Characteristics of Frequent Users of Emergency Departments

doi:10.1016/j.annemergmed.2005.12.030

Annals of Emergency Medicine

Volume 48, Issue 1, July 2006, Pages 1-8

https://doi.org/10.1016/j.annemergmed.2005.12.030 Get rights and content

Study objective

We identify frequent users of the emergency department (ED) and determine the characteristics of these patients.

Methods

Using the 2000 to 2001 population-based, nationally representative Community Tracking Study Household Survey, we determined the number of adults (aged 18 and older) making 1 to 7 or more ED visits and the number of visits for which they accounted. Based on the distribution of visits, we established a definition for frequent user of 4 or more visits. Multivariate analysis assessed the likelihood that individuals with specific characteristics used the ED more frequently.

Results

An estimated 45.2 million adults had 1 or more ED visits. Overall, 92% of adult users made 3 or fewer visits, accounting for 72% of all adult ED visits; the 8% of users with 4 or more visits were responsible for 28% of adult ED visits. Most frequent users had health insurance (84%) and a usual source of care (81%). Characteristics independently associated with frequent use included poor physical health (odds ratio [OR] 2.54; 95% confidence interval [CI] 2.08 to 3.10), poor mental health (OR 1.70; 95% CI 1.42 to 2.02), greater than or equal to 5 outpatient visits annually (OR 3.02; 95% CI 1.94 to 4.71), and family income below the poverty threshold (OR 2.36; 95% CI 1.70 to 3.28). Uninsured individuals were more likely to report frequent use, but this result was only marginally significant (OR 2.38; 95% CI 0.99 to 5.74). Individuals who lacked a usual source of care were actually less likely to be frequent users.

Conclusion

The majority of adults who use the ED frequently have insurance and a usual source of care but are more likely than less frequent users to be in poor health and require medical attention. Additional support systems and better access to alternative sites of care would have the benefit of improving the health of these individuals and may help to reduce ED use.

Introduction

Emergency department (ED) utilization has risen in recent years, with a 26% increase in the number of visits between 1993 and 2003.¹ In fact, the majority of EDs reported that they were at or over capacity for at least 50% of the time in 2003.² Frequent users of the ED are a much-studied group in the literature,3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 in part because of the presumption that they contribute substantially to ED crowding and that their use is inappropriate.

Most previous assessments of the contribution of frequent users to ED crowding are limited by the fact that they use patient data from 1 ED, making the results difficult to generalize. Additionally, ED-based studies are not as likely to have access to patient health information, such as their health status, usual source of care, and their use of other health care resources. Finally, there is no widely accepted definition of a frequent user. Definitions of frequent use range from as few as 3 visits annually to 12 or more visits annually, often without a clear rationale for the choice.4, 6, 7, 29, 30 Thus, it is difficult to compare or integrate the results of these studies.

Frequent use is often considered a major contributor to ED crowding. Solutions to crowding that target this group of ED visitors may require significant resources. Understanding the characteristics of frequent ED users and the impact of frequent use on total ED utilization is essential to ensuring that policies are successful in reducing ED crowding and in addressing the needs of these patients.

We studied a national, population-based data source to investigate frequent ED use. The goals of this study were to describe the frequency of visits among adults who report ED visits and to characterize frequent users.

Section snippets

Study Design

The Community Tracking Study Household Survey, conducted by the Center for Studying Health System Change, is designed to measure health care use and the characteristics associated with use, such as income, education, insurance, and health status.³¹ Data for the current analysis were collected from July 2000 through June 2001. Community Tracking Study estimates of population ED use, which are based on self-reported data, are similar to estimates from the hospital-based National Hospital

Results

An estimated 23% of US adults (45.2 million persons) reported at least 1 visit to the ED during the study period, for a total of 79.5 million visits. The percentage of adults who reported 1 to 7 or more annual ED visits and the proportion of total ED visits made by individuals with each level of use are shown in Figure 1. Overall, 92% of individuals made 3 or fewer visits and accounted for 72% of all adult ED visits. The 8% of users with 4 or more visits were responsible for 28% of visits.

