Article Summary
1. Why is this topic important? Although frequent Emergency
The well-described phenomenon of frequent Emergency Department (ED) use by some patients was highlighted in the recent health care reform debate as a possible target for cost saving, and as an exacerbating factor in ED crowding 1, 2, 3, 4, 5, 6, 7. ED crowding has reached a critical state, demonstrated by the ubiquity of ambulance diversion, patients leaving without being seen, and most alarmingly, resulting bad clinical outcomes 8, 9, 10. Meanwhile, frequent users were often assumed to be uninsured and clogging EDs in search of primary care. Frequent ED users, most commonly defined as patients with ≥4 visits/year, account for approximately 25% of all ED visits (11). Thus, ED recidivism is an important component of visit volume, one of a number of contributors to crowding.
Although frequent ED users represent a sizeable portion of all ED visits, a small but visible minority of patients use their EDs at much higher rates 1, 5, 12, 13, 14, 15. This subgroup of high-frequency ED users, well known to Emergency Physicians, may qualitatively account for the prejudices held against sicker patients who require the ED with relative regularity (11). In one of the only analyses to isolate high-frequency ED users, Ruger et al. described patients with 20 or more visits per year (visit frequency was divided into five groups), of which there were 23 in a patient census of over 50,000 (6). The authors found these high-frequency users had lower acuity visits, were less likely to be insured, and were at greater risk of elopement compared to any other group of patients (6).
A number of institutions have reported programs to address social and medical needs of high-frequency users, but beyond a few studies, the group itself remains poorly defined 6, 16, 17, 18, 19, 20, 21. Here we present the results of a pilot study designed to further characterize this challenging population and bolster the data for what is, by definition, a small patient sample. Describing this population will inform future attempts to address the underlying medical or social determinants of high-frequency ED use.
The study included all ED visits over a 12-month period to a tertiary care medical center with 96,000 annual ED visits (with approximately 59,000 unique patients). The site is one of 13 EDs within an urban county of 1.5 million inhabitants. The study was approved by the center's Institutional Review Board.
This was an observational study with retrospective data collection. The primary objective was to provide descriptive demographic and utilization statistics for this group (see Measures).
Thirty-one unique patients out of 59,172 (0.05%) were identified as having 20 or more ED visits within the 12-month study period. The visit distribution for all frequent users (≥4 visits/year) and high-frequency users is shown in Figure 1. Frequent users comprised a group of 4045 (7.3%) patients who contributed 23,217 ED visits during the study period, or 23% of all ED visits. Furthermore, high-frequency users accounted for 1059 ED visits, or 1.1% of all ED visits. Figure 2 demonstrates the
In our institution, frequent ED users (≥4 visits/year) contributed a large proportion of visits – nearly one-quarter of all visits – a finding consistent across other studies 1, 5, 12, 13, 14, 15. High-frequency users (≥20 visits/year), by definition over-represented in the ED, contributed only about 1% of visits. Membership in this cohort is fleeting, as demonstrated by the high turnover from the year before this study period. This could be systems-related (i.e., the result of case management
High-frequency users are patients with significant social and psychiatric comorbidities. Given their small proportion of visits, lower admission rates, and favorable insurance status, high-frequency users are unlikely to represent an important financial impact on the ED. However, we suspect the preponderance of psychosocial cofactors within this subset of patients may be adversely influencing the perception of a much larger group of chronically ill frequent ED users. 1. Why is this topic important? Although frequent EmergencyArticle Summary
The authors would like to acknowledge the voluntary statistical consultations of Jason Fletcher, phd and Clyde Schechter, md.
We conceptualize race and ethnicity as a proxy for exposure to racism in housing markets and healthcare settings (Quillian et al., 2020; Reskin, 2012; Yearby, 2018). In progressive adjustment models, we controlled for additional health-related variables: health insurance status (insured/uninsured) (Zewde et al., 2019; Zhou et al., 2017), number of comorbidities (continuous, from a select-all-that-apply list of 20 common conditions) (Fisher et al., 2021; Cabral et al., 2019; Hajat et al., 2021), and whether a participant reported ever being diagnosed with a mental health condition (yes/no) (Desmond, 2016; LaCalle et al., 2013; Padgett, 2020). All theorized confounders were measured at T0 (baseline).
Third, outcomes of ED visits after UCC visits have not been widely studied. ED visit within 72 h after UCC visit was used due to existing ED literature on similar topics (9,11). This arbitrary time assignment remains controversial, even as a measure of quality of care in the ED.
The high frequency of ED visits related to suicidal behaviors among homeless veterans is troubling particularly because suicide represents VA's top clinical priority [27] and previous studies have found homeless veterans are already at elevated risk for suicide [28,29]. Our findings are consistent with some previous studies that have found that frequent ED users often have significant psychiatric and social comorbidities [30]. The presenting diagnoses for ED use we found were also similar to previous studies in settings where there is no comprehensive healthcare coverage.
Emergency departments (EDs) are critical providers of acute care for persons affected by the current overdose crisis in the United States.1 Persons with substance use disorders and other comorbid conditions, such as mental illness or homelessness, commonly seek care in ED settings, often as a result of lack of access to regular sources of primary and specialty care.2-4 Frequent hospital and ED use has been linked to greater risk of experiencing both nonfatal and fatal overdoses,5,6 and both US and international research has found ED utilization to be highest in the months preceding and after overdose.7-9