Reducing frequent visits to the emergency department: a systematic review of interventions

Variation in attendance at emergency departments in England across local areas: A system under unequal pressure

BACKGROUND

Crowding in Accident and Emergency Departments (AEDs) and long waiting times are critical issues contributing to adverse patient outcomes and system inefficiencies. These challenges are exacerbated by varying levels of AED attendance across different local areas, which may reflect underlying disparities in primary care provision and population characteristics.

METHOD

We used regression analysis to determine how much variation across local areas in England of attendance at emergency departments remained after controlling for population risk factors and alternative urgent care provision.

FINDINGS

There is substantial residual variation of the order of 3 to 1 (highest to lowest) in per person attendance rate across different areas. This is not related to in-hospital capacity as proxied by the per person number of hospital emergency doctors in an area.

CONCLUSION

Some areas in England have emergency departments that are under much greater pressure than others, and this cannot be explained in terms of their population characteristics or the availability of alternative treatment options. It is imperative to better understand the drivers of this variation so that effective interventions to address utilisation can be designed.

Opportunities of integrated care to improve equity for adults with complex needs: a qualitative study of case management in primary care

BACKGROUND

People living in precarious socio-economic conditions are at greater risk of developing mental and physical health disorders, and of having complex needs. This places them at risk of health inequity. Addressing social determinants of health (SDH) can contribute to reducing this inequity. Case management in primary care is an integrated care approach which could be an opportunity to better address SDH. The aim of this study is to better understand how case management in primary care may address the SDH of people with complex needs.

METHODS

A case management program (CMP) for people with complex needs was implemented in four urban primary care clinics. A qualitative study was conducted with semi-structured interviews and a focus group with key informants (n = 24). An inductive thematic analysis was carried out to identify emerging themes.

RESULTS

Primary care case managers were well-positioned to provide a holistic evaluation of the person's situation, to develop trust with them, and to act as their advocates. These actions helped case managers to better address individuals' unmet social needs (e.g., poor housing, social isolation, difficulty affording transportation, food, medication, etc.). Creating partnerships with the community (e.g., streetworkers) improved the capacity in assisting people with housing relocation, access to transportation, and access to care. Assuming people provide their consent, involving a significant relative or member of their community in an individualized services plan could support people in addressing their social needs.

CONCLUSIONS

Case management in primary care may better address SDH and improve health equity by developing a trusting relationship with people with complex needs, improving interdisciplinary and intersectoral collaboration and social support. Future research should explore ways to enhance partnerships between primary care and community organizations.

Payment Innovation in Emergency Care: A Case for Global Clinician Budgets

The fee-for-service funding model for US emergency department (ED) clinician groups is increasingly fragile. Traditional fee-for-service payment systems offer no financial incentives to improve quality, address population health, or make value-based clinical decisions. Fee-for-service also does not support maintaining ED capacity to handle peak demand periods. In fee-for-service, clinicians rely heavily on cross-subsidization, where high reimbursement from commercial payors offsets low reimbursement from government payors and the uninsured. Although fee-for-service survived decades of steady cuts in government reimbursement rates, it is increasingly strained because of visit volatility and the effects of the No Surprises Act, which is driving down commercial reimbursement. Financial pressures on ED clinician groups and higher hospital boarding and clinical workloads are increasing workforce attrition. Here, we propose an alternative model to address some of these fundamental issues: an all-payer-funded, voluntary global budget for ED clinician services. If designed and implemented effectively, the model could support robust clinician staffing over the long term, ensure stability in clinical workload, and potentially improve equity in payments. The model could also be combined with population health programs (eg, pre-ED and post-ED telehealth, frequent ED use programs, and other innovations), offering significant payer returns and addressing quality and value. A linked program could also change hospital incentives that contribute to boarding. Strategies exist to test and refine ED clinician global budgets through existing government programs in Maryland and potentially through state-level legislation as a precursor to broader adoption.

Aspiring to clinical significance: Insights from developing and evaluating a machine learning model to predict emergency department return visit admissions

Return visit admissions (RVA), which are instances where patients discharged from the emergency department (ED) rapidly return and require hospital admission, have been associated with quality issues and adverse outcomes. We developed and validated a machine learning model to predict 72-hour RVA using electronic health records (EHR) data. Study data were extracted from EHR data in 2019 from three urban EDs. The development and independent validation datasets included 62,154 patients from two EDs and 73,453 patients from one ED, respectively. Multiple machine learning algorithms were evaluated, including deep significance clustering (DICE), regularized logistic regression (LR), Gradient Boosting Decision Tree, and XGBoost. These machine learning models were also compared against an existing clinical risk score. To support clinical actionability, clinician investigators conducted manual chart reviews of the cases identified by the model. Chart reviews categorized predicted cases across index ED discharge diagnosis and RVA root cause classifications. The best-performing model achieved an AUC of 0.87 in the development site (test set) and 0.75 in the independent validation set. The model, which combined DICE and LR, boosted predictive performance while providing well-defined features. The model was relatively robust to sensitivity analyses regarding performance across age, race, and by varying predictor availability but less robust across diagnostic groups. Clinician examination demonstrated discrete model performance characteristics within clinical subtypes of RVA. This machine learning model demonstrated a strong predictive performance for 72- RVA. Despite the limited clinical actionability potentially due to model complexity, the rarity of the outcome, and variable relevance, the clinical examination offered guidance on further variable inclusion for enhanced predictive accuracy and actionability.

Emergency care in Brazil: factors leading to clinically inappropriate use of emergency care among young adult users in the Brazilian context

BACKGROUND

This study aims to investigate the prevalence and associated risk factors of inappropriate use of emergency services among young adults in Vitória, Brazil.

METHODS

A cross-sectional study was conducted over 30 consecutive days in November and December 2019, involving systematic random sampling of young adults (aged 18-39) visiting the municipal emergency care unit. Data were collected through structured interviews, utilizing the Hospital Urgency Appropriateness Protocol (HUAP) to identify inappropriate use. Demographic characteristics, healthcare utilization patterns, and medical diagnoses were assessed. Poisson regression models were employed to explore associations between variables.

RESULTS

Among the 631 young adults surveyed, 30.6% exhibited inappropriate use of the emergency care unit. Factors associated with higher rates of inappropriate use included not seeking previous care in other healthcare services; having specific medical diagnoses like diseases of the respiratory system (PR: 2.03), diseases of the skin (PR: 4.13), and diseases of the ear and mastoid (PR: 3.74).

CONCLUSION

The study underscores the significance of addressing inappropriate use of emergency services among young adults. Though the prevalence of inappropriate use was not significantly different from other age groups, the demographic characteristics and healthcare utilization patterns of young adults contribute to their unique challenges. To mitigate inappropriate use, efforts should focus on improving access to primary healthcare services, enhancing continuity of care, and raising awareness about appropriate healthcare-seeking behaviors among young adults. Ultimately, these interventions can foster a more effective and sustainable healthcare system that better serves the needs of the community.

Case management in primary healthcare for people with complex needs to improve integrated care: a large-scale implementation study protocol

INTRODUCTION

Case management (CM) is among the most studied effective models of integrated care for people with complex needs. The goal of this study is to scale up and assess CM in primary healthcare for people with complex needs.

METHODS AND ANALYSIS

The research questions are: (1) which mechanisms contribute to the successful scale-up of CM for people with complex needs in primary healthcare?; (2) how do contextual factors within primary healthcare organisations contribute to these mechanisms? and (3) what are the relationships between the actors, contextual factors, mechanisms and outcomes when scaling-up CM for people with complex needs in primary healthcare? We will conduct a mixed methods Canadian interprovincial project in Quebec, New-Brunswick and Nova Scotia. It will include a scale-up phase and an evaluation phase. At inception, a scale-up committee will be formed in each province to oversee the scale-up phase. We will assess scale-up using a realist evaluation guided by the RAMESES checklist to develop an initial programme theory on CM scale-up. Then we will test and refine the programme theory using a mixed-methods multiple case study with 10 cases, each case being the scalable unit of the intervention in a region. Each primary care clinic within the case will recruit 30 adult patients with complex needs who frequently use healthcare services. Qualitative data will be used to identify contexts, mechanisms and certain outcomes for developing context-mechanism-outcome configurations. Quantitative data will be used to describe patient characteristics and measure scale-up outcomes.

ETHICS AND DISSEMINATION

Ethics approval was obtained. Engaging researchers, decision-makers, clinicians and patient partners on the study Steering Committee will foster knowledge mobilisation and impact. The dissemination plan will be developed with the Steering Committee with messages and dissemination methods targeted for each audience.

Community Mental Health Services for Frequent Emergency Department Users: A Qualitative Study of Outcomes Perceived by Program Clients and Case Managers

PURPOSE OF STUDY

This study aimed to investigate the perceived outcomes and mechanisms of change of a community mental health service combining system navigation and intensive case management supports for frequent emergency department users presenting with mental illness or addiction.

PRIMARY PRACTICE SETTING

The study setting was a community mental health agency receiving automated referrals directly from hospitals in a midsize Canadian city for all individuals attending an emergency department two or more times within 30 days for mental illness or addiction.

METHODOLOGY AND SAMPLE

Qualitative interviews with 15 program clients. Focus groups with six program case managers. Data were analyzed using pragmatic qualitative thematic analysis.

