- Email: [email protected]
Non-urgent visits to a hospital emergency department in Italy
Public Health (2003) 117, 250–255
Non-urgent visits to a hospital emergency department in Italy A. Bianco, C. Pileggi, I.F. Angelillo* Medical School, University of Catanzaro ‘Magna Græcia’, Via Tommaso Campanella, 88100 Catanzaro, Italy Received 10 May 2002; received in revised form 28 October 2002; accepted 26 November 2002
KEYWORDS Emergency department; Hospital; Italy; Nonurgent visits
Summary The purpose of this study was to determine the extent of non-urgent visits and the effect of different characteristics on such visits to one public hospital emergency department located in Catanzaro, Italy. Of 581 patients aged 15 years and older who were registered for care in the emergency department, 40 were excluded from the study as they were too ill or distressed. The survey questionnaire included questions about the patients’ demographic and socio-economic characteristics, distance from home to hospital, usual health status and health status at the time of presentation to the emergency department. Of the 541 patients who agreed to participate, 19.6% of patients, according to the judgement of two observers, had nonurgent conditions. The results of the multiple logistic regression analysis showed that among all variables tested, age and sex were significant predisposing factors for utilization of the emergency department for non-urgent visits. Indeed, the odds of presenting for non-urgent care were significantly higher if patients were younger and female. Moreover, the odds of requiring non-urgent care were significantly higher in patients who present to the emergency department without medical referral and in patients who present with problems of longer duration. The most frequent reason given by patients for their visit to the emergency department was that they felt their problem was an emergency. Further investigations are necessary to evaluate the use of primary care since closer co-operation within the healthcare organization system may provide a more responsive service. Q 2003 The Royal Institute of Public Health. Published by Elsevier Science Ltd. All rights reserved.
Introduction The efficiency and effectiveness of medical service delivery has raised serious concerns among healthcare professionals and administrators, both because of the level of healthcare use and because *Corresponding author. Tel.: þ39-961-777669; fax: þ 39-961777345. E-mail address: [email protected]
of the possibility of choice of a more suitable level of care with equity of access to appropriate care. A number of studies in different countries have evaluated inappropriate utilization of hospital resources and increasing costs to the healthcare system.1 – 5 Hospital emergency departments have become ubiquitous as the source of care for many patients, especially those patients who are of lower education level and who do not have a regular source
0033-3506/03/$ - see front matter Q 2003 The Royal Institute of Public Health. Published by Elsevier Science Ltd. All rights reserved. doi:10.1016/S0033-3506(03)00069-6
Non-urgent visits to a hospital emergency department in Italy
of primary care. They tend to use emergency departments as a substitute for a general practitioner to treat minor or unexpected illnesses. In Italy, great efforts have been made to contain the hospital care costs whilst also responding to the population’s health needs. The healthcare payment system in accident and emergency departments has been modified so that investigations performed are only free of charge for patients older than 65 years and younger than 9 years, or patients with trauma or injuries. In spite of this, subjects continue to use emergency departments as a regular source of care when they have an acute medical problem. To the best of our knowledge, few studies have been published from European countries6 – 9 or the USA10, 11 assessing the frequency of patients attending emergency departments for non-urgent visits. Further, no data are available for Italian hospitals. Therefore, we conducted a study on the utilization of a hospital emergency department to estimate how many visits were for non-urgent problems and which characteristics were related to the utilization of the emergency department as a source of non-urgent care in Italy.
Materials and methods A cross-sectional study was carried out in the emergency department of a 714-bed (occupancy rate 75%) public regional general hospital in Catanzaro, Italy from July to December 2001. The hospital covers the healthcare needs of the 370,000 inhabitants of the Catanzaro province (15,000 km2) in the Calabria Region (2 million inhabitants). In our region, 36 of 38 hospitals have an emergency department. A stratified sample of 2-h sessions was selected at random to include, respectively, two weekday and one weekend session running from 8.30 AM to 2.00 PM or 3.00 to 7.00 PM for each week of the study period. Patients waiting for emergency care were eligible for inclusion in the study if they were 15 years of age or older. A medical interviewer, who has at least 6 months experience at the emergency department and who was not involved in care, who had been trained previously, collected the data by interviewing all patients who agreed to participate immediately after the admittance and nurse triage, and before examination by the medical staff of the emergency department. The survey questionnaire included questions about the patients’ demographic and socio-economic characteristics, distance from home to hospital, usual health status and health status at the time of presentation to
251
the emergency department. When patients could not be interviewed because of their health status, their relatives were asked to provide information. Patients who were too ill or distressed were excluded from the study. All medical staff of the emergency department were asked to complete a form for each patient seen, including chemical pathology, electrocardiography, haematology, microbiology, radiographic investigations, medical or surgical examinations, items prescribed, final medical diagnoses, referral and discharge decisions made. The following definitions of levels of urgent care were developed before the beginning of the study according to previously published surveys:7,10,11 † the patient should be seen promptly by a physician in the emergency department to assess and treat possible life-threatening conditions, and immediate care was necessary within 24 h in order to avoid severe consequences for the patient (extreme emergency); † the patient required care within 24 – 48 h, or the technical equipment of the hospital had to be used for diagnosis or therapeutic purposes (emergency); † the patient was worried by the appearance or the recent worsening of symptoms (e.g. a left arm pain or a chest pain, which could be related to an acute myocardial infarction), although the vital or functional prognosis was not threatened within 24 h. The patient’s condition is appropriate for referral to a general or subspecialty clinic (emergency as perceived by patient); † the patient has no active symptoms or they were recent and minor, without any feeling of emergency and he/she desires a check-up, a prescription refill or a return-to-work release (non-urgent case).
