Frequent Emergency Department Users Research Articles

Identifying subgroups and risk among frequent emergency department users in British Columbia.

Objective: Frequent emergency department (ED) users are heterogeneous. We aimed to identify subgroups and assess their mortality. Methods: We identified patients ≥18 years with ≥1 ED visit in British Columbia from April 1, 2012 to March 31, 2015, and linked to hospitalization, physician billing, prescription, and mortality data. Frequent users were the top 10% of patients by ED visits.We employed cluster analysis to identify frequent user subgroups. We assessed 365‐day mortality using Kaplan‐Meier curves and conducted Cox regressions to assess mortality risk factors within subgroups. Results: We identified 4 subgroups. Subgroup 1 (“Elderly”) had median age 77 years (interquartile range [IQR]: 66–85), 5 visits/year (IQR: 4–6), median 8 prescription medications (IQR: 5–11), and 24.7% mortality. Subgroup 2 (“Mental Health and Alcohol Use”) had median age 48 years (IQR: 34–61), 13 visits/year (IQR: 10–16), and 12.3% mortality. They made a median 31 general practitioner visits (IQR: 19–51); however, only 23.7% received a majority of services from 1 primary care physician. Subgroup 3 (“Young Mental Health”) had median age 39 years (IQR: 28–51), 5 visits/year (IQR: 4–6), and 2.2% mortality. Subgroup 4 (“Short‐term”) had median age 50 years (IQR: 34–65), 4 visits/year (IQR: 4–5) regularly spaced over a short term, and 1.4% mortality. Male sex (all subgroups), long‐term care (“Mental Health and Alcohol Use;” “Young Mental Health”), and rural residence (“Elderly” in long‐term care; “Young Mental Health”) were associated with increased mortality. Conclusions: Our results identify frequent user subgroups with varying mortality. Future research should explore subgroups’ unmet needs and tailor interventions toward them.

Healthcare Providers' Perceptions of Challenges with Frequent Users of Emergency Department Care in Switzerland: A Qualitative Study.

Frequent users of emergency departments (FUED; ≥ 5 ED visits/year) commonly cumulate medical, social, and substance use problems requiring complex and sustained care coordination often unavailable in ED. This study aimed to explore ED healthcare providers’ challenges related to FUED care to gain insight into the support and resources required to address FUED complex needs. An online survey was sent to all general adult emergency services within Switzerland (N = 106). Participants were asked to indicate the extent to which they perceived that FUED represented a problem and to describe the main challenges encountered. In total, 208 physicians and nurses from 75 EDs (70.7%) completed the survey. Among the 208 participants, 134 (64%) reported that FUED represented a challenge and 133 described 1 to 5 challenges encountered. A conventional content analysis yielded 4 main categories of perceived challenges. Negative consequences in the ED secondary to FUED’s presence (eg, ED overcrowding, staff helplessness, and fatigue) was the most frequently reported challenge, followed by challenges related to FUEDs’ characteristics (eg, mental health and social problems) leading to healthcare complexity. The third most frequently encountered challenge was related to the ED inappropriateness and inefficiency to address FUEDs’ needs. Finally, challenges related to the lack of FUED healthcare network were the least often mentioned. ED healthcare providers experience a wide range of challenges related to FUED care. These findings suggest that currently EDs nor their staff are equipped to address FUEDs’ complex needs.

Emergency department frequent users in rural Tuscany: who, why and how? A descriptive retrospective analysis

article: Emergency department frequent users in rural Tuscany: who, why and how? A descriptive retrospective analysis - Italian Journal of Emergency Medicine 2020 December;9(3):178-87 - Minerva Medica - Journals

Characteristics of frequent emergency department users in British Columbia, Canada: a retrospective analysis.

