Frequent attenders to an emergency department: a study of primary health care use, medical profile, and psychosocial characteristics

Feasibility and Acceptability of a Colocated Homeless-Tailored Primary Care Clinic and Emergency Department

Objectives: Homeless adults have low primary care engagement and high emergency department (ED) utilization. Homeless-tailored, patient-centered medical homes (PCMH) decrease this population’s acute care use. We studied the feasibility (focused on patient recruitment) and acceptability (conceptualized as clinicians’ attitudes/beliefs) of a pilot initiative to colocate a homeless-tailored PCMH with an ED. After ED triage, low-acuity patients appropriate for outpatient care were screened for homelessness; homeless patients chose between a colocated PCMH or ED visit. Methods: To study feasibility, we captured (from May to September 2012) the number of patients screened for homelessness, positive screens, unique patients seen, and primary care visits. We focused on acceptability to ED clinicians (physicians, nurses, social workers); we sent a 32-item survey to ED clinicians (n = 57) who worked during clinic hours. Questions derived from an instrument measuring clinician attitudes toward homeless persons; acceptability of homelessness screening and the clinic itself were also explored. Results: Over the 5 months of interest, 281 patients were screened; 172 (61.2%) screened positive for homelessness; 112 (65.1%) of these positive screens were seen over 215 visits. Acceptability data were obtained from 56% (n = 32) of surveyed clinicians. Attitudes toward homeless patients were similar to prior studies of primary care physicians. Most (54.6%) clinicians agreed with the homelessness screening procedures. Nearly all (90.3%) clinicians supported expansion of the homeless-tailored clinic; a minority (42.0%) agreed that ED colocation worked well. Conclusion: Our data suggest the feasibility of recruiting patients to a homeless-tailored primary care clinic colocated with the ED; however, the clinic’s acceptability was mixed. Future quality improvement work should focus on tailoring the clinic to increase its acceptability among ED clinicians, while assessing its impact on health, housing, and costs.

High-Cost Patients: Hot-Spotters Don't Explain the Half of It

BACKGROUND

Understanding resource utilization patterns among high-cost patients may inform cost reduction strategies.

OBJECTIVE

To identify patterns of high-cost healthcare utilization and associated clinical diagnoses and to quantify the significance of hot-spotters among high-cost users.

DESIGN

Retrospective analysis of high-cost patients in 2012 using data from electronic medical records, internal cost accounting, and the Centers for Medicare and Medicaid Services. K-medoids cluster analysis was performed on utilization measures of the highest-cost decile of patients. Clusters were compared using clinical diagnoses. We defined "hot-spotters" as those in the highest-cost decile with ≥4 hospitalizations or ED visits during the study period.

PARTICIPANTS AND EXPOSURE

A total of 14,855 Medicare Fee-for-service beneficiaries identified by the Medicare Quality Resource and Use Report as having received 100 % of inpatient care and ≥90 % of primary care services at Cleveland Clinic Health System (CCHS) in Northeast Ohio. The highest-cost decile was selected from this population.

MAIN MEASURES

Healthcare utilization and diagnoses.

KEY RESULTS

The highest-cost decile of patients (n = 1486) accounted for 60 % of total costs. We identified five patient clusters: "Ambulatory," with 0 admissions; "Surgical," with a median of 2 surgeries; "Critically Ill," with a median of 4 ICU days; "Frequent Care," with a median of 2 admissions, 3 ED visits, and 29 outpatient visits; and "Mixed Utilization," with 1 median admission and 1 ED visit. Cancer diagnoses were prevalent in the Ambulatory group, care complications in the Surgical group, cardiac diseases in the Critically Ill group, and psychiatric disorders in the Frequent Care group. Most hot-spotters (55 %) were in the "frequent care" cluster. Overall, hot-spotters represented 9 % of the high-cost population and accounted for 19 % of their overall costs.

CONCLUSIONS

High-cost patients are heterogeneous; most are not so-called "hot-spotters" with frequent admissions. Effective interventions to reduce costs will require a more multi-faceted approach to the high-cost population.

Perceived Case Management Needs and Service Preferences of Frequent Emergency Department Users: Lessons Learned in a Large Urban Centre

Objectives

This study aimed to explore the service needs and preferences of frequent emergency department users with mental health and addictions concerns who participated in a brief intensive case management intervention.

Methods

We conducted semi-structured individual interviews with 20 frequent emergency department users with mental health and addictions challenges, 13 service providers involved in the delivery of a brief case management intervention, and a focus group with intervention case managers. Thematic analysis was used to explore perceived service user profiles, service needs and preferences of care.

Results

Service users experienced complex health and social needs and social isolation, while exhibiting resilience and the desire to contribute. They described multiple instances of stigmatization in interactions with healthcare professionals. Components of the brief intensive case management intervention perceived to be helpful included system navigation, advocacy, intermediation, and practical needs assistance. Frequent service users valued relational responsiveness, a non-judgmental stance, and a recovery orientation in case managers.

Conclusion

Interventions for frequent service users in mental health may be enhanced by focusing on the engagement of formal and informal social supports, practical needs assistance, system navigation, advocacy and intermediation, and attention to the recovery goals of service users.

Anemia is not a risk factor for developing pulmonary embolism

OBJECTIVE

Our aim was to validate the previously published claim of a positive relationship between low blood hemoglobin level (anemia) and pulmonary embolism (PE).

METHODS

This was a retrospective study of patients undergoing cross-sectional imaging to evaluate for PE at an academic medical center. Patients were identified using billing records for charges attributed to either magnetic resonance angiography or computed tomography angiography of the chest from 2008 to 2013. The main outcome measure was mean hemoglobin levels among those with and without PE. Our reference standard for PE status included index imaging results and a 6-month clinical follow-up for the presence of interval venous thromboembolism, conducted via review of the electronic medical record. Secondarily, we performed a subgroup analysis of only those patients who were seen in the emergency department. Finally, we again compared mean hemoglobin levels when limiting our control population to an age- and sex-matched cohort of the included cases.

RESULTS

There were 1294 potentially eligible patients identified, of whom 121 were excluded. Of the remaining 1173 patients, 921 had hemoglobin levels analyzed within 24 hours of their index scan and thus were included in the main analysis. Of those 921 patients, 107 (11.6%; 107/921) were positive for PE. We found no significant difference in mean hemoglobin level between those with and without PE regardless of the control group used (12.4 ± 2.1 g/dL and 12.3 ± 2.0 g/dL [P = .85], respectively).

CONCLUSIONS

Our data demonstrated no relationship between anemia and PE.

Alternative Destination Transport? The Role of Paramedics in Optimal Use of the Emergency Department

Introduction

Alternative destination transportation by emergency medical services (EMS) is a subject of hot debate between those favoring all patients being evaluated by an emergency physician (EP) and those recognizing the need to reduce emergency department (ED) crowding. This study aimed to determine whether paramedics could accurately assess a patient’s acuity level to determine the need to transport to an ED.

Methods

We performed a prospective double-blinded analysis of responses recorded by paramedics and EPs of arriving patients’ acuity level in a large Level II trauma center between April 2015 and November 2015. Under-triage was defined as lower acuity assessed by paramedics but higher acuity by EPs. Over-triage was defined as higher acuity assessed by paramedics but lower acuity by EPs. The degree of agreement between the paramedics and EPs’ evaluations of patient’s acuity level was compared using Chi-square test.

