Recurrent Emergency Department Users: Two Categories with Different Risk Profiles
Abstract
:1. Introduction
2. Experimental Section
2.1. Study Design and Setting
2.2. Endpoints
2.3. Assessment of Other Study Variables
2.4. Statistical Analysis
3. Results
3.1. Leading Symptoms of Repeated and Frequent ED Visitors
3.2. Repeated ED Visitors
3.3. Frequent ED Visitors
3.4. Subgroup of Recurrent Senior ED Patients
4. Discussion
Limitations and Strength of the Study
5. Conclusions
Author Contributions
Funding
Conflicts of Interest
References
- Bundesamt für Statistik. Medienmitteilung: Kosten und Finanzierung des Gesundheitswesens 2016: Provisorische Daten; Nr. 2018-0216-D; Bundesamt für Statistik: Bern, Switzerland, 2018. [Google Scholar]
- Gawande, A. The hot spotters: Can we lower medical costs by giving the neediest patients better care? New Yorker 2011, 24, 40–51. [Google Scholar]
- LaCalle, E.; Rabin, E. Frequent Users of Emergency Departments: The Myths, the Data, and the Policy Implications. Ann. Emerg. Med. 2010, 56, 42–48. [Google Scholar] [CrossRef]
- Trzeciak, S.; Rivers, E.P. Emergency department overcrowding in the United States: An emerging threat to patient safety and public health. Emerg. Med. J. 2003, 20, 402–405. [Google Scholar] [CrossRef] [PubMed]
- Cowan, R.M.; Trzeciak, S. Clinical review: Emergency department overcrowding and the potential impact on the critically ill. Crit. Care 2005, 9, 291–295. [Google Scholar] [CrossRef] [PubMed]
- Cook, L.J.; Knight, S.; Junkins, E.P.; Mann, N.C.; Dean, J.M.; Olson, L.M. Repeat patients to the emergency department in a Statewide database. Acad. Emerg. Med. 2004, 11, 256–263. [Google Scholar] [CrossRef] [PubMed]
- Miller, J.B.; Brauer, E.; Rao, H.; Wickenheiser, K.; Dev, S.; Omino, R.; Stokes-Buzzelli, S. The most frequent ED patients carry insurance and a significant burden of disease. Am. J. Emerg. Med. 2013, 31, 16–19. [Google Scholar] [CrossRef] [PubMed]
- Sandoval, E.; Smith, S.; Walter, J.; Schuman, S.A.; Olson, M.P.; Striefler, R.; Brown, S.; Hickner, J. A comparison of frequent and infrequent visitors to an urban emergency department. J. Emerg. Med. 2010, 38, 115–121. [Google Scholar] [CrossRef]
- Lucas, R.H.; Sanford, S.M. An analysis of frequent users of emergency care at an urban university hospital. Ann. Emerg. Med. 1998, 32, 563–568. [Google Scholar] [CrossRef]
- Murphy, A.W.; Leonard, C.; Plunkett, P.K.; Brazier, H.; Conroy, R.; Lynam, F.; Bury, G. Characteristics of attenders and their attendances at an urban accident and emergency department over a one year period. J. Accid. Emerg. Med. 1999, 16, 425–427. [Google Scholar] [CrossRef]
- Mandelberg, J.H.; Kuhn, R.E.; Kohn, M.A. Epidemiologic analysis of an urban, public emergency department’s frequent users. Acad. Emerg. Med. 2000, 7, 637–646. [Google Scholar] [CrossRef]
- Okuyemi, K.S.; Frey, B. Describing and predicting frequent users of an emergency department. J. Assoc. Acad. Minor. Phys. 2001, 12, 119–123. [Google Scholar] [PubMed]
- Pines, J.M.; Buford, K. Predictors of frequent emergency department utilization in Southeastern Pennsylvania. J. Asthma 2006, 43, 219–223. [Google Scholar] [CrossRef] [PubMed]
- Hansagi, H.; Olsson, M.; Sjoberg, S.; Tomson, Y.; Göransson, S. Frequent use of the hospital emergency department is indicative of high use of other health care services. Ann. Emerg. Med. 2001, 37, 561–567. [Google Scholar] [CrossRef] [PubMed]
