Understanding Frequent Emergency Department Use Among Primary Care Patients

Abstract

Patients with high emergency department (ED) utilization are an important focus in population health management. This retrospective cohort study analyzed patterns of frequent ED use for 4087 patients enrolled at an academically-affiliated primary care clinic. For all ED visits (n = 4776), the chief complaints, admission rates, number of complaints per patient, and median time between return visits were assessed. Chart reviews were conducted for the 10 highest utilizers from each of the 3 leading complaints to help explain repeated ED use for the same complaints. Results showed that chief complaints for high utilizers were statistically similar to other patients. Nearly half (49.8%) of all ED visits among high utilizers were repeat visits for the same complaint. However, most high utilizers (85%) had 4 or more separate complaints. Their visits clustered temporally, with 55% occurring less than 30 days apart. Visits for psychiatric symptoms demonstrated the shortest time to repeat visit (median 17.5 days, interquartile range: 39.5). Abdominal pain, chest pain, and shortness of breath were the leading complaints and the leading sources of hospital admissions and repeat visits. Chart review revealed that these 3 chief complaints often were associated with a wide range of ongoing chronic conditions, confounded by substance abuse, anxiety, and treatment nonadherence. This study demonstrates an integrative method for examining patterns of ED use among high utilizers. It also highlights the complex nature of high utilization and the inherent difficulty in predicting and addressing the needs of high-utilizer patients.

Characteristics and predictors of adult frequent emergency department users in the United States: A systematic literature review

“…The majority of FEDU had 4 to 10 visits in 1 year, but 5% of FEDU reported to have 21 or more ED visits . The mean number of ED visits across studies was 6.6 to 8.7 visits . Studies that used higher thresholds for FEDU (≥10 or ≥12 ED visits in the past 12 months) found that FEDU had a mean of 19 and 17 ED visits in the previous 12 months, respectively .…”

“…We identified four sources of bias within studies related to (1) strategies to deal with confounding variables (eg, selective reporting of results for studies that did not deal with confounding variables), (2) failure to use proper statistical methods, (3) sample size, or (4) valid and reliable measurement of outcomes (eg, response and recall bias for survey‐based results) (Figure ) 21‐31. The risk of bias across studies was low, since we extracted most information from studies with low risk of bias…”

“…One particular study compared the top 108 FEDU with more than 12 visits/year with 108 randomly assigned non‐FEDU (<4 visits/year) . The proportion of FEDU ranged from 3.8% to 16% of the overall ED users, and they accounted for 14.6% to 47% of all ED visits (Appendix ).…”

Exploring the Value Proposition of Primary Care for Safety-Net Patients Who Utilize Emergency Departments to Address Unmet Needs

“… 25 , 45 This may be particularly relevant to patients with multiple chronic illnesses, who often have fewer personal resources but utilize more services overall (ED and non-ED), compared with those without chronic illnesses. 43 , 46 - 48 Although patients with multiple co-morbidities are more likely to report having non-ED USOC providers, management of their chronic diseases may be suboptimal; as such, there are increased calls to provide more patient-centered primary care to coordinate services for high-risk populations. 14 - 17 , 47 The availability of “one-stop shopping” at the ED, which may exemplify high quality for patients who associate “more” with “better” health care, and the successes of hospitals’ continuous quality improvement initiatives 30 may also confound efforts to differentiate the value proposition of primary versus ED care for safety-net patients.…”

A multicenter randomized control trial evaluating professional practice assessment of patient pain management after simulation training course: Study protocol

“…Its management answers a humanistic, ethical, and human dignity objective because of the numerous physical and psychological repercussions [ 3 ]. Pain is one of the main symptoms motivating patients to consult in emergency settings [ 4 ], and are the leading complaints and the leading sources of hospital admissions and repeat visits [ 5 ]. However, in Emergency Departments (ED), it is underestimated and insufficiently treated [ 6 ].…”