Identifying frequent users of emergency department resources

Substance Use Disorders, Mental Illness, and Health Care Utilization Among Adults With Recent Criminal Legal Involvement

OBJECTIVE

Individuals involved with the criminal legal system have higher rates of mental illness, addiction, and health care utilization. The authors examined whether substance use disorders and mental illness alone or in combination drive health care utilization among those with recent criminal legal involvement.

METHODS

This cross-sectional analysis used nationally representative data from U.S. adults with past-year criminal legal involvement (N=9,039) recorded in the National Survey on Drug Use and Health (2015-2019). Using adjusted negative binomial regression models, the authors estimated relative risks for health care utilization. Primary independent variable categories included neither substance use disorder nor mental illness, substance use disorder only, mental illness only, and both conditions. Health care utilization included emergency department (ED) visits and nights spent in inpatient care.

RESULTS

Relative to neither mental illness nor substance use disorder, mental illness alone was associated with significantly increased acute health care services use: for ED visits, incidence risk ratio (IRR)=1.43 (95% CI=1.18-1.75) and for inpatient stays, IRR=2.14 (95% CI=1.47-3.11). Having both conditions was associated with increased ED visits (IRR=1.62, 95% CI=1.38-1.91) and inpatient stays (IRR=4.16, 95% CI=2.98-5.82). Substance use disorder alone was associated only with higher risk for ED visits compared with neither condition (IRR=1.23, 95% CI=1.01-1.50).

CONCLUSIONS

Mental illness with or without co-occurring substance use disorder is a strong driver of acute health care utilization after interaction with the criminal legal system. Interventions tailored to the unique needs of individuals with mental illness or substance use disorder are needed for those with recent criminal legal involvement.

Where Have All the FLOWERS Gone? A Multicenter Investigation of Frequent Users of Midwest Emergency Department Services During the COVID-19 Stay-at-home Orders

Introduction: In this study we aimed to determine the impact of the mandatory coronavirus disease 2019 (COVID-19) pandemic stay-at-home order on the proportional makeup of emergency department (ED) visits by frequent users and super users. Methods: We conducted a secondary analysis of existing data using a multisite review of the medical records of 280,053 patients to measure the impact of the COVID-19 pandemic stay-at-home order on ED visits. The primary outcomes included analysis before and during the lockdown in determining ED use and unique characteristics of non-frequent, frequent, and super users of emergency services. Results: During the mandatory COVID-19 stay-at-home order (lockdown), the percentage of frequent users increased from 7.8% (pre-lockdown) to 21.8%. Super users increased from 0.7% to 4.7%, while non-frequent users dropped from 91.5% to 73.4%. Frequent users comprised 23.7% of all visits (4% increase), while super user encounters (4.7%) increased by 53%. Patients who used Medicaid and Medicare increased by 39.3% and 4.6%, respectively, while those who were uninsured increased ED use by 190.3% during the lockdown. Conclusion: When barriers to accessing healthcare are implemented as part of a broader measure to reduce the spread of an infectious agent, individuals reliant on these services are more likely to seek out the ED for their medical needs. Policymakers considering future pandemic planning should consider this finding to ensure that vital healthcare resources are allocated appropriately.

Characteristics and Resource Utilization Associated with Frequent Users of Emergency Departments

Background

Frequent emergency department (ED) users place a huge influence and burden on healthcare systems and medical costs. In Taiwan, citizens have very easy access to medical services and the national health insurance (NHI) puts very few restrictions on the frequency and facilities which the patients go to. However, there is still a certain percentage of frequent ED users in Taiwan, and yet, there are few research studies investigating the features of such users and their impact on the healthcare system. We conducted this study to investigate the prevalence and characteristics of the repeated ED users in a tertiary care medical center with more than 80000 emergency visits in a year and hypothesized that frequent ED users have unique medical and social characteristics and results in increased medical expense.

