INTRODUCTION

There are over 350 million visits for acute care annually in the USA,1 and the acute care delivery system is struggling to meet the timeliness of patient care needs.2 Evidence of difficulties with accessing acute care abound in both the medical and lay press literature, with stories of frustration with the healthcare delivery system, difficulties with primary care access, and visits to the emergency department (ED) for “nonurgent” conditions.2,3,4,5,6,7

While the delivery of acute care has been a central principle of primary care,1, 8 fewer than half acute care visits involve the patient’s PC physician.1 This may be due, in part, to the evolution in primary care, with the focus of primary care dramatically shifting with an increased emphasis toward provision of care related to aging, chronic disease management, and coordination of specialty care.1, 9,10,11 As a result, an increasing number of acute care visits occur in the ED.1 Unfortunately, ED visits are rising while the number of EDs is decreasing12 resulting in ED crowding, boarding, and ambulance diversion, thereby potentially further limiting patient access to acute care services and increasing the difficulties with successfully meeting public health needs.13, 14

The Institute of Medicine has recommended that healthcare be “safe, effective, patient-centered, timely, efficient, and equitable”.15 In order to develop patient-centered timely healthcare, a comprehensive understanding of the reasons patients choose a specific healthcare setting over another for acute care needs is indicated. The qualitative studies to evaluate reasons patient choose one setting over another for their acute care needs have primarily been at single centers and have involved small numbers of patients. Synthesizing data from multiple qualitative studies will provide beneficial insight into patient choices for acute care while simultaneously enhancing the transferability of the qualitative study findings.16, 17 Therefore, we critically evaluated and synthesized qualitative studies on reasons for seeking care in the ED instead of through primary care. The specific research question for this qualitative metasynthesis was “What are patients’ perspectives on reasons to seek healthcare services in the ED instead of through primary care?”

METHODS

Study Design

We conducted a qualitative metasynthesis grounded in social constructivist epistemology using an established framework for metasynthesis of qualitative data.17 We identified the research question, determined the nature and scope of the articles for inclusion in the study, conducted a standardized assessment of article quality, and performed a team-based inductive analysis to identify reciprocal themes. The process involved interpretations of the articles’ interpretations and a team-based integrative synthesis of the data.18, 19 Since the purpose of the investigation was to derive new knowledge from the existing studies, we followed the established metasynthesis approach of Noblit and Hare which indicates that qualitative studies about similar topics can be combined to obtain new, broader interpretive meaning.20

Inclusion and Exclusion Criteria

For the metasynthesis, we included published studies on adult (≥ 18 years of age) patients that mentioned accessing the ED instead of primary care and were indexed in a bibliographic database by December 2018. We excluded non-English articles, conference abstracts, surveys, mixed-methods studies, and systematic reviews.

Search Strategy

We searched to identify articles for inclusion in the metasynthesis using PubMed, Web of Science, PsycINFO, and the Current Index to Nursing and Allied Health Literature (CINAHL). The search was limited to articles published from 2000 to 2018. The following search terms were used to identify the most relevant articles for the qualitative metasynthesis: ED, emergency room, emergency, utilization, healthcare utilization, frequency, over-utilization, and primary care. The database searches were supplemented with review of reference lists of articles and review articles on the topics of ED and primary care utilization.

Two reviewers (J.V. and M.L.B.) independently performed the searches in a stepwise fashion. First, they examined each title for relevance to our study question. Second, among the articles potentially relevant to the study question, they examined the abstract of the article. Finally, if the article abstract demonstrated relevance to the study question, the entire article was assessed for inclusion in the metasynthesis. Both reviewers agreed upon the final set of articles included in the metasynthesis.

