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The American Journal of Managed Care January 2013
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Emergency Department Nonurgent Visits in Iran: Prevalence and Associated Factors
Mohammad Jalili, MD; Farzaneh Shirani, MD; Mohamad Hosseininejad, MD; and Hossein Asl-e-Soleimani, MD
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Emergency Department Nonurgent Visits in Iran: Prevalence and Associated Factors

Mohammad Jalili, MD; Farzaneh Shirani, MD; Mohamad Hosseininejad, MD; and Hossein Asl-e-Soleimani, MD
Inappropriate use of emergency department resources in Iran is a frequent problem that calls for effective approaches and interventions.
Objectives: To estimate the number of emergency department (ED) visits due to nonurgent problems and to describe the characteristics of those patients, as well as their reasons for presenting to the ED.

Study Design: Descriptive cross-sectional study.

Methods: In this study, all adult (aged >15 years) patients presenting to the ED over a 2-week period were evaluated. Data regarding the age, sex, marital status, educational level, and insurance status of all patients were recorded. The time and date of the presentation were also noted. Those classified by the triage nurse as having nonurgent conditions were surveyed regarding their reasons for presenting to the ED.

Results: Out of 1923 visits, 400 (20.8%) were classified as nonurgent. The prevalence of inappropriate ED visits was slightly greater in patients aged 15 to 49 years. Patients whose visits were paid for by health insurance accounted for the majority of inappropriate visits (82.75%). There were higher rates of inappropriate visits in the evening and night shifts compared with morning and afternoon shifts (17.39% vs 25.03%). The most common reason for presenting to the ED was “to obtain rapid treatment” (76.5%); only 10.75% presented because of a perceived urgent problem.

Conclusions: The results of our study corroborate the previous findings that inappropriate use of the ED is common. The prevalence of presentation for nonurgent problems was substantive between 6 PM and 6 AM. Gender, marital status, education, insurance, and day of the week had no association with nonurgent presentation.

(Am J Manag Care. 2013;19(1):e1-e8)
Little is known about the appropriateness of the utilization of the services in emergency departments (EDs) in Iran. This prospective observational study evaluated the characteristics of all patients over age 15 years presenting to the ED over a 2-week period.

  • The prevalence of inappropriate ED visits was 20.8%.

  • The most common reason for patients with nonurgent conditions to visit the ED was “to obtain rapid treatment” (76.5%); only 10.75% presented because of a perceived urgent problem.

  • Effective approaches and interventions are needed to address the inappropriate use of ED resources in Iran.
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.


Study Design

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.

Study Protocol

To examine the characteristics of the patients who utilize our ED services, all demographic information including age, sex, marital status, educational level, and insurance status of all patients aged 15 years or older presenting to the ED during the study period was collected from the ED medical records. The time and date of the presentation for all patients were recorded as well. Individuals who returned more than once during the study period were included only once.

To identify the patients who utilize our ED for less urgent reasons, all patients who were categorized by triage nurse as acuity level either IV or V were approached and asked to participate in the survey. The interviewers recorded the patient’s name on a separate form coded to the questionnaire number, answered any questions, and completed the questionnaires. Data not recorded on the data form were collected by chart review or by a telephone call to the patient. Patients who refused to be interviewed after up to 3 attempts were classified as refusals. Individuals were excluded if they were brought to the ED by the police for forensic medical exams. When patients could not be interviewed because of their health status, their relatives were asked to provide the necessary information.

The interviews were carried out by 3 trained interviewers (1 during each shift), who were briefed about the objectives of the study but were not involved in the care of the patients. The field work was supervised by the lead author. The variables were coded by the interviewers, and the research coordinator reviewed each collected field.

All emergency medicine residents and attending physicians in our department were informed about the study, and the survey was pilot-tested for 24 hours prior to the actual data collection in order to ensure that data collection and recording proceeded smoothly. The data from this pilot study, however, were not used in the final statistical analysis.


The survey instrument consisted of a 1-page questionnaire. The questionnaire had 4 parts: characteristics of the visit such as date, time, day of the week, and the person (patient or his or her relative) who was interviewed; characteristics of the patient such as age, sex, marital status, health insurance, level of education, and the frequency of presentation to the ED; the chief complaint or reason for which the patient sought medical attention; and the main reason for coming to the ED on this occasion. These variables were chosen based on literature review and the authors’ experience.

Data Analysis

Data were entered into a Microsoft Excel database and were analyzed using descriptive statistics, which included calculation of prevalence, means, and standard deviations of all variables. Crude associations were evaluated by the x2 test. The level of significance for the analyses was set at P <.05. Data were analyzed using SPSS 14.0 software (SPSS Inc, Chicago, Illinois).


During the 2-week study period, there were 2114 ED visits, with 11 individuals returning more than once. Among the remaining 2103 patients, 5.6% (n = 117) were excluded from the study (115 patients <15 years old and 2 patients brought by the police) and 3.2% of the eligible subjects (n = 63) refused to participate in the study, resulting in a final sample of 1923 patients.

Data forms were completed for 91% of total visits (1923 patients) during the study period (Figure). There were no unusual events during this period that would change the number or the type of ED visits.

The mean age of patients was 34.73 years (standard deviation 11.36 years; range 15-100 years); 62.2% (n = 1196) of the patients were male and 37.8% (n = 727) were female. With respect to marital status, 54.7% of patients were married and 45.3% were single, widowed, or divorced. Only 10.1% of patients had a college education, and 4.1% (n = 78) were illiterate. The majority of the patients (85.8%) had an educational level of 12 years (high school diploma) or less.

About 80% of the patients had government insurance, which is obligatory for government personnel and pays for all or most ED costs, while the rest (20%) lacked any health insurance and hence were self-paying.

About half (49.5%) of the patients (n = 952) sought healthcare during the afternoon hours (between midday and 5:59 PM). Whereas 41.4% of patients (n = 796) visited the ED during evening hours (between 6:00 PM and 11:59 PM), 5.8% (n = 112) visited the ED between 6:00 AM and 11:59 AM (morning shift). Fewer than 4% of patients (n = 63) visited the ED between midnight and 5:59 AM (night shift).

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