Frequent emergency attenders: is there a better way?
Sue E. Kirby A B , Sarah M. Dennis A , Upali W. Jayasinghe A and Mark F. Harris AA Research Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia.
B Corresponding author. Email: s.kirby@student.unsw.edu.au
Australian Health Review 35(4) 462-467 https://doi.org/10.1071/AH10964
Submitted: 9 August 2010 Accepted: 16 February 2011 Published: 14 October 2011
Abstract
Background. Understanding the reasons for frequent re-attendances will assist in developing solutions to hospital overcrowding. This study aimed to identify the factors associated with frequent re-attendances in a regional hospital thereby highlighting possible solutions to the problem.
Methods. A retrospective analysis was performed on emergency department data from 2008. Frequent re-attenders were defined as those with four or more presentations in a year. Clinical, service usage and demographic patient characteristics were examined for their influence on re-presentations using multivariate analysis.
Results. A total of 8% of the total patients presenting to emergency re-attended four or more times in the year. Frequent re-attenders were older, presented with an unplanned returned visit and had a diagnosis of neurosis, chronic obstructive pulmonary disease (COPD), convulsions, dyspnoea or repeat prescriptions, follow-up examinations or dressings and sutures and less likely to present in summer. Frequent re-attendances were unrelated to sex, time of presentation or country of birth.
Conclusions. Diversion of patients with minor conditions to alternative services; referral of COPD patients to follow-up respiratory services and patients with neurosis to community mental health services would reduce emergency utilisation. Improving access to and resourcing of alternative non-hospital services should be investigated to reduce emergency overcrowding.
What is known about the topic? Frequent re-attendances at emergency contribute to emergency overcrowding and are a problem worldwide. Generally, frequent re-attendances have been associated with disadvantage. Identifying patient factors that predict re-attendances will assist in developing strategies to prevent their occurrence. The reasons for re-attendances may vary depending on access to other services and the role of the hospital.
What does this paper add? This paper adds to the field by demonstrating how routinely collected hospital data can be used to determine patient characteristics important in frequent re-attendances. The factors associated with frequently re-attending patients include older age, type of condition, unplanned return visit and season.
What are the implications for practitioners? This paper has implications for both administrators and clinicians. The diversion of attending patients with neurosis, COPD, dyspnoea or repeat prescriptions, follow-up examinations or dressings and sutures to alternative affordable and accessible services would reduce overcrowding in the emergency department.
References
[1] Byrne M, Murphy AW, Plunkett PK, McGee HM, Murray A, Bury G. Frequent attenders to an emergency department: a study of primary health care use, medical profile, and psychosocial characteristics. Ann Emerg Med 2003; 41 309–18.| Frequent attenders to an emergency department: a study of primary health care use, medical profile, and psychosocial characteristics.Crossref | GoogleScholarGoogle Scholar | 12605196PubMed |
[2] Locker TE, Baston S, Mason SM, Nicholl J. Defining frequent use of an urban emergency department. Emerg Med J 2007; 24 398–401.
| Defining frequent use of an urban emergency department.Crossref | GoogleScholarGoogle Scholar | 17513534PubMed |
[3] Williams ERL, Guthrie E, Mackway-Jones K, James M, Tomenson B, Eastham J, McNally D. Psychiatric status, somatisation, and health care utilization of frequent attenders at the emergency department: a comparison with routine attenders. J Psychosom Res 2001; 50 161–7.
| Psychiatric status, somatisation, and health care utilization of frequent attenders at the emergency department: a comparison with routine attenders.Crossref | GoogleScholarGoogle Scholar |
[4] Lynch RM, Greaves I. Regular attenders to the accident and emergency department. J Accid Emerg Med 2000; 17 351–4.
| 11005407PubMed |
[5] Chan BTB, Ovens HJ. Frequent users of emergency departments. Do they also use family physicians’ services? Can Fam Physician 2002; 48 1654–60.
[6] Pope D, Fernandes CM, Bouthillette F, Etherington J. Frequent users of the emergency department: a program to improve care and reduce visits. CMAJ 2000; 162 1017–20.
| 10763402PubMed |
[7] Olsson M, Hansagi H. Repeated use of the emergency department: qualitative study of the patient’s perspective. Emerg Med J 2001; 18 430–4.
| Repeated use of the emergency department: qualitative study of the patient’s perspective.Crossref | GoogleScholarGoogle Scholar | 11696488PubMed |
[8] Andrén KG, Rosenqvist U. Heavy users of an emergency department – a two year follow-up study. Soc Sci Med 1987; 25 825–31.
| Heavy users of an emergency department – a two year follow-up study.Crossref | GoogleScholarGoogle Scholar |
[9] Hansagi H, Olsson M, Sjoberg S, Tomson Y, Goransson S. Frequent use of the hospital emergency department is indicative of high use of other health care services. Ann Emerg Med 2001; 37 561–7.
