Trends In

Emergency Department
Utilization

A. CHAITON, MD

SUMMARY
Increasing demand for non-urgent medical services provided in emergency
departments is an unforeseen consequence of our present health care system.
Factors in the organization, finance and payment of health services may account
for escalating utilization rates. In this paper, patient characteristics, patterns of
medical practice, present obligations of hospital emergency departments, and
universal health insurance are examined to determine their influence on the
demand for emergency department care.
Finally, methods for providing equally available and accessible health care
services more appropriate to the primary health care demands seen in emergency
departments are discussed.
Dr. Chaiton practices family medicine in Toronto, and is currently studying
for his master's degree in clinical epidemiology and statistics at McMaster
University in Hamilton.

NUMEROUS STUDIES have confirmed two distinct trends in

hospital emergency department use in
both Canada and the United States in
recent years: a general increase in
overall utilization ranging from 10-30
percent per year'-3 and a disproportionate increase in the number of
non-urgent cases, estimated at 30-80
percent of all visits.2' 4-6 Hence,
access to the medical care system is
increasingly via the emergency department. Baltzan' reported that 20 percent of primary care visits in Saskatoon were provided in the city's
emergency department. In the United
States in 1954, 10 of every 100
patient-physician contacts were in
hospital clinics and emergency departments; by 1970, this had risen to 20
percent.8 Brook estimated that seven
percent of all physician visits in Baltimore were made to an emergency
department.9 The increase in the delivery of medical care in the emergency department has been a major
unplanned consequence of our present
medical care system and thus deserves
close scrutiny.
Many studies have been limited to a
description of the characteristics of
people seeking emergency medical care
and to a classification of their complaints as emergency, urgent or nonurgent.2' 3, 4. 7 10, 11 Other studies

have suggested explanations for the

increase in demand for emergency
services, including shortage of physicians and their desire for regular work-

and health insurance. By focusing on

these key elements, I intend to demonstrate that the increased use of the
emergency department is a predictable
development in primary care services,
not discouraged by physicians, unrestricted by hospitals and favored by
patients, industry and community

"Medical care presumes access to a physician. Factors

affecting this access, agencies.
Can we identify characteristics of
whether due to changes in emergency
department users which
patterns of practice or differentiate them from the general
changing patient demands population? Until recently, the emergency department was considered to
are ultimately reflected in be
the provider of primary care to the
increased emergency room poor, indigent,
and itinerants who
utilization for primary care, were unable to enter the health care
through established channels
since there are remarkably system
(the physician's office). Although
few external controls to males and the younger age groups are
limit its utilization. The over-represented, there is considerable
patient variation, depending on
providers must accept whether
hospital studied is rural,
social responsibility for urban or the
suburban.'3' 14 Social class
assuring appropriate access was not a good predictor of nonurgent hospital emergency utilization
to care."
in Hamilton, Ontariol5 or New Haven,
Connecticut.' 6 Emergency users in
ing hours,7 patient mobility,'0 and
increasing health insurance
coverage.' 2
The determinants of emergency
medical care utilization must relate
directly to the principals involved: the
patients, the physicians, the hospitals

CANADIAN FAMILY PHYSICIAN/JANUARY, 1975

Canada now tend to be representative

of the populations particular hospitals
serve.
About 20 percent of illness requiring primary care is acute, short-term
and unpredictable at onset.' This
places a burden on physicians to pro11 5

vide such care while running efficient

offices. Circumstances such as a
heavily booked office, resulting in
delays in scheduling appointments,
frequently force patients to seek episodic care elsewhere, although both
physicians and patients have considered the care delivered by personal
physicians to be the most desirable.
Several studies report that between 60
and 90 percent of emergency room
users can identify a family
doctor.", 7, 11, 17 The majority did
not try to contact their physician and
came directly to the emergency room.
This pattern of behavior may have
been conditioned by previous experiences. Disappointed in their attempts
to reach a private physician, or once
having done so, being referred to the
hospital, patients have increasingly
assumed that the quickest and easiest
place to receive medical care is at the
hospital emergency department. Five
to 10 percent of patients report being
referred directly to the emergency
room by their doctors on previous
occasions. To some extent emergency
room utilization by patients who have
private physicians has been a learned
pattern of behavior, indirectly encouraged by their physicians. Patients
have found that they could walk in
with routine problems and receive care
which was convenient, efficient and of
reasonable quality. Over one-third of
emergency patients were repeaters at
St. Joseph's Hospital, Hamilton"1 and
the Toronto Hospital for Sick
Children.' 8 These findings suggest
that once people learn about emergency department care, they readily
return and probably for an increasing
scope of complaints. This cumulative
effect will accelerate utilization beyond that expected by normal demand. Hence, for many patients convenience has over-ridden continuity.