- Hunt, K.A.; Weber, E.J.; Showstack, J.A.; Colby, D.C.; Callaham, M.L. Characteristics of frequent users of emergency departments. Ann. Emerg. Med. 2006, 48, 1–8. [Google Scholar] [CrossRef] [PubMed]
- Sun, B.C.; Burstin, H.R.; Brennan, T.A. Predictors and outcomes of frequent emergency department users. Acad. Emerg. Med. 2003, 10, 320–328. [Google Scholar] [CrossRef] [PubMed]
- Krieg, C.; Hudon, C.; Chouinard, M.C.; Dufour, I. Individual predictors of frequent emergency department use: A scoping review. BMC Health Serv. Res. 2016, 16, 594. [Google Scholar] [CrossRef] [PubMed]
- Bieler, G.; Paroz, S.; Faouzi, M.; Trueb, L.; Vaucher, P.; Althaus, F.; Daeppen, J.B.; Bodenmann, P. Social and medical vulnerability factors of emergency department frequent users in a universal health insurance system. Acad. Emerg. Med. 2012, 19, 63–68. [Google Scholar] [CrossRef]
- Palmer, E.; Leblanc-Duchin, D.; Murray, J.; Atkinson, P. Emergency department use. Can. Fam. Phys. 2014, 60, E223–E229. [Google Scholar]
- Grossmann, F.F.; Delport, K.; Keller, D.I. Emergency Severity Index. Translation of a valid triage instrument into German. Notf. Rett. 2009, 12, 290–292. [Google Scholar] [CrossRef]
- Grumbach, K.; Keane, D.; Bindman, A.B. Primary-Care and Public Emergency Department Overcrowding—Respond. Am. J. Public Health 1994, 84, 124. [Google Scholar] [CrossRef]
- McCusker, J.; Healy, E.; Bellavance, F.; Connolly, B. Predictors of repeat emergency department visits by elders. Acad. Emerg. Med. 1997, 4, 581–588. [Google Scholar] [CrossRef] [PubMed]
- Blank, F.S.J.; Li, H.P.; Henneman, P.L.; Smithline, H.A.; Santoro, J.S.; Provost, D.; Maynard, A.M. A descriptive study of heavy emergency department users at an academic emergency department reveals heavy ED users have better access to care than average users. J. Emerg. Nurs. 2005, 31, 139–144. [Google Scholar] [CrossRef]
- Zuckerman, S.; Shen, Y.C. Characteristics of occasional and frequent emergency department users—Do insurance coverage and access to care matter? Med. Care 2004, 42, 176–182. [Google Scholar] [CrossRef] [PubMed]
- Vinton, D.T.; Capp, R.; Rooks, S.P.; Abbott, J.T.; Ginde, A.A. Frequent users of US emergency departments: Characteristics and opportunities for intervention. Emerg. Med. J. 2014, 31, 526–532. [Google Scholar] [CrossRef] [PubMed]
- Andren, K.G.; Rosenqvist, U. Heavy Users of an Emergency Department—Psycho-Social and Medical Characteristics, Other Health-Care Contacts and the Effect of a Hospital Social-Worker Intervention. Soc. Sci. Med. 1985, 21, 761–770. [Google Scholar] [CrossRef]
- Eitel, D.R.; Travers, D.A.; Rosenau, A.M.; Gilboy, N.; Wuerz, R.C. The emergency severity index triage algorithm version 2 is reliable and valid. Acad. Emerg. Med. 2003, 10, 1070–1080. [Google Scholar] [CrossRef]
- Gilboy, N.; Travers, D.; Wuerz, R. Re-evaluating triage in the new millennium: A comprehensive look at the need for standardization and quality. J. Emerg. Nurs. 1999, 25, 468–473. [Google Scholar] [CrossRef]
- Wuerz, R.C.; Milne, L.W.; Eitel, D.R.; Travers, D.; Gilboy, N. Reliability and validity of a new five-level triage instrument. Acad. Emerg. Med. 2000, 7, 236–242. [Google Scholar] [CrossRef] [PubMed]
