Frequent flyers not seen as abusing emergency departments
■ Studies in four states conclude that most heavy users are coming in for urgent conditions.
Studies on emergency department patients in different parts of the country challenge the long-time misconception that so-called frequent flyers — those who regularly end up in EDs — are abusing their access to emergency care. Instead, a high proportion of these patients have chronic conditions and mental disorders and go to the ED because they don’t have another readily accessible source of care.
Frequent users represent a small percentage of all ED patients but a disproportionate share of visits, said Robert O’Connor, MD, MPH. He’s a co-author of one of seven study abstracts on frequent ED use that were released Oct. 9 at the American College of Emergency Physicians’ scientific meeting in Denver. Four of the studies originated in San Diego, and the remaining came from Massachusetts, Virginia and Wisconsin. The abstracts appeared in the October issue of Annals of Emergency Medicine.
In one of the California studies, which drew data from 18 acute care hospitals in the San Diego area in 2008-10, frequent users accounted for 3.1% of patients but 16.5% of visits to the emergency department, said Dr. O’Connor, who co-wrote the Virginia study. He’s a professor and chair of the Dept. of Emergency Medicine at the University of Virginia School of Medicine and a member of ACEP’s board of directors.
The definition of a frequent ED user can vary, according to ACEP. It could be a patient who visits more than seven times in a year or someone who seeks emergency care at least four times a year. Many of these patients are characterized by complicated medical problems and mental illnesses. They often live near a hospital, and although they tend to fall into low-income brackets, “most frequent users are insured by Medicare and Medicaid. They’re not necessarily uninsured,” Dr. O’Connor said.
Frequent users also are a heterogeneous group, and they don’t just represent one type of patient with one type of symptom, said ACEP President Andrew Sama, MD, during a teleconference. He’s the chair of the Dept. of Emergency Medicine at North Shore University Hospital in Manhasset, N.Y.
In an interview, Dr. O’Connor stressed that these types of patients appear to be coming in for real emergencies and are not just using the ED for nonemergent primary care issues. The Massachusetts study, for example, found more concrete examples of frequent users seeking ED treatment for urgent mental health, drug, and alcohol-related issues as opposed to primary care-treatable problems.
It’s also a common assumption that frequent users visit because of social issues, such as homelessness and other nonmedical problems. Yet the research found that a high proportion of these patients have recurrent medical issues, Dr. O’Connor said.
Social factors can contribute to why these patients end up in the ED, said Susan Mende, MPH, BSN, senior program officer with the Robert Wood Johnson Foundation. A diabetic patient who comes to the ED in a diabetic coma because he or she is not getting adequate, ongoing care may not have a house in which to draw insulin safely, or “might have tumultuous home conditions that don’t support managing diabetes,” she said. “So sometimes emergent medical problems are the tip of the iceberg.”
This underscores the importance of developing models that integrate medical care of the patient with social services he or she needs, Mende said. “It might mean looking at their housing situations, or getting them adequate transportation so they can actually make it to their medical appointments, or hooking them up with sources of food, or getting them into ongoing mental health services or substance abuse services,” she said.
Authors of the Massachusetts study suggested that policies on frequent ED users should try to focus on managing substance abuse and mental health problems.
The seven studies yielded varied results on whether these patients had greater-than-average hospital admission rates. In the Virginia study, which focused on one emergency department, high repeat users had a greater chance of being readmitted after 30 days.
Frequent ED utilization often is associated with higher rates of 30-day hospital readmissions. Under an Affordable Care Act provision that began in October, Medicare will start penalizing hospitals for excessive readmission rates, a measure that some hospital advocates view as unfair treatment of those facilities that take care of a large proportion of severely ill patients.
Nancy Foster, vice president of quality and patient safety policy with the American Hospital Assn., said the AHA is concerned that the current readmissions payment program “may unduly punish those hospitals who are doing the right thing serving this sicker population of patients.” The AHA has been urging the federal government and Congress “to review their policies to ensure that they do not have unintended consequences for these patients,” Foster said.
Making sure that hospitals don’t get penalized means physicians and other health care professionals must work together to try to manage frequent ED users better and keep them out of the hospital, Dr. Sama said.