Dataset Information

Persistent frequent emergency department users with chronic conditions: A population-based cohort study.

ABSTRACT: BACKGROUND:Frequent emergency department users are patients cumulating at least four visits per year. Few studies have focused on persistent frequent users, who maintain their frequent user status for multiple consecutive years. This study targets an adult population with chronic conditions, and its aims are: 1) to estimate the prevalence of persistent frequent ED use; 2) to identify factors associated with persistent frequent ED use (frequent use for three consecutive years) and compare their importance with those associated with occasional frequent ED use (frequent use during the year following the index date); and 3) to compare characteristics of "persistent frequent users" to "occasional frequent users" and to "users other than persistent frequent users". METHODS:This is a retrospective cohort study using Quebec administrative databases. All adult patients who visited the emergency department in 2012, diagnosed with chronic conditions, and living in non-remote areas were included. Patients who died in the three years following their index date were excluded. The main outcome was persistent frequent use (?4 visits per year during three consecutive years). Potential predictors included sociodemographic characteristics, physical and mental comorbidities, and prior healthcare utilization. Odds ratios were computed using multivariable logistic regression. RESULTS:Out of 297,182 patients who visited ED at least once in 2012, 3,357 (1.10%) were persistent frequent users. Their main characteristics included poor socioeconomic status, mental and physical comorbidity, and substance abuse. Those characteristics were also present for occasional frequent users, although with higher percentages for the persistent user group. The number of previous visits to the emergency department was the most important factor in the regression model. The occasional frequent users' attrition rate was higher between the first and second year of follow-up than between the second and third year. CONCLUSIONS:Persistent frequent users are a subpopulation of frequent users with whom they share characteristics, such as physical and mental comorbidities, though the former are poorer and younger. More research is needed in order to better understand what factors can contribute to persistent frequent use.

SUBMITTER: Chiu YM

PROVIDER: S-EPMC7015381 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Persistent frequent emergency department users with chronic conditions: A population-based cohort study.

Chiu Yohann Moanahere YM Vanasse Alain A Courteau Josiane J Chouinard Maud-Christine MC Dubois Marie-France MF Dubuc Nicole N Elazhary Nicolas N Dufour Isabelle I Hudon Catherine C

PloS one 20200212 2

<h4>Background</h4>Frequent emergency department users are patients cumulating at least four visits per year. Few studies have focused on persistent frequent users, who maintain their frequent user status for multiple consecutive years. This study targets an adult population with chronic conditions, and its aims are: 1) to estimate the prevalence of persistent frequent ED use; 2) to identify factors associated with persistent frequent ED use (frequent use for three consecutive years) and compare ...[more]

PMID: 32050010

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Project description:BackgroundEfforts to reduce emergency department (ED) volumes often target frequent users. We examined transitions in care across ED, hospital, and community settings, and in-hospital death, for high system users (HSUs) compared to controls.MethodsPopulation-based databases provided ED visits and hospitalizations in Alberta and Ontario, Canada. The retrospective cohort included the top 10% of all the ED users during 2015/2016 (termed HSUs) and a random sample of controls (4 per each HSU) from the bottom 90% per province. Rates of transitions among ED, hospitalization, community settings, and in-hospital mortality were adjusted for sociodemographic and ED variables in a multistate statistical model.ResultsThere were 2,684,924 patients and 579,230 (21.6%) were HSUs. Patient characteristics associated with shorter community to ED transition times for HSUs included Alberta residence (ratio of hazard ratio [RHR] = 1.11, 95% confidence interval [CI] 1.11,1.12), living in areas in the lower income quintile (RHR = 1.06, 95%CI 1.06,1.06), and Ontario residents without a primary health care provider (RHR = 1.13, 95%CI 1.13,1.14). Once at the ED, characteristics associated with shorter ED to hospital transition times for HSUs included higher acuity (e.g., RHR = 1.70, 95% CI 1.61, 1.81 for emergent), and for many diagnoses including chest pain (RHR = 1.71, 95%CI 1.65,1.76) and gastrointestinal (RHR = 1.66, 95%CI 1.62,1.71). Once admitted to hospital, HSUs did not necessarily have longer stays except for conditions such as chest pain (RHR = 0.90, 95% CI 0.86, 0.95). HSUs had shorter times to death in the ED if they presented for cancer (RHR = 2.51), congestive heart failure (RHR = 1.93), myocardial infarction (RHR = 1.53), and stroke (RHR = 1.84), and shorter times to death in-hospital if they presented with cancer (RHR = 1.29).ConclusionsDifferences between HSUs and controls in predictors of transitions among care settings were identified. Co-morbidities and limitations in access to primary care are associated with more rapid transitions from community to ED and hospital among HSUs. Interventions targeting these challenges may better serve patients across health systems..Trial registrationNot applicable.

