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

Physical multimorbidity, concurrent psychiatric morbidity, and emergency department presentation among adults released from prison: a prospective cohort study from Queensland, Australia

BACKGROUND

People released from prison have elevated rates of physical and psychiatric morbidity, and emergency department (ED) presentation when compared with the general population. However, little is known about the specific health concerns that are associated with these high rates of ED presentation. The aims of this study were to (a) ascertain the prevalence of multimorbidity (physical multimorbidity and concurrent psychiatric morbidity) in a sample of adults prior to release from prison, and (b) examine the association between physical multimorbidity, psychiatric morbidity, and ED presentations in this sample following release from prison.

METHODS

We prospectively linked pre-release survey data collected between 1 August 2008 and 31 July 2010 from a representative cohort of 1325 sentenced adults in Queensland, Australia, to person-level ED, correctional, and death records. We assessed the multimorbidity of participants using the Cumulative Illness Rating Scale. The association between multimorbidity and rate of ED presentations was assessed by fitting a multivariable Andersen-Gill model to identify sociodemographic and criminal justice covariates. A sensitivity analysis was also conducted in which psychiatric morbidity was disaggregated into a 4-level dual diagnosis variable (none, mental illness only, substance use disorder only, dual diagnosis) and was fit separately from the physical multimorbidity measure to ascertain the degree to which these factors predicted ED presentation rates.

RESULTS

502 (48.0%) participants had multimorbidity, 265 (25.3%) had physical multimorbidity, and 608 (58.2%) had psychiatric morbidity. After adjustment for model covariates including dual diagnosis status, there was no statistically significant association between physical multimorbidity and ED presentation rate. However, after adjusting for model covariates including physical multimorbidity, participants with a diagnosis of either mental illness (aHR: 1.48; 95%CI: 1.08-2.03) or both mental illness and substance use disorder (aHR: 1.78; 95%CI: 1.33-2.37) had a higher rate of ED presentation than their counterparts without these diagnoses.

CONCLUSION

The presence of psychiatric morbidity is associated with an increased rate of ED presentation. Targeted interventions for adults released from prison with psychiatric morbidity are urgently needed.

Adolescent mental health presentations to a New Zealand emergency department: A 16-year retrospective observational study

ObjectiveTo examine trends in adolescent mental health presentations to Christchurch Emergency Department (ED) and contribute to the limited data on long-term trends in adolescent mental health within New Zealand.MethodA retrospective observational study of mental health presentations by adolescents aged 10-17 years to the Christchurch ED over 2007-2022. Data on patient demographics, rates of frequent presenters (≥5 presentations in a calendar year) and hospital admissions were analysed using simple descriptive statistics.ResultsRates of adolescent mental health ED presentations increased by 289% over 16 years, while rates of adolescent all-cause ED presentations increased by 9.8%. Female presentations increased over five-fold while male rates nearly doubled. Rates of medical hospital admissions increased by 70% and numbers of frequent presenters increased from 0 in 2007 to a peak of 19 in 2022.ConclusionThere has been a significant increase in adolescent mental health ED presentations over the study period. Demographic trends - including higher presentation rates for females and Māori - are consistent with those observed in the Youth2000 survey series. Ongoing monitoring of adolescent mental health ED presentation rates will be an important way of assessing the efficacy of any changes to the mental health system.

Is frequent emergency department use a complement or substitute for other healthcare services? Evidence from South Carolina Medicaid enrollees

OBJECTIVE

To compare healthcare services utilization across the healthcare system between frequent and non-frequent emergency department (ED) users among Medicaid enrollees in South Carolina.

STUDY SETTING AND DESIGN

We conducted a retrospective, longitudinal study of individuals with at least one ED visit in 2017 in South Carolina and identified their healthcare services visits over 730 days (2 years) after their first ED visit. We classified individuals based on intensity of ED use: superfrequent (≥9 ED visits/year), frequent (4-8 ED visits/year), and non-frequent ED users (≤3 visits/year). We estimated differences between the three groups of ED users and non-ED hospital and office-based visits using multivariable two-part regression models.

DATA SOURCES AND ANALYTIC SAMPLE

We used statewide Medicaid claims from January 2017 to December 2019 for ED users aged 18-64 years with continuous Medicaid enrollment. We analyzed data on all frequent and superfrequent users and selected a 4:1 random sample among all non-frequent users (~half of all non-frequent users).

PRINCIPAL FINDINGS

The study included 52,845 ED users, of whom 42,764 were non-frequent, 7677 frequent, and 2404 superfrequent users. Within 2 years from the date of their first ED visit, superfrequent ED users averaged 38.3 ED visits, frequent ED users 10.9 ED visits, and non-frequent ED users 2.6 ED visits (p < 0.001). Compared with non-frequent users, frequent and superfrequent ED users had more comorbidities and chronic conditions on average (1.6 vs. 3.5 vs. 6.4, p < 0.001). Both frequent and superfrequent users had more hospital visits beyond the ED overall (marginal effects: 0.23, 95% CI 0.18-0.27; 0.40, 95% CI 0.29-0.50), and more outpatient office visits overall (marginal effects: 4.39, 95% CI 2.52-6.27; 9.23, 95% CI 5.66-12.81), including primary care and most specialists' visits, compared with non-frequent users.

CONCLUSIONS

Frequent ED users utilized non-ED hospital and outpatient office-based healthcare services significantly more than non-frequent ED users. These findings can guide tailored interventions using data across the healthcare system to efficiently coordinate care, contain costs, and improve health outcomes for these individuals.

Using machine learning to identify frequent attendance at accident and emergency services in Lanarkshire

Background

Frequent attenders to accident and emergency (A&E) services pose complex challenges for healthcare providers, often driven by critical clinical needs. Machine learning (ML) offers potential for predictive approaches to managing frequent attendance, yet its application in this area is limited. Existing studies often focus on specific populations or models, raising concerns about generalisability. Identifying risk factors for frequent attendance and high resource use is crucial for effective prevention strategies.

Objectives

This research aims to evaluate the strengths and weaknesses of ML approaches in predicting frequent A&E attendance in NHS Lanarkshire, Scotland, identify associated risk factors and compare findings with existing research to uncover commonalities and differences.

Method

Health and social care data were collected from 17,437 A&E patients in NHS Lanarkshire (2021-2022), including clinical, social and demographic information. Five classification models were tested: multinomial logistic regression (LR), random forests (RF), support vector machine (SVM) classifier, k-nearest neighbours (k-NN) and multi-layer perceptron (MLP) classifier. Models were evaluated using a confusion matrix and metrics such as precision, recall, F1 and area under the curve. Shapley values were used to identify risk factors.

Results

MLP achieved the highest F1 score (0.75), followed by k-NN, RF and SVM (0.72 each), and LR (0.70). Key health conditions and risk factors consistently predicted frequent attendance across models, with some variation highlighting dataset-specific characteristics.

Conclusions

This study underscores the utility of combining ML models to enhance prediction accuracy and identify risk factors. Findings align with existing research but reveal unique insights specific to the dataset and methodology.

Effects of alcohol-related problems on the costs of frequent emergency department use: an economic analysis of a case-control study in Spain

Introduction

Alcohol-related problems increase the probability of frequent emergency department (ED) use. In this study, we compared the direct healthcare expenses incurred during a single visit among frequent and non-frequent ED users and analyzed the impact of alcohol-related issues in healthcare costs arising from ED usage.

Methods

The study relied on secondary analyses of economic data from a 1:1 matched case-control study with the primary aim of identifying the clinical characteristics of hospital ED frequent users in a Mediterranean European environment with a public, universal, and tax-funded health system. The participants ranged in age from 18 to 65 years and underwent ED visits at a high-complexity Spanish hospital (cases ≥5 times, controls <5) from December 2018 to November 2019. Each case was matched to a control with the same age, gender, and date of attendance at the ED. Clinical data and direct healthcare costs for a single ED visit were obtained by a retrospective review of the first electronic medical register. Costs and duration of stay were compared between cases and controls using paired-samples t-tests, and ED users with and without alcohol-related problems were compared using bivariate (independent-samples t-tests, one-way analysis of variance, Chi square tests, and multiple linear regression) and multivariate analyses (multiple linear regression models with backward stepwise selection algorithm, and dependent variable: total mean direct costs).

Results

Among 609 case-control pairs (total n = 1218), mean total healthcare direct costs per ED visit were 22.2% higher among frequent compared with non-frequent users [mean difference 44.44 euros; 95% confidence interval (CI) 13.4-75.5; t(608) = 2.811; p = 0.005]. Multiple linear regression identified length of stay, triage level, ambulance arrival, and the specialty discharging the patient as associated with total healthcare costs for frequent users. In bivariate analyses, a history of alcohol-related problems was associated with a 32.5% higher mean total healthcare costs among frequent users [mean difference 72.61 euros; 95% confidence interval 25.24-119.97; t(320.016) = 3.015; p = 0.003].