Methodological Critical Review

Articles meeting criteria for inclusion were critically appraised by three members of our research team: two emergency medicine physicians (J.A.V. and K.L.R.) and a master’s-level trained social worker (M.L.B.). Article quality was assessed using the McMaster Quality Assessment Guidelines—Qualitative Studies Critical Review Form 2.0.21 This critical appraisal tool was specifically developed to facilitate critical appraisal of qualitative research articles. The instrument includes assessments of key components and domains of qualitative research articles, including study purpose, review of background literature, study design, sampling, data collection, data analyses, and conclusions.21

Approach to the Metasynthesis

We used reciprocal translation analysis as our meta-synthetic approach. Each interdisciplinary research team member (J.A.V., K.L.R., and M.L.B.) independently reviewed all the articles and developed a list of themes and subthemes. Subsequently, we met to compare potential themes, using consensus to select the final themes and subthemes.

RESULTS

Our initial search of the literature produced 743 articles. We excluded articles that were mixed methods, were not qualitative studies, did not address the “patient” perspective on our research topic, and those that included data on pediatric (< 18 years of age) patients. After exclusions, nine articles met criteria for inclusion in our measynthesis.2, 22,23,24,25,26,27,28,29 The results of our search are outlined in Figure 1.

Figure 1
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Article selection process for the qualitative metasynthesis.

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The final nine studies included in this metasynthesis were chosen by consensus after full article review: Durand,22 Howard,23 Hunter,24 Kangovi,25 Koziol-McLain,26 Lowthian,27 Rising,2 Schmeidhofer,28 and Shaw.29 The characteristics of the studies included are described in Table 1. Five of the included studies were conducted in the USA and the remaining four studies were conducted in Germany, France, Northwest England, and Australia. The sample size for the studies included in the metasynthesis ranged from 30 to 100 patients.

Table 1 Characteristics of Studies Included in the Qualitative Metasynthesis
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The results of the methodologic review for the study are outlined in Table 2. The metasynthesis produced four themes and several subthemes which are outlined in Table 3. The themes associated with patients choosing the ED over primary care included the following: acuity of condition, barriers to primary care, advantages of the ED, and quality of hospital-based care and fulfillment of healthcare needs. Each of these themes is described below.

Table 2 Summary of Critical Review of Studies Included in Metasynthesis
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Table 3 Team Synthesis and Reciprocal Translation for Qualitative Metasynthesis
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Theme 1: Acuity of Condition

Many individuals visited the ED based on the perceived acuity and urgency of the condition or illness requiring immediate medical attention. Visitors to the ED were specifically concerned about the severity of their illness or condition and the level of pain which may be associated with a serious medical condition. They reported, “It’s urgent because it hurts.”22 “I was afraid; I was concerned because I did not know if my problem was serious”.22 Patients reported difficulty ascertaining whether their concern was life-threatening; “I didn’t want to take a chance, because I’m no doctor. I’m no nurse. I’m just a patient”.2 Pain control was also a concern for ED visitors; “It’s just that painful, you’ve just got to go [to the hospital].”24 “So I jus’ been trying to bear with it. Then I just couldn’t handle it anymore, so I came in.”26 Within this theme, individuals also reported the desire for reassurance that everything was alright. “I do not know what I have, but it worried me, so I preferred to come immediately to the ED so at least I am reassured”.22 The theme of visiting the ED for acute conditions speaks to the understanding of the importance of the ED in the community as a critical link in the chain of healthcare provision in which healthcare providers are available to address emergent and urgent conditions and pain. There was a general awareness among ED visitors that the ED was the “place to go to” for help when faced with a serious of acute medical concern.

