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.     

Hospitalizations and return visits after chronic obstructive pulmonary disease ED visits

Purpose

The aim of this study was to describe population-based patterns of chronic obstructive pulmonary disease (COPD)–related emergency department (ED) visits.

Methods

We analyzed all COPD-related ED visits made by North Carolina residents 45 years or older in 2008 to 2009 using statewide surveillance system data. Return visits were identified when patients returned to the same ED within 3 or 14 days of a prior COPD-related visit. We quantify the prevalence of hospitalization and return visits by age, sex, and payment method and describe ED disposition patterns.

Results

Nearly half (46.3%) of the 97?511 COPD-related ED visits resulted in hospital admission. The percent of visits preceded by another COPD-related visit within 3 and 14 days was 1.6% and 6.2%, respectively. Emergency department–related hospitalizations increased with age; there were no differences by sex. Hospitalizations were less likely for uninsured, Medicare, and Medicaid visits than for privately insured visits. In contrast, 3- and 14-day return visits were more likely to be uninsured, Medicare, and Medicaid visits than privately insured visits. Fourteen-day returns were more likely to be made by men. Return visits initially increased with age compared with the 45- to 49-year age group, then decreased steadily after age 65 years. When return visits were made, discharge at both visits was the most common disposition pattern. However, 33.7% of 3-day returns and 22.7% of 14-day returns were discharged at the first visit and hospitalized upon returning to the ED.

Conclusions

Chronic obstructive pulmonary disease–related hospital admissions and short-term return ED visits were common and varied by age and insurance status. Chronic obstructive pulmonary disease management remains a critical area for intervention and quality improvement.     

Resource utilization and health care charges associated with the most frequent ED users

Study objective

Emergency department (ED) visits have continued to rise, and frequent ED users account for up to 8% of all ED visits. Reducing visits by frequent ED users may be one way to help reduce health care costs. We hypothesize that frequent users have unique ED utilization patterns resulting in differences in health care charges.

Methods

We conducted a retrospective review of electronic medical records from an urban community teaching hospital for the year 2012 comparing the top 108 frequent ED users (> 12 visits/year) to a randomly selected group of 108 nonfrequent users (< 4 visits/year). We compared demographic characteristics, distance lived from the hospital, medical and psychiatric history, substance abuse history, diagnostic testing, disposition, and amount charged to the patient for each visit. We compared data using χ² for proportions and t test or Wilcoxon rank sum based on normality of the data.

Results

The top 108 frequent ED users accounted for 1922 visits (2.9%), whereas the 108 nonfrequent users accounted for 150 visits (0.2%), in 2012 (all ED visits n = 65,398). Frequent users were more often unemployed, have public insurance, have mental health conditions, use tobacco, have a greater number of allergies to medications, and live closer to the hospital (P < .01). Disposition and median charge per visit did not differ between frequent and nonfrequent users ($1220 vs $1280). The total charges of the frequent ED users’ visits were $10,465,216.07 versus $1,012,610.21 for nonfrequent users.

Conclusions

Frequent users have unique medical and social characteristics; however, disposition and visit charges did not differ from nonfrequent users.     

Magnitude of national ED visits and resource utilization by the uninsured

Background

For nearly 51 million persons in the United States who lack health care insurance, the emergency department (ED) functions as a safety net where no patient is denied care based on ability to pay, and much public rhetoric has characterized ED utilization by uninsured patients. We estimated national ED utilization by uninsured patients and compared uninsured and insured ED patients in terms of demographics, diagnostic testing, disposition and final diagnoses.

Methods

We analyzed data from the National Hospital Ambulatory Medical Care Survey (2006-2009) stratified by insurance status. Demographic data, diagnoses, testing, and procedures performed in the ED were tabulated for each visit. Weighted percentages provided by National Hospital Ambulatory Medical Care Survey were used to estimate national rates for each variable, and multivariate models were constructed for predicting testing, procedures, and admission.

Results

The 135 085 ED visits represent 475 million patients visits, of which 78.9 million (16.6%) were uninsured. Compared with insured patients, uninsured patients were more often male (51.1% vs 44.3%) and younger (age 18-44 years, 66.2% vs 35.4%). Uninsured patients had lower rates of circulatory/cardiovascular (7.5% vs 4.1%) and respiratory diagnoses (14.6% vs 11.8%). Uninsured patients had fewer diagnostic tests and procedures and fewer hospital admissions than those with insurance. In our multivariate models, insurance status was predictive of testing and procedures but not hospital admission.

Conclusions

Uninsured patients account for approximately 20 million or 1 in 6 ED visits annually in the United States and have differences in demographics, diagnoses, and ED utilization patterns from those with insurance.     