Conclusion

The findings confirm the high cost of frequent ED use among people with alcohol-related problems, suggesting that costs could be reduced through implementation of intervention protocols.

Health mediation does not reduce the readmission rate of frequent users of emergency departments living in precarious conditions: what lessons can be learned from this randomised controlled trial?

BACKGROUND

Severe overcrowding of emergency departments (EDs) affects the quality of healthcare. One factor of overcrowding is precariousness, but it has rarely been considered a key factor in designing interventions to improve ED care. Health mediation (HM) aims to facilitate access to rights, prevention, and care for the most vulnerable persons and to raise awareness among healthcare providers about obstacles in accessing healthcare. The primary aim was to determine whether HM intervention for frequent users of EDs (FUED) living in precarious conditions could reduce the readmission rate at 90 days.

METHODS

Between February 2019 and May 2022, we enrolled and interviewed 726 FUED in four EDs of southeastern France in this randomised controlled trial. The HM intervention started in the ED and lasted 90 days. In addition to the primary endpoint (first readmission at 90 days), secondary endpoints (readmission at 30 and 180 days, number of hospitalisations at 30, 90, 180 days, admissions for the same reasons as the first admission) were also studied. The outcomes were measured in the ED information systems. Statistical methods included an intention-to-treat analysis and a per-protocol analysis. Comparisons were adjusted for gender, age, ED, and health mediator.

RESULTS

46% of patients reported attending the ED because they felt their life was in danger, and 42% had been referred to the ED by the emergency medical dispatch centre or their GP; 40% of patients were considered to be in a serious condition by ED physicians. The proportion of patients who were readmitted at 90 days was high but did not differ between the control and the HM intervention groups (31.7% vs. 36.3%, p = 0.23). There was no significant difference in any of the secondary outcome measures between the control and HM intervention groups. Per-protocol analysis also showed no significant difference for the primary and secondary endpoints.

CONCLUSIONS

This randomised controlled trial did not show that our health mediation intervention was effective in reducing the use of emergency services by FUED living in precarious conditions. Some limitations are discussed: the duration of the intervention (90 days), the long-term effects (> 6 months), the involvement of the ED staff.

TRIAL REGISTRATION

Registered on clinicaltrials.gov as NCT03660215 on 4th September 2018.

Fixing the leaky physician-scientist pipeline: Integrated-dedicated research period programs in emergency medicine

Emergency physicians (EPs) are well positioned to perform medical research. EPs are exposed to a wide range of disease types, medical specialties, and treatment modalities. Furthermore, emergency medicine (EM) serves as the safety net for the U.S. health care system. The diverse exposure provides a vast opportunity for EP to perform many worthwhile research projects. Yet, EM has historically had the lowest amount of funding and a lower number of National Institutes of Health-funded research projects. Many suggest the etiology is a "leaky" educational pipeline with loss of many potential physician-scientists over the training and development course. Current research training options for the EM physician-scientist includes MD-PhD, 4-year EM residency program and postresidency fellowships. While each has its advantages and disadvantages, we describe an additional educational alternative of EM physician-scientists, which we have named the integrated-dedicated research period within an EM residency. We describe the features of these programs and preliminary results from the graduates and current trainees.

Longitudinal Outcomes of the top 20 Utilizers of VA Connecticut's Psychiatric Emergency Services Between 2010 and 2020

Frequent utilizers of emergency services represent a clinically important cohort with potentially unmet health care needs despite demanding a high volume of costly services. However, not much is known about their longitudinal course. This study identified the top 20 utilizers of VA Connecticut's psychiatric emergency services and conducted a chart review of their longitudinal outcomes during an 11-year period between 2010 and 2020, including their visit diagnoses, medical and psychiatric comorbidities, and types and frequency of other medical services and supports received. At the index visit, 19 of the 20 patients had substance use disorder and 14 patients had at least one non-substance psychiatric diagnosis. Despite all patients receiving primary care and other services, such as residential treatments, outpatient therapy, and social work consults, 11 of the 12 patients remaining alive and residing in the state continued to utilize psychiatric emergency services in 2020, revealing a pattern of persistent use.

Disparities in Perinatal and Emergency Care Receipt Among Women With Perinatal Opioid Use Disorder in Medicaid, 2007 to 2012

OBJECTIVES

This study aimed to better understand receipt of perinatal and emergency care among women with perinatal opioid use disorder (OUD) and explore variation by race/ethnicity.

METHODS

We used 2007-2012 Medicaid Analytic eXtract (MAX) data from all 50 states and the District of Columbia to examine 6,823,471 deliveries for women 18 to 44 years old. Logistic regressions modeled the association between (1) OUD status and receipt of perinatal and emergency care, and (2) receipt of perinatal and emergency care and race/ethnicity, conditional on OUD diagnosis and controlling for patient and county characteristics. We used robust SEs, clustered at the individual level, and included state and year fixed effects.

RESULTS

Women with perinatal OUD were less likely to receive adequate prenatal care (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.44-0.46) and attend the postpartum visit (aOR, 0.46; 95% CI, 0.45-0.47) and more likely to seek emergency care (aOR, 1.48; 95% CI, 1.45-1.51) than women without perinatal OUD. Among women with perinatal OUD, Black, Hispanic, and American Indian and Alaskan Native (AI/AN) women were less likely to receive adequate prenatal care (aOR, 0.68 [95% CI, 0.64-0.72]; aOR, 0.86 [95% CI, 0.80-0.92]; aOR, 0.71 [95% CI, 0.64-0.79]) and attend the postpartum visit (aOR, 0.85 [95% CI, 0.80-0.91]; aOR, 0.86 [95% CI, 0.80-0.93]; aOR, 0.83 [95% CI, 0.73-0.94]) relative to non-Hispanic White women. Black and AI/AN women were also more likely to receive emergency care (aOR, 1.13 [95% CI, 1.05-1.20]; aOR, 1.12 [95% CI, 1.00-1.26]).

CONCLUSIONS

Our findings suggest that women with perinatal OUD, in particular Black, Hispanic, and AI/AN women, may be missing opportunities for preventive care and comprehensive management of their physical and behavioral health during pregnancy.

Health mediation: an intervention mode for improving emergency department care and support for patients living in precarious conditions

BACKGROUND

Severe overcrowding of emergency departments (EDs) impacts the quality of healthcare. One factor of this overcrowding is precariousness, but it has rarely been considered a key factor in designing interventions to improve ED care. Health mediation (HM) aims to facilitate access to rights, prevention, and care for the most vulnerable persons and to raise awareness among healthcare providers about obstacles in accessing healthcare. We here present the results of an ancillary qualitative study to explore the prospects regarding a health mediation intervention implemented in EDs for deprived persons who are frequent ED users, from professionals' and patients' perspectives.

METHODS

Design, data collection, and data analysis were done according to a psychosocial approach, based on thematic content analysis and semi-structured interviews of 16 frequent ED users and deprived patients exposed to HM and of 14 professionals in 4 EDs of South-eastern France.

RESULTS

All patients reported multifactorial distress. Most of them expressed experiencing isolation and powerlessness, and lacking personal resources to cope with healthcare. They mentioned the use of ED as a way of quickly meeting a professional to respond to their suffering, and recognized the trustworthy alliance with health mediators (HMrs) as a means to put them back in a healthcare pathway. The presence of HMrs in EDs was appreciated by ED professionals because HMrs responded to requests they were not able to access and were perceived as an efficient support for caring for deprived persons in emergency contexts.

CONCLUSIONS

Our results are in favour of health mediation in EDs as a promising solution, requested by patients and ED professionals, to cope with frequent ED users and deprived patients. Our results could also be used to adapt other strategies for the most vulnerable populations to reduce the frequency of ED readmissions. At the interface of the patients' health experience and the medico-social sector, HM could complete the immediate responses to medical needs given in EDs and contribute in alleviating the social inequalities of health.

Economic evaluation of an integrated virtual care programme for people with chronic illness who are frequent users of health services in Australia

OBJECTIVE

The MeCare programme is a tailored virtual care initiative targeted at frequent users of health services who have at least one chronic condition including cardiovascular disease, chronic respiratory disease, diabetes or chronic kidney disease. The programme aims to prevent unnecessary hospitalisations by helping patients to self-manage, improve their health literacy and engage in positive health behaviours. This study investigates the impact of the MeCare programme on healthcare resource use, costs and patient-reported outcomes.