Background:Frequent emergency department users disproportionately account for rising health care costs. We aimed to characterize frequent emergency department users in British Columbia, Canada.Methods:We performed a retrospective analysis using health administrative databases. We included patients aged 18 years or more with at least 1 emergency department visit from 2012/13 to 2015/16, linked to hospital, physician billing, prescription and mortality data. We used annual emergency department visits made by the top 10% of patients to define frequent users (≥ 3 visits/year).Results:Over the study period, 13.8%–15.3% of patients seen in emergency departments were frequent users. We identified 205 136 frequent users among 1 196 353 emergency department visitors. Frequent users made 40.3% of total visits in 2015/16. From 2012/13 to 2015/16, their visit rates per 100 000 BC population showed a relative increase of 21.8%, versus 13.1% among all emergency department patients. Only 1.8% were frequent users in all study years. Mental illness accounted for 8.2% of visits among those less than 60 years of age, and circulatory or respiratory diagnoses for 13.3% of visits among those aged 60 or more. In 2015/16, frequent users were older and had lower household incomes than nonfrequent users; the sex distribution was similar. Frequent users had more prescriptions (median 9, interquartile range [IQR] 5–14 v. 1, IQR 1–3), primary care visits (median 15, IQR 9–27 v. 7, IQR 4–12) and hospital admissions (median 2, IQR 1–3 v. 1, IQR 1–1), and higher 1-year mortality (10.2% v. 3.5%) than nonfrequent users.Interpretation:Emergency department use by frequent users increased in BC between 2012/13 and 2015/16; these patients were heterogenous, had high mortality and rarely remained frequent users over multiple years. Our results suggest that interventions must account for heterogeneity and address triggers of frequent use episodes.

Case management for frequent emergency department users: no longer a question of if but when, where and how.

Case management for frequent emergency department users: no longer a question of if but when, where and how.

Patient-specific record linkage between emergency department and hospital admission data for a cohort of people who inject drugs: methodological considerations for frequent presenters

BackgroundPeople who inject drugs (PWID) have been identified as frequent users of emergency department (ED) and hospital inpatient services. The specific challenges of record linkage in cohorts with numerous administrative health records occurring in close proximity are not well understood. Here, we present a method for patient-specific record linkage of ED and hospital admission data for a cohort of PWID.MethodsData from 688 PWID were linked to two state-wide administrative health databases identifying all ED visits and hospital admissions for the cohort between January 2008 and June 2013. We linked patient-specific ED and hospital admissions data, using administrative date-time timestamps and pre-specified linkage criteria, to identify hospital admissions stemming from ED presentations for a given individual. The ability of standalone databases to identify linked ED visits or hospital admissions was examined.ResultsThere were 3459 ED visits and 1877 hospital admissions identified during the study period. Thirty-four percent of ED visits were linked to hospital admissions. Most links had hospital admission timestamps in-between or identical to their ED visit timestamps (n = 1035, 87%). Allowing 24-h between ED visits and hospital admissions captured more linked records, but increased manual inspection requirements. In linked records (n = 1190), the ED ‘departure status’ variable correctly reflected subsequent hospital admission in only 68% of cases. The hospital ‘admission type’ variable was non-specific in identifying if a preceding ED visit had occurred.ConclusionsLinking ED visits with subsequent hospital admissions in PWID requires access to date and time variables for accurate temporal sorting, especially for same-day presentations. Selecting time-windows to capture linked records requires discretion. Researchers risk under-ascertainment of hospital admissions if using ED data alone.

Characteristics of frequent paediatric users of emergency departments in England: an observational study using routine national data

BackgroundFrequent attendances of the same users in emergency departments (ED) can intensify workload pressures and are common among children, yet little is known about the characteristics of paediatric frequent users...

Addressing social disconnection among frequent users of community hospital emergency departments: A statewide implementation evaluation

Addressing social disconnection among frequent users of community hospital emergency departments: A statewide implementation evaluation

Management of frequent ED users by community paramedics improves patient experiences and reduces EMS utilization

Management of frequent ED users by community paramedics improves patient experiences and reduces EMS utilization

Profiles of Frequent Geriatric Users of Emergency Departments: A Latent Class Analysis.

Frequent geriatric users of emergency departments (EDs) represent a complex and heterogeneous population. Identifying their specific subgroups would allow the development of interventions better customized to their needs and characteristics. Thus, this study aimed to develop profiles of frequent geriatric ED users using the individual characteristics of patients. This was a retrospective cohort study. Databases from the Régie de l'assurance maladie du Québec (RAMQ) were utilized. PARTICIPANTSThis study included individuals aged 65 years or older living in the community in the Province of Quebec (Canada), who consulted in an ED at least four times in the year after an ED index date (an ED visit, chosen randomly, during an index period of January 1, 2012 to December 31, 2013) and who had received a diagnosis of ambulatory care-sensitive conditions (ACSCs) in the 2 years preceding the index date. A latent class analysis was used to identify subgroups of frequent geriatric ED users according to their individual characteristics, including ACSC type, dementia, mental health disorders, cancer diagnosis, and comorbidity index. The study cohort consisted of 21,393 frequent geriatric ED users. Four groups of frequent geriatric ED users were identified: people with low comorbidity (39.0%), comprising the individuals with the lowest number of physical and mental health conditions; people with cancer (32.7%); people with pulmonaryand cardiac diseases (18.1%); and people with dementia or mental health disorders (10.2%), composed of individuals with the highest proportion of common and severe mental health disease, as well as dementia. This group accounts for the highest use of overall healthcare services. These profiles will be useful in developing customized interventions addressing the needs of each subgroup of frequent geriatric ED users. More research is needed to bridge the remaining gaps, especially regarding the healthiest frequent geriatric users of EDs.

