visits. Finding the answers to these questions might provide some cost savings27 for the healthcare system and might also help reduce the problem of ED overcrowding.
We designed this study with 2 objectives. The first objective was to estimate the number of ED visits in our institution that were due to nonurgent problems and to describe the characteristics of those patients. The second objective was to determine the reasons for nonurgent use of our ED.
To determine how many visits in our hospital ED were for nonurgent problems, we conducted a descriptive cross-sectional study of all consecutive adult patients (>15 years old) visiting the ED of our institution in a 2-week period in December 2009. The University Research and Ethics Committee approved the research protocol. This committee is in compliance with the Helsinki Declaration. Patients were aware that they were being enrolled into a study and that participation was voluntary and confidential, but informed written consent was not obtained.
Study Setting and Population
Our institution is a 700-bed tertiarycare teaching hospital (occupancy rate >90%) with an emergency medicine residency training program. The hospital is located in the capital city of Tehran and offers 24-hour emergency care. It serves a patient population mixed in demographic(s), income, education levels, and health status that includes a large number of people who are referred from neighboring towns. The ED has an annual census of about 40,000 visits. As per department protocol, all arriving patients are seen by the triage nurse and assigned a Canadian Triage and Acuity Scale level.
Because characteristics of the patients had the potential to vary based on the day of the week and the time of day, a schedule was prepared so that weekday, weekend, daytime, and evening shifts were sampled in 6-hour blocks. Overall, 56 blocks were studied in 14 days. It should be mentioned that there is no comprehensive and uniform health insurance plan in Iran. There are 4 basic types of health insurance organizations in Iran: the Social Security Organization, the Medical Service Insurance Organization, the Emdade-Emam Committee for socioeconomically disadvantaged people, and the Military Personal Insurance Organization.28 Several complementary health insurance plans also exist. Although some patients may have basic and complementary insurance, many patients do not have any insurance.
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