Cardiology clinic follow-up did not decrease return visits to the ED for chest pain patients

Background

We initiated a program to rapidly rule out myocardial infarction and make an appointment (with no co-payment) with a cardiologist within 72 hours for patients with low-risk chest pain.

Objective

The objectives of this study were to determine if the rate of return emergency department (ED) visits for chest pain decreased among patients who kept their appointments and to evaluate factors that impacted clinic no-show rates.

Methods

The study was conducted at a safety net facility with 65 000 adult patient visits per year. This study was a retrospective review of patients with chest pain discharged from the ED with a scheduled cardiology clinic appointment between October 2008 and December 2009. We compared those who kept their clinic appointment with those who did not for repeat ED visits for 6 months after the study period. Multivariate analysis evaluated factors associated with keeping appointments.

Results

Of 381 patients, 265 (70%) kept their appointments. Show rates did not differ based on age, sex, race, or language. Patients with commercial insurance were more likely to keep appointments than Medicare, Medicaid, and uninsured (OR, 51.3; 95% confidence interval [CI], 2.53-1041.64; P = .010). The 116 no-show patients averaged 0.39 return ED visits (95% CI, 0.15-0.63), and the 265 patients who kept their appointments averaged 0.28 (95% CI, 0.17-0.39). Two hundred twenty-nine patients who kept their appointment had no return ED visits, but 36 patients had 74 return ED visits. There was no difference in return ED visits between the 18 who had diagnostic cardiac testing (mean, 1.78; 95% CI, 1.60-3.06) and the 18 who did not (mean, 2.33; 95% CI, 1.20-2.36; P = .251).

Conclusions

This program did not reduce repeat ED visits. Patients with insurance were more likely to keep follow-up appointments.     

Impact of Physician Screening in the Emergency Department on Patient Flow

Background

Physician triage is one of many front-end interventions being implemented to improve emergency department (ED) efficiency.

Study Objective

We aim to determine the impact of this intervention on some key components of ED patient flow, including time to physician evaluation, treatment order entry, diagnostic order entry, and disposition time for admitted patients.

Methods

We conducted a 2-year before–after analysis of a physician triage system at an urban tertiary academic center with 90,000 annual visits. The goal of the physician in triage was to arrange safe disposition of straightforward patients as well as to initiate work-ups. All medium-acuity patients arriving during the hours of the intervention were impacted and thus included in the analysis. Our primary outcome was the time to disposition decision. In addition to before–after analysis, comparison was made with high-acuity patients, a group not impacted by this intervention. Patient flow data were extracted from the ED information system. Outcomes were summarized with medians and interquartiles. Multivariable regression analysis was performed to investigate the intervention effect controlling for potential confounding variables.

Results

The median time to disposition decision decreased by 6 min, and the time to physician evaluation, analgesia, antiemetic, antibiotic, and radiology order decreased by 16, 70, 66, 36, and 16 min, respectively. These findings were all statistically significant. Similar results were observed from the multivariable regression models after controlling for potential confounding factors.

Conclusions

Physician triage led to earlier evaluation, physician orders, and a decrease in the time to disposition decision.     

Improved Physician Consult Response Times in an Academic Emergency Department After Implementation of an Institutional Guideline

Background

Physician consultation in the Emergency Department (ED) can account for a significant portion of ED length of stay, which can lead to poor clinical outcomes.

Objective

The purpose of this study was to determine whether an institutional guideline could lead to a reduction in time between consult request and admission decision. This guideline codified a 90-min expected time interval to arrive and complete an admission disposition where the consulting and admitting service were the same in an academic ED with weekly audits and reports to departmental chairs and hospital administrators.

Methods

This was a study of consultation times of patients who presented to an academic ED 6 months before the adoption of an institutional guideline and 6 months after the adoption of the guideline. Data measurement in both periods included the length of time from ED consult order to admission disposition, time of ED discharge, number of ED consultations (single and multiple), ED admissions, and the hospital discharge time of admitted patients.

Results

Physician consult response time decreased from 121 min to 100 min (p < 0.0001), and patients left the ED 18 min earlier (p = 0.0221) after implementation of the consultation guideline despite more ED visits, consultations, and admissions in the post-implementation time period. Patients were discharged from the inpatient setting 50 min later (p < 0.0001) after implementation of the guideline.

Conclusion

An institutional guideline codifying timely ED consultations led to a significant reduction in the time from ED consultation to admission disposition while also allowing patients to leave the ED earlier in a high-occupancy academic medical center. However, the discharge time of admitted hospital patients was later after implementation of the guideline.     

