Frequent emergency department use in Sweden: implications for emergency medicine in the United States

From Their Perspective: The Connection between Life Stressors and Health Care Service Use Patterns of Homeless Frequent Users of the Emergency Department

The perspective of homeless adults on their health care service utilization is not well studied. This article describes a study that used in-depth, semistructured interviews with 18 individuals to highlight the viewpoints of homeless people who are frequent users of the emergency department (ED) about the influence of life events on service utilization. Participants reported high levels of pain and comorbid psychiatric, substance use, and medical conditions. They also reported an identifiable pattern of health care utilization, often centered on a crisis event, influenced by high perceived medical needs, inability to cope after crisis, predisposing vulnerability from social determinants of health, and health care system factors. A social work case management intervention often led to a period of stability and use of ED alternatives. Modifiable targets for intervention at the health care system and local levels include improving trust and convenience of ED alternatives, enhancing consistency of care at ED-alternative sites, and educating those at risk of frequent ED use about community alternatives.

Screening for frailty among older emergency department visitors: Validation of the new FRESH-screening instrument

Background

The identification of frail older persons in different health care settings is widely seen as an important step in improving the healthcare system. Screening at an emergency department (ED) should be handled in just a few minutes without the use of tests or measurements. The FRESH-screening was developed for this purpose. This study’s aim was to evaluate the FRESH-screening and its construct validity; also assessed were the sensitivity, specificity, and predictive values for frailty screening.

Methods

The study had a cross-sectional design. A total of 161 elderly people who sought care at the emergency department at Mölndal Hospital were included. Inclusion criteria were ages ≥80 years or ages 65–79 with at least one chronic disease and dependence in at least one daily living activity. Sensitivity, specificity, and predictive values were calculated to describe the accuracy of the FRESH-screening in identifying those with frailty, as assessed by eight frailty indicators. Sensitivity and specificity were both set at a minimum of 80 %, and a percentage sum ≥150 of the sensitivity and positive prediction was considered a measure of excellent value.

Result

Both sensitivity and specificity were high (81 % and 80 %, respectively) when comparing the four questions of the FRESH-screening against the eight frailty indicators. The percentage sum of sensitivity and positive prediction was 173 (81 % + 92 %), thus exceeding the 150 cutoff.

Conclusion

This study shows the FRESH-screening to be of excellent clinical value. Additionally, the clinical experience is that the instrument is simple and rapid to use, takes only a few minutes to administer, and requires minimal energy input by older persons.

Effectiveness of interventions targeting frequent users of emergency departments: a systematic review

STUDY OBJECTIVE

Frequent users of emergency departments (EDs) are a relatively small group of vulnerable patients accounting for a disproportionally high number of ED visits. Our objective is to perform a systematic review of the type and effectiveness of interventions to reduce the number of ED visits by frequent users.

METHODS

We searched MEDLINE, EMBASE, CINAHL, PsychINFO, the Cochrane Library, and ISI Web of Science for randomized controlled trials, nonrandomized controlled trials, interrupted time series, and controlled and noncontrolled before-and-after studies describing interventions targeting adult frequent users of EDs. Primary outcome of interest was the reduction in ED use. We also explored costs analyses and various clinical (alcohol and drug use, psychiatric symptoms, mortality) and social (homelessness, insurance status, social security support) outcomes.

RESULTS

We included 11 studies (3 randomized controlled trials, 2 controlled and 6 noncontrolled before-and-after studies). Heterogeneity in both study designs and definitions of frequent users precluded meta-analyses of the results. The most studied intervention was case management (n=7). Only 1 of 3 randomized controlled trials showed a significant reduction in ED use compared with usual care. Six of the 8 before-and-after studies reported a significant reduction in ED use, and 1 study showed a significant increase. ED cost reductions were demonstrated in 3 studies. Social outcomes such as reduction of homelessness were favorable in 3 of 3 studies, and clinical outcomes trended toward positive results in 2 of 3 studies.

CONCLUSION

Interventions targeting frequent users may reduce ED use. Case management, the most frequently described intervention, reduced ED costs and seemed to improve social and clinical outcomes. It appears to be beneficial to patients and justifiable for hospitals to implement case management for frequent users in the framework of a clear and consensual definition of frequent users and standardized outcome measures.

Frequent users of Massachusetts emergency departments: a statewide analysis

STUDY OBJECTIVE

We describe the epidemiology of frequent users of emergency departments (EDs), using a statewide dataset derived from linked ED, observation stay, and inpatient hospital discharge databases.

METHODS

Unique patient identifiers were used to link visits across databases, encompassing all ED visits regardless of disposition. Individuals with 5 or more visits during a year were considered frequent users and were compared with infrequent users, as well as nonusers, using descriptive statistics.

RESULTS

Only 1% of Massachusetts residents were frequent users, but they made 17.6% of all ED visits in fiscal year 2003; 57.8% of residents used multiple EDs. Compared with infrequent users, frequent users were more likely to die at their last visit (2.6% of frequent users versus 1.1% of infrequent users), were hospitalized at higher rates (18.8% versus 14.2% of visits), and were transported more frequently by ambulance (18.6% versus 12.1% of visits). Two percent of the uninsured individuals were frequent users compared with 2.1% of Medicaid enrollees, 2.0% of Medicare enrollees, and 0.4% of privately insured individuals. Only 15% of frequent users were uninsured. Frequent ED use is typically temporary; just 28.4% of frequent users in fiscal year 2002 remained frequent users in fiscal year 2003.

CONCLUSION

Uninsured individuals are no more likely than publicly insured individuals to be ED frequent users and compose only 15% of them. Frequent users tend to be sicker than infrequent users, but most use the ED at high rates temporarily and visit the ED less frequently or not at all the following year.

Frequent attenders to an emergency department: a study of primary health care use, medical profile, and psychosocial characteristics

STUDY OBJECTIVE

We describe, in comparison with a control group, frequent attenders to an emergency department in terms of their general health service use and their clinical, psychological, and social profiles.

METHODS

One hundred frequent attenders (those who had made > or =4 visits in the previous year) and 100 nonfrequent attenders matched for sex, age, and triage category were interviewed in the ED. Data were gathered on health service use, mental health (by using the General Health Questionnaire-12 item), and perceived social support (by using the Multidimensional Scale of Perceived Social Support). Patients' general practitioners were contacted to validate attendance data. Medical charts were searched for evidence of psychological problems and alcohol or drug abuse.

RESULTS

In the overall sample of 200 patients, 32% were female, and the mean age was 55 years (SD 20). Frequent attenders had made more visits to their general practitioner in the past year compared with control patients (median 12 versus 3 visits); a higher proportion of frequent attenders had used public health nursing services, community welfare services, social work services, addiction counseling, and psychiatric services in the past year. Frequent attenders had made more other hospital visits and had spent more nights in the hospital than control patients. General Health Questionnaire-12 item scores were higher for frequent attenders than control patients, indicating poorer mental health. Frequent attenders had lower levels of perceived social support.

CONCLUSION

Frequent attenders to the ED are also heavy users of general practice services, other primary care services, and other hospital services. General Medical Services-eligible patients (84% of frequent attenders) frequently attend the ED, even though they have free access to primary care. Frequent attenders are a psychosocially vulnerable group, and service providers and policy makers need to take account of this vulnerable patient profile as they endeavor to meet their service needs.