Frequent flyers not seen as abusing emergency departments

Studies in four states conclude that most heavy users are coming in for urgent conditions.

By — Posted Oct. 22, 2012

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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.

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$2 million grant to fund study of ED super-users

A new initiative by the Robert Wood Johnson Foundation is seeking to find out who the “super-utilizers” of emergency departments are, determine how to stabilize them and then transition them back into a primary care setting.

The foundation recently awarded $2.1 million in grants, including $200,000 each to six quality improvement alliances that are a part of its Aligning Forces for Quality Initiative, to seek solutions related to ED overuse. Frequent users, or super-utilizers, make up a population “that has been relatively unstudied,” said Henry White, MD. He’s the clinical director of the Brookline Community Mental Health Center, a partner in the quality initiative in Massachusetts that will be using its grant to scale up a pilot project that Brookline has spearheaded for several years. The pilot has shown initial success in transitioning frequent ED users to more stable primary care environments.

The remaining $900,000 in foundation grant money is going toward the New Jersey-based Camden Coalition of Healthcare Providers, a strategic initiative that develops models of integrated care for these types of patients, said Susan Mende, MPH, BSN, senior program officer with the Robert Wood Johnson Foundation. The coalition will provide technical support and work directly with each of the six alliances to help them design their own super-utilizer models. In addition, it will develop a resource guide based on its experience working with the alliances and on other efforts, Mende said.

Grant recipients of this new initiative will tailor their approaches to address super-utilizers within their communities, Mende said. Some communities, for example, will be setting up a team in the ED itself. When super-utilizers are identified, the team will start to work with them directly and provide a different path of care for them, she said.

ED super-utilizers, many of whom have both chronic physical and mental illnesses, “are seen through the lens of the emergency department where they come and go, but understanding what goes on in between emergency department visits and when they fall off that particular radar is really an unknown quantity,” Dr. White said. “These are the 1% of patients who result in 18% of visits. It’s a relatively small number but extraordinarily costly.”

Part of Brookline’s “Healthy Lives” pilot strategy has been to identify a patient’s problem and then connect him or her to appropriate primary care resources, “often serving as a translator between the patient and primary care,” Dr. White said. In one case involving a woman with a chronic, severe connective tissue disease and a personality disorder, an important intervention was to re-establish her primary care setting and settle conflicts with her caregivers so she could obtain needed outpatient care and avoid further hospitalizations. The patient has been in the program for six months and since has been a stable outpatient, Dr. White said.

The pilot initially started with about 25 patients in Brookline. With the foundation’s grant money, the pilot will be applied in a much larger setting, serving the urban population of Beth Israel Deaconess Medical Center in Boston.

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External links

“ ‘Frequent Users’ of the ER — NOT Abusers of the System,” ACEP Tele-News Conference: 2012 Scientific Assembly (link)

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