High Emergency Department Users Research Articles

Characteristics for Low, High and Very High Emergency Department Use for Mental Health Diagnoses from Health Records and Structured Interviews.

Patients with mental health diagnoses (MHD) are among the most frequent emergency department (ED) users, suggesting the importance of identifying additional factors associated with their ED use frequency. In this study we assessed various patient sociodemographic and clinical characteristics, and service use associated with low ED users (1-3 visits/year), compared to high (4-7) and very high (8+) ED users with MHD. Our study was conducted in four large Quebec (Canada) ED networks. A total of 299 patients with MHD were randomly recruited from these ED in 2021-2022. Structured interviews complemented data from network health records, providing extensive data on participant profiles and their quality of care. We used multivariable multinomial logistic regression to compare low ED use to high and very high ED use. Over a 12-month period, 39% of patients were low ED users, 37% high, and 24% very high ED users. Compared with low ED users, those at greater probability for high or very high ED use exhibited more violent/disturbed behaviors or social problems, chronic physical illnesses, and barriers to unmet needs. Patients previously hospitalized 1-2 times had lower risk of high or very high ED use than those not previously hospitalized. Compared with low ED users, high and very high ED users showed higher prevalence of personality disorders and suicidal behaviors, respectively. Women had greater probability of high ED use than men. Patients living in rental housing had greater probability of being very high ED users than those living in private housing. Using at least 5+ primary care services and being recurrent ED users two years prior to the last year of ED use had increased probability of very high ED use. Frequency of ED use was associated with complex issues and higher perceived barriers to unmet needs among patients. Very high ED users had more severe recurrent conditions, such as isolation and suicidal behaviors, despite using more primary care services. Results suggested substantial reduction of barriers to care and improvement on both access and continuity of care for these vulnerable patients, integrating crisis resolution and supported housing services. Limited hospitalizations may sometimes be indicated, protecting against ED use.

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.

Profiles of high emergency department users with mental disorders.

This study aimed to (1) identify profiles of high emergency department (ED) users (3+ visits/year) among 5409 patients with mental disorders (MD) based on their patterns of ED use and clinical characteristics; (2) identify sociodemographic and service use correlates linked to high ED user profiles; and (3) assess risks of death in a 12-month follow-up period, controlling for sex and age. Using varied medico-administrative databases, this 5-year study collected patient data for six Quebec (Canada) ED. Latent class analysis was used to distinguish profiles of high ED users for a 3-year period, while bivariate analyses subsequently assessed associations between high ED user profiles and sociodemographic and service use correlates. Survival analysis were also applied to examine relationships between profile memberships of high ED users and risk of death in the 12 months following period of high ED use. Three profiles of high ED use were identified, Profile 1: 3-year recurrent very high ED users (10+ ED visits/year), Profile 2: 2-year recurrent high ED users, and Profile 3: 1-year high ED users. Profiles differed according to severity of health conditions, intensity of service use, particularly frequent hospitalizations, and risk of death: high in Profile 1, moderate in Profile 2, and low in Profile 3. Compared to 1-year high ED users, 3-year recurrent very high ED users and 2-year recurrent high ED users had poorer health and higher risk of death. More targeted interventions may be improved for especially recurrent high ED users and recurrent very high ED use.

Heart Failure and Hospital Utilization Trajectories Before and After Hip Fracture Surgery

According to the World Dementia Council, three components are important to effectively engage a community to become dementia inclusive, 1) raising awareness and consequently decreasing stigma, 2) enabling participation, and 3) providing support—including in health and care settings. Too many times these components are separate initiatives thus limiting their effectiveness and sustainability. By applying the collective impact model and utilizing the Dementia Friends program as the link between the three, all dementia inclusive efforts can be enhanced and sustained regardless of the range of activities and approaches a community chooses to adopt. This symposium provides both evidence and examples of how to personalize and employ the Dementia Friends program to optimize the process, outcome, and impact of dementia inclusive initiatives. By engaging the entire community, awareness is raised, the structure is in place to enable action, and cross-sector collaboration will ensure continuation and sustainability of these important efforts.