Limitations

Similar to other survey data, our findings may be limited by recall bias and lack of response. However, the sampling and weighting methods of the Community Tracking Study were designed to include a nationally representative sample and to account for differences in the likelihood of selection and differential response rates. The study sample could also potentially underrepresent homeless persons, who might account for a disproportionate share of frequent ED visits.⁴¹ It is unlikely that our

Discussion

Most adults who use the ED frequently have insurance and a usual source of care but are more likely to be in poor health than other users. Adults who use the ED more frequently are also more likely to be poor, heavy users of other parts of the health care system, and dissatisfied with their medical care. Contrary to common perceptions, individuals who lack a usual source of care are actually less likely to be frequent users than those who have usual source of care. The absolute number of

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Supervising editor: Robert K. Knopp, MD

Author contributions: KAH, EJW, JAS, DCC, and MLC conceived the study, determined the theoretical model, and interpreted the results. EJW, JAS, and KAH designed the analyses. KAH and JAS provided statistical consultation; KAH programmed the data. KAH drafted the manuscript, with contributions from EJW and JAS. All authors contributed substantially to its revision. KAH takes responsibility for the paper as a whole.

The interpretations and opinions are those of the authors and may not necessarily reflect those of the Robert Wood Johnson Foundation or the University of California, San Francisco.

Funding and support: The authors report this study did not receive any outside funding or support.

Disclaimer: Michael Callaham, MD, recused himself from the editorial decision process for this article.

Reprints not available from the authors.

View full text

Health policy and clinical practice/original researchCharacteristics of Frequent Users of Emergency Departments

Study objective

Methods

Results

Conclusion

Introduction

Section snippets

Study Design

Results

Limitations

Discussion

National Hospital Ambulatory Medical Care Survey: 2003 emergency department summary: advance data from vital and health statistics, No 358

American Hospital Association Trendwatch Chartbook

Insured Americans Drive Surge in Emergency Department VisitsIssue Brief No. 70

Characteristics of occasional and frequent emergency department usersdo insurance coverage and access to care matter?

Med Care

Heavy users of an emergency departmenta two year follow-up study

Soc Sci Med

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

Ann Emerg Med

Frequent users of emergency departmentsdo they also use family physicians’ services?

Can Fam Phys

Repeat patients to the emergency department in a statewide database

Acad Emerg Med

The heaviest repeat users of an inner city emergency department are not general practice patients

Emerg Med

Frequent use of the hospital emergency department is indicative of high use of other health care services

Ann Emerg Med

Frequent attenders at Christchurch Hospital’s emergency department

N Z Med J

Factors associated with frequent users of emergency services in a medical center

J Formos Med Assoc

Factors associated with ED use by “repeater” and “nonrepeater” patients

J Emerg Nurs

Frequent attenders at Christchurch Hospital’s emergency departmenta 4-year study of attendance patterns

N Z Med J

Frequent ED userspatterns of use over time

Am J Emerg Med

An analysis of frequent users of emergency care at an urban university hospital

Ann Emerg Med

Epidemiological analysis of an urban, public emergency department’s frequent users

Acad Emerg Med

The effects of clinical case management on hospital service use among ED frequent users

Am J Emerg Med

Describing and predicting frequent users of an emergency department

J Assoc Acad Minor Phys

Repeated use of the emergency departmentqualitative study of the patient’s perspective

Emerg Med J Online

An attempt to influence health care visits of frequent hospital emergency facility users

Clin Pediatr

Frequent users of the emergency departmenta program to improve care and reduce visits

CMAJ

The chronic emergency department patient

Ann Emerg Med

High users of VA emergency room facilitiesare outpatients abusing the system or is the system abusing them?

Inquiry

Health policy and clinical practice/original research
Characteristics of Frequent Users of Emergency Departments