METHODS AND ANALYSIS

A retrospective pre-post study design was adopted. Data on emergency department presentations, hospital admissions, outpatient appointments and their associated costs were obtained from administrative databases. Probabilistic sensitivity analysis using Monte Carlo simulation was used to model changes in resource use and costs prior to, and following, participant enrolment on the MeCare programme. Generalised linear models were used to investigate the observed changes in patient-reported outcomes.

RESULTS

The MeCare programme cost $A624 per participant month to deliver. Median monthly rates of ED presentations, hospital admissions and average length of stay post-MeCare reduced by 76%, 50% and 12%, respectively. This translated to a median net cost saving of $A982 per participant month (IQR: -1936; -152). A significant, positive trend in patient experience based on responses to the Patient Assessment of Care for Chronic Conditions Questionnaire was observed over the duration of programme enrolment.

DISCUSSION

The MeCare programme is likely to result in substantial cost savings to the health system, while maintaining or improving patient-reported outcomes. Further research in multisite randomised studies is needed to confirm the generalisability of these results.

Integrated case management between primary care clinics and hospitals for people with complex needs who frequently use healthcare services: A multiple-case embedded study

INTRODUCTION

Case management (CM) is recognized to improve care integration and outcomes of people with complex needs who frequently use healthcare services, but challenges remain regarding interaction between primary care clinics and hospitals. This study aimed to implement and evaluate an integrated CM program for this population where nurses in primary care clinics worked with a hospital case manager.

METHODS

A multiple embedded case study was conducted in the Saguenay-Lac-Saint-Jean region (Québec, Canada), in four dyads including a clinic and a hospital. Mixed data collection included, at baseline and 6 months, interviews and focus groups with stakeholders, patient questionnaires (patient experience of integrated care and self-management), and emergency department (ED) visits in the previous 6 months.

RESULTS

Integrated CM implementation was optimal when all stakeholders provided collective leadership, and were supportive of the program, particularly the physicians. The 6-month program enabled the observation of positive qualitative outcomes in most clinic-hospital dyads where implementation occurred. Full implementation was associated with improved care integration.

DISCUSSION AND CONCLUSION

Integrated CM between primary care clinics and hospitals is a promising innovation to improve care integration for people with complex needs who frequently use healthcare services. Collective leadership and physicians' buy-in to integrated CM are important to foster the implementation.

Use of urgent, emergency and acute care by mental health service users: A record-level cohort study

BACKGROUND

People with serious mental illness experience worse physical health and greater mortality than the general population. Crude rates of A&E attendance and acute hospital admission are higher in people with serious mental illness than other hospital users. We aimed to further these findings by undertaking a standardised comparison of urgent and emergency care pathway use among users of mental health services and the general population.

METHODS

Retrospective cohort analysis using routine data from 2013-2016 from the CUREd dataset for urgent and emergency care contacts (NHS 111, ambulance, A&E and acute admissions) and linked mental health trust data for Sheffield, England. We compared annual age- and sex-standardised usage rates for each urgent and emergency care service between users of mental health services and those without a recent history of mental health service use.

RESULTS

We found marked differences in usage rates for all four urgent and emergency care services between the general population and users of mental health services. Usage rates and the proportion of users were 5-6 times and 3-4 times higher in users of mental health services, respectively, for all urgent and emergency care services. Users of mental health services were often more likely to experience the highest or lowest acuity usage characteristics.

CONCLUSIONS

Current users of mental health services were heavily over-represented among urgent and emergency care users, and they made more contacts per-person. Higher service use among users of mental health services could be addressed by improved community care, more integrated physical and mental health support, and more proactive primary care. A complex pattern of service use among users of mental health services suggests this will need careful targeting to reduce avoidable contacts and optimise patient outcomes.

Increased demand for paramedic transports to the emergency department in Ontario, Canada: a population-level descriptive study from 2010 to 2019

Purpose

We examined changes in annual paramedic transport incidence over the ten years prior to COVID-19 in comparison to increases in population growth and emergency department (ED) visitation by walk-in.

Methods

We conducted a population-level cohort study using the National Ambulatory Care Reporting System from January 1, 2010 to December 31, 2019 in Ontario, Canada. We included all patients triaged in the ED who arrived by either paramedic transport or walk-in. We clustered geographical regions using the Local Health Integration Network boundaries. Descriptive statistics, rate ratios (RR), and 95% confidence intervals were calculated to explore population-adjusted changes in transport volumes.

Results

Overall incidence of paramedic transports increased by 38.3% (n = 264,134), exceeding population growth fourfold (9.4%) and walk-in ED visitation threefold (13.4%). Population-adjusted transport rates increased by 26.2% (rate ratio 1.26, 95% CI 1.26–1.27) compared to 3.4% for ED visit by walk-in (rate ratio 1.03, 95% CI 1.03–1.04). Patient and visit characteristics remained consistent (age, gender, triage acuity, number of comorbidities, ED disposition, 30-day repeat ED visits) across the years of study. The majority of transports in 2019 had non-emergent triage scores (60.0%) and were discharged home directly from the ED (63.7%). The largest users were persons aged 65 or greater (43.7%). The majority of transports occurred in urbanized regions, though rural and northern regions experienced similar paramedic transport growth rates.

Conclusion

There was a substantial increase in the demand for paramedic transportation. Growth in paramedic demand outpaced population growth markedly and may continue to surge alongside population aging. Increases in the rate of paramedic transports per population were not bound to urbanized regions, but were province-wide. Our findings indicate a mounting need to develop innovative solutions to meet the increased demand on paramedic services and to implement long-term strategies across provincial paramedic systems.

Comparison Groups Matter in Traumatic Brain Injury Research: An Example with Dementia

The association between traumatic brain injury (TBI) and risk for Alzheimer's disease and related dementias (ADRD) has been investigated in multiple studies yet reported effect sizes have varied widely. Large differences in comorbid and demographic characteristics between individuals with and without TBI could result in spurious associations between TBI and poor outcomes, even when control for confounding is attempted. Yet, inadvertent control for post-TBI exposures (e.g., psychological and physical trauma) could result in an underestimate of the effect of TBI. Choice of the unexposed or comparison group is critical to estimating total associated risk. The objective of this study was to highlight how selection of the comparison group impacts estimates of the effect of TBI on risk for ADRD. Using data on veterans aged ≥55 years obtained from the Veterans Health Administration (VA) for years 1999-2019, we compared risk of ADRD between veterans with incident TBI (n=9,440) and 1) the general population of veterans who receive care at the VA (All VA)(n=119,003); 2) veterans who received care at a VA emergency department (VA ED)(n=111,342); and 3) veterans who received care at a VA ED for non-TBI trauma (VA ED NTT)(n=65,710). In inverse probability of treatment weighted models, TBI was associated with increased risk of ADRD compared to All VA (HR 1.94; 95% CI 1.84, 2.04), VA ED (HR 1.42; 95% CI 1.35, 1.50), and VA ED NTT (HR 1.12; 95% CI 1.06, 1.18). The estimated effect of TBI on incident ADRD was strongly impacted by choice of the comparison group.

Transitions of care for hospital discharges in a primary care network

Transitions to and from primary care are a time of concern, especially for patients with chronic conditions and complex care needs. The Edmonton Southside Primary Care Network (ESPCN) developed a process for nurses to ensure timely post-discharge follow-up calls and physician appointments after hospitalization, assessing readmission risk with LACE and Clinical Frailty scores. Over 84% of eligible high-risk discharges received follow-up within 14 days. Of 7,400 index discharges, 1,464 had an emergency department revisit and 725 patients were readmitted within 30 days. Overall, ESPCN rates of readmission (9.8%) and rates of Family Practice Sensitive Conditions (FPSC) (5.7%) were significantly lower than national and provincial rates. FPSC rates for high-risk patients were significantly lower than low- or medium-risk groups. Consistent processes that support nursing involvement enable primary care teams to focus on those with highest risk for adverse outcomes and support patients to access the most appropriate place for the care they need.

Emergency Medicine Residents’ “Just World” Bias Is Not Associated with a Biased Case Mix

Introduction

Belief in a just world is the cognitive bias that “one gets what they deserve.” Stronger belief in a just world for others (BJW-O) has been associated with discrimination against individuals with low socioeconomic status (SES) or poor health status, as they may be perceived to have “deserved” their situation. Emergency medicine (EM) residents have been shown to “cherry pick” patients; in this study we sought to determine whether BJW-O is associated with a biased case mix seen in residency.

Methods

We assessed EM residents on their BJW-O using a scale with previous validity evidence and behavioral correlates. We identified chief complaints that residents may associate with low SES or poor health status, including psychiatric disease, substance use disorder (SUD); and patients with multidisciplinary care plans due to frequent ED visits. We then calculated the percentage of each of these patient types seen by each resident as well as correlations and a multiple linear regression.