Methods

We searched the integrated medical database of an urban tertiary medical center in 2017. We compared frequent ED users (≧4 visits/year) with nonfrequent users (<4 visits/year) with regards to the medical history, distance from home to the hospital, main visiting purposes, whether patients had used outpatient care or other medical resources at the same time, and the charge to the patients for each visit.

Results

In 2017, 2191 patients (3.37%) were listed as frequent users and accounted for 12166 visits (14.20%). Most of the frequent users were over 65 years old (53.1%) and more than half of them had suffered from cancer (55.1%). The most significant features of frequent ED users were male, educational attainment below university, low-income households, drug or food allergies, terminal stage of illness, possession of IC Cards for Severe Illness, hospitalization in the past year, multiple outpatient visits in same year, and with certain medical history including anemia, cerebrovascular accident, congestive heart failure, peptic ulcer disease, ileus, cirrhosis, chronic obstructive pulmonary disease, and psychiatric disease. There were significant differences between frequent and nonfrequent users in disposition and median charge per visit (US$137 vs. $117, p < 0.001).

Conclusions

Frequent users of ED are a heterogeneous group who usually suffer from multiple chronic diseases. There were higher rates of hospital admission and medical costs among frequent ED users compared to nonfrequent users. In addition to emergency services, frequent users also utilized outpatient resources heavily.

Frequent Emergency Department Visitors Associated With a Pain-Discharge Diagnosis

BACKGROUND

Emergency departments (EDs) have experienced an increase in annual patient visits and length of stay over the past decade. Management of frequent-user patients with pain-related diagnoses are challenging in a time-limited setting.

OBJECTIVE

The purpose of this study was to describe characteristics of frequent ED users with pain-related diagnoses.

METHODS

This was a retrospective longitudinal cohort study of hospital ED visits from two EDs in using encounters from September 2016 to August 2018. Frequent users were characterized as having four or more visits in a 1-year period and were further classified into three categories based on the number of pain-related visits in the study period. Descriptive statistics and regression analysis results are reported for all demographic and clinical characteristics for index encounters, patient level data, and pain subgroups.

RESULTS

Of all patients, 11.3% (n = 5174) were identified as frequent users, accounting for 38.9% (n = 91,114) of all ED visits. Overall, frequent pain users were more likely to be of middle age (odds ratio [OR] 1.70, 95% confidence interval [CI] 0.80-1.72), female (OR 2.43, 95% CI 1.79-3.29), have commercial insurance (OR 1.91, 95% CI 1.37-2.66), and have 10 or more ED encounters (super user status) in a 12-month period (OR 23.66, 95% CI 17.12-32.71).

CONCLUSION

Understanding characteristics of ED frequent users with pain-related diagnoses may inform community-based interventions designed to reduce episodic care and thereby improve care coordination and management.

Tracing frequent users of regional care services using emergency medical services data: a networked approach

OBJECTIVES

This study shows how a networked approach relying on 'real-world' emergency medical services (EMS) records might contribute to tracing frequent users of care services on a regional scale. Their tracing is considered of importance for policy-makers and clinicians, since they represent a considerable workload and use of scarce resources. While existing approaches for data collection on frequent users tend to limit scope to individual or associated care providers, the proposed approach exploits the role of EMS as the network's 'ferryman' overseeing and recording patient calls made to an entire network of care providers.

DESIGN

A retrospective study was performed analysing 2012-2017 EMS calls in the province of Drenthe, the Netherlands. Using EMS data, benefits of the networked approach versus existing approaches are assessed by quantifying the number of frequent users and their associated calls for various categories of care providers. Main categories considered are hospitals, nursing homes and EMS.

SETTING

EMS in the province of Drenthe, the Netherlands, serving a population of 491 867.

PARTICIPANTS

Analyses are based on secondary patient data from EMS records, entailing 212 967 transports and 126 758 patients, over 6 years (2012-2017).

RESULTS

Use of the networked approach for analysing calls made to hospitals in Drenthe resulted in a 20% average increase of frequent users traced. Extending the analysis by including hospitals outside Drenthe increased ascertainment by 28%. Extending to all categories of care providers, inside Drenthe, and subsequently, irrespective of their location, resulted in an average increase of 132% and 152% of frequent users identified, respectively.

