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

Abstract

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.

Subgroups of people who make frequent emergency department visits in Ontario and Alberta: a retrospective cohort study

“…10,40 For our clustering algorithm, we included variables pertaining to emergency department visit patterns and characteristics in NACRS. As is commonly done, 41 we used our previous analyses 5,10 and clinical experience to inform the inclusion of variables that would be clinically useful for emergency physicians. 10,40 We excluded patients with missing information.…”

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People who present frequently to emergency departments are a minority that account for disproportionate health care spending: 1 the highest 3% of this group comprise 30% of charges. 2,3 They are also high users of other health care [3][4][5][6] and are hospitalized and die more often than nonfrequent visitors to the emergency department, 7,8 suggesting a need for interventions that optimize patient outcomes and service allocation. 9 Effective interventions must recognize these patients' clinical and demographic heterogeneity.

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People who make frequent emergency department visits based on persistence of frequent use in Ontario and Alberta: a retrospective cohort study

“…6 Patients in the top 3% of emergency department utilization account for 30% of health care costs, and costs increase with persistent frequent use. 7,8 Previous studies have indicated that one-third of high-cost health care users 9 and 16.5% to 21.9% of people who make frequent visits to the emergency department (including those in our previous analysis in British Columbia) 1 continue to do so over multiple years. People with persistent frequent emergency department use have complex health needs and more conditions related to mental health and substance use than those with short-term frequent use.…”

“…Consistent with previous studies, we identified that frequent use is most often short-term. 10,35,36 Associations between persistent frequent use and increasing comorbidity, mental health, substance use and homelessness could indicate predispositions to medical complications, return visits seeking more compassionate treatment 37 or gaps in effectual alternatives to emergency department care (e.g., primary or addictions care), in rural areas for instance.…”

“…I n many Canadian jurisdictions, the number of emergency department visits attributable to frequent users is increasing; understanding the drivers of high emergency department use is imperative so that patient needs can be addressed. 1,2 For instance, emergency department use is higher in low-income neighbourhoods and rural communities with limited access to primary care. 3,4 As well, 1 in 5 emergency department visits could be dealt with more efficiently in settings other than the emergency department.…”