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The American Journal of Managed Care January 2013
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Emergency Department Visits for Nonurgent Conditions: Systematic Literature Review
Lori Uscher-Pines, PhD, MSc; Jesse Pines, MD, MBA; Arthur Kellermann, MD, MPH; Emily Gillen, MA; and Ateev Mehrotra, MD, MS
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Emergency Department Visits for Nonurgent Conditions: Systematic Literature Review

Lori Uscher-Pines, PhD, MSc; Jesse Pines, MD, MBA; Arthur Kellermann, MD, MPH; Emily Gillen, MA; and Ateev Mehrotra, MD, MS
This article presents a systematic review of the US literature on factors influencing the decision to visit the emergency department for nonurgent conditions.
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

Convenience. Convenience refers to the ease with which a patient can seek care, including travel, timing, and location. Among the 3 articles that discussed convenience,16,34,50 all found that convenience factors played a role in driving nonurgent ED use. For example, 1 study reported that the leading reason why the nonurgent group used the ED was “ease of use.”34 A descriptive study of nonurgent ED users found that 60% of nonurgent ED patients felt that the ED was more convenient than their PCP.9

Cost. Cost refers to the financial burden incurred by the patient. While no article that compared nonurgent with urgent patients assessed cost, 1 study of just nonurgent ED patients found that 42% chose the ED because of payment flexibility (ie, no requirement to pay at the time of care).3

Access. Access refers to the ability of the patient to obtain timely care outside the ED. Four articles found an association between poor access (eg, difficulty in obtaining healthcare, not having a regular physician) and nonurgent ED use.1,16,48,50 Only 1 article (which focused exclusively on a population of homeless adults) identified no association between poor access and likelihood of having a nonurgent visit.45 Furthermore, a Harris Interactive survey reported that ED physicians felt that waiting times for appointments with PCPs and limited access to physicians on weekends were the leading reasons for nonurgent ED use.16 In a descriptive study of nonurgent ED patients, authors reported that the most significant barrier to getting care outside the ED was inability to get an appointment at a clinic.35

Referral/Advice. Referral/advice refers to being counseled to go to the ED by a provider. Two articles (1 with a comparison group and 1 on only nonurgent ED users) suggested that healthcare provider referral may be a substantial driving force in nonurgent attendance.9,34 One article found that about half of the nonurgent patients who presented during business hours were advised to go there by a PCP.9 Beliefs and Knowledge About Alternatives. A total of 3 articles (2 with comparison groups and 1 on only nonurgent ED users) directly addressed beliefs about alternatives. One article reported that 76% of nonurgent ED users chose the ED because they felt they would receive better care there.3 A Harris Interactive survey reported that nonurgent ED users were more likely to think that other places were more expensive than the ED.16 Finally, another article found that persons who were not satisfied with their regular source of care were more likely to make a nonurgent visit to an ED.50


Due to the heterogeneity and limitations of the articles, it is challenging to summarize what drives the decision to seek ED care for nonurgent conditions. The limited evidence suggests that younger age, greater convenience of the ED compared with other ambulatory care alternatives, referral to the ED by a healthcare provider, and negative perceptions of non-ED care sites all play a role in decisions to seek care in the ED for nonurgent problems. Other factors appear unrelated to nonurgent ED use, or more commonly, the results are inconclusive due to inconsistencies across studies or because the factors have rarely been studied. Because of the weak evidence base, we argue that all of the factors assessed in the literature are candidates for future research.

We believe a key limitation of these prior studies is the lack of a robust theoretical framework on what drives nonurgent ED use. To potentially guide future work, we created a theoretical model of the decision-making process and factors that may influence a patient’s decision to visit the ED for a nonurgent condition. We based the model on review of included studies, as well as qualitative studies and commentaries. 6,7,22,24,26,27,30,31,52 Qualitative studies that used patient interviews and focus groups were important to include because they generated hypotheses regarding reasons for use that can be probed in future empirical work.

The model depicted in Figure 2 suggests that a patient arrives at a decision to seek care in an ED by consciously or unconsciously weighing several considerations. First, the patient experiences acute symptoms—either a new problem or a flare-up of a chronic condition that is not immediately debilitating or clearly emergent (eg, chest pain, signs of stroke). The patient then considers various options including going to the ED, going to another location, or not seeking care.

In our model, the decision to go the ED is influenced by an array of causal pathway factors and associated factors. While all of the factors depicted in the model likely influence nonurgent ED use, the causal pathway factors act as independent predictors. In contrast, we believe associated factors influence ED use via one of the causal pathway factors. For example, while certain models suggest that gender may be associated with nonurgent use, there is no a priori explanation as to why gender would be influential. We believe that gender, an associated factor, could possibly impact the decision to seek care in the ED for a nonurgent condition by affecting the perceived severity of the condition and beliefs and knowledge about alternatives (both causal pathway factors). In our review, the distinction between causal pathway and associated factors is also important, as almost all interventions to decrease nonurgent ED use focus on causal pathway factors.

Although our model does not directly address healthcare supply because we focused on the perspective of the individual patient, one could imagine that the availability (or lack thereof) of options, including a limited supply of providers or an extended wait to be seen, could raise or lower the threshold for seeking care. In addition, while features of the healthcare system such as overall access to care or societal context are not the focus of our framework, they play a role in an individual’s decision making by influencing their knowledge, beliefs, and attitudes about alternative locations for care.

The literature we reviewed on nonurgent ED use has several key limitations. First, descriptive studies of just nonurgent ED visits are hard to interpret. For example, although the selfperceived severity of their problem was high among patients who visited the ED for what others judged to be nonurgent, we do not know whether perceived severity is similar among those who go to other care sites. Second, the comparison of urgent with nonurgent ED visits used in the vast majority of studies might be flawed. Urgent problems (eg, chest pain) are qualitatively different than nonurgent problems (eg, sore throat). The more relevant question is: why does the patient with a self-recognized nonurgent problem choose the ED rather than seek care at an alternative location or simply stay home? Only 2 studies compared nonurgent ED visits with nonurgent PCP visits.33,37 However, we cannot draw conclusions based on these papers because they did not evaluate similar independent variables. Ideally, future studies would also include patients who became ill with a time-limited condition but chose not to seek care. Third, studies disproportionately focused on associated factors (eg, age, sex) that are easy to measure and classify but do not provide a causal mechanism for driving nonurgent ED use and are difficult or impossible to modify. We hope that our theoretical model can guide future work to assess the frequency and relative importance of different causal factors.33,37 Fourth, there are problems in clarifying the relationship between predictors of nonurgent ED use and the definition of nonurgent use itself. For example, based on current research it is unclear whether older adults are in fact less likely to go to the ED for minor conditions or whether their visits are more likely to be deemed “urgent” because they are frail or have multiple comorbid conditions. Lastly, health services research often makes broad generalizations about populations. Because nonurgent ED users are likely a diverse group, the better approach might be to try to break up nonurgent ED users into different strata.34 For example, some individuals may be using the ED due to habit, preference, or lack of education regarding alternatives. The ideal intervention might vary by the different strata. Prior to applying them, the precise issues or challenges need be identified so that the correct intervention(s) is applied to encourage or enable desired behavior by patients.

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