The most frequent ED patients carry insurance and a significant burden of disease

Study Objective

The objective of this study was to determine factors that impact emergency department (ED) utilization among the most frequent ED users.

Methods

This prospective observational study consisting of questionnaires was conducted in an urban ED with an annual census of 95 000 patients. A convenience sample of the top 1% of adult frequent users (≥ 9 ED visits in the previous 12 months) was enrolled from February 2009 to March 2010. Patients were excluded because of intoxication, altered mental status, or acute psychosis.

Results

A total of 115 patients were enrolled, with an average age of 44 years and median number of 22 ± 13 ED visits in the preceding 12 months. Seventy-eight percent of frequent users reported adequate health insurance coverage, and 75% reported one or more chronic medical conditions. Despite the high rates of insured patients, 75% identified the ED as their primary health care site. Half of the cohort had 2 or more hospital admissions over the past 12 months, of which 24% were patients with end-stage renal disease.

Conclusions

The top 1% of frequent users usually had adequate health insurance and primary care access but were burdened by chronic conditions and frequent hospital admissions. Such patients may require more extensive coordinated medical management to decrease ED utilization.     

Racial disparities in insurance reimbursement for physician professional services in the ED

Objective

We sought to determine whether racial disparities exist in emergency physician professional services reimbursement from insurance. We hypothesized that insured adult African American emergency department (ED) visits are reimbursed at a lower level than White visits.

Methods

We conducted a retrospective, observational cohort study of insured adult White and African American ED visits (January 1, 2012, to June 30, 2013) to a tertiary center. We downloaded for each included visit age, sex, race, residential zip code, insurance type, admission status, Current Procedural Terminology (CPT) Evaluation and Management (E/M) code charge reimbursement, and median household income for residential zip code. We chose as our primary outcome measure visit mean total insurance reimbursement/work relative value unit (wRVU). We report racial variation for this outcome measure with 95% confidence intervals (CI) and present the β coefficient related to African American race within a multivariable regression model.

Results

A total of 50 297 visits met inclusion criteria (35 574 Whites and 14 723 African Americans). Overall, mean total insurance reimbursement/wRVU for White visits was $39.99 (95% CI, 39.80-40.18), for African American visits, $34.15 (95% CI, 33.88-34.42); P < .01. At the CPT E/M code level, African American visit reimbursement was lower than for White visits, ranging from $2.18/wRVU (95% CI, 0.87-3.49) (99282) to $7.55/wRVU (95 CI, 6.52-8.58) (99285). At the primary insurance level, African American visits showed lower reimbursement than White visits, ranging from $1.70/wRVU (95% CI, 0.75-2.65) in commercial insurance to $7.70/wRVU (95% CI, 5.42-9.98) in other insurance. Within the multivariable regression model, the β coefficient for African American race was −$1.51/wRVU (95% CI, −1.85 to −1.18); P < .001.

Conclusion

In this single-center study, professional services reimbursement was lower for African American ED visits compared with those of Whites.     

The Effect of Boarders on Emergency Department Process Flow

Background

Emergency department (ED) overcrowding with boarders and waiting times are a significant concern in many countries.

Objective

We aim to show the relationship between boarders in the ED and the percentage time to disposition in under 6 h for our ED patients.

Method

A review was carried out to show the percentage of patients presenting to the ED compliant with a 6-h standard per day compared to the number of attendances, the number of admissions to the hospital, and the number of boarders in the ED per day.

Results

Over the 2-year study period, there was an average 0.37% fall in the ED's rate of compliance per day, with a 6-h standard for each boarder in the ED.

Conclusion

Boarding patients in the ED has a negative effect on compliance with our 6-h standard of time to disposition.     

Does lack of social support lead to more ED visits for older adults?

Objective

The goals of this study were to (1) determine whether level of social support and living situation predicted emergency department (ED) use among older adults and (2) identify correlates of ED visits according to whether the patient was admitted to the hospital.

Methods

Secondary analysis of a longitudinal, prospective study was conducted.

Results

In adjusted analyses, subjects who lived alone were 60% more likely to visit the ED than those who lived solely with their spouse. Neither type nor level of social support as measured by the Duke Social Support Index predicted ED use. Indicators of poor physical health (prior hospitalization, poorer self-rated health, and functional disability) were predictors of ED visits that resulted in hospitalization; however, these were not significantly associated with outpatient ED visits.

Discussion

Older adults who live alone are more likely to visit the ED. Additional study is needed to understand the determinants of outpatient ED visits.     