Financial Considerations
To some extent, the demand for
convenient care may relate to the
financial consequences of illness. not
covered by insurance. Beck,' 9 in a
longitudinal analysis of accessibility to
medical care services in Saskatchewan
from 1963 to 1968, (the first few
years of universal medical care insurance), found that the disparity between income classes in access to
services narrowed but did not disappear. Financial losses in using such
services (loss of work time, travel
costs, drug cost) may continue to
deter lower economic groups from

using health services. It is not surprising, then, that a large proportion

of non-urgent care is sought in the
emergency department on evenings
and weekends, out of working hours,
at times when cars and babysitters are
more available.
Emergency care is considered episodic in that only the presenting problem is dealt with. Patients are referred
to an outpatient department or a local
physician for continuing care. In contrast, clinic or private physician care is
considered continuous because the
patient is cared for by the same
physicians. As a greater proportion of
primary medical care is demanded in
emergency departments, one might ask
if patients are actively choosing the
kind of medical care they wish to
receive. Is episodic care preferred over
continuous care? In interviews of 1,694
out-patients in six Montreal hospitals
prior to the introduction of
Medicare,20 two-thirds said they
would prefer the outpatient department even if all medical care were free,
even though 70 percent thought that
continuity of physician care was important. The Hamilton General Hospital study2' found 80 percent of
outpatient users sampled intended to
continue using the outpatient department even though the majority stated
that a private physician was their usual
source of care.

'Continuous Care'
Everyone having a private physician
does not necessarily receive continuous care. Many people identify
more than one doctor. In the Montreal
study cited,20 16 percent of those
who received hospital ambulatory care
preferred to select their doctor according to the nature of their illness.
Sussman22 in Cleveland, found that
one-third of patients do not consider it
important to see the same physician
on each visit. Two-thirds did not see
the same physician and were satisfied.
In Pittsburgh, Solon & Rigg'4 found
that 40-53 percent of emergency patients used multiple sources for their
primary care.
The police, community agencies,
industry, schools and nursing homes
have often referred individuals to the
emergency department for evaluation
and care. Employees injured on the
job are frequently sent to the local
hospital instead of being referred to
the nearest doctor, especially if the
plant has no employee health service.
Such referrals emphasize the hospital's

CANADIAN FAMILY PHYSICIAN/JANUARY, 1975

role in providing fast, efficient care,

not only for organizational groups, but
for private citizens if the need arises.

The Doctors
Is a deficiency in the number of
primary care physicians shifting the
unmet needs for non-emergency medical care to the hospital emergency
departments? Spaulding & Spitzer23
reported a relatively stable population
to primary physician ratio for the
province of Ontario between 1961 and
1971 - approximately one primary
physician to 1,725 people. It seems
unlikely that inadequate physician
availability accounted for the escalation in emergency room utilization,
especially in urban Canadian areas
where 86 percent of physicians are
caring for 59 percent of the population.24
In Ontario, manpower ratios are
adequate and distribution of physicians to rural and northern regions is
improving.23 Yet, accessibility to
physician services for acute, short-term
illness is increasingly difficult to obtain. The Pickering Report, commissioned by the Ontario Medical Association,25 found that many interviewees
complained about delayed appointments and crowded waiting rooms.
Enterline,26 in a survey of practice
patterns prior to and after the introduction of Quebec Medicare, found
the average waiting time for a doctor's
appointment had increased from six
to 11 days. Both studies suggest that
the increased demand for services,
accentuated by the introduction of
government-sponsored medical insurance (1969), has limited accessibility
to primary care physicians.
Weekend office hours and house
calls are declining as established patterns of primary care practice. The
financial motivation to practice at
inconvenient times and to provide
'uneconomical" services, such as house
calls, is not having a major influence
on practice patterns, since physicians'
incomes have risen substantially.
Medicare has increased the demand
for insured medical services and virtually eliminated uncollectable accounts.
Thus, physician productivity has increased and the increase in physician
incomes accelerated. The Task Force
Report on the cost of Health
Services27 indicates that gross earnings
for physicians in active practice rose
six percent per year from 1957 to
1966 and 11.6 percent per year from
1966 to 1970. A report of the Depart117

