Study objective We conducted a systematic literature review to identify and to update patient characteristics and contextual factors for adult frequent emergency department users (FEDUs) compared with non-FEDU in an era where the US health care system underwent substantial changes. Methods We searched MEDLINE, CINAHL, and EMBASE to identify all relevant articles after 2010 through July 2018 that describe FEDU. We included US studies on adult FEDU only and excluded studies on specific subgroups of FEDU. We included demographic, clinical, and health care utilization information, and two reviewers independently evaluated the studies using the Joanna Briggs Institute Critical Appraisal tool. Results The 11 studies included in the review indicated that FEDU were 4% to 16% of total ED users but accounted for 14% to 47% of ED visits, with six to nine visits per year on average. The majority of FEDU were young or middle-aged adults, females, of low socioeconomic status and high school or less education, with public insurance, multiple primary care provider visits, and chronic conditions. Fair or poor self-perceived health status, unemployment, unmet needs from primary care providers (PCPs), mental health, and substance abuse were predictors of FEDU. Conclusion FEDUs are disproportionally sicker and are also heavy users of non-ED health care service providers. The limited data for non-ED health services use in facility-specific studies of FEDU may contribute to findings in such studies that complex and unmet needs from PCPs contributed to ED visits. This suggests the need for more comprehensive data analysis beyond a few sites that can inform systemic management approaches.

Characteristics and predictors of adult frequent emergency department users in the United States: A systematic literature review

High utilizers (HUs) are a small group of patients who impose a disproportionately high burden on the healthcare system due to their elevated resource use. Identification of persistent HUs is pertinent as interventions have not been effective due to regression to the mean in majority of patients. This study will use cost and utilization metrics to segment a hospital-based patient population into HU groups. The index visit for each adult patient to an Academic Medical Centre in Singapore during 2006 to 2012 was identified. Cost, length of stay (LOS) and number of specialist outpatient clinic (SOC) visits within 1 year following the index visit were extracted and aggregated. Patients were HUs if they exceeded the 90th percentile of any metric, and Non-HU otherwise. Seven different HU groups and a Non-HU group were constructed. The groups were described in terms of cost and utilization patterns, socio-demographic information, multi-morbidity scores and medical history. Logistic regression compared the groups’ persistence as a HU in any group into the subsequent year, adjusting for socio-demographic information and diagnosis history. A total of 388,162 patients above the age of 21 were included in the study. Cost-LOS-SOC HUs had the highest multi-morbidity and persistence into the second year. Common conditions among Cost-LOS and Cost-LOS-SOC HUs were cardiovascular disease, acute cerebrovascular disease and pneumonia, while most LOS and LOS-SOC HUs were diagnosed with at least one mental health condition. Regression analyses revealed that HUs across all groups were more likely to persist compared to Non-HUs, with stronger relationships seen in groups with high SOC utilization. Similar trends remained after further adjustment. HUs of healthcare services are a diverse group and can be further segmented into different subgroups based on cost and utilization patterns. Segmentation by these metrics revealed differences in socio-demographic characteristics, disease profile and persistence. Most HUs did not persist in their high utilization, and high SOC users should be prioritized for further longitudinal analyses. Segmentation will enable policy makers to better identify the diverse needs of patients, detect gaps in current care and focus their efforts in delivering care relevant and tailored to each segment.

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Characterization of high healthcare utilizer groups using administrative data from an electronic medical record database.

Background
ED super-utilizers (patients with 5 or more visits/year) comprise only 5% of the patients seen yet comprise 25% of total ED visits. Though the reasons for this are multifactorial, the cost to the patient and the community is exceedingly high. The cost is not just monetary; care of these patients is inappropriately fragmented and their presence in the ED may contribute to overcrowding affecting the community's emergency readiness. Previous studies using staff trained to help patients navigate their care options have had conflicting results.

Objectives
To determine whether a trained Patient Navigator (PN) can reduce ED use and costs in super-utilizers over a one year period.

Methods
Super-utilizers were enrolled in a prospective randomized controlled clinical trial. Patients were randomized into the treatment arm and met with a PN who reviewed their diagnosis, associated care plan and identified proper primary care services and community resources for follow-up. The remaining control group was provided standard care. Both groups were given a follow-up call and survey by the PN within 7 days of their visit who assessed primary care follow-up and patient satisfaction using a 4 point Likert scale. After twelve months, the patients’ return ED visits and ED costs were compared to the year prior and primary care compliance and satisfaction were measured using Student-T tests with Bonferroni correction or Mann-Whitney U tests.

