|Year : 2018 | Volume
| Issue : 2 | Page : 48-53
Accessibility to primary health care and emergency department visits
Abdulrhman Mohammed Al-Arifi, Meshal Khunfur Al-Rashdi
Department of Family Medicine, King Saud Medical City, Riyadh, Saudi Arabia
|Date of Submission||30-Oct-2018|
|Date of Acceptance||06-Nov-2018|
|Date of Web Publication||12-Dec-2018|
Dr. Abdulrhman Mohammed Al-Arifi
Department of Family Medicine, King Saud Medical City, Riyadh
Source of Support: None, Conflict of Interest: None
Background: It is widely acknowledged in many countries that the delivery of accessible primary health care (PHC) is one of the most important national priorities. On the other hand, frequent complaints relating to longer waits to access hospital care and overutilization of emergency services are still common.
Objectives: The objective of this study was to determine patients' accessibility to PHC nonurgent emergency department (ED) and its influence factors to improve primary care quality and reduce ED crowding.
Subjects and Methods: This was an observational cross-sectional study. Convenience sample of ED patients was chosen from the Prince Sultan Military Medical City hospital ED in Riyadh, Saudi Arabia. An interview questionnaire was designed to collect the data. The data were analyzed using SPSS software, version 24.
Results: A total of 89 nonurgent ED patients participated in this study and their mean age was 36.45 (standard deviation = 14.8). Most of the participants (70.8%) were male and half of them (51.7%) had “secondary or diploma” degree. Most of the participants (85.4%) mentioned that they never visited PHCs. Almost half of the participants (51.7%) mentioned that they visited ED only one time in the last 12 months. About fifth (20.2%) of the patients mentioned that they did not access to PHC due to long waiting in the doctor's office. Patients' education status and duration of presenting complaint were significantly associated with their trying to go to PHC and visiting ED in the last year.
Conclusion: According to the results of this study, it is necessary to develop strategies to implement policies aimed at reducing nonurgent ER use as well as make health-care services more available to the population.
Keywords: Accessibility, emergency department, primary health care, Saudi Arabia
|How to cite this article:|
Al-Arifi AM, Al-Rashdi MK. Accessibility to primary health care and emergency department visits. Imam J Appl Sci 2018;3:48-53
|How to cite this URL:|
Al-Arifi AM, Al-Rashdi MK. Accessibility to primary health care and emergency department visits. Imam J Appl Sci [serial online] 2018 [cited 2019 Jun 16];3:48-53. Available from: http://www.e-ijas.org/text.asp?2018/3/2/48/247316
| Introduction|| |
During the past few decades, a continuous increase in the emergency department (ED) visits has been universally observed. This increase adds organizational problems (such as laboratory delays, admission delays, shortage of staff, and others), and this explains why an ED becomes overcrowded, with inevitable consequences.
Between 37% and 60% of these visits are for nonurgent (NU) complaints, and much research has focused on identifying and characterizing patients who are frequent users of the ED; however, evidence suggests that not all frequent ED users are the same.
Some patients seen in the EDs in England attribute their visit to the inability to see a primary care physician who supports the hypothesis that ED utilization could be reduced by improving access to primary care.
Studies that examined the relationship between accessibility to primary care and NU ED utilization has had conflicting results.
In Saudi Arabia, a study was done about the trends in ED utilization in a hospital in the Eastern region (2003–2005), and the ED utilization increased during the study period, with almost no change in the proportions for triage category. The numbers of patients requiring hospital admission increased as the length of their stay. Nearly 60% of the emergency visits are for the Canadian Triage and Acuity Scale (CTAS) IV and V care (less urgent to NU), and there were significant patients with multiple visits to ED. However, in large cross-sectional ecological studies done in 2007–2009 in North London, access to primary health care (PHC) did not explain the differences in potentially avoidable ED attendance patterns across General Practitioner (GP) practices; it is not possible to say that, in Brent, patients registered to GP practices that have poor access are more likely to self-refer to EDs than patients that are registered to GP practices that have good access.
