Original Contributions
Frequent use of the hospital emergency department is indicative of high use of other health care services,☆☆

https://doi.org/10.1067/mem.2001.111762Get rights and content

Abstract

Study objective: We sought to determine the proportion of emergency department patients who frequently use the ED and to compare their frequency of use of other health care services at non-ED sites. Methods: A computerized patient database covering all ambulatory visits and hospital admissions at all care facilities in the county of Stockholm, Sweden, was used. Frequent ED patients were defined as those making 4 or more visits in a 12-month period. Results: Frequent users comprised 4% of total ED patients, accounting for 18% of the ED visits. The ED was the only source of ambulatory care for 13% of frequent versus 27% of rare ED users (1 ED visit). Primary care visits were made by 72% of frequent ED users versus 57% by rare ED visitors. The corresponding figures for hospital admission were 80% and 36%, respectively. Frequent ED visitors were also more likely to use other care facilities repeatedly: their odds ratio (adjusted for age and sex) was 3.43 (95% confidence interval [CI] 3.10 to 3.78) for 5 or more primary care visits and 29.98 (95% CI 26.33 to 34.15) for 5 or more hospital admissions. In addition, heavy users had an elevated mortality (standardized mortality ratio 1.55; 95% CI 1.26 to 1.90). Conclusion: High ED use patients are also high users of other health care services, presumably because they are sicker than average. A further indication of serious ill health is their higher than expected mortality. This knowledge might be helpful for care providers in their endeavors to find appropriate ways of meeting the needs of this vulnerable patient category. [Hansagi H, Olsson M, Sjöberg S, Tomson Y, Göransson S. Frequent use of the hospital emergency department is indicative of high use of other health care services. Ann Emerg Med. June 2001;37:561-567.]

Introduction

Hospital emergency departments are designed to provide highly professional medical treatment, with immediate availability of special resources to those in need of urgent or emergency care at any time of day or night. However, regardless of how health care systems are organized, the function of the ED has gradually changed during the last decades.1, 2, 3, 4 Studies from several Western countries have demonstrated that patients also often rely on the ED for health problems other than emergencies.5, 6, 7 A subgroup of patients use the ED frequently and constitute a considerable proportion of the total number of visits.8, 9, 10, 11 Many of these visits by heavy ED users are for conditions that medical personnel view as nonurgent and that therefore could be more adequately managed in primary care settings.12, 13 It has been suggested that the reasons for overreliance on the ED—aside from the around-the-clock availability, high-technology equipment, convenience, and socioeconomics among others—may be that patients lack a regular source of ambulatory care14, 15 or that they identify the ED as their regular source of care.16, 17

Whether the ED is the only source of care for heavy ED users or whether they also use additional health care facilities has not previously been studied. Such knowledge should be of importance for both the medical treatment of the individual patient and for health care planning. Studies that have attempted to assess ED patients’ use of other care sites usually encompassed short time periods before or after the current ED visit; moreover, these studies relied on patients’ own accounts.14, 15, 16, 17 The aim of our study was to determine the number of individual users of a hospital ED during a 1-year period, to ascertain the proportion of frequent ED users, and then to relate use of health care services at other sites to frequency of ED visits. A computerized patient database covering all public health care services enabled us to conduct this investigation.

Section snippets

Materials and methods

We conducted our study at Huddinge University Hospital, 1 of 10 public hospitals in Stockholm County, Sweden, and located in a suburban area of Stockholm city. This hospital ED has an average census of 70,000 visits per year.

Health care delivery in Sweden has traditionally been the concern of public authorities, namely the county councils, and all residents are covered by the national health insurance system, which is financed primarily by taxes. All physicians, including the majority of those

Results

During the study period, 47,349 individuals made a total of 70,700 visits to the hospital ED. The majority of the patients (74%) sought care at the ED once during the year (ED class A). Frequent ED users (≥4 visits, mean=6.0, ED class D) comprised only 4% of total patients but accounted for 18% of all the visits to the ED (Table 1).The top 100 patients visited the ED 12 to 74 times each, averaging 19.5 visits. Within ED class D, the proportion of women was insignificantly higher than that of

Discussion

The computerized patient database provided valid data on overall health care use by ED patients. Studies with similar aims undertaken before the data era were, of necessity, restricted to interviewing patients, a method that is subject to the inherent weaknesses of self-reports, such as memory bias or unwillingness to answer. In the present study the compilation of data concerning use of different health care sources was unproblematic because of a unique patient identifier. Because the private

Acknowledgements

We thank Anne Reimers, BA, for her help with data compilation.

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    Supported by The Swedish Council for Social Research (project 98-0228:1B) and the Southwestern Health Care District of Stockholm County.

    ☆☆

    Address for reprints: Helen Hansagi, PhD, Department of Clinical Neuroscience, Karolinska Hospital M4:04, S-171 76 Stockholm, Sweden; +46 8 5177 16 54, fax +46 8 5177 66 15; E-mail [email protected]

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