Characteristics of Medicaid enrollees with frequent ED use

Background

Medicaid enrollees are disproportionately represented among patients with frequent Emergency Department (ED) visits, yet prior studies investigating frequent ED users have focused on patients with all insurance types.

Methods

This was a single center, retrospective study of Medicaid-insured frequent ED users (defined as ≥ 4 ED visits/year not resulting in hospital admission) to assess patients’ sociodemographic and clinical characteristics and evaluate differences in these characteristics by frequency of use (4-6, 7-17, and ≥ 18 ED visits).

Results

Twelve percent (n = 1619) of Medicaid enrollees who visited the ED during the 1-year study period were frequent ED users, accounting for 38% of all ED visits (n = 10,337). Most frequent ED users (n = 1165, 72%) had 4-6 visits; 416 (26%) had 7-17 visits, and 38 (2%) had ≥ 18 visits. Overall, 67% had a primary care provider and 56% had at least one chronic medical condition. The most common ED diagnosis among patients with 4-6 visits was abdominal pain (7%); among patients with 7-17 and ≥ 18 ED visits, the most common diagnosis was alcohol-related disorders (11% and 36%, respectively). Compared with those who had 4-6 visits, patients with ≥ 18 visits were more likely to be homeless (7% vs 42%, P < .05) and suffer from alcohol abuse (15% vs 42%, P < .05).

Conclusion

One out of 8 Medicaid enrollees who visited the ED had ≥ 4 visits in a year. Efforts to reduce frequent ED use should focus on reducing barriers to accessing primary care. More tailored interventions are needed to meet the complex needs of adults with ≥ 18 visits per year.     

Pain Scores among Emergency Department (ED) Patients: Comparison by ED Diagnosis

Background

Treatment for pain and pain-related conditions has been identified as the most common reason for Emergency Department (ED) visits.

Objective

This study was undertaken to characterize the distribution of self-reported pain scores for common ED diagnoses.

Methods

In this retrospective exploratory chart review, eligible participants included all adult ED patients age 18 years and over, with a self-reported triage pain score of 1 or higher during January–June 2011. Data were collected from ED electronic medical records.

Results

Among 1229 patients, the mean age was 44 years; 56% of patients were female, and 59% were white. The mean triage pain score for all patients was 7.1 (interquartile range 6–9). The most common reported diagnoses included: minor injuries (10%), abdominal pain (8%), and respiratory infections (8%). The diagnoses with the highest mean pain scores were: sickle cell crisis (mean pain score 8.7), back/neck/shoulder pain (8.5), and headache/migraine (8.3). Higher pain scores were significantly correlated with younger age (p < 0.001) and number of ED visits (p < 0.001). Demographic factors including female gender, African American race, and Medicaid insurance reported significantly higher pain scores (p < 0.001). Patients with multiple ED visits in the recent 12 months reported significantly higher pain scores (p < 0.001).

Conclusion

ED patients report a wide variety of pain scores. Factors associated with higher pain scores included younger age, female gender, African American race, Medicaid insurance status, multiple ED visits in the past year, and ED diagnoses of sickle cell crisis, back/neck/shoulder pain, and headache.     

Outcomes in Canadian Emergency Department Syncope Patients – Are We Doing a Good Job?

Background

Little is known about the outcomes of adults with syncope seen in Canadian Emergency Departments (EDs).

Objectives

We sought to determine the frequency, timing, and type of serious adverse outcomes occurring in these patients, and the proportion that occur outside the hospital.

Methods

We conducted a health records review of syncope patients presenting to a tertiary care ED over an 18-month period. We included all patients older than 16 years of age who fulfilled the syncope definition (sudden transient loss of consciousness with spontaneous complete recovery), and excluded those with altered mental status, alcohol or illicit drug use, seizure, or trauma. We assessed for outcomes in the ED and after ED disposition. We also evaluated follow-up arrangements for patients discharged from the ED.

Results

Of the total 87,508 patient visits, 505 (0.6%) were due to syncope. The mean age was 58.5 years (range 16–101 years), 70.1% arrived by ambulance, and 12.3% were admitted to the hospital. Five patients died: 2 in the ED, 1 as an inpatient, and 2 after discharge. Overall, there were 49 (9.7%) serious outcomes, with dysrhythmias being the most common (4.6%); 22 (4.4%) occurred in the ED, 15 (3.0%) in the hospital, and 12 (2.4%) outside the hospital. Eight serious outcomes occurred in patients discharged from the ED without any planned follow-up.

Conclusion

Although syncope represented < 1% of all patient visits, morbidity was substantial, particularly in patients discharged from the ED. Future research should help clinicians identify syncope patients at high risk for serious outcomes.     