Statistical analysis Multiple logistic regression analysis with forward elimination was performed. A model was developed in order to describe the profile of patients who attend the emergency department for non-urgent care and the following explanatory variables were included: age (continuous), sex (1 ¼ male, 2 ¼ female), marital status (1 ¼ married, 2 ¼ single/separated/divorced/widowed), number of persons in the household (three categories: 1 ¼ 0, 2 ¼ 1 – 2, 3 ¼ . 2), educational level (five categories: 1 ¼ no formal education, 2 ¼ 5 years, 3 ¼ 8 years, 4 ¼ 13 years, 5 ¼ . 13 years), distance in kilometres between home and hospital (1 ¼ # 5, 2 ¼ 6 – 35, 3 ¼ . 35), stated chronic disease
252
(0 ¼ no, 1 ¼ yes), who referred the patient to the emergency department (0 ¼ physician, 1 ¼ self referral/relative), hour of arrival at the emergency department (1 ¼ 8.30 AM – 2.00 PM, 2 ¼ 3.00 – 7.00 PM), day of the week of attending the emergency department (0 ¼ Monday – Thursday, 1 ¼ Friday – Saturday), and duration in hours of presenting problem (three categories: 1 ¼ , 1, 2 ¼ 1 – 24, 3 ¼ . 24). The significance level for variables entering the models was set at 0.2 and for removing from the models at 0.4. Adjusted odds ratio (OR) and 95% confidence intervals (CI) were calculated. Overall agreement and the k statistic were used to assess the inter-rater reliability regarding the definition of urgent care. Data were analysed using the Stata software program.12
Results Overall inter-rater agreement was excellent within the reviewers, since the agreement and the k statistic for the assessment of urgent care were always higher than 95% and 0.92. Of 581 patients aged 15 years or older registered for care in the emergency department during the study period, 40 were excluded from the study since they were too ill or distressed. Of 541 patients who agreed to participate, 500 were interviewed and relatives provided information for 41 patients. Their principal characteristics are presented in Table 1. The mean age was 50.6 years (range 15 –98 years), almost two-thirds of patients had attained a middle- or higher-school education level, more than three-quarters of patients were admitted to hospital from Monday to Thursday, and only 5.7% stated that they lived alone. Patients were rarely referred to the emergency department by a physician, since the vast majority were self referred or referred by relatives (84.1%), and more than three-quarters of patients sought care for problems that had been present for at least 24 h. Of 541 patients aged 15 years or older who were surveyed at the emergency department, 19.6%, according to the judgement of the two observers, had non-urgent conditions. Table 2 presents the distribution of non-urgent visits to the emergency department according to various explanatory characteristics. Attending the emergency department with a non-urgent condition was associated with the patient’s age (x2 test for trend ¼ 11.98, 1 df, P ¼ 0:0005) and it was also, although not significantly, associated with the distance from patients’ home to hospital,
