The researchers want more information on the people who frequently use emergency care and why.
The authors, publishing online in the Emergency Medicine Journal, call against “a narrow, biased and potentially dangerous view of this issue” and say that frequent ER/ED users have unmet needs and “merit focused attention.”
The systematic review summarized the findings of 31 observational studies by mostly US authors, but also studies about emergency departments from a number of other countries. These compared mortality and health services outcomes between frequent and nonfrequent ED users.
Frequent use of emergency care was defined as visiting departments for between 4 and 20 times a year. The analysis concludes that such users are more than twice as likely as infrequent users to die, be admitted to hospital, or need other outpatient treatment.
To test whether or not high visiting rates resulted in rises in these three outcomes, the 31 studies analyzed had been plucked from over 4,000 reviewed for relevance, and data in the final analysis relate to the years between 1990 and 2013.
The breakdown against the three measures was as follows on the likelihood of rises for frequent attenders compared with those who rarely sought help from emergency care:
- On deaths, seven studies examined the outcome – and from across these, dying was more than twice as likely
- With the hospital admissions outcome, it was included by most studies – and frequent users of ED were 2.5 times as likely to be admitted
- 10 studies examined other hospital outpatient care – and the review gives a higher likelihood, by more than 2.5 times, of needing at least one outpatient clinic visit.
The analysis finds that the risks are higher but cannot itself answer why exactly. But in describing the problems that frequent users have, the authors say they represent a “heterogeneous group of high-needs patients.” The studies reviewed included various definitions of employment but the authors were able to identify subgroups of patients with:
- Mental health and addiction issues
- Homelessness or unstable housing
- Chronic diseases (heart failure and chronic obstructive pulmonary disease were examples)
- Conditions that may “require transient increased needs” (including the examples cellulitis/abscess treatment, missed diagnoses, complications).
Heterogeneous group – but high risk a common factor
The authors of the paper describe frustrated efforts to reach clarity about who frequent users are exactly, and therefore to best measure the problems and find solutions, but they do conclude that despite this “heterogeneity,” their results suggest that “frequent users are a distinct and high-risk group.”
The “striking” lack of consensus across studies as to what constitutes a frequent user makes comparison difficult. Potential recommendations that could be generalized across the high-risk group are also therefore difficult, the researchers add, and that this “needs addressing as a matter of urgency.”
One suggestion, though, is that frequent visitors to the ED might benefit from a more targeted proactive approach.
“Appropriate interventions will depend on the needs of the targeted group; however, case management has been shown to be helpful in many cases,” the authors add. Their views on the way in which frequent users can be labeled reads:
“Clearly, to view frequent users as merely a nuisance or drain on resources represents a narrow, biased and potentially dangerous view of this issue.
Our findings suggest that frequent ED users merit focused attention, continued research, and implementation of interventions designed to meet their unmet needs from practitioners, health administrators and policymakers.”
In background evidence for the review, the authors cite that frequent users account for less than a tenth of all ED patients but are estimated to contribute to between a fifth and toward a third of all visits.
Written by Markus MacGill