Frequent use of emergency departments in Saudi public hospitals: implications for primary health care services

To Admit or Not to Admit to the Emergency Department: The Disposition Question at a Tertiary Teaching and Referral Hospital

BACKGROUND

Disposition decision-making in the emergency department (ED) is crucial to patient safety and quality of care. It can inform better care, lower chance of infections, appropriate follow-up care, and reduced healthcare costs. The aim of this study was to examine correlates of ED disposition among adult patients at a teaching and referral hospital based on patients' demographic, socioeconomic, and clinical characteristics.

METHOD

A cross-sectional study conducted at the ED of the King Abdulaziz Medical City hospital in Riyadh. A two-level validated questionnaire was used-a patient questionnaire and healthcare staff/facility survey. The survey employed a systematic random sampling technique to recruit subjects at a pre-specified interval as patients arrived at the registration desk. We analyzed 303 adult patients visiting the ED, who were triaged, consented to participate in the study, completed the survey, and admitted to a hospital bed or discharged home. We used descriptive and inferential statistics to summarize and determine the interdependence and relationships of variables. We used logistic multivariate regression analysis to establish relationships and the odds of admission to a hospital bed.

RESULTS

The mean age of the patients was 50.9 (SD = 21.4, Range 18 to 101). A total of 201 (66%) were discharged home while the rest were admitted to a hospital bed. Results of the unadjusted analysis suggest that older patients, males, patients with low level of education, and those with comorbidities and middle-income were more likely to be admitted to the hospital. The results of the multivariate analysis suggest that patients with comorbidities, urgent conditions, prior history of hospitalization, and higher triage levels were more likely to be admitted to a hospital bed.

CONCLUSIONS

Having proper triage and timely stopgap review measures in the admission process can help new patients to locations that best support their needs and improve the quality and efficiency of the facility. The findings may be a sentinel indicator that informs overuse or inappropriate use of EDs for non-emergency care, which is a concern in the Saudi Arabian publicly funded health system.

Risk profiles of frequent outpatients among public assistance recipients in Japan: a retrospective cohort study using a classification and regression trees algorithm

OBJECTIVES

Although several individual risk factors of frequent outpatient attendance (FOA) have previously been reported, identifying a specific risk profile is needed to provide effective intervention for impoverished citizens with complex biopsychosocial needs. We aimed to identify potential risk profiles of FOA among public assistance recipients in Japan by using classification and regression trees (CART) and discussed the possibilities of applying the CART to policypractice as compared with the results of conventional regression analyses.

DESIGN

We conducted a retrospective cohort study.

SETTING

We used secondary data from the public assistance databases of six municipalities in Japan.

PARTICIPANTS

The study population included all adults on public assistance in April 2016, observed until March 2017. We obtained the data of 15 739 people on public assistance. During the observational period, 435 recipients (2.7%) experienced FOA.

OUTCOME MEASURE

We dichotomised a cumulative incidence of FOA during the study period into a binary variable of exhibiting FOA or not. We adopted the definition of FOA by the Ministry of Health, Labour, and Welfare: visiting the same medical institution more than 15 days a month.

RESULTS

The results of the CART showed that an employed subpopulation with mental disabilities exhibited the highest risk of FOA (incidence proportion: 16.7%). Meanwhile, multiple Poisson regression showed that the adjusted incidence ratio of being unemployed (vs employed) was 1.71 (95% CI 1.13 to 2.59).

CONCLUSIONS

Using the CART model, we could identify specific risk profiles that could have been overlooked when considering only the risk factors obtained from regression analysis. Public health activities can be provided effectively by focusing on risk factors and the risk profiles.

Epidemiology of Frequent Visits to the Emergency Department at a Tertiary Care Hospital in Saudi Arabia: Rate, Visitors' Characteristics, and Associated Factors

Background

Emergency department overcrowding is becoming a challenge for the healthcare management system globally and locally. This study aimed to estimate the frequency of ED visits, describe the patients’ profile along with visit-related characteristics, and associated factors in a tertiary care hospital.

