Abstract
This study aims to determine the prevalence, factors and reasons associated with the frequent use of public emergency departments (EDs) in Riyadh, Saudi Arabia. The study employed a self-administered questionnaire to collect data from adult patients on aspects such as demographic characteristics, accessibility, and health-related factors. Bivariate and multivariate analyses were used to explore the issue. The results indicated that about 30% of respondents were considered as “frequent users” of the EDs. Males, older patients, those living closer to EDs, and patients who had chronic illnesses or were hospitalized in the past year were more likely to use EDs frequently. Moreover, the study found that patients who were labeled as “frequent users” of the EDs were also frequent users of “other” health care facilities. Health decision makers should facilitate primary health centers with necessary resources that fulfill the patients’ health needs and reduce the burden on EDs.
Introduction
The terms “frequent attenders” and “frequent users” are used interchangeably in the medical literature to describe patients who use health care facilities more frequently than most patients. 1 Studies conducted in different parts of the world, irrespective of the prevailing health care system indicate that the growth in the use of emergency departments (EDs) comes mostly from patients who come to the ED with complaints that can be treated in primary health care (PHC) centers.2-4 Authors of these studies indicate that such patients account for a considerable percentage of the total workload, overcrowding, violent episodes and patients who leave without being seen in these facilities.
Studies suggest that factors associated with the frequent use of ED include sociodemographic characteristics of patients such as their age, gender, level of education, marital status, income, and insurance coverage 5 Medical factors include health status, type of health complaint, and the severity of illness. 6 Organizational factors include factors mostly related to PHC facilities such as their opening hours, 7 availability of appointments, 8 waiting times, 9 and their distribution in the community. 10 Moreover, dissatisfaction with the quality services provided in PHC centers 11 and dissatisfaction with PHC staff 12 were also associated with frequent use of EDs. However, the literature suggests that “frequent use” of EDs is multifactorial and no one factor could claim to be the only contributor to such health seeking behavior. 13
Authors reported that patients who frequently bypass their PHC providers and go directly to the ED lack the continuity of care and are unlikely to see the same doctor twice because of constantly changing rosters in EDs. 14 The continuous relationship between the patient and the PHC doctor has long been thought to have a positive effect on health care use and outcomes. 15 Previous studies suggest that patients who had continuity of care with their health care providers are more satisfied with their treatment, 16 are more likely to take medications correctly, and are less likely to be hospitalized. 17
Over the past decade, there was an increase in the utilization of public EDs in Saudi Arabia. For example, the number of visits made to the Ministry of Health EDs rose from 9 million visits in 2000 to about 18 million visits in 2009. 18 In fact, number of patients seen in the EDs in 2009 exceeded the number of patients seen in all other departments in the Ministry of Health hospitals by more than 6.4 million patients. In Saudi hospitals, the characteristics of visits made to such departments are seldom recorded. However, authors from different parts of the world indicate that a substantial percentage of visits to EDs are usually made by a small group of patients who present to EDs repeatedly with health conditions that are more appropriate to be managed in PHC facilities. 1
In Saudi Arabia, there are no studies supporting the common claim that EDs are used repeatedly by patients who could be treated appropriately at lower levels of care. If frequent users of EDs are to be directed to more appropriate facilities, it is first necessary to gain an understanding of the characteristics of patients who use EDs frequently and factor associated with such use. 19 Therefore, the main objectives of the present study were to (a) determine the prevalence of frequent use of EDs in the public hospitals, (b) determine factors associated with such use, and (c) identify patients’ reasons for frequent use. It is anticipated that the findings of this study will be of value in understanding the frequent use of EDs in the public hospitals and therefore be of importance to decision makers in developing meaningful interventions that may alleviate some of the burden on the EDs.
Methods
This is a cross-sectional descriptive study. A survey questionnaire was developed to explore the frequency of ED attendance at one of the largest public hospitals in Riyadh city. The study population comprised all adult patients (18 years or older) who presented to the ED during a 2-week period in May 2011. To obtain a representative sample, 900 patients (10% of the total population) were selected using stratified random sampling in order to represent male and female patients who attended to the ED at different working shifts. Such sample size was determined to increase the accuracy and to replace missing or uncompleted questionnaires. 20
Out of the 900 distributed questionnaires, 666 (74%) were completed and were valid for analysis. The remaining 234 (26%) questionnaires were excluded because of incompleteness. The vast majority of respondents were Saudis (82.9%), young with an average age of 41.2 ± 17.2 years (range 18-86 years), married (70.4%), and had an educational attainment of high school or above (64.7%). Males accounted for 58.6% of the total respondents and those who were in employment comprised about half (50.6%) of the study sample.
