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A Comparison of Frequent and Infrequent Visitors to an Urban Emergency Department
The Journal of Emergency Medicine, Vol. 38, No. 2, pp. 115–121, 2010 Copyright © 2010 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/08 $–see front matter
doi:10.1016/j.jemermed.2007.09.042
Original Contributions
A COMPARISON OF FREQUENT AND INFREQUENT VISITORS TO AN URBAN EMERGENCY DEPARTMENT Elizabeth Sandoval, BA,* Sandy Smith, PHD,† James Walter, MD,‡ Sarah-Anne Henning Schuman, MD,† Mary Pat Olson, RN, MSPH,§ Rebecca Striefler, LCSW,储 Stephen Brown, MSW,¶ and John Hickner, MD, MSC† *University of Chicago, Chicago, Illinois, †Department of Family Medicine and ‡Section of Emergency Medicine, Department of Medicine, University of Chicago, Chicago, Illinois, §Metropolitan Chicago Healthcare Council, Chicago, Illinois, 储American Red Cross of Greater Chicago, Chicago, Illinois, and ¶University of Chicago Medical Center, Chicago, Illinois Reprint Address: John Hickner, MD, MSC, Department of Family Medicine, The University of Chicago Pritzker School of Medicine, 5841 S. Maryland Ave., MC7110 Room M-160, Chicago, IL 60637
much more likely to screen positive for depression (47% vs. 27%, respectively, p ⴝ 0.017). Frequent visitors were more likely to have a primary care physician (75% vs. 66%, respectively), and 45% of the frequent visitors had a primary care physician at the ED hospital compared to 23% of the infrequent visitors. These findings suggest the need to improve access to frequent visitors’ primary care physicians, screen them for depression, and offer psychological and social services more aggressively. These findings may apply to other inner city EDs. © 2010 Elsevier Inc.
e Abstract—Frequent visitors account for a high proportion of Emergency Department (ED) visits and costs. Some of these visits could be handled effectively in less expensive primary care settings. Effective interventions to redirect these patients to primary care depend on an in-depth understanding of frequent visitors and the reasons they seek care in the ED. The objective of this study was to explore the differences between frequent visitors and infrequent visitors who seek medical care in one urban ED, as a first step toward developing effective interventions to direct patients to effective sources of care. In structured interviews, we asked 69 frequent visitors and 99 infrequent visitors to an inner-city, adult ED about medical diagnoses, general health, depression, alcohol abuse, physical functioning, selfperceived social support, primary care and ED service use, payment method, satisfaction with their primary care physician, and demographic characteristics. Differences in responses between groups were compared using t-tests for continuous variables and chi-square for categorical variables. Frequent visitors were more likely than infrequent visitors to be insured by Medicaid (53% vs. 39%, respectively) and less likely to be uninsured (13% vs. 24%, respectively) or have private insurance (6% vs. 15%, respectively). They reported higher levels of stress, lower levels of social support, and worse general health status. They were
e Keywords—access; primary care; Emergency Department utilization
INTRODUCTION Frequent visitors to Emergency Departments (EDs) are responsible for a large proportion of ED visits. Studies that define a frequent visitor as a patient who makes a minimum of four visits in the prior year have found that 4% of ED patients are responsible for 20 –30% of annual visits (1– 4). A study that defined a frequent ED patient as one with at least three ED visits in the prior year found that frequent visitors accounted for 73% of visits (5). Frequent visitors contribute to long waiting times for more seriously ill patients and higher economic costs for hospitals (2,6 –10). Although frequent visitors have their
This study was supported in part by a Healthy Community Access Program grant from the Bureau of Primary Health Care of the Health Resources and Services Administration.
RECEIVED: 29 November 2006; FINAL ACCEPTED: 12 September 2007
SUBMISSION RECEIVED:
10 September 2007;
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share of serious medical problems, the medical complaints of frequent visitors can often be managed effectively in a primary care setting (11,12). Frequent ED visitors are also at risk of receiving inadequate care due to insufficient attention to prevention, and by having their medical problem diagnosed differently by multiple doctors (10,13,14). To improve their quality of care, it is essential to obtain a detailed understanding of the reasons why frequent visitors continually seek medical care at the ED and then to formulate a strategy that will address their specific needs. Several studies have compared frequent visitors to control groups of non-frequent visitors to the ED (1,4,12,15–21). Frequent visitors experienced more accidents and health problems and self-reported a low health status (16). They are more likely to visit the ED for alcohol abuse and for exacerbations of chronic conditions or existing illnesses (1,4,15). They experience more psychosocial problems and have poorer mental health (15,18). A record of frequent ED use is indicative of future frequent ED visits and increased use of public services such as psychiatric and social services (17,19). Frequent visitors are more likely to have a usual source of medical care other than the ED, be AfricanAmerican, and be uninsured or have Medicaid or Medicare coverage (4,12,15,18,20). Other studies of frequent visitors, however, described only frequent visitors with no control group of infrequent visitors to allow one to distinguish unique characteristics of frequent visitors (2,3,5–11,13,14,22–24,26 –30). The goal of this study was to describe differences between frequent visitors and infrequent visitors at an inner-city, adult ED as an initial step in developing interventions to reduce inappropriate frequent utilization of ED services.
Patient Recruitment The patients surveyed were adults at least 18 years of age. Patients were approached between 8:00 a.m. and 11:00 p.m. Patients who were severely ill, unable to speak English, unable to communicate, or actively intoxicated were excluded. Intoxicated patients were approached once they were sober. By reviewing the ED Tracker, a computerized system used to monitor patient activity; social workers and the research assistant identified whether or not patients were frequent visitors and documented identification information such as medical history number, patient ID, and the patient’s number of UCMC-ED visits in the past year. They approached eligible patients in the triage area, the waiting room, and in examination cubicles as the patients waited to be seen by a physician. If the patient gave informed consent, the researcher read the interview questions along with or to the patient and wrote down the answers. If a patient declined, the research assistant and social workers continued in consecutive order down the ED Tracker to find another patient and repeated the process until a patient agreed to participate. Every frequent visitor in the ED during the times when the research assistant was present was asked to participate in the survey. Thus, a systematic sample of frequent visitors was recruited during the times the research assistant was in the ED. To recruit the control group of infrequent visitors, the researchers used a similar approach. They identified patients who did not qualify as a frequent visitor by reviewing the ED tracker system, approached those who were available to participate in the study, and interviewed those willing to participate in the study.
The Survey METHODS Study Design and Setting This was a cross-sectional comparison of frequent visitors and infrequent visitors at the adult, inner-city ED of the University of Chicago Medical Center (UCMC-ED). We defined frequent visitors as patients having at least three visits to the UCMC-ED in the prior 12 months. At the time of the study, 49,000 patients were seen in the ED per year; 7% were frequent visitors, and they accounted for 30% of the total ED visits. ED patients were asked to participate in this study on a volunteer basis by completing a questionnaire. The questionnaire was administered by a research assistant or social worker and took approximately 10 –15 min to complete. The study took place in July–September of 2005.