Results

38 of 48 (79%) residents completed the BJW-O, representing 98,825 total patient encounters. The median BJW-O score was 3.25 (interquartile range 2.81–3.75). There were no significant correlations observed between BJW-O and the percentage of patients with multidisciplinary care plans who were seen, or patients with psychiatric, SUD, dental or sickle cell chief complaints seen; and a multiple linear regression showed no significant association.

Conclusion

Higher BJW-O scores in EM residents are not significantly associated with a biased case mix of patients seen in residency.

Exploring the prevalence of personality disorder and the feasibility of using the SAPAS as a screening tool for personality disorder in an emergency department in India

BACKGROUND

Personality disorders (PD) lead to frequent emergency department (ED) visits. Existing studies have evaluated high-risk ED populations in Western settings. PD screening tools, such as the Standardized Assessment of Personality - Abbreviated Scale (SAPAS), have thus far only been validated in Western populations.

AIMS

This study aimed to establish the screened prevalence of PD, and to evaluate the performance of the SAPAS as a screening tool within an ED setting in India.

METHODS

The study took place in the ED of a private multi-speciality hospital in Kolkata, India. All attendees were approached during two days per week over three months, except those who were medically unfit to participate. The SAPAS and the International Personality Disorder Examination (IPDE) were translated into Bengali and then used as screening tools for PD and as the reference standard for PD diagnosis.

RESULTS

Out of 120 ED attendees approached, 97 participated (48 men and 49 women), of whom 24% met the criteria for a diagnosis of PD. A cut-off score of 4 on the SAPAS provided the best trade-off between sensitivity and specificity for detecting PD.

CONCLUSION

The prevalence of PD was similar to Western samples, and the SAPAS showed promise for use in a non-Western setting.

Case Management Programs for Improving Integrated Care for Frequent Users of Healthcare Services: An Implementation Analysis

INTRODUCTION

Case management programs (CMP) for frequent users of healthcare services presenting complex healthcare needs constitute an effective strategy to improve patient experience of integrated care and to decrease healthcare overuse and cost. This study sought to identify characteristics of these programs, and their implementation contexts, that help to improve patient self-management, experience of integrated care, and healthcare services use.

METHODS

A mixed methods multiple embedded case study design was conducted, with six CMP implemented in six hospitals of a region of Quebec (Canada).

RESULTS

Within-case analysis describes the structural, environmental, organizational, practitioner, patient, and innovation level characteristics of each CMP and their services integration outcomes based on patient experience, self-management and healthcare services use. Cross-case analysis suggests that the skills, leadership and experience of the case manager, providers' access to the individualized services plan, consideration of the needs of the patient and family members, their participation in decision-making, and the self-management approach, impact integrated care and healthcare services use.

CONCLUSION AND DISCUSSION

This study underscores the necessity of an experienced, knowledgeable and well-trained case manager with interpersonal skills to optimize CMP implementation such that patients are more proactive in their care and their outcomes improve.

Case management programs for people with complex needs: Towards better engagement of community pharmacies and community-based organisations

Introduction

The objectives of this study were 1) to describe how case management programs engaged community pharmacies and community-based organisations in a perspective of integrated care for people with complex needs, and 2) to identify enablers, barriers and potential strategies for this engagement.

Methods

Using a descriptive qualitative design, individual interviews and focus groups with patients, healthcare providers and managers were analysed according to a mixed thematic analysis based on a deductive (Rainbow Model of Integrated Care) and an inductive approach.

Results and discussion

Participants highlighted the individualized service plan as a significant tool to foster a shared person-focused vision of care, information exchanges and concerted efforts. Openness to collaboration was also considered as an enabler for community stakeholders’ engagement. The lack of recognition of community-based organisations by certain providers and the time required to participate in individualized service plans were outlined as barriers to professional integration. Limited opportunities for community stakeholders to be involved in decision-making within case management programs were reported as another constraint to their engagement. Cultural differences between organisations regarding the focus of the intervention (psychosocial vs healthcare needs) and differences in bureaucratic structures and funding mechanisms may negatively affect community stakeholders’ engagement. Formal consultation mechanisms and improvement of communication channels between healthcare providers and community stakeholders were suggested as ways to overcome these barriers.

Conclusion

Efforts to improve care integration in case management programs should be directed toward the recognition of community stakeholders as co-producers of care and co-builders of social policies across the entire care continuum for people with complex needs.

Reducing Frequency of Emergency Department and Inpatient Visits Through Focused Case Management

PURPOSE OF STUDY

To evaluate whether the Oklahoma State University (OSU) Health Access Network's (HAN's) case management program is effective in reducing the attendance of frequent users to the emergency department (ED) and inpatient department.

PRIMARY PRACTICE SETTING

This is a 2-year retrospective pre/post-case management analysis. Emergency department usage data from 2013 to 2016 of the OSU HAN contracted clinics are used in this study. This study involves case management interventions for high ED users and high-risk patients. The patients in the study must be enrolled in SoonerCare choice to be case managed.

METHODOLOGY AND SAMPLE

Patients who visited the ED 3 times or more in 12 months prior to their HAN enrollment and patients with 12 months of data preenrollment and postenrollment were included in the study. A historical control was used to compare ED and inpatient use per patient per month pre- and post-HAN case management. Chi-square and Wilcoxon's signed-rank tests were used to assess the data.

RESULTS

A total of 29 patients met the inclusion criteria. The number of ED and inpatient visits was reduced after HAN intervention (181 vs. 110, p < .001; 35 vs. 11, p < .001). The ED and inpatient use per patient per month reduced significantly from 0.52 to 0.31 (p < .001) and 0.10 to 0.03 (p < .01), respectively.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

This study suggests that continuous case management and implementation of various care plans with frequent follow-up are effective in reducing the cost of care and subsequent ED and inpatient visits.

Predictive Model-Driven Hotspotting to Decrease Emergency Department Visits: a Randomized Controlled Trial

BACKGROUND

Emergency department (ED) visits contribute substantially to health care expenditures. Case management has been proposed as a strategy to address the medical and social needs of complex patients. However, strong research designs to evaluate the effectiveness of such interventions are limited.

OBJECTIVES

To evaluate whether a community-based case management program was associated with reduced ED utilization among complex patients.

DESIGN

Patients whose risk exceeded a threshold were randomly assigned to a group offered case management or to the control group. Assignment occurred at five intervals between November 2017 and January 2019. Program effectiveness for all assigned patients was assessed using an intention-to-treat effect. Program effectiveness among those who received treatment was assessed using a local average treatment effect, estimated using instrumental variables. Both estimators were adjusted for baseline characteristics using linear models.

PARTICIPANTS

Adults over age 18 with at least one health care encounter with Michigan Medicine or St. Joseph Mercy Health System between June 2, 2016, and November 27, 2018.

INTERVENTIONS

Intervention arm participants (n = 486) were offered coordinated case management across medical, mental health, and social service organizations. Control arm participants (n = 409) received usual care.

MAIN MEASURES

The primary outcome was the number of ED visits in the 6 months following randomization into the study. Secondary outcomes were 6-month counts of inpatient and outpatient visits.

KEY RESULTS

Of the 486 patients assigned to the intervention, 131 (27%) consented to receive case management. The intention-to-treat effect on ED visits was + 0.14 (95% CI: - 0.27 to + 0.55). The local average treatment effect among those who consented and received case management was + 0.53 (95% CI: - 1.00 to + 2.05). Intention-to-treat and local average treatment effects were not significant for secondary outcomes.

CONCLUSIONS

The community case management intervention targeting ED visits was not associated with reduced utilization. Future case management interventions may benefit from additional patient engagement strategies and longer evaluation time periods.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT03293160.

Heterogeneity of reasons for attendance in frequent attenders of emergency departments and its relationship to future attendance

BACKGROUND

EDs globally are under increasing pressure through rising demand. Frequent attenders are known to have complex health needs and use a disproportionate amount of resources. We hypothesised that heterogeneity of patients' reason for attendance would be associated with multimorbidity and increasing age, and predict future attendance.

METHOD

We analysed an anonymised dataset of all ED visits over the course of 2014 in Yorkshire, UK. We identified 15 986 patients who had five or more ED encounters at any ED in the calendar year. Presenting complaint was categorised into one of 14 categories based on the Emergency Care Data Set (ECDS). We calculated measures of heterogeneity (count of ECDs categories and entropy of categories) and examined their relationship to total number of ED visits and to patient characteristics. We examined the predictive value of these and other features on future attendance.