A. Bianco et al.
Table 1 Selected characteristics of the study population. Characteristic
n
%
Sex Male Female
261 280
48.2 51.8
Age (years) 15–25 26–35 36–45 46–55 56–65 66–75 . 75
74 93 74 70 65 86 79
13.7 17.2 13.7 12.9 12 15.9 14.6
Marital status Married Others
402 139
74.3 25.7
Education (years) None 5 8 13 . 13
109 97 166 135 34
20.2 17.9 30.6 25 6.3
Number of persons in the household 0 1–2 .2
31 257 253
5.7 47.5 46.8
Distance from patients’ home to hospital (km) #5 6–35 . 35
269 157 115
49.7 29 21.3
Stated chronic disease No Yes
410 131
75.8 24.2
Day of the week of attending the emergency department Monday–Thursday Friday– Saturday
423 118
78.2 21.8
Arrival time at the emergency department 8.30 AM –2.00 PM 3.00–7.00 PM
308 233
56.9 43.1
Referral to the emergency department Self/relative referral Primary-care physician Specialist physician Ambulatory emergency care
455 51 20 15
84.1 9.4 3.7 2.8
Duration of presenting problem (hours) ,1 1–24 . 24
86 332 123
15.9 61.4 22.7
as it increased with decreasing distance. The visits considered to be non-urgent varied according to the referral, with a higher percentage of nonurgent cases being self or relative referred
Non-urgent visits to a hospital emergency department in Italy
253
Table 2 Distribution of urgent and non-urgent visits according to explanatory variables. Characteristic
Sex Male Female x2 ¼ 2:4; 1 df, P ¼ 0:12 Age (years) 15–25 26–35 36–45 46–55 56–65 66–75 . 75 x2 test for trend ¼ 11.98, 1 df, P ¼ 0:0005 Marital status Married Others x2 ¼ 2:04; 1 df, P ¼ 0:15 Education (years) None 5 8 13 . 13 x2 ¼ 1:17; 4 df, P ¼ 0:89 Number of persons in the household 0 1–2 .2 x2 ¼ 1:38; 2 df, P ¼ 0:5 Distance from patients’ home to hospital (km) #5 6–35 . 35 x2 ¼ 5:9; 2 df, P ¼ 0:052 Stated chronic disease No Yes x2 ¼ 2:84; 1 df, P ¼ 0:09 Day of the week of attending the emergency department Monday–Thursday Friday–Saturday x2 ¼ 1:8; 1 df, P ¼ 0:18 Arrival time at the emergency department 8.30 AM –2.00 PM 3.00–7.00 PM x2 ¼ 0:01; 1 df, P ¼ 0:94 Referral to the emergency department Self referral/relative Medical referral x2 ¼ 5:41; 1 df, P ¼ 0:02 Duration of presenting problem (hours) ,1 1–24 . 24 x2 ¼ 6:14; 2 df, P ¼ 0:046
(21.3%), and it is interesting to note that only 5% of non-urgent cases had already been seen by a specialist physician outside the hospital setting. Overall, non-urgent cases were significantly more
Urgent
Non-urgent
n
%
n
%
217 218
83.1 77.9
44 62
16.9 22.1
55 66 59 53 60 72 70
74.3 71 79.7 75.7 92.3 83.7 88.6
19 27 15 17 5 14 9
25.7 29 20.3 24.3 7.7 16.3 11.4
329 106
81.8 76.3
73 33
18.2 23.7
89 79 130 108 29
81.7 81.4 78.3 80 85.3
20 18 36 27 5
18.3 18.6 21.7 20 14.7
24 212 199
77.4 82.5 78.7
7 45 54
22.6 17.5 21.3
207 136 92
76.9 86.6 80
62 21 23
23.1 13.4 20
323 112
78.8 85.5
87 19
21.2 14.5
335 100
79.2 84.7
88 18
20.8 15.3
248 187
80.5 80.3
60 46
19.5 19.7
358 77
78.7 89.5
97 9
21.3 10.5
74 271 90
86.1 81.6 73.2
12 61 33
13.9 18.4 26.8
frequently self or relative referred compared with urgent cases (x2 ¼ 5:41; 1 df, P ¼ 0:02) and with problems of longer duration (x2 ¼ 6:14; 2 df, P ¼ 0:046). The proportion of patients whose
254
A. Bianco et al.
visit was considered to be non-urgent varied according to the number of investigations received in the emergency department, since the frequency of those receiving at least one investigation or a medical/surgical examination was significantly lower in non-urgent cases (11.7 vs 22.5%) (x2 ¼ 7:79; 1 df, P ¼ 0:005) (data not shown). The results of the multiple logistic regression analysis partially confirmed the findings of the univariate analysis. Among all variables tested, age and sex were significant predisposing factors for utilization of the emergency department for non-urgent conditions. Indeed, the odds of presenting for non-urgent care were significantly higher if patients were younger (OR ¼ 0.98, 95% CI ¼ 0.96 – 0.99) and female (OR ¼ 1.56, 95% CI ¼ 1.00 –2.51). Moreover, the odds of being a non-urgent case were significantly higher in patients who presented to the emergency department without medical referral (selfor relative-referred patients) (OR ¼ 2.42, 95% CI ¼ 1.13 –5.16) and in patients who presented with problems of longer duration (OR ¼ 1.78, 95% CI ¼ 1.23 –2.58) (Table 3). When patients were asked to indicate why they chose the emergency department for their health care, the most frequent reason stated for the visit was that they believed it was an emergency. Interestingly, this was more frequently indicated by the patients judged to be presenting with nonurgent conditions (91%) compared with other patients (81.3%).
Table 3 Logistic regression model results. Variable
OR
SE
95% CI
Log-likelihood ¼ 2249.45, x2 ¼ 36:37; P , 0:0001 Age 0.98 0.01 0.96–0.99 Duration of presenting 1.78 0.34 1.23–2.58 problem Referral to the 2.42 0.93 1.13–5.16 emergency department Sex 1.56 0.37 1.00–2.51 Education 0.79 0.09 0.63–1.00 Day of the week 0.72 0.21 0.41–1.27 of attending the emergency department Number of persons 0.82 0.17 0.55–1.25 in the household Stated chronic disease 0.77 0.23 0.43–1.38 Distance from patients’ 0.88 0.13 0.65–1.18 home to hospital
P
,0.001 0.002 0.022 0.049 0.052 0.258
0.357 0.376 0.390
Outcome: Profile of patients who attend the emergency department for non-urgent care. OR, odds ratio; SE, standard error; CI, confidence intervals.