Theme 2: Barriers to Access to Primary Care

The second theme for the metasynthesis was barriers to accessing primary care. ED visitors indicated that primary care physicians had significantly limited availability thereby impacting their decision to visit the ED. Many ED visitors indicated that it is difficult to obtain a primary care physician appointment when ill. “I like him (speaking of her primary care physician) but it is impossible to see him if you are sick. It is weeks before you can get an appointment.”23 “Very very rare have I phoned up the doctor and been able to get in … to see my general practitioner within two or three days. It’s nearly always next week or the week after or whatever.. you need out the out of hours doctors really to help you out for them situations.”24 “The ED is quicker than getting an appointment with the general practitioner.”27 Many ED visitors indicated that the wait at their primary care physician’s office once they arrived for an appointment was prohibitive. “I feel like I sit for hours for him to see me for 2 minutes; it is much quicker to come out here.”23 Other ED visitors suggested that due to limited availability of the primary care physician, they had to visit the ED for care. “When I am sick and miss a day of work, I need to see a doctor that day. I can’t afford to be off work any longer. I need to feel better and go back to work the next day.”22 “It is easier to come out here [to the ED]. At least here I know I will be seen by a doctor.”23 Finally, patients indicated that the PCP had sent them to the ED in the past, “like the last time, I went and told my situation to my doctor; she told me to go to the hospital when you leave here.”2 Overall, the themes related to the primary care reflected inaccessibility in times of need and overall lack of efficiency in the provision of healthcare services resulting in inconvenience and delay in care for patients.

Theme 3: Advantages of the Emergency Department

Many ED visitors chose to come to the ED due to the availability of diagnostic tests, treatment, and medical expertise. Many ED visitors favored the opportunity to have the diagnostic and medical services necessary for their care readily available instead of having to attend several appointments or sites to receive the necessary services; the single-site care provided by the ED was considered to be a significant advantage. “My doctor cannot do X-rays of laboratory tests, while the ED has all the technical support.”22 “Everything is in one place.”22 “The doctors (referring to the ED physicians) perform things a lot faster.”22 “The ER is the quickest way to get checked out.”23 “I always get seen straightaway, no matter what... when I’m there, I know I’m alright, because I know they can pinpoint what it is and what’s doing it”.24

ED visitors sited convenience as another factor in using the ED for healthcare services. Work schedules, transportation opportunities, and child care concerns impacted the decision to seek care in the ED instead of the primary care physician office. Many ED visitors had already missed work due to their illness and did not want to miss any additional work time awaiting a primary care physician appointment. “It is really important to me because I need to get feeling better so I can get back to work tomorrow.”23 One mother noted, “I have four children and the ones I leave at home can’t stay there for a long time alone. If they are not at school, I will take them along with me. Sometimes my mom will keep them if she is at home.”23 “Our days are really long, that is why it is easier to come in at night”.26 Many ED visitors found the accessibility of the ED, with care available 24 h a day, 7 days a week particularly advantageous.

Theme 4: Quality of Hospital-Based Care and Fulfillment of Healthcare Needs

The review of the qualitative literature suggests that ED visitors have a specific perception of the quality of ED services and the likelihood of fulfillment of healthcare needs if a person visits the ED. “I wasn’t getting anywhere with my outpatient appointment, so my general practitioner said let’s try going to the ED and see if that speeds it up.. and it did!”27 “The hospital is where you go if you are sick or in pain at all, and the primary is just for checkups.”25 “I always feel that the hospital is safer.”28 The comments from the articles and themes identified in the metasynthesis suggest that the ED is perceived by patients as a place that will provide timely diagnoses, information, and pain control when one is unwell.

DISCUSSION

The metasynthesis provides unique, distinct insight into patient’s perspectives on where they choose to seek acute care. By collapsing data across several qualitative studies, we were able to collectively bring together data from multiple sites and patients in different countries. We found the reasons patients visit the ED over primary care included (1) urgency of the medical condition, (2) barriers to accessing primary care, (3) advantages of the ED, and (4) fulfillment of medical needs and quality of care in the ED. The themes identified in the articles in this metasynthesis were pervasive across different healthcare settings and delivery systems. Countries represented in the articles included the USA, France, Northwest England, Germany, and Australia, which have differing approaches to healthcare access, insurance, and delivery. Despite the different healthcare systems included in the metasynthesis, common themes across articles emerged.