ED use by older adults attempting suicide

Objective

The objective of this study was to describe patterns of older adult patient visits to emergency departments (EDs) for self-harm and suicide-related injuries.

Methods

A retrospective, secondary data analysis of the Nationwide Emergency Department Sample was conducted. Nationally representative estimates of patient visits by older adults attempting suicide were calculated using available sampling weights. Population estimates were calculated using estimates from the US Census Bureau.

Results

Findings suggest that 22 444 ED patient visits were made by adults aged 65 years and older for suicide-related injuries, representing an estimated population rate of 63 ED patient visits per 100 000 adults aged 65 years and older, with nearly half of all visits involving substance use. Total ED and hospital charges exceeded $353.9 million.

Conclusions

Effort is needed to better integrate and deliver suicide screening and support services in the ED, while also connecting at-risk older adults with mental health services before and after the ED encounter.     

Profiling Frequent Presenters to the Emergency Department for Mental Health Complaints: Socio-Demographic,Clinical, and Service Use Characteristics

Background

A small subset of individuals makes a disproportionate number of ED visits for mental health complaints.

Study Objectives

To explore the population profile and associated socio-demographic, clinical, and service use factors of individuals who make frequent visits (5 + annually) to hospital EDs for mental health complaints.

Methods

Case-control study using electronic health record data.

Results

Frequent presenters represented 3% of mental health ED patients and accounted for 18% of visits. Several factors were significantly associated with frequent ED use, including limited social support, documented personality disorder/traits, regular antipsychotic use, self-reported alcohol use, and having multiple referral sources.     

National differences between ED and ambulatory visits for suicidal ideation and attempts and depression

Background

Many suicidal and depressed patients are seen in emergency departments (EDs), whereas outpatient visits for depression remain high.

Study objective

The primary objective of the study is to determine a relationship between the incidence of suicidal and depressed patients presenting to EDs and the incidence of depressed patients presenting to outpatient clinics. The secondary objective is to analyze trends among suicidal patients.

Methods

The National Hospital Ambulatory Medical Care Survey and the National Ambulatory Medical Care Survey were screened to provide a sampling of ED and outpatient visits, respectively. Suicidal and depressed patients presenting to EDs were compared with depressed patients presenting to outpatient clinics. Subgroup analyses included age, sex, race/ethnicity, method of payment, regional variation, and urban verses rural distribution.

Results

Emergency department visits for depression (1.16% of visits in 2002) and suicide attempts (0.51% of visits in 2002) remained stable over the years. Office visits for depression decreased from 3.14% of visits in 2002 to 2.65% of visits in 2008. Non-Latino whites had a higher percentage of ED visits for depression and suicide attempt and office visits for depression than other groups. The percentage of ED visits for suicide attempt resulting in hospital admission decreased by 2.06% per year.

Conclusion

From 2002 to 2008, the percentage of outpatient visits for depression decreased, whereas ED visits for depression and suicide remained stable. When examined in the context of a decreasing prevalence of depression among adults, we conclude that an increasing percentage of the total patients with depression are being evaluated in the ED, vs outpatient clinics.     

Pediatric syncope: national hospital ambulatory medical care survey results

Background

Syncope is a common problem in children and adolescents. The diagnostic yield for most tests commonly used in the evaluation of pediatric patients with syncope is low.

Study Objective

To examine the epidemiology of pediatric patients presenting to United States (US) emergency departments (EDs) with a complaint of syncope and compare their initial management to published guidelines.

Methods

ED visits from the National Hospital Ambulatory Medical Care Survey for 2003–2007 for patients aged 7–18 years were analyzed. Outcome variables were diagnostic tests and management of patients presenting with syncope.

Results

There were 627,489 (95% confidence interval [CI] 527,237–727,722) ED visits for syncope (0.9% of all ED visits for patients aged 7–18 years). Patients presenting to the ED for syncope were more commonly female (p < 0.01), adolescent (13–18 years) (p < 0.01), covered by private insurance (p = 0.01), and more likely to arrive to the ED by ambulance (p < 0.01), compared to those presenting with other complaints. Only 58.1% (95% CI 50.3–66.0%) of syncope patients received an electrocardiogram, and 26.5% (95% CI 18.2–34.7%) received a computed tomography (CT) or magnetic resonance imaging (MRI) scan as part of their diagnostic work-up.

Conclusions

When evaluating pediatric patients presenting with syncope, there should be an increased use of the electrocardiogram to screen for underlying cardiac abnormalities. There should also be a tempered use of CT/ MRI imaging in this population.