| Frequent use of the hospital emergency department is indicative of high use of other health care services.Crossref | GoogleScholarGoogle Scholar | 11385324PubMed |
[10] Ansari Z, Laditka JN, Laditka SB. Access to health care and hospitalization for ambulatory care sensitive conditions. Med Care Res Rev 2006; 63 719–41.
| Access to health care and hospitalization for ambulatory care sensitive conditions.Crossref | GoogleScholarGoogle Scholar | 17099123PubMed |
[11] Kne T, Young R, Spillane L. Frequent ED users: patterns of use over time. Am J Emerg Med 1998; 16 648–52.
| Frequent ED users: patterns of use over time.Crossref | GoogleScholarGoogle Scholar | 9827738PubMed |
[12] Zuckerman S, Shen YC. Characteristics of occasional and frequent emergency department users do insurance coverage and access to care matter? Med Care 2004; 42 176–82.
| Characteristics of occasional and frequent emergency department users do insurance coverage and access to care matter?Crossref | GoogleScholarGoogle Scholar | 14734955PubMed |
[13] Mandelberg JH, Kuhn RE, Kohn MA. Epidemiologic analysis of an urban, public emergency department’s frequent users. Acad Emerg Med 2000; 7 637–46.
| Epidemiologic analysis of an urban, public emergency department’s frequent users.Crossref | GoogleScholarGoogle Scholar | 10905642PubMed |
[14] Blank FSJ, Li H, Henneman PL, Smithline HA, Santoro JS, Provost D, Maynard AM. A descriptive study of heavy emergency department users at an academic emergency department reveals heavy ED users have better access to care than average users. J Emerg Nurs 2005; 31 139–44.
| A descriptive study of heavy emergency department users at an academic emergency department reveals heavy ED users have better access to care than average users.Crossref | GoogleScholarGoogle Scholar |
[15] Bianco A, Pileggi C, Angelillo IF. Non-urgent visits to a hospital emergency department in Italy. Public Health 2003; 117 250–5.
| Non-urgent visits to a hospital emergency department in Italy.Crossref | GoogleScholarGoogle Scholar | 12966745PubMed |
[16] Huang J-A, Hu W-H, Yang D-Y, Weng R-H, Tsai W-C. Analysis of emergency department utilization by elderly patients under national health insurance. Kaohsiung J Med Sci 2003; 19 113–9.
| Analysis of emergency department utilization by elderly patients under national health insurance.Crossref | GoogleScholarGoogle Scholar | 12751871PubMed |
[17] Huang C-L, Choi W-M. Characteristics of emergency services for the elderly–a regional hospital example. Int J Geront 2009; 3 217–22.
| Characteristics of emergency services for the elderly–a regional hospital example.Crossref | GoogleScholarGoogle Scholar |
[18] Richardson DB. Elderly patients in the emergency department: a prospective study of characteristics and outcome. Med J Aust 1992; 157 234–9.
| 1435437PubMed |
[19] Dent AW, Phillips GA, Chenhall AJ, McGregor LR. The heaviest repeat users of an inner city emergency department are not general practice patients. Emerg Med 2003; 15 322–9.
| The heaviest repeat users of an inner city emergency department are not general practice patients.Crossref | GoogleScholarGoogle Scholar |
[20] Jelinek GA, Jiwa M, Gibson NP, Lynch AM. Frequent attenders at emergency departments: a linked-data population study of adult patients. Med J Aust 2008; 189 552–6.
| 19012551PubMed |
[21] Moore G, Gerdtz M, Manias E, Hepworth G, Dent A. Socio-demographic and clinical characteristics of re-presentation to an Australian inner-city emergency department: Implications for service delivery. BMC Public Health 2007; 7 320–330.
| Socio-demographic and clinical characteristics of re-presentation to an Australian inner-city emergency department: Implications for service delivery.Crossref | GoogleScholarGoogle Scholar | 17996112PubMed |
[22] Kirby SE, Dennis SM, Jayasingh UW, Harris MF. Patient related factors in frequent readmissions: the influence of condition, access to services and patient choice. BMC Health Serv Res 2010; 10 216
| Patient related factors in frequent readmissions: the influence of condition, access to services and patient choice.Crossref | GoogleScholarGoogle Scholar | 20663141PubMed |
[23] Hong R, Baumann BM, Boudreaux ED. The emergency department for routine healthcare: race/ethnicity, socioeconomic status, and perceptual factors. J Emerg Med 2007; 32 149–58.
| The emergency department for routine healthcare: race/ethnicity, socioeconomic status, and perceptual factors.Crossref | GoogleScholarGoogle Scholar | 17307624PubMed |
[24] How can we ground the ‘frequent fliers’? J Am Geriatr Soc 2007; 55 467–8.
| How can we ground the ‘frequent fliers’?Crossref | GoogleScholarGoogle Scholar |
[25] Campbell MK, Silver RW, Hoch JS, Ostbye T, Stewart M, Barnsley J, Hutchison B, Mathews M, Tyrrell C. Re-utilization outcomes and costs of minor acute illness treated at family physician offices, walk-in clinics, and emergency departments. Can Fam Physician 2005; 51 82–3.
