Most ED ‘Frequent Flyers’ Justified in Seeking Urgent Care

By: Sherry Boschert
Source: IMNG Medical News

DENVER – Frequent visitors to emergency departments come in mainly for valid reasons that usually are related to acute illness, mental illness, pain, or substance abuse, results of seven new studies show.

These so-called frequent flyers are a heterogeneous group of patients who typically are frequent users of emergency services for a year or less and have been mischaracterized as abusers of the health care system, speakers suggested in a press conference at the annual meeting of the American College of Emergency Physicians (ACEP).

Frequent flyers were significantly more likely than other emergency department visitors to be insured by Medicare or Medicaid; be chronically ill; have a pain diagnosis, mental illness, or substance abuse problem; and visit multiple hospitals for care. If admitted, they also were significantly more likely to be readmitted within 30 days, the studies found.

Better use of electronic health records, with information shared among hospitals in a region, could help identify frequent flyers so that individualized care plans might be created for each patient, reducing emergency department use, said Dr. Andrew Sama, president of ACEP. He is chairman of emergency medicine at North Shore University Hospital in New Hyde Park, N.Y., and Long Island Jewish Medical Center in Manhasset, N.Y., and chief of emergency medicine at Huntington (N.Y.) Hospital.

New federal policies that will reduce reimbursements to hospitals for patients readmitted within 30 days of discharge, implemented as of October 2012, amount to a blanket penalty for a nuanced problem and could end up harming some frequent flyers, said Dr. Robert E. O’Connor, professor and chair of emergency medicine at the University of Virginia, Charlottesville.

“While I think we could probably drive down the 30-day readmission rate through a variety of techniques that improve home health care, there’s going to be some irreducible percentage – it will never go to zero. I think that’s what these studies all say: There is a subsegment of the population that is not going to proceed in the usual manner of recovery from whatever illness they have, but will have complications that are unforeseen and unpreventable, and that’s when they end up back in the emergency department,” Dr. O’Connor said in an interview.

The studies included data from four states:

Virginia: Repeat users accounted for 20% of visitors and 40% of visits to Dr. O’Connor’s emergency department in a 6-month period. These patients were more likely than single-visit patients to be African American, indigent, and chronically ill, and to live close to the hospital and be covered by public insurance. Patients who made greater than nine visits were more likely to be on Medicare and to have psychiatric comorbidities.

Notably, the likelihood of admission was similar among single-visit patients, “low-repeat users” who made 2-3 visits, and “moderate-repeat users” who made 4-9 visits (14%-15% admitted from each subgroup). The admission rate was lower among the high-repeat users (10 or more visits), who were hospitalized 5% of the time. The lack of a significant difference in admission rates for all but the high-repeat users suggests that admissions were necessary and justifiable for low-repeat or moderate-repeat users, the investigators concluded.

High-repeat users who were admitted had significantly shorter stays than did non-repeat users (4 vs. 6 days). All repeat-user subgroups were significantly more likely to be readmitted within 30 days (26%-68%) compared with non-repeat users (7%), the retrospective study found.

Physicians should not assume that repeat users come in for the same problem on each visit, he cautioned. “If you start assuming that this is the same reason they came in last week, you will miss something at some point,” he said.

“My message to colleagues is to create individualized treatment plans for each frequent user. One of the investigators from Wisconsin told me that the extremely high users who were repeatedly admitted were 39 patients. You could come up with 39 treatment plans,” Dr. O’Connor said.

Better outpatient services for people with mental health, pain, or substance abuse problems also would help, such as increasing clinic hours to cover nights, weekends, and holidays, he added.

While that would be nice, it’s also an expensive strategy, Dr. Sama commented.

If health reform goes as planned and is successful, 38-40 million Americans without insurance will get coverage, which will increase emergency department use. If primary care coverage also expands for these patients as planned, “we may see a flattening or decrease in urgent visits,” Dr. Sama said in an interview.

He urged emergency physicians to develop comprehensive plans to identify frequent flyers “and then work with your organizations or community resources that are available to add social workers, care coordinators, and home care specialists to begin to focus on plans to do at-home, proactive, in-the-community assessments of these patients to lower the number of frequent users, which we hope will decrease hospital utilization, save money, and make the system better,” he said.

Wisconsin: Efforts to characterize frequent flyers have produced conflicting results because of great variance in this population. Amanda G. Polsinelli, a medical student at the University of Wisconsin, Madison, and her associates reviewed data on 779 patients who made emergency visits to their institution at least seven times in any year between 2008 and 2011. They differentiated frequent flyers (who were admitted less than 10% of the time) from “hot spotters” (who were admitted more than 50% of the time).

Most of the 779 patients were frequent users of the emergency department for 1 year only (77%), and 5% were frequent visitors in each of the 4 years of the study. Frequent flyers were younger (mean age, 38 years) and accounted for only 2% of admissions among all patients in the study; hot spotters (mean age, 48 years) accounted for 60% of admissions. Frequent flyers had a lower triage acuity and stayed in the hospital for 3 days on average, compared with 4 days for hot spotters.