- Charlson, M.E.; Pompei, P.; Ales, K.L.; MacKenzie, C.R. A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J. Chronic Dis. 1987, 40, 373–383. [Google Scholar] [CrossRef]
- De Groot, V.; Beckerman, H.; Lankhorst, G.; Bouter, L.M. How to measure comorbidity: A critical review of available methods. J. Clin. Epidemiol. 2004, 57, 323. [Google Scholar] [CrossRef]
- Yamamoto, L.G.; Zimmerman, K.R.; Butts, R.J.; Anaya, C.; Lee, P.; Miller, N.C.; Shirai, L.K.; Tanaka, T.T.; Leung, Y.K. Characteristics of frequent pediatric emergency department users. Pediatr. Emerg. Care 1995, 11, 340–346. [Google Scholar] [CrossRef] [PubMed]
- Kne, T.; Young, R.; Spillane, L. Frequent ED users: Patterns of use over time. Am. J. Emerg. Med. 1998, 16, 648–652. [Google Scholar] [CrossRef]
- Fuda, K.K.; Immekus, R. Frequent users of Massachusetts emergency departments: A statewide analysis. Ann. Emerg. Med. 2006, 48, 9–16. [Google Scholar] [CrossRef] [PubMed]
- Curran, G.M.; Sullivan, G.; Williams, K.; Han, X.; Allee, E.; Kotrla, K.J. The association of psychiatric comorbidity and use of the emergency department among persons with substance use disorders: An observational cohort study. BMC Emerg. Med. 2008, 8, 17. [Google Scholar] [CrossRef] [PubMed]
- Milbrett, P.; Halm, M. Characteristics and Predictors of Frequent Utilization of Emergency Services. J. Emerg. Nurs. 2009, 35, 191–198. [Google Scholar] [CrossRef] [PubMed]
- LaCalle, E.J.; Rabin, E.J.; Genes, N.G. High-frequency users of emergency department care. J. Emerg. Med. 2013, 44, 1167–1173. [Google Scholar] [CrossRef] [PubMed]
- Doupe, M.B.; Palatnick, W.; Day, S.; Chateau, D.; Soodeen, R.A.; Burchill, C.; Derksen, S. Frequent users of emergency departments: Developing standard definitions and defining prominent risk factors. Ann. Emerg. Med. 2012, 60, 24–32. [Google Scholar] [CrossRef]
- Wooden, M.D.; Air, T.M.; Schrader, G.D.; Wieland, B.; Goldney, R.D. Frequent attenders with mental disorders at a general hospital emergency department. Emerg. Med. Australas. 2009, 21, 191–195. [Google Scholar] [CrossRef]
- Ruger, J.P.; Richter, C.J.; Spitznagel, E.L.; Lewis, L.M. Analysis of costs, length of stay, and utilization of emergency department services by frequent users: Implications for health policy. Acad. Emerg. Med. 2004, 11, 1311–1317. [Google Scholar] [CrossRef]
- Byrne, M.; Murphy, A.W.; Plunkett, P.K.; McGee, H.M.; Murray, A.; Bury, G. Frequent attenders to an emergency department: A study of primary health care use, medical profile, and psychosocial characteristics. Ann. Emerg. Med. 2003, 41, 309–318. [Google Scholar] [CrossRef]
- Liu, S.W.; Nagurney, J.T.; Chang, Y.C.; Parry, B.A.; Smulowitz, P.; Atlas, S.J. Frequent ED users: Are most visits for mental health, alcohol, and drug-related complaints? Am. J. Emerg. Med. 2013, 31, 1512–1515. [Google Scholar] [CrossRef] [PubMed]
- Kim, J.J.; Kwok, E.S.H.; Cook, O.G.; Calder, L.A. Characterizing Highly Frequent Users of a Large Canadian Urban Emergency Department. West. J. Emerg. Med. 2018, 19, 926–933. [Google Scholar] [CrossRef] [PubMed]
All Recurrent ED Visitors N = 372 | Frequent ED Visitors N = 213 | Repeated ED Visitors N = 159 | |
---|---|---|---|
Age, years | 50.3 (18.5) | 51.2 (19.1) | 49.2 (17.6) |
Sex (female), n (%) | 154 (41.4%) | 85 (39.9%) | 69 (43.4%) |
Charlson co-morbidity index | 2 (0–6) | 3 (0–6) | 1 (0–4) |