Project description:ObjectivesMany interventions have been developed over the years to offer frequent users of the emergency department (FUEDs) better access to quality coordinated healthcare. Despite recognising the role primary care physicians (PCPs) play in FUEDs' care, to date their perceptions of case management, the most studied intervention, have rarely been assessed. Furthermore, a gap regarding PCPs' experience of caring for FUEDs persists. Thus, this study aimed to explore PCPs' perceptions of the care provided to FUEDs in emergency and primary care settings, their views on the local case management team (CMT), and their suggestions to improve FUEDs' care.DesignQualitative study using in-depth semistructured interviews and inductive thematic analysis.SettingCanton of Vaud, Switzerland.ParticipantsThirty PCPs participated, 16 in private practice (PP-PCPs) and 14 based at the Lausanne University Centre of General Medicine and Public Health (Unisanté-U-PCPs).ResultsU-PCPs and PP-PCPs thought that most FUEDs' emergency department (ED) visits were legitimate, but questioned ED adequacy to meet FUEDs' needs. Yet, both PCP groups reported encountering many challenges in FUEDs' care themselves. In this context, PP-PCPs seemed more satisfied of the care they provided to FUEDs than U-PCPs. Generally, U-PCPs seemed to find more value in the CMT to help them care for FUEDs than PP-PCPs. To enhance FUEDs' care, U-PCPs and PP-PCPs suggested enhancing collaboration with other healthcare providers. U-PCPs also wished to increase their availability, and some PP-PCPs considered outpatient clinics, larger group practices or medical centres most appropriate to handle FUEDs' needs.ConclusionsThis study highlights the many challenges PCPs face in caring for FUEDs, that a CM intervention has the potential to mitigate, and provides ways forward in improving FUEDs' care, including reinforced communication with the CMT and ED physicians, and structural changes to their own way of delivering care to FUEDs.

Project description:BackgroundThe factors that underlie persistent frequent visits to the emergency department are poorly understood. This study aimed to characterize people who visit emergency departments frequently in Ontario and Alberta, by number of years of frequent use.MethodsThis was a retrospective cohort study aimed at capturing information about patients visiting emergency departments in Ontario and Alberta, Canada, from Apr. 1, 2011, to Mar. 31, 2016. We identified people 18 years or older with frequent emergency department use (top 10% of emergency department use) in fiscal year 2015/16, using the Dynamic Cohort from the Canadian Institute of Health Information. We then organized them into subgroups based on the number of years (1 to 5) in which they met the threshold for frequent use over the study period. We characterized subgroups using linked emergency department, hospitalization and mental health-related hospitalization data.ResultsWe identified 252 737 people in Ontario and 63 238 people in Alberta who made frequent visits to the emergency department. In Ontario and Alberta, 44.3% and 44.7%, respectively, met the threshold for frequent use in only 1 year and made 37.9% and 38.5% of visits; 6.8% and 8.2% met the threshold for frequent use over 5 years and made 11.9% and 13.2% of visits. Many characteristics followed gradients based on persistence of frequent use: as years of frequent visits increased (1 to 5 years), people had more comorbidities, homelessness, rural residence, annual emergency department visits, alcohol- and substance use-related presentations, mental health hospitalizations and instances of leaving hospital against medical advice.InterpretationHigher levels of comorbidities, mental health issues, substance use and rural residence were seen with increasing years of frequent emergency department use. Interventions upstream and in the emergency department must address unmet needs, including services for substance use and social supports.

Dataset Information

Persistent frequent emergency department users with chronic conditions: A population-based cohort study.

Publications

Persistent frequent emergency department users with chronic conditions: A population-based cohort study.

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