Nonurgent emergency department patient characteristics and barriers to primary care

Objective: Nonurgent (NU) emergency department (ED) use is at the forefront of medico-political agendas, and diversion of NU patients has been entertained as a management strategy. Before policy changes are implemented, this population should be better understood with respect to their characteristics and reasons for not presenting to primary care providers (PCPs) instead of EDs. This study compares NU with urgent and semiurgent (USU) patients and describes the NU patients' reasons for not seeking care with a PCP before presenting to the ED. Methods: This was a secondary analysis from a cross-sectional study with sequential sampling in the EDs of five Quebec tertiary care hospitals (October 19, 1999, to May 26, 2000). Data on medical history, social support, awareness and utilization of health care, ED visits, referrals, activities of daily living, and sociodemographics were obtained. The NU group included patients with triage code 5 and the USU group included patients with triage codes 2, 3, and 4 using the Canadian Triage and Acuity Scale. Patient characteristics were structured into the Andersen behavioral model for health care utilization. Results: Of 2,348 patients approached, 1,783 patients (77%) were eligible and agreed to participate. NU patients (n = 454) were younger than USU patients (n = 1,329) (mean age, 43 [SD +/- 18.1] vs. 49 [SD +/- 20.1] years). Patients in the NU group had better health (number of prior conditions, 3.1 vs. 3.9), were less likely to arrive by ambulance (5% vs. 22%), and were less often admitted from the ED (4% vs. 24%). While 70% of NU compared with 75% of USU patients were followed up by a PCP, only 22% of NU and 27% of USU patients sought PCP care before presenting to the ED. The reasons given by NU patients for not seeking PCP care were accessibility (32%), perception of need (22%), referral/follow-up to the ED (20%), familiarity with the ED (11%), trust of the ED (7%), and no reason (7%). Conclusions: NU ED patients are different from USU patients and have multiple reasons for not seeking primary care before going to the ED. This may help explain why various diversion strategies have been unsuccessful and indicate that a multifaceted approach may be better suited to this group of patients. The design of new interventions, however, will benefit from further research that clarifies the impact of NU patients on the health care system.