RESULTS

Participants generally reported perceiving that the program contributed to reduced emergency department use, reduced mental illness symptom severity, and improved quality of life. Perceived outcomes were more mixed for outcomes related to addiction. Reported mechanisms of change emphasized the importance of positive working relationships between program clients and case managers, as well as focused efforts to develop practical skills.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Community mental health services including intensive case management for frequent emergency department users presenting with mental illness or addiction were perceived to effectively address client needs while reducing emergency department resource burden. Similar programs should emphasize the development of consistent and warm working relationships between program clients and case managers, as well as practical skills development to support client health and well-being.

Examining management plans for patients who frequently presented to the emergency department

BACKGROUND

Patients who frequently present to Emergency Department (ED) experience complex health and social needs. While research has examined interventions that aim to decrease frequent ED attendances, there is a need to understand the types of interventions provided to patients by hospital clinicians during presentations.

METHODS

Using qualitative content analysis, 82 management plans were evaluated to understand the scope and type of interventions provided by clinicians for patients frequently presenting to the ED at the Royal Melbourne Hospital, Australia.

RESULTS

Patients often presented to the ED due to mental and psychological distress, substance use and physical health concerns alongside psychosocial vulnerabilities. The goals of care documented in plans focussed on management of health issues, aggression within the ED, and coordinating care with community services. Recommended interventions addressed presenting needs with multi-disciplinary approach to respond to distress and aggression. Finally, the plans provided insight into service coordination dynamics between the ED and community-based health and social care services.

CONCLUSIONS

The plans recommended interventions that sought to provide holistic care for patients in collaboration with relevant community-based services. The findings suggest that clinicians in the ED can provide appropriate and meaningful care for patients who experience frequent presentations.

Health mediation does not reduce the readmission rate of frequent users of emergency departments living in precarious conditions: what lessons can be learned from this randomised controlled trial?

BACKGROUND

Severe overcrowding of emergency departments (EDs) affects the quality of healthcare. One factor of overcrowding is precariousness, but it has rarely been considered a key factor in designing interventions to improve ED care. Health mediation (HM) aims to facilitate access to rights, prevention, and care for the most vulnerable persons and to raise awareness among healthcare providers about obstacles in accessing healthcare. The primary aim was to determine whether HM intervention for frequent users of EDs (FUED) living in precarious conditions could reduce the readmission rate at 90 days.

METHODS

Between February 2019 and May 2022, we enrolled and interviewed 726 FUED in four EDs of southeastern France in this randomised controlled trial. The HM intervention started in the ED and lasted 90 days. In addition to the primary endpoint (first readmission at 90 days), secondary endpoints (readmission at 30 and 180 days, number of hospitalisations at 30, 90, 180 days, admissions for the same reasons as the first admission) were also studied. The outcomes were measured in the ED information systems. Statistical methods included an intention-to-treat analysis and a per-protocol analysis. Comparisons were adjusted for gender, age, ED, and health mediator.

RESULTS

46% of patients reported attending the ED because they felt their life was in danger, and 42% had been referred to the ED by the emergency medical dispatch centre or their GP; 40% of patients were considered to be in a serious condition by ED physicians. The proportion of patients who were readmitted at 90 days was high but did not differ between the control and the HM intervention groups (31.7% vs. 36.3%, p = 0.23). There was no significant difference in any of the secondary outcome measures between the control and HM intervention groups. Per-protocol analysis also showed no significant difference for the primary and secondary endpoints.

CONCLUSIONS

This randomised controlled trial did not show that our health mediation intervention was effective in reducing the use of emergency services by FUED living in precarious conditions. Some limitations are discussed: the duration of the intervention (90 days), the long-term effects (> 6 months), the involvement of the ED staff.

TRIAL REGISTRATION

Registered on clinicaltrials.gov as NCT03660215 on 4th September 2018.

Development of an Emergency Department Case Management Case-Finding Tool

PURPOSE OF STUDY

Identifying emergency department (ED) patients who are at high risk for return visits is an important goal for case management to improve patient care. This quality improvement study describes the development and evaluation of the Emergency Department Case Management Priority Score (EDCMPS), an electronic medical record (EMR)-based "case-finding" system, and its ability to identify these high-risk patients. In addition, the authors present data about its acceptability among emergency department case managers (ED CMs).

PRIMARY PRACTICE SETTINGS

Emergency departments with case management availability and staffing.

METHODOLOGY AND SAMPLE

A retrospective analysis at Duke University Hospital ED compared patient data pre- and postimplementation of the EDCMPS. The tool was developed using the LEAN and Plan-Do-Study-Act (PDSA) quality improvement methodologies, with ED CM participation. ED return and hospitalization rates within 7 and 30 days between both methods were compared, and a survey evaluated CM satisfaction with the EDCMPS.

RESULTS

The 2-month preintervention period (July 1, 2022, to August 31, 2022) included 8,677 patients discharged from the ED, with 897 patients (10.3%) identified as at high risk for return based on the previous manual methodology. In the 3-month postintervention period (September 1, 2022, to November 30, 2022), there were 13,566 patients discharged, with 692 patients (5.1%) identified as at high risk for return using the EDCMPS. The EDCMPS outperformed the manual method, yielding a significantly higher odds ratio (OR) for 7- and 30-day ED return or hospitalization (e.g., 30-day any return OR = 4.21 vs. 1.69). The survey showed broad ED CM agreement on the tool's superior performance, especially in organizing outpatient resources and referring to support programs. However, challenges in securing primary care follow-up, housing, and health insurance applications were identified. The tool's collaborative development approach ensured its fit to ED CM needs, contributing to its success.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

The EDCMPS showcases promise in enhancing ED CM efficiency, with strong frontline staff endorsement. It pinpoints areas needing focus for patient support and has the potential to reduce ED revisits and therefore health care utilization. Its methodology offers insights for similar future implementations in health care institutions.

Determinants of Persistent, Multi-Year, Frequent Emergency Department Use Among Children and Young Adults in Three US States

OBJECTIVE

This study examines the factors associated with persistent, multi-year, and frequent emergency department (ED) use among children and young adults.

METHODS

We conducted a retrospective secondary analysis using the 2012-2017 Healthcare Cost and Utilization Project State Emergency Department Databases for children and young adults aged 0-19 who visited any ED in Florida, Massachusetts, and New York. We estimated the association between persistent frequent ED use and individuals' characteristics using multivariable logistic regression models.

RESULTS

Among 1.3 million patients with 1.8 million ED visits in 2012, 2.9% (37,558) exhibited frequent ED use (≥4 visits in 2012) and accounted for 10.2% (181,138) of all ED visits. Longitudinal follow-up of frequent ED users indicated that 15.4% (5770) remained frequent users periodically over the next 1 or 2 years, while 2.2% (831) exhibited persistent frequent use over the next 3-5 years. Over the 6-year study period, persistent frequent users had 31,551 ED visits at an average of 38.0 (standard deviation = 16.2) visits. Persistent frequent ED use was associated with higher intensity of ED use in 2012, public health insurance coverage, inconsistent health insurance coverage over time, residence in non-metropolitan and lower-income areas, multimorbidity, and more ED visits for less medically urgent conditions.

CONCLUSIONS

Clinicians and policymakers should consider the diverse characteristics and needs of pediatric persistent frequent ED users compared to broader definitions of frequent users when designing and implementing interventions to improve health outcomes and contain ED visit costs.

Assertive community treatment for high-utilizing alcohol misuse patients: a before-and-after cohort study protocol

BACKGROUND

The challenge posed by Alcohol-Related Frequent Attenders (ARFAs) in Emergency Departments (EDs) is growing in Singapore, marked by limited engagement with conventional addiction treatment pathways. Recognizing this gap, this study aims to explore the potential benefits of Assertive Community Treatment (ACT) - an innovative, community-centered, harm-reduction strategy-in mitigating the frequency of ED visits, curbing Emergency Medical Services (EMS) calls, and uplifting health outcomes across a quartet of Singaporean healthcare institutions.

METHODS

Employing a prospective before-and-after cohort design, this investigation targeted ARFAs aged 21 years and above, fluent in English or Mandarin. Eligibility was determined by a history of at least five ED visits in the preceding year, with no fewer than two due to alcohol-related issues. The study contrasted health outcomes of patients integrated into the ACT care model versus their experiences under the exclusive provision of standard emergency care across Hospitals A, B, C and D. Following participants for half a year post-initial assessment, the evaluation metrics encompassed socio-demographic factors, ED, and EMS engagement frequencies, along with validated health assessment tools, namely Christo Inventory for Substance-misuse Services (CISS) scores, University of California, Los Angeles (UCLA) Loneliness scores, and Centre for Epidemiologic Studies Depression Scale Revised (CESD-R-10) scores.

DISCUSSION

Confronted with intricate socio-economic and medical challenges, the ARFA cohort often grapples with heightened vulnerabilities in relation to alcohol misuse. Pioneering the exploration of ACT's efficacy with ARFAs in a Singaporean context, our research is anchored in a patient-centered approach, designed to comprehensively address these multifaceted clinical profiles. While challenges, like potential high attrition rates and sporadic data collection, are anticipated, the model's prospective contribution towards enhancing patient well-being and driving healthcare efficiencies in Singapore is substantial. Our findings have the potential to reshape healthcare strategies and policy recommendations.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04447079. Initiated on 25 June 2020.

Fostering collective leadership to improve integrated primary care: lessons learned from the PriCARE program

Case management (CM) is an intervention for improving integrated care for patients with complex care needs. The implementation of this complex intervention often raises opportunities for change and collective leadership has the potential to optimize the implementation. However, the application of collective leadership in real-world is not often described in the literature. This commentary highlights challenges faced during the implantation of a CM intervention in primary care for people with complex care needs, including stakeholders' buy-in and providers' willingness to change their practice, selection of the best person for the case manager position and staff turnover. Based on lessons learned from PriCARE research program, this paper encourages researchers to adopt collective leadership strategies for the implementation of complex interventions, including promoting a collaborative approach, fostering stakeholders' engagement in a trusting and fair environment, providing a high level of communication, and enhancing collective leadership attitudes and skills. The learnings from the PriCARE program may help guide researchers for implementing complex healthcare interventions.

