Health Status of Nonemergency Patients in the Emergency Department Using the EQ-5D

Background Emergency department (ED) overcrowding is influenced by several factors including the hospital's capacity, staff, patient discharges, and community resources. The number of annual ED visits has increased, with patients' medical needs exceeding emergency capacity, resulting in a widespread concern about emergency room overcrowding. Nonemergency patients tend to use large amounts of emergency medical resources, which is one reason for ED overcrowding. Most patients consider their medical cases urgent, whereas medical professionals consider many cases to be nonemergency. Only a few studies have examined self-rated health among nonemergency patients. Methods This cross-sectional study was conducted in the ED of a tertiary hospital in China using the European Quality of Life Five-Dimensional Questionnaire to investigate the health status of nonemergency patients. Results Among the 545 respondents, 246 (45.14%) self-assessed their health as excellent, 186 (34.13%) as very good, 70 (12.84%) as good, 32 (5.87%) as average, and 11 (2.02%) as poor. Problems related to pain/discomfort were reported by 317 (58.17%) participants, 214 (39.27%) responded that they had problems related to daily activities, 212 (38.90%) responded that they felt anxious or depressed, 211 (38.35%) responded that they had problems related to self-care, and some or extreme problems related to mobility were stated by 193 people (35.41%). Conclusions Nonemergency patients generally reported good health. Pain/discomfort was the most significant factor affecting the health of nonemergency patients, followed by limitation of daily activities. The duration of illness onset and self-rated health status were common factors influencing the health status of nonemergency patients. This trial is registered with ChiCTR1900023578.


Introduction
Emergency department (ED) overcrowding is multifactorial [1].It is related to the hospital's capacity, staf, patient discharge, community resources, and other factors.Te number of ED visits has been increasing year by year, and the patient's medical needs can exceed the emergency capacity, causing ED crowding to be a phenomenon of widespread concern globally [2][3][4].A study has reported that 32.7% of ED visits were for nonemergency health issues [5].Another study conducted at the ED of King Abdullah bin Abdulaziz University Hospital reported a nonemergency attendance rate of 61.4% [6], and a cross-sectional study in Iran showed that nonemergency visits accounted for 64.6% of ED visits [7].Wang et al. [8] reported that the average percentage of true emergencies in EDs in China is very low.Long queues in the ED have become the norm in the EDs of many large general hospitals, and the utilization of emergency resources by nonemergency patients is also very common.Emergency medical treatment for nonemergency patients is also an important reason for ED crowding and has greatly increased the operating pressure on the ED system [9].Researchers have attempted to explore nonemergency patients and their reasons for ED presentation [5,10].Tere are various reasons for nonemergency patients using the ED, which can be summarized into three aspects: the patient's own perceived need for emergency medical treatment, the inability of alternative medical service resources to meet their diagnosis and treatment needs, and the convenience of emergency resources [11][12][13][14][15][16][17].Tese phenomena indicate that, on the one hand, nonemergency patients adopt emergency treatment due to patients, family members, or friends overestimating the severity of the disease and expect reassurance from the ED due to concerns about disease progression.Primary care facilities, on the other hand, lack radiology or laboratory testing and have difculty accepting outpatient appointments.
Te EuroQoL fve-dimensional questionnaire (EQ-5D) is a short, reliable, and validated instrument commonly used to assess health status [18].Te EQ-5D is easy to use and places few demands on the cognitive function of study subjects.Yang and Tang [19] used the EQ-5D to measure health-related quality of life and its infuencing factors in patients with chronic diseases, and Ping et al. [20] used the EQ-5D to assess health-related quality of life during the COVID-19 pandemic in China.Te health status of nonemergency patients refects their overall state of physical, mental, social, spiritual, and personal functioning.Terefore, this study used the EQ-5D to investigate the health status of nonemergency patients in the ED, with the aim of providing a reference for clinical practice in the scientifc management of this group.

Study Design and Setting
. Tis cross-sectional study (registration number: ChiCTR1900023578) was conducted in the ED of the West China Hospital of Sichuan University, a 4300-bed tertiary teaching hospital with 250,000 ED visits per year.Tis study was scheduled to be conducted between June 1 and 20, 2019.Participants who were defned as nonemergency visits were recruited by trained triage nurses 24 h a day using convenience sampling.After the triage procedure, the target patients were briefed on the study protocol.A questionnaire survey was administered to the patients who agreed to participate.Participants were instructed to use their mobile phone to scan QR codes for the survey.Prior to the study, several training sessions were conducted to ensure proper implementation of the survey.A 60 min group training session was provided to all triage nurses to promote a consistent understanding of the study objectives and survey instruments.