Discussion This is the first study in Italy to investigate the impact of non-urgent patient visits to an accident and emergency department, and this survey was part of a larger project that investigated the appropriateness of hospital healthcare, particularly admissions and unnecessary days of hospital stay.2, 5,13,14
Our results indicate that 19.6% of patients aged 15 years or older who attended the accident and emergency department presented with nonurgent problems, meaning that required interventions could have been provided by more appropriate care sources, such as primary healthcare centres, without attendance at a highly specialized emergency department. Comparisons with the most recent international research findings obtained both in European countries and abroad must be interpreted cautiously since several factors may influence the prevalence of non-urgent visits. Indeed, the following variables may play an important role: (a) the target population studied according to age; (b) the survey’s methodology and the instrument applied; (c) the levels of definition of non-urgent visit developed; (d) the healthcare organization system; and (e) the attitudes and behaviour of the physician and patient. The prevalence of non-urgent visits found in this study is in agreement with observations from other European hospitals. In Sweden, similar results have been reported in the emergency department of a university hospital, with 27% of all care-seekers identified by the reception staff as presenting with non-urgent needs;15 in France and Spain, 29 and 29.6%, respectively, of all visits to university hospitals were considered to be non-urgent.7,9 Despite excluding patients in a distressed state, our figures were lower than in other industrialized countries. Indeed, in UK, 40.9% of attenders at a teaching hospital were classified by triage as presenting with problems more appropriately dealt with by primary-care professionals;6 and in Australia, a prevalence of non-urgent visits of 40 – 50% has been reported.16 Considerably higher values were found in the USA with levels ranging from 66.8% (for patients waiting to be seen by a physician in California)10 to 87% (for those waiting for care in emergency department services in San Francisco).11 This extreme heterogeneity in findings across various countries documents the difficulties in defining non-urgent visits presented by patients at emergency departments, and suggests that a more universal and specific definition may be
Non-urgent visits to a hospital emergency department in Italy
helpful. However, cultural and organizational differences between different healthcare systems would still make comparison difficult. Multivariate analysis of the demographic and social characteristics predictive of non-urgent care indicated that there is evidence that age and sex are significant indicators of outcome of interest. Younger, female patients were more likely to present with non-urgent conditions. Moreover, self- or relative-referred patients and those who presented with problems of longer duration were more likely to be non-urgent cases. Our results are partially consistent with those reported in previous studies conducted in other countries.7 – 9 There is a finding of particular concern regarding the pattern of medical care usage in an area with hospital emergency department services which provide 24-h availability and open access, while the primary-care services are only available during office hours for 32 h/week, and there are 47,000 general practitioners in the area, each caring for approximately 1100 inhabitants. More than twothirds of patients examined in this study were self or relative referred to the emergency department. In comparison, patients referred by physicians showed a significantly lower proportion of nonurgent visits. The most frequent reason stated by patients for choosing the emergency department for their care was that they believed it was an emergency. This observation emphasizes that, although all patients aged 15 years or older in our national healthcare system have a general practitioner who should provide primary care, the emergency department is used as a primary healthcare facility and, therefore, this prevents general practitioners from acting as an effective interface between hospital- and community-based services. In conclusion, in order to provide a service responsive to the real needs of patients, we need to understand how primary care is organized, especially in relation to access out of hours. Greater co-operation between primary care and hospital services may help to reduce inappropriate attendance at hospital emergency departments.