Heart Failure and Hospital Utilization Trajectories Before and After Hip Fracture Surgery

Long-term hospital utilization trajectories in the context of surgery are understudied. Heart Failure (HF) is associated with an increased risk for rehospitalization after hip fracture surgery. This study aimed to examine whether older adults (>= 65 years old) have distinct patterns of long-term hospital utilization trajectories and whether HF influences these trajectories before and after hip fracture surgery. An initial cohort of 1,172 older adults hospitalized for hip fracture surgery between October 2015 and December 2018 was extracted from electronic health records. To adjust selection bias in baseline characteristics, we used propensity score 1:1 ratio matching to identify a final cohort of older adults with (n = 288) and without (n = 288) HF. Monthly frequencies of emergency department (ED) and inpatient encounters 1-year before and after the hip fracture surgery were used to identify distinct utilization trajectories from group-based trajectory analysis. Logistic regression models were used to compare the differences in ED and inpatient trajectories among patients with and without HF. High ED users (9.5%) had constant high ED use, and high inpatient users (20.1%) had significantly higher inpatient usage around the index hip fracture surgery hospitalization. Both low ED (90.5%) and inpatient (79.9%) users had low but slightly increased use around the index hospitalization. Compared with older adults without HF, older adults with HF were more likely to be long-term high inpatient user (OR = 1.94, 95% CI 1.25-3.01, p = 0.003), but not significantly different in long-term ED utilization (OR=1.87, 95% CI 0.97-3.59, p = 0.62).

Integrated care effectiveness for adults with co-occurring disorders

PurposeThis study examined effectiveness of an integrated care program on emergency department visits within a longitudinal sample of patients with both primary care and behavioral health diagnoses.Design/methodology/approachPatients with co-occurring disorders enrolled in an integrated care clinic and were followed over time to determine whether participation in the clinic, including engagement in wellness/peer services, predicted decreases in Emergency Department (ED) use. Associations between socio-demographic characteristics of patients and ED use were also analyzed.FindingsAfter 6 months, clinic patients had decreases in ED use that continued for twelve months, albeit to a lesser degree. Demographics and program services were not related to ED use; however, multiple associations existed between high ED utilizers, severe mental illness (SMI), substance use disorders (SUD) and non-retention in services.Research limitations/implicationsThe study lacked a comparison group and there was no distinction between avoidable and unavoidable ED visits. A small sample size across time points led to inconclusive post hoc findings.Originality/valueThis study explored effectiveness of primary care integration into a behavioral health clinic for persons with multiple morbidities. Although initial decreases in ED visits were present, results indicate that these models may not be effective for persons with SMI or SMI/SUD who are already high ED users. This study provides support for integrated care in reducing ED use among persons with multiple morbidities and calls for further research on designing effective integrated models for persons with SMI and SUD.

4269 Frequent emergency department use among homeless individuals seen in emergent care: High risks of opioid-related diagnoses and adverse health services utilization outcomes