Methods

A retrospective cohort study was conducted at a tertiary care hospital. The study included patients age 14 years and above visiting the main emergency department in year 2013. Data were extracted from electronic medical records by a qualified data extraction team. Statistical analyses were performed, including the odds ratio and 95% confidence interval for the factors associated with highly frequent (≥14 visits) ED visits using logistic regression models.

Results

There were 150,727 visits to the emergency department within a year. The number of frequent visitors was 7696 (9.38%), with 42,226 visits (28.01% of total ED visits). Highly frequent visitors totaled 249 (0.30%), with 5173 visits (3.43% of total ED visits). The frequent visitors’ average age was 42.55 (SD 20.14), and 48.99 (SD 21.33) for the highly frequent visitors’ group. More than half of the emergency visitors were females. The most common complaints among the highly frequent visitors were Gastrointestinal (21.34%), followed by Respiratory (13.47%), Orthopedic (12.57%), and Cardiovascular (12.43%). Multivariate analysis indicated that age, history of diabetes, history of cardiac diseases, insurance status, and nationality were significant predicators of highly frequent visits to the hospital emergency.

Conclusion

Frequent and highly frequent visitors to emergency departments represent a significant proportion of adult patients presenting to ED. Their visits constitute almost one-third of total ED visits. Several factors associated with highly frequent ED visits have been identified. This study provides local empirical evidence to develop improvement policy and actions related to chronic issue of frequent and highly frequent visitation to hospital ED.

The Impact of Socioeconomic Status on Hospital Accessibility in Otorhinolaryngological Disease in Korea

This study aimed to investigate the impact of socioeconomic status (SES) on otorhinolaryngology disease severity status diagnosed at the first hospital visit. We conducted a retrospective study over 20 years (2000-2019). Otorhinolaryngological diseases included chronic rhinosinusitis (CRS), sensorineural hearing loss (SNHL), oral ulcer, and malignant neoplasms. A logistic regression model was employed to assess the effect of SES on the severity of each disease at the first hospital visit. The severity of CRS increased in patients with lower SES (P = .028). The severities of SNHL (P = .032) and oral ulcer (P < .001) also associated with SES. In contrast, between the low- and high-SES groups observed no differences in cancer stage (P = .845). Patients with SNHL, oral ulcer, and CRS had a more severe disease status in the low-SES group than in the high-SES group at the first hospital visit. Efforts to increase hospital accessibility for low-SES otorhinolaryngological patients should be made.

Frequent outpatient attendance among people on the governmental welfare programme in Japan: assessing both patient and supplier characteristics

OBJECTIVES

Using linkage data from two municipal public assistance databases and medical assistance claim data, this study aimed to identify characteristics associated with frequent outpatient attendance by people on public assistance, who can access medical care services without copayment in Japan, with simultaneous consideration of supplier factors.

DESIGN

We performed a retrospective cohort study.

SETTING

We used secondary data from the public assistance databases of two suburban municipalities in Japan.

PARTICIPANTS

The study population included all adults on public assistance in January 2016, who were observed until December 2016. A total of 6016 people was included in the analysis. Among them, 2956 (49.1%) were men, and 2030 (33.7%) were living alone.

OUTCOME MEASURE

We adopted the definition of frequent outpatient attendance by the Japanese Ministry of Health, Labour and Welfare, visiting the same medical facility 15 times or more in a month for the same health problem.

RESULTS

Of 6016 included people, 139 (2.3%) were engaged in frequent outpatient attendance. Multiple Poisson regression showed that, as for the individual factors, the adjusted incidence ratio for frequent outpatient attendance was 1.58 (95% CI 1.05 to 2.39) for people living alone (vs living with others). As for the suppliers, the adjusted incidence ratio for frequent outpatient attendance was 1.74 (95% CI 1.20 to 2.52) for private institutions (vs medical corporations). There were no significant associations between frequent outpatient attendance and individual disability certificate or long-term care needs.