CONCLUSIONS

Many frequent users of care services are network users relying on multiple regional care providers, possibly representing inefficient use of scarce resources. Network users are effectively and efficiently traced by using EMS records offering high coverage of calls made to regional care providers.

Characteristics and predictors of adult frequent emergency department users in the United States: A systematic literature review

STUDY OBJECTIVE

We conducted a systematic literature review to identify and to update patient characteristics and contextual factors for adult frequent emergency department users (FEDUs) compared with non-FEDU in an era where the US health care system underwent substantial changes.

METHODS

We searched MEDLINE, CINAHL, and EMBASE to identify all relevant articles after 2010 through July 2018 that describe FEDU. We included US studies on adult FEDU only and excluded studies on specific subgroups of FEDU. We included demographic, clinical, and health care utilization information, and two reviewers independently evaluated the studies using the Joanna Briggs Institute Critical Appraisal tool.

RESULTS

The 11 studies included in the review indicated that FEDU were 4% to 16% of total ED users but accounted for 14% to 47% of ED visits, with six to nine visits per year on average. The majority of FEDU were young or middle-aged adults, females, of low socioeconomic status and high school or less education, with public insurance, multiple primary care provider visits, and chronic conditions. Fair or poor self-perceived health status, unemployment, unmet needs from primary care providers (PCPs), mental health, and substance abuse were predictors of FEDU.

CONCLUSION

FEDUs are disproportionally sicker and are also heavy users of non-ED health care service providers. The limited data for non-ED health services use in facility-specific studies of FEDU may contribute to findings in such studies that complex and unmet needs from PCPs contributed to ED visits. This suggests the need for more comprehensive data analysis beyond a few sites that can inform systemic management approaches.

Characterizing pediatric high frequency users of California emergency departments

OBJECTIVE

Emergency department (ED) utilization has increased for the last several decades. Despite a focus on adult frequent ED users, little research has examined pediatric frequent ED users. The purpose of this study was to assess pediatric ED utilization in California and to describe those identified as frequent ED users.

METHODS

This was a retrospective multi-facility study of ED visits by children 1-17 years of age using statewide data from the California Office of Statewide Health Planning and Development. Patients were classified into utilization groups by the number of ED visits in a one-year period prior to their last visit in 2016: occasional (1-5 visits) vs. frequent (>5 visits). Differences in patient characteristics were compared between occasional and frequent users.

RESULTS

There were 690,130 patients between 1 and 17 years of age with 1,238,262 visits during the study period. Children with ≥6 visits (2.3%) accounted for 9.3% of all visits. 67% of frequent users had no visits to a pediatric ED. Over 40% (41.4%) of frequent users visited 2 or more hospitals, compared to 7.7% of occasional users. In multivariate analysis, the characteristics with the largest associations with frequent ED use were age, payer, and being admitted/transferred.

CONCLUSIONS

The majority of pediatric frequent users do not seek care in pediatric EDs. Age, prior admission, and Medicare/Medicaid appear to have the largest associations with pediatric patient frequent ED utilization.

Substance Use, Homelessness, Mental Illness and Medicaid Coverage: A Set-up for High Emergency Department Utilization

Introduction

Frequent users of emergency departments (ED) account for 21–28% of all ED visits nationwide. The objective of our study was to identify characteristics unique to patients with psychiatric illness who are frequent ED users for mental health care. Understanding unique features of this population could lead to better care and lower healthcare costs.

Methods

This retrospective analysis of adult ED visits for mental healthcare from all acute care hospitals in California from 2009–2014 used patient-level data from California’s Office of Statewide Health Planning and Development. We calculated patient demographic and visit characteristics for patients with a primary diagnosis of a mental health disorder as a percentage of total adult ED visits. Frequent ED users were defined as patients with more than four visits in a 12-month period. We calculated adjusted rate ratios (aRR) to assess the association between classification as an ED frequent user and patient age, sex, payer, homelessness, and substance use disorder.

