Original contribution
A Comparison of Frequent and Infrequent Visitors to an Urban Emergency Department

https://doi.org/10.1016/j.jemermed.2007.09.042Get rights and content

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, self-perceived 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 much more likely to screen positive for depression (47% vs. 27%, respectively, p = 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.

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, 2, 3, 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, 7, 8, 9, 10). Although frequent visitors have their 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, 16, 17, 18, 19, 20, 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 African-American, 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, 6, 7, 8, 9, 10, 11, 13, 14, 22, 23, 24, 25, 26, 27, 28, 29, 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.

Section snippets

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

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.

Demographic information about the

Discussion

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. Frequent 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

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, African-American, 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

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    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.

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