Appropriateness of healthdirect referrals to the emergency department compared with self-referrals and GP referrals

Objective: To assess the appropriateness of healthdirect referrals to the emergency department (ED) and compare these to self-referrals and general practitioner referrals. Design and setting: Prospective observational study conducted at the Royal Perth Hospital ED from August 2008 to April 2009, using the healthdirect database to cross check healthdirect advice with ED data. Patients: Consecutive patients at triage, identified as healthdirect-referred, self-referred or GP-referred (720 patients per group). Main outcome measure: Appropriateness of referrals, using an a-priori definition. Results: The healthdirect-referred patients were significantly younger than self-referred and GP-referred patients (mean age, 41.6 years v 45.5 years and 50.1 years, respectively; P < 0.01), more likely to be female (60.3% v 43.8% and 46.4%, respectively; P < 0.01) and more likely to attend the ED out of hours (64.0% v 45.8% and 21.0%, respectively; P < 0.01). Self-referred patients had the highest acuity profile (P < 0.01). The proportions of referrals that were assessed as being appropriate were: healthdirect-referred, 72.9% (95% CI, 69.7%-76.2%); self-referred, 73.8% (95% CI, 70.5%-77.0%); and GP-referred, 89.7% (95% CI, 87.5%-91.9%). Of the 534 calls that could be traced back to the healthdirect database, 280 (52.4%) represented patients who attended the ED despite a contrary recommendation. Conclusions: GP referrals had the highest level of appropriateness, and healthdirect- and self-referrals had similar levels of appropriateness. More than half the healthdirect-referred patients attended the ED despite a contrary recommendation, probably due to difficulty accessing after-hours health services.