RESULTS

Most frequent attenders had more than one presenting complaint type. Heterogeneity increased with number of attendances, but heterogeneity adjusted for number of attendances did not vary substantially with age or sex. Heterogeneity was associated with the presence of one or more contacts for a mental health problem. For a given number of attendances, prior mental health contact but not heterogeneity was associated with further attendance.

CONCLUSIONS

Heterogeneity of presenting complaint can be quantified and analysed for ED use: it is increased where there is a history of mental disorder but not with age. This suggests it reflects more than the number of medical conditions.

Qualitative evaluation of primary care providers' experiences caring for frequent users of the emergency department

OBJECTIVES

Many interventions have been developed over the years to offer frequent users of the emergency department (FUEDs) better access to quality coordinated healthcare. Despite recognising the role primary care physicians (PCPs) play in FUEDs' care, to date their perceptions of case management, the most studied intervention, have rarely been assessed. Furthermore, a gap regarding PCPs' experience of caring for FUEDs persists. Thus, this study aimed to explore PCPs' perceptions of the care provided to FUEDs in emergency and primary care settings, their views on the local case management team (CMT), and their suggestions to improve FUEDs' care.

DESIGN

Qualitative study using in-depth semistructured interviews and inductive thematic analysis.

SETTING

Canton of Vaud, Switzerland.

PARTICIPANTS

Thirty PCPs participated, 16 in private practice (PP-PCPs) and 14 based at the Lausanne University Centre of General Medicine and Public Health (Unisanté-U-PCPs).

RESULTS

U-PCPs and PP-PCPs thought that most FUEDs' emergency department (ED) visits were legitimate, but questioned ED adequacy to meet FUEDs' needs. Yet, both PCP groups reported encountering many challenges in FUEDs' care themselves. In this context, PP-PCPs seemed more satisfied of the care they provided to FUEDs than U-PCPs. Generally, U-PCPs seemed to find more value in the CMT to help them care for FUEDs than PP-PCPs. To enhance FUEDs' care, U-PCPs and PP-PCPs suggested enhancing collaboration with other healthcare providers. U-PCPs also wished to increase their availability, and some PP-PCPs considered outpatient clinics, larger group practices or medical centres most appropriate to handle FUEDs' needs.

CONCLUSIONS

This study highlights the many challenges PCPs face in caring for FUEDs, that a CM intervention has the potential to mitigate, and provides ways forward in improving FUEDs' care, including reinforced communication with the CMT and ED physicians, and structural changes to their own way of delivering care to FUEDs.

Epidemiology of Frequent Visits to the Emergency Department at a Tertiary Care Hospital in Saudi Arabia: Rate, Visitors' Characteristics, and Associated Factors

Background

Emergency department overcrowding is becoming a challenge for the healthcare management system globally and locally. This study aimed to estimate the frequency of ED visits, describe the patients’ profile along with visit-related characteristics, and associated factors in a tertiary care hospital.

Methods

A retrospective cohort study was conducted at a tertiary care hospital. The study included patients age 14 years and above visiting the main emergency department in year 2013. Data were extracted from electronic medical records by a qualified data extraction team. Statistical analyses were performed, including the odds ratio and 95% confidence interval for the factors associated with highly frequent (≥14 visits) ED visits using logistic regression models.

Results

There were 150,727 visits to the emergency department within a year. The number of frequent visitors was 7696 (9.38%), with 42,226 visits (28.01% of total ED visits). Highly frequent visitors totaled 249 (0.30%), with 5173 visits (3.43% of total ED visits). The frequent visitors’ average age was 42.55 (SD 20.14), and 48.99 (SD 21.33) for the highly frequent visitors’ group. More than half of the emergency visitors were females. The most common complaints among the highly frequent visitors were Gastrointestinal (21.34%), followed by Respiratory (13.47%), Orthopedic (12.57%), and Cardiovascular (12.43%). Multivariate analysis indicated that age, history of diabetes, history of cardiac diseases, insurance status, and nationality were significant predicators of highly frequent visits to the hospital emergency.

Conclusion

Frequent and highly frequent visitors to emergency departments represent a significant proportion of adult patients presenting to ED. Their visits constitute almost one-third of total ED visits. Several factors associated with highly frequent ED visits have been identified. This study provides local empirical evidence to develop improvement policy and actions related to chronic issue of frequent and highly frequent visitation to hospital ED.

Identifying subgroups and risk among frequent emergency department users in British Columbia

Objective: Frequent emergency department (ED) users are heterogeneous. We aimed to identify subgroups and assess their mortality. Methods: We identified patients ≥18 years with ≥1 ED visit in British Columbia from April 1, 2012 to March 31, 2015, and linked to hospitalization, physician billing, prescription, and mortality data. Frequent users were the top 10% of patients by ED visits. We employed cluster analysis to identify frequent user subgroups. We assessed 365-day mortality using Kaplan-Meier curves and conducted Cox regressions to assess mortality risk factors within subgroups. Results: We identified 4 subgroups. Subgroup 1 ("Elderly") had median age 77 years (interquartile range [IQR]: 66-85), 5 visits/year (IQR: 4-6), median 8 prescription medications (IQR: 5-11), and 24.7% mortality. Subgroup 2 ("Mental Health and Alcohol Use") had median age 48 years (IQR: 34-61), 13 visits/year (IQR: 10-16), and 12.3% mortality. They made a median 31 general practitioner visits (IQR: 19-51); however, only 23.7% received a majority of services from 1 primary care physician. Subgroup 3 ("Young Mental Health") had median age 39 years (IQR: 28-51), 5 visits/year (IQR: 4-6), and 2.2% mortality. Subgroup 4 ("Short-term") had median age 50 years (IQR: 34-65), 4 visits/year (IQR: 4-5) regularly spaced over a short term, and 1.4% mortality. Male sex (all subgroups), long-term care ("Mental Health and Alcohol Use;" "Young Mental Health"), and rural residence ("Elderly" in long-term care; "Young Mental Health") were associated with increased mortality. Conclusions: Our results identify frequent user subgroups with varying mortality. Future research should explore subgroups' unmet needs and tailor interventions toward them.

Health care providers' perception of the frequent emergency department user issue and of targeted case management interventions: a cross-sectional national survey in Switzerland

Background

Frequent users of emergency departments (FUEDs) (≥5 ED visits/year) represent a vulnerable population with complex needs accounting for a significant number of emergency department (ED) consultations, thus contributing to EDs overcrowding. Research exploring ED staff perceptions of FUEDs is scarce.

Objectives

The current study aimed to evaluate in ED staff a) the extent to which FUEDs are perceived as an issue; b) their perceived levels of knowledge and understanding of FUEDs; c) levels of perceived usefulness of case management (CM) and interest in implementing this intervention in their ED service.

Methods

Head physicians of the EDs at all public hospitals in Switzerland (of various level of specialization) were sent a 19-item web-based survey, pilot tested prior to its dissemination. The head physicians were asked to forward the survey to ED staff members from different health professional backgrounds.

Results

The hospital response rate was 81% (85/106). The exploitable hospital response rate was 71% (75/106 hospitals) including 208 responding health professionals. Issues and difficulties around FUEDs were perceived as important by 64% of respondents. The perceived frequency of being confronted with FUEDs was higher among nurses in more specialized EDs. In total, 64% of respondents felt poorly informed about FUEDs, nurses feeling less informed than physicians. The understanding of FUEDs was lower in the French-Italian-speaking parts (FISP) of Switzerland than in the German-speaking part. Eighty-one percent of respondents had no precise knowledge of FUED-related interventions. The perceived usefulness of CM interventions after receiving explanations about it was high (92%). However, the overall level of interest for CM implementation was 59%. The interest in CM by physicians was low across all regions and ED categories. Nurses, on the other hand, showed more interest, especially those in EDs of high specialization.

Conclusions

The majority of ED staff reported being confronted with FUEDs on a regular basis. Staff perceived FUEDs as a vulnerable population, yet, they felt poorly informed about how to manage the issue. The majority of ED staff thought a CM intervention would be useful for FUEDs, however there appears to be a gap in their desire or willingness to implement such interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-020-00397-w.

The suburban-city divide: an evaluation of emergency department mental health presentations across two centres

OBJECTIVE

To evaluate the characteristics of mental health presentations to the emergency department in two different hospital settings.

METHODS

This was a retrospective cross-sectional study examining ED referrals to psychiatry in an inner-city and suburban centre. The authors collected data on gender, age, employment, housing, clinical presentation, time of assessment and admissions, over a 1-month period.