Results

We included a total of 503 patients in the final analysis. For paramedics, 2 51 (49.9%) patients were assessed to be emergent, 178 (35.4%) assessed as urgent, and 74 (14.7%) assessed as non-emergent/non-urgent. In comparison, the EPs assessed 296 (58.9%) patients as emergent, 148 (29.4%) assessed as urgent, and 59 (11.7%) assessed as non-emergent/non-urgent. Paramedics agreed with EPs regarding the acuity level assessment on 71.8% of the cases. The overall under- and over-triage were 19.3% and 8.9%, respectively. A moderate Kappa=0.5174 indicated moderate inter-rater agreement between paramedics’ and EPs’ assessment on the same cohort of patients.

Conclusion

There is a significant difference in paramedic and physician assessment of patients into emergent, urgent, or non-emergent/non-urgent categories. The field triage of a patient to an alternative destination by paramedics under their current scope of practice and training cannot be supported.

Effectiveness of case management interventions for frequent users of healthcare services: a scoping review

OBJECTIVE

Frequent users of healthcare services are a vulnerable population, often socioeconomically disadvantaged, who can present multiple chronic conditions as well as mental health problems. Case management (CM) is the most frequently performed intervention to reduce healthcare use and cost. This study aimed to examine the evidence of the effectiveness of CM interventions for frequent users of healthcare services.

DESIGN

Scoping review.

DATA SOURCES

An electronic literature search was conducted using the MEDLINE, Scopus and CINAHL databases covering January 2004 to December 2015. A specific search strategy was developed for each database using keywords 'case management' and 'frequent use'.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

To be included in the review, studies had to report effects of a CM intervention on healthcare use and cost or patient outcomes. Eligible designs included randomised and non-randomised controlled trials and controlled and non-controlled before-after studies. Studies limited to specific groups of patients or targeting a single disease were excluded. Three reviewers screened abstracts, screened each full-text article and extracted data, and discrepancies were resolved by consensus.

RESULTS

The final review included 11 articles evaluating the effectiveness of CM interventions among frequent users of healthcare services. Two non-randomised controlled studies and 4 before-after studies reported positives outcomes on healthcare use or cost. Two randomised controlled trials, 2 before-after studies and 1 non-randomised controlled study presented mitigated results. Patient outcomes such as drug and alcohol use, health locus of control, patient satisfaction and psychological functioning were evaluated in 3 studies, but no change was reported.

CONCLUSIONS

Many studies suggest that CM could reduce emergency department visits and hospitalisations as well as cost. However, pragmatic randomised controlled trials of adequate power that recruit the most frequent users of healthcare services are still needed to clearly confirm its effectiveness.

The HOME Team: Evaluating the Effect of an EMS-based Outreach Team to Decrease the Frequency of 911 Use Among High Utilizers of EMS

OBJECTIVES

The San Francisco Fire Department's (SFFD; San Francisco, California USA) Homeless Outreach and Medical Emergency (HOME) Team is the United States' first Emergency Medical Services (EMS)-based outreach effort using a specially trained paramedic to redirect frequent users of EMS to other types of services. The effectiveness of this program at reducing repeat use of emergency services during the first seven months of the team's existence was examined.

METHODS

A retrospective analysis of EMS use frequency and demographic characteristics of frequent users was conducted. Clients that used emergency services at least four times per month from March 2004 through May 2005 were contacted for intervention. Patterns for each frequent user before and after intervention were analyzed. Changes in EMS use during the 15-month study interval was the primary outcome measurement.

RESULTS

A total of 59 clients were included. The target population had a median age of 55.1 years and was 68% male. Additionally, 38.0% of the target population was homeless, 43.4% had no primary care, 88.9% had a substance abuse disorder at time of contact, and 83.0% had a history of psychiatric disorder. The HOME Team undertook 320 distinct contacts with 65 frequent users during the study period. The average EMS use prior to HOME Team contact was 18.72 responses per month (SD=19.40), and after the first contact with the HOME Team, use dropped to 8.61 (SD=10.84), P<.001.

CONCLUSION

Frequent users of EMS suffer from disproportionate comorbidities, particularly substance abuse and psychiatric disorders. This population responds well to the intervention of a specially trained paramedic as measured by EMS usage. Tangherlini N , Villar J , Brown J , Rodriguez RM , Yeh C , Friedman BT , Wada P . The HOME Team: evaluating the effect of an EMS-based outreach team to decrease the frequency of 911 use among high utilizers of EMS. Prehosp Disaster Med. 2016;31(6):603-607.

High-Volume Repeaters of Self-Harm

Abstract. Background: Repetition of self-harm is common and is strongly associated with suicide. Despite this, there is limited research on high-volume repetition. Aim: To investigate individuals with high-volume repeat self-harm attendances to the emergency department (ED), including their patterns of attendance and mortality. Method: Data from the Multicentre Study of Self-Harm in England were used. High-volume repetition was defined as ⩾15 attendances within 4 years. An attendance timeline was constructed for each high-volume repeater (HVR) and the different patterns of attendance were explored using an executive sorting task and hierarchical cluster analysis. Results: A small proportion of self-harm patients are HVRs (0.6%) but they account for a large percentage of self-harm attendances (10%). In this study, the new methodological approach resulted in three types of attendance patterns. All of the HVRs had clusters of attendance and a greater proportion died from external causes compared with non-HVRs. Conclusion: The approach used in this study offers a new method for investigating this problem that could have both clinical and research benefits. The need for early intervention is highlighted by the large number of self-harm episodes per patient, the clustered nature of attendances, and the higher prevalence of death from external causes.

Designing services for frequent attenders to the emergency department: a characterisation of this population to inform service design

Frequent attendance to the emergency department (ED) is a growing public health concern. Designing services for frequent attenders poses challenges, given the heterogeneous nature of this group. This was a two-part observational study identifying frequent attenders from ED records. The first stage studied trends and developed personas with emphasis on differentiating moderate frequent attenders (attending between 5 and 20 times per year) and extreme frequent attenders (attending more than 20 times). Stage 2 included a case note review of 100 consecutive frequent attenders. Results showed an increase in frequent attendance from 2.59% to 4.12% over 8 years. Moderate frequent attenders accounted for 97%. Of the 100 frequent attenders studied, 45% had medically unexplained symptoms (MUS), associated with younger age (p<0.001) but not with gender (p>0.05). In conclusion, the ED is a useful hub for identifying frequent attenders with MUS, particularly among moderate frequent attenders; service design for this group should consider a 'whole-systems approach' with integration between primary and secondary care, including specialist liaison psychiatry services where appropriate.

Family physician-patient relationship and frequent attendance of primary and specialist health care: Results from a German population-based cohort study

OBJECTIVE

To investigate the association between the quality of the family physician-patient relationship and frequent attendance of primary and specialist health care.

METHODS

Cross-sectional survey of a representative German population sample (N=2.266). Family physician-patient relationship was assessed with the Patient Doctor Relationship Questionnaire (PDRQ-9). Determinants of frequent attendance were analyzed using logistic regression.

RESULTS

Frequent attendance of family physicians was associated with lower income (OR 1.43, 95% CI 1.02-2.00), not being in paid work (OR 1.58, CI 1.08-2.30), psychological distress (OR 1.14, CI 1.07-1.22), somatic symptoms (OR 1.07, CI 1.04-1.11), and physical comorbidity (OR 1.54, CI 1.36-1.74) in the multivariate analysis. Frequent attendance of specialists was related to psychological distress (OR 1.12, CI 1.04-1.20), somatic symptoms (OR 1.08, CI 1.04-1.11), and physical comorbidity (OR 1.69, CI 1.48-1.93) in the multivariate analysis. Quality of the relationship was associated with frequent attendance only in the univariate analyses. A stronger relationship with the family physician was not associated with reduced contact with specialists.