ment of National Health and Welfare,28 indicates a similar trend in

gross earnings of active practicing
physicians after the introduction of
government-sponsored health insurance. Thus, adequate earnings can be
anticipated in established practices
keeping conventional business hours.
This change in practice patterns has
directed some of the demands for
episodic illness to the hospital emergency department.
Understandably, there is little professional opposition to this change in
practice pattern. The emergency departments are usually staffed by
younger physicians. Emergency department practice allows them to earn
an income without overhead expense
and encourages growth of their own
private practices. Other 'casualty
officers' may be physicians involved in
specialty training who take on night
and weekend emergency coverage for
interest, experience and added income.
Full-time casualty officers may depend
on a reasonable emergency department
patient volume to justify their employment. By encouraging patients to use
emergency department services,
private physicians enjoy increased freedom and leisure, ease the demands
made on them and at the same time,
stimulate work and income for their
colleagues.
At one time, physicians served their
rotation in the emergency department
as a community service. Little income
was expected, bills had low collection
rates and welfare agencies had long
delays in reimbursement. The disappearance of charity medical services,
the introduction of universal health
insurance and the increase in demand
for episodic care in emergency departments has now made emergency department medicine financially rewarding. An increasing number of physicians are choosing emergency department medical practice as a career. In
the Hamilton region, four percent of
MDs provide care predominantly in
emergency departments, many. of
these as full-time casualty officers. At
present, approximately six* percent or
15,000 physicians in the U.S. devote
most of their time to emergency

medicine.29

The Hospital
The Canadian Council on Hospital
Accreditation has ruled that no one
shall be turned away from an emergency department without examination, advice or treatment.30 Few hos-

pitals overtly refuse services, even for

inappropriate demands. Although
some emergency staff engage in subtle
hints to discourage non-urgent utilization, ("why haven't you phoned your
family doctor?"), legal obligations require emergency departments to yield
to patient demands. As demands rise,
emergency staff and facilities are expanded to handle the increased work
load,5 and the use of emergency services for episodic and routine care is
perpetuated.

Availability/Use
There is reason to believe that the
availability of medical services stimulates its own demand. Vayda and
Anderson31 found that provinces with
the most hospital beds had the highest
annual admission rates and that provinces with the fewest beds used the
fewest bed days. Thus, bed use was
strongly correlated with bed availability. Roemer32 believes that the size,
location and net bed-population ratio
in an area determines, in a large part,
the aggregate volume of hospital service that will be provided. In Ontario,
hospital funding is dependent, in part,
on bed capacity and occupancy rates;
hence, utilization of available beds
maximizes operating funds. To control
costs, some provincial ministries of
health have restricted bed availability
by decreasing bed-population ratios.
The Ontario government has recently
reduced this ratio from 5.2 to four
acute care beds per 1,000 population.
While the availability of hospital
beds is under government control,
patient allocation to these beds is at
the discretion of physicians. Similar
controls are lacking for use of ambulatory care services. In particular, availability of care and accessibility to care
in emergency departments are entirely
determined by patient demand. Unrestricted, available and accessible medical services provided in emergency
departments have the potential to
attract an increasing number of nonurgent demands.

Universal Health Insurance

In a report to the Royal Commission on Health Services, Berry found
that more medical services were used
by those who carry medical insurance
than by those without.33 This was
confirmed by observations in England
and Wales34 and Saskatchewan35
where sharp increases in the utilization
of hospital and physician services were
recorded after comprehensive govern-

CANADIAN FAMILY PHYSICIAN/JANUARY, 1975

mental health insurance plans were

introduced. While health insurance
may account for a general increase in
utilization of hospitals, doctors and
other insured services in Canada, Great
Britain and, to a lesser extent, the
United States, can it explain the disproportionate increase in emergency
medical services, especially for nonurgent problems?
From 1948 to 1961 (prior to the
introduction of Medicare), hospital admissions increased 30 percent, while
emergency department demands increased 240 percent.24 Read36 cited
an Ontario Hospital Association study
in which an annual increase of 10
percent in utilization of emergency
services in larger hospitals and 25
percent in small hospitals had been
occurring for some time before the
comprehensive Medicare program.

