Utilization of the Emergency Department and Predicting Factors Associated With Its Use at the Saudi Ministry of Health General Hospitals

Overuse of emergency rooms (ER) is a public health problem. To investigate this issue, a cross-sectional survey was conducted at the ERs of King Abdul-Aziz Hospital, King Fahd Hospital, and Al-Thaghor Hospital in November 2013 with the aims of estimating emergency service utilization for non-urgent cases, identifying the predictors of ER utilization for non-urgent cases, and measuring patients’ knowledge of primary healthcare centers (PHCCs). Patients were interviewed using a structured questionnaire and the data were analyzed using the Statistical Package for the Social Sciences. We recruited 300 patients; males comprised 50.7% of the sample. A higher proportion of patients with non-urgent cases visited the ER three to four times a year (P=0.001). A higher proportion of patients without emergencies had not attempted to visit an outpatient clinic before the ER (P=0.003). Most patients without emergencies thought the ER was the first place to consult in case of illness. Most patients who visited the ER were single, < 15 years, and had lower incomes. Patients requested ER services for primary care-treatable conditions because of limited services and resources as well as limited working hours at PHCCs. Most patients (90.0%) were knowledgeable about PHCCs, with those of lower education being more knowledgeable. Patients reported long ER waiting times (≥ 3 hours), no organization (85.9%), and lack of medical staff. Overall, overuse of ER services is high at the Ministry of Health hospitals in Jeddah. The risk factors for ER overuse are age < 15 years, singlehood, and low incomes. Policy makers and health providers have a challenging task to control ER overuse. We recommend developing strategies to implement policies aimed at reducing non-urgent ER use as well as making healthcare services more available to the population.


Introduction
The unique characteristics of public health research are its focus on assessing, measuring, and monitoring the health of populations. However, traditional biomedical research deals with the study of diseases and treatments for individual patients (Lasker, 1997). When compared with other medical specialties, emergency medicine (EM) is well positioned to connect biomedical and public health approaches for preventing disease as well as injury and promoting health through population-based strategies targeted at the community (Clancy & Eisenberg, 1997).
to access the ED.
All cases were categorized as urgent and non-urgent according to the Canadian classification for ED attendance.

Validity and Reliability
The study instrument is a pretested and validated questionnaire (Porro et al., 2013). It was modified for use in this research, and it has been endorsed by experts.

Data Analysis
The data were analyzed using the Statistical Package for the Social Sciences (SSPS Inc., Chicago, IL, USA), version 20.0. Descriptive statistics were performed for all variables. The chi-square was used to assess the relationship between categorical variables, while the independent t-test was used to compare group means for continuous variables. Statistical significance was set at the 0.05 alpha level.

Ethical Consideration
Permission to conduct this study was granted by the ethics research committees of King Abdul-Aziz Hospital, King Fahd Hospital, and Al-Thaghor. Participants were informed that participation in this study was voluntary. Informed consent was obtained from all participants prior to their inclusion in this study. The consent form, which also explained the purpose of this study, was included in the questionnaire. All data were confidential and used solely for the purpose of this study.

Estimation of Emergency Room Utilization
Three hundred patients, 100 from each of the three MOH, were included in this study. Males and females constituted approximately equal proportions of the sample (Table 1). Most patients were aged 16-23 years; patients >60 years comprised the lowest proportion of patients (7.3%). Over half of the patients had not completed at least high school and earned salaries between 3000-5000 SR; 20 patients had high salaries (> 15001 SR). Of the 300 cases, 53.0% were non urgent. Al-Thaghor Hospital received a significantly high number of non-urgent ER cases as compared with the other two hospitals (Table 2). As shown in Table 3, patients frequently visited the ER for non-urgent health problems. In particular, a significantly high proportion of patients visited the ER three to four times a year (68.5%) for non-urgent health issues (P=0.001). A significantly higher proportion of non-urgent cases had experienced symptoms of one to two day's duration (P=0.001). A significantly higher proportion of patients without emergencies had not attempted to see a doctor at an outpatient clinic prior to visiting the ER (58.7% versus 41.3% for urgent cases). Of the 92 patients who had visited the ER, 37 (40.2%) without emergencies had attempted to see a doctor at an outpatient clinic as against 55 (59.8%) with emergency health issues who had attempted to visit an outpatient clinic prior to visiting the ER (P=0.003).