The survey questionnaire was designed to capture information on different aspects serving the purpose of the study and was divided into 4 sections. The first section was devoted to obtain demographic background of ED users such as their gender (1 = male, 2 = female), age (1 = less than 45 years, 2 = 45 years or older), nationality (1 = Saudi, 2 = non-Saudi), educational level (1 = less than high school, 2 = high school or higher), marital status (1 = married, 2 = unmarried), and whether they were in employment (1 = employed, 2 = unemployed). The second section dealt with questions about access-related variables such as the usual distance the patient had to travel to get to the ED (1 = less than 5 km, 2 = 5 km or higher), the mode of transportation (1 = on foot, 2 = by car), and whether the patient is registered with a PHC center (1 = yes, 2 = no). The third section focused on health-related aspects such as whether the respondent was having chronic illness (1 = yes, 2 = no), had used other health facilities (1 = yes, 2 = no), and whether the patient was admitted to an inpatient services during the past 12 months (1 = yes, 2 = no). In this section, patients were also asked to report the number of visits paid to the EDs and other health care facilities. In section 4, respondents who visited the ED 3 times or more in the past 12 months (the frequent users) were requested to report their reasons for using ED rather than going to other sites of care. In this section, respondents were presented with a table containing the most common reasons reported in the literature and were instructed to mark as many reasons as applied.
A number of steps were taken to increase the content validity of the questionnaire. First, a review of the relevant literature was carried out to cite some variables and reasons that may influence the frequent use of EDs. Second, 2 academic staff and 2 emergency medicine specialists reviewed the questionnaire. Finally, a pilot survey of 30 adult patients was conducted. On the basis of the outcome of the pilot survey and the suggestions of the questionnaire reviewers, few questions were added or modified. The pilot survey questionnaires were excluded from the main survey. The covering letter of the questionnaire outlined the title and purpose of the study and the identity of the researchers. The ethical approval for the study was granted by the relevant research ethics committee and informed consent was obtained from the study subjects.
The independent variables used in this study were demographic, access-related, and health-related variables mentioned above. The outcome variable was the “frequent use” of the ED. In the literature, the definition of “frequent use” was arbitrary and mostly based on the number of visits made to the ED. Since there is no standard definition on what constitutes a “frequent use” of the ED, the dependent variable in this study was dichotomized into “frequent users” (referring to patients who made 3 visits or more to the EDs in the past 12 months) and “nonfrequent users” (referring to patients who made less than 3 visits to the EDs in the past 12 months). A 1-year recall time was considered a conservative period for determining frequency of use of EDs 1 ; other studies have examined the use of health care facilities as far back as the previous 8 years. 21
For the purpose of this study, descriptive statistics (frequency distribution and percentages), χ2 tests and multiple logistic regression analyses were conducted. χ2 tests were used to assess the difference of ED use among categories of each demographic variable. The logistic regression was used to estimate the adjusted odds ratio for each independent factor, with 95% confidence intervals. Results were considered statistically significant if P < .05, and the statistical analysis was performed using the Statistical Package for Social Sciences, version 11.0 (IBM SPSS, Chicago, IL).
Results
Based on the definition used in this study, there were 212 (31.8%) patients labeled as “frequent users” (ie, those who made ≥3 visits to the EDs in the past 12 months) and 454 (68.2%) patients were considered as “nonfrequent users” (ie, those who made <3 visits to the EDs in the past 12 months).
The association between each of the independent variables and the outcome variable (frequent use of ED) is presented in Table 1. The results indicated that males, older respondents, and those who were in employment were more likely to use EDs than their counterparts (P < .001). The results also revealed that those who travelled shorter distances and those who usually come to the ED on foot were more likely to use EDs than their counterparts (P < .001 and P < .05, respectively). Additionally, those who had used “other” health care facilities (such as PHCs, outpatient departments, and private clinics) in the past 12 months were more likely to use the EDs than their counterparts (P < .001). Likewise, respondents who reported having “chronic illness” or being hospitalized in the past 12 months made a significantly higher percentage of ED use than their counterparts (P < .001).
Variables Associated With Frequent Use of Emergency Departments.
P < .001.
P < .05.