Frequent users of emergency departments and patient flow in Alberta and Ontario, Canada: an administrative data study

BackgroundThis paper describes and compares patient flow characteristics of adult high system users (HSUs) and control groups in Alberta and Ontario emergency departments (EDs), Canada.MethodsAnnual cohorts of HSUs were created by identifying patients who made up the top 10% of ED users (by count of ED presentations) in the National Ambulatory Care Reporting System during 2011–2016. Random samples of patients not in the HSU groups were selected as controls. Presentation (e.g., acuity) and ED times (e.g., time to physician initial assessment [PIA], length of stay) data were extracted and described. The length of stay for 2015/2016 data was decomposed into stages and Cox models compared time between stages.ResultsThere were 20,343,230 and 18,222,969 ED presentations made by 7,032,655 and 1,923,462 individuals in the control and HSU groups, respectively. The Ontario groups had higher acuity than the Alberta groups: about 20% in the Ontario groups were from the emergent level whereas Alberta had 11–15%. Time to PIA was similar across provinces and groups (medians of 60 min to 67 min). Lengths of stay were longest for Ontario HSUs (median = 3 h) and shortest for Alberta HSUs (median = 2.2 h). HSUs had shorter times to PIA (hazard ratio [HR] = 1.03; 95% confidence interval [CI] 1.02,1.03), longer times from PIA to decision (HR = 0.84; 95%CI 0.84,0.84), and longer times from decision to leaving the ED (HR = 0.91; 95%CI 0.91,0.91).ConclusionsOntario HSUs had higher acuity and longer ED lengths of stay than the other groups. In both provinces, HSU had shorter times to PIA and longer times after assessment.

Frequent-users of emergency department: a mixed-methods observational retrospective study in Emilia-Romagna (Italy)

Background. The overcrowding of Emergency Departments (EDs) represents a major concern in Italy. Frequent users (FUs) contribute to overcrowding, wasting health care resources. Objective. To describe the characteristics of FUs and to evaluate the reliability of the ED information systems. Design. An observational single-centre retrospective study.Methods. A quali-quantitative analysis of medical records from FU admissions to the ED in a 15-month period at a Teaching Hospital in Italy.Conclusions. The adoption of a patient-centred approach oriented towards chronic conditions could result in richer information and better management of FUs.

Differences between frequent emergency department users in a secondary rural hospital and a tertiary suburban hospital in central Japan: a prevalence study

ObjectivesAlthough frequent emergency department (ED) use is a global issue, little research has been conducted in a country like Japan where universal health insurance is available. The study aims to...

Experience of being a frequent user of primary care and emergency department services: a qualitative systematic review and thematic synthesis

BackgroundFrequent users of healthcare services are often categorised as ‘heavy-cost patients’. In the recent years, many jurisdictions have attempted to implement different public policies to optimise the use of health...

Optimizing telehealth pain care after COVID-19.

Optimizing telehealth pain care after COVID-19.

Abstract 5769: Opioid prescription characteristics associated with frequent emergency department use among hospitalized cancer patients: a comparative cohort study

