Factors associated with non-urgent utilization of Accident and Emergency services: a case-control study in Hong Kong

Accident and Emergency Departments (A&E) have been a popular source of primary care, and studies have shown that up to two thirds of patients attending A&E have problems that could be managed by general practitioners (GPs). Although many studies have found that patients of lower socio-economic class with less social support have a higher utilization rate of A&E, some recent studies have revealed contrary evidence. In this study 2410 patients were randomly selected from four A&E at different times. The gold standard in differentiating true emergency cases and GP cases was based on a retrospective record review conducted independently by a panel of emergency physicians. Two emergency physicians reviewed each case independently, and if their independent ratings were in agreement, this became the gold standard. Patients classified as GP cases were given a telephone interview, and a sample was selected and matched with cases from general out patient clinics (GOPC) in the public sector by morbidity. Reasons for not attending a private GP included closure of clinic, deterioration of symptoms, GPs' inability to diagnose properly, and patients' wish to continue medical treatment in the same hospital. Reasons why non-urgent patients did not choose to attend the nearby public GOPC included affordability, closure of the GOPC, patients' wish to continue treatment at the same hospital, GOPC too far away, no improvement shown after visits to GOPC doctors, and GOPC doctors' inability to make proper diagnoses. The reasons for high level of utilization of A&E services are complex and reflect problems of delivery of GP services. There is an urgent need for GPs to set up a network system to provide out of hours services, and also for a better interfacing between primary and secondary care, and between public and private sectors, so that patients can be referred back to GPs. Interim clinical services provided to those non-urgent cases by nursing practitioners or by GPs working in A&E could also facilitate discharge of patients to primary care facilities.