Profiles of Emergency Department Users with Psychiatric Disorders Related to Barriers to Outpatient Care

Emergency department (ED) overcrowding is a growing problem worldwide. High ED users have been historically targeted to reduce ED overcrowding and associated high costs. Patients with psychiatric disorders, including substance-related disorders (SRDs), are among the largest contributors to high ED use. Since EDs are meant for urgent cases, they are not an appropriate setting for treating recurrent patients or replacing outpatient care. Identifying ED user profiles in terms of perceived barriers to care, service use, and sociodemographic and clinical characteristics is crucial to reduce ED use and unmet needs. Data were extracted from medical records and a survey was conducted among 299 ED patients from 2021 to 2022 in large Quebec networks. Cluster algorithms and comparison tests identified three profiles. Profile 1 had the most patients without barriers to care, with case managers, and received the best primary care. Profile 2 reported moderate barriers to care and low primary care use, best quality of life, and more serious psychiatric disorders. Profile 3 had the most barriers to care, high ED users, and lower service satisfaction and perceived mental/health conditions. Our findings and recommendations inform decision-makers on evidence-based strategies to address the unmet needs of these vulnerable populations.

Supporting High-impAct useRs in Emergency Departments (SHarED) quality improvement: a mixed-method evaluation

BACKGROUND

The need to better manage frequent attenders or high-impact users (HIUs) in hospital emergency departments (EDs) is widely recognised. These patients often have complex medical needs and are also frequent users of other health and care services. The West of England Academic Health Science Network launched its Supporting High impAct useRs in Emergency Departments (SHarED) quality improvement programme to spread a local HIU intervention across six other EDs in five Trusts.

AIM

SHarED aimed to reduce ED attendance and hospital admissions by 20% for enrolled HIUs. To evaluate the implementation of SHarED, we sought to learn about the experience of staff with HIU roles and their ED colleagues and assess the impact on HIU attendance and admissions.

METHODS

We analysed a range of data including semistructured interviews with 10 HIU staff; the number of ED staff trained in HIU management; an ED staff experience survey; and ED attendances and hospital admissions for 148 HIUs enrolled in SHarED.

RESULTS

Staff with HIU roles were unanimously positive about the benefits of SHarED for both staff and patients. SHarED contributed to supporting ED staff with patient-centred recommendations and provided the basis for more integrated case management across the health and care system. 55% of ED staff received training. There were improvements in staff views relating to confidence, support, training and HIUs receiving more appropriate care. The mean monthly ED attendance per HIU reduced over time. Follow-up data for 86% (127/148) of cases showed a mean monthly ED attendances per HIU reduced by 33%, from 2.1 to 1.4, between the 6 months pre-enrolment and post-enrolment (p<0.001).

CONCLUSION

SHarED illustrates the considerable potential for a quality improvement programme to promote more integrated case management by specialist teams across the health and care system for particularly vulnerable individuals and improve working arrangements for hard-pressed staff.

Factors associated with recurrent emergency department visits among people living with dementia: A retrospective cohort study

BACKGROUND

Research on factors associated with recurrent emergency department (ED) visits and their implications for improving dementia care is lacking. The objective of this study was to examine associations between the individual characteristics of older adults living with dementia and recurrent ED visits.

METHODS

We used health administrative databases to conduct a population-based retrospective cohort study among older adults with dementia in Ontario, Canada. We included community-dwelling adults 66 years and older who visited the ED between April 1, 2010, and March 31, 2019 and were discharged home. We recorded all ED visits within one year after the baseline visit. We used recurrent event Cox regression to examine associations between repeat ED visits and individual clinical, demographic, and health service use characteristics. We fit conditional inference trees to identify the most important factors and define subgroups of varying risk.

RESULTS

Our cohort included 175,863 older adults with dementia. ED use in the year prior to baseline had the strongest association with recurrent visits (3+ vs.0 adjusted hazard ratio (aHR): 1.92 (1.89, 1.94), 2vs.0 aHR: 1.45 (1.43, 1.47), 1vs.0 aHR: 1.23 (1.21, 1.24)). The conditional inference tree utilized history of ED visits and comorbidity count to define 12 subgroups with ED revisit rates ranging from 0.79 to 7.27 per year. Older adults in higher risk groups were more likely to live in rural and low-income areas and had higher use of anticonvulsants, antipsychotics, and benzodiazepines.

CONCLUSIONS

History of ED visits may be a useful measure to identify older adults with dementia who would benefit from additional interventions and supports. A substantial proportion of older adults with dementia have a pattern of recurrent visits and may benefit from dementia-friendly and geriatric-focused EDs. Collaborative medication review in the ED and closer follow-up and engagement with community supports could improve patient care and experience.

Characteristics of Allergic, Eosinophilic, and Overlapping Asthma Phenotypes Among Pediatric Patients with Current Asthma: A Cross-Sectional Study from Saudi Arabia

Purpose

Asthma is one of the most common chronic diseases affecting 10%-30% of children in Saudi Arabia. Although data exist on adult asthma phenotyping and endotyping in Saudi Arabia, little is known about asthma phenotypes in Saudi children.

Patients and Methods

This cross-sectional study enrolled pediatric patients diagnosed with bronchial asthma and followed in the pediatric pulmonology clinic of the Abha Maternity and Children Hospital between August 2021 and May 2023.

Results

A total of 321 children (aged 5-14 years) were analyzed. The population was classified into allergic [169 (52.6%)], eosinophilic [144 (44.9%)], and overlapping allergic and eosinophilic asthma [97 (30.2%)] phenotypes. Regarding asthma severity, 35.5%, 50.2%, and 14.3% were classified as mild, moderate, and severe, respectively. Of the 321 patients in the study, 124 (38.6%) had at least one asthma exacerbation that required hospitalization. The number of reported missed school days in the previous year was 1571 days [190 (59.2%) patients reported at least one missed school day]. The factors associated with the likelihood of uncontrolled asthma for all study participants included: emergency room (ER) visit last year (OR = 3.7, 95% CI:0.6-15.9]), overlapping eosinophilic and allergic (OR = 3.2, 95% CI = 1.8-5.9), and allergic phenotype (OR = 2.7, 95% CI = 1.3-5.4). The level of asthma control differed significantly among the three asthma phenotypes (p = 0.037).

Conclusion

Allergic asthma is the most prevalent asthma phenotype in this study, followed by the eosinophilic phenotype. The research has also shown that several factors predict uncontrolled asthma, including a family history of asthma, previous admission to the PICU, and previous hospitalization ever. There is, therefore, a definite need for multicenter cohort studies to better understand the phenotypes and endotypes of childhood asthma, as it could offer therapeutic and prognostic relevance.

Effectiveness of emergency department based interventions for frequent users with mental health issues: A systematic review

Frequent emergency department (ED) users with mental health issues are particularly vulnerable patients, who often receive insufficient or inadequate outpatient care. This systematic review identified and evaluated studies on ED-based interventions to reduce acute care use by this population, while improving outpatient service use and patient outcomes. Searches were conducted in five databases for studies published between January 1, 2000, and April 30, 2022. Eligibility criteria included: patients with mental health issues who made 2+ ED visits in the previous 6 months or were high ED users (3+ visits/year), and who received ED-based interventions to reduce ED use. The review included 12 studies of 11,082 articles screened. Four intervention groups were identified: care plan (n = 4), case management (n = 4), peer-support (n = 2) and brief interventions (n = 2). The definitions of frequent users varied considerably, while the quality assessment rated studies from moderate to good and risk of bias from low to high. Eight studies used pre-post design, and four were randomized controlled trials. Ten studies assessed outcomes related to use of other services than ED, mainly hospitalizations, while five assessed patients' clinical conditions and three, social conditions (e.g., housing status). This review revealed that case management and care plan interventions, based in ED, decrease ED use among frequent users, while case management also showed promising results for outpatient service use and clinical and social outcomes. Thus, the results support continued deployment of intensive ED-based interventions for frequent ED users with mental health issues although firm conclusions regarding the effectiveness of these interventions, particularly outcomes related to services other than ED, require further investigation.

Caring for high-need patients

OBJECTIVE

We aimed to explore the construct of "high need" and identify common need domains among high-need patients, their care professionals, and healthcare organizations; and to describe the interventions that health care systems use to address these needs, including exploring the potential unintended consequences of interventions.

METHODS

We conducted a modified Delphi panel informed by an environmental scan. Expert stakeholders included patients, interdisciplinary healthcare practitioners (physicians, social workers, peer navigators), implementation scientists, and policy makers. The environmental scan used a rapid literature review and semi-structured interviews with key informants who provide healthcare for high-need patients. We convened a day-long virtual panel meeting, preceded and followed by online surveys to establish consensus.

RESULTS

The environmental scan identified 46 systematic reviews on high-need patients, 19 empirical studies documenting needs, 14 intervention taxonomies, and 9 studies providing construct validity for the concept "high need." Panelists explored the construct and terminology and established that individual patients' needs are unique, but areas of commonality exist across all high-need patients. Panelists agreed on 11 domains describing patient (e.g., social circumstances), 5 care professional (e.g., communication), and 8 organizational (e.g., staffing arrangements) needs. Panelists developed a taxonomy of interventions with 15 categories (e.g., care navigation, care coordination, identification and monitoring) directed at patients, care professionals, or the organization. The project identified potentially unintended consequences of interventions for high-need patients, including high costs incurred for patients, increased time and effort for care professionals, and identification of needs without resources to respond appropriately.