Table 2 provides the adjusted odds ratios and 95% confidence intervals that quantify the association between independent variables (demographic characteristics, access-related factors, and health-related factors) and the dependent variable (frequent vs nonfrequent users). The results indicated that males were about 3 times more likely to be frequent users than females and that older respondents were more than 3 times more likely to be frequent users than younger ones (P < .001). Similarly, respondents who were in employment were 2.7 times more likely to be frequent users than those who were not (P < .001). Those who travelled shorter distances to get to the ED were about 2.3 times more likely to be frequent users than those who travelled longer distances (P < .05).
Variables Associated With Frequent Use of Emergency Departments in the Logistic Regression. a
After adjusting for all covariates in the model (as shown in the table). Reference means reference category in the logistic regression model.
P< .001.
P < .05.
The results also revealed that respondents who reported having chronic illness were more than 4 times more likely to be frequent users of EDs than those who did not report such health condition (P < .001). Similarly, respondents who were hospitalized in the past 12 months were about 3.5 times more likely to be frequent users of EDs than those who were not (P < .05). Finally, respondents who used “other” health care facilities in the past year were about 3 times more likely to be frequent users of EDs than those who did not (P < .001).
Respondents who were labeled “frequent users” were requested to report their reasons for such health seeking behavior. About half of these respondents reported that the PHC center was either “closed at times when care is needed” (51.4%) or that “ED has better quality of health care” than PHC centers (49.5%). Similarly, respondents gave “the PHC could not deal with my health problem” and “ED offers quick services” as reasons for using EDs (46.7% and 40.6%, respectively). About one third of respondents cited that the “availability of modern diagnostic equipment” and “to avoid taking time off from work” as reasons for using EDs (37.3% and 33.0%, respectively). The surveyed patients reported other reasons for using ED frequently such as “the health condition requires urgent care,” “ED dispenses better medications,” “no appointment is required,” and because of “dissatisfaction with PHC services” (Table 3).
Frequent Users’ Reasons for Using EDs (N = 212).
Abbreviations: ED, emergency department; PHC, primary health care.
The numbers do not add up to 100% as patients might have more than one reason at a time.
Discussion
Based on the definition employed in this study, about one third of respondents were labeled as “frequent users” of the EDs. The prevalence of frequent use of EDs reported in studies from different countries is inconsistent and showed a wide variation in the estimation of frequent users. In fact, there is no standard or uniform standard definition of what constitutes “frequent use” and the term is controversial. 22 However, authors gave evidence that most of visits made to EDs were potentially appropriate for primary care facilities and accordingly these visits are considered as “inappropriate” to be treated in EDs.
The fact that about one third of respondents were considered as “frequent users” indicates the importance of the EDs in the provision of health care to the general population. It is possible that the open-door policy adopted by the Saudi public health sector together with the ease of access to such facilities were among the contributory factors to the high volume of EDs use. However, the concern is that EDs were not designed to treat patients who present with nonurgent health conditions. Studies gave evidence that such health seeking behavior has negative effects on patients’ quality of care, increase the overall health care costs and jeopardize the health care provided to patients with serious conditions in the EDs.23-25
The results of this study indicate that the risk or the likelihood that a patient is a “frequent user” of ED varies significantly by individual, organizational, and health-related factors. The results showed that male respondents were more inclined to be frequent users of EDs. This finding is in line with other research work. 26 However, these findings are expected given the fact that males are more mobile than their female counterparts. Similarly, older respondents were more likely to use EDs more frequently than younger respondents. In the literature, there is a general assumption that elderly patients tend to have life-threatening conditions and multiple illnesses more often than younger ones,14 and accordingly they tend to use critical services more frequently than younger patients.
The results of this study indicated that employed respondents were far more likely to be frequent users than unemployed respondents. This finding contradicts the results reported by other researchers who found that a significantly higher percentage of frequent users of EDs were more likely to be unemployed or of lower economic status. 27 It is possible that the patients in our study were busy at their work during the day and they usually return home at times when most health care facilities are closed. Accordingly the only place to rely on for treatment is the ED. This finding may question both the opening hours of PHC centers and the out-of-hours arrangements.
