High Utilisation Behaviour in Emergency Departments: Predictors in Baixo Alentejo Region

The objective was to characterize the medical, social, and psychiatric correlates of frequent emergency department (ED) use among released prisoners with human immunodeficiency virus (HIV). Data on all ED visits by 151 released prisoners with HIV on antiretroviral therapy (ART) were prospectively collected for 12 months. Correlates of frequent ED use, defined as having two or more ED visits postrelease, were described using univariate and multivariate models and generated medical, psychiatric, and social multimorbidity indices. Forty-four (29%) of the 151 participants were defined as frequent ED users, accounting for 81% of the 227 ED visits. Frequent ED users were more likely than infrequent or nonusers to be female; have chronic medical illnesses that included seizures, asthma, and migraines; and have worse physical health-related quality of life (HRQoL). In multivariate Poisson regression models, frequent ED use was associated with lower physical HRQoL (odds ratio [OR] = 0.95, p = 0.02) and having not had prerelease discharge planning (OR = 3.16, p = 0.04). Frequent ED use was positively correlated with increasing psychiatric multimorbidity index values. Among released prisoners with HIV, frequent ED use is driven primarily by extensive comorbid medical and psychiatric illness. Frequent ED users were also less likely to have received prerelease discharge planning, suggesting missed opportunities for seamless linkages to care.

The authors sought to describe the epidemiology of and risk factors for recurrent and high-frequency use of the emergency department (ED) by children. This was a retrospective cohort study using a database of children aged 0 to 17 years, inclusive, presenting to 22 EDs of the Pediatric Emergency Care Applied Research Network (PECARN) during 2007, with 12-month follow-up after each index visit. ED diagnoses for each visit were categorized as trauma, acute medical, or chronic medical conditions. Recurrent visits were defined as any repeat visit; high-frequency use was defined as four or more recurrent visits. Generalized estimating equations (GEEs) were used to measure the strength of associations between patient and visit characteristics and recurrent ED use. A total of 695,188 unique children had at least one ED visit each in 2007, with 455,588 recurrent ED visits in the 12 months following the index visits. Sixty-four percent of patients had no recurrent visits, 20% had one, 8% had two, 4% had three, and 4% had four or more recurrent visits. Acute medical diagnoses accounted for most visits regardless of the number of recurrent visits. As the number of recurrent visits per patient rose, chronic diseases were increasingly represented, with asthma being the most common ED diagnosis. Trauma-related diagnoses were more common among patients without recurrent visits than among those with high-frequency recurrent visits (28% vs. 9%; p<0.001). High-frequency recurrent visits were more often within the highest severity score classifications. In multivariable analysis, recurrent visits were associated with younger age, black or Hispanic race or ethnicity, and public health insurance. Risk factors for recurrent ED use by children include age, race and ethnicity, and insurance status. Although asthma plays an important role in recurrent ED use, acute illnesses account for the majority of recurrent ED visits.

Identifying older emergency department (ED) patients with clinical features associated with adverse postdischarge outcomes may lead to improved clinical reasoning and better targeting for preventative interventions. Previous studies have used single-country samples to identify limited sets of determinants for a limited number of proxy outcomes. The objective of this study was to identify and compare geriatric syndromes that influence the probability of postdischarge outcomes among older ED patients from a multinational context. A multinational prospective cohort study of ED patients aged 75 years or older was conducted. A total of 13 ED sites from Australia, Belgium, Canada, Germany, Iceland, India, and Sweden participated. Patients who were expected to die within 24 hours or did not speak the native language were excluded. Of the 2,475 patients approached for inclusion, 2,282 (92.2%) were enrolled. Patients were assessed at ED admission with the interRAI ED Contact Assessment, a geriatric ED assessment. Outcomes were examined for patients admitted to a hospital ward (62.9%, n=1,436) or discharged to a community setting (34.0%, n=775) after an ED visit. Overall, 3% of patients were lost to follow-up. Hospital length of stay (LOS) and discharge to higher level of care was recorded for patients admitted to a hospital ward. Any ED or hospital use within 28 days of discharge was recorded for patients discharged to a community setting. Unadjusted and adjusted odds ratios (ORs) were used to describe determinants using standard and multilevel logistic regression. A multi-country model including living alone (OR=1.78, p≤0.01), informal caregiver distress (OR=1.69, p=0.02), deficits in ambulation (OR=1.94, p≤0.01), poor self-report (OR = 1.84, p≤0.01), and traumatic injury (OR=2.18, p≤0.01) best described older patients at risk of longer hospital lengths of stay. A model including recent ED visits (OR=2.10, p≤0.01), baseline functional impairment (OR=1.68, p≤0.01), and anhedonia (OR=1.73, p≤0.01) best described older patients at risk of proximate repeat hospital use. A sufficiently accurate and generalizable model to describe the risk of discharge to higher levels of care among admitted patients was not achieved. Despite markedly different health care systems, the probability of long hospital lengths of stay and repeat hospital use among older ED patients is detectable at the multinational level with moderate accuracy. This study demonstrates the potential utility of incorporating common geriatric clinical features in routine clinical examination and disposition planning for older patients in EDs.