CONCLUSIONS

Care for high-need patients requires a thoughtful approach; differentiating need domains provides multiple entry points for interventions directed at patients, care professionals, and organizations. Implementation efforts should consider outlined intended and unintended downstream effects on patients, care professionals, and organizations.

A qualitative system model to describe the causes and drivers of frequent potentially avoidable presentations to the emergency department

Frequent potentially avoidable presentations to Emergency Departments (EDs) represent a complex problem, driven by multiple interdependent and interacting factors that change over time and influence one another. We sought to describe and map the drivers of frequent potentially avoidable presentations to a regional ED, servicing regional and rural areas, and identify possible solutions from the perspectives of key stakeholders. This study used a qualitative, community-based systems dynamics approach utilising Group Model Building (GMB). Data were collected from two 3-h online workshops embedded with small-group discussions and conducted with stakeholder groups operating within a regional health system. Stakeholders were guided through a series of participatory tasks to develop a causal loop diagram (CLD) using Systems Thinking in Community Knowledge Exchange software (n=29, workshop one), identify potential action points and generate a prioritised action list to intervene in the system (n=21, workshop two). Data were collected through note taking, real-time system mapping, and recording the workshops. Each action was considered against the Public Health 12 framework describing twelve leverage points to intervene in a system. A CLD illustrating the complex and interrelated factors that drive frequent potentially avoidable ED presentations was developed and classified into four categories: (1) access to services; (2) coordination; (3) patient needs; and (4) knowledge and skills. Nine action areas were identified, with many relating to care and service coordination. Most actions aligned with lower-level system impact actions. This study provides an in-depth understanding of influencing factors and potential solutions for frequent potentially avoidable ED presentations across a regional health system. The CLD demonstrates frequent potentially avoidable ED presentations are a complex problem and identified that a prevention response should engage with system- and individual-level solutions. Further work is needed to prioritise actions to support the implementation of higher-level system impacts.

Reducing the length of stay of cardiac patients in the Adult Emergency department by using a Quality improvement framework

BACKGROUND

Crowding is now a familiar challenge in the Emergency Department that can lead to significant adverse outcomes, including reduced quality of care and increased length of stay.

OBJECTIVE

Reduce cardiac patient length of stay from 72 h to 48 h in the Tikur Anbessa Specialized Hospital Adult Emergency department from August 16, 2021, to January 29, 2022, in Addis Ababa, Ethiopia.

METHODS

Process mapping was done by members of the team working in the emergency department on patient treatment and divided into three categories. Problems were then identified in each category that contributed to prolonged stay length. The run chart was then used to display the data for analysis, and nonrandom variation was looked for using the four-run chart rules.

RESULTS

Improved patient throughput in the Emergency Department (ED) was achieved, reducing the average length of stay from 78 h to 25 h by implementing the following change strategies: Streamlining morning discharge times by adjusting from the baseline of 9:10 AM to 9:00 AM; Enhancing patient handover processes to ensure 100% of patients are included on the handover form during transition hours; and Consistently assigning residents to the waiting area, resulting in a 100% presence rate. These changes effectively decreased the prolonged patient length of stay in the ED.

CONCLUSION

Poor management support and staff integration were identified as the leading cause of prolonged patient stay. In conclusion, a bundle of interventions is necessary to reduce the prolonged patient length of stay.

Stakeholders' perceptions of a nurse-led telehealth case management intervention in primary care for patients with complex care needs: a qualitative descriptive study

OBJECTIVE

With the onset of the COVID-19 pandemic, telehealth case management (TCM) was introduced in primary care for patients requiring care by distance. While not all healthcare needs can be addressed via telehealth, the use of information and communication technology to support healthcare delivery has the potential to contribute to the management of patients with chronic conditions and associated complex care needs. However, few qualitative studies have documented stakeholders' perceptions of TCM. This study aimed to describe patients', primary care providers' and clinic managers' perceptions of the use of a nurse-led TCM intervention for primary care patients with complex care needs.

DESIGN

Qualitative descriptive study.

SETTING

Three primary care clinics in three Canadian provinces.

PARTICIPANTS

Patients with complex care needs (n=30), primary care providers (n=11) and clinic managers (n=2) participated in qualitative individual interviews and focus groups.

INTERVENTION

TCM intervention was delivered by nurse case managers over a 6-month period.

RESULTS

Participants' perceptions of the TCM intervention were summarised in three themes: (1) improved patient access, comfort and sense of reassurance; (2) trusting relationships and skilled nurse case managers; (3) activities more suitable for TCM. TCM was a generally accepted mode of primary care delivery, had many benefits for patients and providers and worked well for most activities that do not require physical assessment or treatment. Participants found TCM to be useful and a viable alternative to in-person care.

CONCLUSIONS

TCM improves access to care and is successful when a relationship of trust between the nurse case manager and patient can develop over time. Healthcare policymakers and primary care providers should consider the benefits of TCM and promote this mode of delivery as a complement to in-person care for patients with complex care needs.

Introduction of a New Method to Monitor Patient-Relevant Outcomes and Costs: Using a Quality Improvement Project in Transcatheter Aortic Valve Implantation Care as an Example

BACKGROUND AND OBJECTIVE

Routine outcome monitoring is becoming standard in care evaluations, but costs are still underrepresented in these efforts. The primary aim of this study was therefore to assess if patient-relevant cost drivers can be used alongside clinical outcomes to evaluate an improvement project and to provide insight into (remaining) areas for improvement.

METHODS

Data from patients who underwent transcatheter aortic valve implantation (TAVI) between 2013 and 2018 at a single center in the Netherlands were used. A quality improvement strategy was implemented in October 2015, and pre- (A) and post-quality improvement cohorts (B) were distinguished. For each cohort, clinical outcomes, quality of life (QoL), and cost drivers were collected from the national cardiac registry and hospital registration data. The most appropriate cost drivers in TAVI care were selected from hospital registration data using a novel stepwise approach with an expert panel of physicians, managers, and patient representatives. A radar chart was used to visualize the clinical outcomes, QoL and the selected costs drivers.

RESULTS

We included 81 patients in cohort A and 136 patients in cohort B. All-cause mortality at 30 days was borderline significantly lower in cohort B than in cohort A (1.5% vs 7.4%, P = .055). QoL improved after TAVI for both cohorts. The stepwise approach resulted in 21 patient-relevant cost drivers. Costs for pre-procedural outpatient clinic visits (€535, interquartile range [IQR] = 321-675, vs €650, IQR = 512-890, P < .001), costs for the procedure (€1354, IQR = 1236-1686, vs €1474, IQR = 1372-1620, P < .001), and imaging during admission (€318, IQR = 174-441, vs €329, IQR = 267-682, P = .002) were significantly lower in cohort B than in cohort A. Possible improvement potential was seen in 30-day pacemaker implantation and 120-day readmission.

CONCLUSION

A selection of patient-relevant cost drivers is a valuable addition to clinical outcomes for use in evaluation of improvement projects and identification of room for further improvement.

Using Chronic Care Management Visits to Reduce the Number of Frequent Emergency Department Visits: A Pilot Study

Background Emergency department (ED) visits are increasing in number and cost and becoming a major way patients are interacting with the healthcare system. Patients who frequently visit the ED are deemed "super-utilizers" who visit for a variety of reasons, including, but not limited to, multiple chronic medical illnesses, homelessness, and substance use disorder, but fail to have an established long-term treatment plan. Methodology We enrolled our hospital's top 50 super-utilizing patients into the Chronic Care Management Program. These patients received monthly telehealth visits to discuss concerns, chronic medical conditions, barriers to care, and support systems unique to each patient's living and social situation (i.e., social determinants of health). Telehealth visits also connected patients to community resources and helped them initiate advanced care services. Results The t-test investigating the frequency of avoidable visits pre- and post-intervention revealed a statistically significant decrease in the number of avoidable visits between the pre-intervention and post-intervention. Results also revealed a non-statistically significant difference in the cost of avoidable visits before and after the intervention. Conclusions The findings revealed a statistically significant decrease in patients' frequency of avoidable visits before and after the intervention.

Emergency Department Use Among Recently Homeless Adults in a Nationally Representative Sample

Introduction: In this study we examined the association of homelessness and emergency department (ED) use, considering social, medical, and mental health factors associated with both homelessness and ED use. We hypothesized that social disadvantage alone could account for most of the association between ED use and homelessness. Methods: We used nationally representative data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III). Emergency department use within the prior year was categorized into no use (27,674; 76.61%); moderate use (1-4 visits: 7,972; 22.1%); and high use (5 or more visits: 475; 1.32%). We used bivariate analyses followed by multivariable-adjusted logistic regression analyses to identify demographic, social, medical, and mental health characteristics associated with ED use. Results: Among 36,121 respondents, unadjusted logistic regression showed prior-year homelessness was strongly associated with moderate and high prior-year ED use (odds ratio [OR] 2.31 and 7.34, respectively, P < 0.001). After adjusting for sociodemographic factors, the associations of homelessness with moderate/high ED use diminished (adjusted OR [AOR] 1.27 and 1.62, respectively, both P < 0.05). Adjusting for medical/mental health variables, alone, similarly diminished the association between homelessness and moderate/high ED use (AOR 1.26, P < .05 and 2.07, P < 0.001, respectively). In a final stepwise model including social and health variables, homelessness was no longer significantly associated with moderate or high ED use in the prior year. Conclusion: After adjustment for social disadvantage and health problems, we found no statistically significant association between homelessness and ED use. The implications of our findings suggest that ED service delivery must address both health issues and social factors.