Participants.
Generally speaking, nonemergency patients refer to those who have no acute symptoms, no or few complaints of discomfort, require fewer emergency resources, and whose treatment can be delayed for several hours.For patients attending the ED, their emergency status was determined based on triage standards.Patients with the lowest emergency levels, IV and/or V, were defned as nonemergency patients [21,22].An experienced advanced triage nurse identifed nonemergency patients, including those of diferent age groups, sexes, and ethnicities.Patients who refused to participate, did not speak Chinese, or were mentally unable to participate were excluded.Patients for whom there were missing data were also excluded.For patients <14 years of age, their caregivers were asked to complete the EQ-5D.Te fnal number of participants was 545.To ensure anonymity, all patient data were accessible only to the research team.Te sample size was calculated based on the proportion of patients who had tried alternative services before their ED visits.Assuming that 60% of nonemergency patients try alternative services [23], a sample of 425 patients is required.Assuming a sampling error of 0.1 and a nonresponse rate of 20%, the target was a total of 510 patients.Some data were missing due to the incomplete completion of the questionnaire.Tis lack of data could be systematic (nonrandom) in that certain patient groups may have been unable to fully complete the questionnaire.

Instrument.
Developed in 1990 by the EuroQoL Group, a voluntary multinational collaboration of European researchers, the EQ-5D is applicable to a wide range of health conditions and includes single indicator values of health status and self-rating visual analog scales (VAS) available in population health surveys.To check the validity of the initial questionnaire, fve local experts with more than 10 years of ED work experience and at least associate senior professional titles completed the questionnaire.Te content validity of the questionnaire was good, with an overall content validity index score of 0.8854.After appropriate modifcations, the questionnaire was pretested on 35 patients to ensure readability.Te fnal questionnaire collected information on sociodemographic characteristics, medical resource allocation, health status, and the EQ-5D (Table 1).Socioeconomic and demographic information included sex, age, ethnicity, employment status, education level, marital status, income, health insurance, and living conditions.Medical resource allocation included the distance to the emergency room, nearest medical service institution, distance to the nearest medical service institution, mode of transportation for emergency medical treatment, and whether the institution was considered to meet health needs in the near future.Health status included the onset time, presence of chronic diseases, self-evaluation of health status, and self-evaluation of urgency.Te EQ-5D [18,24,25] consisted of two parts: the health description system and the EQ visual analogue scales (EQ-VAS).Te health description system included fve dimensions: mobility, self-care, daily activities, pain/ discomfort, and anxiety/depression.Each dimension was divided into three levels: no difculty, difculty, and extreme difculty.Participants were asked to answer fve questions about whether they had a problem and the severity of the problem.Te EQ-VAS is a 20-cm-long vertical visual scale.Te score ranges from 0 to 100, with the top score of 100 representing the best health status in mind, "no pain" or "complete comfort," and the bottom score of 0 representing the worst health status in mind, "worst pain" or "complete discomfort."Respondents were asked to mark the point on a straight line where they felt pain or discomfort.We divided the VAS score into fve ranges: 81-100, 61-80, 41-60, 21-40, and 0-20 points, with higher scores indicating better overall 2 Emergency Medicine International

Participant Characteristics.
During the study period, 10,450 emergency room visits occurred, 980 of which were defned as nonemergencies.Of these patients, 187 declined to participate, and 190 patients were unsuccessfully enrolled (186 patients were missed when the ED was at its busiest, and 4 patients were excluded due to aggressive language and behavior).Of the 603 patients who participated in the study, 58 were excluded because they did not complete all survey questions.Table 1 presents the characteristics of the study participants.Among the 545 respondents, 274 were female (50.28%), 217 were aged 19-44 years (39.81%),514 were Han ethnicity (94.31%), 219 were employed (40.18%), and 338 were educated to high school level or lower (62.02%).

EQ-5D
Responses.Of the 545 participants, 193 (35.41%) stated that they had some or extreme problems related to mobility, 211 (38.35%) responded that they had problems related to self-care, 214 (39.27%) responded that they had some or extreme problems related to daily activities, 317 (58.17%) said they had some or extreme problems related to pain/discomfort, and 212 (38.90%) responded that they felt anxious or depressed.Pain/discomfort was the most serious factor afecting the health status, followed by limitation of daily activities (Table 3).
Transportation mode, illness duration, and self-rated health status were signifcantly associated with pain and discomfort.Transportation by bus/subway (OR � 0.375, P � 0.013) and private car (OR � 0.421, P � 0.026), longer illness duration (OR � 1.553, P < 0.001), and lower selfrated health status (OR � 0.755, P � 0.028) were associated with worse reported pain/discomfort.Private car users experienced higher pain/discomfort than bus/ subway users.
Tere were signifcant associations between illness duration, self-rated health status, and anxiety/depression.Longer illness duration (OR � 1.716, P < 0.001) and lower self-rated health status (OR � 0.611, P < 0.001) were associated with more anxiety and depression.