CONCLUSIONS

The quality of the family physician-patient relationship is not independently associated with frequent attendance.

PRACTICE IMPLICATIONS

Family physicians should be aware that need factors, i.e. symptom burden and physical comorbidities, are main drivers of frequent attendance.

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

OBJECTIVES

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.

METHODS

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).

RESULTS

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.

CONCLUSIONS

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.

High prevalence of frequent attendance in the over 65s

INTRODUCTION

Characteristics of older frequent users of Emergency Departments (EDs) are poorly understood. Our aim was to examine the characteristics of the ED frequent attenders (FAs) by age (under 65 and over 65 years).

METHODS

We examined the prevalence of FA attending the ED of an Urban Teaching Hospital in a cross-sectional study between 2009 and 2011. FA was defined as an individual who presented to the ED four or more times over a 12-month period. Randomly selected groups of FA and non-FA from two age groups (under 65 and over 65 years) were then examined to compare the characteristics between older FAs and non-FAs and older FAs and younger FAs. Logistic regression was used to calculate the odds ratio and 95% confidence intervals for 12-month mortality in FA compared with non-FA aged at least 65 years.

RESULTS

Overall, 137 150 ED attendances were recorded between 2009 and 2011. A total of 21.6% were aged at least 65 years, 4.4% of whom were FAs, accounting for 18.4% of attendances by patients older than 65 years. There was a bimodal age distribution of FA (mean±SD; under 65 years 40±12.7; and over 65 years 76.9±7.4). Older FAs were five times more likely to present outside normal working hours and 5.5 times more likely to require admission. Cardiovascular emergencies were the most common complaint, in contrast with the younger FA group, where injury and psychosocial conditions dominated. The odds ratio for death at 12 months was 2.07 (95% confidence interval 0.93-4.63; P=0.07), adjusting for age and sex.

CONCLUSION

One-in-five ED patients older than 65 years of age are FAs. Older FAs largely present with complex medical conditions. Enhanced access to expert gerontology assessment should be considered as part of effective intervention strategies for older ED users.

Frequent Emergency Department Utilizers Among Children with Cancer

BACKGROUND

Pediatric frequent emergency department (ED) utilizers contribute a significant proportion of ED visits, but no studies specifically address children with cancer.

METHODS

A retrospective study of Pediatric Health Information System analyzing ED visits for children with cancer, including ED visits within 365 days from the first inpatient encounter with a discharge diagnosis code for malignancy. We defined frequent ED utilizers as those with four or more visits in the year (top 10th percentile). Patient characteristics and ED services (medications, laboratory, or imaging) for discharged children were assessed. Factors associated with being a frequent ED utilizer were examined with multivariable regression.

RESULTS

Frequent utilizers accounted for 58% of ED visits. Frequent utilizers differed from infrequent utilizers in terms of type of cancer; 39.3% of frequent utilizers had acute lymphoblastic leukemia (ALL) and 16.0% had central nervous system (CNS) tumors compared with infrequent utilizers (21.9% had ALL and 24.8% CNS tumors, P-value < 0.001). Frequent utilization was associated with age 5-9 years (odds ratio [OR] = 1.4, 95% confidence interval [CI] 1.2-1.6) or 1-4 years (OR = 2.1, 95% CI 1.8-2.4) or <1 year (OR = 2.2, 95% CI 1.9-2.6) compared to 15-19 years and Hispanic ethnicity (OR 1.3, 95% CI 1.1-1.5) compared to white, non-Hispanics, and urban residence (OR = 1.5, 95% CI 1.3-1.7). Few children with cancer received no medication, laboratory, or imaging during their ED visit (frequent 11.0% vs. infrequent 12.5%, P = 0.01).

CONCLUSIONS

The ED is integral to the care provided to children with cancer. The subset of frequent utilizers should be the focus of future research and quality improvement efforts.

Care Transfers for Patients With Upper Extremity Trauma: Influence of Health Insurance Type

PURPOSE

To understand the differences in transfer incidence for patients with upper extremity trauma by hospital trauma center designation. We hypothesized that patients with public or no insurance were more likely to be transferred to another facility compared with privately insured patients.

METHODS

Trauma centers are designated by local authorities and verified by the American College of Surgeons. Using the 2012 National Trauma Data Bank, we examined the probability of being transferred from one center to another for patients who sustained isolated upper extremity trauma. We used multivariable logistic regression with a clustered variance method to adjust for intrahospital correlation to compare risk-adjusted transfer incidence for patients with upper extremity injuries by trauma center designation.

RESULTS

In 2012, 6,214 patients ages 18-64 with isolated upper extremity trauma presented to 477 hospitals. Overall, transfer incidence was significantly higher among level III trauma centers (26%) compared with level II (11%) or level I (2%) trauma centers. Adjusting for patient and hospital characteristics patients with Medicaid were more likely to be transferred from level III trauma centers to another center compared with privately insured patients.

CONCLUSIONS

Current regulations may not prevent unnecessary patient transfers based on insurance status among level III trauma centers. Policy makers should compensate or provide incentives to hospitals that take care of poorly insured patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/decision III.

Adherence to health regimens among frequent attenders of Finnish healthcare

Objectives

The aim of the study was to describe adherence to health regimens and the factors associated with it among adult frequent attenders (FAs).

Design

This was a cross-sectional study. The study sample consisted of 462 healthcare FAs in 7 municipal health centres in northern Finland. An FA is a person who has had 8 or more outpatient visits to a GP (in a health centre) or 4 or more outpatient visits to a university hospital during 1 year. The main outcome was self-reported adherence to health regimens.

Results

Of the FAs, 82% adhered well to their health regimens. Carrying out self-care, medical care and feeling responsible for self-care were the most significant predictors to good adherence in all models. No significant differences in adherence were found in male and female subjects, age groups or educational levels. Support from healthcare providers and support from relatives were not significant predictors of good adherence.

Conclusion

FAs in Finland adhere well to health regimens and exceptionally well to medication. Variables that predict the best adherence of FAs to health regimens are carrying out self-care, receiving medical care and feeling responsible for self-care.

Targeting frequent users of emergency departments: Prominent risk factors and policy implications

This study investigates the characteristics of frequent users of accident and emergency departments (AEDs) and recommends alternative medical services for such patients. Prominent demographic and clinical risk factors for individuals accessing seven AEDs located in the metropolitan area of Genoa, Italy are identified and analysed. A truncated count data model is implemented to establish the determinants of access, while a multinomial logistic regression is used to highlight potential differences among different user categories. According to previous studies, empirical findings suggest that despite the relevance of demographic drivers, vulnerability conditions (e.g. abuse of alcohol and drugs, chronic conditions, and psychological distress) are the main reasons behind frequent AED use; the analysis seems to confirm an association between AED frequent use and lower level of urgency. Since frequent and highly frequent users are found responsible for disproportionate resource absorption with respect to total amount of AED costs (they represent roughly 10% of the total number of patients, but contribute to more than 19% of the total annual AED cost), policies aiming to reduce frequent use of AEDs could bring significant savings in economic resources. Thus, efficient actions could be oriented toward extending primary care services outside AED and toward instituting local aid services specifically addressed to people under the influence of substances or in conditions of mental distress.