Factors associated with persistent multiyear frequent emergency department use

BACKGROUND

Although frequent emergency department (ED) users have been widely studied in cross-sectional settings, there is some evidence suggesting that most frequent ED users do not remain frequent users over multiple consecutive years. The objective of this study was to explore the association between persistent multiyear frequent ED use and individuals' characteristics.

METHODS

A retrospective analysis using the Healthcare Cost and Utilization Project State Emergency Department Databases (2012-2017) for individuals aged 18-59 who visited any ED in Florida, Massachusetts and New York was conducted. Multivariable regression models were used to estimate the association between persistent frequent ED use over time (≥4 ED visits in each data year) and individuals' characteristics and clinical factors compared with non-persistent frequent users (≥4 ED visits only in the baseline year).

RESULTS

The databases for the three states included 3.3 million patients, who accounted for 4.5 million ED visits in the baseline year (2012). Of those, 3.2% of patients were frequent ED users (≥4 visits) accounting for 13.2% of all ED visits in the baseline year. Longitudinal follow-up revealed that 14.9% (15 617) of frequent users in 2012 remained persistently frequent ED users for 2-3 consecutive years and 3.6% (3774) for 4-6 consecutive years. Persistent frequent ED users differed significantly from non-persistent frequent ED users; they had more ED visits in the index year, were more likely to have no health insurance or public health insurance coverage, and had a higher prevalence of chronic conditions and comorbidities, and more ED visits for less medically urgent conditions.

CONCLUSION

Differences exist between persistent and non-persistent frequent ED users that should be considered when implementing interventions designed to improve health outcomes and curtail healthcare expenditures generated by the broad population of frequent ED users.

Targeted care navigation to reduce hospital readmissions in 'at-risk' patients

BACKGROUND

Care navigation is commonly used to reduce preventable hospitalisation. The use of Electronic Health Record-derived algorithms may enable better targeting of this intervention for greater impact.

AIMS

To evaluate if community-based Targeted Care Navigation, supported by an Electronic Health Record-derived readmission risk algorithm, is associated with reduced rehospitalisation.

METHODS

A propensity score matching cohort (5 comparison to 1 intervention cohort ratio) study was conducted in an 850-bed Victorian public metropolitan health service, Australia, from May to November 2017. Admitted acute care patients with a non-surgical condition, identified as at-risk of hospital readmission using an Electronic Health Record-derived readmission risk algorithm provide by the state health department, were eligible. Targeted Care Navigation involved telephone follow-up support provided for 30 days post-discharge by a registered nurse. The hazard ratio for hospital readmission was calculated at 30, 60 and 90 days post-discharge using multivariable Cox Proportional Hazards regression.

RESULTS

Sixty-five recipients received care navigation and were matched to 262 people who did not receive care navigation. Excellent matching was achieved with standardised differences between groups being <0.1 for all 11 variables included in the propensity score, including the readmission risk score. The Targeted Care Navigation group had a significantly reduced hazard of readmission at 30 days (hazard ratio 0.34; 95% confidence interval: 0.12, 0.94) compared with the comparison group. The effect size was reduced at 60 and 90 days post-discharge.

CONCLUSION

We provide preliminary evidence that Targeted Care Navigation supported by an Electronic Health Record-derived readmission risk algorithm may reduce 30-day hospital readmissions.

Health mediation: an intervention mode for improving emergency department care and support for patients living in precarious conditions

BACKGROUND

Severe overcrowding of emergency departments (EDs) impacts the quality of healthcare. One factor of this overcrowding is precariousness, but it has rarely been considered a key factor in designing interventions to improve ED care. Health mediation (HM) aims to facilitate access to rights, prevention, and care for the most vulnerable persons and to raise awareness among healthcare providers about obstacles in accessing healthcare. We here present the results of an ancillary qualitative study to explore the prospects regarding a health mediation intervention implemented in EDs for deprived persons who are frequent ED users, from professionals' and patients' perspectives.

METHODS

Design, data collection, and data analysis were done according to a psychosocial approach, based on thematic content analysis and semi-structured interviews of 16 frequent ED users and deprived patients exposed to HM and of 14 professionals in 4 EDs of South-eastern France.

RESULTS

All patients reported multifactorial distress. Most of them expressed experiencing isolation and powerlessness, and lacking personal resources to cope with healthcare. They mentioned the use of ED as a way of quickly meeting a professional to respond to their suffering, and recognized the trustworthy alliance with health mediators (HMrs) as a means to put them back in a healthcare pathway. The presence of HMrs in EDs was appreciated by ED professionals because HMrs responded to requests they were not able to access and were perceived as an efficient support for caring for deprived persons in emergency contexts.

CONCLUSIONS

Our results are in favour of health mediation in EDs as a promising solution, requested by patients and ED professionals, to cope with frequent ED users and deprived patients. Our results could also be used to adapt other strategies for the most vulnerable populations to reduce the frequency of ED readmissions. At the interface of the patients' health experience and the medico-social sector, HM could complete the immediate responses to medical needs given in EDs and contribute in alleviating the social inequalities of health.

Evaluation of a Health Information Exchange for Linkage to Mental Health Care After an Emergency Department Visit

Aligning with Washington State's goal of reducing unnecessary emergency department (ED) use and improving linkage to outpatient primary and behavioral health care, this study evaluated whether an Emergency Department Information Exchange (EDIE) improved linkage to care for Medicaid enrollees with mental health conditions. Follow-up with any physician at 30 days increased slightly, although mental health-specific follow-up declined over time. Difference-in-differences estimates revealed no effect of EDIE on linkage to care after an ED visit. Medicaid beneficiaries with mental health needs and high utilization of the ED likely require additional support to increase timely and appropriate follow-up care.

Experiences of Frequent Users of Emergency Departments in Health Care Setting in French-Speaking Switzerland: A Qualitative Study

AIMS

Frequent users of the emergency department (FUED; five ED visits or more per year) often have negative experiences in health care settings, potentially aggravating their health problems. Scarce research has explored FUED experiences in health care in Europe, none in Switzerland. Thus, this study aimed to conduct an in-depth exploration of FUED experiences in health care settings in Switzerland.

METHODS

Semi-structured interviews were conducted among 20 FUED (75% female; mean age = 40.6, SD = 12.8). Qualitative data were subject to inductive content analysis.

RESULTS

Five main themes emerged from the analysis. The main findings documented that FUED experiences in health care were mostly negative, leading to negative emotions, dissatisfaction and a loss of confidence in the system, although some positive experiences were reported as well. The relationship with health care workers was perceived as playing a key role in FUED experiences.

CONCLUSION

The findings indicate that FUED often have negative experiences in the health care system in Switzerland. The relationship with the health care staff is reported as a decisive ingredient of the experience in health care. Future research is needed to develop awareness-raising interventions for health care staff to improve FUED experiences in health care.

Implementation analysis of a case management intervention for people with complex care needs in primary care: a multiple case study across Canada

BACKGROUND

Case management is one of the most frequently performed interventions to mitigate the negative effects of high healthcare use on patients, primary care providers and the healthcare system. Reviews have addressed factors influencing case management interventions (CMI) implementation and reported common themes related to the case manager role and activities, collaboration with other primary care providers, CMI training and relationships with the patients. However, the heterogeneity of the settings in which CMI have been implemented may impair the transferability of the findings. Moreover, the underlying factors influencing the first steps of CMI implementation need to be further assessed. This study aimed to evaluate facilitators and barriers of the first implementation steps of a CMI by primary care nurses for people with complex care needs who frequently use healthcare services.

METHODS

A qualitative multiple case study was conducted including six primary care clinics across four provinces in Canada. In-depth interviews and focus groups with nurse case managers, health services managers, and other primary care providers were conducted. Field notes also formed part of the data. A mixed thematic analysis, deductive and inductive, was carried out.

RESULTS

Leadership of the primary care providers and managers facilitated the first steps of the of CMI implementation, as did the experience and skills of the nurse case managers and capacity development within the teams. The time required to establish CMI was a barrier at the beginning of the CMI implementation. Most nurse case managers expressed apprehension about developing an "individualized services plan" with multiple health professionals and the patient. Clinic team meetings and a nurse case managers community of practice created opportunities to address primary care providers' concerns. Participants generally perceived the CMI as a comprehensive, adaptable, and organized approach to care, providing more resources and support for patients and better coordination in primary care.

CONCLUSION

Results of this study will be useful for decision makers, care providers, patients and researchers who are considering the implementation of CMI in primary care. Providing knowledge about first steps of CMI implementation will also help inform policies and best practices.

Integrated case management between primary care clinics and hospitals for people with complex needs who frequently use healthcare services: A multiple-case embedded study

INTRODUCTION

Case management (CM) is recognized to improve care integration and outcomes of people with complex needs who frequently use healthcare services, but challenges remain regarding interaction between primary care clinics and hospitals. This study aimed to implement and evaluate an integrated CM program for this population where nurses in primary care clinics worked with a hospital case manager.

METHODS

A multiple embedded case study was conducted in the Saguenay-Lac-Saint-Jean region (Québec, Canada), in four dyads including a clinic and a hospital. Mixed data collection included, at baseline and 6 months, interviews and focus groups with stakeholders, patient questionnaires (patient experience of integrated care and self-management), and emergency department (ED) visits in the previous 6 months.