Although 72-hour emergency department (ED) revisits are increasingly used as a hospital metric, there is no known empirical basis for this 72-hour threshold. The objective of this study was to determine the timing of ED revisits for adult patients within 30 days of ED discharge. This was a retrospective cohort study of all nonfederal ED discharges in Florida and Nebraska from April 1, 2010, to March 31, 2011, using data from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP). ED discharges were followed forward to identify ED revisits occurring at any hospital within the same state within 30 days. The cumulative hazard of an ED revisit was plotted. Parametric and nonparametric modeling was performed to characterize the rate of ED revisits. There were 4,782,045 ED discharges, with 7.5% (95% confidence interval [CI] = 7.4% to 7.5%) associated with 3-day revisits, and 22.4% (95% CI = 22.3% to 22.4%) associated with 30-day revisits, inclusive of the 3-day revisits. A double-exponential model fit the data best (p < 0.0001), and a single hinge point at 9 days (multivariate adaptive regression splines [MARS] model) yielded the best linear fit to the data, suggesting 9 days as the most reasonable cutoff for identification of acute ED revisits. Multiple stratified and subgroup analyses produced similar results. Future work should focus on identifying primary reasons for potentially avoidable return ED visits instead of on the revisit occurrence itself, thus more directly measuring potential lapses in delivery of high-quality care. Almost one-quarter of ED discharges are linked to 30-day ED revisits, and the current 72-hour ED metric misses close to 70% of these patients. Our findings support 9 days as a more inclusive cutoff for studies of ED revisits.

Impact of Permanent Supportive Housing on the Use of Acute Care Health Services by Homeless Adults

Efforts to address high emergency department (ED) use among persons experiencing homelessness may be strengthened by identifying risk factors and clarifying whether the primary care experience influences subsequent ED utilization. Although homeless-tailored primary care clinics receive more favorable patient ratings, it remains unclear whether patient experience or clinic type predicts future ED use. To identify clinical and social predictors of high ED utilization among homeless-experienced veterans (HEVs) and to test whether (a) unfavorable care ratings predict higher ED use and (b) care in homeless-tailored primary care clinics predicts lower ED use compared with mainstream clinics. A retrospective cohort study linking national survey data with electronic health record data was conducted to assess ED utilization during the 1-year following survey completion. Five thousand seventy-nine HEVs engaged in Veterans Health Administration primary care who completed the 2018 Primary Care Quality-Homeless Services Tailoring (PCQ-HoST) survey. Primary care type (homeless-tailored or mainstream), patient-reported primary care experience on a validated survey, and ED utilization (defined as high based on four or more visits). KEY RESULTS: Among 5079 HEVs, 474 (9.3%) had high ED utilization. High utilization was associated with current and chronic homelessness, chronic pain, medical and psychiatric comorbidities, and substance use disorders. An unfavorable primary care experience was associated with higher odds of subsequent high ED utilization (OR 1.31; 95% CI 1.26-1.68). Primary care clinic type was not independently associated with high ED utilization.In post hoc count-based models, care in a homeless-tailored clinic was associated with 0.15 fewer ED visits annually. Among HEVs engaged in primary care, high ED utilization is driven primarily by clinical complexity and housing instability. However, an unfavorable patient-reported primary care experience was independently associated with subsequent ED use, suggesting that improving primary care interactions may contribute to broader efforts to address high ED utilization in this population.