Emergency Department Frequent Utilization for Non-Emergent Presentments: Results from a Regional Urban Trauma Center Study

OBJECTIVES

First, to test a model of the drivers of frequent emergency department utilization conceptualized as falling within predisposing, enabling, and need dimensions. Second, to extend the model to include social networks and service quality as predictors of frequent utilization. Third, to illustrate the variation in thresholds that define frequent utilization in terms of the number of emergency department encounters by the predictors within the model.

DATA SOURCE

Primary data collection over an eight week period within a level-1 trauma urban hospital's emergency department.

STUDY DESIGN

Representative randomized sample of 1,443 adult patients triaged ESI levels 4-5. Physicians and research staff interviewed patients as they received services. Relationships with the outcome variable, utilization, were tested using logistic regression to establish odds-ratios.

PRINCIPAL FINDINGS

70.6 percent of patients have two or more, 48.3 percent have three or more, 25.3 percent have four or more, and 14.9 percent have five or more emergency department visits within 12 months. Factors associated with frequent utilization include gender, race, poor mental health, mental health drugs, prescription drug abuse, social networks, employment, perceptions of service quality, seriousness of condition, persistence of condition, and previous hospital admittance.

CONCLUSIONS

Interventions targeting associated factors will change global emergency department encounters, although the mutability varies. Policy interventions to address predisposing factors such as substance abuse or access to mental health treatment as well as interventions that speak to enabling factors such as promoting the resiliency of social networks may result in decreased frequency of emergency department utilization.

Characterizing the vulnerability of frequent emergency department users by applying a conceptual framework: a controlled, cross-sectional study

BACKGROUND

Frequent emergency department (ED) users meet several of the criteria of vulnerability, but this needs to be further examined taking into consideration all vulnerability's different dimensions. This study aimed to characterize frequent ED users and to define risk factors of frequent ED use within a universal health care coverage system, applying a conceptual framework of vulnerability.

METHODS

A controlled, cross-sectional study comparing frequent ED users to a control group of non-frequent users was conducted at the Lausanne University Hospital, Switzerland. Frequent users were defined as patients with five or more visits to the ED in the previous 12 months. The two groups were compared using validated scales for each one of the five dimensions of an innovative conceptual framework: socio-demographic characteristics; somatic, mental, and risk-behavior indicators; and use of health care services. Independent t-tests, Wilcoxon rank-sum tests, Pearson's Chi-squared test and Fisher's exact test were used for the comparison. To examine the -related to vulnerability- risk factors for being a frequent ED user, univariate and multivariate logistic regression models were used.

RESULTS

We compared 226 frequent users and 173 controls. Frequent users had more vulnerabilities in all five dimensions of the conceptual framework. They were younger, and more often immigrants from low/middle-income countries or unemployed, had more somatic and psychiatric comorbidities, were more often tobacco users, and had more primary care physician (PCP) visits. The most significant frequent ED use risk factors were a history of more than three hospital admissions in the previous 12 months (adj OR:23.2, 95%CI = 9.1-59.2), the absence of a PCP (adj OR:8.4, 95%CI = 2.1-32.7), living less than 5 km from an ED (adj OR:4.4, 95%CI = 2.1-9.0), and household income lower than USD 2,800/month (adj OR:4.3, 95%CI = 2.0-9.2).

CONCLUSIONS

Frequent ED users within a universal health coverage system form a highly vulnerable population, when taking into account all five dimensions of a conceptual framework of vulnerability. The predictive factors identified could be useful in the early detection of future frequent users, in order to address their specific needs and decrease vulnerability, a key priority for health care policy makers. Application of the conceptual framework in future research is warranted.

Case Management in Primary Care for Frequent Users of Health Care Services With Chronic Diseases: A Qualitative Study of Patient and Family Experience

PURPOSE

Although case management (CM) is increasingly being implemented to address the complex needs of vulnerable clienteles, few studies have examined the patient experience of CM. This study aimed to examine the experience of patients and their family members with care integration as part of a primary care CM intervention. Patients in the study were frequent users of health care services who had chronic diseases.

METHODS

A descriptive, qualitative approach was conducted involving 25 patients and 8 of their family members. Data were collected through in-depth interviews of the patients and 2 focus groups of family members and were analyzed thematically.

RESULTS

While some participants did not fully understand the CM intervention and a few believed that it involved too many appointments, the CM nurses were patients' preferred contact with primary care. The nurses actively involved the patients in developing and carrying out their individualized services plans (ISPs) with other health care partners. Patients felt that their needs were taken into consideration, especially regarding access to the health care system. The case manager facilitated access to information as well as communication and coordination among health care and community partners. This improved communication comforted the patients and nurtured a relationship of trust. Participants were actively involved in decision-making. Their ISPs helped them know where they were going and improved transitions between services.

CONCLUSIONS

The experience of patients and family members was overall very positive regarding care integration. They reported improved access, communication, coordination, and involvement in decision-making as well as better health care transitions.

Medicaid beneficiaries who continue to use the ED: a focus on the Illinois Medical Home Network

OBJECTIVES

Frequent, nonurgent emergency department use continues to plague the American health care system through ineffective disease management and unnecessary costs. In 2012, the Illinois Medical Home Network (MHN) was implemented to, in part, reduce an overreliance on already stressed emergency departments through better care coordination and access to primary care. The purpose of this study is to characterize MHN patients and compare them with non-MHN patients for a preliminary understanding of MHN patients who visit the emergency department. Variables of interest include (1) frequency of emergency department use during the previous 12 months, (2) demographic characteristics, (3) acuity, (4) disposition, and (5) comorbidities.

METHODS

We performed a retrospective data analysis of all emergency department visits at a large, urban academic medical center in 2013. Binary logistic regression analyses and analysis of variance were used to analyze data.

RESULTS

Medical Home Network patients visited the emergency department more often than did non-MHN patients. Medical Home Network patients were more likely to be African American, Hispanic/Latino, female, and minors when compared with non-MHN patients. Greater proportions of MHN patients visiting the emergency department had asthma diagnoses. Medical Home Network patients possessed higher acuity but were more likely to be discharged from the emergency department compared with non-MHN patients.

CONCLUSIONS

This research may assist with developing and evaluating intervention strategies targeting the reduction of health disparities through decreased use of emergency department services in these traditionally underserved populations.

Poor Self-Rated Health Influences Hospital Service Use in Hospitalized Inpatients With Chronic Conditions in Taiwan

Our aim was to investigate the association between self-rated health (SRH) and use of hospital services (ie, medical outpatient department, emergency department, and general ward. admissions). Cross-sectional study data were collected from 230 consecutive patients admitted to medical departments of a 2000-bed academic medical center in Taiwan using standardized operating procedures for data collection of SRH (ie, a single-item question inquiring overall perceived health status), medical disorders, depressive symptoms, and combined service utilization over a 1-year period (ie, number of visits to outpatient department, number of visits to emergency department, and number of hospitalizations). Electronic medical records were retrieved, with self-reported external medical visits added to in-hospital frequencies of service use to provide better estimation of health service utilization. Fifty-two percent of study patients rated their health as poor or very poor. Poor SRH was associated with more visits to medical outpatient department, emergency department, and hospital admission. Multivariate logistic regression demonstrated an independent association between poor SRH and services utilization after adjustment for age, gender, hypertension, diabetes, metastatic cancer, number of chronic illness, life-threatening event, life-time suicidal ideation, and depression. SRH may be a useful research tool to model medical service use for inpatients with chronic conditions.