The Trend Maintained

Was this established trend altered
after the introduction of Medicare in
Canada? In a study of hospital ambulatory services, Spitzer et al2l reported
that little change in utilization patterns of established emergency and
outpatient department users occurred
after Ontario Medicare. Chipman37
found no change in the pattern of
emergency room utilization following
introduction of Nova Scotia Medicare.
In Beck's study19 on access to physician services in Saskatchewan from
1963 to 1968, there was an increase of
approximately five percent in low income users of emergency services after
Medicare. No appreciable change was
seen in other income groups.
In the United States, Vaughan and
Gamester' 2 considered that third
party payment played an insignificant
role in utilization of emergency departments when they studied utilization patterns of the insured and uninsured patients in several emergency
departments.
With a 10 percent increase in emergency services per year since 1950, one
is hard pressed to identify the possible
additive effect of health insurance. If
universal insurance played a role, it
was a minor one, overshadowed by
changes in availability and expectations.
Rising health care costs emphasize
the need for an efficient and economical health care delivery system. Providing routine ambulatory care in
emergency facilities is costly. Present
concern should be directed toward the
development of other primary care
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facilities appropriately staffed and

equipped to meet primary care demands.
In order to discourage patients
from going to emergency departments,
alternatives are necessary. New facilities should be accessible and adopt
hours based on community needs.
Group practice has been an attempt on
the part of private physicians to serve
both the needs and demands of the
communities they serve on a rotational
basis. This system pools manpower
and facilitates physician availability to
provide comprehensive care, since no
one person can be available 24 hours a
day. In Canada, it is estimated that 40
percent of physicians practice either in
groups or partnerships; and 80 percent
of these were formed after 1940.
The community health centre concept described by Hastings39 adopts a
similar concept of available and accessible health services, but provided by a
team of health professionals. Ontario
has failed to adopt this report on a full
scale, possibly because the system advocated may be more expensive. Also,
some physicians in urban centres view
the community health centre concept
as an adversary they will be forced to
compete with.
If patients continue to seek care at
hospitals, an alternative is to restrict
admission to the emergency unit.
Weinerman,40 using a screening procedure termed medical triage, was able
to refer 18 percent of emergency
department patients to other community services using conservative decision criteria. Numerous hospitals are
using this system in conjunction with
an outpatient or ambulatory care
service equipped and staffed to provide primary care. By assigning nonurgent conditions to the appropriate
facility within the hospital, hospitals
fulfill their legal requirement without
turning the patient away.
Some argue that patient education
would result in a more rational and
appropriate use of emergency
services.2 Downey40 reported that a
large sign in the emergency department explaining the function of an
adjacent walk-in ambulatory clinic
enabled most patients to triage themselves. Patients came to the emergency
department, for the most part, aware
of the kinds of services they needed
and many were apparently determined
to seek non-urgent care at a time
convenient to them. Apparently availability of alternate facilities with comparable accessibility would be more

CANADIAN FAMILY PHYSICIAN/JANUARY, 1975

effective in discouraging non-urgent

emergency use than public education
programs.

Conclusion
Medical care presumes access to a
physician. Factors affecting this
access, whether due to changes in
patterns of practice or changing
patient demands, are ultimately reflected in increased emergency room
utilization for primary care, since
there are remarkably few external controls to limit its utilization. The providers must accept social responsibility
for assuring appropriate access to care.
This may take the form of a community health centre or a hospital-based
triage system in conjunction with an
outpatient department, ambulatory
care unit or other community health
resource. Community acceptance is a
function of availability. People come
to emergency departments because
they are available. They would just as
readily use other sources of care if
availability and accessibility were
assured.
<

Acknowledgement
I am indebted to Dr. Eugene
Vayda, professor of clinical epidemiology, McMaster University, for his
encouragement and critical review during the preparation of this manuscript.

References

1. BALTZAN, M. A.: New Role of the

Hospital Emergency Department. Can. Med.
Assoc. J. 106:249-256, 1972.
2. JACOBS, A. R., GRA VETT, J. W. and
WERSINGER, R.: Emergency Department
Utilization in an Urban Community. J.
Amer. med. Ass. 216:307-312, 1971.
3. STEWART, M. et al: Use of the Emergency Department at the Victoria General
Hospital, Halifax, Nova Scotia. Dalhousie
University Press. Halifax. 1971.
4. TEGLAS, A. L.: Patterns of Emergency
Practice. CANADIAN FAMILY PHYSICIAN 15:10:56-59, 1969.
5. BOOKER, J. and VANSANT, J. H.: The
Changing Status of the Emergency Room.
Virginia Med. Monthly. 96:96-99, 1969.
6. STEINMETZ, N: The Use of Hospital
Emergency Rooms and Outpatient Departments in Montreal. Unpublished report.
7. BAIN, S. and JOHNSON, S.: Use and
Abuse of Hospital Emergency Department:
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FAMILY

PHYSICIAN.