The present study was carried out to determine NU ED patients' accessibility to PHC and ED. In addition, their influence factors were assessed as well as to explore the reason/s for ED visit over PHC among the NU patients in Riyadh, Saudi Arabia, to improve the primary care quality and reduce ED crowding.
| Subjects and Methods|| |
This was an observational, cross-sectional study using a convenience sample of ED patients from the Prince Sultan Military Medical City (PSMMC) in Riyadh city, Saudi Arabia. NU patients were assigned as CTAS code 4 or 5 for treatment in the Blue Clinic. CTAS refers to the CTAS triage tool used in the ED of PSMMC. CTAS is a five-point scale, with triage scores ranging from 1to 5. Code 1 denotes a patient requiring immediate medical assessment or resuscitation. Code 2 is an emergent condition, that is, potentially a threat to life, limb, or function, requiring medical intervention within 15 min. Code 3 is an urgent condition that could potentially progress to a serious problem, requiring emergency intervention within 30 min. Code 4 is a condition that is related to patient age, distress, and potential for deterioration or complications and can wait up to 1 h to be seen. Code 5 denotes an NU patient who can wait 2 h before being seen by a physician. Patients designated code 3, 4, and 5 were sent to the Blue Clinic which can receive up to eight patients at a time run by three family medicine doctors. The clinic opens every day from 8 am to 2 am the next day. The interviews were conducted in a period from June 4th, 2015 to June 24th, 2015 on different days. the inclusion criteria were all patients 18 years of age and older, eligible for treatment in PHC centers in Riyadh city, and were assigned by the triage clinic as non-urgent. Patients who were referred from a clinic were excluded from the study. The interviews were all conducted by the researcher after taking permission from the patients and reading the consent section, and verbal agreement was taken the researcher proceeded to ask the stud questions and answers were documented at the same time to insure the safety of data each patient had an individual questionnaire form time taken 2–3 min for each patient.
An interview questionnaire was designed to collect the data. It was designed based on the study objectives, taking help from the previous literature. The questionnaire was divided into two main parts: The first part dealing with the sociodemographic factors such as age, gender, and education. The second part consisted of the questions about reasons that made patient come to ED and specifically on accessibility to PHC, and the questionnaire was face validated by two experts and the it was pretested on five patients in PHC to make sure the questions were clear, and comprehensive minor changes were done.
Ethical approval obtained from the research ethics committee in the PSMMC, Riyadh, Saudi Arabia.
The data were analyzed using Statistical Package for the Social Sciences (SPSS) software version 22 (Armonk, New York, United States). Descriptive and analytical statistic tests were used to analysis the data. Chi-square test and Fischer's exact test were used to analysis categorized data. P < 0.05 was considered statistically significant.
| Results|| |
The study included 89 NU ED patients. The participants' characteristics are shown in [Table 1]. The mean age of the participants was 36.45 (standard deviation [SD] = 14.8). Most of the patients were <30 years, whereas only 15.7% of them aged 50 and over. Most of the participants (70.8%) were male and half of them (51.7%) had “secondary or diploma” degree. Half of the participants (49.4%) had a kind of government jobs such as teacher and soldier. Twenty-seven were retired or unemployed (students and housewives), and 20.2% of the participants had a kind of private jobs.
Most of the participants (78.7%) were residing in Riyadh city.
[Table 2] shows almost one-third of (30.3%) the participants mentioned that the duration of presenting complaints was 1 day, whereas 43.8% of them mentioned that the duration of presenting complaints was >4 days. Majority of the participants (85.4%) mentioned that they never visited PHCs. Most of the participants (87.6%) lived closer to PHC than ED. Half of the participants (51.7%) mentioned that they visited ED only one time in the last 12 months, while only 3.4% mentioned that they visited ED >5 times in the last year. The mean of visiting ED in the last year was 2.01 (SD = 2.3).
|Table 2: Frequency of the participant's answers based on their primary health care and emergency department accessibility|
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Concerning the reasons for visiting ED over PHC, more than a quarter of the patients (28%) mentioned that it was due to the accessibility to EDs, whereas the in ED services (18%), urgent need (15%), and availability of services (12%) were other reasons. Minority of the participants (3%) mentioned that they visited ED over PHCs due to shorter waiting time [Figure 1].
|Figure 1: Reasons for the emergency department visit over primary health care among the participants|
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Regarding the barriers to access to PHC center, [Table 3] shows that 44.9% of the patients never experienced barriers to access to PHC center. Long waiting in the doctor's office was the most frequent barrier (20.2%), which followed by difficulty in getting an appointment through the phone (19.1%), being closed (16.9%), difficulty in getting an appointment soon enough (7.9%), and transportation issue (1.1%).
|Table 3: Barriers to access to primary health care among the participants|
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[Table 4] shows that there was no significant difference between age groups, gender, job status, residency place, and distance to ED than PHC and their visiting ED in the last year. The results also showed that there was a significant difference between participants' education status, duration of presenting complaint, and trying to go to PHC and their visiting ED in the last year. The results revealed that the participants who were high educated visited ED higher than low-educated participants in the last year (P = 0.009). The participants who mentioned that their duration of presenting complaint was 1 day visited ED higher than those their duration of presenting complaint was 3 days (P = 0.04). Participants who mentioned that they did not try to go to PHC before coming to ED, visited ED in the last year higher than those who did try (P = 0.01).