Results

In the study period, 846,867 ED visits for mental healthcare occurred including 238,892 (28.2%) visits by frequent users. Patients with a primary mental health diagnosis and a co-occurring substance use diagnosis in the prior 12 months (77% vs. 37%, aRR [4.02], 95% confidence interval [CI] [3.92–4.12]), homelessness (2.9% vs 1.1%, odds ratio [1.35], 95% [CI] [1.27–1.43]) were more likely to be frequent users. Those covered by Medicare (aRR [3.37], 95% CI [3.20–3.55]) or the state’s Medicaid program Medi-Cal (aRR [3.10], 95% CI [2.94–3.25]) were also more likely to be frequent users compared with those with private insurance coverage.

Conclusion

Patients with substance use disorders, homelessness and public healthcare coverage are more likely to be frequent users of EDs for mental illness. Substance use and housing needs are important factors to address in this population.

Patterns of emergency department utilization by patients on chronic dialysis: A population-based study

Importance

Patients on dialysis are often elderly and frail, with multiple comorbid conditions, and are heavy users of Emergency Department (ED) services. However, objective data on the frequency and pattern of ED utilization by dialysis patients are sparse. Such data could identify periods of highest risk for ED visits and inform health systems interventions to mitigate these risks and improve outcomes

Objective

To describe the pattern and frequency of presentation to ER by dialysis patients

Design

Retrospective cohort study using administrative data collected over ten years (2000–2009) in the Province of Manitoba, Canada.

Setting

Patients presenting to any of 9 ED’s in Winnipeg and Brandon Manitoba. These departments serve >90% of the population of Manitoba, Canada (population 1.2 million).

Participants

All patients presenting to an ED in any of 9 emergency departments in Manitoba, Canada.

Exposure

Dialysis status

Main outcomes

Presentation to the ED

Results

Over 2.1 million ED visits by more than 1.2 million non-dialysis patients and 17,782 ED visits by 3257 dialysis patients were included. Dialysis patients presented 8.5 times more frequently to the ED than the general population (age and sex adjusted, p<0.001). For dialysis patients, ED utilization was significantly higher following the long interdialytic interval (33.6% higher Mondays and 19.5% higher Tuesdays vs. other days of the week, p<0.001) and was 10-fold higher in the 7 days before and after the initiation of dialysis.

Conclusion and relevance

The heavy use of ED services by dialysis patients spikes upward following the long interdialytic interval and also in the week before and after dialysis initiation. The relative risks associated with these vulnerable periods were much higher than those reported for clinical patient characteristics. We propose that intrinsic gaps in the structure of care delivery (e.g. 3 times a week dialysis, imperfect surveillance and clinical monitoring of patients with low GFR) may be the fundamental drivers of this periodicity. Strategies to mitigate this excess health risk are needed.

Case Management Reduces Length of Stay, Charges, and Testing in Emergency Department Frequent Users

Introduction

Case management is an effective, short-term means to reduce emergency department (ED) visits in frequent users of the ED. This study sought to determine the effectiveness of case management on frequent ED users, in terms of reducing ED and hospital length of stay (LOS), accrued costs, and utilization of diagnostic tests.

Methods

The study consisted of a retrospective chart review of ED and inpatient visits in our hospital's ED case management program, comparing patient visits made in the one year prior to enrollment in the program, to the visits made in the one year after enrollment in the program. We examined the LOS, use of diagnostic testing, and monetary charges incurred by these patients one year prior and one year after enrollment into case management.

Results

The study consisted of 158 patients in case management. Comparing the one year prior to enrollment to the one year after enrollment, ED visits decreased by 49%, inpatient admissions decreased by 39%, the use of computed tomography imaging decreased 41%, the use of ultrasound imaging decreased 52%, and the use of radiographs decreased 38%. LOS in the ED and for inpatient admissions decreased by 39%, reducing total LOS for these patients by 178 days. ED and hospital charges incurred by these patients decreased by 5.8 million dollars, a 41% reduction. All differences were statistically significant.

