Emergency Department Versus Primary Care Use: A Patient Perspective

Decreasing emergency department (ED) use has been at the forefront of various programs to curb the rising costs of health care and address timely access to care. US EDs see an estimated 144 million visits a year totaling $76 billion dollars,¹ and one in five adults visit the ED at least once per year.² Many of these visits include nonurgent ailments that could easily be treated at the primary care office. These burdens were highlighted by the COVID-19 pandemic when many hospitals were working over capacity to care for the sick, thus limiting access at a time of need.^3,4 Particularly for patients who have an established primary care physician (PCP), the factors driving ED use remain poorly understood. While studies have examined patient demographics associated with increased ED use,^5-10 qualitative data that includes the patient perspective is sparse. This study was conducted to highlight patient voice to better understand driving factors for ED use.

A list of patients who were seen within the last 24 hours at the local ED and had a PCP at the study’s clinic was generated daily for review. After excluding those younger than 18 and those presenting for COVID-19 testing only, the list was randomized, and calls were conducted within the same week of presentation between December 2021 and March 2022. We conducted 30 interviews from the cumulative list of 118 patients, consistent with previous studies that achieved data saturation with a similar sample size.^11,12 We implemented a qualitative assessment to examine responses to open-ended interview questions, using a guided interview by the lead investigator who completed all the interviews. Descriptive statistics provided for patient characteristics, and Likert scale responses also were included in the analysis. Patients received $20 gift cards via email as compensation. Analyses were conducted in SAS Enterprise Guide version 8.2 (SAS Institute Inc). For the qualitative analysis, interview responses were independently reviewed by three individuals to establish five common themes. The reviewers then came together to review their themes and reach a consensus on a final five overall themes. The project received approval from our institutional review board.

The key investigator (N.W.) conducted a total of 30 interviews, with the mean participant age of 37.6 years (age range was 19 to 67 years). Survey questions and results are shown in Table 1. A majority of patients (83.3%) did not see the ED as a place to get their usual care. Regarding who to turn to for health care advice, the answers were a mix of family/friend (26.7%), physician (40%), and Internet/social media (33.3%). A majority of patients cited the ED as being more expensive (90% stated “more expensive in the ED”) but did not necessarily have a copay (53.3% stated $0 copay, and 20% stated “I don’t know” to their copay cost). Most respondents stated that choosing between the ED and PCP office was an easy decision (73.3% “I can easily make that decision” vs 6.7% “I always have trouble making that decision”); but if they were to have the same symptoms they would choose to go to the ED again (53.3% very likely to return and 16.7% likely to return) despite not needing an inpatient stay (70% “I know I did not require a hospital stay” or “I don’t think I required a hospital stay”). Chief complaints ranged from hemorrhoids to seizure and are listed in Table 2.

Using qualitative data from interview transcripts, three reviewers extracted themes and agreed on five. Themes and their supporting quotes are listed in Table 3. Theme 1: Patients found the relationship with their PCP valuable. Theme 2: When investigating health concerns, patients went to a variety of sources including the Internet, family/friend, or physician. Theme 3: Most patients subjectively justified their symptoms as emergent. Theme 4: Cost was not a major hindrance for seeking emergent care. Theme 5: Patients valued time spent with their physician as well as overall time spent in the facility.

Theme 1 highlights the importance of the personalized physician-patient relationship. The PCP office was described as more familiar, required less wait time, and perceived to be less costly. Patients valued that they had a relationship with their PCP and that their physician already knew their medical history.

Themes 2 and 3 showcase the wide availability of medical information and how patients may have consulted multiple sources before deciding the ED was appropriate. In an age of technology where people are used to instant gratification, patients are also seeking quick answers to their individual health questions. As noted in themes 4 and 5, while patients did not equate “faster and more expensive” care in the ED with better “quality” of care, understanding that the PCP’s office requires appointments and turnover time for labs and imaging also provided “quality” and value. The ED was described by patients as busy and less personal but more accessible than waiting for a PCP appointment and waiting for test results.

This study had limitations. The sample was based on patients who already had an ED visit and therefore did not capture patients who had an urgent concern and chose to see their PCP. For simplicity, this study did not include urgent care as a third option. At this institution, urgent care and the ED refer patients to one another based on triage. While patient responses began to show similarity after 30 interviews, assessing and defining saturation was challenging because the themes had not yet been agreed upon. The sample size was largely limited by unanswered phone calls and exclusion of those presenting for COVID-19 testing during the winter months.

While patients valued the relationship with their PCP, most patients presented to the ER to seek quick answers to symptoms they felt were emergent after consulting a variety of sources, not necessarily because they were concerned that they required an inpatient stay and were not hindered by perceived cost. By including patient voice, policymakers and health care systems may better understand the patient perspective and preferences for PCP and ED use.