Fragmented systems create challenges for medical, social, and psychological needs
Working in any emergency department (ED), over time clinicians will notice some familiar faces. These patients, characterized as frequent emergency department users (FEDUs), have more than 5 visits per year, and the implications of their frequent visits can be significant. While FEDUs are a small portion of all ED users (4%-16%), they account for up to half of total ED visits, contributing to crowding and health care costs. Previous work has characterized FEDUs as patients from lower socioeconomic and educational level who are often sicker with complex comorbidities. But for FEDUs using multiple sites, are there other factors driving this?
A recent study addressed this question, with aims to determine how many frequent ED users seek care at multiple sites (> 3 sites per year) and to identify the associated social, clinical, and contextual factors. The study used Health Cost and Utilization Project data from 2011 – 2014 for all outpatient ED visits in New York, Massachusetts, and Florida.
The study found that across all 3 states, 1,033,626 FEDUs accounted for more than 7 million visits. Nearly one-quarter of all FEDUs were also multisite users, accounting for 30% of the overall ED visits. Moreover, multisite frequent users were more likely to have diagnoses related to mental health and substance abuse than single site frequent users. Thus, this correlation highlights that in order to mitigate multisite ED use, there is a need for the implementation of integrated mental health and substance abuse treatment programs across health systems targeting high utilizers, expanding beyond the scope of a single emergency department. Policies must address the lack of cohesive infrastructure leading to high utilization by multi-site FEDUs, since a fragmented health care system creates challenges in addressing the medical, social, and psychological needs of frequent utilizers.
As we witness our health system's shortcomings through the lens of the COVID-19 pandemic, let us acknowledge the need for supportive community infrastructure for FEDUs. Positioned at the frontline of the medical system, advocacy by emergency physicians for community wide approaches to coordinated mental health and substance abuse counseling and support, as well as chronic disease prevention and treatment, is paramount in order to influence the systems impacting our most frequent visitors.
Abstract: Giannouchos TV, Washburn DJ, Kum HC, Sage WM, Ohsfeldt RL. Predictors of Multiple Emergency Department Utilization Among Frequent Emergency Department Users in 3 States. Med Care. 2020;58(2):137-145.
Objective: The objective of this study was to determine how many frequent ED users seek care at multiple EDs and to identify sociodemographic, clinical, and contextual factors associated with such behavior.
Research design: We used the 2011-2014 Healthcare Cost and Utilization Project State Emergency Department Databases data on all outpatient ED visits in New York, Massachusetts, and Florida. We studied all adult ED users with ≥5 visits in a year and defined multisite use as visits to ≥3 different sites. We estimated predictors of multisite use with multivariate logistic regressions.
Results: Across all 3 states, 1,033,626 frequent users accounted for 7,613,077 ED visits. Of frequent users, 25% were multisite users, accounting for 30% of the visits studied. Frequent users with at least 1 visit for mental health or substance use-related diagnosis were more likely to use multiple sites. Uninsured frequent users and those with public insurance were associated with less use of multiple EDs than those with private coverage while lacking consistent coverage by the same insurance within each year were associated with using multiple sites.
Conclusions: Health policy interventions to reduce duplicative or unnecessary ED use should apply a population health perspective and engage multiple hospitals. Community-level preventive approaches and a stronger infrastructure for mental health and substance use are essential to mitigate multisite ED use.
EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA
As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems. As EM residents and fellows, we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill. Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.