RESULTS

Integrated CM implementation was optimal when all stakeholders provided collective leadership, and were supportive of the program, particularly the physicians. The 6-month program enabled the observation of positive qualitative outcomes in most clinic-hospital dyads where implementation occurred. Full implementation was associated with improved care integration.

DISCUSSION AND CONCLUSION

Integrated CM between primary care clinics and hospitals is a promising innovation to improve care integration for people with complex needs who frequently use healthcare services. Collective leadership and physicians' buy-in to integrated CM are important to foster the implementation.

Integrating case management for patients with complex needs in the ground practice: the importance of context in evaluative designs

Responding to complex needs calls for integrating care across providers, settings and sectors. Among models to improve integrated care, case management demonstrates a good evidence base of facilitating the appropriate delivery of healthcare services. Since case management is a complex, multi component intervention, with its component parts interacting in a non-linear manner, effectiveness is largely influenced by the context in which the intervention is implemented. This paper discusses how to respond to implementation challenges to evaluating complex interventions for patients with complex needs. Building on the example of case management, we suggest that documenting innovation effectiveness remains important, but that evaluation needs to include theory-based and systems perspectives. We also suggest that implementation science needs to be part of intervention design while engaging stakeholders to define the most relevant research questions and implementation effectiveness, to optimize successful implementation and sustainability.

Prevalence and characteristics of frequent presenters to Auburn Hospital emergency department

OBJECTIVES

Frequent presenters (FPs) to the ED are common and contribute to ED overcrowding. Our aim was to identify the proportion of FPs over a 12-month period and to investigate the sociodemographic, clinical and attendance characteristics of FPs.

METHODS

A retrospective cohort study of adult patients (≥18 years) presenting to Auburn Hospital ED between 1 January 2018 to 31 December 2018. Patients with ≥4 presentations in 12 months were classified as FP. Multivariable logistic regression was used to assess associations between sociodemographic characteristics and FP.

RESULTS

During the study period, there were 22 679 presentations to the ED from 16 624 adult patients. FPs represented 5.1% (95% confidence interval [CI] 4.8-5.5) of the total population, but 15.8% of the total ED visits. Median age of FPs was 46 years (interquartile range 29-72), 51.9% were males. Age over 65 was the strongest determinant of FP (odds ratio [OR] 2.33; 95% CI 2.01-2.72 adjusted for sex). FP was more likely for Arabic speakers compared to English speakers (OR 1.54; 95% CI 1.28-1.86 adjusted for age and sex) and least likely for Mandarin speakers (adjusted OR 0.40; 95% CI 0.27-0.59).

CONCLUSIONS

FPs represent a significant proportion of ED visits, yet a small proportion of ED patients. Our findings suggest that identifying ways to provide targeted services to older FPs may reduce the overall rates. The differences between language groups and FP highlights the importance of social context and culture when developing targeted interventions.

Analysis of Emergency Department Encounters Among High Users of Health Care and Social Service Systems Before and During the COVID-19 Pandemic

IMPORTANCE

Although the general US population had fewer emergency department (ED) visits during the COVID-19 pandemic, patterns of use among high users are unknown.

OBJECTIVES

To examine natural trends in ED visits among high users of health and social services during an extended period and assess whether these trends differed during COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study combined data from 9 unique cohorts, 1 for each fiscal year (July 1 to June 30) from 2012 to 2021, and used mixed-effects, negative binomial regression to model ED visits over time and assess ED use among the top 5% of high users of multiple systems during COVID-19. Data were obtained from the Coordinated Care Management System, a San Francisco Department of Public Health platform that integrates medical and social information with service use.

EXPOSURES

Fiscal year 2020 was defined as the COVID-19 year.

MAIN OUTCOMES AND MEASURES

Measured variables were age, gender, language, race and ethnicity, homelessness, insurance status, jail health encounters, mental health and substance use diagnoses, and mortality. The main outcome was annual mean ED visit counts. Incidence rate ratios (IRRs) were used to describe changes in ED visit rates both over time and in COVID-19 vs non-COVID-19 years.

RESULTS

Of the 8967 participants, 3289 (36.7%) identified as White, 3005 (33.5%) as Black, and 1513 (16.9%) as Latinx; and 7932 (88.5%) preferred English. The mean (SD) age was 46.7 (14.2) years, 6071 (67.7%) identified as men, and 7042 (78.5%) had experienced homelessness. A statistically significant decrease was found in annual mean ED visits among high users for every year of follow-up until year 8, with the largest decrease occurring in the first year of follow-up (IRR, 0.41; 95% CI, 0.40-0.43). However, during the pandemic, ED visits decreased 25% beyond the mean reduction seen in prepandemic years (IRR, 0.75; 95% CI, 0.72-0.79).

CONCLUSIONS AND RELEVANCE

In this study, multiple cohorts of the top 5% of high users of multiple health care systems in San Francisco had sustained annual decreases in ED visits from 2012 to 2021, with significantly greater decreases during COVID-19. Further research is needed to elucidate pandemic-specific factors associated with these findings and understand how this change in use was associated with health outcomes.

Challenges in the diagnosis of asthma in children, what are the solutions? A scoping review of 3 countries in sub Saharan Africa

Background

Asthma is the commonest chronic respiratory tract disease in children. In low-income countries, challenges exist in asthma diagnosis. In surveys done in children, the prevalence of ‘asthma’ defined by symptoms is high compared to ‘doctor diagnosed asthma’. The questions answered by this review are (i) What challenges have been experienced in the diagnosis of asthma in children? (ii) What solutions will address these challenges?

Methods

The Arksey and O’Malley’s framework for scoping reviews was used for the study methodology, while the PRISMA-ScR checklist guided the reporting process. Electronic databases: PubMed Central, EMBASE and Google Scholar were searched. Primary quantitative and qualitative studies and reviews from 2010 to 2021, from Nigeria, South Africa and Uganda written in English or translated to English, which answered the study questions were included. The author, title, country, study type, methods, purpose, findings and references were captured onto a predefined data collection table. The ‘Preview, Question, Read, Summarise’ system was used and a narrative report was used to summarise the findings.

Results

A total of 28 studies were included. The causes of under-diagnosis of asthma include lack of community knowledge and perception of asthma, poor accessibility to health care, strained health systems, lack of diagnostic tests including spirometry, low levels of knowledge among health-care workers and lack of or non-implementation of asthma guidelines. Strategies to improve asthma diagnosis will include community and school based education programmes, revision of asthma diagnostic terms, guideline development and implementation and health systems strengthening.

Conclusion

This scoping review provides research evidence for policy makers and health-workers involved in the care of asthmatic children on challenges faced in asthma diagnosis and strategies to improve asthma diagnosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02170-y.

An observational pilot study: Prevalence and cost of high frequency emergency department users at Örebro University Hospital, Sweden

Background

There is little research on high frequency emergency department users (HEDU) in Sweden. We aim to determine the prevalence and costs of HEDU compared to non-HEDU at Örebro University Hospital (ÖUH). Additionally, we will determine the factors and outcomes associated with being a HEDU.

Methods

This was a retrospective, observational cohort study of ED patients presenting to ÖUH, Sweden between 2018–19. Analyses used electronic registry, ambulance, and cost data. The definition for HEDU was ≥4 visits/year. HEDUs were categorized further into Repeat, High and Super HEDU with 4–7, 8–18 and ≥19 visits/year, respectively. We used multivariable logistic regression to determine the adjusted odds ratios for factors and outcomes between HEDU and non-HEDU.

Findings

Of all ÖUH ED patients, 6.1% were HEDU and accounted for 22.4% of ED visits and associated costs. Compared to the mean cost of non-HEDU, the Repeat, High and Super HEDU were more costly by factors of 4, 8 and 27, respectively. The HEDUs were more likely to be male, self-referred, present with abdominal pain, arrive by ambulance, at night and from the Örebro municipal region. Super HEDU were more likely to be of adult age and assigned lower acuity scores. HEDU were more likely to be directed to the surgical zone, less likely to receive radiologic imaging or achieve a 4-hr time target. In contrast to the Repeat and High HEDU, Super HEDU were less likely to be admitted, but more likely to leave without being seen.

Conclusion

ÖUH has a HEDU population with associated factors and outcomes. They account for a substantial proportion of ED costs compared to non-HEDU.

Case management intervention of high users of the emergency department of a Portuguese hospital: a before-after design analysis

Background

Emergency department (ED) High users (HU), defined as having more than ten visits to the ED per year, are a small group of patients that use a significant proportion of ED resources. The High Users Resolution Group (GRHU) identifies and provides care to HU to improve their health conditions and reduce the frequency of ED visits by delivering patient-centered case management integrated care. The main objective of this study was to measure the impact of the GRHU intervention in reducing ED visits, outpatient appointments, and hospitalizations. As secondary objectives, we aimed to compare the GRHU intervention costs against its potential savings or additional costs. Finally, we intend to study the impact of this intervention across different groups of patients.

Methods

We studied the changes triggered by the GRHU program in a retrospective, non-controlled before-after analysis of patients’ hospital utilization data on 6 and 12-month windows from the first appointment.

Results

A total of 238 ED HU were intervened. A sample of 152 and 88 patients was analyzed during the 6 and 12-month window, respectively. On the 12-month window, GRHU intervention was associated with a statistically significant reduction of 51% in ED visits and hospitalizations and a non-statistically significant increase in the total number of outpatient appointments. Overall costs were reduced by 43.56%. We estimated the intervention costs to be €79,935.34. The net cost saving was €104,305.25. The program’s Return on Investment (ROI) was estimated to be €2.3.