OBJECTIVES/GOALS: Using multi-state discharge data, to identify predictors of frequent emergency department (ED) use among the homeless patients seen in emergent care, and to compare frequent versus less frequent homeless ED users for their risk of serious health services utilization outcomes. METHODS/STUDY POPULATION: Based on the State Emergency Department Database and the State Inpatient Database, homeless individuals (n = 88,541) who made at least one ED visit in four states (Florida, Maryland, Massachusetts, and New York) in 2014. In this retrospective cross-sectional analysis, patient-level demographic and clinical factors were assessed as predictors for increased ED use. Risks of opioid overdose, opioid-related hospital admission/ED visit, in-hospital mortality, mechanical ventilation, and number of hospitalizations were compared between individuals with 4 or more vs. 2-3 vs. 1 ED visit(s), adjusting for potential confounders including hospital fixed effects (allowing for within hospital comparisons). RESULTS/ANTICIPATED RESULTS: Higher rates of ED use were associated with Medicare coverage <65; primary diagnosis of alcohol abuse, asthma, or abdominal pain; and co-morbidity of alcohol abuse, psychoses, or chronic pulmonary disease. Individuals with ≥4 visits had significantly higher adjusted risk of opioid overdose (3.7% vs. 1.2% vs. 1.0%), opioid-related hospitalizations/ED visits (17.9% vs. 8.5% vs. 6.6%), mechanical ventilation (9.8% vs. 7.0% vs. 4.7%), and greater # of hospitalizations (3.2 vs. 1.3 vs. 0.8) compared to individuals with 2-3 or 1 ED visit. Individuals with ≥4 and 2-3 ED visits had similar but increased risks of in-hospital mortality compared to individuals with 1 ED visit (2.8% vs. 2.8% vs. 2.3%). DISCUSSION/SIGNIFICANCE OF IMPACT: Homeless patients who were high ED users were more likely to be hospitalized and have other adverse outcomes. These findings encourage targeted interventions (i.e. housing) for the high-utilizer homeless population to reduce the burden of serious outcomes and costs for the patient and society.

Profiles of persons with current or previous experience of homelessness using emergency departments

A typology for emergency department (ED) use was developed among persons with current or previous experience of homelessness in Quebec (Canada) (n = 455). Cluster analysis identified four profiles: (1) Low or high ED users in permanent housing: high use of primary care services; (2) High ED users in temporary housing or emergency shelters: complex health problems, frequent hospitalizations, without case managers; (3) Low or non-ED users in temporary housing: middle-aged, low quality of life, few chronic physical illnesses, little service use; and (4) Non-ED users in permanent housing: high quality of life, few affected by stigma, infrequent service use. Needs factors mainly accounted for ED use, but use of diversified health services and professionals reduced ED use. Results also suggested that improving access to health services may reduce stigma. Living in permanent housing and having a case manager were related to lower ED use, fewer hospitalizations, and greater satisfaction with services.

Utilisation de l’urgence au Québec des patients avec des troubles mentaux incluant les troubles liés aux substances psychoactives

Objectives This study investigated emergency department (ED) use, reasons for emergency visits, hospitalization rates, and duration of hospitalization in 2014-15 for a cohort of patients with mental disorders (MDs) including substance use disorders (SUDs), regarding sex, age and residential areas. Results were compared with data from patients without MDs for 2014-15, and with another cohort from 2000-01, which marked the beginning of primary care reform in Quebec and elsewhere, with the aim of measuring ED use over time. Methods Based on data from the Quebec Integrated Chronic Disease Surveillance System (QICDSS), participants included patients age 12 and over, diagnosed with at least one MD (or SUD) during an ED visit, hospitalization, or outpatient consultation in 2014-15 and 2000-01. Frequency distributions for ED visits and hospitalizations were produced, as well as for MDs or SUDs exclusively, or for co-occurring MDs-SUDs, and among high or very high ED users (4 to 11 visits/year, ≥12 visits/year), by gender, age (12-17, 18-24, 25-44, 45-64, and 65 and over) and residential area (Montreal, urban areas:>100,000, semi-urban areas: <100,000, and rural areas: <10,000). The age-standardized method based on the age structure of the 2014-15 population was used to compare data from 2014-15 to 2000-01. Frequency distributions for patients with and without MDs, and on ED and hospitalization rates were also produced for 2014-15. Results For the Quebec population, 12% had MDs including SUDs, of whom 39% had visited an ED, a decrease of 6% since 2000-01. Approximately twice as many patients with MDs had ED visits or hospitalizations, compared to patients without MDs. Nearly 17% of patients were high or very high ED users; and 34% were hospitalized. ED use was higher among patients 65 years and older, and those living in rural areas. Sixty-eight percent of ED visits for MDs exclusively were made by patients affected by anxiety-depression; whereas 51% of visits for SUDs exclusively were alcohol-related. Physical illnesses were the main reason for ED visits and hospitalizations; yet patients with severe MDs, co-occurring MDs and SUDs as well as those with more frequent ED visits tended to use EDs more for MD reasons. Conclusion This study demonstrated a very high volume of ED visits and hospitalizations among patients with MDs, including SUDs, compared to patients without MDs. Co-occurring disorders, especially physical conditions and multiple and severe MDs, contributed to frequent ED use and hospitalizations. Better care management, including more comprehensive personal care, for patients with MDs including SUDs and co-occurring disorders is needed, as well as the deployment of strategies that provide integrated mental health and medical care, particularly in Montreal where ED use by patients with predominantly severe and co-occurring MDs and physical illnesses, is more frequent.