Strategies for addressing frequent emergency department users should accommodate differences in these subgroups to be most effective, the investigators suggested.

California: Four studies were done by investigators with the University of California (UC), San Diego. The studies retrospectively analyzed data on 925,719 patients seen in more than 2 million emergency department visits between 2008 and 2010 in all 18 nonmilitary acute-care hospitals in the San Diego region. The data were drawn from the California Office of Statewide Health Planning and Development.

The 97% of patients who were “occasional users” (defined as one to five visits to emergency departments in 12 consecutive months) accounted for 79% of all visits. The 3% of patients who were “frequent users” (6-20 visits in 12 months) were seen in 16% of visits, and the less than 1% of patients who were “superusers” (more than 20 visits in a year) made up 5% of emergency department visits, Edward M. Castillo, Ph.D., and associates reported.

As a whole, the subgroups of frequent users accounted for a large and disproportionate share of emergency visits, reported Dr. Castillo of UC San Diego.

Respiratory and abdominal symptoms were the leading problems in each subgroup. The superusers were more likely to have Medi-Cal (California’s Medicaid program) (35%) compared with occasional users (18%) and frequent users (29%); they also were more likely to be self-paying patients (22%) compared with occasional or frequent users (14% each).

Patients with a “pain diagnosis” were 14 times more likely to be frequent users compared with occasional users. Patients with heart failure were seven times more likely to be frequent users, and patients on Medicare or Medi-Cal were five times more likely to be frequent users compared with occasional users.

A separate analysis of the data by Dr. Gary M. Vilke, professor of clinical medicine at UC San Diego, and his associates found that 8% of patients had at least four visits to emergency departments, accounting for 34% of all visits. Among these frequent users, 59% came for reasons unrelated to pain, 36% occasionally visited emergency departments due to pain, and 6% frequently gave pain as the reason for the visit.

Pain-related visits were defined as those with a primary diagnosis of pain, migraine, abdominal symptoms, head and neck symptoms, and other disorders of the back.

The “frequent-pain” users were younger, less likely to be admitted, and more likely to have a mental disorder and be dependent on or abusing drugs or alcohol compared with “non-pain” users and “occasional-pain” users. A total of 24% of frequent-pain users visited more than five hospitals during the study period, compared with 2% of non-pain users and 4% of occasional-pain users.

A third analysis of the data by Jesse J. Brennan and his associates revealed that, among patients with more than four emergency visits in 12 months, 81% were seen for nonpsychiatric reasons, 16% came in occasionally for psychiatric-related reasons, and 3% visited frequently for psychiatric reasons. “Frequent psychiatric users” were younger, more often male, and more likely to be admitted to an inpatient service and to leave against medical advice compared with nonpsychiatric or occasional-psychiatric users, according to Mr. Brennan, who is a statistician at UC San Diego, and his colleagues. Both occasional-psychiatric and frequent-psychiatric users were significantly more likely to visit more than five hospitals (8% and 27%, respectively) compared with nonpsychiatric users (2%). The difference between occasional- and frequent-psychiatric users also was statistically significant.

The fourth California analysis defined frequent users as patients who visited emergency departments 6-20 times during 12 consecutive months and superusers as those making at least 21 visits. Seventy percent of frequent users and 97% of superusers were seen in multiple hospitals. If individual hospitals used only their own data, they would fail to identify 33% of 28,569 frequent users and 66% of 1,661 superusers compared with using community-wide shared data to identify patients, the investigators calculated.

Part of the aim of the UC San Diego studies is to develop a regional system for identifying frequent users, Dr. Castillo said.

Dr. O’Connor noted that such a system would be valued in Virginia. “If we could have access to simple things – medications, diagnoses, and imaging studies that were done elsewhere – it would be much more efficient. We could save a ton of money and resources,” he said.

Massachusetts: Investigators at Massachusetts General Hospital and Beth Israel Deaconess Medical Center, both in Boston, hypothesized that frequent emergency department users would be more likely to visit due to nonemergent conditions that might be amenable to timely primary care, but their review of 65,149 patients who made emergency visits in 2010 could not clearly support that supposition.

Analysis showed that 2% of the patients were frequent visitors (making at least five visits), accounting for 12% of 91,198 visits. Frequent visitors were more likely to be older men insured by Medicare, Medicaid, and/or welfare compared with non-frequent users, S.W. Liu and associates reported.

Fewer visits by frequent users were classified as nonemergent compared with visits by non-frequent users (20% vs. 22%), but there were no significant differences between subgroups in diagnoses that might be addressed in a primary care setting.

After controlling for the effects of other factors, frequent users were 10% less likely to be admitted compared with non-frequent users, 39% more likely to come to the emergency department for a reason related to mental health, twice as likely to visit for reasons related to drugs, and four times as likely to visit for reasons related to alcohol.

General, nontargeted approaches to reducing frequent visits to emergency departments may not be productive, they concluded, and strategies that focus on managing mental health and substance abuse might be more helpful.

Dr. Sama, Dr. O’Connor, and Dr. Castilla reported having no financial disclosures. Disclosures for the other investigators were not available.

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