Figure 1. Reasons why patients had not seen a specialist doctor
A total of 208 patients had not attempted to see a specialist doctor before an ER visit. Difficulty in getting an appointment was cited as the most common reason why patients did not visit a specialist doctor prior to an ER visit. Other reasons are as shown in Figure 1.
We found that 119 patients (71.7%) with non-urgent health issues as against 47 (28.3%) with emergency health problems had difficulties in getting an appointment (P<0.001). Only three patients with non-emergencies (7.1%) versus 39 (92.9%) with emergencies reported not having difficulties getting an appointment. In total, 166 patients had difficulties getting an appointment at a specialized clinic.
A significantly higher proportion of patients without emergency conditions thought the ER was the first place to consult in case of illness (57.1% versus 42.9% for patients with emergencies; P = 0.020 Approximately 65.1% of the 83 patients who went to a clinic reported that the treatment was unsatisfactory, and only 26.5% (eight being non-urgent cases) were referred from PHCCs to an ER ( Figure 2).
Of the patients who consulted at the ER, 274 (91.3%) had never been denied services although 148 cases were not emergencies (Table 4). However, these results did not reach statistical significance.  Diabetes was the most common chronic health problem reported by the 84 patients, followed by high blood pressure and asthma ( Figure 3).

Predictor of Emergency Room Utilization for Non-Emergent Conditions
A significant relationship existed between emergency status and the patient's marital status (P < 0.001), age (P < 0.001), and income (P = 0.049). Most patients who visited the ER for non-urgent conditions were single, <15 years old, and had lower incomes (Table 5). Of the 131 patients, over half (52.7%) with non-urgent conditions admitted that they got better quality services at the ER as compared to the treatment they received at clinics. However, 55.9% of 247 patients reported that they had the option to visit a clinic; 162 patients (54.3%) with non-urgent conditions had the option to visit a PHCC (Table 6).  Although PHHCs could offer the same services, patients cited various reasons for not using their services ( Figure  4).  Figure 5.

Patients' Knowledge about Primary Healthcare
Ninety percent of the patients were knowledgeable about PHCCs although some were not knowledgeable about the services offered by these centers (Table 8). The mean score of the patients (n=270) was 73.6 (SD, 32.8).  The patients' mean knowledge score regarding PHCCs was 73.62 (SD 32.8). Further analysis showed that there was no significant relationship between patients' knowledge of services offered by PHCCs and emergency status. Table 9 shows that 44.9% of 136 patients who had urgent conditions reported that they did not get treatment as they expected. In addition, patients reportedly suffered long waiting times at the ER (up to three hours or more). Besides long waiting times at the ER, 156 patients complained of no organization (85.9%), followed by lack of medical staff (35.9%: Figure 6).

Figure 6. Problems Encountered by Patients at the Emergency Room
Forty-six patients with non-urgent conditions reported having ever left the ER without receiving treatment versus 32 (41.0%) with urgent conditions (p=0.219). The main reason, as reported by 93.6% of the 78 patients, was because of overcrowding; 14.1% left because of the absence of a doctor.
A significantly higher proportion of patients with non-urgent conditions (n=151; 60.6%) visited the ED clinic as compared with patients with urgent problems (n=98; 39.4%; P<0.001). Of the 51 patients who visited the ER, eight patients (15.7%) had non-urgent conditions. Educational levels were significantly associated with patients' knowledge about PHCCs, with those of lower educational level being more knowledgeable than those with a higher level (P = 0.007; Table 10).

