title: Self-referring patients at the emergency department: appropriateness of ED use and motives for self-referral.
abstract: BACKGROUND
  Nearly all Dutch citizens have a general practitioner (GP), acting as a gatekeeper to secondary care. Some patients bypass the GP and present to the emergency department (ED). To make best use of existing emergency care, Dutch health policy makers and insurance companies have proposed the integration of EDs and GP cooperatives (GPCs) into one facility. In this study, we examined ED use and assessed the characteristics of self-referrals and non-self-referrals, their need for hospital emergency care and self-referrals' motives for presenting at the ED.
  
  
  METHODS
  A descriptive cohort study was conducted in a Dutch level 1 trauma centre. Differences in patient characteristics, time of presentation and need for hospital emergency care were analysed using χ (2) tests and t tests. A patient was considered to need hospital emergency care when he/she was admitted to the hospital, had an extremity fracture and/or when diagnostic tests were performed. Main determinants of self-referral were identified via logistic regression.
  
  
  RESULTS
  Of the 5,003 consecutive ED patients registering within the 5-week study period, 3,028 (60.5%) were self-referrals. Thirty-nine percent of the self-referrals had urgent acuity levels, as opposed to 65% of the non-self-referrals. Self-referrals more often suffered from injuries (49 vs. 20%). One third of the self-referrals presented during office hours. Of all self-referrals, 51% needed hospital emergency care. Younger age; non-urgent acuity level; chest pain, ear, nose or throat problems; and injuries were independent predictors for self-referral. Most cited motives for self-referring were 'accessibility and convenience' and perceived 'medical necessity'.
  
  
  CONCLUSIONS
  A substantial part of the self-referrals needed hospital emergency care. The 49% self-referrals who were eligible for GP care presented during out-of-hours as well as during office hours. This calls for an integrative approach to this health care problem.
authors.affiliation: Accident and Emergency Department, Medical Centre Haaglanden, The Hague 2501 CK, The Netherlands.
authors.forename: M Christien
authors.initials: MC
authors.lastname: van der Linden
authors.affiliation: Division of Clinical Methods and Public Health, Master Evidence Based Practice, Academic Medical Centre, University of Amsterdam, Amsterdam 1100 DD, The Netherlands.
authors.forename: Robert
authors.initials: R
authors.lastname: Lindeboom
authors.affiliation: Institute for Medical Technology Assessment, Erasmus University Rotterdam, P.O. Box 1738, Rotterdam 3000 DR, The Netherlands.
authors.forename: Naomi
authors.initials: N
authors.lastname: van der Linden
authors.affiliation: Accident and Emergency Department, Medical Centre Haaglanden, The Hague 2501 CK, The Netherlands.
authors.forename: Crispijn L
authors.initials: CL
authors.lastname: van den Brand
authors.affiliation: Accident and Emergency Department, Medical Centre Haaglanden, The Hague 2501 CK, The Netherlands.
authors.forename: Rianne C
authors.initials: RC
authors.lastname: Lam
authors.affiliation: Division of Clinical Methods and Public Health, Master Evidence Based Practice, Academic Medical Centre, University of Amsterdam, Amsterdam 1100 DD, The Netherlands.
authors.forename: Cees
authors.initials: C
authors.lastname: Lucas
authors.affiliation: Clinical Research Unit, Academic Medical Centre, University of Amsterdam, J1b-118, Amsterdam 1100 DD, The Netherlands.
authors.forename: Rob
authors.initials: R
authors.lastname: de Haan
authors.affiliation: Trauma Unit, Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam 1100 DD, The Netherlands.
authors.forename: J Carel
authors.initials: JC
authors.lastname: Goslings
keywords: Emergency care; Emergency department; Primary care; Self-referrals
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