Factors Contributing to Inappropriate Visits of Frequent Attenders and Their Economic Effects at an Emergency Department in Singapore

OBJECTIVES

This study aimed to determine which factors contribute to frequent visits at the emergency department (ED) and what proportion were inappropriate in comparison with nonfrequent visits.

METHODS

This study was a retrospective, case-control study comparing a random sample of frequent attenders and nonfrequent attenders, with details of their ED visits recorded over a 12-month duration. Frequent attenders were defined as patients with four or more visits during the study period.

RESULTS

In comparison with nonfrequent attenders (median age = 45.0 years, interquartile range [IQR] = 28.0 to 61.0 years), frequent attenders were older (median = 57.5 years, IQR = 34.0 to 74.8 years; p = 0.0003). They were also found to have more comorbidities, where 53.3% of frequent attenders had three or more chronic illnesses compared to 14% of nonfrequent attenders (p < 0.0001), and were often triaged to higher priority (more severe) classes (frequent 52.2% vs. nonfrequent 37.6%, p = 0.0004). Social issues such as bad debts (12.7%), heavy drinking (3.3%), and substance abuse (2.7%) were very low in frequent attenders compared to Western studies. Frequent attenders had a similar rate of appropriate visits to the ED as nonfrequent attenders (55.2% vs. 48.1%, p = 0.0892), but were more often triaged to P1 priority triage class (6.7% vs. 3.2%, p = 0.0014) and were more often admitted for further management compared to nonfrequent attenders (47.5% vs. 29.6%, p < 0.001). The majority of frequent attender visits were appropriate (55.2%), and of these, 81.1% resulted in admission. For the same number of patients, total visits made by frequent attenders ($174,247.60) cost four times as much as for nonfrequent attenders ($40,912.40). This represents a significant economic burden on the health care system.

CONCLUSIONS

ED frequent attenders in Singapore were associated with higher age and presence of multiple comorbidities rather than with social causes of ED use. Even in integrated health systems, repeat ED visits are frequent and expensive, despite minimal social causes of acute care. EDs in aging populations must anticipate the influx of vulnerable, elderly patients and have in place interventional programs to care for them.

The highest utilizers of care: individualized care plans to coordinate care, improve healthcare service utilization, and reduce costs at an academic tertiary care center

BACKGROUND

High utilizers are medically and psychosocially complex, have high rates of emergency department (ED) visits and hospital admissions, and contribute to rising healthcare costs.

OBJECTIVE

Develop individualized care plans to reduce unnecessary healthcare service utilization and hospital costs for complex, high utilizers of inpatient and ED care.

DESIGN

Quality-improvement intervention with a retrospective pre/post intervention analysis.

SETTING

Nine hundred twenty-four-bed tertiary academic medical center.

PATIENTS

Twenty-four medically and psychosocially complex patients with the highest rates of inpatient admissions and ED visits from August 1, 2012 to August 31, 2013.

INTERVENTION

A multidisciplinary team developed individualized care plans integrated into our electronic medical record (EMR) that summarize patient histories, utilization patterns, and management strategies.

MEASUREMENTS

Primary outcomes included inpatient admissions, ED visits, and corresponding variable direct costs 6 and 12 months after care-plan implementation. Secondary outcomes include inpatient length of stay (LOS) and 30-day readmissions.

RESULTS

Hospital admissions decreased by 56% (P < 0.001) and 50.5% (P = 0.003), 6 and 12 months after care-plan implementation. Thirty-day readmissions decreased by 66% (P < 0.001) and 51.5% (P = 0.002), 6 and 12 months after care-plan implementation. ED visits, ED costs, and inpatient LOS did not significantly change. Inpatient variable direct costs were reduced by 47.7% (P = 0.001) and 35.8% (P = 0.052), 6 and 12 months after care-plan implementation.

CONCLUSIONS

Individualized care plans developed by a multidisciplinary team and integrated with the existing healthcare workforce and EMR reduce hospital admissions, 30-day readmissions, and hospital costs for complex, high-utilizing patients.

Prevalence of and Predictors for Frequent Utilization of Emergency Department: A Population-Based Study

Frequent emergency department (ED) users contribute to a disproportionate number of ED visits that consume a substantial amount of medical resources. Additionally, people with frequent ED visits may be at greater risks of illnesses and injury and are vulnerable to even more severe health events. We conducted, based on a nationally representative sample, a population-based study to estimate the prevalence of frequent ED users among all ED users, and to explore factors associated with frequent ED visits. This is a population-based cross-sectional study. Data of 1 million people randomly selected from all beneficiaries of Taiwan's National Health Insurance claim database in 2010 were analyzed to estimate the distribution of ED visit among ED users. Multivariate logistic regression was employed to calculate the independent associations of factors with prevalence of frequent (4-12 ED visits per year) and highly frequent (>12 ED visits per year) ED visits. Of the 1 million beneficiaries 170,475 subjects used ED service in 2010 and 103,111 (60.5%), 37,964 (22.3%), 14,881 (8.7%), 14,041 (8.2%), and 460 (0.3%) subjects had 1, 2, 3, 4 to 12, and more than 12 ED visits, respectively. ED users with 4 to 12 visits and those with >12 visits disproportionally accounted for 24.1% and 3.0%, respectively, of all ED visits in 2010. We noted significant associations of frequent ED visit with a number of factors including socio-demographics, health care utilization, and comorbidity. Among them, the most increased adjusted odds ratio (AOR) was noted for hospitalization during the past year (AOR = 1.85) and younger ages (1-6 years) (AOR = 1.84). On the contrary, the significant predictors for highly frequent ED visit with greater AOR included hospitalization during the past year (AOR = 3.95), > 12 outpatient visits during the past year (AOR = 2.66), and a history of congestive heart failure (AOR = 2.64) and psychiatric disorders (AOR = 2.35). People admitted and with frequent outpatient visits were at greater risk of frequent ED visit. Because people with a history of various comorbidities were also vulnerable to become frequent ED users, careful management of those comorbidities by clinicians may help further reduce the likelihood of frequent ED visit.

Child Mental Health Services in the Emergency Department: Disparities in Access

OBJECTIVE

Recent research suggests that increasing numbers of caregivers are bringing their children to the emergency department (ED) for mental health services and that a large proportion of these children have Medicaid as their insurance. The objective of this study was to examine the characteristics of children with Medicaid who present with psychiatric conditions in Florida hospital EDs.

METHODS

A retrospective research design was used, and the insurance claims of children who went to the ED for mental health care were analyzed. A logistic regression model was constructed to determine whether age, race, ethnicity, sex, and residence in an area with mental health professional shortage increased the odds of a psychiatric ED visit for children with Medicaid.

RESULTS

All 5 predictor variables were significantly associated with the likelihood of an ED visit for mental health reasons by children with Medicaid.

CONCLUSIONS

The ED is an entry point into the child mental health system of care for children with Medicaid.

A highlight from the LUPUS 2014 meeting: eight great ideas

This review describes eight 'great ideas' regarding bench-to-bedside considerations in systemic lupus erythematosus (SLE) presented at the second international LUPUS meeting in Quebec, September 2014. The topics included: correcting the impaired clearance of apoptotic fragments; optimisation of clinical trial design: the PERFECT (Pre Evaluation Reducing Frighteningly Elevated Coverable Targets) study; lipidomics and metabolomics in SLE; importance of the inflammasome; identification and treatment of asymptomatic autoimmunity: prevention of SLE; combining low doses of hydroxychloroquine and quinacrine for long-term maintenance therapy of SLE; reducing emergency room visits and the critical relevance of the autoantigen.

