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