Abstract Background: Opioid use is associated with greater health resource utilization, namely unplanned emergency department (ED) visits. The purpose of this study was to characterize ED visit patterns by patients hospitalized for cancer based on their use of prescription opioids in the community. Design & Methods: A prospective cohort study of cancer patients discharged from medical and surgical units at an academic health center in Montreal (Canada) between October 2014 and November 2016 was assembled. The main outcome was frequent ED use (≥4 ED visits) in the year following hospital discharge. Clinical information linked to health administrative claims from the provincial universal health care program (RAMQ) was used in multivariable logistic regression to model patient and opioid prescription characteristics, comparing frequent ED users to non-frequent ED users. Potential predictors included history of chronic pain condition, mental health diagnoses, type of cancer, receipt of radiotherapy/chemotherapy, medication history (previous use of opioids, history of antidepressant use, benzodiazepines), receipt of surgery during the hospitalization as well as characteristics of the discharge prescription (e.g: receipt of an opioid, presence of a multi-modal pain regimen). Results: A cohort of 1253 cancer patients discharged from the medical and surgical units was assembled. The mean age for these patients was 70.9 (11.8) and the most frequent cancers included 488 (38.9%) respiratory and 309 (24.6%) upper digestive cancer. Overall, 54% of cancer patients (n =654) had at least one ED visit in the year post-discharge. Of these, all had filled at least one opioid prescription during the follow-up period. Of patients with at least one ED visit in the one year post-discharge, 29% (n = 188) became frequent ED users. In adjusted multivariable logistic model, the strongest associations of frequent ED use were receipt of chemotherapy one year before their index hospitalization (odds ratio (OR) 1.67; 95% CI: 1.08 - 2.61) and respiratory cancer diagnoses (OR 1.69; 95% CI: 1.07 - 2.67). With respect to opioid prescribing, most the dispensations were for oxycodone (51.4%) and hydromorphone (33.6%). Patients receiving a daily dose >90 MME (morphine milligram equivalents) had an odds ratio of 2.24 (95% CI: 1.14- 4.40) of becoming frequent ED users. Those who filled more than one type of opioid during the follow-up were 1.81 times more likely to become repeated ED users (95% CI: 1.23 - 2.70). Conclusions: Cancer patients with higher opioid use after hospital discharge and active use of more than two different type of opioids within one year time of discharge are at higher risk of encoring unplanned health visits in the ER. A new approach to care planning and coordination is recommended to better monitor opioid prescribing practices and improve outcomes. Citation Format: Siyana Kurteva, Robyn Tamblyn, Ari Meguerditchian. Opioid prescription characteristics associated with frequent emergency department use among hospitalized cancer patients: a comparative cohort study [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5769.

Medicaid Expansion Resulted in Decreased Odds of Frequent Emergency Department Use Among Medicaid Beneficiaries and the Uninsured in New York

Research ObjectiveFrequent emergency department (ED) use has been often cited as a marker of fragmented health care provision and is an indicator of poor quality of care. The Affordable Care Act (ACA) attempted to address the rising costs related to the utilization of ED services, among others, by expanding insurance coverage, by fortifying primary care, by supporting the development of integrated health care delivery models, and by introducing alternative quality‐adjusted payment models. The objective of this study is to describe and to compare frequent ED users before and after the Medicaid expansion under the ACA and to estimate the policy’s effect on the likelihood of frequent ED utilization in New York.Study DesignWe used the 2011 to 2016 Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD) and State Inpatient Databases (SID) for New York. The number of ED visits per patient was calculated using a patient identifier across the HCUP SEDD and SID data. We defined frequent ED use as four or more visits in one year. Multivariate logistic regression was used to estimate the changes in the likelihood of frequent ED use in the post‐Medicaid expansion period. We conducted sensitivity analyses using alternative definitions of frequent use and falsification analyses examining only pre‐expansion years.Population StudiedIn‐state residents aged 18‐64, who had Medicaid or private coverage or were uninsured.Principal FindingsFrequent users represented 7.1% of all ED patients before and 7.3% after the policy implementation and accounted for 26.1% and 27.0% of all ED visits, respectively. Frequent users were mostly covered through Medicaid across all years (69% vs 35%, P < .001) and had higher rates of comorbidities and chronic conditions compared with infrequent users. After controlling for patient and county‐level characteristics, the policy implementation was associated with 4% (P < .001) and 12% (P < .001) reductions in the likelihood of being a frequent ED user among Medicaid beneficiaries and the uninsured, respectively, while the likelihood of frequent use increased by 9% (P < .001) for private insurance enrollees. Beyond the policy, high ED reliance was continuously associated with patients who had multiple comorbidities and chronic conditions, including mental health, substance, and alcohol use, as well as conditions that could be prevented and treated in non‐ED settings.ConclusionsAfter New York expanded Medicaid in 2014, the likelihood of frequent ED use declined among Medicaid beneficiaries and those remaining uninsured.Implications for Policy or PracticeThe high share of frequent users in Medicaid plans indicates the continuous need to address social determinants of health at community level, particularly for Medicaid patients.

Frequent Emergency Department Visitors Associated With a Pain-Discharge Diagnosis.