To characterize high emergency department (ED) use by children with tracheostomies and complex chronic conditions, to distinguish avoidable from unavoidable ED visits, and to describe the financial impact of avoidable visits. Children with tracheostomies in a pediatric tertiary care center with the highest ED utilization were identified via analysis of administrative data. Six experts in interdisciplinary dyads reviewed the records from all ED visits for these children, and distinguished avoidable from unavoidable visits. Hospital cost data for avoidable visits is described. Among 75 children with tracheostomies and complex chronic conditions, 23 (31%) were high ED utilizers. These 23 children accounted for 74% of all ED discharges the total group of 75 children from 2008 to 2011. Four of these 23 children with high utilization were excluded, leaving 19 subjects for review. These 19 children had 312 ED visits, of which 103 (33%) were deemed avoidable. Leading reasons for avoidable visits were uncomplicated upper respiratory infections, gastrointestinal infections, and enteral feeding system problems. Avoidable visits cost the hospital {$}67,940. One-third of ED visits by children with tracheostomies and complex chronic conditions may be avoidable. Increased ambulatory access to interdisciplinary teams of providers familiar with these children's unique needs might reduce avoidable ED visits and improve health outcomes. Further studies on how this model of ambulatory care might affect ED utilization and total healthcare costs are needed.

247EMF Cluster Analysis of Acute Care Utilization Yields Insights for Tailored Pediatric Asthma Interventions

Does lack of a usual source of care or health insurance increase the likelihood of an emergency department visit? Results of a national population-based study

Mood disorders in the emergency department: the challenge of linking patients to appropriate services

25 Factors Associated with Emergency Department Use among Adults with Newly Diagnosed Cancer

Sickle cell disease (SCD) is a complex hemoglobinopathy. Vaso-occlusive episodes are the primary cause of emergency department (ED) utilization among individuals with SCD. Literature lacks a standardized definition for high ED utilization. To explore ED utilization, redefine high ED utilization, and describe factors associated with super-high ED utilization among individuals with SCD. This retrospective cohort study analyzed the North Carolina Hospital Discharge Datasets (2013-2019). Participants were included if they had SCD, defined as at least 3 SCD visits (ED, inpatient, or outpatient surgery) in a rolling 5-year period. All age groups, sexes, and payers, regardless of state of residence, were included. Data were analyzed from July 2023 to August 2024. Variables included sex, race, ethnicity, age, age at death, distance (in miles) to the closest SCD center, number of annual ED visits, and social vulnerability index (SVI). To determine ED utilization categories, first the distribution of people based on the number of annual ED visits was examined, then the categories across years were identified to determine the data-informed cutoff for each category. Univariate analysis determined differences between participants based on the ED utilization category using χ2 tests of independence or analysis of variance, as applicable. Descriptive statistics were conducted to describe characteristics of utilization in the sample and by ED utilization group. A parsimonious multinomial regression was conducted using significant factors from the univariate analysis. The cohort included 9964 unique patients (5364 [53.83%] female; mean [SD] age, 24.49 [17.54] years), including 9355 Black patients (93.89%), with 100 188 total ED visits from 2013 to 2019. ED visits were categorized into 4 levels: low (0-1 visits per year), moderate (2-9 visits per year), high (10-32 visits per year), and super high (≥33 visits per year). A small subset (178 patients [1.79%]) exhibited super-high ED utilization, contributing disproportionately to the total number of ED visits. Older age, younger age for in-facility deaths, and higher SVI were significantly associated with higher ED utilization. Patients with high utilization were more likely to die, die younger (eg, median [IQR] age at death, 33.0 [30.0-44.0] years in the super-high utilization group vs 50 [38.0-61.0] years in the moderate utilization group), use multiple EDs (eg, 93.8% of participants in the super-high utilization group vs 40.08% of participants in the moderate utilization group), and reside in counties more disadvantaged on socioeconomic and transportation characteristics. This cohort study of 7 years of North Carolina Hospital Discharge Data described 4 new categories of ED utilization in SCD. These categories could be used to reframe how high ED use is determined.

