Effectiveness of a targeted telephone-based case management service on activity in an Emergency Department in the UK: a pragmatic difference-in-differences evaluation

BACKGROUND

This study evaluates the effectiveness of a targeted telephone-based case management service that aimed to reduce ED attendance amongst frequent attenders, known to disproportionately contribute to demand. Evidence on the effectiveness of these services varies.

METHODS

A 24-month controlled before-and-after study, following 808 patients (128 cases and 680 controls (41 were non-compliant)) who were offered the service in the first four months of operation within a UK ED department. Patients stratified as high-risk of reattending ED within 6 months by a predictive model were manually screened. Those positively reviewed were offered a non-clinical, nurse-led, telephone-based health coaching, consisting of care planning, coordination and goal setting for up to 9 months. Service effectiveness was estimated using a difference-in-differences (DiD) analysis. Incident rate of ED and Minor Injury Unit (MIU) attendances and average length of stay in intervention recipients and controls over 12 months after receiving their service offer following ED attendance were compared, adjusting for the prior 12-month period, sex and age, to give an incidence rate ratio (IRR).

RESULTS

Intervention recipients were more likely to be female (63.3% versus 55.4%), younger (mean of 69 years versus 76 years), and have higher levels of ED activity (except for MIU) than controls. Mean rates fell between periods for all outcomes (except for MIU attendance). The Intention-to-Treat analysis indicated non-statistically significant effect of the intervention in reducing all outcomes, except for MIU attendances, with IRRs: ED attendances, 0.856 (95% CI: 0.631, 1.160); ED admissions, 0.871 (95% CI: 0.628, 1.208); length of stay for emergency and elective admissions: 0.844 (95% CI: 0.619, 1.151) and 0.781 (95% CI: 0.420, 1.454). MIU attendance increased with an IRR: 2.638 (95% CI: 1.041, 6.680).

CONCLUSIONS

Telephone-based health coaching appears to be effective in reducing ED attendances and admissions, with shorter lengths of stay, in intervention recipients over controls. Future studies need to capture outcomes beyond acute activity, and better understand how services like this provide added value.

Characteristics and economic burden of frequent attenders with medically unexplained symptoms in primary care in Israel

Background

Frequent Attenders with Medically Unexplained Symptoms (FA/MUS) are common in primary care, though challenging to identify and treat.

Objectives

This study sought to compare FA/MUS to FA with organic illnesses (FA/OI) and the general clinic population (Non-FA) to understand their demographic characteristics and healthcare utilisation patterns.

Methods

For this retrospective, observational study, Electronic Medical Records (EMR) were obtained from Clalit Health Services, regarding the population of a sizeable primary care clinic in Be’er-Sheva, Israel. Electronic medical records were screened to identify the top 5% of FA. FA were stratified based on whether they had OI. FA without OI were then corroborated as having MUS by their physicians. Demographics, healthcare utilisation and costs were analysed for FA/OI, FA/MUS and Non-FA.

Results

Out of 594 FA, 305 (53.6%) were FA/OI and 264 (46.4%) were FA/MUS. FA/OI were older (69.1 vs. 56.4 years, p<.001) and costlier (ILS27693 vs. ILS9075, p<.001) than FA/MUS. Average costs for FA/MUS were over four times higher than Non-FA (ILS9075 vs. ILS2035, p<.001). The largest disparities between FA/OI and FA/MUS were in hospitalisations (ILS6998 vs. ILS2033) and surgical procedures (ILS8143 vs. ILS3175). Regarding laboratory tests, differences were smaller between groups of FA but significantly different between FA and Non-FA.

Conclusion

FA/MUS are more costly than Non-FA and exhibit unique healthcare utilisation and costs patterns. FA/OI had more severe illnesses necessitating hospitalisations and surgical interventions, while FA/MUS had more investigations and tests, attempting to find an explanation for their symptoms.

Frequent short sickness absence, occupational health service utilisation and long-term sickness absence due to mental disorders among young employees

Objectives

We examined whether frequent short-term sickness absence (FSTSA) and primary care use in occupational health service (OHS) were associated with medically-certified long-term sickness absence (LTSA) due to mental disorders among young employees.

Methods

We used record-linkage data covering the young employees (< 35 years) of the City of Helsinki, Finland (n = 8,282) from 2010 to 2014. The outcome was LTSA due to mental disorders. Cox regression models were fitted.