255
References 1. Chopard P, Perneger TV, Gaspoz JM, et al. Predictors of inappropriate hospital days in a department of internal medicine. Int J Epidemiol 1998;27:513—9. 2. Angelillo IF, Ricciardi G, Nante N, Boccia A, Collaborative group. Appropriateness of hospital utilization in Italy. Public Health 2000;114:9—14. 3. McDonagh MS, Smith DH, Goddard M. Measuring appropriate use of acute beds. A systematic review of methods and results. Health Policy 2000;53:157—84. 4. Smeets PM, Verheggen FW, Pop P, Panis LJ, Carpay JJ. Assessing the necessity of hospital stay by means of the appropriateness evaluation protocol: how strong is the evidence to proceed? Int J Qual Health Care 2000;12: 483—93. 5. Bianco A, Pileggi C, Di Stasio S, Angelillo IF. Inappropriate hospital use by medically urgent patients in Italy. Public Health, submitted for publication 6. Dale J, Green J, Reid F, Glucksman E. Primary care in the accident and emergency department: I. Prospective identification of patients. BMJ 1995;311:423—6. 7. Lang T, Davido A, Diakite ´ B, Agay E, Viel JF, Flicoteaux B. Non-urgent care in the hospital medical emergency department in France: how much and which health needs does it reflect? J Epidemiol Comm Health 1996; 50:456—62. 8. Lang T, Davido A, Diakite ´ B, Agay E, Viel JF, Flicoteaux B. Using the hospital emergency department as a regular source of care. Eur J Epidemiol 1997;13:223—8. 9. Sempere-Selva T, Peiro ` S, Sendra-Pina P, Martinez-Espı´n C, Lo ´pez-Aguilera I. Inappropriate use of an accident and emergency department: magnitude, associated factors, and reasons. An approach with explicit criteria. Ann Emerg Med 2001;37:568—79. 10. Baker DW, Stevens CD, Brook RH. Patients who leave a public hospital emergency department without being seen by a physician. JAMA 1991;266:1085—90. 11. Grumbach K, Keane D, Bindman A. Primary care and public emergency department overcrowding. Am J Public Health 1993;83:372—8. 12. Stata Corporation. Stata reference manual. Release 5.0, College Station: Stata Corporation; 1997. 13. Bianco A, Foresta MR, Greco MA, Teti V, Angelillo IF. Appropriate and inappropriate use of day-hospital care in Italy. Public Health 2002;116:368—73. 14. Bianco A, Pileggi C, Trani F, Angelillo IF. Appropriateness of admissions and days of stay in pediatric wards of Italy. Pediatrics in press. 15. Hansagi H, Carlsson B, Olsson M, Edhag O. Trial of a method of reducing inappropriate demands on a hospital emergency department. Public Health 1987;101:99—105. 16. Andersen NA, Gaudry PL. Patients attending an accident and emergency department for primary medical care. Fam Pract 1984;1:79—85.
Non-urgent visits to a hospital emergency department in Italy A. Bianco, C. Pileggi, I.F. Angelillo* Medical School, University of Catanzaro ‘Magna Græcia’, Via Tommaso Campanella, 88100 Catanzaro, Italy Received 10 May 2002; received in revised form 28 October 2002; accepted 26 November 2002
KEYWORDS Emergency department; Hospital; Italy; Nonurgent visits
Summary The purpose of this study was to determine the extent of non-urgent visits and the effect of different characteristics on such visits to one public hospital emergency department located in Catanzaro, Italy. Of 581 patients aged 15 years and older who were registered for care in the emergency department, 40 were excluded from the study as they were too ill or distressed. The survey questionnaire included questions about the patients’ demographic and socio-economic characteristics, distance from home to hospital, usual health status and health status at the time of presentation to the emergency department. Of the 541 patients who agreed to participate, 19.6% of patients, according to the judgement of two observers, had nonurgent conditions. The results of the multiple logistic regression analysis showed that among all variables tested, age and sex were significant predisposing factors for utilization of the emergency department for non-urgent visits. Indeed, the odds of presenting for non-urgent care were significantly higher if patients were younger and female. Moreover, the odds of requiring non-urgent care were significantly higher in patients who present to the emergency department without medical referral and in patients who present with problems of longer duration. The most frequent reason given by patients for their visit to the emergency department was that they felt their problem was an emergency. Further investigations are necessary to evaluate the use of primary care since closer co-operation within the healthcare organization system may provide a more responsive service. Q 2003 The Royal Institute of Public Health. Published by Elsevier Science Ltd. All rights reserved.
Introduction The efficiency and effectiveness of medical service delivery has raised serious concerns among healthcare professionals and administrators, both because of the level of healthcare use and because *Corresponding author. Tel.: þ39-961-777669; fax: þ 39-961777345. E-mail address: [email protected]
of the possibility of choice of a more suitable level of care with equity of access to appropriate care. A number of studies in different countries have evaluated inappropriate utilization of hospital resources and increasing costs to the healthcare system.1 – 5 Hospital emergency departments have become ubiquitous as the source of care for many patients, especially those patients who are of lower education level and who do not have a regular source
0033-3506/03/$ - see front matter Q 2003 The Royal Institute of Public Health. Published by Elsevier Science Ltd. All rights reserved. doi:10.1016/S0033-3506(03)00069-6
Non-urgent visits to a hospital emergency department in Italy
of primary care. They tend to use emergency departments as a substitute for a general practitioner to treat minor or unexpected illnesses. In Italy, great efforts have been made to contain the hospital care costs whilst also responding to the population’s health needs. The healthcare payment system in accident and emergency departments has been modified so that investigations performed are only free of charge for patients older than 65 years and younger than 9 years, or patients with trauma or injuries. In spite of this, subjects continue to use emergency departments as a regular source of care when they have an acute medical problem. To the best of our knowledge, few studies have been published from European countries6 – 9 or the USA10, 11 assessing the frequency of patients attending emergency departments for non-urgent visits. Further, no data are available for Italian hospitals. Therefore, we conducted a study on the utilization of a hospital emergency department to estimate how many visits were for non-urgent problems and which characteristics were related to the utilization of the emergency department as a source of non-urgent care in Italy.