<4, n (%) | 225 (60.5%) | 113 (53.1%) | 112 (70.4%) |
≥4, n (%) | 147 (39.5%) | 100 (46.9%) | 47 (29.6%) |
Arterial hypertension, n (%) | 147 (39.5%) | 92 (43.2%) | 55 (34.6%) |
Mental disorders, n (%) | 121 (32.5%) | 47 (22.1%) | 74 (46.5%) |
Chronic kidney failure, n (%) | 86 (23.1%) | 61 (28.6%) | 25 (15.8%) |
Rheumatic disease, n (%) | 81 (21.8%) | 66 (31.0%) | 15 (9.4%) |
Malignant disease, n (%) | 69 (18.6%) | 49 (23.0%) | 20 (12.6%) |
Metastatic disease, n (%) | 26 (7.0%) | 20 (9.4%) | 6 (3.8%) |
Coronary heart disease, n (%) | 60 (16.1%) | 39 (18.3%) | 21 (13.2%) |
Diabetes mellitus, n (%) | 59 (15.9%) | 32 (15.0%) | 27 (17%) |
Chronic obstructive pulmonary disease, n (%) | 49 (13.2%) | 16 (7.5%) | 33 (20.8%) |
Chronic liver insufficiency, n (%) | 20 (5.4%) | 13 (6.1%) | 7 (4.4%) |
Cerebrovascular disease, n (%) | 16 (4.3%) | 11 (5.2%) | 5 (3.1%) |
Regular drug abuse, n (%) | 58 (15.6%) | 35 (16.4%) | 23 (14.5%) |
Past drug abuse, n (%) | 23 (6.2%) | 17 (8.0%) | 6 (3.8%) |
Suicide attempt in the past, n (%) | 43 (11.6%) | 19 (8.9%) | 24 (15.1%) |
Domestic violence in the history, n (%) | 21 (5.6%) | 13 (6.1%) | 8 (5.0%) |
All Recurrent ED Visitors N = 372 | Frequent ED Visitors N = 213 | Repeated ED Visitors N = 159 | |
---|---|---|---|
General physician available, n (%) | 289 (77.7%) | 163 (76.5%) | 126 (79.2%) |
Social homeless, n (%) | 17 (4.6%) | 10 (4.7%) | 7 (4.4%) |
Decaying condition, n (%) | 26 (7.0%) | 15 (7.0%) | 11 (6.9%) |
Housing, n (%) | |||
Living alone | 116 (31.2%) | 60 (28.2%) | 56 (35.2%) |
Living with others | 224 (60.2%) | 135 (63.4%) | 89 (56.0%) |
Supervised living | 28 (7.5%) | 18 (8.4%) | 10 (6.3%) |
Unknown | 4 (1.1%) | 0% | 4 (2.5%) |
Marital status, n (%) | |||
Single | 132 (35.5%) | 66 (31.0%) | 66 (41.5%) |
Married/in partnership | 170 (45.7%) | 109 (51.2%) | 61 (38.4%) |
Divorced | 57 (15.3%) | 28 (13.1%) | 29 (18.2%) |
Widowed | 13 (3.5%) | 10 (4.7%) | 3 (1.9%) |
Children, n (%) | 189 (50.8%) | 114 (53.5%) | 75 (47.2%) |
Minors | 163 (43.8%) | 136 (63.8%) | 27 (17.0%) |
Professional status, n (%) | |||
Employed | 117 (31.5%) | 59 (27.7%) | 58 (36.5%) |
Unemployed | 56 (15.0%) | 34 (16.0%) | 22 (13.8%) |
In training | 19 (5.1%) | 12 (5.6%) | 7 (4.4%) |
Retired | 94 (25.3%) | 53 (24.9%) | 41 (25.8%) |
Disabled | 86 (23.1%) | 55 (25.8%) | 31 (19.5%) |
All Recurrent ED Visits N = 1921 | Frequent ED Visits N = 1016 | Repeated ED Visits N = 905 | |
---|---|---|---|
Number ED visits | 4 (4–5) | 4 (4–5) | 5 (4–6) |
Triage by the emergency severity index (ESI), n (%) | |||
ESI 1 | 16 (0.8%) | 11 (1.1%) | 5 (0.6%) |
ESI 2 | 148 (7.7%) | 75 (7.4%) | 73 (8.0%) |
ESI 3 | 1346 (70.1%) | 680 (66.9%) | 666 (73.6%) |
ESI 4/5 | 411 (21.4%) | 250 (24.6%) | 161 (17.8%) |
Number of ED presentations from, | |||
n (%): | |||
8 am–5 pm | 955 (49.7%) | 525 (51.7%) | 430 (47.5%) |
5 pm–23 pm | 496 (25.8%) | 254 (25.0%) | 242 (26.7%) |
11 pm–8 am | 470 (24.5%) | 237 (23.3%) | 233 (25.8%) |
Number of self-admittances | 4 (3–5) | 4 (3–4) | 4 (3–5) |
Number of admittances by paramedics | 0 (0–2) | 0 (0–1) | 0 (0–2) |
Number of emergency allocations by external doctors | 1 (0–2) | 1 (0–2) | 1 (0–2) |
Repeated ED Visitors N = 159 | |
---|---|
Symptoms due to mental disorders, n (%) | 45 (28.3%) |
With substance abuse, n (%) | 22 (48.9%) |