[26] Andersen R, Newman JF. Societal and individual determinants of medical care utilization in the United States. Milbank Mem Fund Q 1973; 51 95–124.
| Societal and individual determinants of medical care utilization in the United States.Crossref | GoogleScholarGoogle Scholar |
[27] Penchansky R, Thomas JW. The concept of access. Definition and relationship to consumer satisfaction. Med Care 1981; 19 127–40.
| The concept of access. Definition and relationship to consumer satisfaction.Crossref | GoogleScholarGoogle Scholar |
[28] Policy on the Australian Triage Scale. Australasian College of Emergency Medicine; 2000 Available at http://www.acem.org.au/media/policies_and_guidelines/P06_Aust_Triage_Scale_-_Nov_2000.pdf [verified 26 September 2011].
[29] Pallant J. SPSS Survival Manual. Sydney: Allen & Unwin; 2007.
[30] Tabachnick BG, Fidell LS. Using Multivariate Statistics. Boston, MA: Pearson; 2007.
[31] Nagelkerke NJD. A note on the general definition of the coefficient of determination. Biometrika 1991; 78 691–2.
| A note on the general definition of the coefficient of determination.Crossref | GoogleScholarGoogle Scholar |
[32] Norusis MJ. SPSS professional statistics 6.1. Chicago, IL: SPSS Inc.; 1994.
[33] Supply of GPs in the Shellharbour area. Illawarra Division of General Practice; 2010. Available at http://www.idgp.org.au/general/information-for-general-practice.html [verified 27 July 2010].
[34] Planning & Report Summary for the year 2004–2005. Illawarra Division of General Practice, Primary Health Care Research & Information Service; 2005. Available at http://www.phcris.org.au/divisions/view.php?div=216&yearbp=2004 [verified 6 October 2011].
[35] Konstantikaki V, Kostikas K, Minas M, Batavanis G, Daniil Z, Gourgoulianis KI, Hatzoglou C. Comparison of a network of primary care physicians and an open spirometry programme for COPD diagnosis. Respir Med 2011; 105 274–81.
| Comparison of a network of primary care physicians and an open spirometry programme for COPD diagnosis.Crossref | GoogleScholarGoogle Scholar |
[36] Ansari K, Shamssain M, Farrow M, Keaney NP. Hospital-at-home care for exacerbations of chronic obstructive pulmonary disease: an observational cohort study of patients managed in hospital or by nurse practitioners in the community. Chron Respir Dis 2009; 6 69–74.
| Hospital-at-home care for exacerbations of chronic obstructive pulmonary disease: an observational cohort study of patients managed in hospital or by nurse practitioners in the community.Crossref | GoogleScholarGoogle Scholar |
[37] Bourbeau J, Van Der Palen J. Promoting effective self-management programmes to improve COPD. Eur Respir J 2009; 33 461–3.
| Promoting effective self-management programmes to improve COPD.Crossref | GoogleScholarGoogle Scholar |
[38] Bourbeau J. Preventing hospitalization for COPD exacerbations. Semin Respir Crit Care Med 2010; 31 313–20.
| Preventing hospitalization for COPD exacerbations.Crossref | GoogleScholarGoogle Scholar |
[39] The Health of the People of New South Wales. Report of the Chief health Officer, NSW, Sydney: NSW Health; 2010.
[40] Ieraci S, Cunningham P, Talbot-Stern J, Walker S. Emergency medicine and ‘acute’ general practice: comparing apples with oranges. Aust Health Rev 2000; 23 152–61.
| Emergency medicine and ‘acute’ general practice: comparing apples with oranges.Crossref | GoogleScholarGoogle Scholar |
[41] O’Connell T. Welcome: redesign for Hospital Avoidance. NSW Health; 2008. Available at http://www.changechampions.com.au/resource/Tony_OConnell.pdf [verified 26 September 2011].
[42] Bernstein GA, Massie ED, Thuras PD, Perwien AR, Borchardt CM, Crosby RD. Somatic symptoms in anxious-depressed school refusers. J Am Acad Child Adolesc Psychiatry 1997; 36 661–8.
| Somatic symptoms in anxious-depressed school refusers.Crossref | GoogleScholarGoogle Scholar |
[43] Fleishman JA, Cohen JW, Manning WG, Kosinski M. Using the SF-12 health status measure to improve predictions of medical expenditures. Med Care 2006; 44 I54–63.