The survey was created mainly using previously validated scales, including the General Health Questionnaire, a two-question depression screener, a single-question alcohol screening tool, a stress management scale, and a short version of the Multidimensional Scale of Perceived Social Support (31–35). The General Health Questionnaire provides self-reports of patients’ overall health, bodily pain, and social limitations of health using 5-point Likert-type scales. The depression screening tool comprises two items with Yes/No responses about the experience of negative or flat affect within the last month. The stress management scale recorded levels of stress within the last month with a 5-point Likert-type scale where a higher score indicated a higher level of stress. To reduce the length of the survey, we used only 6 of the 12 questions from the Multidimensional Scale of Perceived Social Support. We used the two questions from each of
Comparison of Frequent and Infrequent ED Visitors
the three domains of social support (family, friends, and significant other) that had the highest correlations with the three factors, as reported by the authors (35). These included questions such as “I get the emotional support I need from my family,” “I can talk about my problems with my friends,” and “I have a special person in my life who cares about my feelings.” Responses were recorded on a 7-point Likert scale where 1 ⫽ Very strongly disagree and 7 ⫽ Very strongly agree. The survey also explored patients’ reasons for coming to the ED that particular day and the factors that led to this decision. These questions included: “What is the problem that you came to get help with today?” and “Why did you come here instead of going elsewhere, such as a clinic or another emergency department?” The survey included questions regarding usual sources of health care and patients’ experiences with and opinions of their primary care physicians. Examples of these questions are “How much do you trust your physician (clinic) to give you the medical care you need?,” “How good is the care you receive there?,” and “Is your doctor or clinic available when you are in need?” Patients responded to these questions on 5-point rating scales. The survey included questions about demographic information, chronic diseases, and difficulty with physical function due to health. The survey instrument was pilot-tested with 5 patients and revised and simplified based on the pilot testing. The study was approved by Institutional Review Board at the study medical center. Analysis The data were analyzed using SPSS Version 14 (SPSS Inc., Chicago, IL) in the following manner: frequency data were analyzed using chi-squared tests, whereas interval data such as age, stress, physical functioning, and social support were analyzed using analysis of variance or t-tests where appropriate. Details of the significant tests are given in the relevant tables of means. RESULTS Comparison of Demographic Characteristics of Frequent Visitors and Infrequent Visitors Over a 3-month period, 168 patients between the ages of 18 and 87 years were enrolled in the study, including 69 frequent visitors and 99 infrequent visitors. An estimated 250 patients were approached during the study, 120 frequent visitors and 130 infrequent visitors. Thirty-one of the infrequent visitors and 51 of the frequent visitors refused to participate, yielding participation rates of 58% for frequent visitors and 76% for infrequent visitors.
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Demographic information about the participants is in Table 1. Over 85% of the patients were African-American/ black, a direct reflection of the general population within the surrounding community. Frequent visitors were more likely to be black and male. On average, frequent visitors were significantly older (mean age 45 years) than infrequent visitors (mean age 38 years). Frequent visitors were more likely to be insured through Medicaid and less likely to have private insurance or be uninsured. Frequent visitors were less likely to work full time and more likely to be disabled, retired, or unemployed. The groups were similar in marital status and education.
Comparison of Other Characteristics of Frequent Visitors and Infrequent Visitors Most patients (65% of the frequent visitors and 71% of the infrequent visitors) reported having experienced their physical problem for 1 week or less (p ⫽ 0.05). There was no difference between frequent and infrequent visitors in the reasons for the ED visit categorized as injury/ accident (7% vs. 10%, respectively), minor acute complaint (30% vs. 36%, respectively), major acute complaint (41% vs. 36%, respectively), exacerbation of chronic illness (19% vs.13%, respectively), and mental health issue (0% vs. 1%, respectively) (p ⫽ 0.77). We found no differences in the reason for seeking care at the study center ED rather than elsewhere (p ⫽ 0.68), with reported reasons being geographical proximity (23% vs. 30%, respectively), established association (45% vs. 39%, respectively), other’s decision (16% vs. 13%, respectively), and the study center’s reputation (16% vs. 13%, respectively). A comparison of selected common chronic diseases between frequent and infrequent visitors is given in Table 2, with significant differences in frequency noted for hypertension, sickle cell anemia, and depression. Fortyseven percent of the frequent visitors screened positive for depression, in comparison to 27% of infrequent visitors (p ⫽ 0.017). There were no differences between groups in the screening for alcohol-related disorders. Frequent visitors and infrequent visitors reported similar amounts of bodily pain and limitations of social activities due to health (Table 3). Frequent visitors, however, reported poorer overall health, greater difficulties with physical functioning, and higher levels of stress. They reported that income loss, family problems, and physical problems are their greatest sources of stress (Table 4). Although there was no difference between the groups for overall perceived social support, there was a trend toward lower perceived support from family members and significant others by frequent visitors. There
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Table 1. Characteristics of Frequent and Infrequent Visitors to the Emergency Department ED Visitor Type Variable
Frequent Visitors n ⫽ 69
Infrequent Visitors n ⫽ 99
41.09 (19.66) 48.91 (17.53) 45.12 (17.53)
37.03 (16.88) 39.88 (13.66) 38.01 (15.87)
34 (49) 35 (51)
65 (66) 34 (34)
69 (99) 0 (0) 0 (0) 1 (1)
87 (88) 7 (7) 3 (3) 2 (2)
43 (62) 8 (12) 11 (16) 7 (10)
67 (68) 15 (15) 9 (9) 8 (8)
18 (26) 4 (6) 20 (29) 4 (6) 10 (14) 13 (19)
39 (40) 11 (11) 21 (21) 13 (13) 8 (8) 6 (6)
16 (23) 26 (38) 14 (20) 13 (19)
13 (13) 49 (50) 12 (12) 25 (25)
4 (6) 19 (28) 37 (53) 9 (13)
15 (15) 22 (22) 38 (39) 24 (24)
Age, years: Mean (SD) Women* Men Overall Sex: n (%) Female Male Race: n (%) Black/African-American White Latino Other Marital status: n (%) Single Married Divorced Widowed Employment status: n (%) Full time Part time Unemployed Student Retired Disabled Education: n (%) High school not completed Graduated high school/GED Training after high school College graduate Payer status: n (%) Private insurance Medicare Public/Medicaid Self pay
p-Value 0.018*
0.038 0.036
0.503
0.023
0.156
0.032
* A two-factor analysis of variance found significant effects for Sex (F[1, 163] ⫽ 3.8, p ⫽ 0.053) and Status (F[1, 163] ⫽ 5.71. The 95% confidence interval for the difference in age across status was .94 –17.12 with power ⫽ .66.
Frequent Visitor n ⫽ 69
Infrequent Visitor n ⫽ 99
n (%)
n (%)
p-Value
tively, p ⫽ .09), but they were considerably more likely to have a primary care physician at the study center hospital (45% vs. 23%, respectively, p ⫽ 0.01). For patients who had a primary care physician, we found no significant difference between frequent and infrequent visitors in their responses to questions about their trust in (p ⫽ 0.8), the availability of (p ⫽ 0.7), and quality of care (p ⫽ 0.6) given them by their primary care doctor. For patients with a primary care physician, the frequent visitors reported making an average of eight visits to their primary care physician per year, whereas infrequent visitors reported making an average of four visits per year.