Symptoms due to gastrointestinal disorders, n (%) | 34 (21.4%) |
Symptoms due to cardiac disorders, n (%) | 20 (12.6%) |
Symptoms due to neurological disorders, n (%) | 17 (10.7%) |
Symptoms due to respiratory disorders, n (%) | 13 (8.2%) |
Symptoms following accidents & complications, n (%) | 12 (7.5%) |
Symptoms due to genito-urinary disorders (incl. nephrology), n (%) | 9 (5.7%) |
Others, n (%) | 9 (5.7%) |
Number of Frequent ED Visits N = 1016 | |
---|---|
Symptoms due to gastrointestinal disorders, n (%) | 176 (17.3%) |
Symptoms following head and extremity traumas, n (%) | 136 (13.4%) |
Symptoms due to mental disorders, n (%) | 105 (10.3%) |
Of them with substance abuse, n (%) | 40 (38.1%) |
Symptoms due to neurological disorders, n (%) | 97 (9.5%) |
Symptoms due to cardiac disorders, n (%) | 95 (9.4%) |
Symptoms due to general infection, n (%) | 94 (9.3%) |
Symptoms due to respiratory disorders, n (%) | 78 (7.7%) |
Symptoms due to musculoskeletal disorders, n (%) | 72 (7.1%) |
Symptoms due to complications of previous surgeries, n (%) | 70 (6.9%) |
Symptoms due to genito-urinary disorders (incl. nephrology), n (%) | 68 (6.7%) |
Others, n (%) | 25 (2.4%) |
Repeated ED Visitors Not Because of Mental Disorders N = 114 | Repeated ED Visitors Due to Mental Disorders N = 45 | Unadjusted Difference (95% CI, p-Value) | Adjusted Difference (95% CI, p-Value) | |
---|---|---|---|---|
Number of EB visits | 5 (4–5) | 6 (4–7) | 1.5 (0.5–2.5, p = 0.004) | 1.6 (0.6–2.7, p = 0.003) |
Number of hospital admissions | 2 (0–3) | 2 (0–4) | 0.5 (−0.3–1.2, p = 0.20) | 0.9 (0.2–1.6, p = 0.011) |
Number of day presentations (8 am to 5 pm) | 2.5 (1–4) | 3 (2–4) | 0.05 (−0.7–0.6, p = 0.89) | 0.1 (−0.6–0.8, p = 0.83) |
Number of day presentations (5 pm to 11 pm) | 1 (0–2) | 2 (1–3) | 0.7 (0.2–1.2, p = 0.010) | 0.7 (0.2–1.3, p = 0.008) |
Number of day presentations (11 pm to 8 pm) | 1 (0–2) | 2 (1–3) | 0.9 (0.3–1.5, p = 0.004) | 0.9 (0.2–1.5, p = 0.008) |
Unadjusted OR (95% CI, p-Value) | Adjusted OR (95% CI, p-Value) | |||
Drug abuse in the history, n (%) | 9 (7.9%) | 14 (31.1%) | 5.3 (2.1–13.3, p < 0.001) | 3.9 (1.4–11.1, p = 0.010) |
Suicide in the history, n (%) | 7 (6.1%) | 14 (31.1%) | 9.3 (3.5–24.6, p < 0.001) | 9.7 (3.3–28.4, p < 0.001) |
Substance abuse at the ED, n (%) | 4 (3.5%) | 18 (40%) | 18.3 (5.7–58.6, p < 0.001) | 19.6 (5.5–69.5, p < 0.001) |
Single, n (%) | 37 (32.5%) | 29 (64.4%) | 3.8 (1.8–7.8, p < 0.001) | 3.1 (1.3–7.2, p = 0.010) |
Out of work, n (%) | 7 (6.1%) | 15 (33.3%) | 7.6 (2.9–20.5, p < 0.001) | 6.7 (2.3–19.5, p < 0.001) |
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Slankamenac, K.; Zehnder, M.; Langner, T.O.; Krähenmann, K.; Keller, D.I. Recurrent Emergency Department Users: Two Categories with Different Risk Profiles. J. Clin. Med. 2019, 8, 333. https://doi.org/10.3390/jcm8030333
Slankamenac K, Zehnder M, Langner TO, Krähenmann K, Keller DI. Recurrent Emergency Department Users: Two Categories with Different Risk Profiles. Journal of Clinical Medicine. 2019; 8(3):333. https://doi.org/10.3390/jcm8030333
Chicago/Turabian StyleSlankamenac, Ksenija, Meret Zehnder, Tim O. Langner, Kathrin Krähenmann, and Dagmar I. Keller. 2019. "Recurrent Emergency Department Users: Two Categories with Different Risk Profiles" Journal of Clinical Medicine 8, no. 3: 333. https://doi.org/10.3390/jcm8030333