New research highlights misconceptions about frequent ED users, utilization patterns

Experts find fault with growing focus on cost of ED care

In an effort to drive down health care expenditures, a key target of state legislatures and health care policy makers in recent years has been frequent users of the ED. The thought is that many of these patients are using the ED for routine or non-urgent care when they really should be opting for less-expensive care settings. However, new research into exactly who these frequent users are suggests that a high percentage of these patients are, in fact, using the ED for urgent or emergent concerns, and that efforts to find cost-savings could be better focused elsewhere.

As this issue is of high concern to the American College of Emergency Physicians (ACEP), several investigations looking at this issue were presented in October at the group's scientific meeting in Denver, CO. Robert O'Connor, MD, MPH, chair of Emergency Medicine at the University of Virginia School of Medicine, Charlottesville, VA, and a co-author of one of the studies presented at the ACEP meeting, notes that while the investigations utilized varying definitions of how many visits to the ED qualified a patient as a frequent user, they did arrive at many similar insights about this patient group.

"Despite the widespread belief that these patients can easily be directed elsewhere in the health care system for less-expensive care, and that these patients are somehow abusing the system, the reality is much more complicated," says O'Connor. "These patients actually need, for the most part, to be treated when they come in. And regardless of the definition used, most of the studies found frequent users to be a very small percentage of the total number of emergency patients, although these patients did make up a disproportionate share of ED visits." (Also, see "Dearth of referral resources a source of frustration for emergency providers." below.)

In his own study looking at the characteristics of repeat ED users at a university medical center, O'Connor found that frequent users made up about 20% of the volume in the ED and accounted for nearly 40% of the visits.1 However, in most of the other studies, O'Connor notes that frequent users made up a smaller proportion of the ED volume.

For example, in a study out of Harvard, frequent users made up 2.1% of all emergency patients and accounted for 11.5% of all visits.2 Similarly, a study conducted at the University of Wisconsin (UW) found that frequent users represented about 8% of all emergency patients and accounted for about 26% of all visits.3 And a study out of the University of California at San Diego (UCSD) found that frequent users represented 3.1% of all emergency patients and accounted for 16.5% of all emergency visits.4

New re-admission penalty unfair?

Another insight O'Connor notes from these studies is that while many health care experts believe that frequent users tend to be uninsured, it turns out that is not true. "Most frequent users are likely to be insured by Medicare or Medicaid," he says. "What we found in our study was that the distribution by type of insurer roughly represents the community as a whole."

Similarly, O'Connor notes the UCSD study found that the percentage of frequent users who were self-pay patients was similar to the percentage of uninsured patients overall, which was about 14.2%.

The UCSD study found that the most common diagnoses among frequent users were the same as for the occasional users: respiratory complaints and abdominal symptoms. Being a frequent user was also linked with a pain diagnosis or a heart failure diagnosis, says O'Connor.

O'Connor notes that the UW study found that 77% of the frequent users with seven or more visits during a 12-month period were only frequent users for one year, and most of these patients had the same rates of non-urgent visits as the non-frequent users.

"In our study, low and moderate repeat users were just as likely as non-repeat users to be admitted to the hospital from the ED," says O'Connor. "This suggests that the ED visits for these patients are justified as necessary for an acute illness, and high repeat users, once admitted to the hospital, were more likely to require re-admission."

Such findings raise questions about the recently implemented Medicare rule that penalizes hospitals for higher than average 30-day re-admission rates, notes O'Connor. "If you have a sick population that you are caring for, such as at a university hospital, I think it is unfair to the patients and to the hospital to penalize them for re-admission rates."

Misconceptions persist

ACEP's incoming president, Andrew Sama, MD, FACEP, senior vice president, Emergency Services, North Shore — Long Island Jewish Health System, Manhasset, NY, notes that the studies make clear that there are a number of misconceptions about who these frequent users are and how they use the health care system.