Results
282 patients were enrolled (148 in navigation treatment group, 134 controls). Patients were similarly matched in age, race, gender, insurance and chief complaints. Overall ED visits decreased during the 12 month study period, compared to the 12 months prior to enrollment (2249 visits prior to 2050 visits during study period, -8.8%). There was a greater decrease in ED visits from the pre-enrollment year to post-enrollment year in the treatment group (1148 visits to 996 visits, -13.2%) compared to the control group (1101 visits to 1054 visits, -4.3%)(p <0.05). Overall healthcare costs (ED and hospital) for all 282 patients decreased in the year after compared to the 12 months prior to enrollment ($3.9M to $3.1M) with a greater decrease in the navigation treatment group (-26.6%) compared to the control group (-17.5%). Patient surveys found no difference in patient satisfaction in pre and post-enrollment periods but there was an increase in PCP use over the 12 month follow-up period in the treatment group (6.42 visits/patient) compared to the control group (4.07 visits/patient) (p < 0.05).

Conclusion
Our data showed that the overall number of return ED visits and costs did decrease for both groups, potentially inferring a placebo effect for the use of a PN, however the decrease in ED visits and costs were greater in the treatment group. One year follow-up noted an increase in PCP visits in the navigation group. Use of a PN may be cost effective.

This article is protected by copyright. All rights reserved.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/acem.13280

Patient Navigation for Patients Frequently Visiting the Emergency Department: A Randomized, Controlled Trial

Few studies have explored racial/ethnic differences in health care outcomes among patients receiving home health care (HHC), despite known differences in other care settings. We conducted a retrospective cohort study examining racial/ethnic disparities in rehospitalization and emergency room (ER) use among post-acute patients served by a large northeastern HHC agency between 2013 and 2014 (N = 22,722). We used multivariable binomial logistic regression to describe the relationship between race/ethnicity and health care utilization outcomes, adjusting for individual-level factors that are conceptually related to health service use. Overall rates of rehospitalization and ER visits were 10% and 13%, respectively. African American and Hispanic patients experienced higher odds of ER visits or rehospitalization during their HHC episode. Racial/ethnic differences in utilization were mediated by enabling factors, such as caregiver availability, and illness-level factors, such as illness severity, functional status, and symptoms. Intervention targets may include early risk assessment, proactive management of clinical conditions, rehabilitative therapy, and caregiver training.

Relationships Between Race/Ethnicity and Health Care Utilization Among Older Post-Acute Home Health Care Patients:

Objectives: Using the Andersen's Behavioral Model of Health Services Use, we explored social, behavioral, and health factors that are associated with emergency department (ED) utilization among underserved African American (AA) older adults in one of the most economically disadvantaged urban areas in South Los Angeles, California Methods: This cross-sectional study recruited a convenience sample of 609 non-institutionalized AA older adults (age ≥ 65 years) from South Los Angeles, California Participants were interviewed for demographic factors, self-rated health, chronic medication conditions (CMCs), pain, depressive symptoms, access to care, and continuity of care Outcomes included 1 or 2+ ED visits in the last 12 months Polynomial regression was used for data analysis Results: Almost 41% of participants were treated at an ED during the last 12 months In all, 27% of participants attended an ED once and 14% two or more times Half of those with 6+ chronic conditions reported being treated at an ED once; one quarter at least twice Factors that predicted no ED visit were male gender (OR = 050, 95% CI = 029-085), higher continuity of medical care (OR = 155, 95% CI = 104-231), individuals with two CMCs or less (OR = 261 (103-659), second tertile of pain severity (OR = 280, 95% CI = 136-573) Factors that predicted only one ED visit were male gender (OR = 045, 95% CI = 025-082), higher continuity of medical care (OR = 139, 95% CI = 101-215) and second tertile of pain severity (OR = 242, 95% CI = 113-519) Conclusions: This study documented that a lack of continuity of care for individuals with multiple chronic conditions leads to a higher rate of ED presentations The results are significant given that ED visits may contribute to health disparities among AA older adults Future research should examine whether case management decreases ED utilization among underserved AA older adults with multiple chronic conditions and/or severe pain To explore the generalizability of these findings, the study should be repeated in other settings

https://www.mdpi.com/1660-4601/16/7/1175/pdf

Emergency department utilization among underserved African American older adults in South Los Angeles