RESULTS

The total number referred was 213: inner-city n = 109 and suburban n = 104. The inner-city saw a younger population; 47/109 (43%) were aged between 20 and 29 years, compared with 28/104 (27%) of suburban presenters (P value 0.0134). A higher number of presenters were aged over 60 in the suburban centre n = 13/104 (12.5%) versus the inner-city centre 3/109 (2.8%) (P value 0.0084). In the inner-city, the proportion of homeless presenters was significantly higher at 30/109 (28%) versus 5/104 (4.8%) in the suburban setting (P < 0.0001). Presentations related to substances were highest, a total of 73 (34.3%) across both centres, with no significant difference in clinical presentations across the two centres. The majority were seen in the on-call period, 74/109 (67.9%) in the inner-city centre and 66/104 (63.5%) in the suburban centre. The psychiatric admission rate was significantly different between the two centres, with 33/109 (30.3%) patients admitted in the inner-city centre and 13/104 (12.5%) patients admitted in the suburban centre (P value 0.002).

CONCLUSIONS

A large proportion of ED referrals to psychiatry constitute patients with unmet social and addiction needs, who are seen out of hours. This prompts consideration of expanding both ED and community services to comprise a more multidisciplinary-resourced, 24/7 care model.

Healthcare Providers' Perceptions of Challenges with Frequent Users of Emergency Department Care in Switzerland: A Qualitative Study

Frequent users of emergency departments (FUED; ≥ 5 ED visits/year) commonly cumulate medical, social, and substance use problems requiring complex and sustained care coordination often unavailable in ED. This study aimed to explore ED healthcare providers' challenges related to FUED care to gain insight into the support and resources required to address FUED complex needs. An online survey was sent to all general adult emergency services within Switzerland (N = 106). Participants were asked to indicate the extent to which they perceived that FUED represented a problem and to describe the main challenges encountered. In total, 208 physicians and nurses from 75 EDs (70.7%) completed the survey. Among the 208 participants, 134 (64%) reported that FUED represented a challenge and 133 described 1 to 5 challenges encountered. A conventional content analysis yielded 4 main categories of perceived challenges. Negative consequences in the ED secondary to FUED's presence (eg, ED overcrowding, staff helplessness, and fatigue) was the most frequently reported challenge, followed by challenges related to FUEDs' characteristics (eg, mental health and social problems) leading to healthcare complexity. The third most frequently encountered challenge was related to the ED inappropriateness and inefficiency to address FUEDs' needs. Finally, challenges related to the lack of FUED healthcare network were the least often mentioned. ED healthcare providers experience a wide range of challenges related to FUED care. These findings suggest that currently EDs nor their staff are equipped to address FUEDs' complex needs.

Towards Better Health, Social, and Community-Based Services Integration for Patients with Chronic Conditions and Complex Care Needs: Stakeholders' Recommendations

The objective was to report on issues related to patients with complex care needs and recommendations identified by 160 key participants at a summit in Quebec City about better integration of primary health care services for patients with chronic diseases and complex care needs. A descriptive qualitative approach was used. While focus groups were led by a facilitator, a rapporteur noted highlights and a research team member took independent notes. All notes were analyzed by using a thematic analysis according to an inductive method. Seven issues were identified, leading to the formulation of recommendations: (1) valuing the experience of the patient; (2) early detecting of a non-homogeneous patient population; (3) defining interprofessional collaboration based on patient needs; (4) conciliating services provided by clinical settings according to a registered clientele-based logic with the population-based logic; (5) working with the community sector; (6) aligning patient-oriented research values with existing challenges to primary care integration; and (7) promoting resource allocation consistent with targeted recommendations. The summit highlighted the importance of engaging all stakeholders in improvement of integrated care for patients with complex care needs. The resulting recommendations target shared priorities towards better health, social, and community-based services integration for these patients.

General practitioner follow-up after hospitalisation in Central and Eastern Sydney, Australia: access and impact on health services

Objectives General practitioner (GP) follow-up after a hospital admission is an important indicator of integrated care. We examined the characteristics of patients who saw a GP within 2 weeks of hospital discharge in the Central and Eastern Sydney (CES) region, Australia, and the relationship between GP follow-up and subsequent hospitalisation. Methods This data linkage study used a cohort of 10240 people from the 45 and Up Study who resided in CES and experienced an overnight hospitalisation in the 5 years following recruitment (2007-14). Characteristics of participants who saw a GP within 2 weeks of discharge were compared with those who did not using generalised linear models. Time to subsequent hospitalisation was compared for the two groups using Cox proportional hazards regression models stratified by prior frequency of GP use. Results Within 2 weeks of discharge, 64.3% participants saw a GP. Seeing a GP within 2 weeks of discharge was associated with lower rates of rehospitalisation for infrequent GP users (i.e. <8 visits in year before the index hospitalisation; hazard ratio (HR) 0.83; 95% confidence interval (CI) 0.70-0.97) but not frequent GP users (i.e. ≥8 plus visits; HR 1.02; 95% CI 0.90-1.17). Conclusion The effect of seeing a GP on subsequent hospitalisation was protective but differed depending on patient care needs. What is known about the topic? There is general consensus among healthcare providers that primary care is a significant source of ongoing health care provision. What does this paper add? This study explored the relationship between GP follow-up after an uncomplicated hospitalisation and its effect on rehospitalisation. What are the implications for practitioners? Discharge planning and the transfer of care from hospital to GP through discharge arrangements have substantial benefits for both patients and the health system.

High Users of Healthcare Services: Development and Alpha Testing of a Patient Decision Aid for Case Management

BACKGROUND

Some patients with complex healthcare needs become high users of healthcare services. Case management allows these patients and their interprofessional team to work together to evaluate their needs, priorities and available resources. High-user patients must make an informed decision when choosing whether to engage in case management and currently there is no tool to support them.

OBJECTIVE

The objective of this study was to develop and conduct a pilot alpha testing of a patient decision aid that supports high-user patients with complex needs and the teams who guide those patients in shared decision making when engaging in case management.

METHODS

We chose a user-centered design to co-develop a patient decision aid with stakeholders informed by the Ottawa Research Institute and International Patient Decision Aid Standards frameworks. Perceptions and preferences for the patient decision aid's content and format were assessed with patients and clinicians and were iteratively collected through interviews and focus groups. We developed a prototype and assessed its acceptability by using a think-aloud method and a questionnaire with three patient-partners, six clinicians and seven high-user patients with complex needs.

RESULTS

The three rounds of evaluation to assess the decision aid's acceptability highlighted comments related to simplicity, readability and visual aspect. A section presenting clinical vignettes including story telling was identified as the most helpful.

CONCLUSIONS

We created and evaluated a patient decision aid. Considering the positive comments, we believe that this aid has the potential to help high-user patients with complex care needs make better choices concerning case management.

What is the prevalence of frequent attendance to emergency departments and what is the impact on emergency department utilisation? A systematic review and meta-analysis

Patients who frequently attend to emergency departments are a varying group and have complex health care needs. This systematic review and meta-analysis aimed to determine the prevalence of patients who have frequent attendance to emergency departments. A systematic review was performed in line with PRISMA guidelines. A database search was conducted, and studies were included in the final review if they analysed a population of frequent attendance. Meta-analysis was performed only on population-based studies to estimate prevalence. The search yielded 2922 nonduplicate publications, of which 27 were included in the meta-analysis. The most common definition used for frequent attendance was greater than three presentations a year. The proportion of people who frequently attended as a percentage of the total study population ranged from 0.01 to 20.9%, with emergency department presentations from frequent attenders ranging from 0.2 to 34%. When limiting the definition of frequent attendance to greater than three visits in a 12-month period, people who frequently attended contributed between 3 and 10% [pooled estimate 6%; CI 4-7%] of emergency department presentations and between 12 and 34% [pooled estimate 21%; CI 15-27%] of total emergency department presentations. Meta-analysis found substantial heterogeneity between estimates [I² > 50%]. The prevalence of frequent attendance compared to the total population of patients seeking emergency care was small, but the impact on emergency department utilisation is significant. Early identification of people attending for frequent care at an emergency department provides the opportunity to implement alternative models of care.

Homeless people under the influence of alcohol admitted to hospital emergency departments in Poland

Aim:

To assess the incidence of diagnoses related to alcohol use in the population of homeless people admitted to hospital emergency departments (EDs).

Material and method:

Data were analysed from three hospitals concerning stays of homeless people in three EDs in Bydgoszcz, Poland, in 2013–2015; 3133 stays were identified. The data were compiled using Microsoft Excel and Statistica 10 statistical software.

Results:

At the time of admission to EDs, 31% of homeless people were considered to be under the influence of alcohol. Diagnoses related to alcohol use accounted for 25% of all diagnoses. The average blood alcohol concentration in the patients was 2.97 per mille. The average blood alcohol concentration in the group of men was significantly higher than that in the group of women (p = 0.015). The average length of stay in the ED of patients under the influence of alcohol was significantly longer (p < 0.0001) than among sober patients.

