Administration of Emergency Medicine
High-Frequency Users of Emergency Department Care

https://doi.org/10.1016/j.jemermed.2012.11.042Get rights and content

Abstract

Background

The heterogeneous group of patients who frequently use the Emergency Department (ED) have been of interest in public health care reform debate, but little is known about the subgroup of the highest frequency users.

Study Objectives

We sought to describe the demographic and utilization characteristics of patients who visit the ED 20 or more times per year.

Methods

We retrospectively studied patients who visited a large, urban ED over a 1-year period, identifying all patients using the department 20 or more times. Age, gender, insurance, psychosocial factors, chief complaint, and visit disposition were described for all visits. Inferential tests assessed associations between demographic variables, insurance status, and admission rates.

Results

Of the 59,172 unique patients to visit the ED between December 1, 2009 and November 30, 2010, 31 patients were identified as high-frequency ED users, contributing 1.1% of all visits. Patients were more likely to be 30–59 years of age (52%), stably insured (81%), and have at least one significant psychosocial cofactor (65%). Their admission rate was 15%, as compared to 21% for all other patients.

Conclusions

High-frequency users are patients with significant psychiatric and social comorbidities. Given their small proportion of visits, lower admission rates, and favorable insurance status, the impact of high-frequency users of the ED may be out of proportion to common perceptions.

Introduction

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.

Section snippets

Study Setting and Design

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).

Results

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

Discussion

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

Conclusions

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.

Article Summary

1. Why is this topic important?

  1. Although frequent Emergency

Acknowledgments

The authors would like to acknowledge the voluntary statistical consultations of Jason Fletcher, phd and Clyde Schechter, md.

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