Emergency departments (EDs) have experienced an increase in annual patient visits and length of stay over the past decade. Management of frequent-user patients with pain-related diagnoses are challenging in a time-limited setting. The purpose of this study was to describe characteristics of frequent ED users with pain-related diagnoses. This was a retrospective longitudinal cohort study of hospital ED visits from two EDs in using encounters from September 2016 to August 2018. Frequent users were characterized as having four or more visits in a 1-year period and were further classified into three categories based on the number of pain-related visits in the study period. Descriptive statistics and regression analysis results are reported for all demographic and clinical characteristics for index encounters, patient level data, and pain subgroups. Of all patients, 11.3% (n=5174) were identified as frequent users, accounting for 38.9% (n=91,114) of all ED visits. Overall, frequent pain users were more likely to be of middle age (odds ratio [OR] 1.70, 95% confidence interval [CI] 0.80-1.72), female (OR 2.43, 95% CI 1.79-3.29), have commercial insurance (OR 1.91, 95% CI 1.37-2.66), and have 10 or more ED encounters (super user status) in a 12-month period (OR 23.66, 95% CI 17.12-32.71). Understanding characteristics of ED frequent users with pain-related diagnoses may inform community-based interventions designed to reduce episodic care and thereby improve care coordination and management.

Effectiveness of interventions to reduce adverse outcomes among older adults following emergency department discharge: Protocol for an overview of systematic reviews

Background: Older adults are frequent users of Emergency departments (ED) and this trend will continue due to population ageing and the associated increase in healthcare needs. Older adults are vulnerable to adverse outcomes following ED discharge. A number of heterogeneous interventions have been developed and implemented to improve clinical outcomes among this cohort. A growing number of systematic reviews have synthesised evidence regarding ED interventions using varying methodologies. This overview aims to synthesise the totality of evidence in order to evaluate the effectiveness of interventions to reduce adverse outcomes in older adults discharged from the ED. Methods: To identify relevant reviews, the following databases will be searched: Cochrane Database of Systematic reviews, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Databases of s of Reviews of Effects, PubMed, MEDLINE, Epistemonikos, Ageline, Embase, PEDro, Scopus, CINAHL and the PROSPERO register. The search for grey literature will include Open Grey and Grey Literature Reports. Systematic reviews of randomised controlled trials will be analysed to assess the effect of ED interventions on clinical and process outcomes in older adults. Methodological quality of the reviews will be assessed using the Assessment of Multiple Systematic Reviews 2 tool. The review will be reported in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Summary of findings will include a hierarchical rank of interventions based on estimates of effects and the quality of evidence. Discussion: This overview is required given the number of systematic reviews published regarding the effectiveness of various ED interventions for older adults at risk of adverse outcomes following discharge from the ED. There is a need to examine the totality of evidence using rigorous analytic techniques to inform best care and potentially develop a hierarchy of treatment options. PROSPERO registration: CRD42020145315 (28/04/2020)

Methamphetamine, Amphetamine, and MDMA Use and Emergency Department Recidivism.

Emergency department (ED) recidivism and the use of amphetamine and associated derivatives such as methamphetamine and MDMA (MAE), are intersecting public health concerns. This study aims to determine the frequency of ED recidivism of patients who use MAE and associated factors. The study was a retrospective 6-year electronic medical record review of patients with MAE-positive toxicology screens and single and multiple ED visits in the span of 12months. There were 7844 ED visits by 5568 MAE-positive patients. Average age was 42±13years. The majority were male (65%), white (46%), tobacco smokers (55%), and in the psychiatric discharge diagnostic-related group (41%), followed by blunt trauma (20%). Admission rate was 35%, with another 17% transferred to inpatient psychiatric treatment facilities. Occasional (2-5 visits/year), heavy (6-11 visits/year), and super users (≥12 visits/year) altogether accounted for 20% of patients and 43% of visits. Heavy and super users combined represented 2% of patients and 10% of visits, with significant differences for race/ethnicity, health insurance, tobacco smoking, and psychiatric/cardiovascular/trauma discharge diagnostic-related groups. Heavy and super users were less likely to be admitted and more likely to be discharged to an inpatient psychiatric treatment facility. Regression analysis revealed racial/ethnic differences, female gender, and tobacco smoking to be associated with super and heavy use. Heavy users were more likely to have cardiovascular-related discharge diagnoses. The prevalence of ED recidivism in patients who use MAE is similar to published ranges for general ED users. Significant differences in demographics, discharge diagnoses, insurance, smoking, and disposition exist between nonfrequent and frequent ED users.