"The perception is that these are only people who are uninsured or they have mental health problems or they are abusing pain medication. In fact, there is a significant number of patients who fall into those categories, but this is also a group of people who, over a period of time, have a significant medical or surgical illness, have complications, and require recurrent and intermittent evaluation and treatment," says Sama. "Some of these folks are medically very sick and do present with new, acute problems in percentages that are very similar to the general population."

Sama adds that it is important to recognize that frequent users are actually a heterogeneous group of patients rather than a single patient type that can be easily matched with a single solution. "What we are trying to do as emergency physicians, state by state, and location by location, is put together intelligent processes and policies and procedures to begin to manage the very types of patients who are frequent users of emergency care so we can actually make improvements that can preclude some of this activity from occurring," he says. "It is not a simple problem; it is a social, medical, mental health, and community resource problem."

Further, Sama notes that the type of patients being seen in the ED today are more complex and require higher-level medical decision-making than in the past. "Five years ago, there were very few retail clinics and maybe half as many urgent care centers. Currently, there are 170-180 million patients who are being seen in retail clinics and urgent care centers, and these are the lower-acuity patients who used to be seen in the ED," he says. "We are seeing a shift."

While the studies did not specifically look at the cost associated with frequent ED users, O'Connor points out that most of these patients lack other care options. "Someone who is five days post surgery, who is having nausea and vomiting and can't keep anything down at 3 o'clock in the morning, has nowhere else to go, so they come to the ED," he observes. "They then may go home and develop a second complication from the surgery, which is totally unforeseen, and so they come back."

In this instance, O'Connor notes that utilizing the ED is actually less expensive than to trying to replicate the kind of care offered in the ED somewhere else. "Where else is someone going to go at 3 o'clock in the morning, unless you set up a parallel emergency care system?"

While the financial implications of frequent ED utilization are a concern, Sama points out that EDs are open every day around the clock, and they have 136 million encounters every year. "Emergency care in the United States only costs 2% of the entire national health care budget," he explains. "Only spending 2% on all of those acute care encounters is actually a pretty good return on investment."

Triage decisions tell a different story

Many of the findings about frequent ED users unveiled at ACEP's scientific meeting echo the results of similar studies released earlier this year. For example, a study unveiled in July by the Washington, DC-based Center for Studying Health System Change (CSHC) found that contrary to common belief, the majority of ED visits made by non-elderly Medicaid patients are for symptoms that suggest they have urgent or emergent problems.5

Such findings contrast with earlier research, but Emily Carrier, MD, MCSI, an emergency physician and senior health researcher at CSHC, explains that this is because most researchers have based their findings on claims data, which reflect final diagnoses. "When looking at final diagnoses, you end up with one picture of why people use the ED, but when a patient on Medicaid (or some other type of coverage) enters they ED, they obviously don't know what their final diagnosis is going to be," says Carrier. "We looked at triage acuity, and that gives you a very different picture."

For example, Carrier observes that most patients who come to the ED complaining of chest pain are not having a heart attack, but they do what public information campaigns tell them to do, which is to come to the ED and get checked out. "For many of these people, the problem is going to turn out to be something as benign as reflux disease or heartburn," she says. "Most of these people are not going to have a heart attack and die, but they don't know that in the beginning."

Similarly, parents commonly come to the ED with young children who have high fevers and appear to be very sick. Many of these cases turn out to be viruses for which there is supportive care and reassurance available in the ED.

"In retrospect, you could say that they didn't really need to come in, but at the time the parent was bringing in the child, they were very concerned, and a small proportion of those kids are going to be really sick and have a potentially life-threatening illness," she says. "What our study shows is that most of the patients who came in had concerns that appeared to be significant — not just to them, but to the triage staff who evaluated them as well."

While the researchers found no evidence that patients on Medicaid have any special propensity to abuse the ED, Medicaid patients did tend to use the ED about twice as often as patients with private insurance. "If you went to an ED waiting room and started interviewing people, you would find a lot more who had Medicaid relative to the overall proportion of the population who have Medicaid than you would for people with private insurance," says Carrier. "But if you asked them what brings them here, you would find that folks with Medicaid were about as likely as folks with private insurance to describe a really concerning symptom or a minor symptom."

