Elaine Rabin

Frequent Users of Emergency Departments: The Myths, the Data, and the Policy Implications

STUDY OBJECTIVE Frequent emergency department (ED) users have been the targets of health care reform proposals and hospital crowding interventions, but it is not clear that common assumptions about this group are supported by data. We review the literature pertaining to frequent ED users, their demographics, acuity of illness, and patterns of health care utilization. We seek to inform development of policies directed at frequent ED use and to highlight potential related challenges. METHODS A systematic review of the literature on frequent ED users was performed. RESULTS Frequent users comprise 4.5% to 8% of all ED patients but account for 21% to 28% of all visits. Most frequent ED users are white and insured; public insurance is overrepresented. Age is bimodal, with peaks in the group aged 25 to 44 years and older than 65 years. On average, these patients have higher acuity complaints and are at greater risk for hospitalization than occasional ED users. However, the opposite may be true of the highest-frequency ED users. Frequent users are also heavy users of other parts of the health care system. Only a minority of frequent ED users remain in this group long term. Complaints vary with age, location, and usage patterns. CONCLUSION Frequent ED users are a heterogeneous group along many dimensions and defy popular assumptions. The subgroups have not yet been sufficiently defined to allow clearly directed policy design, and many frequent users present with true medical needs, which may explain why existing attempts to address the phenomena have had mixed success at best.

Emergency department throughput, crowding, and financial outcomes for hospitals.

Emergency department (ED) crowding has been identified as a major public health problem in the United States by the Institute of Medicine. ED crowding not only is associated with poorer patient outcomes, but it also contributes to lost demand for ED services when patients leave without being seen and hospitals must go on ambulance diversion. However, somewhat paradoxically, ED crowding may financially benefit hospitals. This is because ED crowding allows hospitals to maximize occupancy with well-insured, elective patients while patients wait in the ED. In this article, the authors propose a more holistic model of hospital flow and revenue that contradicts this notion and offer suggestions for improvements in ED and hospital management that may not only reduce crowding and improve quality, but also increase hospital revenues. Also proposed is that increased efficiency and quality in U.S. hospitals will require changes in systematic microeconomic and macroeconomic incentives that drive the delivery of health services in the United States. Finally, the authors address several questions to propose mutually beneficial solutions to ED crowding that include the realignment of hospital incentives, changing culture to promote flow, and several ED-based strategies to improve ED efficiency.

High-Frequency Users of Emergency Department Care

BACKGROUND The heterogeneous group of patients who frequently use the Emergency Department (ED) have been of interest in public health care reform debate, but little is known about the subgroup of the highest frequency users. STUDY OBJECTIVES We sought to describe the demographic and utilization characteristics of patients who visit the ED 20 or more times per year. METHODS We retrospectively studied patients who visited a large, urban ED over a 1-year period, identifying all patients using the department 20 or more times. Age, gender, insurance, psychosocial factors, chief complaint, and visit disposition were described for all visits. Inferential tests assessed associations between demographic variables, insurance status, and admission rates. RESULTS Of the 59,172 unique patients to visit the ED between December 1, 2009 and November 30, 2010, 31 patients were identified as high-frequency ED users, contributing 1.1% of all visits. Patients were more likely to be 30-59 years of age (52%), stably insured (81%), and have at least one significant psychosocial cofactor (65%). Their admission rate was 15%, as compared to 21% for all other patients. CONCLUSIONS High-frequency users are patients with significant psychiatric and social comorbidities. Given their small proportion of visits, lower admission rates, and favorable insurance status, the impact of high-frequency users of the ED may be out of proportion to common perceptions.

The Affordable Care Act and Emergency Care

The Affordable Care Act (ACA) will have far-reaching effects on the way health care is designed and delivered. Several elements of the ACA will directly affect both demand for ED care and expectations for its role in providing coordinated care. Hospitals will need to employ strategies to reduce ED crowding as the ACA expands insurance coverage. Discussions between EDs and primary care physicians about their respective roles providing acute unscheduled care would promote the goals of the ACA.

A Broader View of Quality: Choosing Wisely Recommendations From Other Specialties With High Relevance to Emergency Care

Study objective: The American College of Emergency Physicians (ACEP) joined the Choosing Wisely campaign in 2013 and has contributed 10 recommendations to reduce low‐value care. Recommendations from other specialties may also identify opportunities to improve quality and patient safety in emergency care. The Choosing Wisely work group of the ACEP Quality and Patient Safety Committee seeks to identify and characterize the Choosing Wisely recommendations from other professional societies with the highest relevance to emergency care. Methods: In June 2016, all Choosing Wisely recommendations from other specialties were obtained from the American Board of Internal Medicine Foundation. Using a modified Delphi method, the 10 group members rated recommendations for relevance on a validated 7‐point scale. Recommendations identified as highly relevant (median score=7) were rated on 3 additional characteristics: cost savings (1=large, 5=none), risk‐benefit profile (1=benefit >risk, 5=risk >benefit), and actionability by emergency physicians (1=complete, 5=none). Results are presented as overall means (eg, mean of subcategory means) and subcategory means with SDs. Results: Initial review of 412 recommendations identified 49 items as highly relevant to emergency care. Eleven were redundant with ACEP recommendations, leaving 38 items from 25 professional societies. Overall means for items ranged from 1.57 to 3.1. Recommendations’ scores averaged 3.2 (SD 0.6) for cost savings, 1.9 (SD 0.4) for risk‐benefit, and 1.6 (SD 0.5) for actionability. The most common conditions in these recommendations were infectious diseases (14 items; 37%), head injury (4 items; 11%), and primary headache disorders (4 items; 11%). The most frequently addressed interventions were imaging studies (11 items; 29%) and antibiotics (9 items; 24%). Conclusion: Thirty‐eight Choosing Wisely recommendations from other specialties are highly relevant to emergency care. Imaging studies and antibiotic use are heavily represented among them.

Expanding Health Information Exchange Improves Identification of Frequent Emergency Department Users

Study objective Frequent emergency department (ED) users are of interest to policymakers and hospitals. The objective of this study is to examine the effect of health information exchange size on the identification of frequent ED users. Methods We retrospectively analyzed data from Healthix, a health information exchange in New York that previously included 10 hospitals and then grew to 31 hospitals. We divided patients into 3 cohorts: high‐frequency ED users with 4 or more visits in any 30‐day period, medium‐frequency ED users with 4 or more visits in any year, and infrequent ED users with fewer than 4 visits in any year. For both the smaller (10‐hospital) and larger (31‐hospital) health information exchanges, we compared the identification rate of frequent ED users that was based on hospital‐specific data with the corresponding rates that were based on health information exchange data. Results The smaller health information exchange (n=1,696,279 unique ED patients) identified 11.4% more high‐frequency users (33,467 versus 30,057) and 9.5% more medium‐frequency users (109,497 versus 100,014) than the hospital‐specific data. The larger health information exchange (n=3,684,999) identified 19.6% more high‐frequency patients (52,727 versus 44,079) and 18.2% more medium‐frequency patients (222,574 versus 192,541) than the hospital‐specific data. Expanding from the smaller health information exchange to the larger one, we found an absolute increase of 8.2% and 8.7% identified high‐ and medium‐frequency users, respectively. Conclusion Increasing health information exchange size more accurately reflects how patients access EDs and ultimately improves not only the total number of identified frequent ED users but also their identification rate.