306
Review article
Systematic review of frequent users of emergency departments in non-US hospitals: state of the art Sofie van Tiela, Pleunie P.M. Rooda, Aida M. Bertoli-Avellaa, Vicky Erasmusb, Juanita Haagsmab, Ed van Beeckb, Peter Patkaa and Suzanne Polinderb This review focuses on frequent users (FUs) of the emergency department (ED). Elucidation of the characteristics of frequent ED users will help to improve healthcare services. A systematic review of the literature (from 1999 onwards) on frequent ED users in non-US hospitals was performed. Twenty-two studies were included. FUs are responsible for a wide variety of 1–31% of ED visits depending on the FU definition used. They have a mean age between 40 and 50 years and are older than nonfrequent users. Chronic physical and mental diseases seem to be the main reasons for frequent ED visits. In terms of social characteristics, lacking a partner is more frequently reported among FUs in some studies. The absence of a universal definition for FUs complicates the determination of the burden on emergency healthcare services. FUs are a
Introduction Hospital emergency departments (EDs) worldwide have experienced a sharp increase in patient volume in the past two decades [1]. Increasing interest has focused on a group of patients who contribute toward a disproportionate number of visits and may account for a large part of the resources and healthcare capacity at the ED [2]. To adapt healthcare facilities for the special needs of frequent users (FUs), the characteristics of these patients and their differences from nonfrequent users (NFUs) of the ED should be known. It is often assumed that FUs unfairly use EDs for primary care complaints and create unnecessary return visits for a variety of medical, mental, and social problems [3,4]. European literature supporting or refuting these assumptions is currently scarce. In 2010, LaCalle and Rabin [2] reviewed the literature on frequent ED visitors in hospitals across the USA. They concluded that FUs are a heterogeneous group and subgroups have not yet been sufficiently defined to allow clearly directed policy decisions. In this review, we aim to summarize patient characteristics of frequent ED visitors in non-US hospitals and describe how frequent ED use is influenced by social, disease, and care-related factors.
heterogeneous group of patients with genuine medical needs and high consumption of other healthcare services. European Journal of Emergency Medicine 22:306–315 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. European Journal of Emergency Medicine 2015, 22:306–315 Keywords: emergency department, frequent users, patient characteristics Departments of aEmergency Medicine and bPublic Health, Erasmus University Medical Centre, Rotterdam, The Netherlands Correspondence to Sofie van Tiel, MD, PO Box 2040, 3000 CA Rotterdam, The Netherlands Tel: + 31 10 703 8430; fax: + 31 10 703 5004; e-mail: [email protected] Received 7 October 2014 Accepted 22 December 2014
(1) Studies describing patients making four or more ED visits per year, which is the threshold used commonly in studies on FUs [2,4–6]. The study population comprises patients 18 years or older. (2) Studies describing one or more of the following information on the population of FUs: (a) Social history-related factors (age, sex, ethnicity, and marital status). (b) Disease-related factors (type and severity of illness). (c) Care-related factors [general practitioner (GP) or insurance status]. (3) Articles written in English and published after 1999 as we aimed to identify frequent ED users in the 21th century. Exclusion criteria were as follows: (1) Studies describing only one specific patient population who frequently visit the ED – for example, HIV patients, or homeless people. (2) Studies carried out in the USA as a recently published systematic review described the characteristics of frequent ED users in this country [2]. Search strategy
Methods Study selection
We included studies describing patient characteristics of frequent ED visitors. The inclusion criteria were as follows: 0969-9546 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
A systematic review of the literature was performed. As no standardized terms for this topic have been established, MEDLINE, Embase, and PubMed were searched (14 August 2013) using the following keywords: ‘emergency health service’ OR ‘emergency ward’ OR DOI: 10.1097/MEJ.0000000000000242
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Frequent emergency department users van Tiel et al. 307
(emergen* OR trauma OR acute OR accident* OR urgenc* OR department* OR ward* OR service* OR unit* OR center* OR room) AND (frequent OR return* OR patient* OR attend* OR user* OR usage OR use OR utili* OR presenter* OR visit* OR frequent us* OR returning patient OR frequent attend* OR frequent utili* OR frequent present*).
Data extraction
Two reviewers (S.v.T. and S.P.) independently examined the results retrieved through the database search to identify potentially relevant papers. Relevant papers were selected by screening the titles (first step), abstracts (second step), and entire articles (third step) to ensure that they fulfilled the selection criteria listed above. Fulltext articles were appraised critically, including methodological details and relevant outcomes, using data extraction forms, including information on study characteristics, the definition for frequent ED use, and different FU characteristics.