CONCLUSIONS

This study suggests that among recipients of public assistance who can access medical services without copayment, social isolation may be associated with frequent outpatient attendance. Private clinics may also be associated with this phenomenon. Interventions to prevent social isolation-by for example, providing health and social care in a more integrated manner-may thus be efficacious in reducing the healthcare demands of socially vulnerable individuals.

Emergency medicine in Saudi Arabia: a century of progress and a bright vision for the future

Although emergency medical services (EMS) and pre-hospital care have existed in the Kingdom of Saudi Arabia (KSA) since 1934, emergency medicine (EM) is a relatively new medical field in the country that was not formally recognized as a medical specialty until 2001. In 2005, the Saudi Board of Emergency Medicine formed to develop, implement, and evaluate a standardized curriculum for EM residents. Since then, EM and the pre-hospital system in the KSA has evolved and grown. This article provides an overview of emergency medicine in Saudi Arabia and the progress it has made in the pre-hospital system, healthcare delivery system, and emergency medicine training. Finally, we will discuss the challenges and opportunities faced as this specialty continues to develop.

Statistical tools used for analyses of frequent users of emergency department: a scoping review

OBJECTIVE

Frequent users represent a small proportion of emergency department users, but they account for a disproportionately large number of visits. Their use of emergency departments is often considered suboptimal. It would be more efficient to identify and treat those patients earlier in their health problem trajectory. It is therefore essential to describe their characteristics and to predict their emergency department use. In order to do so, adequate statistical tools are needed. The objective of this study was to determine the statistical tools used in identifying variables associated with frequent use or predicting the risk of becoming a frequent user.

METHODS

We performed a scoping review following an established 5-stage methodological framework. We searched PubMed, Scopus and CINAHL databases in February 2019 using search strategies defined with the help of an information specialist. Out of 4534 potential abstracts, we selected 114 articles based on defined criteria and presented in a content analysis.

RESULTS

We identified four classes of statistical tools. Regression models were found to be the most common practice, followed by hypothesis testing. The logistic regression was found to be the most used statistical tool, followed by χ2 test and t-test of associations between variables. Other tools were marginally used.

CONCLUSIONS

This scoping review lists common statistical tools used for analysing frequent users in emergency departments. It highlights the fact that some are well established while others are much less so. More research is needed to apply appropriate techniques to health data or to diversify statistical point of views.

Frequent Users of Hospital Emergency Departments in Korea Characterized by Claims Data from the National Health Insurance: A Cross Sectional Study

The Korean National Health Insurance, which provides universal coverage for the entire Korean population, is now facing financial instability. Frequent emergency department (ED) users may represent a medically vulnerable population who could benefit from interventions that both improve care and lower costs. To understand the nature of frequent ED users in Korea, we analyzed claims data from a population-based national representative sample. We performed both bivariate and multivariable analyses to investigate the association between patient characteristics and frequent ED use (4+ ED visits in a year) using claims data of a 1% random sample of the Korean population, collected in 2009. Among 156,246 total ED users, 4,835 (3.1%) were frequent ED users. These patients accounted for 14% of 209,326 total ED visits and 17.2% of $76,253,784 total medical expenses generated from all ED visits in the 1% data sample. Frequent ED users tended to be older, male, and of lower socio-economic status compared with occasional ED users (p < 0.001 for each). Moreover, frequent ED users had longer stays in the hospital when admitted, higher probability of undergoing an operative procedure, and increased mortality. Among 8,425 primary diagnoses, alcohol-related complaints and schizophrenia showed the strongest positive correlation with the number of ED visits. Among the frequent ED users, mortality and annual outpatient department visits were significantly lower in the alcohol-related patient subgroup compared with other frequent ED users; furthermore, the rate was even lower than that for non-frequent ED users. Our findings suggest that expanding mental health and alcohol treatment programs may be a reasonable strategy to decrease the dependence of these patients on the ED.