Pre-emergency-department care-seeking patterns are associated with the severity of presenting condition for emergency department visit and subsequent adverse events: a timeframe episode analysis

Background

Many patients treated in Emergency Department (ED) visits can be treated at primary or urgent care sectors, despite the fact that a number of ED visitors seek other forms of care prior to an ED visit. However, little is known regarding how the pre-ED activity episodes affect ED visits.

Objectives

We investigated whether care-seeking patterns involve the use of health care services of various types prior to ED visits and examined the associations of these patterns with the severity of the presenting condition for the ED visit (EDVS) and subsequent events.

Methods

This retrospective observational study used administrative data on beneficiaries of the universal health care insurance program in Taiwan. The service type, treatment capacity, and relative diagnosis were used to classify pre-ED visits into 8 care types. Frequent pattern analysis was used to identify sequential care-seeking patterns and to classify 667,183 eligible pre-ED episodes into patterns. Generalized linear models were developed using generalized estimating equations to examine the associations of these patterns with EDVS and subsequent events.

Results

The results revealed 17 care-seeking patterns. The EDVS and likelihood of subsequent events significantly differed among patterns. The ED severity index of patterns differ from patterns seeking directly ED care (coefficients ranged from -0.05 to 0.13), and the odds-ratios for the likelihood of subsequent ED visits and hospitalization ranged from 1.18 to 1.86 and 1.16 to 2.84, respectively.

Conclusions

The pre-ED care-seeking patterns differ in severity of presenting condition and subsequent events that may represent different causes of ED visit. Future health policy maker may adopt different intervention strategies for targeted population to reduce unnecessary ED visit effectively.

Frequent users of an inner-city emergency department

Background:

Within the emergency department (ED) patient population there is a subset of patients who make frequent visits. This chart review sought to characterize this population and identify strategies to reduce frequent ED visits.

Methods:

Frequent use at an urban tertiary care centre was defined as 15 or more visits over 1 year. The details of each visit—demographics, entrance complaint, discharge diagnosis, arrival method, Canadian Triage and Acuity Scale (CTAS) score, and length of stay—were analyzed and compared to data from the entire ED population for the same period.

Results:

Ninety-two patients generated 2,390 ED visits (of 25,523 patients and 44,204 visits). This population was predominantly male (66%) and middle-aged (median 42 years), with no fixed address (27.2%). Patients arrived by ambulance in 59.3% of visits with less acute CTAS scores than the general population. Substance use accounted for 26.9% of entrance complaints. Increased lengths of stay were associated with female gender and abnormal vital signs, whereas shorter stays were associated with no fixed address and substance use (p&lt; 0.05). Admissions were lower than the general population, and women were twice as likely as men to be admitted (p&lt; 0.05). Patients left without being seen in 15.8% of visits.

Conclusions:

High-frequency ED users are more likely to be male, younger, and marginally housed and to present secondary to substance use. Although admissions among this population are low, the costs associated with these presentations are high. Interventions designed to decrease visits and improve the health of this population appear warranted.

Mortality, admission rates and outpatient use among frequent users of emergency departments: a systematic review

OBJECTIVE

This systematic review examines whether frequent emergency department (ED) users experience higher mortality, hospital admissions and outpatient visits than non-frequent ED users.

DESIGN

We published an a priori study protocol in PROSPERO. Our search strategy combined terms for 'frequent users' and 'emergency department'. At least two independent reviewers screened, selected, assessed quality and extracted data. Third-party adjudication resolved conflicts. Results were synthesised based on median effect sizes.

DATA SOURCES

We searched seven electronic databases with no limits and performed an extensive grey literature search.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included observational analytical studies that focused on adult patients, had a comparison group of non-frequent ED users and reported deaths, admissions and/or outpatient outcomes.

RESULTS

The search strategy identified 4004 citations; 374 were screened by full text and 31 cohort and cross-sectional studies were included. Authors used many different definitions to describe frequent users; the overall quality of the included studies was moderate. Across seven studies examining mortality, frequent users had a median 2.2-fold increased odds of mortality compared with non-frequent users. Twenty-eight studies assessing hospital admissions found a median increased odds of admissions per visit at 1.16 and of admissions per patient at 2.58. Ten studies reported outpatient visits with a median 2.65-fold increased risk of having at least one outpatient encounter post-ED visit.

CONCLUSIONS

Frequent ED users appear to experience higher mortality, hospital admissions and outpatient visits compared with non-frequent users, and may benefit from targeted interventions. Standardised definitions to facilitate comparable research are urgently needed.

REVIEW REGISTRATION NUMBER

PROSPERO (CRD42013005855).

Partners for the optimal organisation of the healthcare continuum for high users of health and social services: protocol of a developmental evaluation case study design

INTRODUCTION

Case management allows us to respond to the complex needs of a vulnerable clientele through a structured approach that promotes enhanced interaction between partners. Syntheses on the subject converge towards a need for a better description of the relationships between programmes and their local context, as well as the characteristics of the clienteles and programmes that contribute to positive impacts. The purpose of this project is thus to describe and evaluate the case management programmes of four health and social services centres in the Saguenay-Lac- Saint-Jean region of Québec, Canada, in order to inform their improvement while creating knowledge on case management that can be useful in other contexts.

METHODS AND ANALYSIS

This research relies on a multiple embedded case study design based on a developmental evaluation approach. We will work with the case management programme for high users of hospital services of each centre. Three different units of analysis will be interwoven to obtain an in-depth understanding of each case, that is: (1) health and social services centre and local services network, (2) case management programme and (3) patients who are high users of services. Two strategies for programme evaluation (logic models and implementation analysis) will guide the mixed data collection based on qualitative and quantitative methods. This data collection will rely on: (1) individual interviews and focus groups; (2) participant observation; (3) document analysis; (4) clinical and administrative data and (5) questionnaires. Description and comparison of cases, and integration of qualitative and quantitative data will be used to guide the data analysis.

ETHICS AND DISSEMINATION

The study protocol was approved by the Ethics Research Boards of the four health and social services centres (HSSCs) involved. Findings will be disseminated by publications in peer-reviewed journals, conferences, and policy and practice partners in local and national government.

Predictors of frequent emergency department use among patients with psychiatric illness

OBJECTIVE

To identify the patient characteristics associated with frequent emergency department (ED) use and develop a tool to predict risk for returning in the next month.

METHOD

Prospective cohort study of 863 adults with psychiatric illness presenting to one of four general hospital EDs. ED visits and relevant clinical information in the year before and one month after the index visit were abstracted.

RESULTS

One hundred sixty-seven of the patients (19%) were considered frequent users. Characteristics associated with frequent user status were homelessness, cocaine-positive toxicology screen, Medicare insurance, a personality disorder and hepatobiliary disease (all P<.05). Patients scoring in the highest risk category had nearly five times the odds of returning to the ED in the month subsequent to the index visit.

CONCLUSIONS

Psychiatric patients with frequent ED use are a heterogeneous group, but there are specific target conditions which, if confirmed, may facilitate reduced ED use and be replaced by more appropriate treatment.

Retrospective study of elderly frequent attenders presenting with chest pain at emergency department

BACKGROUND

The aims of the study were to identify the characteristics of elderly frequent attenders to the emergency department (ED) presenting with chest pain and to assess the 1-year prognosis for developing adverse cardiac events.