Conclusions:

Homeless people under the influence of alcohol account for a third of the population of homeless patients admitted to hospital emergency departments, while alcohol-related ICD-10 diagnoses account for a fourth of all diagnoses in these patients. Homeless patients under the influence of alcohol stay longer in hospital emergency departments than do sober homeless people, which may translate into more frequent acts of aggression towards medical personnel. In Poland there are no systemic ED-level solutions as regards dealing with homeless patients for whom alcohol dependence is in many cases a reality.

Experience of being a frequent user of primary care and emergency department services: a qualitative systematic review and thematic synthesis

BACKGROUND

Frequent users of healthcare services are often categorised as 'heavy-cost patients'. In the recent years, many jurisdictions have attempted to implement different public policies to optimise the use of health services by frequent users. However, throughout this process, little attention has been paid to their experience as patients.

OBJECTIVE

To thematically synthesise qualitative studies that explore the experience of frequent users of primary care and emergency department services.

DESIGN

Qualitative systematic review and thematic synthesis.

SETTING

Primary care and emergency department.

PARTICIPANTS

Frequent users of primary care and emergency department services.

METHODS

A qualitative systematic review was conducted using three online databases (MEDLINE with full text, CINAHL with full text and PsycINFO). This search was combined to an extensive manual search of reference lists and related citations. A thematic synthesis was performed to develop descriptive themes and analytical constructs.

STUDY SELECTION

Twelve studies were included. All included studies met the following inclusion criteria: qualitative design; published in English; discussed frequent users' experiences from their own perspectives and users' experiences occurred in primary care and/or emergency departments.

RESULTS

The predominant aspects of frequent users' experiences were: (1) the experience of being ill and (2) the healthcare experience. The experience of being ill encompassed four central themes: physical limitations, mental suffering, impact on relationships and the role of self-management. The healthcare experience embraced the experience of accessing healthcare and the global experience of receiving care.

CONCLUSION

This synthesis sheds light on potential changes to healthcare delivery in order to improve frequent users' experiences: individualised care plans or case management interventions to support self-management of symptoms and reduce psychological distress; and giving greater importance on the patient-providers relationship as a central facet of healthcare delivery. This synthesis also highlights future research directions that would benefit frequent users.

What role does the GP play for emergency department utilizers? A qualitative exploration of respiratory patients' perspectives in Berlin, Germany

BACKGROUND

While motives for emergency department (ED) self-referrals have been investigated in a number of studies, the relevance of general practitioner (GP) care for these patients has not been comprehensively evaluated. Respiratory symptoms constitute an important utilization trigger in both EDs and in primary care. In this qualitative study, we aimed to explore the role of GP care for patients visiting EDs as outpatients for respiratory complaints and the relevance of the relationship between patient and GP in the decision making process leading up to an ED visit.

METHODS

Qualitative descriptive study. Semi-structured, face-to-face interviews with a sample of 17 respiratory ED patients in Berlin, Germany. Interviews were recorded and transcribed verbatim. Qualitative content analysis was performed. The study was embedded into the EMACROSS (Emergency and Acute Care for Respiratory Diseases beyond Sectoral Separation) cohort of ED patients with respiratory symptoms, which is part of EMANet (Emergency and Acute Medicine Network for Health Care Research).

RESULTS

Three patterns of GP utilization could be differentiated: long-term regular consulters, sporadic consulters and patients without GP. In sporadic consulters and patients without GP, an ambivalent or even aversive view of GP care was prevalent, with lack of confidence in GPs' competence and a deficit in trust as seemingly relevant influencing factors. Regardless of utilization or relationship type, patients frequently made contact with a GP before visiting an ED.

CONCLUSIONS

With regard to respiratory symptoms, our qualitative data suggest a hypothesis of limited relevance of patients' primary care utilization pattern and GP-patient relationship for ED consultation decisions.

Understanding Barriers to and Facilitators of Case Management in Primary Care: A Systematic Review and Thematic Synthesis

PURPOSE

Despite evidence on the benefits of case management for the care of patients with complex needs in primary care, implementing the program-necessary to achieve its benefits-has been challenging worldwide. Evidence on factors affecting implementation remains disparate. Accordingly, the objective of this systematic review was to identify barriers to and facilitators of case management, from the perspectives of health care professionals, in primary care settings around the world.

METHODS

We conducted a systematic review and thematic synthesis of qualitative findings. In collaboration with 2 librarians, we searched 3 electronic databases (MEDLINE, CINAHL, EMBASE) for studies related to factors affecting case management function in primary care. Two researchers screened titles, abstracts, and full texts for inclusion, then assessed included studies for quality. Results from included studies were synthesized by thematic synthesis, and a framework was developed.

RESULTS

Of 1,640 unique records identified, 22 studies, originating from 6 countries, met the inclusion criteria. We identified 9 barriers and facilitators: family context; policy and available resources; physician buy-in and understanding of the case manager role; relationship building; team communication practices; autonomy of case managers; training in technology; relationships with patients; and time pressure and workload. We describe these factors, then present a framework demonstrating the relationships among them.

CONCLUSIONS

Our study's findings show that multiple factors influence case management implementation. These findings have implications for researchers, clinicians, and policy makers who strive to implement or reform case management programs in local or larger primary care settings.

Frequency of health-care utilization by adults who use illicit drugs: a systematic review and meta-analysis

AIMS

To summarize evidence on the frequency and predictors of health-care utilization among people who use illicit drugs.

DESIGN

Systematic search of MEDLINE, EMBASE and PsychINFO for observational studies reporting health-care utilization published between 1 January 2000 and 3 December 2018. We conducted narrative synthesis and meta-analysis following a registered protocol (identifier: CRD42017076525).

SETTING AND PARTICIPANTS

People who use heroin, powder cocaine, crack cocaine, methamphetamine, amphetamine, ecstasy/3,4-methyl​enedioxy​methamphetamine (MDMA), cannabis, hallucinogens or novel psychoactive substances; have a diagnosis of 'substance use disorder'; or use drug treatment services.

MEASUREMENTS

Primary outcomes were the cumulative incidence (risk) and rate of care episodes in three settings: primary care, hospital admissions (in-patient) and emergency department (ED).

FINDINGS

Ninety-two studies were included, 84% from North America and Australia. Most studies focused on people using heroin, methamphetamine or crack cocaine, or who had a diagnosis of drug dependence. We were able to conduct a meta-analysis of rates across 25 studies reporting ED episodes and 25 reporting hospital admissions, finding pooled rates of 151 [95% confidence interval (CI) = 114-201] and 41 (95% CI = 30-57) per 100 person-years, respectively; on average 4.8 and 7.1 times more often than the general population. Heterogeneity was very high and was not explained by drugs used, country of study, recruitment setting or demographic characteristics. Predictors of health-care utilization were consistent across studies and included unstable housing, drug injection and mental health problems. Opioid substitution therapy was consistently associated with reduced ED presentation and hospital admission. There was minimal research on health-care utilization by people using ecstasy/MDMA, powder cocaine, hallucinogens or novel psychoactive substances.

CONCLUSIONS

People who use illicit drugs are admitted to emergency department or hospital several times more often than the general population.

Characteristics of frequent users of the emergency department with chronic pain

OBJECTIVES

To identify the proportion of high-frequency users of the emergency department (ED) who have chronic pain.

METHODS

We reviewed medical records of adult patients with ≥ 12 visits to a tertiary-care, academic hospital ED in Canada in 2012-2013. We collected the following demographics: 1) patient age and sex; 2) visit details - number of ED visits, inpatient admissions, length of inpatient admissions, diagnosis, and primary location of pain; 3) current and past substance abuse, mental health and medical conditions. Charts were reviewed independently by two reviewers. ED visits were classified as either "chronic pain" or "not chronic pain" related.

RESULTS

We analyzed 4,646 visits for 247 patients, mean age was 47.2 years (standard deviation = 17.8), and 50.2% were female. This chart review study found 38% of high-frequency users presented with chronic pain to the ED and that women were overrepresented in this group (64.5%). All high-frequency users presented with co-morbidities and/or mental health concerns. High-frequency users with chronic pain had more ED visits than those without and 52.7% were prescribed an opioid. Chronic abdominal pain was the primary concern for 54.8% of high-frequency users presenting with chronic pain.

CONCLUSIONS

Chronic pain, specifically chronic abdominal pain, is a significant driver of ED visits among patients who frequently use the ED. Interventions to support high-frequency users with chronic pain that take into account the complexity of patient's physical and mental health needs will likely achieve better clinical outcomes and reduce ED utilization.

