Abstract
BackgroundFrequent emergency department (ED) users meet several of the criteria of vulnerability, but this needs to be further examined taking into consideration all vulnerability’s different dimensions. This study aimed to characterize frequent ED users and to define risk factors of frequent ED use within a universal health care coverage system, applying a conceptual framework of vulnerability.MethodsA controlled, cross-sectional study comparing frequent ED users to a control group of non-frequent users was conducted at the Lausanne University Hospital, Switzerland. Frequent users were defined as patients with five or more visits to the ED in the previous 12 months. The two groups were compared using validated scales for each one of the five dimensions of an innovative conceptual framework: socio-demographic characteristics; somatic, mental, and risk-behavior indicators; and use of health care services. Independent t-tests, Wilcoxon rank-sum tests, Pearson’s Chi-squared test and Fisher’s exact test were used for the comparison. To examine the -related to vulnerability- risk factors for being a frequent ED user, univariate and multivariate logistic regression models were used.ResultsWe compared 226 frequent users and 173 controls. Frequent users had more vulnerabilities in all five dimensions of the conceptual framework. They were younger, and more often immigrants from low/middle-income countries or unemployed, had more somatic and psychiatric comorbidities, were more often tobacco users, and had more primary care physician (PCP) visits. The most significant frequent ED use risk factors were a history of more than three hospital admissions in the previous 12 months (adj OR:23.2, 95%CI = 9.1-59.2), the absence of a PCP (adj OR:8.4, 95%CI = 2.1-32.7), living less than 5 km from an ED (adj OR:4.4, 95%CI = 2.1-9.0), and household income lower than USD 2,800/month (adj OR:4.3, 95%CI = 2.0-9.2).ConclusionsFrequent ED users within a universal health coverage system form a highly vulnerable population, when taking into account all five dimensions of a conceptual framework of vulnerability. The predictive factors identified could be useful in the early detection of future frequent users, in order to address their specific needs and decrease vulnerability, a key priority for health care policy makers. Application of the conceptual framework in future research is warranted.Electronic supplementary materialThe online version of this article (doi:10.1186/s12939-015-0277-5) contains supplementary material, which is available to authorized users.
Highlights
Frequent emergency department (ED) users meet several of the criteria of vulnerability, but this needs to be further examined taking into consideration all vulnerability’s different dimensions
The predictive factors identified could be useful in the early detection of future frequent users, in order to address their specific needs and decrease vulnerability, a key priority for health care policy makers
Baseline characteristics of frequent ED users compared to non-frequent ED users In terms of the socio-cultural and demographic characteristics presented in Table 2, frequent and non-frequent ED users were comparable with regards to gender and education
Summary
This study aimed to characterize frequent ED users and to define risk factors of frequent ED use within a universal health care coverage system, applying a conceptual framework of vulnerability. A heterogeneous subgroup of patients uses the emergency department (ED) frequently and accounts for a substantial proportion of all ED visits in developed countries [1] These “frequent users” have a high burden of complex social and medical needs and can be considered a vulnerable population [2]. Recent studies evaluating the medical and social factors associated with frequent ED use have demonstrated the compounding effect of these variables taken together [2, 9] Based on these results, the Lausanne University Hospital created a clinical evaluation grid of vulnerability. Based on the clinical experience of using this evaluation grid over 5 years, we created a researchoriented, conceptual framework of vulnerability involving five dimensions: 1) socio-cultural and demographic background (social determinants of health, deprivation, origin, and nationality), 2) at-risk behaviors (addictions to alcohol, tobacco, and/or drugs; violence and/or sexual risk behaviors), 3) somatic health (diagnosis, comorbidity and subjective health), 4) mental health (diagnosis, comorbidity, and subjective health), and 5) health care consumption (resources involved in the previous 12 months)
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