Dear Editor, Emergency departments (EDs) are critical units of hospitals that operate 24/7 to ensure that patients with life-threatening conditions can access care as quickly as possible. However, ED crowding is one of the leading problems of health systems worldwide. This has become a major issue in Türkiye as well. In 2021, the number of ED visits in Türkiye was reported as 205 per 100 people.1 In the same year, the United States reported 47 ED visits per 100 people,2 while the average of countries in the Organisation for Economic Co-operation and Development (OECD) was 27.3 In Portugal and Spain—both OECD countries—ED visits exceed 50 per 100 people.3 For these countries, it has been noted that high use may indicate inappropriate and inefficient functioning when many nonurgent cases that could be managed in primary or community care present to EDs.3 The same concern should also be prioritized for Türkiye. In Türkiye, overcrowding is driven by the ease of ED access, the availability of 24/7 service allowing out-of-hours attendance, and the fact that examinations are free of charge under the General Health Insurance system; as a result, patients tend to present directly to EDs even for very minor symptoms. Such overcrowding can prolong waiting times for examination, reduce the quality of care, increase incidents of violence against healthcare workers, and—together with psychosocial consequences—disrupt service delivery.4,5 To improve health literacy, efforts should target all segments of society, beginning from primary school, educating the public on distinguishing urgent from nonurgent conditions and encouraging nonurgent patients to present to primary care facilities. In the study by Butun et al.,1 when patients were asked why they presented to the ED, 62.8% stated that they believed they were in an emergency situation. Even if we assume that most of those who perceived their situation as urgent were patients with myocardial ischemia, stroke, or trauma, it is evident that some patients used the ED despite not having an emergency. In the same study, more than one-third of patients reported coming to the ED because it is open 24/7 or because they did not want to wait. If left unaddressed, the ED’s core mission will drift toward purposes for which it was not intended. In inefficiently organized emergency care, this drift manifests as progressive deterioration across the health system. While free emergency care is cited as a reason for ED use in countries outside Türkiye,1,2 in Türkiye, general health insurance is mandatory, and patients can also receive outpatient clinic examinations free of charge, as in the ED. However, the Turkish example shows that providing free health services does not deter nonurgent patients from using the ED. These unnecessary visits hinder timely treatment for patients who truly need urgent care. For this patient group—which consumes health system resources and workforce unnecessarily—charging a fee for each nonurgent ED presentation may serve as a deterrent. In Türkiye, patients also present to EDs because they cannot obtain outpatient appointments. Yet appointment systems are clogged by patients who book the wrong specialty, do not show up, or occupy limited capacity with appointments that do not require specialist evaluation. Again, improving health literacy could help resolve this problem. If a formal referral system cannot be implemented, public education should explain which complaints warrant visiting a family physician, which require a specific specialty, and what self-care measures can be taken at home for simple conditions such as the common cold (e.g., fever control). Alongside this, educating the public about true emergencies may help ensure appropriate ED use. In conclusion, considering that Türkiye records 205 ED visits per 100 people, which is at least 4 times the figures for the United States and OECD countries,1–3 it is essential—starting from early school ages—to implement education that enhances health literacy across society; to raise public awareness about the functioning and scope of emergency services; and, where necessary, to adopt policy measures including sanctions. These steps are crucial to achieve a sustainable healthcare system with the existing workforce and material resources. Conflict of interest statement The authors have no conflicts of interest to disclose. Author contributions Umit TB wrote the original draft, curated data, and contributed to investigation, validation, and conceptualization. Funding None. Ethical approval of studies and informed consent Not applicable. Acknowledgements None.
Tuba Betül Ümit (Wed,) studied this question.