Conclusion

Case management for frequent users of the ED is an effective method to reduce patient visits, the use of diagnostic testing, length of stay, and cost within our institution.

Difficult Patients in the Emergency Department: Personality Disorders and Beyond

Physician-patient encounters in clinical settings, especially in the emergency department, can be of varying degrees of difficulty. Medically complicated, challenging cases can be paradoxically rewarding, whereas psychologically driven difficulty is frustrating and counterproductive for patient care. This article presents 3 different complementary perspectives on difficult patients: clinical presentations, manifestations of personality traits and disorders in clinical settings, and how physician feelings may affect care. Management strategies are discussed.

[Frequent attenders in Primary Health Care Centres and frequent attenders in Emergency Departments]

Objetivo

Identificar factores predictores de hiperfrecuentación en Atención Primaria (AP) en una muestra de pacientes hiperfrecuentadores (HF) en servicios de urgencias hospitalarios (SUH).

Diseño

Estudio observacional retrospectivo multicéntrico.

Participantes

Se seleccionaron pacientes mayores de 14 años HF en el SUH entre el 1 de enero y el 31 de diciembre de 2013. Emplazamiento: se reclutaron pacientes atendidos en los SUH de 17 hospitales públicos de la Comunidad de Madrid.

Método

Se recogieron variables relativas a la visita índice del SUH. Se analizó la muestra en función de ser o no HF en AP. Se considera HF al paciente que realizó al menos 10 visitas en cada nivel asistencial durante un año.

Resultados

Se incluyeron 1.284 pacientes HF en SUH. Se analizaron 423 (32,9%) HF en AP con 16 visitas (RIC 12-25) frente a 861 (67,1%) pacientes no HF en AP con 4 visitas (RIC 2-6). Factores independientes predictores de HF en AP fueron la edad > 65 años (OR: 1,51; IC 95%: 1,07-2,13; p = 0,019), el deterioro cognitivo (OR: 1,63; IC 95%: 1,01-2,65; p = 0,049), el número de fármacos ≥3 (OR: 1,56; IC 95%: 1,06-2,30; p = 0,025) y vivir en la comunidad frente a vivir institucionalizado o en la calle (OR: 3,05; IC 95%: 1,14-8,16; p = 0,026).

Conclusiones

En una muestra de pacientes HF en los SUH, el hecho de ser mayor de 65 años, tomar 3 o más fármacos, presentar deterioro cognitivo y vivir en la comunidad se consideran factores predictores de ser HF también en AP.

A Comprehensive View of Frequent Emergency Department Users Based on Data from a Regional HIE

OBJECTIVES

A small but significant number of patients make frequent emergency department (ED) visits to multiple EDs within a region. We have a unique health information exchange (HIE) that includes every ED encounter in all hospital systems in our region. Using our HIE we were able to characterize all frequent ED users in our region, regardless of hospital visited or payer class. The objective of our study was to use data from an HIE to characterize patients in a region who are frequent ED users (FEDUs).

METHODS

We constructed a database from a cohort of adult patients (18 years old or older) with information in a regional HIE for a 1-year period beginning in April 2012. Patients were defined as FEDUs (those who made four or more visits during the study period) and non-FEDUs (those who made fewer than four ED visits during the study period). Predictor variables included age, race, sex, payer class, county of residence, and International Classification of Diseases, Ninth Revision codes. Bivariate (χ(2)) and multivariate (logistic regression) analyses were performed to determine associations between predictor variables and the outcome of being a FEDU.

RESULTS

The database contained 127,672 patients, 12,293 (9.6%) of whom were FEDUs. Logistic regression showed the following patient characteristics to be significantly associated with the outcome of being a FEDU: age 35 to 44 years; African American race; Medicaid, Medicare, and dual-pay payer class; and International Classification of Diseases, Ninth Revision codes 630 to 679 (complications of pregnancy, childbirth, and puerperium), 780 to 799 (ill-defined conditions), 280 to 289 (diseases of the blood), 290-319 (mental disorders), 680 to 709 (diseases of the skin and subcutaneous tissue), 710 to 739 (musculoskeletal and connective tissue disease), 460 to 519 (respiratory disease), and 520 to 579 (digestive disease). No significant differences were noted between men and women.