Objectives A small but significant number of patients make frequent emergency department (ED) visits to multiple EDs within a region. We have a unique health information exchange (HIE) that includes every ED encounter in all hospital systems in our region. Using our HIE we were able to characterize all frequent ED users in our region, regardless of hospital visited or payer class. The objective of our study was to use data from an HIE to characterize patients in a region who are frequent ED users (FEDUs). Methods We constructed a database from a cohort of adult patients (18 years old or older) with information in a regional HIE for a 1-year period beginning in April 2012. Patients were defined as FEDUs (those who made four or more visits during the study period) and non-FEDUs (those who made fewer than four ED visits during the study period). Predictor variables included age, race, sex, payer class, county of residence, and International Classification of Diseases, Ninth Revision codes. Bivariate (χ(2)) and multivariate (logistic regression) analyses were performed to determine associations between predictor variables and the outcome of being a FEDU. Results The database contained 127,672 patients, 12,293 (9.6%) of whom were FEDUs. Logistic regression showed the following patient characteristics to be significantly associated with the outcome of being a FEDU: age 35 to 44 years; African American race; Medicaid, Medicare, and dual-pay payer class; and International Classification of Diseases, Ninth Revision codes 630 to 679 (complications of pregnancy, childbirth, and puerperium), 780 to 799 (ill-defined conditions), 280 to 289 (diseases of the blood), 290-319 (mental disorders), 680 to 709 (diseases of the skin and subcutaneous tissue), 710 to 739 (musculoskeletal and connective tissue disease), 460 to 519 (respiratory disease), and 520 to 579 (digestive disease). No significant differences were noted between men and women. Conclusions Data from an HIE can be used to describe all of the patients within a region who are FEDUs, regardless of the hospital system they visited. This information can be used to focus care coordination efforts and link appropriate patients to a medical home. Future studies can be designed to learn the reasons why patients become FEDUs, and interventions can be developed to address deficiencies in health care that result in frequent ED visits.

/pdf/a-comprehensive-view-of-frequent-emergency-department-users-2wz5fsecgy.pdf

A Comprehensive View of Frequent Emergency Department Users Based on Data from a Regional HIE

OBJECTIVES Health information exchanges (HIEs) make possible the construction of databases to characterize patients as multisystem users (MSUs), those visiting emergency departments (EDs) of more than one hospital system within a region during a 1-year period. HIE data can inform an algorithm highlighting patients for whom information is more likely to be present in the HIE, leading to a higher yield HIE experience for ED clinicians and incentivizing their adoption of HIE. Our objective was to describe patient characteristics that determine which ED patients are likely to be MSUs and therefore have information in an HIE, thereby improving the efficacy of HIE use and increasing ED clinician perception of HIE benefit. METHODS Data were extracted from a regional HIE involving four hospital systems (11 EDs) in the Charleston, South Carolina area. We used univariate and multivariable regression analyses to develop a predictive model for MSU status. RESULTS Factors associated with MSUs included younger age groups, dual-payer insurance status, living in counties that are more rural, and one of at least six specific diagnoses: mental disorders; symptoms, signs, and ill-defined conditions; complications of pregnancy, childbirth, and puerperium; diseases of the musculoskeletal system; injury and poisoning; and diseases of the blood and blood-forming organs. For patients with multiple ED visits during 1 year, 43.8% of MSUs had ≥4 visits, compared with 18.0% of non-MSUs (P < 0.0001). CONCLUSIONS This predictive model accurately identified patients cared for at multiple hospital systems and can be used to increase the likelihood that time spent logging on to the HIE will be a value-added effort for emergency physicians.

/pdf/when-should-ed-physicians-use-an-hie-predicting-presence-of-2nue38se4p.pdf

Adam B Sendor

Papers

A Comprehensive View of Frequent Emergency Department Users Based on Data from a Regional HIE

When Should ED Physicians Use an HIE? Predicting Presence of Patient Data in an HIE.