12 (17) 31 (45) 17 (25) 6 (9)
15 (15) 26 (26) 15 (15) 0 (0)
0.427 0.01 0.162 0.004
DISCUSSION
7 (10) 20 (29)
5 (5) 13 (13)
0.235 .017
was no difference between the groups in perceived social support from friends (Table 5). Frequent visitors were as likely as infrequent visitors to have a primary care physician (75% vs. 66%, respec-
Table 2. A Comparison of Prevalence of Self-reported Chronic Diseases in Frequent and Infrequent Visitors*
Diabetes Hypertension Asthma Sickle cell disease Alcoholism Depression
* Based on Yes/No responses.
In this study we confirmed some findings from prior frequent visitor studies, but a number of our findings are at odds with previous studies or are new findings. Fre-
Comparison of Frequent and Infrequent ED Visitors
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Table 3. A Comparison of Self-reported Scores of Stress, Overall Functioning, and Physical Functioning between Frequent Visitors and Infrequent Visitors Frequent Visitors n ⫽ 69
Infrequent Visitors n ⫽ 99
Mean (SD)
Mean (SD)
p-Value*
95% CI
2.67 (1.18) 3.72 (1.54) 2.51 (1.58) 3.04 (1.68)
3.25 (1.08) 3.4 (1.46) 2.16 (1.50) 2.35 (1.55)
0.001† 0.174 0.152 0.007‡
⫺.934–⫺.238
2.22 (.89) 1.99 (.88) 1.65 (.82)
1.79 (.88) 1.62 (.88) 1.41 (.74)
0.002§ 0.008 0.052
.155–.704 .097–.642
Overall health† Bodily pain‡ Social limitations‡ Stress management‡ Physical functioning Running§ Uphill/stairs§ Walking§
.193–1.187
* Based on independent groups t-tests with df ⫽ 166. † This variable was measured with a 5-point Likert-type scale, and a higher score denotes better overall health. ‡ These variables are reverse-scored on a 5-point Likert-type scale, and a higher score indicates greater bodily pain, social limitation, and stress. § Measured on 3-point Likert-type scales where a higher score denotes greater difficulty.
quent visitors to the University of Chicago Medical Center Emergency Department are more likely to be unemployed, retired or disabled, African-American, and have Medicaid; these findings are consistent with other studies. However, frequent visitors to UCMC-ED are only half as likely to be uninsured compared to infrequent visitors, a finding not consistent with prior US studies; and they are more likely to be male. Unlike prior US studies, we found that marital status and having Medicare did not differentiate frequent from infrequent visitors (1,2,4,12,15). As in prior frequent visitor studies, we found some evidence that ED frequent visitors are a psychosocially vulnerable group of patients. They report higher levels of stress and there is a trend toward lower levels of social support from family and significant others. However, there was no difference in social support from friends.
Several other studies have found a strong correlation between the lack of adequate social support and frequent ED use (7,22,26). We did not find this strong association in our population. However, nearly half of the ED frequent visitors screened positive for depression. The finding that frequent visitors were significantly more likely to be depressed than infrequent visitors suggests that their depression may be under-diagnosed or under-treated. Our findings suggest that, in determining the actual needs of these patients, a social services consultation should be considered. Communication between ED personnel and the patient’s primary care physician regarding the ED visit and follow-up care plans should occur routinely. Patients without a primary care physician should be connected with a regular source of primary health care. As noted above, frequent visitors were less likely to be uninsured than infrequent visitors, and this finding is at odds with other descriptive studies of frequent visitors. Uninsured patients without access to primary care often
Table 4. Sources of Self-reported Stress for Frequent and Infrequent Visitors* Table 5. Perceived Social Support Scores Frequent Infrequent Visitors n ⫽ 69 Visitors n ⫽ 99
Housing School Transportation Child care Job Income loss Family problems Relationship problems Physical problems Financial problems Spiritual/religious
n (%)
n (%)
p-Value
9 (13) 6 (7) 5 (7) 6 (7) 12 (17) 13 (19) 18 (26) 5 (7)
6 (6) 10 (10) 4 (4) 4 (4) 18 (18) 6 (6) 11 (11) 5 (5)
0.22 0.76 0.36 0.21 0.69 0.01 0.01 0.21
23 (33) 3 (4) 3 (4)
9 (9) 6 (6) 3 (3)
0.00 0.34 0.36
* Based on Yes/No responses.
Subscale score† Significant other Friends Family Total score‡
Frequent Visitors (n ⫽ 69)
Infrequent Visitors (n ⫽ 99)
Mean (SD)
Mean (SD)
p-Value*
5.90 (1.78) 4.34 (1.54) 5.46 (1.95) 15.71 (4.05)
6.36 (1.34) 4.30 (1.43) 6.00 (1.59) 16.66 (3.53)
0.062 0.854 0.051§ 0.110
* Based on independent groups t-tests with df ⫽ 166. † Based on the average score of two items measured with 7-point Likert-scales. A higher score denotes higher social support. ‡ The total of the three subscale scores. § 95% CI ⫺1.076 –⫺.003, power ⫽ .496.
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use EDs for non-acute visits. However, fear of the high cost of an ED visit can also keep uninsured patients with acute problems away from the ED. In future studies, it would be interesting to examine more closely a group of uninsured patients to determine whether the acuity of their condition is higher than insured patients, and whether or not they are less likely to be connected to a primary care provider. Our frequent visitors reported an average of eight visits to their primary care physician per year, whereas infrequent visitors reported making four. Byrne et al. and Sun et al. found a similar relationship between frequent visitors and having a primary care physician (19,24). They found that frequent visitors were more likely to be from an extremely disadvantaged socioeconomic group, yet were more likely than the reference population to have a primary care doctor and access to care. Therefore, it does not seem that lack of access drives frequent ED visits. When asked whether any problems or circumstances existed in accessing their primary care physician for the physical problem presented at the ED, at least 70% of both groups answered no. This suggests that frequent visitors have a greater perceived urgency or actual physical necessity to seek medical care. Their level of perceived urgency is reflected in their higher scores for stress and pain. Yet there was no difference in the reason for visit, suggesting that frequent visitors and infrequent visitors seek emergent care for similar physical problems, but stress and depression may play a role in the frequent visitor’s need to seek care frequently and urgently at an ED. Although high health care utilization may be appropriate for some frequent visitors, we believe that case management with a strong emphasis on management of psychosocial issues may be useful for decreasing frequent and costly ED visits. In a Canadian study, Pope had some success with a case management approach to frequent ED visitors (30). Although there was no significant difference in the reason for visit between frequent and infrequent visitors, it is interesting to point out that approximately one-third of the total ED visits were for “minor acute complaints.” Many of these visits could likely have been appropriately managed in primary care physicians’ offices. Because most frequent visitors do have primary care providers, expanding access to same-day care for minor acute complaints at these primary care sites may help reduce reliance on the ED.
