Characteristics of Frequent Users of Three Hospital Emergency Departments
Discussion and Implications
The emergency department (ED) is an important and frequently used care setting. In 2014, more than 137 million ED visits took place in the United States.1 A sizable minority of patients returns to the ED frequently and accounts for a disproportionately large share of overall visits and costs. Published studies estimate that between 4.5 percent and 8 percent of patients revisit the ED four or more times per year and account for 21 percent to 28 percent of all ED visits.2-6
Nonurgent revisits are associated with overcrowding, unnecessary delays in care, dissatisfaction, and avoidable patient harm.7-9 Since the ED is also an expensive place to receive care, ED revisits can be an important contributor to high health care costs. It has been estimated that ED care costs two to five times as much as the same treatment delivered by a primary care physician. Eliminating revisits and inappropriate ED use could reduce health care spending by as much as $32 billion each year.3-5,10
In 2013, the Agency for Healthcare Research and Quality (AHRQ) funded an ACTION II field-based research project, led by a team from Johns Hopkins University (JHU), to learn more on the specific vulnerabilities of patients at highest risk of frequent ED use and how they might be addressed during their ED visit. This research brief summarizes findings from this study.
The ultimate goal of this study was to identify the factors that drive patients’ frequent ED use in order to better address their needs through ED-based interventions. More specifically, JHU researchers sought to develop and test a tool to identify frequent ED users whose needs could be addressed through hospital-based interventions. To this end, the JHU team began by conducting an environmental scan of the literature, which pointed to a host of medical problems and social factors as predicting high ED use.
From the factors identified in the scan, the JHU team selected six “modifiable” factors associated with high ED use. Modifiable risk factors were those the research team judged could be alleviated or addressed through hospital-based interventions. The six selected factors were:
- Lack of insurance;
- Lack of primary care physician;
- Psychiatric illness;
- Substance abuse;
- Cognitive/physical impairment; and
- Difficulty understanding discharge instructions.
The team then developed a Screening Checklist that could be used to quickly, efficiently, and systematically identify patients with one or more of these risk factors. They also created a sample User's Guide listing interventions targeting the risk factors.i
Between July 1, 2014, and February 20, 2015, the JHU research team identified 386 patients from across three hospital EDs who, based on their medical records, met at least one of the criteria for frequent ED use described in the literature. These criteria were:
- Four or more prior visits in the previous 12 months OR
- Three or more prior visits in the previous 3 months OR
- One or more prior visit in the previous 72 hours.
These identified “high-risk patients” were then screened by a research assistant using the Screening Checklist. Screening for the first five risk factors was achieved through a combination of patient interviews and review of the patients’ medical records. The sixth risk factor, difficulty understanding discharge instructions, was assessed during a followup phone call after discharge.
In addition to the information required for completion of the Screening Checklist, the research team extracted information from the patients' medical records, including past diagnoses of any of five chronic conditions (asthma, coronary artery disease, diabetes, heart failure, high blood pressure).
Complete Report of Test Results available upon request by contacting email@example.com.
Frequent ED users across the three EDs in the study had the following characteristicsii:
- Just under half (44%) of patients had none of the six risk factors included in the screening.
- Only 6.7 percent did not have insurance.
- Close to 10 percent (9.1%) had a history or current chief complaint of substance abuse.
- Only 14.3 percent did not have a primary care provider.
- About one-third (33%) had a history of schizophrenia, bipolar disease, or psychosis.
- Nearly 40 percent (39.6%) did not understand which symptoms would signal a possible need to seek prompt medical advice.
- Nearly half (48.7%) reported taking four or more medicines.
- More than half (56%) did not understand their discharge instructions.
Discussion and Implications
Overall, findings from this limited study indicate that patient characteristics and associated risk factors included in the checklist play a less significant role in driving ED revisits than was initially expected based on the environmental scan. Close to half (44%) of the screened patients had none of the six risk factors included in the screening. Equally notable were the surprisingly low percentages of patients who lacked insurance or a primary care provider (6.7% and 14.3%, respectively). The percentage of patients with a history or chief complaint of substance abuse was also lower than might have been expected (9.1%).