Among the access-related variables, the distance was the only significant factor in both bivariate and the logistic analyses. In fact, research on the utilization of health services suggests that the proximity to health facilities affects a patient’s decision to use health care services. 28 These studies indicate that the shorter the distance a patient had to travel to the ED, the more likely he or she would be a frequent user. Authors from different countries29,30 noted that distance to health care facilities in terms of travelling time and costs is considered an important factor that influences the utilization of health care services. It could be argued that if proximity to the ED is a major factor in influencing people’s decision to use health care facilities, then any program targeted at reducing frequent use of EDs should be directed to the population living closer to these facilities.
In this study, it was expected that “frequent use” of the ED would be caused by patients who lack a regular source of primary care, but the findings did not support such expectation. In fact, the majority of frequent users in this study were registered with PHC centers and they did not appear to use the ED as a substitute for their primary care. It is possible, as has been indicated in previous studies from Saudi Arabia, that patients who were registered with PHC centers do not necessarily have access to their services,31 that patients were dissatisfied with them, 32 or that PHC centers have insufficient facilities that are necessary for the management of patients’ illnesses such as laboratory or radiology services. 33
The results reported here showed that respondents who were in poor health conditions use ED frequently. These findings are in accordance with those reported in previous research, 5 which indicate that patients living with chronic illness or recently hospitalized were more likely to become frequent users of sophisticated health resources, in an attempt to get their health problems resolved. The literature indicates that such patients are vulnerable groups and their health seeking behavior is largely explained by their health needs rather than their demographic or socioeconomic characteristics. 8 This suggests that increasing access to high quality of primary care that fulfills patients’ health needs could potentially reduce unnecessary visits to hospital EDs10,33 and ensure continuity of care. 15
An important finding of this study is that frequent users were obtaining not only medical services exclusively at the EDs but also use other health facilities such as PHC centers, outpatient departments, and private clinics. This might be a reflection of the unique needs of this group of patients. This may also indicate that having access to PHC services might not be sufficient to divert patients away from using the EDs. In this regard, previous research reported that educating patients about situations requiring ED visits has little impact on reducing ED use. 34 In fact, the patients of this study indicated that ED has convenient opening hours, has qualified health personnel, and has better equipment and medication. These results reinforce the findings of previous studies on this topic.11,12
The findings reported here have several policy implications and suggest that the current services provided at PHC facilities may not be responsive to the needs of the population’s health. This suggests that interventions to reduce frequent ED use should be targeted at the primary care level. For example, extending the PHC opening hours, increasing the availability of adequate diagnostic services, and hiring qualified health personnel are among the important steps that might make PHC centers more attractive to patients. Any strategy that aims to decrease the frequent ED use would require the removal of accessibility obstacles and improving the quality of care provided in PHC facilities.
This study has several limitations that could have affected the results. First, the study was conducted for 2 weeks only and the study sample was drawn from a single hospital. Therefore, the results may not be generalizable to other hospitals or users. However, the hospital is one of the largest hospitals in Riyadh city and accordingly it is fairly assumed that patients attending this hospital would represent the general population. Second, the results were based on information disclosed by the patients themselves and therefore the findings were subjective and were associated with recall bias. Third, this study is limited by the cross-sectional nature of data collection. Fourth, there are other relevant variables that were not included in the study (eg, place of departure to the EDs, time taken to get to the ED, appropriateness of the ED visit, type of health complaints presented, and the source of referral to the EDs). Therefore, these missing variables may have created an incomplete picture of the common characteristics of patients who frequently use EDs. Finally, the classification of patients into “frequent” and “nonfrequent” was arbitrary and was not based on an objective criterion. However, an agreed definition of what constitutes “frequent use” is lacking and none of the authors has provided a generally accepted and validated classification to distinguish between “frequent” and “nonfrequent” users of EDs.
Despite these limitations, the study elicited important information on the frequent use of EDs in public hospitals that is difficult to obtain from other sources. The analysis has also highlighted the importance of spatial accessibility and health-related factors in triggering patients to become heavy users of ED services. Retaining patients to appropriate health care facilities, such as PHC centers would require a removal of the barriers prohibiting them from using such facilities.
Conclusion
Frequent use of EDs by patients with “primary care” conditions may undermine the efficiency of services provided in these facilities. Fulfilling patients’ health needs through better accessibility and availability of health resources in the PHC centers is clearly an area that should be improved in order to reduce frequent attendance at EDs. If patients continue using public EDs for primary care conditions, it will markedly increase the burden on these departments and adversely affect their effectiveness.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article:
The authors extend their appreciation to the Deanship of Scientific Research at King Saud University for funding the work through the research group project number RGP-VPP-013.