|Table 4: Frequency of visiting the emergency department in the last year according to the participant's characteristics|
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| Discussion|| |
In the current study, most of the participants (85.4%) mentioned that they never visited PHCs, while all of them visited EDs in the last year. The results of the study also showed that the mean of visiting the ED in the last year was 2.01 (SD = 2.3). Another Saudi study documented that there is considerable variation in the quality of primary care services across the country. Previous studies showed that the percentage of visiting EDs by NU patients in Saudi Arabia was high.,, Similarly, a new report showed that >75% of cases in EDs in Abu Dhabi were NU. The percentage was higher even in developed countries. For example, in a study carried out in Canada, 83.3% of all emergency visits were related to semi and NU emergency visits in 2014.
The results of this study revealed that most of the participants (70.8%) who visited EDs were male. This is in line with previous studies that showed that most of the EDs users were male., The higher rate of visiting EDs among males may be attributed to the fact that they have more chances to encounter with life stressors, which are related to their jobs.
The results of the present study also showed that most of the participants were <30 years. In contrast with that, previous studies showed that most of the EDs users were adults in the United Arab Emirates, Australia, and Spain.,, Almost half of the participants (49.4%) in the current study had a kind of government job. People with government job are more likely to seek ED services because of the possibility of having free care and medications. Furthermore, in Saudi Arabia, there are still challenges in the health-care insurance sector, and many patients would rather seek services from the ED.
In this study, majority of the patients (87.6%) lived very close to ED than PHCs. This increases the chance to use ED rather than PHCs. Previous studies showed that convenience and accessibility factors are main factors in the patient's decisions.
Concerning reasons for visiting ED over PHC, participants have mentioned accessibility to ED as the main reason, followed by the trust in ED services, urgent need, and availability of services. Previous studies revealed that the majority of the patients come with minor health issues and self-limiting complaints., There is an urgent need to educate patients.
In agreement with this study, previous studies found that low-acuity ED patients frequently sought NU service in the ED and their reasons for doing so were insufficient or untimely access to PHC., As previous studies highlighted, the main contributory factors in the use of ED compared with PHCs were less/NU care include suitability, limited access to PHC, and limited availability of social assistance., The high rate of visiting EDs among NU patients resulted in increased waiting time for urgent cases. Frequent complaints relating to longer waits to access hospital care and overutilization of emergency services are still common. For example, in public hospitals, patients may need to wait several months to a year to undergo nonemergency surgeries. These problems have been linked to an increase in the use of private health-care services. In general, the quality of services offered by the Ministry of Health-run hospitals is perceived to be inferior to those provided by private companies or other state-run providers.
As participants in this study mentioned that they do not use PHC services due to long waiting in the doctor's office, it is necessary that PHC physicians would increase their knowledge about the emergency medicine., Several studies in Saudi Arabia have shown that physicians' communication skills were more satisfactory to patients than their professional skills.,
The results also showed that there was a significant association between participants' education status, duration of presenting complaint, and trying to go to PHC and their visiting ED in the last year. Previous studies showed that some NU patients might visit the ED due to a habit or preference; others might choose ED services due to awareness of PHCs. Patients know that although they would visit the ED for primary care-treatable conditions, PHCs had limited services, resources, and working hours, and patients did not trust these centers.
Previous studies pointed out that the decisions to visit the ED were mainly influenced by participants' perceptions of worsening condition and urgency and requirement for diagnostics.,, Significantly, long wait times and overcrowding in ED were found to be direct results of the lack of primary care providers and access to local health care. NU patients contributed significantly to the problem and caused delays for patients with acute illnesses. A lack of education and community awareness of how EDs operate and that patients considered tertiary hospitals as providing greater levels of care, so, therefore, chose not to use primary care centers or local community-based hospitals.
| Conclusion|| |
It is necessary to develop strategies to implement policies aimed at reducing NU ER use as well as make health-care services more available to the population.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Almalki M, Fitzgerald G, Clark M. Health care system in Saudi Arabia: An overview. East Mediterr Health J 2011;17:784-93.
Carret ML, Fassa AC, Domingues MR. Inappropriate use of emergency services: A systematic review of prevalence and associated factors. Cad Saude Publica 2009;25:7-28.