The finding that such a large percentage had none of the selected risk factors likely resulted, at least in part, from the decision to screen only for risk factors that could be mitigated or modified during the ED stay. Other, nonmodifiable risk factors cited in the literature may be expected to drive a greater percentage of revisits than those assessed by the checklist. In fact, 87 percent of the study population had at least one chronic condition, a risk factor not included in the checklist because it was not modifiable from within the ED.
Further implications of these study findings that merit consideration include:
- Having a primary care provider (PCP) is not sufficient to deter frequent ED use by high-risk patients. Lack of a primary care provider is apparently a flawed proxy for the challenge of lack of access that it was expected to reflect. Based on interviews with the enrolled patients and analysis of their responses to open-ended questions about barriers to care , other explanations for ED use primarily related to greater convenience and accessibility of ED care (e.g., limited office hours of primary care providers). These are not challenges that can be addressed from or by the ED.
- Expanding insurance coverage by itself is not likely to have a large impact on frequent ED use. More than 90 percent of frequent ED users in the study had some level of insurance coverage. This finding suggests there are other more likely drivers of ED use, including issues associated with adequacy of coverage (e.g., high copays, limitations of coverage), as well as anticipated long waits for specialists or diagnostic tests and frequent changes in patients' insurance status.
- Attention to lack of patient comprehension of discharge instructions could have real value. Difficulty understanding discharge instructions was the risk factor included in the checklist that characterized most (56%) of the screened patients. The need to improve patient comprehension in all settings is well documented and there have been many efforts to meet this challenge in hospitals, including some funded by AHRQ.iii
The fast-paced nature of the ED exacerbates the challenge of ensuring comprehension of discharge instructions. But with nearly 40 percent of frequent ED users failing to understand worrisome symptoms that would signal a possible need to seek further medical advice, action is clearly needed. Possible interventions include communication training for ED staff, particularly in the teach-back methodiv of confirming patient understanding, and conducting postvisit followup phone calls.v
All told, the most important implication of the study may be that a sizable portion of ED revisits may be driven by factors that cannot be readily addressed from or by EDs themselves. Significant reductions in frequent ED use are instead likely to require strategies beyond the scope or capacity of individual EDs to undertake. The large portion of the study population who had one or more chronic conditions is consistent with the literature. It points to the well-recognized fragmentation of the medical system whereby complex patients without ready access to medical services and continuous and coordinated oversight of their conditions deteriorate and end up in the ED.
While some better resourced hospitals with strong links to community providers may be in a position to link patients with available services, in most cases the level of care coordination required will exceed what any ED can reasonably be expected to offer. Findings from the Community-based Care Transitions Program may be able to provide information on the types of resources required to meet the needs of these complex, high-burden patients.vi
In other words, ultimately, effective solutions to the problem of excessive hospital revisits will have to emerge from coordinated, system-level efforts that include, but are not housed within or principally overseen by, the ED. These might range from limited efforts to create more accessible care options (e.g., non-ED-based after-hours care) to broad-based efforts aimed at providing complex patients with resources and education to help them navigate the health care system and more actively engage in managing their conditions.
More widespread adoption of the Chronic Care Model,11 which delivers proactive, planned care to engaged patients in the context of a health care system linked to the community, would represent an especially important focus for such efforts. Perhaps today's more competitive health care environment will provide a much needed further impetus for this type of collaborative, system-level change.
- Introduction to the HCUP Nationwide Emergency Department Sample (NEDS) 2014. Rockville, MD: Agency for Healthcare Research and Quality; December 2016. Accessed June 26, 2017.
- Cook LJ, Knight S, Junkins EP Jr, et al. Repeat patients to the emergency department in a statewide database. Acad Emerg Med 2004;11(3):256-63.
- Fuda KK, Immekus R. Frequent users of Massachusetts emergency departments: a statewide analysis. Ann Emerg Med. 2006;48(1):9-16.
- Hunt KA, Weber EJ, Showstack JA, et al. Characteristics of frequent users of emergency departments. Ann Emerg Med. 2006;48(1):1-8.