Case Management in Primary Care for Frequent Users of Health Care Services: A Realist Synthesis

PURPOSE

Case management (CM) is a promising intervention for frequent users of health care services. Our research question was how and under what circumstances does CM in primary care work to improve outcomes among frequent users with chronic conditions?

METHODS

We conducted a realist synthesis, searching MEDLINE, CINAHL, Embase, and PsycINFO (1996 to September 2017) for articles meeting the following criteria: (1) population: adult frequent users with chronic disease, (2) intervention: CM in a primary care setting with a postintervention evaluation, and (3) primary outcomes: integration of services, health care system use, cost, and patient outcome measures. Academic and gray literature were evaluated for relevance and robustness. Independent reviewers extracted data to identify context, mechanism, and outcome (CMO) configurations. Analysis of CMO configurations allowed for the modification of an initial program theory toward a refined program theory.

RESULTS

Of the 9,295 records retrieved, 21 peer-reviewed articles and an additional 89 documents were retained. We evaluated 19 CM interventions and identified 11 CMO configurations. The development of a trusting relationship fostering patient and clinician engagement in the CM intervention was recurrent in many CMO configurations.

CONCLUSION

Our refined program theory proposes that in the context of easy access to an experienced and trusted case manager who provides comprehensive care while maintaining positive interactions with patients, the development of this relationship fosters the engagement of both individuals and yields positive outcomes when the following mechanisms are triggered: patients and clinicians feel supported, respected, accepted, engaged, and committed; and patients feel less anxious, more secure, and empowered to self-manage.

A "Behind-the-Scenes" Look at Interprofessional Care Coordination: How Person-Centered Care in Safety-Net Health System Complex Care Clinics Produce Better Outcomes

Introduction:

While the effectiveness of team-based care and wrap-around services for high utilizers is clear, how complex care clinics deliver effective, person-centered care to these vulnerable populations is not well understood. This paper describes how interactions among interprofessional team members enabled individualized, rapid responses to the complex needs of vulnerable patients at the Virginia Commonwealth University Health System’s Complex Care Clinic.

Methods:

Researchers attended twenty weekly care coordination meetings, audio-recorded the proceedings, and wrote brief observational field notes. Researchers also qualitatively interviewed ten clinic team members. Emergent coding based on grounded theory and a consensus process were used to identify and describe key themes.

Results:

Analysis resulted in three themes that evidence the structures, processes, and interactions which contributed to the ability to provide person-centred care: team-based communication strategies, interprofessional problem-solving, and personalized patient engagement efforts.

Conclusion:

Our study suggests that in care coordination meetings team members were able to strategize, brainstorm, and reflect on how to better care for patients. Specifically, flexible team leadership opened an inter-disciplinary communicative space to foster conversations, which revealed connections between the physical, and socio-emotional components of patients’ lives and hidden factors undermining progress, while proactive strategies prevented patient’s rapid deterioration and unnecessary use of inappropriate health services.

Evaluating complex interventions in real context: Logic analysis of a case management program for frequent users of healthcare services

Case management programs for frequent users of healthcare services are complex interventions which implementation and application are challenging to evaluate. The aim of this article was to conduct a logic analysis to evaluate a case management program for frequent users of healthcare services. The study proceeded in three phases: 1) establishing causal links between the program's components by the construction of a logic model, 2) developing an integrated framework from a realistic synthesis, and 3) making a new reading of the case management program in regard of the integrated framework. The study demonstrated, on one hand, strengths and weaknesses of the actual case management program, and, on the other hand, how logic analysis can create a constructive dialogue between theory and practice. The evaluative process with decision-makers, clinicians and patients has helped to make connexions between theory, practice, experience and services organization.

Persistent frequent emergency department users with chronic conditions: A population-based cohort study

BACKGROUND

Frequent emergency department users are patients cumulating at least four visits per year. Few studies have focused on persistent frequent users, who maintain their frequent user status for multiple consecutive years. This study targets an adult population with chronic conditions, and its aims are: 1) to estimate the prevalence of persistent frequent ED use; 2) to identify factors associated with persistent frequent ED use (frequent use for three consecutive years) and compare their importance with those associated with occasional frequent ED use (frequent use during the year following the index date); and 3) to compare characteristics of "persistent frequent users" to "occasional frequent users" and to "users other than persistent frequent users".

METHODS

This is a retrospective cohort study using Quebec administrative databases. All adult patients who visited the emergency department in 2012, diagnosed with chronic conditions, and living in non-remote areas were included. Patients who died in the three years following their index date were excluded. The main outcome was persistent frequent use (≥4 visits per year during three consecutive years). Potential predictors included sociodemographic characteristics, physical and mental comorbidities, and prior healthcare utilization. Odds ratios were computed using multivariable logistic regression.

RESULTS

Out of 297,182 patients who visited ED at least once in 2012, 3,357 (1.10%) were persistent frequent users. Their main characteristics included poor socioeconomic status, mental and physical comorbidity, and substance abuse. Those characteristics were also present for occasional frequent users, although with higher percentages for the persistent user group. The number of previous visits to the emergency department was the most important factor in the regression model. The occasional frequent users' attrition rate was higher between the first and second year of follow-up than between the second and third year.

CONCLUSIONS

Persistent frequent users are a subpopulation of frequent users with whom they share characteristics, such as physical and mental comorbidities, though the former are poorer and younger. More research is needed in order to better understand what factors can contribute to persistent frequent use.

Mental and behavioral disorders in the population of homeless patients admitted to hospital emergency departments

The aim of the study is to identify the most common mental and behavioral disorders diagnosed in homeless patients admitted to hospital emergency departments and to identify performed medical procedures including diagnostic and therapeutic measures in this range.

Material and Method:Data from information systems of three hospitals concerning stays of homeless people in ED in Bydgoszcz in 2013-2015 were analyzed. As any as 3133 stays were identified. The data was compiled using the Microsoft Excel spreadsheet and Statistica 10 statistical software package.

Results: Diagnoses in the category of mental disorders and behavioral disorders constituted 23.3% of diagnoses made in the studied population, of which two thirds were psychiatric disorders and behavioral disorders caused by alcohol use. Specific personality disorders (5.84%), schizophrenia (3.82%), and mild mental retardation (2.24%) were diagnosed in patients. One tenth of all the ICD-9 procedures performed were the procedures of the category 94- Procedures related to mental condition

Conclusions: Mental and behavioral disorders are one of the main reasons for admission of homeless people to hospital emergency departments. Most diseases is diagnosed in facilities where psychiatric consultation is possible, as well as where the number of procedures related to mental condition performed is the highest. Homeless patients suffering from mental and behavioral disorders are rarely admitted to hospital wards for hospitalization. Psychiatric care for homeless patients admitted to emergency departments is an ad hoc intervention and depends on the availability of a psychiatrist. Providing homeless patients with access to a psychiatric diagnosis at ED level would affect the quality of psychiatric care and would contribute to the improvement of mental health of homeless people.

Prediction of Recurrent Emergency Department Visits in Patients With Mental Disorders

BACKGROUND

Patients with mental disorders are more likely to be frequent emergency department (ED) users than patients with somatic illnesses. There is little information about recurrent ED visitors (≥four ED visits/year) due to mental health problems in Switzerland. Therefore, our aim was to investigate the prevalence of recurrent ED visits due to mental disorders and to determine which mental disorders and risk factors were associated with recurrent ED visits.

METHODS

In a retrospective analysis, we investigated patients suffering from mental health problems between January and December 2015 who presented more than once in the ED of a tertiary care hospital. ED patients who sought out the ED due to mental disorders were grouped in a recurrent group with at least four ED visits per year or in a control group visiting the ED twice or three times within a year. The primary endpoint was to assess the prevalence of recurrent ED patients due to acute symptoms of mental disorders. As secondary endpoints, we investigated which mental disorders and risk factors were associated with recurrent ED visits.

RESULT

Of 33,335 primary ED visits, 642 ED visits (1.9%) were by 177 visitors suffering from acute mental health problems. Forty-five (25.4%) of these 177 patients were recurrent ED visitors; 132 (74.6%) visited the ED twice or three times (control). Patients with personality disorders had a four-times higher risk (p = 0.011) of being a recurrent ED visitor. Recurrent ED visitors with mental disorders had significantly more in-house admissions (p < 0.001), self-mutilations (p < 0.001), acute drug toxicity (p = 0.007) and were more often persons of single status (p = 0.045). Although recurrent ED visitors more often had an outpatient general physician or psychiatrist, they visited the ED more frequently within office hours (p < 0.001).

CONCLUSION

A quarter of frequent ED users with mental disorders are recurrent ED visitors and were more likely to suffer from personality disorders. Recurrent ED visits are associated with higher rates of self-mutilation, acute drug toxicity, and a greater number of in-house admissions.