FINDINGS

Patients over 75 years old, with four or more attendances to the ED between 1 January 2010 and 31 December 2010 with at least one attendance due to chest pain, were selected from a database. Data was collected on demographic details, visit history, disposition and admission outcomes. Each patient was followed up for 12 months after the index episode via the hospital electronic registry for adverse cardiac outcome. Adverse cardiac outcomes included death from cardiac event, acute myocardial infarction (ST elevation myocardial infarction (STEMI)/non-ST elevation myocardial infarction (NSTEMI)) or unstable angina. A total of 158 patients with 4 or more visits to the ED accounted for 290 visits with chest pain during 2010. There is a high prevalence of coronary risk factors in this cohort (hypertension 92.4%, hyperlipidaemia 65.2%, diabetes 49.4% and smoking 26.6%). The hospital admission rate was also high at 83.5%. Over the ensuing 12 months, 8 patients died of a primary cardiac event and a further 29 patients developed 36 non-fatal cardiac events. We could not establish any significant relationship between increase in adverse cardiac outcome and individual risk factors or even two or more risk factors (P = 0.0572). Patients with two or more attendances with chest pain were more likely to develop adverse cardiac outcome (P = 0.0068).

CONCLUSIONS

Elderly frequent attenders to the ED, who present with chest pain, have more cardiac risk factors and are more likely to develop adverse coronary outcomes if they re-attend with chest pain.

Demand for hospital emergency departments: a conceptual understanding

BACKGROUND

Emergency departments (EDs) are critical to the management of acute illness and injury, and the provision of health system access. However, EDs have become increasingly congested due to increased demand, increased complexity of care and blocked access to ongoing care (access block). Congestion has clinical and organisational implications. This paper aims to describe the factors that appear to influence demand for ED services, and their interrelationships as the basis for further research into the role of private hospital EDs.

DATA SOURCES

Multiple databases (PubMed, ProQuest, Academic Search Elite and Science Direct) and relevant journals were searched using terms related to EDs and emergency health needs. Literature pertaining to emergency department utilisation worldwide was identified, and articles selected for further examination on the basis of their relevance and significance to ED demand.

RESULTS

Factors influencing ED demand can be categorized into those describing the health needs of the patients, those predisposing a patient to seeking help, and those relating to policy factors such as provision of services and insurance status. This paper describes the factors influencing ED presentations, and proposes a novel conceptual map of their interrelationship.

CONCLUSION

This review has explored the factors contributing to the growing demand for ED care, the influence these factors have on ED demand, and their interrelationships depicted in the conceptual model.

Case management for frequent users of the emergency department: study protocol of a randomised controlled trial

Background

We devised a randomised controlled trial to evaluate the effectiveness and efficiency of an intervention based on case management care for frequent emergency department users. The aim of the intervention is to reduce such patients’ emergency department use, to improve their quality of life, and to reduce costs consequent on frequent use. The intervention consists of a combination of comprehensive case management care and standard emergency care. It uses a clinical case management model that is patient-identified, patient-directed, and developed to provide high intensity services. It provides a continuum of hospital- and community-based patient services, which include clinical assessment, outreach referral, and coordination and communication with other service providers.

Methods/Design

We aim to recruit, during the first year of the study, 250 patients who visit the emergency department of the University Hospital of Lausanne, Switzerland. Eligible patients will have visited the emergency department 5 or more times during the previous 12 months. Randomisation of the participants to the intervention or control groups will be computer generated and concealed. The statistician and each patient will be blinded to the patient’s allocation. Participants in the intervention group (N = 125), additionally to standard emergency care, will receive case management from a team, 1 (ambulatory care) to 3 (hospitalization) times during their stay and after 1, 3, and 5 months, at their residence, in the hospital or in the ambulatory care setting. In between the consultations provided, the patients will have the opportunity to contact, at any moment, the case management team. Participants in the control group (N = 125) will receive standard emergency care only. Data will be collected at baseline and 2, 5.5, 9, and 12 months later, including: number of emergency department visits, quality of life (EuroQOL and WHOQOL), health services use, and relevant costs. Data on feelings of discrimination and patient’s satisfaction will also be collected at the baseline and 12 months later.

Discussion

Our study will help to clarify knowledge gaps regarding the positive outcomes (emergency department visits, quality of life, efficiency, and cost-utility) of an intervention based on case management care.

Trial registration

ClinicalTrials.gov Identifier: NCT01934322.

VA health service utilization for homeless and low-income Veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles

BACKGROUND

The US Department of Housing and Urban Development (HUD)-VA Supportive Housing (VASH) program-the VA's Housing First effort-is central to efforts to end Veteran homelessness. Yet, little is known about health care utilization patterns associated with achieving HUD-VASH housing.

OBJECTIVES

We compare health service utilization at the VA Greater Los Angeles among: (1) formerly homeless Veterans housed through HUD-VASH (HUD-VASH Veterans); (2) currently homeless Veterans; (3) housed, low-income Veterans not in HUD-VASH; and (4) housed, not low-income Veterans.

RESEARCH DESIGN

We performed a secondary database analysis of Veterans (n=62,459) who received VA Greater Los Angeles care between October 1, 2010 and September 30, 2011. We described medical/surgical and mental health utilization [inpatient, outpatient, and emergency department (ED)]. We controlled for demographics, need, and primary care use in regression analyses of utilization data by housing and income status.

RESULTS

HUD-VASH Veterans had more inpatient, outpatient, and ED use than currently homeless Veterans. Adjusting for demographics and need, HUD-VASH Veterans and the low-income housed Veterans had similar likelihoods of medical/surgical inpatient and outpatient utilization, compared with the housed, not low-income group. Adjusting first for demographics and need (model 1), then also for primary care use (model 2), HUD-VASH Veterans had the greatest decrease in incident rates of specialty medical/surgical, mental health, and ED care from models 1 to 2, becoming similar to the currently homeless, compared with the housed, not low-income group.

CONCLUSIONS

Our findings suggest that currently homeless Veterans underuse health care relative to housed Veterans. HUD-VASH may address this disparity by providing housing and linkages to primary care.

Frequent attenders to the ED: patients who present with repeated asthma exacerbations

BACKGROUND

Asthma has been reported as one of the main causes of frequent attendance to the emergency department (ED), and many of those visits are potentially preventable. Understanding the characteristics of frequent attender (FA) patients with asthmatic exacerbations will help to identify factors associated with frequent attendance and improve case management. The aim of this study is to describe the characteristics of FA who present multiple times to the ED for asthma exacerbations.

METHODS

This study was a retrospective review of cases presented to Singapore General Hospital ED in 2010. Patients who attended the ED for 4 times or more with at least 1 visit attributable to asthma exacerbations in 2010 were included. They were then categorized as FA with multiple exacerbations (FAME) and those with fewer exacerbations.

RESULTS

Of 105616 ED patients, 155 patients attending the ED in 2010 were identified as FA with asthma, and 26 (17%) of these patients were classified as FAME, resulting in 213 visits (45% of total visits). Compared with FA with fewer exacerbations group, FAME were more likely to be men (P = .002), unemployed (P < .000), bad debtors (P = .045), substance abusers (P = .022), previously known to medical social workers (P = .002), and were found to spend a longer amount of time in the ED (>6 hours) (P = .03).

CONCLUSION

We found that a small number of FAME patients accumulated a large number of ED visits and spent a significantly longer time in the ED. This group tended to be males with social, financial, and addiction problems.

An observational study of emergency department utilization among enrollees of Minnesota Health Care Programs: financial and non-financial barriers have different associations

BACKGROUND

Emergency department (ED) use is costly, and especially frequent among publicly insured populations in the US, who also disproportionately encounter financial (cost/coverage-related) and non-financial/practical barriers to care. The present study examines the distinct associations financial and non-financial barriers to care have with patterns of ED use among a publicly insured population.