Limitations There are several limitations to our study. We did not use a random sampling method to identify patients for interview. We were, however, very meticulous in approach-
E. Sandoval et al.
ing consecutive patients who were available to be interviewed when the research assistant was in the ED. Also, frequent visitors were more difficult to recruit than infrequent visitors, and we cannot be sure that patients who agreed to be interviewed are representative of those who refused to participate. During patient recruitment, we excluded patients who were actively intoxicated or seriously ill. Therefore, our data do not apply to these ED patients. Patients were selected only from 8:00 a.m. to 11:00 p.m.; therefore, the study findings do not apply to patients who visit the ED from 11:00 p.m. to 8:00 a.m. We defined frequent visitors as patients with at least three visits to the UCMC-ED during the prior year. Other investigators have used different cutoff points to distinguish a frequent visitor from an infrequent visitor. Therefore, a degree of uncertainty exists in comparing our results to research that defined a frequent visitor with a different number of visits, especially those with a very high frequency of visits. Furthermore, the ED population we studied is typical of inner cities in the United States that have a large proportion (over 80%) of economically disadvantaged African-American residents, but a small Hispanic and non-Hispanic white population. Our findings may not apply to suburban, rural, and wealthy urban populations. The relatively small sample size limited our ability to detect some small but meaningful differences. For example, the difference rate of alcoholism reported by patients was 5%, but this difference was not statistically significant. Moreover, the sample size was unequal between groups, mainly due to the lower proportion of frequent visitors who seek care in the ED each day and the greater difficulty recruiting them for the study.
CONCLUSIONS With the aforementioned limitations in mind, this study confirmed several characteristics of frequent ED visitors noted by previous investigators. Frequent visitors are more likely to be unemployed, retired or disabled, AfricanAmerican, and to have Medicaid. They are more likely to be depressed and to report higher levels of stress. They are better connected than infrequent visitors to the medical system, including primary care physicians. The new findings from this study are the very high prevalence of positive depression screens and the fact that uninsured patients are less likely to be frequent visitors. Our findings suggest the need to better understand the urgency that brings frequent visitors to the ED instead of their own physicians’ offices, to screen them for depression and to offer psychological and social services more aggressively.
Comparison of Frequent and Infrequent ED Visitors
REFERENCES 1. Mandelberg J, Kuhn R, Kohn M. Epidemiologic analysis of an urban, public emergency department’s frequent users. Acad Emerg Med 2000;7:637– 46. 2. Murphy AW. ‘Inappropriate’ attenders at accident and emergency department I: definition, incidence, and reasons for attendance. Fam Pract 1998;15:23–32. 3. Hansagi H, Olsson M, Sjoberg S, Tomson Y, Goransson S. Frequent use of the hospital emergency department is indicative of high use of other health care services. Ann Emerg Med 2001;37: 561–7. 4. Lucas R, Sanford S. An analysis of frequent users of emergency care at an urban university hospital. Ann Emerg Med 1998;32: 563– 8. 5. Scneider KC, Dove HG. High users of VA emergency room facilities: are outpatients abusing the system or is the system abusing them? Inquiry 1983;20:47– 64. 6. Hansagi H, Edhago O, Allebeck P. High consumers of health care in emergency units: how to improve their quality of care. Qual Assur Health Care 1991;3:51– 62. 7. Malone RE. Heavy users of emergency services: social construction of a policy problem. Soc Sci Med 1995;40:469 –77. 8. Baker DW, Stevens CD, Brook RH. Regular source of ambulatory care and medical care utilization by patients presenting to a public hospital emergency department. JAMA 1994;271:1909 –12. 9. Bond TK, Stearns S, Peters M. Analysis of chronic emergency department use. Nurs Econ 1999;17:207–13. 10. Olsson M, Hansagi H. Repeated use of the emergency department: qualitative study of the patient’s perspective. Emerg Med 2001; 18:430 – 4. 11. Hunt K, Weber E, Showstack J, et al. Characteristics of frequent users of emergency departments. Ann Emerg Med 2006;48:1– 8. 12. Fuda K, Immekus R. Frequent users of Massachusetts emergency departments: a statewide analysis. Ann Emerg Med 2006;48:9 –16. 13. Ettinger WH, Casani JA, Coon PJ, et al. Patterns of use of the emergency department by elderly patients. J Gerontol 1987;42: 638 – 42. 14. Dale J, Green J, Reid F, Glucksman E, Higgs R. Primary care in the accident and emergency department: II comparison of general practitioner and hospital doctors. BMJ 1995;311:427–30. 15. Andrén KG, Rosenqvist U. Heavy users of an emergency department: psychosocial and medical characteristics, other health care contacts and the effect of a hospital social worker intervention. Soc Sci Med 1985;21:761–70. 16. Brown E, Goel V. Factors related to emergency department use: results from the Ontario health survey 1990. Ann Emerg Med 1994;24:1083–91. 17. Okuyemi K, Frey B. Describing and predicting frequent users of an emergency department. J Assoc Acad Minor Phys 2001;12: 119 –23.
121 18. Chan B, Ovens H. Frequent users of emergency departments. Do they also use family physicians’ services? Can Fam Physician 2002;48:1654 –728. 19. Byrne M, Murphy A, Plunkett P, et al. Frequent attenders to an emergency department: a study of primary health care use, medical profile, and psychosocial characteristics. Ann Emerg Med 2003; 41:309 –18. 20. Blank F, Li H, Henneman P, et al. A descriptive study of heavy emergency department users at an academic emergency department reveals heavy ED users have better access to care than average users. J Emerg Nurs 2005;31:139 – 44. 21. Zuckerman S, Shen Y. Characteristics of occasional and frequent emergency department users: do insurance coverage and access to care matter? Med Care 2004;42:176 – 82. 22. Padgett D, Brodsky B. Psychosocial factors influencing non-urgent use of the emergency room: a review of the literature recommendations for research and improved services delivery. Soc Sci Med 1992;35:1189 –97. 23. O’Brien GM, Stein MD, Zieler S, et al. Use of ED as a regular source of care: associated factors beyond lack of health insurance. Ann Emerg Med 1997;30:286 –91. 24. Sun B, Burstin H, Brennan T. Predictors and outcomes of frequent emergency department users. Acad Emerg Med 2003;10:320 – 8. 25. Ruger J, Richter C, Spitznagel E, et al. Analysis of costs, length of stay, and utilization of emergency department services by frequent users: implications for health policy. Acad Emerg Med 2004;11: 1311–7. 26. Genell Andrén K, Rosenqvist U. Heavy users of an emergency department—a two year follow-up study. Soc Sci Med 1987;25: 825–31. 27. Purdie FR, Honigman B, Rosen P. The chronic emergency department patient. Ann Emerg Med 1981;10:298 –301. 28. Kne T, Young R, Spillane L. Frequent ED users: patterns of use over time. Am J Emerg Med 1998;16:648 –52. 29. Ullman R, Black JA, Stratmann WC. An emergency room’s patients: their characteristics and utilization of hospital services. Med Care 1975;13:1011–20. 30. Pope D, Fernandes C, Bouthillette F, Etherington J. Frequent users of the emergency department: a program to improve care and reduce visits. CMAJ 2000;162:1017–20. 31. Goldberg D. General Health Questionnaire (GHQ-12). Windsor, UK: NFER-Nelson Publishing; 1992. 32. Arroll B, Khin N, Kerse N. Screening for depression in primary care with two verbally asked questions: cross sectional study. BMJ 2003;327;1144 – 6. 33. Vinson D, Galliher J, Redinger C, Kappus JA. Comfortably engaging: which approach to alcohol screening should we use? Ann Fam Med 2004;2:398 – 404. 34. Distress Management Assessment Tool (Dis-A). Version 1.2007. Fort Washington, PA: National Comprehensive Cancer Network, Inc.; 2006. 35. Zimet GD, Dahlem NW, Zimet SG, et al. Multidimensional scale of perceived social support. J Pers Assess 1988;52:30 – 41.