- Riggs JE, Davis SM, Hobbs GR, et al. Association between early returns and frequent ED visits at a rural academic medical center. Am J Emerg Med. 2003;21(1):30-1.
- Lucas RH, Sanford SM. An analysis of frequent users of emergency care at an urban university hospital. Ann Emerg Med 1998;32(5):563-8.
- Mandelberg JH, Kuhn RE, Kohn MA. Epidemiologic analysis of an urban, public emergency department's frequent users. Acad Emerg Med 2000;7(6):637-46.
- Milbrett P, Halm M. Characteristics and predictors of frequent utilization of emergency services. J Emerg Nurs 2009;35(3):191-8; quiz 273.
- Li G, Lau JT, McCarthy ML, et al. Emergency department utilization in the United States and Ontario, Canada. Acad Emerg Med 2007;14(6):582-4.
- Hazlett SB, McCarthy ML, Londner MS, et al. Epidemiology of adult psychiatric visits to US emergency departments. Acad Emerg Med 2004;11(2):193-5.
- Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002;288(14):1775-9.
ED Discharge High-Risk Screening Checklist
|___| Frequent ED User (FEDU)
(not including scheduled revisits [e.g., for wound check, suture removal])
Check all that apply if the patient meets the Frequent ED User criteria above.
|___| Uninsured (obtain from medical record)
- Self-pay or uninsured status identified in the medical record
- Confirmed with patient
|___| Lack of Primary Care Physician
- No named primary care physician or clinic in the medical record
- Confirmed with patient
|___| Psychiatric Disease (obtain from medical record)
- Past medical history of: schizophrenia, bipolar disorder, psychosis
- Current chief complaint involving: homicidal ideation, suicidal ideation
|___| Substance Dependence (obtain from medical record)
- Past medical history of: alcohol dependence, narcotic dependence
- Current chief complaint involving: acute alcohol intoxication, alcohol withdrawal, narcotic overdose
|___| Difficulties in Self-Care [physical impairment, cognitive impairment, complexity of medical condition]
- Refer to physical/cognitive impairment tool (next page).
|___| Patient-perceived barriers to receiving medical care
- Ask the patient the following question: “What kind of challenges do you experience in getting medical care?”
- Refer to possible barriers to receiving medical care (next page).
Possible Barriers to Receiving Medical Care
Physical/Cognitive Impairment Tool*
|1. In general, do you have trouble seeing well?|||___| Yes|||___| No|
|2. In general, do you have serious problems with your memory?|||___| Yes|||___| No|
|3. Do you use walking aids or need assistance when walking or transferring (getting up and down from a chair or bed)?|||___| Yes|||___| No|
|4. Do you take four or more (>4) prescription medications? (see medication list)|||___| Yes|||___| No|
* Patients screen positive if they have two or more of any of these conditions.
i The User's Guide is available upon request from firstname.lastname@example.org. Proposed interventions included: assistance with or guidance about insurance options; referrals to primary care providers, psychiatrists, or mental health or substance abuse detox or rehabilitation clinics; provision of a medication voucher; transportation assistance; additional case-management services; and followup phone calls.
ii The additional study finding that the hospital that had the highest rate of patients visiting the ED four or more times per year had the lowest rate of uninsured patients further indicates that uninsured patients do not necessarily use ED services more frequently than insured patients.
iii The Re-Engineered Discharge Toolkit and the Project BOOST Implementation Toolkit were based on research conducted under AHRQ grants. Go to Preventing Avoidable Readmissions. Also go to TeamSTEPPS LEP Module and the Guide to Patient and Family Engagement in Hospital Quality and Safety Strategy 4: Care Transitions From Hospital to Home: IDEAL Discharge Planning.
iv Go to Tool 5: Use the Teach-Back Method in the AHRQ Health Literacy Universal Precautions Toolkit.
v Go to Tool 5: How To Conduct a Postdischarge Followup Phone Call in the Re-Engineered (RED) Toolkit.
vi Go to Community-based Care Transitions Program.