Nonemergency Patients Report Tat Teir Overall Health
Status Is Good.Consistent with the results of many studies in this feld, e.g., [26], our results showed that most nonemergency patients were <45 years of age (369, 67.71%), with good health status (432, 79.2%) and low chronic disease morbidity (123, 22.57%).Our study found that nonemergency patients in the ED generally reported good health.Tis result is consistent with our expectations because nonemergency patients often seek care for nonserious acute conditions.Additionally, nonemergency patients tend to subjectively evaluate their health status as good because of their relatively low experience of acute illness and better quality of daily life.However, although nonemergency patients reported good health, this does not imply that they do not require attention or treatment.Instead, we should focus on chronic disease management and health maintenance to prevent disease progression and improve quality of life.

Pain/Discomfort Is the Most Important Factor Afecting the Health Status of Nonemergency Patients, Followed by Daily
Activities.Our research found that among the fve dimensions of EQ-5D in nonemergency patients, the factor that most signifcantly afected the health status was pain or discomfort.Yang et al. [27] reported that the discomfort dimension had the greatest impact on health status, which is consistent with the present results.Tis shows that even if patients do not have an acute illness, pain or discomfort remains an important factor afecting their health and quality of life.Pain may limit a patient's ability to perform daily activities and afect work, social, and family life.Our study found that the second most common dimension, limited daily activities, was also an important factor afecting the health status of nonemergency patients.Tis may be because of pain, limited physical function, or other chronic health issues.Limitations in daily activities can afect patients' quality of life and increase their risk of anxiety and depression.However, another study reported that the second most common dimension was anxiety/depression [20], which is inconsistent with the current results.One possible explanation is that nonemergency patients may have chronic illnesses or underlying risk factors that limit their daily activities.

Analysis of Factors Afecting the Health Status of Nonemergency Patients.
Te study found that illness duration and self-rated health status were common infuencing factors for the fve dimensions of health status of nonemergency patients in the ED.Prolonged disease duration showed a trend consistent with the deterioration of multiple health dimensions.Long-term illness may lead to a reduced quality of life, lower self-rated health, and exacerbation of various health problems.In particular, pain/discomfort and anxiety/ depression may worsen over time, suggesting that long-term illness has a negative impact on patients' mental health [28].
Tere is a complex relationship between patients' evaluations of their health status and health behaviors.Patients with lower self-rated health may neglect self-care and report lower levels of daily activity.Te interaction between selfrated health status and health behaviors requires greater attention in treatment and rehabilitation programs.Overall, these fndings highlight the important infuence of illness duration and self-rated health on the health status of nonemergency patients presenting to the ED.Emergency Medicine International Te study found that the higher the educational level, the stronger the self-care ability.Tis may be because higher education levels ensure a better ability to acquire health knowledge and increase health awareness.Well-educated people are generally likely to have higher incomes and more social resources, and they can access better medical care including quality, accessibility, and efciency.Te study found that patients' medical choices may be infuenced by their experiences and that their experience with medical services increases their expectations when seeking urgent care.Te Han people's ability to take care of themselves was higher than that of ethnic minorities.China is a multiethnic country dominated by the Han people.Due to a lack of social resources such as health education and medical services, ethnic minorities are often regarded as vulnerable groups.Minority participants' frequent emergency care use for nonemergency conditions may be due to their lower levels of health literacy or difculty in accessing general health services [29].Ethnicity has been shown to be a relevant factor afecting health service utilization patterns; therefore, we consider that ethnicity is an important demographic factor because cultural diferences among diferent ethnic groups may afect health service utilization.

4.4.
Limitations.Tis study had several limitations.First, the sample size was small because the patients were recruited from only one hospital.Terefore, further studies are needed to confrm the generalizability of the fndings.Secondly, misclassifcation of the emergency level may have occurred, such as grade 4 patients being incorrectly registered as grade 3 patients.Additionally, high nonparticipation rates among eligible participants may have afected the representativeness of the sample.For children under 14 years of age, caregivers completed questionnaires on their behalf, and the agent may not have fully understood or reported the child's feelings, behaviors, or needs.Te agent's perspective may be infuenced by their own beliefs, expectations, and experiences, which may not fully align with the child's actual experience.Other potential limitations associated with the mode and timing of administration should be considered in future studies.

Conclusions
Tis study provides a multidimensional understanding of the health status of nonemergency patients attending the ED, including mobility, self-care, daily activities, pain/discomfort, and anxiety/depression.People triaged as nonemergency reported generally good health status, but this was poorer among people who had a longer duration of illness.Health status defcits most commonly afected the pain and discomfort domain.Future research and clinical practice should explore the complex relationships among these factors and develop more efective interventions to promote the overall health and well-being of patients.When evaluating and treating such patients, these aspects must be comprehensively considered to provide efective management and to improve their quality of life and health.

Table 1 :
Basic information of respondents.

Table 2 :
Health status scores of nonemergency patients.