Conclusion

Patient-centered case management for ED HU seems to effectively reduce ED visits and hospitalizations, leading to better use of resources.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00716-3.

Real-world implementation of an eHealth system based on an artificial intelligence designed to predict and reduce emergency department visits by older adults: pragmatic trial

Background

Frail older people use emergency services extensively, and digital systems that monitor health remotely could be useful in reducing these visits by earlier detection of worsening health conditions.

Objective

We aimed to implement a system that produces alerts when the machine learning algorithm identifies a short-term risk for an emergency department (ED) visit and examine health interventions delivered after these alerts and users’ experience. This study highlights the feasibility of the general system and its performance in reducing ED visits. It also evaluates the accuracy of alerts’ prediction.

Methods

An uncontrolled multicenter trial was conducted in community-dwelling older adults receiving assistance from home aides (HAs). We implemented an eHealth system that produces an alert for a high risk of ED visits. After each home visit, the HAs completed a questionnaire on participants’ functional status, using a smartphone app, and the information was processed in real time by a previously developed machine learning algorithm that identifies patients at risk of an ED visit within 14 days. In case of risk, the eHealth system alerted a coordinating nurse who could then inform the family carer and the patient’s nurses or general practitioner. The primary outcomes were the rate of ED visits and the number of deaths after alert-triggered health interventions (ATHIs) and users’ experience with the eHealth system; the secondary outcome was the accuracy of the eHealth system in predicting ED visits.

Results

We included 206 patients (mean age 85, SD 8 years; 161/206, 78% women) who received aid from 109 HAs, and the mean follow-up period was 10 months. The HAs monitored 2656 visits, which resulted in 405 alerts. Two ED visits were recorded following 131 alerts with an ATHI (2/131, 1.5%), whereas 36 ED visits were recorded following 274 alerts that did not result in an ATHI (36/274, 13.4%), corresponding to an odds ratio of 0.10 (95% IC 0.02-0.43; P<.001). Five patients died during the study. All had alerts, 4 did not have an ATHI and were hospitalized, and 1 had an ATHI (P=.04). In terms of overall usability, the digital system was easy to use for 90% (98/109) of HAs, and response time was acceptable for 89% (98/109) of them.

Conclusions

The eHealth system has been successfully implemented, was appreciated by users, and produced relevant alerts. ATHIs were associated with a lower rate of ED visits, suggesting that the eHealth system might be effective in lowering the number of ED visits in this population.

Trial Registration

clinicaltrials.gov NCT05221697; https://clinicaltrials.gov/ct2/show/NCT05221697.

Characterizing people with frequent emergency department visits and substance use: a retrospective cohort study of linked administrative data in Ontario, Alberta, and B.C., Canada

Background

Substance use is common among people who visit emergency departments (EDs) frequently. We aimed to characterize subgroups within this cohort to better understand care needs/gaps, and generalizability of characteristics in three Canadian provinces.

Methods

This was a retrospective cohort study (April 1^st, 2013 to March 31^st, 2016) of ED patients in Ontario, Alberta, and British Columbia (B.C.) We included patients ≥ 18 years with substance use-related healthcare contact during the study period and frequent ED visits, defined as those in the top 10% of ED utilization when all patients were ordered by annual ED visit number. We used linked administrative databases including ED visits and hospitalizations (all provinces); mental heath-related hospitalizations (Ontario and Alberta); and prescriptions, physician services, and mortality (B.C.). We compared to cohorts of people with (1) frequent ED visits and no substance use, and (2) non-frequent ED visits and substance use.

We employed cluster analysis to identify subgroups with distinct visit patterns and clinical characteristics during index year, April 1^st, 2014 to March 31^st, 2015.

Results

In 2014/15, we identified 19,604, 7,706, and 9,404 people with frequent ED visits and substance use in Ontario, Alberta, and B.C (median 37–43 years; 60.9–63.0% male), whose ED visits and hospitalizations were higher than comparison groups.

In all provinces, cluster analyses identified subgroups with “extreme” and “moderate” frequent visits (median 13–19 versus 4–6 visits/year). “Extreme” versus “moderate” subgroups had more hospitalizations, mental health-related ED visits, general practitioner visits but less continuity with one provider, more commonly left against medical advice, and had higher 365-day mortality in B.C. (9.3% versus 6.6%; versus 10.4% among people with frequent ED visits and no substance use, and 4.3% among people with non-frequent ED visits and substance use). The most common ED diagnosis was acute alcohol intoxication in all subgroups.

Conclusions

Subgroups of people with “extreme” (13–19 visits/year) and “moderate” (4–6 visits/year) frequent ED visits and substance use had similar utilization patterns and characteristics in Ontario, Alberta, and B.C., and the “extreme” subgroup had high mortality. Our findings suggest a need for improved evidence-based substance use disorder management, and strengthened continuity with primary and mental healthcare.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00673-x.

Care Coordination Models and Tools-Systematic Review and Key Informant Interviews

BACKGROUND

Care coordination (CC) interventions involve systematic strategies to address fragmentation and enhance continuity of care. However, it remains unclear whether CC can sufficiently address patient needs and improve outcomes.

METHODS

We searched MEDLINE, CINAHL, Embase, Cochrane Database of Systematic Reviews, AHRQ Evidence-based Practice Center, and VA Evidence Synthesis Program, from inception to September 2019. Two individuals reviewed eligibility and rated quality using modified AMSTAR 2. Eligible systematic reviews (SR) examined diverse CC interventions for community-dwelling adults with ambulatory care sensitive conditions and/or at higher risk for acute care. From eligible SR and relevant included primary studies, we abstracted the following: study and intervention characteristics; target population(s); effects on hospitalizations, emergency department (ED) visits, and/or patient experience; setting characteristics; and tools and approaches used. We also conducted semi-structured interviews with individuals who implemented CC interventions.

RESULTS

Of 2324 unique citations, 16 SR were eligible; 14 examined case management or transitional care interventions; and 2 evaluated intensive primary care models. Two SR highlighted selection for specific risk factors as important for effectiveness; one of these also indicated high intensity (e.g., more patient contacts) and/or multidisciplinary plans were key. Most SR found inconsistent effects on reducing hospitalizations or ED visits; few reported on patient experience. Effective interventions were implemented in multiple settings, including rural community hospitals, academic medical centers (in urban settings), and public hospitals serving largely poor, uninsured populations. Primary studies reported variable approaches to improve patient-provider communication, including health coaching and role-playing. SR, primary studies, and key informant interviews did not identify tools for measuring patient trust or care team integration. Sustainability of CC interventions varied and some were adapted over time.

DISCUSSION

CC interventions have inconsistent effects on reducing hospitalizations and ED visits. Future work should address how they should be adapted to different healthcare settings and which tools or approaches are most helpful for implementation.

TRIAL REGISTRATION

PROSPERO #CRD42020156359.

A population level study into health vulnerabilities of mothers and fathers involved in public law care proceedings in Wales, UK between 2011 and 2019

Introduction

Under section 31 of the Children Act 1989, public law care proceedings can be issued if there is concern a child is subject to, or at risk of significant harm, which can lead to removal of a child from parents. Appropriate and effective health and social support are required to potentially prevent some of the need for these proceedings. More comprehensive evidence of the health needs and vulnerabilities of parents will enable enhanced response from family courts and integrated other services.

Objective

To examine health vulnerabilities of parents involved in care proceedings in the two-year period prior to involvement.

Methods

Family court data provided by Cafcass Cymru were linked to population-based health records held within the Secure Anonymised Information Linkage Databank. Linked data were available for 8,821 parents of children involved in care proceedings between 2011 and 2019. Findings were benchmarked with reference to a comparison group of parents matched on sex, age, and deprivation (n = 32,006), not subject to care proceedings. Demographic characteristics, overall health service use, and health profiles of parents were examined. Descriptive and statistical tests of independence were used.

Results

Nearly half of cohort parents (47.6%) resided in the most deprived quintile. They had higher levels of healthcare use compared to the comparison group across multiple healthcare settings, with the most pronounced differences for emergency department attendances (59.3% vs 37.0%). Health conditions with the largest variation between groups were related to mental health (43.6% vs 16.0%), substance use (19.4% vs 1.6%) and injuries (41.5% vs 23.6%).

Conclusion

This study highlights the heightened socioeconomic and health vulnerabilities of parents who experience care proceedings concerning a child. Better understanding of the needs and vulnerabilities of this population may provide opportunities to improve a range of support and preventative interventions that respond to crises in the community.

Death from cancer: frequent unscheduled care

OBJECTIVE

To examine the demographic, clinical, and temporal factors associated with cancer decedents being a frequent or very frequent unscheduled care (GP-general practice Out-Of-Hours (GPOOH) and Accident & Emergency (A&E)) attender, in their last year of life.

METHODS

Retrospective cohort study, of all 2443 cancer decedents in Tayside, Scotland, over 30- months period up to 06/2015, comparing frequent attenders (5-9 attendances/year) and very frequent attenders (≥10 attendances/year) to infrequent attenders (1-4 attendances/year) and non-attenders. Clinical and demographic datasets were linked to routinely-collected clinical data using the Community Health Index number. Anonymised linked data were analysed in SafeHaven, using binary/multinomial logistic regression, and Generalised Estimating Equations analysis.