doi:10.1016/j.jemermed.2007.09.042
Original Contributions
A COMPARISON OF FREQUENT AND INFREQUENT VISITORS TO AN URBAN EMERGENCY DEPARTMENT Elizabeth Sandoval, BA,* Sandy Smith, PHD,† James Walter, MD,‡ Sarah-Anne Henning Schuman, MD,† Mary Pat Olson, RN, MSPH,§ Rebecca Striefler, LCSW,储 Stephen Brown, MSW,¶ and John Hickner, MD, MSC† *University of Chicago, Chicago, Illinois, †Department of Family Medicine and ‡Section of Emergency Medicine, Department of Medicine, University of Chicago, Chicago, Illinois, §Metropolitan Chicago Healthcare Council, Chicago, Illinois, 储American Red Cross of Greater Chicago, Chicago, Illinois, and ¶University of Chicago Medical Center, Chicago, Illinois Reprint Address: John Hickner, MD, MSC, Department of Family Medicine, The University of Chicago Pritzker School of Medicine, 5841 S. Maryland Ave., MC7110 Room M-160, Chicago, IL 60637
much more likely to screen positive for depression (47% vs. 27%, respectively, p ⴝ 0.017). Frequent visitors were more likely to have a primary care physician (75% vs. 66%, respectively), and 45% of the frequent visitors had a primary care physician at the ED hospital compared to 23% of the infrequent visitors. These findings suggest the need to improve access to frequent visitors’ primary care physicians, screen them for depression, and offer psychological and social services more aggressively. These findings may apply to other inner city EDs. © 2010 Elsevier Inc.
e Abstract—Frequent visitors account for a high proportion of Emergency Department (ED) visits and costs. Some of these visits could be handled effectively in less expensive primary care settings. Effective interventions to redirect these patients to primary care depend on an in-depth understanding of frequent visitors and the reasons they seek care in the ED. The objective of this study was to explore the differences between frequent visitors and infrequent visitors who seek medical care in one urban ED, as a first step toward developing effective interventions to direct patients to effective sources of care. In structured interviews, we asked 69 frequent visitors and 99 infrequent visitors to an inner-city, adult ED about medical diagnoses, general health, depression, alcohol abuse, physical functioning, selfperceived social support, primary care and ED service use, payment method, satisfaction with their primary care physician, and demographic characteristics. Differences in responses between groups were compared using t-tests for continuous variables and chi-square for categorical variables. Frequent visitors were more likely than infrequent visitors to be insured by Medicaid (53% vs. 39%, respectively) and less likely to be uninsured (13% vs. 24%, respectively) or have private insurance (6% vs. 15%, respectively). They reported higher levels of stress, lower levels of social support, and worse general health status. They were
e Keywords—access; primary care; Emergency Department utilization
INTRODUCTION Frequent visitors to Emergency Departments (EDs) are responsible for a large proportion of ED visits. Studies that define a frequent visitor as a patient who makes a minimum of four visits in the prior year have found that 4% of ED patients are responsible for 20 –30% of annual visits (1– 4). A study that defined a frequent ED patient as one with at least three ED visits in the prior year found that frequent visitors accounted for 73% of visits (5). Frequent visitors contribute to long waiting times for more seriously ill patients and higher economic costs for hospitals (2,6 –10). Although frequent visitors have their
This study was supported in part by a Healthy Community Access Program grant from the Bureau of Primary Health Care of the Health Resources and Services Administration.
RECEIVED: 29 November 2006; FINAL ACCEPTED: 12 September 2007
SUBMISSION RECEIVED:
10 September 2007;
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share of serious medical problems, the medical complaints of frequent visitors can often be managed effectively in a primary care setting (11,12). Frequent ED visitors are also at risk of receiving inadequate care due to insufficient attention to prevention, and by having their medical problem diagnosed differently by multiple doctors (10,13,14). To improve their quality of care, it is essential to obtain a detailed understanding of the reasons why frequent visitors continually seek medical care at the ED and then to formulate a strategy that will address their specific needs. Several studies have compared frequent visitors to control groups of non-frequent visitors to the ED (1,4,12,15–21). Frequent visitors experienced more accidents and health problems and self-reported a low health status (16). They are more likely to visit the ED for alcohol abuse and for exacerbations of chronic conditions or existing illnesses (1,4,15). They experience more psychosocial problems and have poorer mental health (15,18). A record of frequent ED use is indicative of future frequent ED visits and increased use of public services such as psychiatric and social services (17,19). Frequent visitors are more likely to have a usual source of medical care other than the ED, be AfricanAmerican, and be uninsured or have Medicaid or Medicare coverage (4,12,15,18,20). Other studies of frequent visitors, however, described only frequent visitors with no control group of infrequent visitors to allow one to distinguish unique characteristics of frequent visitors (2,3,5–11,13,14,22–24,26 –30). The goal of this study was to describe differences between frequent visitors and infrequent visitors at an inner-city, adult ED as an initial step in developing interventions to reduce inappropriate frequent utilization of ED services.
Patient Recruitment The patients surveyed were adults at least 18 years of age. Patients were approached between 8:00 a.m. and 11:00 p.m. Patients who were severely ill, unable to speak English, unable to communicate, or actively intoxicated were excluded. Intoxicated patients were approached once they were sober. By reviewing the ED Tracker, a computerized system used to monitor patient activity; social workers and the research assistant identified whether or not patients were frequent visitors and documented identification information such as medical history number, patient ID, and the patient’s number of UCMC-ED visits in the past year. They approached eligible patients in the triage area, the waiting room, and in examination cubicles as the patients waited to be seen by a physician. If the patient gave informed consent, the researcher read the interview questions along with or to the patient and wrote down the answers. If a patient declined, the research assistant and social workers continued in consecutive order down the ED Tracker to find another patient and repeated the process until a patient agreed to participate. Every frequent visitor in the ED during the times when the research assistant was present was asked to participate in the survey. Thus, a systematic sample of frequent visitors was recruited during the times the research assistant was in the ED. To recruit the control group of infrequent visitors, the researchers used a similar approach. They identified patients who did not qualify as a frequent visitor by reviewing the ED tracker system, approached those who were available to participate in the study, and interviewed those willing to participate in the study.
The Survey METHODS Study Design and Setting This was a cross-sectional comparison of frequent visitors and infrequent visitors at the adult, inner-city ED of the University of Chicago Medical Center (UCMC-ED). We defined frequent visitors as patients having at least three visits to the UCMC-ED in the prior 12 months. At the time of the study, 49,000 patients were seen in the ED per year; 7% were frequent visitors, and they accounted for 30% of the total ED visits. ED patients were asked to participate in this study on a volunteer basis by completing a questionnaire. The questionnaire was administered by a research assistant or social worker and took approximately 10 –15 min to complete. The study took place in July–September of 2005.