Materials and methods A cross-sectional study was carried out in the emergency department of a 714-bed (occupancy rate 75%) public regional general hospital in Catanzaro, Italy from July to December 2001. The hospital covers the healthcare needs of the 370,000 inhabitants of the Catanzaro province (15,000 km2) in the Calabria Region (2 million inhabitants). In our region, 36 of 38 hospitals have an emergency department. A stratified sample of 2-h sessions was selected at random to include, respectively, two weekday and one weekend session running from 8.30 AM to 2.00 PM or 3.00 to 7.00 PM for each week of the study period. Patients waiting for emergency care were eligible for inclusion in the study if they were 15 years of age or older. A medical interviewer, who has at least 6 months experience at the emergency department and who was not involved in care, who had been trained previously, collected the data by interviewing all patients who agreed to participate immediately after the admittance and nurse triage, and before examination by the medical staff of the emergency department. The survey questionnaire included questions about the patients’ demographic and socio-economic characteristics, distance from home to hospital, usual health status and health status at the time of presentation to
251
the emergency department. When patients could not be interviewed because of their health status, their relatives were asked to provide information. Patients who were too ill or distressed were excluded from the study. All medical staff of the emergency department were asked to complete a form for each patient seen, including chemical pathology, electrocardiography, haematology, microbiology, radiographic investigations, medical or surgical examinations, items prescribed, final medical diagnoses, referral and discharge decisions made. The following definitions of levels of urgent care were developed before the beginning of the study according to previously published surveys:7,10,11 † the patient should be seen promptly by a physician in the emergency department to assess and treat possible life-threatening conditions, and immediate care was necessary within 24 h in order to avoid severe consequences for the patient (extreme emergency); † the patient required care within 24 – 48 h, or the technical equipment of the hospital had to be used for diagnosis or therapeutic purposes (emergency); † the patient was worried by the appearance or the recent worsening of symptoms (e.g. a left arm pain or a chest pain, which could be related to an acute myocardial infarction), although the vital or functional prognosis was not threatened within 24 h. The patient’s condition is appropriate for referral to a general or subspecialty clinic (emergency as perceived by patient); † the patient has no active symptoms or they were recent and minor, without any feeling of emergency and he/she desires a check-up, a prescription refill or a return-to-work release (non-urgent case).
Statistical analysis Multiple logistic regression analysis with forward elimination was performed. A model was developed in order to describe the profile of patients who attend the emergency department for non-urgent care and the following explanatory variables were included: age (continuous), sex (1 ¼ male, 2 ¼ female), marital status (1 ¼ married, 2 ¼ single/separated/divorced/widowed), number of persons in the household (three categories: 1 ¼ 0, 2 ¼ 1 – 2, 3 ¼ . 2), educational level (five categories: 1 ¼ no formal education, 2 ¼ 5 years, 3 ¼ 8 years, 4 ¼ 13 years, 5 ¼ . 13 years), distance in kilometres between home and hospital (1 ¼ # 5, 2 ¼ 6 – 35, 3 ¼ . 35), stated chronic disease
252
(0 ¼ no, 1 ¼ yes), who referred the patient to the emergency department (0 ¼ physician, 1 ¼ self referral/relative), hour of arrival at the emergency department (1 ¼ 8.30 AM – 2.00 PM, 2 ¼ 3.00 – 7.00 PM), day of the week of attending the emergency department (0 ¼ Monday – Thursday, 1 ¼ Friday – Saturday), and duration in hours of presenting problem (three categories: 1 ¼ , 1, 2 ¼ 1 – 24, 3 ¼ . 24). The significance level for variables entering the models was set at 0.2 and for removing from the models at 0.4. Adjusted odds ratio (OR) and 95% confidence intervals (CI) were calculated. Overall agreement and the k statistic were used to assess the inter-rater reliability regarding the definition of urgent care. Data were analysed using the Stata software program.12
Results Overall inter-rater agreement was excellent within the reviewers, since the agreement and the k statistic for the assessment of urgent care were always higher than 95% and 0.92. Of 581 patients aged 15 years or older registered for care in the emergency department during the study period, 40 were excluded from the study since they were too ill or distressed. Of 541 patients who agreed to participate, 500 were interviewed and relatives provided information for 41 patients. Their principal characteristics are presented in Table 1. The mean age was 50.6 years (range 15 –98 years), almost two-thirds of patients had attained a middle- or higher-school education level, more than three-quarters of patients were admitted to hospital from Monday to Thursday, and only 5.7% stated that they lived alone. Patients were rarely referred to the emergency department by a physician, since the vast majority were self referred or referred by relatives (84.1%), and more than three-quarters of patients sought care for problems that had been present for at least 24 h. Of 541 patients aged 15 years or older who were surveyed at the emergency department, 19.6%, according to the judgement of the two observers, had non-urgent conditions. Table 2 presents the distribution of non-urgent visits to the emergency department according to various explanatory characteristics. Attending the emergency department with a non-urgent condition was associated with the patient’s age (x2 test for trend ¼ 11.98, 1 df, P ¼ 0:0005) and it was also, although not significantly, associated with the distance from patients’ home to hospital,