Results

FSTSAs were associated with subsequent LTSA. Also OHS use predicted LTSA due to mental disorders; however, this association was not found for those with prior FSTSA.

Conclusions

Both FSTSA and primary care use indicate subsequent LTSA independently, and together these indicators identify a larger proportion of individuals at risk of LTSA due to mental disorders.

The wider implications of the COVID-19 pandemic: Assessing the impact of accident and emergency use for frequent attenders

INTRODUCTION

Emergency departments have seen altered patterns of attendance since the beginning of the COVID-19 pandemic, with reductions in the number of attendances for non-COVID-19 - patients. We assessed the use of the emergency department by frequent attenders during the height of the COVID-19 pandemic and explored any changes in emergency department attendance by this group.

METHODS

As part of ongoing improvement work, we utilised a cohort design to evaluate the difference in patterns of attendance for the frequent attender group in a single centre. We created a 2019 'top attender' cohort and a similar cohort for 2020. We compared admission patterns between the two time periods in order to understand the impact of the COVID-19 pandemic on this group.

RESULTS

Both groups were predominately male. Mental health and substance misuse use problems were common across both cohorts. The majority of patients lived in a socio-economically deprived areas. The median number emergency department visits in 2019, for the top attender cohort was 6 (IQR: 4-9) vs 4 (IQR: 2-7) for the top attender cohort of 2020 (p < .0013).

CONCLUSION

This single centre evaluation has shown a significant reduction in emergency department attendances for a frequent attender cohort in a single centre. Future work should investigate the longer-term impact which the COVID-19 pandemic has had on this patient group.

Psychosocial characteristics and affective symptomatology associated with patient self-initiated consultations in Spanish general practice

We aimed to determine the sociodemographic and psychosocial profile, and the associated subclinical affective symptomatology of users above the 95th percentile in the distribution of patient self-initiated, face-to-face consultations. Additionally, we sought to determine the contribution of subclinical symptomatology in differentiating between the groups above or below this cut-off point. A total of 16,803 users who self-initiated at least one face-to-face consultation with a GP at any of 13 PHC practices over 1 year, were eligible. After discarding those fulfilling exclusion criteria, 129 cases and 109 controls, matched by gender and age, answered the Family APGAR, the Duke-UNC and the Goldberg Anxiety-Depression scale. Both groups did not differ significantly on any of the sociodemographic and psychosocial variables recorded showing a similar percentage distribution. However, users with high self-initiated consultation rates obtained lower scores on the affective social support subscale from the Duke-UNC. Regarding Goldberg scale, the two groups differed significantly on the likelihood of displaying depression and/or anxiety symptoms. Users with a high probability of suffering from depression and/or anxiety were more prevalent among users on the top 5% in the distribution. Altogether, results indicate that these users report a lack of affective social support and have a higher probability of suffering from subclinical depression and/or anxiety. Early detection and treatment of affective symptomatology would temperate this excess in consultation. General practitioners, social workers and psychologists could act as gatekeepers, preventing this overuse of medical services and in turn lowering economical costs, professional burnout and patients' suffering and discontent.

Assertive outreach treatment versus care as usual for the treatment of high-need, high-cost alcohol related frequent attenders: study protocol for a randomised controlled trial

BACKGROUND

Alcohol-related hospital admissions have doubled in the last ten years to > 1.2 m per year in England. High-need, high-cost (HNHC) alcohol-related frequent attenders (ARFA) are a relatively small subgroup of patients, having multiple admissions or attendances from alcohol during a short time period. This trial aims to test the effectiveness of an assertive outreach treatment (AOT) approach in improving clinical outcomes for ARFA, and reducing resource use in the acute setting.

METHODS

One hundred and sixty ARFA patients will be recruited and following baseline assessment, randomly assigned to AOT plus care as usual (CAU) or CAU alone in equal numbers. Baseline assessment includes alcohol consumption and related problems, physical and mental health comorbidity and health and social care service use in the previous 6 months using standard validated tools, plus a measure of resource use. Follow-up assessments at 6 and 12 months after randomization includes the same tools as baseline plus standard measure of patient satisfaction. Outcomes for CAU + AOT and CAU at 6 and 12 months will be compared, controlling for pre-specified baseline measures. Primary outcome will be percentage of days abstinent at 12 months. Secondary outcomes include emergency department (ED) attendance, number and length of hospital admissions, alcohol consumption, alcohol-related problems, other health service use, mental and physical comorbidity 6 and 12 months post intervention. Health economic analysis will estimate the economic impact of AOT from health, social care and societal perspectives and explore cost-effectiveness in terms of quality adjusted life years and alcohol consumption at 12-month follow-up.