The survey was created mainly using previously validated scales, including the General Health Questionnaire, a two-question depression screener, a single-question alcohol screening tool, a stress management scale, and a short version of the Multidimensional Scale of Perceived Social Support (31–35). The General Health Questionnaire provides self-reports of patients’ overall health, bodily pain, and social limitations of health using 5-point Likert-type scales. The depression screening tool comprises two items with Yes/No responses about the experience of negative or flat affect within the last month. The stress management scale recorded levels of stress within the last month with a 5-point Likert-type scale where a higher score indicated a higher level of stress. To reduce the length of the survey, we used only 6 of the 12 questions from the Multidimensional Scale of Perceived Social Support. We used the two questions from each of
Comparison of Frequent and Infrequent ED Visitors
the three domains of social support (family, friends, and significant other) that had the highest correlations with the three factors, as reported by the authors (35). These included questions such as “I get the emotional support I need from my family,” “I can talk about my problems with my friends,” and “I have a special person in my life who cares about my feelings.” Responses were recorded on a 7-point Likert scale where 1 ⫽ Very strongly disagree and 7 ⫽ Very strongly agree. The survey also explored patients’ reasons for coming to the ED that particular day and the factors that led to this decision. These questions included: “What is the problem that you came to get help with today?” and “Why did you come here instead of going elsewhere, such as a clinic or another emergency department?” The survey included questions regarding usual sources of health care and patients’ experiences with and opinions of their primary care physicians. Examples of these questions are “How much do you trust your physician (clinic) to give you the medical care you need?,” “How good is the care you receive there?,” and “Is your doctor or clinic available when you are in need?” Patients responded to these questions on 5-point rating scales. The survey included questions about demographic information, chronic diseases, and difficulty with physical function due to health. The survey instrument was pilot-tested with 5 patients and revised and simplified based on the pilot testing. The study was approved by Institutional Review Board at the study medical center. Analysis The data were analyzed using SPSS Version 14 (SPSS Inc., Chicago, IL) in the following manner: frequency data were analyzed using chi-squared tests, whereas interval data such as age, stress, physical functioning, and social support were analyzed using analysis of variance or t-tests where appropriate. Details of the significant tests are given in the relevant tables of means. RESULTS Comparison of Demographic Characteristics of Frequent Visitors and Infrequent Visitors Over a 3-month period, 168 patients between the ages of 18 and 87 years were enrolled in the study, including 69 frequent visitors and 99 infrequent visitors. An estimated 250 patients were approached during the study, 120 frequent visitors and 130 infrequent visitors. Thirty-one of the infrequent visitors and 51 of the frequent visitors refused to participate, yielding participation rates of 58% for frequent visitors and 76% for infrequent visitors.
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Demographic information about the participants is in Table 1. Over 85% of the patients were African-American/ black, a direct reflection of the general population within the surrounding community. Frequent visitors were more likely to be black and male. On average, frequent visitors were significantly older (mean age 45 years) than infrequent visitors (mean age 38 years). Frequent visitors were more likely to be insured through Medicaid and less likely to have private insurance or be uninsured. Frequent visitors were less likely to work full time and more likely to be disabled, retired, or unemployed. The groups were similar in marital status and education.
Comparison of Other Characteristics of Frequent Visitors and Infrequent Visitors Most patients (65% of the frequent visitors and 71% of the infrequent visitors) reported having experienced their physical problem for 1 week or less (p ⫽ 0.05). There was no difference between frequent and infrequent visitors in the reasons for the ED visit categorized as injury/ accident (7% vs. 10%, respectively), minor acute complaint (30% vs. 36%, respectively), major acute complaint (41% vs. 36%, respectively), exacerbation of chronic illness (19% vs.13%, respectively), and mental health issue (0% vs. 1%, respectively) (p ⫽ 0.77). We found no differences in the reason for seeking care at the study center ED rather than elsewhere (p ⫽ 0.68), with reported reasons being geographical proximity (23% vs. 30%, respectively), established association (45% vs. 39%, respectively), other’s decision (16% vs. 13%, respectively), and the study center’s reputation (16% vs. 13%, respectively). A comparison of selected common chronic diseases between frequent and infrequent visitors is given in Table 2, with significant differences in frequency noted for hypertension, sickle cell anemia, and depression. Fortyseven percent of the frequent visitors screened positive for depression, in comparison to 27% of infrequent visitors (p ⫽ 0.017). There were no differences between groups in the screening for alcohol-related disorders. Frequent visitors and infrequent visitors reported similar amounts of bodily pain and limitations of social activities due to health (Table 3). Frequent visitors, however, reported poorer overall health, greater difficulties with physical functioning, and higher levels of stress. They reported that income loss, family problems, and physical problems are their greatest sources of stress (Table 4). Although there was no difference between the groups for overall perceived social support, there was a trend toward lower perceived support from family members and significant others by frequent visitors. There
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Table 1. Characteristics of Frequent and Infrequent Visitors to the Emergency Department ED Visitor Type Variable
Frequent Visitors n ⫽ 69
Infrequent Visitors n ⫽ 99
41.09 (19.66) 48.91 (17.53) 45.12 (17.53)
37.03 (16.88) 39.88 (13.66) 38.01 (15.87)
34 (49) 35 (51)
65 (66) 34 (34)
69 (99) 0 (0) 0 (0) 1 (1)
87 (88) 7 (7) 3 (3) 2 (2)
43 (62) 8 (12) 11 (16) 7 (10)
67 (68) 15 (15) 9 (9) 8 (8)
18 (26) 4 (6) 20 (29) 4 (6) 10 (14) 13 (19)
39 (40) 11 (11) 21 (21) 13 (13) 8 (8) 6 (6)
16 (23) 26 (38) 14 (20) 13 (19)
13 (13) 49 (50) 12 (12) 25 (25)
4 (6) 19 (28) 37 (53) 9 (13)
15 (15) 22 (22) 38 (39) 24 (24)
Age, years: Mean (SD) Women* Men Overall Sex: n (%) Female Male Race: n (%) Black/African-American White Latino Other Marital status: n (%) Single Married Divorced Widowed Employment status: n (%) Full time Part time Unemployed Student Retired Disabled Education: n (%) High school not completed Graduated high school/GED Training after high school College graduate Payer status: n (%) Private insurance Medicare Public/Medicaid Self pay
p-Value 0.018*
0.038 0.036
0.503
0.023
0.156
0.032
* A two-factor analysis of variance found significant effects for Sex (F[1, 163] ⫽ 3.8, p ⫽ 0.053) and Status (F[1, 163] ⫽ 5.71. The 95% confidence interval for the difference in age across status was .94 –17.12 with power ⫽ .66.
Frequent Visitor n ⫽ 69
Infrequent Visitor n ⫽ 99
n (%)
n (%)
p-Value
tively, p ⫽ .09), but they were considerably more likely to have a primary care physician at the study center hospital (45% vs. 23%, respectively, p ⫽ 0.01). For patients who had a primary care physician, we found no significant difference between frequent and infrequent visitors in their responses to questions about their trust in (p ⫽ 0.8), the availability of (p ⫽ 0.7), and quality of care (p ⫽ 0.6) given them by their primary care doctor. For patients with a primary care physician, the frequent visitors reported making an average of eight visits to their primary care physician per year, whereas infrequent visitors reported making an average of four visits per year.