Discussion
Analysis of our data showed that the emergency services at the Saudi MOH hospitals were over-utilized for non-emergent cases. In addition, the frequency of non-urgent cases was significantly higher at Al-Thaghor Hospital as compared with the other two government hospitals. The percentage of non-urgent ER visits in this study is higher than that in other studies conducted abroad (Kellerman, 1994;Guttman, Zimmerman, & Nelson 2003;Northington, Brice, & Zou, 2005;National Center for Health Statistics, 2008;Carret, Fassa & Domingues, 2009;Durand, Gentile, & Devictor, 2011), where the authors reported that <10% of all ER visits were non-urgent. It is plausible that the high percentage of non-urgent ER visits in this study is due to ignorance, on the part of patients, of what constitutes an emergency case and lack of a hospital policy to discourage non-urgent visits. It is also possible that the hospital administration is afraid of being sued by patients for refusal to provide healthcare services, which may consequently tarnish the reputation of the hospital. Access to ER services was least for patients who consulted at King Fahd Hospital probably because the hospital has two triage rooms, one of which declines cold cases. associated with non-urgent ER visits as compared with urgent cases. Patients of the younger age group were more likely to seek ER care for non-urgent conditions probably due to parental worries and its influence. Further, it is possible that the number of single persons is high because of the high proportion of young patients aged less than 15 years. Although there is limited evidence, one report (Uscher-Pines et al., 2013) suggests that younger age affects patients' decisions to seek care in the ER for non-urgent conditions. Regarding income, people with low incomes are more likely to seek ER care at a Ministry of Health hospital because of the possibility of having free care and medications.
Convenience, which refers to the ease with which a patient can seek care, has been reported to be an important factor in driving non-urgent ER use. As depicted by the results of this study, patients with non-urgent conditions did not seek specialized services because of lack of convenience, which included difficulties in getting an appointment and long waiting times. In practice, it takes about a month to get an appointment at a MOH hospital, and it is difficult for patients with low incomes to go to private clinics. These further drive patients to seek care for non-urgent problems. Other studies (Sarver, Cydulka, & Baker, 2002;Harris Interactive, 2006) have also reported the role of convenience factors in driving non-urgent ER use. In one study (Redstone et al., 2008), it was demonstrated that 60% of non-urgent ER patients judged that ER care was more convenient than that provided at their PHCC.
A patient decides to seek care in an ER by consciously or unconsciously taking several factors into consideration. These may include prior visit to a doctor's clinic and the patient's experience of new-onset symptoms or a flare-up of a chronic condition that is not immediately debilitating, such as symptoms related to diabetes, asthma, or signs of stroke. The patient then has the choice of going to the ER or another location that can provide the same level of care or not seeking care. The results of this study showed that over half of the patients with non-urgent conditions decided to seek ER care. The most common reasons that drove patients to visit the ER care for non-urgent health problems were limited services, resources, and working hours as well as a lack of effective diagnosis at PHCCs. Although the organization of primary care services in Saudi Arabia has improved over the last decades, as confirmed by the reasonable number of staff in most PHCCs, studies point to several obstacles, including staff turnover  and shortage of resources . These obstacles discourage patients from using PHCCs. As an example, the lack of X-ray equipment or a technician at a PHCC would require that a physician transfers the patient to an ED, which would not only be time-consuming to the patient, but also more costly. Furthermore, PHCCs usually open during the day and only a few stay open till midnight, but never for 24 hours.
A significantly higher proportion of patients without emergencies had health insurance. About 66.7% of patients without emergencies versus 33.3% with emergencies had health insurance. Of the 63 patients with insurance, 57.1% had insurance by King Fahd Armed Forces Hospital, 28.6% had private insurance, and 14.3% had insurance by National Guard Hospital. Although other factors may have precluded patients with health insurance from consulting at other hospitals, reasons such as proximity and congestion at other governmental hospitals were most commonly cited by patients, and those who had private insurance reported insurance requirements have not yet been completed and some they would not pay the co-payment. Besides, the data suggest that ER staff do not discourage non-urgent ER visits, as shown by the high percentage of non-urgent cases that were received at the EDs of the hospitals. Findings from other studies suggest that cost sharing decreases use of appropriate and inappropriate health services (Newhouse, 1996), essential medications (Tambly, Laprise, & Hanley, 2001;Roblin, Platt, & Goodman, 2005), and preventive services (Redstone et al., 2008). These effects may occasionally cause worse health outcomes compared with health plans that involve lower out-of-pocket demands. Conversely, some studies (Blustein, 1995;Selby, Fireman, & Swain, 1996;Magid, Koepsell, & Every, 1997;Hsu, Price, & Brand, 2006) show that patients decrease elective services when ER care is subject to cost sharing, and this has not been associated with adverse outcomes. However, these observations may not apply to our context, especially when services are offered free of charge in hospitals such as King Fahd, King Abdul-Aziz, and Al-Thaghor hospitals. Moreover, in a developing country such as Saudi Arabia, there are still challenges in the health care insurance sector and many patients with lower incomes would rather seek care from the ER.
Emergency room users constitute a diverse population. While some users might visit the ER due to a habit or preference, others might opt for ER care due to lack of information regarding other options. In the current study, most patients were aware about PHCCs although they would visit the ER for primary care-treatable conditions because, as alluded to earlier, PHCCs had limited services, resources, and working hours and patients did not trust these centers. Patient dissatisfaction in clinics was also an important factor, as 65.1% of 83 patients who consulted at clinics did not find the treatment beneficial.
year for non-urgent conditions. Further, a significantly higher proportion of non-urgent cases had experienced symptoms of one to two days duration prior to visiting the ER. This typically causes overcrowding in ERs and consequently leads to sub-optimal care of patients with urgent conditions. Furthermore, crowding at the ER can lead to poor patient selection at the triage and the inadequate management of patients who present with acuity conditions. In fact, 44.9% of 136 patients who had urgent conditions in this study reported that not getting the treatment they expected. The patients' reports of no organization at the ER, lack of medical staff, slow response of the doctor to see patients, competence and attitudes of other care providers, and long waiting times of up to three hours, which exceed the acceptable waiting limit set by Canadian guidelines, time spent at the ER have been previously reported by other authors (Pilpel, 1996;Goldwag et al., 2002) as factors that determined patient dissatisfaction with the ED.
Finally, patients' educational levels affect their knowledge of PHCCs, with those of lower education being more knowledgeable than those with a higher education level. This may be because persons with lower education levels, owing to their lower incomes, would seek care at PHCCs because services are free of charge or very affordable.