The CSHSC study notes that diagnoses of acute respiratory and other common infections in children and injuries accounted for more than half of the ED visits by children on Medicaid younger than the age of 12 years and more than 60% of ED visits by children younger than 12 years covered by private payers. The authors concluded that the greatest potential to reduce ED use lies in developing appropriate alternative care settings for these conditions, but they caution that such alternative sites would have to be able to provide prompt care.

References

  1. Miller S, O'Connor R, Ghaemmaghami C. Characteristics of repeat emergency department users at a university medical center: Frequent emergency department utilization is associated with higher rates of 30-day inpatient readmission, University of Virginia Health System 2012.
  2. Liu S, Nagurney J, Chang U, et al. Frequent users of the emergency department: Do they make visits that can be addressed in a primary care setting? Massachusetts General Hospital, Beth Israel Deaconess Hospital, Harvard Medical School 2012.
  3. Polsinelli A, Hamedani A, Svenson J. Frequent fliers and hot spotters: Characterization of distinct subgroups of frequent users of the ED, University of Wisconsin-Madison, School of Medicine and Public Health 2012.
  4. Brennan J, Chan T, Vilke G, et al. Identification of frequent users of ED resources using a community-wide approach. University of California, San Diego Emergency Medicine 2012.
  5. Sommers A, Boukus E, Carrier E. Dispelling myths about emergency department use: Majority of medicaid visits are for urgent or more serious symptoms. Center for Studying Health System Change, July 2012, Research Brief No. 23.

Sources

Emily Carrier, MD, MCSI, Emergency Physician and Senior Health Researcher, Center for Studying Health System Change, Washington, DC. E-mail: ecarrier@hschange.org.

Robert O'Connor, MD, MPH, Chair, Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA. E-mail: reo4x@virginia.edu.

Andrew Sama, MD, FACEP, Senior Vice President, Emergency Services, North Shore — Long Island Jewish Health System, Manhasset, NY: E-mail: asama@nshs.edu.

Dearth of referral resources a source of frustration for emergency providers

In the emergency care setting, providers treat all users, regardless of their acuity level or their ability to pay. However, when clinicians see the same patients coming back for care frequently, they are troubled by it.

"Physicians want patients to get better, so if someone comes back frequently, we almost view it as a failure of what we have done because now our usual diagnostic and treatment modalities aren't working as well as they should," explains Robert O'Connor, MD, MPH, chair of Emergency Medicine at the University of Virginia School of Medicine in Charlottesville. "Now we have to dig a little deeper into what we are going to offer the patient, so it becomes a much more challenging case if someone is not getting better."

Such situations become particularly frustrating when the reason a patient is back in the ED is related to the fact he has had trouble accessing the health resources he needed. "We sometimes have trouble getting patients in to see specialists or primary care physicians," adds O'Connor. In other cases, setting up home health care or getting a patient into a nursing home may prove challenging, he says.

"There is some frustration, but we have to step back, be professional, and make sure the patient doesn't have a new problem or a worsening of their existing problem, and take proper care of them," observed O'Connor.

In fact, if better systems of referral were in place, many patients who now come to the ED and are then hospitalized could instead be sent home with appropriate home health care and/or follow-up, notes O'Connor.

Of particular concern is a lack of access to mental health services, stresses Andrew Sama, MD, FACEP, the incoming president of the American College of Emergency Physicians and senior vice president, Emergency Services, North Shore — Long Island Jewish Health System, Manhasset, NY. "There is not very good access to good inpatient or outpatient mental health services, particularly if the patient is on Medicaid or the patient is uninsured," he explained.

Rather than trying to keep patients out of the ED, what O'Connor would like to see is a hub-and-spoke model in which the ED can re-direct patients to needed resources. "What is happening now is things are fragmented. I have difficulty referring patients out, and I also have difficulty accessing records from other hospitals," he explained.

It's a mistake to just key in on one system or department for new efficiencies or cost savings, notes O'Connor. "We really need to step back and look at the whole picture, but focus on the patient as the unit of study," he says. "This is something we are all in."