DISCUSSION

AOT models piloted with alcohol dependent patients have demonstrated significant reductions in alcohol consumption and use of unplanned National Health Service (NHS) care, with increased engagement with alcohol treatment services, compared with patients receiving CAU. While AOT interventions are costlier per case than current standard care in the UK, the rationale for targeting HNHC ARFAs is because of their disproportionate contribution to overall alcohol burden on the NHS. No previous studies have evaluated the clinical and cost-effectiveness of AOT for HNHC ARFAs: this randomized controlled trial (RCT) targeting ARFAs across five South London NHS Trusts is the first.

TRIAL REGISTRATION

International standard randomized controlled trial number (ISRCTN) registry: ISRCTN67000214, retrospectively registered 26/11/2016.

[Perceived quality of care by frequent paediatric healthcare users: A qualitative approach]

INTRODUCTION

Assessing the perceived quality of a healthcare department by its users is essential in a quality management system. In Paediatric Emergency Departments (PED), the demand for urgent care has increased in recent years, as well as an increase in frequent attendance. Paying attention to the opinions of these habitual users by means of qualitative methodology is particularly suitable for assessing the quality of care and identifying opportunities to improve the PED.

METHODS

Two focus groups were held with parents of patients (with and without a chronic disease) who visited the PED on 10or more occasions per year in a third level hospital.

RESULTS

The participants were satisfied overall with the PED. The treatment received was very positively valued, and they never felt that they had received poorer care due to being frequent users. As main strengths, they also highlighted the professional expertise, the friendliness of staff, the quality of information given, the medication received on discharge from hospital, and the follow-up carried out by the PED. The major improvement opportunities identified included: the contagion risks, the lack of coordination between different levels of care, and the need to improve the inclusion of families in the health care process.

CONCLUSIONS

Due to the contributions made by these parents, several improvement strategies have been introduced, such as the implementation of sharing information protocols in shift changes, professional training courses, the establishment of a liaison person between the PED and Primary Care, and a proposal to the Hospital Management Department to assess the identified needs.

An evaluation of the use of management care plans for people who frequently attend the emergency department

OBJECTIVE

To evaluate the use of management plans for people who frequently attend the emergency department (ED).

BACKGROUND

Management plans are used to decrease ED utilisation by people who frequently attend. There is limited evidence regarding the use management plans for this population and the perspectives of staff who use them has previously not been considered.

DESIGN

A descriptive observational design including before and after measures of attendance (November 2010 to September 2014) and survey of staff perceptions (July to November 2014). The setting was a major metropolitan hospital ED in Australia.

METHODS

The date for commencement of each plan was determined. Data were extracted regarding ED attendance 12 months before and after implementation. Staff perspectives were obtained via an online survey.

RESULTS

Fifty-seven patients made 1482 ED attendances. Of these 830 occurred in the 12 months before the management plan was implemented and 652 during the 12 months after. The number of attendances per patient decreased from a median of 11 to 4. Staff considered management plans to be beneficial to care planning practices and individual patient outcomes.

CONCLUSIONS

Management plans were acceptable to staff, and implementation of management plans was associated with a decrease in ED attendance.

Acceptability of the BATHE technique amongst GPs and frequently attending patients in primary care: a nested qualitative study

BACKGROUND

BATHE is a brief psychosocial intervention designed for physician use in patient consultations. The technique has gained some international recognition, but there is currently limited research evidence to demonstrate its acceptability and benefits to patient care. We conducted a pilot cluster randomised controlled trial and feasibility study to explore the use of BATHE as a key component of a person-focused intervention to improve the care of frequent attending patients in UK primary care.

METHODS

A nested qualitative interview study conducted within a pilot trial. The trial took place in six general practices in the South West of England. Eligible patients had been identified as being in the top 3% of attenders in the previous 12 months. General practitioners (GPs) were trained to use BATHE during a one-hour initial training session, and two top-up trainings which included feedback on implementation fidelity. GPs were asked to use BATHE with their study patients for a period of 12 months. 34 GPs were trained and documented using BATHE in a total of 577 consultations with eligible patients during the intervention period. At the end of the intervention period, GPs and study patients from the intervention practices were invited to take part in an interview. Interviews were semi-structured, audio-recorded and transcribed. Thematic analysis was used.