Maternal emergency department (ED) use before or during pregnancy is associated with worse obstetrical outcomes, for reasons including preexisting medical conditions and challenges in accessing health care. It is not known whether maternal prepregnancy ED use is associated with higher use of the ED by their infant. To study the association between maternal prepregnancy ED use and risk of infant ED use in the first year of life. This population-based cohort study included all singleton livebirths in all of Ontario, Canada, from June 2003 to January 2020. Any maternal ED encounter within 90 days preceding the start of the index pregnancy. Any infant ED visit up to 365 days after the index birth hospitalization discharge date. Relative risks (RR) and absolute risk differences (ARD) were adjusted for maternal age, income, rural residence, immigrant status, parity, having a primary care clinician, and number of prepregnancy comorbidities. There were 2 088 111 singleton livebirths; the mean (SD) maternal age was 29.5 (5.4) years, 208 356 (10.0%) were rural dwelling, and 487 773 (23.4%) had 3 or more comorbidities. Among singleton livebirths, 206 539 mothers (9.9%) had an ED visit within 90 days before the index pregnancy. ED use in the first year of life was higher among infants whose mother had visited the ED before pregnancy (570 per 1000) vs those whose mother had not (388 per 1000) (RR, 1.19 [95% CI, 1.18-1.20]; ARD, 91.1 per 1000 [95% CI, 88.6-93.6 per 1000]). Compared with mothers without a prepregnancy ED visit, the RR of infant ED use in the first year was 1.19 (95% CI, 1.18-1.20) if its mother had 1 prepregnancy ED visit, 1.18 (95% CI, 1.17-1.20) following 2 visits, and 1.22 (95% CI, 1.20-1.23) after at least 3 maternal visits. A low-acuity maternal prepregnancy ED visit was associated with an adjusted odds ratio (aOR) of 5.52 (95% CI, 5.16-5.90) for a low-acuity infant ED visit, which was numerically higher than the pairing of a high-acuity ED use between mother and infant (aOR, 1.43, 95% CI, 1.38-1.49). In this cohort study of singleton livebirths, prepregnancy maternal ED use was associated with a higher rate of ED use by the infant in the first year of life, especially for low-acuity ED use. This study's results may suggest a useful trigger for health system interventions aimed at reducing some ED use in infancy.

Elevated Steady State WBC and Platelet Counts Are Associated with Frequent Emergency Room Use in Adults with Sickle Cell Disease

A small fraction of patients use a disproportionately large amount of emergency department (ED) resources. Identifying these patients, especially those with ambulatory care sensitive conditions (ACSC), would allow health care professionals to enhance their outpatient care. The objectives of the study were to determine predictive factors associated with frequent ED use in a Quebec adult population with ACSCs and to compare several models predicting the risk of becoming an ED frequent user following an ED visit. This was an observational population-based cohort study extracted from Quebec's administrative data. The cohort included 451,775 adult patients, living in nonremote areas, with an ED visit between January 2012 and December 2013 (index visit), and previously diagnosed with an ACSC but not dementia. The outcome was frequent ED use (≥4 visits) during the year following the index visit. Predictors included sociodemographics, physical and mental comorbidities, and prior use of health services. We developed several logistic models (with different sets of predictors) on a derivation cohort (2012 cohort) and tested them on a validation cohort (2013 cohort). Frequent ED users represented 5% of the cohort and accounted for 36% of all ED visits. A simple 2-variable prediction model incorporating history of hospitalization and number of previous ED use accurately predicted future frequent ED use. The full model with all sets of predictors performed only slightly better than the simple model (area under the receiver-operating characteristic curve: 0.786 vs. 0.759, respectively; similar positive predictive value and number needed to evaluate curves). The ability to identify frequent ED users based only on previous ED and hospitalization use provides an opportunity to rapidly target this population for appropriate interventions.