Emergency Department Visits for Nonurgent Conditions: Systematic Literature Review
Published Online: January 22, 2013
Lori Uscher-Pines, PhD, MSc; Jesse Pines, MD, MBA; Arthur Kellermann, MD, MPH; Emily Gillen, MA; and Ateev Mehrotra, MD, MS
Six studies (23%) described only visits for nonurgent connditions (Table 13,9,33,35-37). Of those, 4 articles (16%) described nonurgent visits to the ED and 2 articles (8%) compared nonurgent ED visits with PCP visits for similar conditions.33,37 The other 20 articles (77%) compared nonurgent ED visits with other types of ED visits (Table 21,2,12,16,32,34,38-51), including urgent visits, urgent and emergent visits,1,47 and all ED visits.16,34
No 2 studies used the same exact definition of nonurgent visits. A total of 11 articles (42%) identified nonurgent visits through retrospective review of medical records, 11 (42%) identified nonurgent visits prospectively at triage, and 3 articles (12%) used retrospective patient self-report. (See eAppendix at www.ajmc.com for additional detail on definitions.) Across the relevant articles, the average fraction of all ED visits that were judged to be nonurgent (whether prospectively at triage or retrospectively following ED evaluation) was 37% (range 8%-62%). Four articles (15%) presented a conceptual framework to guide the study design and interpretation of results. Three articles used the Anderson model of healthcare utilization,12,33,35 and 1 article used Mechanic’s model of illness behavior.47
In the reminder of this article, we summarize findings from the subset of articles (n = 16) that included a comparison group of either urgent ED patients or all ED patients and examined whether differences among these groups were statistically significant. We also include illustrative examples from the remaining studies (n = 10) regarding self-reported reasons for nonurgent ED use and barriers to use of alternative locations.
Factors Associated With Nonurgent Emergency Department Use
We summarize our findings on sociodemographic factors and other factors associated with nonurgent ED use in Table 3 and Table 4, respectively. These factors are discussed below.
Age. Among the 9 articles that examined age, 6 found that younger adults were more likely to have nonurgent visits compared with older adults.32,41,46,48,50,51 Effect sizes were generally large (odds ratio [OR] >2). Three articles found no association between nonurgent ED use and age.12,34,45
Race. Among the 9 articles that examined race, 4 articles found that blacks were more likely than whites to have a nonurgent visit.12,42,46,51 However, 5 articles reported no association.16,34,45,48,50 One study pointed out that blacks had higher rates of nonurgent ED visits despite the fact that they were less likely to utilize healthcare in general.12
Sex. Findings were inconsistent across the 10 articles that examined gender. Four articles found that women were more likely than men to have a nonurgent visit,32,46,48,50 and 2 articles concluded the opposite (ie, men were more likely than women to have a nonurgent visit).34,41 Four articles found no association.12,16,45,51
Income. Among the 4 articles that assessed income,12,16,34,50 2 reported that persons with low incomes were more likely to have nonurgent ED visits.12,50 Effect sizes were generally moderate (OR <2).
Insurance. Among the 13 articles that examined the uninsured, 2 found that uninsured patients were less likely to use the ED for nonurgent visits,12,49 2 found that the uninsured were more likely to use the ED for nonurgent visits,32,34 and 5 identified no association.1,16,43,45,48 One study found that the uninsured were more likely than HMO patients but less likely than Medicaid patients to have a nonurgent ED visit.44 Articles that looked at Medicaid patients found that either Medicaid was predictive of nonurgent ED use12,32,44,46,51 or there was no association.16,34,43,49 Effect sizes were generally moderate (OR <2).
Social Support. The only social support measure reported in the literature was marital status. Among the 4 articles that looked at the relationship between nonurgent ED use and marital status, no article identified an association.16,34,45,48
Health Status. Among the 4 articles that examined health status, 2 found that persons with poor health were more likely to have nonurgent visits,12,50 and 2 identified no association.16,48
Previous Healthcare Experiences. Previous healthcare experiences refer to an individual’s utilization history both within and outside of the ED. Two articles examined previous healthcare experiences. One article found that a recent hospitalization was associated with lower odds of having a nonurgent visit, more frequent ED visits were associated with higher odds of having a nonurgent visit, and the number of primary care visits had no association with having a nonurgent visit.45 In contrast, another article found that the average number of physician visits in an outpatient setting other than the ED was higher for persons with nonurgent ED visits.12
Culture/Community Norms and Personality. Culture/ community norms refers to the practices of others within one’s community (eg, the propensity of neighbors to use the ED). Personality factors are those related to an individual’s emotional, attitudinal, and behavioral response patterns. Examples of relevant traits include decision-making style and risk aversion. No article that compared nonurgent with urgent patients assessed culture or community norms or personality factors; however, 1 study of nonurgent patients found that personality factors such as coping mechanisms were not associated with going to the ED versus PCP for a nonurgent condition.37
Perceived Severity. Perceived severity refers to the patient’s perception of the urgency of his/her illness, which is a function of both personal beliefs and knowledge about what an emergency is. No article that compared nonurgent with urgent patients explored perceived severity; however, 4 articles that focused only on nonurgent ED visits described patients’ perceptions of the urgency of their conditions. In these cases, the vast majority of patients (>80%) felt that their condition was urgent/could not wait for treatment.3,9,36,38
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