12 (17) 31 (45) 17 (25) 6 (9)
15 (15) 26 (26) 15 (15) 0 (0)
0.427 0.01 0.162 0.004
DISCUSSION
7 (10) 20 (29)
5 (5) 13 (13)
0.235 .017
was no difference between the groups in perceived social support from friends (Table 5). Frequent visitors were as likely as infrequent visitors to have a primary care physician (75% vs. 66%, respec-
Table 2. A Comparison of Prevalence of Self-reported Chronic Diseases in Frequent and Infrequent Visitors*
Diabetes Hypertension Asthma Sickle cell disease Alcoholism Depression
* Based on Yes/No responses.
In this study we confirmed some findings from prior frequent visitor studies, but a number of our findings are at odds with previous studies or are new findings. Fre-
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Table 3. A Comparison of Self-reported Scores of Stress, Overall Functioning, and Physical Functioning between Frequent Visitors and Infrequent Visitors Frequent Visitors n ⫽ 69
Infrequent Visitors n ⫽ 99
Mean (SD)
Mean (SD)
p-Value*
95% CI
2.67 (1.18) 3.72 (1.54) 2.51 (1.58) 3.04 (1.68)
3.25 (1.08) 3.4 (1.46) 2.16 (1.50) 2.35 (1.55)
0.001† 0.174 0.152 0.007‡
⫺.934–⫺.238
2.22 (.89) 1.99 (.88) 1.65 (.82)
1.79 (.88) 1.62 (.88) 1.41 (.74)
0.002§ 0.008 0.052
.155–.704 .097–.642
Overall health† Bodily pain‡ Social limitations‡ Stress management‡ Physical functioning Running§ Uphill/stairs§ Walking§
.193–1.187
* Based on independent groups t-tests with df ⫽ 166. † This variable was measured with a 5-point Likert-type scale, and a higher score denotes better overall health. ‡ These variables are reverse-scored on a 5-point Likert-type scale, and a higher score indicates greater bodily pain, social limitation, and stress. § Measured on 3-point Likert-type scales where a higher score denotes greater difficulty.
quent visitors to the University of Chicago Medical Center Emergency Department are more likely to be unemployed, retired or disabled, African-American, and have Medicaid; these findings are consistent with other studies. However, frequent visitors to UCMC-ED are only half as likely to be uninsured compared to infrequent visitors, a finding not consistent with prior US studies; and they are more likely to be male. Unlike prior US studies, we found that marital status and having Medicare did not differentiate frequent from infrequent visitors (1,2,4,12,15). As in prior frequent visitor studies, we found some evidence that ED frequent visitors are a psychosocially vulnerable group of patients. They report higher levels of stress and there is a trend toward lower levels of social support from family and significant others. However, there was no difference in social support from friends.
Several other studies have found a strong correlation between the lack of adequate social support and frequent ED use (7,22,26). We did not find this strong association in our population. However, nearly half of the ED frequent visitors screened positive for depression. The finding that frequent visitors were significantly more likely to be depressed than infrequent visitors suggests that their depression may be under-diagnosed or under-treated. Our findings suggest that, in determining the actual needs of these patients, a social services consultation should be considered. Communication between ED personnel and the patient’s primary care physician regarding the ED visit and follow-up care plans should occur routinely. Patients without a primary care physician should be connected with a regular source of primary health care. As noted above, frequent visitors were less likely to be uninsured than infrequent visitors, and this finding is at odds with other descriptive studies of frequent visitors. Uninsured patients without access to primary care often
Table 4. Sources of Self-reported Stress for Frequent and Infrequent Visitors* Table 5. Perceived Social Support Scores Frequent Infrequent Visitors n ⫽ 69 Visitors n ⫽ 99
Housing School Transportation Child care Job Income loss Family problems Relationship problems Physical problems Financial problems Spiritual/religious
n (%)
n (%)
p-Value
9 (13) 6 (7) 5 (7) 6 (7) 12 (17) 13 (19) 18 (26) 5 (7)
6 (6) 10 (10) 4 (4) 4 (4) 18 (18) 6 (6) 11 (11) 5 (5)
0.22 0.76 0.36 0.21 0.69 0.01 0.01 0.21
23 (33) 3 (4) 3 (4)
9 (9) 6 (6) 3 (3)
0.00 0.34 0.36
* Based on Yes/No responses.
Subscale score† Significant other Friends Family Total score‡
Frequent Visitors (n ⫽ 69)
Infrequent Visitors (n ⫽ 99)
Mean (SD)
Mean (SD)
p-Value*
5.90 (1.78) 4.34 (1.54) 5.46 (1.95) 15.71 (4.05)
6.36 (1.34) 4.30 (1.43) 6.00 (1.59) 16.66 (3.53)
0.062 0.854 0.051§ 0.110
* Based on independent groups t-tests with df ⫽ 166. † Based on the average score of two items measured with 7-point Likert-scales. A higher score denotes higher social support. ‡ The total of the three subscale scores. § 95% CI ⫺1.076 –⫺.003, power ⫽ .496.
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use EDs for non-acute visits. However, fear of the high cost of an ED visit can also keep uninsured patients with acute problems away from the ED. In future studies, it would be interesting to examine more closely a group of uninsured patients to determine whether the acuity of their condition is higher than insured patients, and whether or not they are less likely to be connected to a primary care provider. Our frequent visitors reported an average of eight visits to their primary care physician per year, whereas infrequent visitors reported making four. Byrne et al. and Sun et al. found a similar relationship between frequent visitors and having a primary care physician (19,24). They found that frequent visitors were more likely to be from an extremely disadvantaged socioeconomic group, yet were more likely than the reference population to have a primary care doctor and access to care. Therefore, it does not seem that lack of access drives frequent ED visits. When asked whether any problems or circumstances existed in accessing their primary care physician for the physical problem presented at the ED, at least 70% of both groups answered no. This suggests that frequent visitors have a greater perceived urgency or actual physical necessity to seek medical care. Their level of perceived urgency is reflected in their higher scores for stress and pain. Yet there was no difference in the reason for visit, suggesting that frequent visitors and infrequent visitors seek emergent care for similar physical problems, but stress and depression may play a role in the frequent visitor’s need to seek care frequently and urgently at an ED. Although high health care utilization may be appropriate for some frequent visitors, we believe that case management with a strong emphasis on management of psychosocial issues may be useful for decreasing frequent and costly ED visits. In a Canadian study, Pope had some success with a case management approach to frequent ED visitors (30). Although there was no significant difference in the reason for visit between frequent and infrequent visitors, it is interesting to point out that approximately one-third of the total ED visits were for “minor acute complaints.” Many of these visits could likely have been appropriately managed in primary care physicians’ offices. Because most frequent visitors do have primary care providers, expanding access to same-day care for minor acute complaints at these primary care sites may help reduce reliance on the ED.