Conclusion and Recommendation
Based on the findings of this study, the following conclusions are drawn: The emergency services at the Ministry of Health hospitals in Jeddah were over-utilized, especially at Al-Thaghor hospital, which received a significantly high proportion of non-urgent cases. Singlehood, younger age, and lower incomes were significantly associated with non-urgent ER use. A significantly high proportion of patients visited the ER three to four times a year and at least six times in one year for non-urgent cases. A significantly higher proportion of patients with non-urgent conditions had experienced symptoms of one to two days duration. A considerable proportion of patients without emergencies had not attempted to see a doctor at an outpatient clinic prior to visiting the ER. In general, most patients would deter from consulting a specialist doctor before seeking emergency care in most cases because of difficulties in getting an appointment at a specialized clinic. A significantly higher proportion of patients without emergencies thought the ER was the first place to consult when they felt symptoms. Compared with patients with non-urgent conditions, a significant proportion of patients with urgent conditions had chronic problems. Although most patients were knowledgeable about PHCCs and the alternatives to seek care, a significant proportion would seek emergency care for non-urgent problems mainly due to negative perceptions about PHCCs and for convenience. A significant proportion of patients who had insurance had non-urgent conditions. Proximity and congestion at other governmental hospitals were the main reasons that drove them to consult emergency services. A significantly proportion of patients with urgent conditions admitted to the ED clinic as they should be admitted to ED room. Non-urgent ER visits resulted in congestion and consequently long waiting times of up to 3 hours. Patients' educational levels were significantly associated with their knowledge of PHCCs, with those of lower education being more knowledgeable than those with a higher education.
The results of our analysis prompt us to make these recommendations: Implement policies aimed at reducing non-urgent use of ERs such as not receive non-urgent cases and direct them to outpatient clinics or PHCC. Re-structure health care delivery systems to provide greater access to primary care and provide more attention to psychosocial aspects of patient care in clinical settings. Develop primary care services in organizations that will assume responsibility for health status, access and coordination of services for individuals and communities in ways that extend beyond their contact with the healthcare system and the provision of walk-in services. Strengthen primary care and promote the integration of service levels requires changing the Canada Health Act, which in fact limits coverage of services to those supplied by hospitals and physicians. Offices with multiple family doctors have to be more accessible. In addition, family doctors' offices have to be close to the ER so that non-urgent cases can be easily referred to and addressed. Policy makers and healthcare providers should develop a health insurance policy that is commensurate with the expectation of the general population. Educate patients about emergency service use and improve their attitudes toward other health care choices. Introduce designated "fast track" units at Ministry of Health hospitals to entail the expeditious management of low acuity patients as well as the introduction of "fast track" improved waiting time for minor injuries without delaying the care of those with more serious injury. Limit boarding of patients in EDs by expanding hospital capacity. This will help in reducing the number of patients admitted at the ED and hence reduce overcrowding. Implement other strategies to address issues related to overcrowding in the various Ministry of Health hospitals, such as establish emergency centres for 24 hour across neighborhoods. Develop an information campaign to emphasize why and when attendance to the ER is inappropriate, and the negative