METHODS

This observational study uses linked administrative-survey data for enrollees of Minnesota Health Care Programs to examine patterns in ED use-specifically, enrollee self-report of the ED as usual source of care, and past-year count of 0, 1, or 2+ ED visits from administrative data. Main independent variables included a count of seven enrollee-reported financial concerns about healthcare costs and coverage, and a count of seven enrollee-reported non-financial, practical barriers to access (e.g., limited office hours, problems with childcare). Covariates included health, health care, and demographic measures.

RESULTS

In multivariate regression models, only financial concerns were positively associated with reporting ED as usual source of care, but only non-financial barriers were significantly associated with greater ED visits. Regression-adjusted values indicated notable differences in ED visits by number of non-financial barriers: zero non-financial barriers meant an adjusted 78% chance of having zero ED visits (95% C.I.: 70.5%-85.5%), 15.9% chance of 1(95% C.I.: 10.4%-21.3%), and 6.2% chance (95% C.I.: 3.5%-8.8%) of 2+ visits, whereas having all seven non-financial barriers meant a 48.2% adjusted chance of zero visits (95% C.I.: 30.9%-65.6%), 31.8% chance of 1 visit (95% C.I.: 24.2%-39.5%), and 20% chance (95% C.I.: 8.4%-31.6%) of 2+ visits.

CONCLUSIONS

Financial barriers were associated with identifying the ED as one's usual source of care but non-financial barriers were associated with actual ED visits. Outreach/literacy efforts may help reduce reliance on/perception of ED as usual source of care, whereas improved targeting/availability of covered services may help curb frequent actual visits, among publicly insured individuals.

Frequent users of US emergency departments: characteristics and opportunities for intervention

OBJECTIVE

To compare the characteristics of US adults by frequency of emergency department (ED) utilisation, specifically the prevalence of chronic diseases and outpatient primary care and mental health utilisation.

METHODS

We analysed 157 818 adult participants of the 2004-2009 US National Health Interview Survey, an annual nationally representative sample. We defined ED utilisation during the past 12 months as non-users (0 ED visits), infrequent users (1-3 visits), frequent users (4-9 visits) and super-frequent users (≥10 visits). We compared demographic data, socioeconomic status, chronic diseases and access to care between these ED utilisation groups using multivariable logistic regression.

RESULTS

Overall, super-frequent use was reported by 0.4% of US adults, frequent use by 2% and infrequent ED use by 19%. Patients reporting ≥4 ED visits were more likely to have Medicaid insurance (OR 1.57; 95% CI 1.34 to 1.85 vs private); fair or poor self-reported health (OR 2.98; 95% CI 2.57 to 3.46 vs excellent-very good); and chronic diseases such as coronary artery disease (OR 1.61; 95% CI 1.40 to 1.86), stroke (OR 1.58; 95% CI 1.36 to 1.83) or asthma (OR 1.64; 95% CI 1.46 to 1.85). While patients reporting the ED as their usual source of sick care were more likely to have ≥4 ED visits (OR 7.09; 95% CI 5.61 to 8.95 vs outpatient clinic as source), ≥10 outpatient visits in the past 12 months was also associated with frequent ED use (OR 11.4; 95% CI 9.09 to 14.2 vs no outpatient visits).

CONCLUSIONS

Frequent ED users had a large burden of chronic diseases that also required high outpatient resources. Interventions designed to divert frequent ED users should focus on chronic disease management and access to outpatient services, particularly for Medicaid beneficiaries and other high risk subpopulations.

Characterising emergency department high-frequency users in a rural hospital

OBJECTIVE

Patients who are frequent users (≥4 visits/year) comprise ∼10% of patients, but account for ∼34% of total yearly emergency department (ED) visits. Non-emergent care provided to frequent ED users affects operating costs and usage. The majority of reports characterising frequent ED use are from urban teaching centres. This study describes frequent users of ED services in a rural community setting and the association between counts of patient's visits and discrete diagnoses.

DESIGN

Retrospective study of 1652 frequent ED adult patients from a rural US hospital over a one-year period. Descriptive statistics and Poisson regression were used to explore the characteristics of frequent users and their patterns of diagnoses.

RESULTS

Frequent user visits ranged from 4 to 66 per patient. Frequent users were 9.41% of patient volume accounting for 33.94% of the total visits and were younger compared with patients with <4 visits. Approximately 36% of frequent user visits were generated by 20 diagnoses when the diagnoses were concatenated into domains which covered ∼76% of the visits. There was a high correlation between the number of visits and discrete diagnoses in frequent users.

CONCLUSIONS

These findings suggest a more complex picture of rural ED services and their relationship with primary care and dental services, which needs to be defined before policy development to reduce ED use.

Characteristics of paediatric frequent presenters to an Australian emergency medicine network

AIM

The study aims to describe the characteristics of paediatric emergency department (ED) patients defined as frequent presenters (FP) presenting to an Australian ED health service and compare these with a cohort of non-frequent presenters (NFP).

METHOD

A retrospective chart review utilising an electronic emergency medicine patient medical record database was performed on paediatric patients (18 years or younger) presenting to Monash Health EDs from March 2009 to March 2010. NFPs were defined as patients presenting five or less times and FPs as presenting eight or more times in the study period. Characteristics of both groups were described and compared.

RESULTS

During the 12-month study period, there were 130 paediatric FP patients with 839 admissions and 34,262 paediatric NFP patients with 46,043 admissions. FPs to the ED were more likely to be female, utilise the ambulance service to arrive at the hospital and more likely to be admitted to hospital. In particular, FPs were more likely to require admission for a mental health-related problem. They were also more likely to have a discharge diagnosis related to oncology, neurology, respiratory, endocrinology and psychiatric complaints, compared with NFP who were more likely to present with a diagnosis related to injury or trauma.

CONCLUSIONS

Paediatric FPs are a vulnerable population with complex multidisciplinary care needs. A holistic approach towards their needs is essential to understanding the reasons for their higher frequency of attendance. By considering all the elements of the child's well-being, the child and family need support to assist in integration with other non-ED service providers. By focusing on wellness and self-management, there is a potential to reduce the reliance on acute emergency care for ongoing chronic health problems.

A qualitative study of patient choices in using emergency health care for long-term conditions: the importance of candidacy and recursivity

OBJECTIVE

We aimed to explore how patients with long-term conditions choose between available healthcare options during a health crisis.

METHODS

Patients in North-West England with one or more of four long-term conditions were invited to take part in a questionnaire cohort study of healthcare use. Semi-structured interviews were conducted with a sub-sample of fifty consenting patients. Data were analysed qualitatively, using a framework approach.

RESULTS

Patients described using emergency care only in response to perceived urgent need. Their judgements about urgency of need, and their choices about what services to use were guided by previous experiences of care, particularly how accessible services were and the perceived expertise of practitioners.

CONCLUSION

Recursivity and candidacy provide a framework for understanding patient decision-making around emergency care use. Patients were knowledgeable and discriminating users of services, drawing on experiential knowledge of healthcare to choose between services. Their sense of 'candidacy' for specific emergency care services, was recursively shaped by previous experiences.

PRACTICE IMPLICATIONS

Strategies that emphasise the need to educate patients about healthcare services use alone are unlikely to change care-seeking behaviour. Practitioners need to modify care experiences that recursively shape patients' judgements of candidacy and their perceptions of accessible expertise in alternative services.