CONCLUSIONS

Data from an HIE can be used to describe all of the patients within a region who are FEDUs, regardless of the hospital system they visited. This information can be used to focus care coordination efforts and link appropriate patients to a medical home. Future studies can be designed to learn the reasons why patients become FEDUs, and interventions can be developed to address deficiencies in health care that result in frequent ED visits.

Factors Influencing the Frequency of Emergency Department Utilization by Individuals with Substance Use Disorders

This study assessed the characteristics of individuals with substance use disorders (ISUDs) according to their frequency of emergency department (ED) utilization, and examined which variables were associated with an increase in ED visits using Andersen's model. Data linkage of administrative databanks from three sources [addiction rehabilitation centre registry, physician billing systems, and hospital discharge databank] for 4526 ISUDs was performed. Predisposing, enabling and need factors associated with number of ED visits were determined using a negative binomial regression model and generalised estimating equations. The rate of ED utilization for this population was 9.6 %. Increased number of ED visits was associated with the following variables: older age, social fragmentation, number of consultations with general practitioners, number of consultations with psychiatrists, number of consultations with other types of physicians, alcohol abuse, drug abuse, schizophrenia, anxiety disorders, personality disorders, co-occurring substance dependence and mental disorders, co-occurring substance dependence and chronic physical disorders, and co-occurring mental health disorders and chronic physical disorders. By contrast, a diagnosis of substance dependence, co-occurring drug and alcohol abuse, and a co-occurring diagnosis of substance dependence with mental health and chronic physical disorders decreased ED visits. Efforts to reduce avoidable use of EDs should focus on chronic-disease management and other related strategies aimed at reinforcing services to ISUDs in the community, especially for ISUDs with a co-occurring diagnosis of either mental health disorders or chronic physical disorders.

Increased 30-Day Emergency Department Revisits Among Homeless Patients with Mental Health Conditions

INTRODUCTION

Patients with mental health conditions frequently use emergency medical services. Many suffer from substance use and homelessness. If they use the emergency department (ED) as their primary source of care, potentially preventable frequent ED revisits and hospital readmissions can worsen an already crowded healthcare system. However, the magnitude to which homelessness affects health service utilization among patients with mental health conditions remains unclear in the medical community. This study assessed the impact of homelessness on 30-day ED revisits and hospital readmissions among patients presenting with mental health conditions in an urban, safety-net hospital.

METHODS

We conducted a secondary analysis of administrative data on all adult ED visits in 2012 in an urban safety-net hospital. Patient demographics, mental health status, homelessness, insurance coverage, level of acuity, and ED disposition per ED visit were analyzed using multilevel modeling to control for multiple visits nested within patients. We performed multivariate logistic regressions to evaluate if homelessness moderated the likelihood of mental health patients' 30-day ED revisits and hospital readmissions.

RESULTS

Study included 139,414 adult ED visits from 92,307 unique patients (43.5±15.1 years, 51.3% male, 68.2% Hispanic/Latino). Nearly 8% of patients presented with mental health conditions, while 4.6% were homeless at any time during the study period. Among patients with mental health conditions, being homeless contributed to an additional 28.0% increase in likelihood (4.28 to 5.48 odds) of 30-day ED revisits and 38.2% increase in likelihood (2.04 to 2.82 odds) of hospital readmission, compared to non-homeless, non-mental health (NHNM) patients as the base category. Adjusted predicted probabilities showed that homeless patients presenting with mental health conditions have a 31.1% chance of returning to the ED within 30-day post discharge and a 3.7% chance of hospital readmission, compared to non-homeless patients presenting with mental health conditions (25.2%, 2.6%) and NHNM (7.7%, 1.5%).