Results The database search identified 1233 titles of potentially relevant articles, of which 22 papers fulfilled the inclusion criteria (Fig. 1). Eleven of the studies included were carried out in European hospitals [7–17]. They all represented data from single hospitals, mostly university or teaching hospitals. The rest of the studies had been carried out in Australia, Canada, New Zealand, and Taiwan [18–28]. Four of these studies reviewed data from multiple hospitals. Only one study comprised patients 17 years and older, with an age range from 17 to 93 years [26]. A summary of the studies is presented in Table 1a and b. Six studies used the threshold of four or more ED visits per year to define FU [8,9,11,12,21,24]. All other studies set a higher number of visits of up to 12 or more ED visits per year [7,18].
Proportion of emergency department patients and emergency department visits
When FUs were defined as making four or more ED visits per year, they accounted for 3.5–7.7% of all ED patients during the study period [8,21,24]. They were responsible for 12.1–18% of all ED visits [8,11,21]. When the definition of 10 to 18 or more visits per year was used, FUs represented 0.1–0.3% of ED visitors [7,13,18–20]. These patients contributed to 0.8–3.6% of all ED visits [7,10,13,14,23]. Pope et al. [28] did not compose a definition for frequent ED use, but the 24 patients described made a total of 616 ED visits during the study period, with a median of 26.5 ED visits per FU during 1 year (Table 1a and b).
Demographic and social characteristics
In 13 out of 22 studies, more than 50% of the FUs were men [8–10,13,14,17,21–25,27,28]. This percentage seemed to increase with an increasing number of ED attendances (Table 2a and b) [13,22]. Doupe et al. [19] found that the majority of FU ED visits (54.3%) were made by men in the high-frequency visiting group (≥18 ED visits/year). Conversely, several other studies reported a percentage of female FU of 60% or more [7,12,26]. FUs had a mean age between 40 and 50 years [7,8,10,15, 16,22–24,27,28]. They were older than NFUs. All except one of the studies comparing the mean age of FUs with NFUs found that FUs are significantly older than NFUs. For example, Jelinek et al. [22] reported a mean age for FUs of 49 years whereas the mean age for NFUs was 45 years (P < 0.001). Several studies indicated that FUs are mainly not in a relationship as they are single, separated, divorced, or widowed [7–9,12,17,21,25,27]. In Canada, Australia, and Switzerland, it appeared that FU are significantly more often immigrants [2,15,29]. Unemployment or being dependent on government welfare applied to 82.6% of FUs in Switzerland [30]. Two other studies found that this percentage was significantly higher in FUs compared with NFUs [8,18]. In Edinburgh, Scotland, they found that 12% of frequent ED visitors are homeless [26]. This is the only study that discussed a relationship of homelessness and FU. Disease characteristics
There was considerable diversity in the primary diagnosis of FUs (Table 3a and b). FUs presented with somatic or mental health complaints or a combination of both. There was a wide variety of somatic complaints. Although a study from Taiwan reported that 19% of the frequent visitors are oncologic patients, studies from Canada reported arthritis (60%) and chronic pain (33.1%) as the reasons for FUs visiting the ED [19,21,28]. Respiratory problems seemed to be an important medical reason for FUs to visit the ED (11.5–37.6%) [11,18,19]. Nervous system problems were another common somatic cause [7,15,18]. Chronic diseases accounted for up to 40% of the ED visits, but few studies specified the chronic medical conditions of their patients. Congestive heart failure, ischemic heart disease, chronic obstructive pulmonary disease, renal insufficiency, diabetes, and cerebral vascular disease were the most mentioned examples [7,12,19]. FUs visits were rarely related to traumatic problems [2]. In Spain, only 4.6% of all ED attendances by FUs were the result of trauma [14]. Many FUs had a medical history of, or presented to, the ED with mental health conditions. The proportion of mental problems was higher in the FUs group in
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European Journal of Emergency Medicine 2015, Vol 22 No 5
Fig. 1
Literature search (MEDLINE, Embase, and PubMed)
Titles and abstracts reviewed N =1233 possible relevant articles
Exclusion based on title and abstract N =1192 excluded n=169
Published before 2000
n=880
Not relevant
n=133
Matched exclusion criteria
n=10
Systematic review articles
n=2
No abstract available
Full articles reviewed N = 41 Possible relevant articles
Exclusion based on full article N =19 excluded n =14
Matched exclusion criteria
n=5
No full text available
Articles included in systematic review N =22
Search strategy, results of literature search and reason for exclusion.