17:5:33-36, 1971.
8. PIORE, N. et al: A Statistical Profile of
Hospital Out-Patient Services in the United
States: Present Scope and Potential Role.
New York Association for the Aid of
Crippled Children. pp 21-24, 1971.
9. BROOK, R. H. et al: Effectiveness of
Non-emergency care via an Emergency
Room. Ann. Intern. Med. 78:333-339,
19 73.
121

10. WEINERMAN, E. R. et al: Yale Studies

in Ambulatory Medical Care. Section 5.
Amer. J. Publ. Hlth. 56:1037-1056, 1966.
11. VA YDA, E., GENT, M., and PAISLEY,
L.: Emergency Services at Hamilton's St.
Joseph 's Hospital. Ont. Med. Rev.

Service in Montreal Before Universal Health 32. ROEMER, M. I.: "Controlling Hospital
Insurance. Med. Care. 11:4:269-286, 1973. Use through Limiting Hospital Bed Supply '
21. SPITZER, W. 0. et al: The Hamilton in Where is Hospital Use Headed? (Chicago:
General Hospital Outpatient: A Profile. Un- University of Chicago, Graduate Program In
published Report, 1971.
Hospital-Administration, 1963). pp. 69-72.
22. SUSSMAN, M. B.: The Walking Patient. 33. BERRY, C. H.: Voluntary Medical InPress of Case Western Reserve University, p. surance and Prepayment. Royal Commission
40:699-706, 1973.
12. VAUGHAN, H. F. and GAMESTER, C. 147, 1967.
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E.: Why Patients Use Hospital Emergency 23. SPAULDING, W. B., and SPITZER, W. 34. STEWART, W. H., ENTERLINE, P. E.:
Departments. Hospitals 40:59-62, 1966.
O.: Implications of Medical Manpower Effect of National Health Service on Physi13. TORRENS, P. R. and YEDVAB, D. G.: Trends in Ontario. 1961-1971. Ont. Med. cian Utilization and Health in England and
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Wales. New. Engl. J. Med. 265:1187-1194,
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terns of Medical Care Among Users of 25. PICKERING, E. A.: Report of the 35. BADGLEY, R. F. et al: Impact of
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15. VA YDA, E., GENT, M., and PAISLEY, tion, 1973.
L.: Social Class and Emergency Utilization 26. ENTERLINE, P. E. et al: The Distribu- 36. READ, J. G.: Predicting the Implicain an Urban Canadian Hospital. CANADIAN tion of Medical Services before and after tions of Medicare. Hosp. Administration in
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16. LAVENHAR, M. A., RATNER, R. S., ence. New Engi. J. Med. 289:1174-1178, 37. CHIPMAN, M. L.: Emergency Departand WEINERMAN, E. R.: Social Class and 1973.
ment in Izaak Walton Killam Hospital for
Medical Care. Med Care. 6:5:368-380, 27. Task Force Report on the Cost of Children, Halifax, Nova Scotia, Department
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Health Services In Canada. Volume 3. of Preventive Medicine, Dalhousie Univer17. WEBB, M. C.: The Emergency Medical Health Services. Information Canada 1970. sity.
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Thesis, School of Hygiene and Public Part II. Canad. med. Ass. J. 110:562-567, Health Centre in Canada. Information
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18. READ, J. G.: Study of the Emergency 29. HANLON, J. J.: Emergency Medical Canada, Ottawa, 1972.
Department: The Hospital for Sick Child- Care as a Comprehensive System. Health 39. WEINERMAN, E. R. et al: Effects of
Medical Triage in Hospital Emergency Servren. Hosp. Admin. in Canada. 8:22-24, Services R eports. 88:5 79-58 7, 1 9 73.
1966.
30. Guide to Hospital Accreditation, ice. Public Health Reports. 80:389-399,
19. BECK, R. G.: Economic Class and Canadian Council on Hospital Accredita- 1965. Public Health Service, U.S. Department of Health, Education and Welfare.
Access to Physician Services Under Public tion, pp. 47-53. 1972.
Medical Care Insurance. Int. J. Hlth. Servs. 31. VA YDA, E. and ANDERSON, G. D.: A 40. DOWNEY, G. W.: Out-patient Centre
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Comparison of Provincial Surgical Rates in Improves Care, Identifies Cost. Mod. Hosp.
20. McDONALD, A. D. et al: Physician 1968. Can. J. Surg., in press, 1975.
120:77-80. 1973.

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