Using the Electronic Medical Record to Identify Patients at High Risk for Frequent Emergency Department Visits and High System Costs

BackgroundA small proportion of patients account for a high proportion of healthcare use. Accurate preemptive identification may facilitate tailored intervention. We sought to determine whether machine learning techniques using text from a family practice electronic medical record can be used to predict future high emergency department use and total costs by patients who are not yet high emergency department users or high cost to the healthcare system. MethodsText from fields of the cumulative patient profile within an electronic medical record of 43,111 patients was indexed. Separate training and validation cohorts were created. After processing, 11,905 words were used to fit a logistic regression model. The primary outcomes of interest in the 12 months after prediction were 3 or more emergency department visits and being in the top 5% in healthcare expenditures. Outcomes were assessed through linkage to administrative databases housed at the Institute for Clinical Evaluative Sciences. ResultsIn the model to predict frequent emergency department visits, after excluding patients who were high emergency department users in the previous year, the area under the receiver operating characteristic curve was 0.71. By using the same methodology, the model to predict the top 5% in total system costs had an area under the receiver operating characteristic curve of 0.76. ConclusionsMachine learning techniques can be applied to analyze free text contained in electronic medical records. This dataset is more predictive of patients who will generate future high costs than future emergency department visits. It remains to be seen whether these predictions can be used to reduce costs by early interventions in this cohort of patients.

Variations in Resource Intensity and Cost Among High Users of the Emergency Department

High users of emergency department (ED) services are often identified by number of visits per year, with little exploration of the distribution/pattern of visits over time. The purpose of this study was to examine patient- and encounter-level factors and costs related to periods of short-term resource intensity among high users of the ED within a tertiary care teaching facility. We identified all adults with at least three visits to the Ottawa Hospital ED within a 1-year period from April 1, 2012, to March 31, 2013. Within this high-user cohort, we then measured intensity of use by calculating average daily visit rates to identify individuals with a cluster of ED visits. Those with at least three ED visits/7 days at any point during follow-up were considered patients with clustered ED use (i.e., a period of short-term resource intensity). Detailed clinical and administrative data were used to compare patient- and encounter-level characteristics and cost profiles between the clustered and nonclustered groups. Analyses were repeated using varying cut points to define high users (at least five and at least eight visits per year). Of the 16,153 patients identified as high ED users during the study period, 13.5% had their visits clustered within a short period of time. These clustered users were more likely to be homeless, to require psychiatric services, and to leave without being seen by a physician and less likely to be admitted to the hospital. Approximately one in three (31.2%) high ED users with clustered visits returned for the same medical problem (namely pain-related disorders, shortness of breath, and cellulitis) within a 1-week period. Similar trends were observed when the high-user cohort was restricted to those with at least five and at least eight ED visits/year. Finally, patients with short-term intensity periods had lower direct and indirect costs per encounter than those without. Using a novel methodology that accounts for both number and intensity of ED encounters over time, we were able to identify specific subpopulations of high ED users. Further work is required to determine if this methodology has utility for targeting care pathways within this heterogeneous and high-risk patient group.