CONCLUSION

Homeless patients presenting with mental health conditions were more likely to return to the ED within 30 days and to be readmitted to the hospital. Interventions providing housing might improve their overall care management and have the potential to reduce ED revisits and hospital readmissions.

Predicting Frequent Emergency Department Use by Pediatric Medicaid Patients

The objective of this study was to determine the patient characteristics and health care utilization patterns that predict frequent emergency department (ED) use (≥4 visits per year) over time to assist health care organizations in targeting patients for care management. This was a retrospective, population-based study of 13,265 Medicaid children aged 0-20 years who were attributed to a single pediatric accountable care organization for at least 2 consecutive years between June 2012 and May 2015. Year-to-year persistence as a frequent ED user was 36.3% (95% confidence interval [CI]: 33.4 to 38.4), which does not support the notion that once a frequent user, always a frequent user. Hence, interventions to reduce frequent ED use may appear to be effective when ED use would have regressed toward the mean without any intervention. At an individual patient level, predictability of frequent ED use was 0.437 (95% CI: 0.358 to 0.485) across frequent ED users of all ages compared with 0.723 (95% CI: 0.435 to 0.824) for those aged <1 year. Accordingly, this latter group may be a better target for interventions than frequent ED users generally.

The prehospital and hospital costs of emergency care for frequent ED patients

INTRODUCTION

Frequent emergency department (ED) use has been identified as a cause of ED overcrowding and increasing health care costs. Studies have examined the expense of frequent patients (FPs) to hospitals but have not added the cost Emergency Medical Services (EMS) to estimate the total cost of this pattern of care.

METHODS

Data on 2012 ED visits to a rural Level I Trauma Center and public safety net hospital were collected through a deidentified patient database. Transport data and 2012 Medicare Reimbursement Schedules were used to estimate the cost of EMS transport. Health information, outcomes, and costs were compared to find differences between the FP and non-FP group.

RESULTS

This study identified 1242 FPs who visited the ED 5 or more times in 2012. Frequent patients comprised 3.25% of ED patients but accounted for 17% of ED visits and 13.7% of hospital costs. Frequent patients had higher rates of chronic disease, severity scores, and mortality. Frequent patients arrived more often via ambulance and accounted for 32% of total transports at an estimated cost of $2.5-$3.2 million. Hospital costs attributable to FPs were $29.1 million, bringing the total cost of emergency care to $31.6-$32.3 million, approximately $25,000 per patient.

CONCLUSIONS

This study demonstrates that the inclusion of a prehospital cost estimate adds approximately 10% to the cost of care for the FP population. In addition to improving care for a sick population of patients, programs that reduce frequent EMS and ED use have the potential to produce a favorable cost benefit to communities and health systems.

Frequent users of the emergency department services in the largest academic hospital in the Netherlands: a 5-year report

OBJECTIVE

To investigate the demographic and service characteristics, motive for consultation, and disposition of adult frequent users (FUs) of the largest academic hospital in the Netherlands over a 5-year period.

PATIENTS AND METHODS

This retrospective study included all patients aged 18 years and older visiting the emergency department (ED) during a 5-year period (2009-2013). Frequent ED use was defined as having four or more visits to the ED during a year. Patient and service characteristics, motive for consultation, and disposition were explored.

RESULTS

Frequent ED users represented 2% of all patients who visited the ED during 2009-2013 (8% of all ED consultations). On average, each FU visited the ED five times per year. Compared with nonfrequent users (NFUs), FUs were significantly less often self-referred, less frequently transported to the hospital by ambulance, received a lower urgency code upon arrival to the ED, and more often admitted to hospital than NFUs. Complaints related to the digestive system (19%), general complaints such as fever (18%), respiratory (10%), or cardiovascular problems (10%) were the main motive for consultations of the frequent ED users. Two percent of the FUs were serial FUs (FUs during 3 or more consecutive years).

CONCLUSION

Frequent use of the ED has been depicted as inappropriate use of these services. However, our study shows that FUs consist of a relatively small number of patients and that FUs suffer from chronic, and often, severe somatic illnesses that require specialized medical care.