RESULTS

Eleven GPs and 16 patients took part in post-intervention interviews. Benefits of using BATHE included making consultations more person-centred, challenging assumptions that the GP knew what was going on for the patient and their main concerns, and supporting self-management. Difficulties reported included changing existing consultation habits, identifying appropriate consultations in which to use BATHE, and organisational constraints.

CONCLUSIONS

The study suggests that using BATHE is both acceptable and beneficial but also highlighted some of the difficulties GPs had incorporating BATHE into routine practice. Strategies to reduce these difficulties are needed before the extent of the potential benefits of BATHE can be fully assessed.

TRIAL REGISTRATION

ISRCTN62939408 Prospectively registered on 24/06/2015.

The effect of integrated care on self-management and emergency department attendance

Aims and methodThe Frequent Attenders Programme is a joint initiative between Hertfordshire Rapid Assessment, Interface and Discharge service and the Emergency Department of the West Hertfordshire NHS Trust, which aims to divert frequent attenders from the emergency department by addressing their unmet needs. This paper describes the range of interventions put in place from the time that the service was set up in 2014 until the introduction of the new national Commissioning for Quality and Innovation 2017-2019, which tasked National Health Service trusts to improve services for people with mental health needs who present to Accident and Emergency. The terms emergency department and Accident and Emergency are used interchangeably, reflecting the practice in policy documents. A subsequent article will report on the impact of the Commissioning for Quality and Innovation in Hertfordshire. RESULTS: Analysis of the interventions indicated a highly significant (P &lt; 0.0001) mean reduction in attendances. Lower gains were made in patients whose primary presentations were alcohol-related. A failure to effect change in two patients led to a significant revision of their respective care plans, resulting in a subsequent reduction in their attendances.Clinical implicationsAn integrated approach to patients with complex presentations was associated with high levels of both patient and referrer satisfaction. It is hypothesised that dismantling the barriers between physical and mental health may lead to similar successes in frequent attenders in other in-patient and community medical and psychiatric services.Declaration of interestNone.

2.5 years on: what are the effects of a 'frequent attenders' service in the Emergency Department?

This study focused on an evaluation over 2.5 years to establish if a frequent attenders' service in an Emergency Department (ED) impacted on the overall number of patients attending as well as the numbers of their attendances. For this, three patient lists from April-September 2015 and three lists from a matched period in 2017 were randomly selected and the two samples compared. Results showed both a reduction in the number of total patients identified as frequent attenders as well as a reduction on the number of attendances to ED. The study suggests that the implementation of a frequent attenders' service is associated with benefits, not only for the individual attendances per patient, but also in an overall reduction of the number patients classed as frequent attenders.Declaration of interestThe authors have no conflict of interest to declare regarding this manuscript.

Personality and psychopathology as predictors of patient-initiated overuse in general practice

OBJECTIVE

We aimed to characterize, by means of the MCMI, the psychopathological profile of users above the 95th percentile in the distribution of patient-initiated, face-to-face consultations. Additionally, we sought to determine the specific contribution of the patterns assessed by the Millon inventory in differentiating between the groups above or below this cut-off point.

METHODS

A total of 16803 users who initiated at least one face-to-face consultation with a GP at any of 13 PHC practices over one year, were eligible. After discarding those meeting our exclusion criteria, 129 cases and 109 controls matched by gender and age completed the MCMI-III.

RESULTS

The profile of users above the 95th percentile showed elevated scores for compulsivity and narcissism, reflecting rigidity and perfectionism with anxious symptomatology but with no physical or psychosomatic complaints. Regarding differentiation between the two groups, the results showed elevated scores for dependency to increase the probability of belonging to the group above the 95th percentile; conversely, elevated scores for compulsivity appeared to be protective, decreasing the probability of belonging to this same group. Furthermore, elevated scores for anxiety and major depression also increased the probability of belonging to this group. The results for clinical syndromes present a profile of overusers reporting anxiety and somatic complaints associated with low self-esteem.

CONCLUSIONS

Excessive patient-initiated consultations can be an easily detectable marker for underlying psychological problems. The results suggest that overusers of patient-initiated consultations above the 95th percentile show an MCMI profile associated with dependency, compulsivity, anxiety, and major depression.