Limitations There are several limitations to our study. We did not use a random sampling method to identify patients for interview. We were, however, very meticulous in approach-
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ing consecutive patients who were available to be interviewed when the research assistant was in the ED. Also, frequent visitors were more difficult to recruit than infrequent visitors, and we cannot be sure that patients who agreed to be interviewed are representative of those who refused to participate. During patient recruitment, we excluded patients who were actively intoxicated or seriously ill. Therefore, our data do not apply to these ED patients. Patients were selected only from 8:00 a.m. to 11:00 p.m.; therefore, the study findings do not apply to patients who visit the ED from 11:00 p.m. to 8:00 a.m. We defined frequent visitors as patients with at least three visits to the UCMC-ED during the prior year. Other investigators have used different cutoff points to distinguish a frequent visitor from an infrequent visitor. Therefore, a degree of uncertainty exists in comparing our results to research that defined a frequent visitor with a different number of visits, especially those with a very high frequency of visits. Furthermore, the ED population we studied is typical of inner cities in the United States that have a large proportion (over 80%) of economically disadvantaged African-American residents, but a small Hispanic and non-Hispanic white population. Our findings may not apply to suburban, rural, and wealthy urban populations. The relatively small sample size limited our ability to detect some small but meaningful differences. For example, the difference rate of alcoholism reported by patients was 5%, but this difference was not statistically significant. Moreover, the sample size was unequal between groups, mainly due to the lower proportion of frequent visitors who seek care in the ED each day and the greater difficulty recruiting them for the study.
CONCLUSIONS With the aforementioned limitations in mind, this study confirmed several characteristics of frequent ED visitors noted by previous investigators. Frequent visitors are more likely to be unemployed, retired or disabled, AfricanAmerican, and to have Medicaid. They are more likely to be depressed and to report higher levels of stress. They are better connected than infrequent visitors to the medical system, including primary care physicians. The new findings from this study are the very high prevalence of positive depression screens and the fact that uninsured patients are less likely to be frequent visitors. Our findings suggest the need to better understand the urgency that brings frequent visitors to the ED instead of their own physicians’ offices, to screen them for depression and to offer psychological and social services more aggressively.
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REFERENCES 1. Mandelberg J, Kuhn R, Kohn M. Epidemiologic analysis of an urban, public emergency department’s frequent users. Acad Emerg Med 2000;7:637– 46. 2. Murphy AW. ‘Inappropriate’ attenders at accident and emergency department I: definition, incidence, and reasons for attendance. Fam Pract 1998;15:23–32. 3. Hansagi H, Olsson M, Sjoberg S, Tomson Y, Goransson S. Frequent use of the hospital emergency department is indicative of high use of other health care services. Ann Emerg Med 2001;37: 561–7. 4. Lucas R, Sanford S. An analysis of frequent users of emergency care at an urban university hospital. Ann Emerg Med 1998;32: 563– 8. 5. Scneider KC, Dove HG. High users of VA emergency room facilities: are outpatients abusing the system or is the system abusing them? Inquiry 1983;20:47– 64. 6. Hansagi H, Edhago O, Allebeck P. High consumers of health care in emergency units: how to improve their quality of care. Qual Assur Health Care 1991;3:51– 62. 7. Malone RE. Heavy users of emergency services: social construction of a policy problem. Soc Sci Med 1995;40:469 –77. 8. Baker DW, Stevens CD, Brook RH. Regular source of ambulatory care and medical care utilization by patients presenting to a public hospital emergency department. JAMA 1994;271:1909 –12. 9. Bond TK, Stearns S, Peters M. Analysis of chronic emergency department use. Nurs Econ 1999;17:207–13. 10. Olsson M, Hansagi H. Repeated use of the emergency department: qualitative study of the patient’s perspective. Emerg Med 2001; 18:430 – 4. 11. Hunt K, Weber E, Showstack J, et al. Characteristics of frequent users of emergency departments. Ann Emerg Med 2006;48:1– 8. 12. Fuda K, Immekus R. Frequent users of Massachusetts emergency departments: a statewide analysis. Ann Emerg Med 2006;48:9 –16. 13. Ettinger WH, Casani JA, Coon PJ, et al. Patterns of use of the emergency department by elderly patients. J Gerontol 1987;42: 638 – 42. 14. Dale J, Green J, Reid F, Glucksman E, Higgs R. Primary care in the accident and emergency department: II comparison of general practitioner and hospital doctors. BMJ 1995;311:427–30. 15. Andrén KG, Rosenqvist U. Heavy users of an emergency department: psychosocial and medical characteristics, other health care contacts and the effect of a hospital social worker intervention. Soc Sci Med 1985;21:761–70. 16. Brown E, Goel V. Factors related to emergency department use: results from the Ontario health survey 1990. Ann Emerg Med 1994;24:1083–91. 17. Okuyemi K, Frey B. Describing and predicting frequent users of an emergency department. J Assoc Acad Minor Phys 2001;12: 119 –23.
121 18. Chan B, Ovens H. Frequent users of emergency departments. Do they also use family physicians’ services? Can Fam Physician 2002;48:1654 –728. 19. Byrne M, Murphy A, Plunkett P, et al. Frequent attenders to an emergency department: a study of primary health care use, medical profile, and psychosocial characteristics. Ann Emerg Med 2003; 41:309 –18. 20. Blank F, Li H, Henneman P, et al. A descriptive study of heavy emergency department users at an academic emergency department reveals heavy ED users have better access to care than average users. J Emerg Nurs 2005;31:139 – 44. 21. Zuckerman S, Shen Y. Characteristics of occasional and frequent emergency department users: do insurance coverage and access to care matter? Med Care 2004;42:176 – 82. 22. Padgett D, Brodsky B. Psychosocial factors influencing non-urgent use of the emergency room: a review of the literature recommendations for research and improved services delivery. Soc Sci Med 1992;35:1189 –97. 23. O’Brien GM, Stein MD, Zieler S, et al. Use of ED as a regular source of care: associated factors beyond lack of health insurance. Ann Emerg Med 1997;30:286 –91. 24. Sun B, Burstin H, Brennan T. Predictors and outcomes of frequent emergency department users. Acad Emerg Med 2003;10:320 – 8. 25. Ruger J, Richter C, Spitznagel E, et al. Analysis of costs, length of stay, and utilization of emergency department services by frequent users: implications for health policy. Acad Emerg Med 2004;11: 1311–7. 26. Genell Andrén K, Rosenqvist U. Heavy users of an emergency department—a two year follow-up study. Soc Sci Med 1987;25: 825–31. 27. Purdie FR, Honigman B, Rosen P. The chronic emergency department patient. Ann Emerg Med 1981;10:298 –301. 28. Kne T, Young R, Spillane L. Frequent ED users: patterns of use over time. Am J Emerg Med 1998;16:648 –52. 29. Ullman R, Black JA, Stratmann WC. An emergency room’s patients: their characteristics and utilization of hospital services. Med Care 1975;13:1011–20. 30. Pope D, Fernandes C, Bouthillette F, Etherington J. Frequent users of the emergency department: a program to improve care and reduce visits. CMAJ 2000;162:1017–20. 31. Goldberg D. General Health Questionnaire (GHQ-12). Windsor, UK: NFER-Nelson Publishing; 1992. 32. Arroll B, Khin N, Kerse N. Screening for depression in primary care with two verbally asked questions: cross sectional study. BMJ 2003;327;1144 – 6. 33. Vinson D, Galliher J, Redinger C, Kappus JA. Comfortably engaging: which approach to alcohol screening should we use? Ann Fam Med 2004;2:398 – 404. 34. Distress Management Assessment Tool (Dis-A). Version 1.2007. Fort Washington, PA: National Comprehensive Cancer Network, Inc.; 2006. 35. Zimet GD, Dahlem NW, Zimet SG, et al. Multidimensional scale of perceived social support. J Pers Assess 1988;52:30 – 41.