Durand AC, Gentile S, Devictor B, Palazzolo S, Vignally P, Gerbeaux P, et al
. ED patients: How nonurgent are they? Systematic review of the emergency medicine literature. Am J Emerg Med 2011;29:333-45.
Northington WE, Brice JH, Zou B. Use of an emergency department by nonurgent patients. Am J Emerg Med 2005;23:131-7.
Mortensen K, Song PH. Minding the gap: A decomposition of emergency department use by medicaid enrollees and the uninsured. Med Care 2008;46:1099-107.
Murray JM. The Canadian triage and acuity scale: A Canadian perspective on emergency department triage. Emerg Med (Fremantle) 2003;15:6-10.
Fares S, Irfan FB, Corder RF, Al Marzouqi MA, Al Zaabi AH, Idrees MM, et al
. Emergency medicine in the United Arab Emirates. Int J Emerg Med 2014;7:4.
Hutchison B, Levesque JF, Strumpf E, Coyle N. Primary health care in Canada: Systems in motion. Milbank Q 2011;89:256-88.
Siddiqui S, Ogbeide DO. Utilization of emergency services in a community hospital. Saudi Med J 2002;23:69-72.
Bakarman M, Njaifan N. Assessment of non-emergency cases attending emergency department at King Fahad General Hospital, Jeddah; pattern and outcomes. Life Sci J 2014;11:20-25.
Margolis SA, Reed RL. Changing use of the emergency department by the elderly in the United Arab Emirates, 1989 and 1999. East Mediterr Health J 2002;8:409-15.
Steele S, Anstett D, Milne WK. Rural emergency department use by CTAS IV and V patients. CJEM 2008;10:209-14.
Oterino de la Fuente D, Baños Pino JF, Blanco VF, Alvarez AR. Does better access to primary care reduce utilization of hospital accident and emergency departments? A time-series analysis. Eur J Public Health 2007;17:186-92.
Dawoud SO, Ahmad AM, Alsharqi OZ, Al-Raddadi RM. Utilization of the emergency department and predicting factors associated with its use at the Saudi ministry of health general hospitals. Glob J Health Sci 2015;8:90-106.
Leon B, Ali OA. The hospital service package in Zanzibar - a review 2009.
Siddiqui S, Ogbeide DO. Use of a hospital-based accident and emergency unit by children (0-12 years) in Alkharj, Saudi Arabia. Ann Trop Paediatr 2002;22:101-5.
Grumbach K, Keane D, Bindman A. Primary care and public emergency department overcrowding. Am J Public Health 1993;83:372-8.
Howard MS, Davis BA, Anderson C, Cherry D, Koller P, Shelton D, et al
. Patients' perspective on choosing the emergency department for nonurgent medical care: A qualitative study exploring one reason for overcrowding. J Emerg Nurs 2005;31:429-35.
Afilalo J, Marinovich A, Afilalo M, Colacone A, Léger R, Unger B, et al
. Nonurgent emergency department patient characteristics and barriers to primary care. Acad Emerg Med 2004;11:1302-10.
Krakau I, Hassler E. Provision for clinic patients in the ED produces more nonemergency visits. Am J Emerg Med 1999;17:18-20.
Walston S, Al-Harbi Y, Al-Omar B. The changing face of healthcare in Saudi Arabia. Ann Saudi Med 2008;28:243-50.
] [Full text]
Jarallah J, Khoja T, Mirdad S. Continuing medical education and primary care physicians in Saudi Arabia: Perception of needs and problems faced. Saudi Med J 1998;19:720-7.
Alakija W, Mahfouz AA, Raoof A, Al-Khuzayem AA, Al-Erian RA. Continuing medical education in primary health care in Saudi Arabia: An epidemiologic study of physicians' needs in the Asir region. J Egypt Public Health Assoc 1994;69:469-79.
Ali M el-S, Mahmoud ME. A study of patient satisfaction with primary health care services in Saudi Arabia. J Community Health 1993;18:49-54.
Al-Doghaither AH, Saeed AA. Consumers' satisfaction with primary health services in the city of Jeddah, Saudi Arabia. Saudi Med J 2000;21:447-54.
Redstone P, Vancura JL, Barry D, Kutner JS. Nonurgent use of the emergency department. J Ambul Care Manage 2008;31:370-6.
Snelson E, Gilchrist J, Wright N. Unplanned paediatric care pathways. Br J Healthc Manage 2009;15:549-56.
Alyasin A, Douglas C. Reasons for non-urgent presentations to the emergency department in Saudi Arabia. Int Emerg Nurs 2014;22:220-5.
Pines JM, Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med 2008;51:1-5.
[Table 1], [Table 2], [Table 3], [Table 4]