Effect of administrative information on visit rate of frequent attenders in primary health care: ten-year follow-up study

Background

Frequent attenders (FAs) use a disproportionately large share of the resources of general practitioners (GPs) working in primary healthcare centres. The aim of this study was to estimate the proportion of FAs among all patients in the primary health care centres of a medium-sized city in Finland, and to examine whether providing GPs with administrative information about their frequent attenders (names and numbers of visits per year) can reduce the number of FAs and the frequency of their visits.

Methods

Statistic data on all GP visits (n = 1.8 million) to 11 public healthcare centres in one city were collected from the electronic patient records covering the period from 2001 to 2010. A FA-patient was defined as a person who made10 or more visits to GPs during one year. The baseline situation in 2001 was compared with the situation in 2006 after administrative information had been provided three times to all GPs working in the healthcare centres. Poisson’s regression analysis was used, and FA numbers and consultation rates in the years 2002–2005 were compared with the year 2006; figures for 2006 were also compared with those for the follow-up period 2007–2010.

Results

During the years 2001–2006, the proportion of visits of FA-patients fell overall from 9.1 to 8.5%, a decline of 0.6% (p < 0.0001). This reduction was equivalent to an annual work load of two GPs in the study center. The proportion of visits of FA patients increased again in the follow-up period (2007–2010), when administrative information was no longer provided.

Conclusion

When GPs are provided with information on the number and names of their FA-patients, the annual rate of FA visits to GPs drops significantly. The method is simple and repeatable. However, without a control group of GPs who have not received such information, it is impossible to assess if the intervention was the only circumstance affecting the reduction in FA consultation rates.

Association between the elderly frequent attender to the emergency department and 30-day mortality: A retrospective study over 10 years

BACKGROUND

To determine if elderly frequent attenders are associated with increased 30-day mortality, assess resource utilization by the elderly frequent attenders and identify associated characteristics that contribute to mortality.

METHODS

Retrospective observational study of electronic clinical records of all emergency department (ED) visits over a 10-year period to an urban tertiary general hospital in Singapore. Patients aged 65 years and older, with 3 or more visits within a calendar year were identified. Outcomes measured include 30-day mortality, admission rate, admission diagnosis and duration spent at ED. Chi-square-tests were used to assess categorical factors and Student t-test was used to assess continuous variables on their association with being a frequent attender. Univariate and multivariate logistic regressions were conducted on all significant independent factors on to the outcome variable (30-day mortality), to determine factor independent odds ratios of being a frequent attender.

RESULTS

1.381 million attendance records were analyzed. Elderly patients accounted for 25.5% of all attendances, of which 31.3% are frequent attenders. Their 30-day mortality rate increased from 4.0% in the first visit, to 8.8% in the third visit, peaking at 10.2% in the sixth visit. Factors associated with mortality include patients with neoplasms, ambulance utilization, male gender and having attended the ED the previous year.

CONCLUSION

Elderly attenders have a higher 30-day mortality risk compared to the overall ED population, with mortality risk more marked for frequent attenders. This study illustrates the importance and need for interventions to address frequent ED visits by the elderly, especially in an aging society.

Designing services for frequent attenders to the emergency department: a characterisation of this population to inform service design

Frequent attendance to the emergency department (ED) is a growing public health concern. Designing services for frequent attenders poses challenges, given the heterogeneous nature of this group. This was a two-part observational study identifying frequent attenders from ED records. The first stage studied trends and developed personas with emphasis on differentiating moderate frequent attenders (attending between 5 and 20 times per year) and extreme frequent attenders (attending more than 20 times). Stage 2 included a case note review of 100 consecutive frequent attenders. Results showed an increase in frequent attendance from 2.59% to 4.12% over 8 years. Moderate frequent attenders accounted for 97%. Of the 100 frequent attenders studied, 45% had medically unexplained symptoms (MUS), associated with younger age (p<0.001) but not with gender (p>0.05). In conclusion, the ED is a useful hub for identifying frequent attenders with MUS, particularly among moderate frequent attenders; service design for this group should consider a 'whole-systems approach' with integration between primary and secondary care, including specialist liaison psychiatry services where appropriate.

Family physician-patient relationship and frequent attendance of primary and specialist health care: Results from a German population-based cohort study

OBJECTIVE

To investigate the association between the quality of the family physician-patient relationship and frequent attendance of primary and specialist health care.

METHODS

Cross-sectional survey of a representative German population sample (N=2.266). Family physician-patient relationship was assessed with the Patient Doctor Relationship Questionnaire (PDRQ-9). Determinants of frequent attendance were analyzed using logistic regression.