A. Bianco et al.
Table 1 Selected characteristics of the study population. Characteristic
n
%
Sex Male Female
261 280
48.2 51.8
Age (years) 15–25 26–35 36–45 46–55 56–65 66–75 . 75
74 93 74 70 65 86 79
13.7 17.2 13.7 12.9 12 15.9 14.6
Marital status Married Others
402 139
74.3 25.7
Education (years) None 5 8 13 . 13
109 97 166 135 34
20.2 17.9 30.6 25 6.3
Number of persons in the household 0 1–2 .2
31 257 253
5.7 47.5 46.8
Distance from patients’ home to hospital (km) #5 6–35 . 35
269 157 115
49.7 29 21.3
Stated chronic disease No Yes
410 131
75.8 24.2
Day of the week of attending the emergency department Monday–Thursday Friday– Saturday
423 118
78.2 21.8
Arrival time at the emergency department 8.30 AM –2.00 PM 3.00–7.00 PM
308 233
56.9 43.1
Referral to the emergency department Self/relative referral Primary-care physician Specialist physician Ambulatory emergency care
455 51 20 15
84.1 9.4 3.7 2.8
Duration of presenting problem (hours) ,1 1–24 . 24
86 332 123
15.9 61.4 22.7
as it increased with decreasing distance. The visits considered to be non-urgent varied according to the referral, with a higher percentage of nonurgent cases being self or relative referred
Non-urgent visits to a hospital emergency department in Italy
253
Table 2 Distribution of urgent and non-urgent visits according to explanatory variables. Characteristic
Sex Male Female x2 ¼ 2:4; 1 df, P ¼ 0:12 Age (years) 15–25 26–35 36–45 46–55 56–65 66–75 . 75 x2 test for trend ¼ 11.98, 1 df, P ¼ 0:0005 Marital status Married Others x2 ¼ 2:04; 1 df, P ¼ 0:15 Education (years) None 5 8 13 . 13 x2 ¼ 1:17; 4 df, P ¼ 0:89 Number of persons in the household 0 1–2 .2 x2 ¼ 1:38; 2 df, P ¼ 0:5 Distance from patients’ home to hospital (km) #5 6–35 . 35 x2 ¼ 5:9; 2 df, P ¼ 0:052 Stated chronic disease No Yes x2 ¼ 2:84; 1 df, P ¼ 0:09 Day of the week of attending the emergency department Monday–Thursday Friday–Saturday x2 ¼ 1:8; 1 df, P ¼ 0:18 Arrival time at the emergency department 8.30 AM –2.00 PM 3.00–7.00 PM x2 ¼ 0:01; 1 df, P ¼ 0:94 Referral to the emergency department Self referral/relative Medical referral x2 ¼ 5:41; 1 df, P ¼ 0:02 Duration of presenting problem (hours) ,1 1–24 . 24 x2 ¼ 6:14; 2 df, P ¼ 0:046
(21.3%), and it is interesting to note that only 5% of non-urgent cases had already been seen by a specialist physician outside the hospital setting. Overall, non-urgent cases were significantly more
Urgent
Non-urgent
n
%
n
%
217 218
83.1 77.9
44 62
16.9 22.1
55 66 59 53 60 72 70
74.3 71 79.7 75.7 92.3 83.7 88.6
19 27 15 17 5 14 9
25.7 29 20.3 24.3 7.7 16.3 11.4
329 106
81.8 76.3
73 33
18.2 23.7
89 79 130 108 29
81.7 81.4 78.3 80 85.3
20 18 36 27 5
18.3 18.6 21.7 20 14.7
24 212 199
77.4 82.5 78.7
7 45 54
22.6 17.5 21.3
207 136 92
76.9 86.6 80
62 21 23
23.1 13.4 20
323 112
78.8 85.5
87 19
21.2 14.5
335 100
79.2 84.7
88 18
20.8 15.3
248 187
80.5 80.3
60 46
19.5 19.7
358 77
78.7 89.5
97 9
21.3 10.5
74 271 90
86.1 81.6 73.2
12 61 33
13.9 18.4 26.8
frequently self or relative referred compared with urgent cases (x2 ¼ 5:41; 1 df, P ¼ 0:02) and with problems of longer duration (x2 ¼ 6:14; 2 df, P ¼ 0:046). The proportion of patients whose
254
A. Bianco et al.
visit was considered to be non-urgent varied according to the number of investigations received in the emergency department, since the frequency of those receiving at least one investigation or a medical/surgical examination was significantly lower in non-urgent cases (11.7 vs 22.5%) (x2 ¼ 7:79; 1 df, P ¼ 0:005) (data not shown). The results of the multiple logistic regression analysis partially confirmed the findings of the univariate analysis. Among all variables tested, age and sex were significant predisposing factors for utilization of the emergency department for non-urgent conditions. Indeed, the odds of presenting for non-urgent care were significantly higher if patients were younger (OR ¼ 0.98, 95% CI ¼ 0.96 – 0.99) and female (OR ¼ 1.56, 95% CI ¼ 1.00 –2.51). Moreover, the odds of being a non-urgent case were significantly higher in patients who presented to the emergency department without medical referral (selfor relative-referred patients) (OR ¼ 2.42, 95% CI ¼ 1.13 –5.16) and in patients who presented with problems of longer duration (OR ¼ 1.78, 95% CI ¼ 1.23 –2.58) (Table 3). When patients were asked to indicate why they chose the emergency department for their health care, the most frequent reason stated for the visit was that they believed it was an emergency. Interestingly, this was more frequently indicated by the patients judged to be presenting with nonurgent conditions (91%) compared with other patients (81.3%).