RESULTS

Frequent attenders were more likely to be older, and have upper gastrointestinal (GI), haematological, breast and ovarian malignancies, and less likely to live in accessible areas or have a late cancer diagnosis. They were more likely to use GPOOH than A&E, less likely to have face-to-face unscheduled care attendances, and less likely to be admitted to hospital following unscheduled care attendance.

CONCLUSIONS

Age, cancer type, accessibility and timing of diagnosis relative to death were associated with increased likelihood of being a frequent or very frequent attender at unscheduled care.

Predictors of no, low and frequent emergency department use for any medical reason among patients with cannabis-related disorders attending Quebec (Canada) addiction treatment centres

INTRODUCTION

Patients with substance-related disorders and mental disorders (MD) contribute substantially to emergency department (ED) overcrowding. Few studies have identified predictors of ED use integrating service use correlates, particularly among patients with cannabis-related disorders (CRD). This study compared predictors of low (1-2 visits/year) or frequent (3+ visits/year) ED use with no ED use for a cohort of 9836 patients with CRD registered at Quebec (Canada) addiction treatment centres in 2012-2013.

METHODS

This longitudinal study used multinomial logistic regression to evaluate clinical, sociodemographic and service use variables from various databases as predictors of the frequency of ED use for any medical reason in 2015-2016 among patients with CRD.

RESULTS

Compared to non-ED users with CRD, frequent ED users included more women, rural residents, patients with serious MD and chronic CRD, dropouts from programs in addiction treatment centres and with less continuity of physician care. Compared with non-users, low ED users had more common MD and there more workers than students.

DISCUSSION AND CONCLUSIONS

Multimorbidity, including MD, chronic physical illnesses and other substance-related disorders than CRD, predicted more ED use and explained frequent use of outpatient services and prior specialised acute care, as did being 12-29 years, after controlling for all other covariates. Better continuity of physician care and reinforcement of programs like assertive community or integrated treatment, and chronic primary care models may protect against frequent ED use. Strategies like screening, brief intervention and treatment referral, including motivational therapy for preventing treatment dropout may also be expanded to decrease ED use.

Reasons for repeated emergency department visits among community-dwelling older adults with dementia in Ontario, Canada

BACKGROUND

Community-dwelling older adults living with dementia visit the emergency department (ED) more frequently than other older adults, but research on the reasons for repeated visits is lacking. We examined the rate of repeated ED visits and reasons for visits in a cohort of individuals with dementia.

METHODS

We conducted a population-based retrospective cohort study of community-dwelling older adults (≥66 years) living with dementia in Ontario, Canada, who visited the ED and were discharged home between April 1, 2010, and March 31, 2019. We calculated the proportion of the population with one, two, and three or more repeat ED visits within 1 year of the baseline visit and the categorized the reason for the visits.

RESULTS

Our cohort contained 175,863 individuals with dementia who visited the ED at least once. Overall, 66.1% returned at least once to the ED within 1 year, 39.4% returned twice, and 23.5% returned 3 or more times. Visit reasons were heterogenous and were most frequently related to general signs and symptoms (25.3%) while being infrequently due to cognitive or behavioral reasons (5.9%). Individuals typically visited for different reasons across successive visits.

CONCLUSIONS

Community-dwelling older adults with dementia who visited an ED were very likely to return to the ED within a year, with a substantial proportion visiting multiple times. The high frequency of repeated visits for different reasons highlights the complexity of caring for this population and indicates greater need for comprehensive community and primary care as well as timely communication between the ED and the community.

Impact of a Statewide Emergency Department Information Exchange on Health Care Use and Expenditures

OBJECTIVE

To assess the effects of a program mandating the statewide adoption of an emergency department information exchange (EDIE) on health care utilization and spending among Medicaid enrollees in Washington state.

DATA SOURCE

Medicaid claims and managed care encounters from the Washington Health Care Authority.

STUDY DESIGN

A difference-in-differences analysis with trends was used to compare changes in ED visits, inpatient admissions, primary care visits, and expenditures among frequent ED users (≥5 ED visits in past year) to those of infrequent users through the second year Washington's program.

DATA EXTRACTION

The study population included adult Medicaid enrollees with ED visits between January 2010-October 2014.

PRINCIPAL FINDINGS

There were 505,667 ED visits among 153,543 unique enrollees included in the analysis. Washington's program was associated with a small, but statistically significant differential change of -0.70 ED visits per enrollee per year (95% CI: -1.24, -0.16) in the first year after EDIE was mandated, or 8.2% of the baseline ED visit rate among frequent users. However, by the second year of implementation, these effects on ED use were no longer significant, nor were there any measurable effects on inpatient admissions, primary care use or expenditures in any period.

CONCLUSIONS

Statewide implementation of EDIE was associated with a small reduction in ED use among frequent users in the first year of the program but did not change overall spending or other utilization outcomes.

Data mining-based clinical profiles of substance use-related emergency department utilizers

OBJECTIVE

Substance-use is a prevalent presentation to the emergency department (ED); however, the clinical characterization of patients who are treated and discharged without admission for further treatment is under-investigated. The study aims to define and characterize the clinical profiles of this patient population.

METHODS

Patients' presentations were examined by clinical data mining (chart review) of ED records of substance use-related events of individuals discharged without admission for further treatment. Records (N = 199) from three major hospitals in New York City from March and June 2017 were randomly sampled with primary diagnosis of alcohol, opioid-related and other psychoactive substance-use presentations. Qualitative thematic coding of clinical presentation with inter-rater reliability was performed. Quantitative distinctive validity tested independence through Pearson's chi-squared and analysis of variance using Fisher's F-test.

RESULTS

Six distinct clinical profiles were identified, including, High Utilizers (chronically intoxicated with comorbid health conditions) (36.7%), Single Episode (20.1%), Service Request (14.1%), Altered Mental Status (13.6%), Overdose (9.0%), and Withdrawal (7.5%). The profiles differed (p < 0.05) in age, housing status, payor, mode of arrival, referral source, index visit time, prescribed treatment, triage acuity level, psychiatric history, and medical history. Differences (p < 0.05) between groups across clinical profiles in age and pain level at triage were observed.

CONCLUSIONS

The identified clinical profiles represent the broad spectrum and complex nature of substance use-related ED utilization, highlighting critical factors of psychosocial and mental-health comorbidities. These findings provide a preliminary foundation to support person-centered interventions to decrease substance use-related ED utilization and to increase engagement/linkage of patients to addiction treatment.

Monthly Identification of High Frequency Emergency Presenters to Improve Care Delivery and Evaluation: A Unique Methodological Approach

Background: Frequent presenters to emergency departments (EDs) pose many challenges around care delivery and health service management. The aim of this study was to investigate the presentation patterns of people with 5 or more ED visits in any calendar month (5+ frequent presenter [FP5+]) to develop a useful methodological framework on which the real impact of interventions may be assessed. Methods: This study is a retrospective analysis of de-identified frequent ED presentation data using segmented regression analysis of an interrupted time series (ITS). Results: A total of 82 FP5+ to this single ED were identified in a year. Of these presenters, 77% had 10 or more presentations in a year. The total FP5+ presentations in the 12 months preceding and after each participant's ≥5 presentations in 1 month (the trigger month for inclusion in the study) accounted for 1,064 and 1,606 visits, respectively. ITS analysis of frequent ED presentations did not show a significant level change or trend change during the data collection period. Monthly review of people who frequently present to a single ED showed that presentations typically occurred in bouts that may span calendar years. Presentation bouts then typically slow, potentially distorting evaluation of the effects of interventions. Conclusion: Rolling monthly examination of presentation data may facilitate timely case review and care delivery, as well as provide a holistic picture of the impacts of interventions targeting patient care needs. This unique analysis demands a reconsideration of the typical before-and-after analysis of interventions for this vulnerable and high-cost group of patients.

Subgroups of people who make frequent emergency department visits in Ontario and Alberta: a retrospective cohort study

BACKGROUND

The population that visits emergency departments frequently is heterogeneous and at high risk for mortality. This study aimed to characterize these patients in Ontario and Alberta, compare them with controls who do not visit emergency departments frequently, and identify subgroups.

METHODS

This was a retrospective cohort study that captured patients in Ontario or Alberta from fiscal years 2011/12 to 2015/16 in the Dynamic Cohort from the Canadian Institute for Health Information, which defined people with frequent visits to the emergency department in the top 10% of annual visits and randomly selected controls from the bottom 90%. We included patients 18 years of age or older and linked to emergency department, hospitalization, continuing care, home care and mental health-related hospitalization data. We characterized people who made frequent visits to the emergency department over time, compared them with controls and identified subgroups using cluster analysis. We examined emergency department visit acuity using the Canadian Triage and Acuity Scale.

RESULTS

The number of patients who made frequent visits to the emergency department ranged from 435 334 to 477 647 each year in Ontario (≥ 4 visits per year), and from 98 840 to 105 047 in Alberta (≥ 5 visits per year). The acuity of these visits increased over time. Those who made frequent visits to the emergency department were older and used more health care services than controls. We identified 4 subgroups of those who made frequent visits: "short duration" (frequent, regularly spaced visits), "older patients" (median ages 69 and 64 years in Ontario and Alberta, respectively; more comorbidities; and more admissions), "young mental health" (median ages 45 and 40 years in Ontario and Alberta, respectively; and common mental health-related and alcohol-related visits) and "injury" (increased prevalence of injury-related visits).

INTERPRETATION

From 2011/12 to 2015/16, people who visited emergency departments frequently had increasing visit acuity, had higher health care use than controls, and comprised distinct subgroups. Emergency departments should codevelop interventions with the identified subgroups to address patient needs.