title: Self-referrals in the emergency department: reasons why patients attend the emergency department without consulting a general practitioner first-a questionnaire study.
abstract: BACKGROUND
  To influence self-referral, it is crucial to know a patient's motives to directly visit the emergency department (ED). The goal of this study is to examine motives for self-referral to the ED and compare these motives in relation to appropriateness.
  
  
  METHODS
  All self-referred patients visiting the ED of a Dutch hospital over four separate months in a 1-year period were included. Patients were handed questionnaires that included questions on their reasons to visit the ED directly and where they would seek medical help next time. Additionally, the motives of patients that either appropriately or inappropriately visited the ED were compared. In a previous study on the same patient cohort, the appropriateness of the ED visits was determined using predefined criteria.
  
  
  RESULTS
  A total of 3196 self-referred patients were included, and 48.9 % completed the questionnaires. The majority of patients (28.0 %) attended the ED without a referral because they thought they would get help faster; the next reason was the easier access to radiologic and laboratory investigations (answered by 23.8 %); and the third was the symptoms were considered too severe to visit a general practitioner (GP) (answered by 22.7 %). The majority (78.5 %) would attend the ED the next time they are faced with similar symptoms. Appropriate visits were significantly more seen in females, elderly, and patients in higher triage categories. Patients who expect investigations are necessary, think their symptoms are too severe to visit a GP, or would return to the ED next time were more often appropriately visiting the ED.
  
  
  CONCLUSIONS
  The choice of patients to self-refer to an ED is often an explicate decision. Patients are looking for specialist help and want fast and easy access to radiologic and laboratory investigations. Even though the primary care network is well developed in the Netherlands, the reasons for self-referral are similar to the reasons found in previous literature based in other countries. Patients who visit the ED because of health concerns visit the ED more often appropriately than patients visiting for practical reasons.
authors.affiliation: Emergency Department, Rijnstate Hospital, Wagnerlaan 55, Arnhem, The Netherlands. n.kraaijvanger@hotmail.nl.
authors.forename: Nicole
authors.initials: N
authors.lastname: Kraaijvanger
authors.affiliation: Emergency Department, Rijnstate Hospital, Wagnerlaan 55, Arnhem, The Netherlands. drijpsma@rijnstate.nl.
authors.forename: Douwe
authors.initials: D
authors.lastname: Rijpsma
authors.affiliation: Department of Internal Medicine/Intensive Care, Rijnstate Hospital, Wagnerlaan 55, Arnhem, The Netherlands. HJvanLeeuwen@rijnstate.nl.
authors.forename: Henk
authors.initials: H
authors.lastname: van Leeuwen
authors.affiliation: Trauma Surgery/Emergency Department, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, The Netherlands. michael.edwards@radboudumc.nl.
authors.forename: Michael
authors.initials: M
authors.lastname: Edwards
keywords: Appropriateness; Emergency department; Motives; Questionnaires; Self-referrals