Table 3 Logistic regression model results. Variable
OR
SE
95% CI
Log-likelihood ¼ 2249.45, x2 ¼ 36:37; P , 0:0001 Age 0.98 0.01 0.96–0.99 Duration of presenting 1.78 0.34 1.23–2.58 problem Referral to the 2.42 0.93 1.13–5.16 emergency department Sex 1.56 0.37 1.00–2.51 Education 0.79 0.09 0.63–1.00 Day of the week 0.72 0.21 0.41–1.27 of attending the emergency department Number of persons 0.82 0.17 0.55–1.25 in the household Stated chronic disease 0.77 0.23 0.43–1.38 Distance from patients’ 0.88 0.13 0.65–1.18 home to hospital
P
,0.001 0.002 0.022 0.049 0.052 0.258
0.357 0.376 0.390
Outcome: Profile of patients who attend the emergency department for non-urgent care. OR, odds ratio; SE, standard error; CI, confidence intervals.
Discussion This is the first study in Italy to investigate the impact of non-urgent patient visits to an accident and emergency department, and this survey was part of a larger project that investigated the appropriateness of hospital healthcare, particularly admissions and unnecessary days of hospital stay.2, 5,13,14
Our results indicate that 19.6% of patients aged 15 years or older who attended the accident and emergency department presented with nonurgent problems, meaning that required interventions could have been provided by more appropriate care sources, such as primary healthcare centres, without attendance at a highly specialized emergency department. Comparisons with the most recent international research findings obtained both in European countries and abroad must be interpreted cautiously since several factors may influence the prevalence of non-urgent visits. Indeed, the following variables may play an important role: (a) the target population studied according to age; (b) the survey’s methodology and the instrument applied; (c) the levels of definition of non-urgent visit developed; (d) the healthcare organization system; and (e) the attitudes and behaviour of the physician and patient. The prevalence of non-urgent visits found in this study is in agreement with observations from other European hospitals. In Sweden, similar results have been reported in the emergency department of a university hospital, with 27% of all care-seekers identified by the reception staff as presenting with non-urgent needs;15 in France and Spain, 29 and 29.6%, respectively, of all visits to university hospitals were considered to be non-urgent.7,9 Despite excluding patients in a distressed state, our figures were lower than in other industrialized countries. Indeed, in UK, 40.9% of attenders at a teaching hospital were classified by triage as presenting with problems more appropriately dealt with by primary-care professionals;6 and in Australia, a prevalence of non-urgent visits of 40 – 50% has been reported.16 Considerably higher values were found in the USA with levels ranging from 66.8% (for patients waiting to be seen by a physician in California)10 to 87% (for those waiting for care in emergency department services in San Francisco).11 This extreme heterogeneity in findings across various countries documents the difficulties in defining non-urgent visits presented by patients at emergency departments, and suggests that a more universal and specific definition may be
Non-urgent visits to a hospital emergency department in Italy
helpful. However, cultural and organizational differences between different healthcare systems would still make comparison difficult. Multivariate analysis of the demographic and social characteristics predictive of non-urgent care indicated that there is evidence that age and sex are significant indicators of outcome of interest. Younger, female patients were more likely to present with non-urgent conditions. Moreover, self- or relative-referred patients and those who presented with problems of longer duration were more likely to be non-urgent cases. Our results are partially consistent with those reported in previous studies conducted in other countries.7 – 9 There is a finding of particular concern regarding the pattern of medical care usage in an area with hospital emergency department services which provide 24-h availability and open access, while the primary-care services are only available during office hours for 32 h/week, and there are 47,000 general practitioners in the area, each caring for approximately 1100 inhabitants. More than twothirds of patients examined in this study were self or relative referred to the emergency department. In comparison, patients referred by physicians showed a significantly lower proportion of nonurgent visits. The most frequent reason stated by patients for choosing the emergency department for their care was that they believed it was an emergency. This observation emphasizes that, although all patients aged 15 years or older in our national healthcare system have a general practitioner who should provide primary care, the emergency department is used as a primary healthcare facility and, therefore, this prevents general practitioners from acting as an effective interface between hospital- and community-based services. In conclusion, in order to provide a service responsive to the real needs of patients, we need to understand how primary care is organized, especially in relation to access out of hours. Greater co-operation between primary care and hospital services may help to reduce inappropriate attendance at hospital emergency departments.
255
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