Our metasynthesis has provided an alternative overarching perspective about the phenomenon of patients who choose to visit the ED instead of primary care. Although some have suggested that ED visitors may be clogging the ED with conditions that could be treated more efficiently in other healthcare settings,30, 31 our metasynthesis of the limited data available suggests that patients often have specific, cogent reasons for deciding to visit the ED. Moreover, they have fears, anxiety, and concerns about acute pain and illnesses necessitating emergent medical care. In these acute circumstances, they may not have ready access to a primary care provider, and/or they may have even been referred by a healthcare provider to the ED. Patients identified the ED as a “haven” with highly skilled providers capable of diagnosing acute conditions in a timely fashion. The view of the ED as an efficient diagnostic center may also be shared by primary care providers who have limited diagnostic tools and options in their offices and send patients to the ED for advanced procedures and testing. Patients may have work, family, or socioeconomic constraints that only allow them to pursue acute care services in the evening and on the weekend, when their only option for acute healthcare services is the ED. The overarching theme of the metasynthesis is that visits to the ED for acute care services are multifactorial in nature, and the ED is an important critical link in the chain of acute healthcare delivery, providing access to care 24 h a day 7 days a week for both patients in need of services and healthcare providers referring their patients to the ED for diagnostic evaluation and further care.

To our knowledge, there has not been any similar comprehensive metasynthesis of the qualitative studies on this important topic. The topic of nonurgent use of the ED has been one of significant interest with the development of algorithms to identify “nonurgent” visits and the potential to tax or penalize individuals using the ED for nonemergent conditions instead of going to primary care. However, data have indicated that providing primary care access is beneficial but insufficient to reduce ED visits.32 This is likely due to the fact that primary care access and availability are entirely different concepts in the “real world” for patients trying to address acute care needs.32 Starfield has suggested that good primary care includes easy accessibility, patient-focused care over time, comprehensive services, and coordination of consultative or subspecialty care. Without all of these components, timely medical care is threatened and the patient may resort to the ED for acute care services.33 Some investigators have suggested that patients “are generally good at deciding where to access care” and indicated “inappropriate choices are generally a function of complex socioeconomic factors and shortcomings in the unscheduled care system”.34, 35 Our data would seem to support this notion, with patients evaluating opportunities for acute care needs in the context of their socioeconomic status including work and family obligations as well as insurance status and making the best decisions they can regarding acute care services.

Our metasynthesis is an important step forward in identifying common themes for the patient-centered selection for healthcare delivery for acute care needs. These data suggest that there are many factors outside of the medical diagnosis that influence the patient’s decision about where to seek acute care. In this era of healthcare reform, there may be opportunities to modify the acute care delivery system in the USA, and the use of this type of patient-centered data to guide future directions in acute care delivery system is critical to successfully ensure “safe, effective, patient-centered, timely, efficient, and equitable” healthcare as recommended by the Institute of Medicine.15

Our study has limitations. We did not include materials that were unpublished, were in languages other than English, or used mixed methods. Exclusion of these studies may have resulted in an unanticipated bias in the theme results we identified in the metasynthesis. The scope, quantity, and quality of the qualitative studies included in the review are a limitation as not all themes related to patient choices between primary care and the ED may have been elucidated in these studies, thereby impacting results. Despite these limitations, we believe our use of a multidisciplinary team, including nursing, social work, and physicians, to conduct this metasynthesis is advantageous. Evaluation of the literature by our multidisciplinary team may have facilitated an interpretation more interdisciplinary in nature, and a multifaceted, interdisciplinary approach will be especially important as interventions are contemplated to help improve the acute care delivery system.

CONCLUSIONS

In this qualitative metasynthesis, reasons patients visit the ED over primary care included (1) urgency of the medical condition, (2) barriers to accessing primary care, (3) advantages of the ED, and (4) fulfillment of medical needs and quality of care in the ED. The themes identified in the articles were pervasive across different healthcare settings and delivery systems. To facilitate successful patient access and use of primary care, restructuring of the acute care delivery system to help effectively meet patients’ healthcare needs utilizing patient-identified advantages of the ED may be beneficial.