RESULTS

Frequent attendance of family physicians was associated with lower income (OR 1.43, 95% CI 1.02-2.00), not being in paid work (OR 1.58, CI 1.08-2.30), psychological distress (OR 1.14, CI 1.07-1.22), somatic symptoms (OR 1.07, CI 1.04-1.11), and physical comorbidity (OR 1.54, CI 1.36-1.74) in the multivariate analysis. Frequent attendance of specialists was related to psychological distress (OR 1.12, CI 1.04-1.20), somatic symptoms (OR 1.08, CI 1.04-1.11), and physical comorbidity (OR 1.69, CI 1.48-1.93) in the multivariate analysis. Quality of the relationship was associated with frequent attendance only in the univariate analyses. A stronger relationship with the family physician was not associated with reduced contact with specialists.

CONCLUSIONS

The quality of the family physician-patient relationship is not independently associated with frequent attendance.

PRACTICE IMPLICATIONS

Family physicians should be aware that need factors, i.e. symptom burden and physical comorbidities, are main drivers of frequent attendance.

Overutilization of ambulatory medical care in the elderly German population?--An empirical study based on national insurance claims data and a review of foreign studies

BACKGROUND

By definition, high utilizers receive a large proportion of medical services and produce relatively high costs. The authors report the results of a study on the utilization of ambulatory medical care by the elderly population in Germany in comparison to other OECD countries. Evidence points to an excessive utilization in Germany. It is important to document these utilization figures and compare them to those in other countries since the healthcare system in Germany stopped recording ambulatory healthcare utilization figures in 2008.

METHODS

The study is based on the claims data of all insurants aged ≥ 65 of a statutory health insurance company in Germany (n = 123,224). Utilization was analyzed by the number of contacts with physicians in ambulatory medical care and by the number of different practices contacted over one year. Criteria for frequent attendance were ≥ 50 contacts with practices or contacts with ≥ 10 different practices or ≥ 3 practices of the same discipline per year. Descriptive statistical analysis and logistic regression were applied. Morbidity was analyzed by prevalence and relative risk for frequent attendance for 46 chronic diseases.

RESULTS

Nineteen percent of the elderly were identified as high utilizers, corresponding to approximately 3.5 million elderly people in Germany. Two main types were identified. One type has many contacts with practices, belongs to the oldest age group, suffers from severe somatic diseases and multimorbidity, and/or is dependent on long-term care. The other type contacts large numbers of practices, consists of younger elderly who often suffer from psychiatric and/or psychosomatic complaints, and is less frequently multimorbid and/or nursing care dependent.

CONCLUSION

We found a very high rate of frequent attendance among the German elderly, which is unique among the OECD countries. Further research should clarify its reasons and if this degree of utilization is beneficial for elderly people.

Retrospective study of elderly frequent attenders presenting with chest pain at emergency department

BACKGROUND

The aims of the study were to identify the characteristics of elderly frequent attenders to the emergency department (ED) presenting with chest pain and to assess the 1-year prognosis for developing adverse cardiac events.

FINDINGS

Patients over 75 years old, with four or more attendances to the ED between 1 January 2010 and 31 December 2010 with at least one attendance due to chest pain, were selected from a database. Data was collected on demographic details, visit history, disposition and admission outcomes. Each patient was followed up for 12 months after the index episode via the hospital electronic registry for adverse cardiac outcome. Adverse cardiac outcomes included death from cardiac event, acute myocardial infarction (ST elevation myocardial infarction (STEMI)/non-ST elevation myocardial infarction (NSTEMI)) or unstable angina. A total of 158 patients with 4 or more visits to the ED accounted for 290 visits with chest pain during 2010. There is a high prevalence of coronary risk factors in this cohort (hypertension 92.4%, hyperlipidaemia 65.2%, diabetes 49.4% and smoking 26.6%). The hospital admission rate was also high at 83.5%. Over the ensuing 12 months, 8 patients died of a primary cardiac event and a further 29 patients developed 36 non-fatal cardiac events. We could not establish any significant relationship between increase in adverse cardiac outcome and individual risk factors or even two or more risk factors (P = 0.0572). Patients with two or more attendances with chest pain were more likely to develop adverse cardiac outcome (P = 0.0068).

CONCLUSIONS

Elderly frequent attenders to the ED, who present with chest pain, have more cardiac risk factors and are more likely to develop adverse coronary outcomes if they re-attend with chest pain.