comparison with NFUs in all studies [8,9,18,21,22,24,25]. In three studies from Canada, mental diseases or psychiatric disorders were the main health problem of frequent ED visitors, ranging from 24 to 60% (Table 3b) [18,19,28]. Doupe et al. [19] calculated a significant higher odds ratio for personality disorders in this group. Another study found that the higher the number of ED visits per year, the larger the difference in the percentage
of mental health problems between the FUs and NFUs groups, with higher numbers of mental health problems in the FU group [22]. Often-presented mental conditions were anxiety and panic disorders, depression, schizophrenia, and somatoform syndromes [7,12,17,18]. Substance abuse was a common problem among FUs (Table 3a and b). Studies from Ireland, Switzerland, and
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Frequent emergency department users van Tiel et al. 309
Table 1
Summary of European (a) and non-European (b) studies included in the literature review
References Countries (a) European studies Hansagi et al. [11] Sweden Hansagi et al. [12] Sweden Skinner et al. [15] Scotland Williams et al. [17] England Theadom et al. [16] England Moore et al. [13] England
Sample size (of FUs)
Sample represents >1 hospital
Percentage of ED visits by FUs (%)b
Described patient characteristics
4
1894
No
18
1–3
4
1799
No
–
1, 2
10 ED visits/6 months
57
No
1.4
1–3
7
77
No
–
1–3
350
No
–
1, 3
Categorized: Single (or 1), 2, 3, 4, 5–9 and ≥ 10 attendances 10
2951
No
2
44
No
4 times/year: 5.1 5–9 times/year: 6.5 ≥ 10 times/year: 2.3 1.9
1, 2
4
1070
No
–
1, 2
4
1591
No
12.1
1–3
12
23
No
0.8
1–3
10
86
No
1.1
1,2
Not specified Median of 26.5 12
24
No
–
1, 2
6839
Yes
–
1–3
7–17
2177
Yes
9.9
1, 2
4
1096
No
14.3
1, 2
6
150
No
–
1–3
5
–
Yes
–
1, 2
4
1222
No
–
1, 2
8
540
Yes
4.2
1, 2
10
1996: 69 1997: 80 1998: 72 1999: 85 77
No
1, 2
No
1996: 1.4 1997: 1.8 1998: 1.8 1999: 2.1 1.7
No
2.3c
2
4 ED visits/6 months
Dent et al. [10] England Byrne et al. [9] Ireland Bieler et al. [8] Switzerland Althaus et al. [7] Switzerland Salazar et al. [14] Spain (b) Studies from other continents Pope et al. [28] Canada Chan and Ovens[18] Canada Doupe et al. [19] Canada Huang et al. [21] Taiwan Phillips et al. [27] Australia Jelinek et al. [22] Australia Kirby et al. [24] Australia Markham and Graudins [25] Australia Helliwell et al. [20] New Zealand
Kennedy and Ardagh [23] New Zealand Peddie et al. [26] New Zealand
Definition of FUs (≥ visits/year)a
10 10
87
1, 2
1, social; 2, disease; 3, care; ED, emergency department; FU, frequent users. a Unless noted otherwise. b Of all ED visits made during the study period. c Includes a small number of pediatric patients.
Canada reported the highest percentages of alcohol/drugs use as the reason for ED visits by FUs (22–38%) [7,9,19,28]. Dent et al. [10] reported concurrent alcohol use or long-term alcohol dependence in 55% of FUs, and 16% had documented use of illicit drugs including heroine, methadone, and cannabis. This was much higher than the 4% drug-dependent FUs described in a Canadian study [18]. Healthcare characteristics of frequent users
Seven studies described data on primary care. In total, 2–33% of FUs had no (registered) GP [7,8,15]. If
possible, FUs attended their GP on a regular basis. Hansagi et al. [11] reported that 72% of FUs made at least one GP visit per year and Chan and Ovens [18] found that more than 50% of their FUs made 12 or more GP visits per year. Williams et al. [17] reported that FUs made significantly more GP visits than NFUs. One study reported that of FUs almost 15% made one outpatient visit to a medical specialist and 49% made three or more visits during the study period [19]. Hansagi et al. [11] showed that 26% of FUs have made at least one visit to another hospital during the study period.
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– –
– – – 53
48
33.1
–
57
–
< 25 years: 40.2% P < 0.001 25–64 years: 45.2% P < 0.001 ≥ 65 years: 14.6% P < 0.001 17–24 years: 15.7% – 25–44 years: 33.1% 45–64 years: 26.2% 65–74 years: 9.2% ≥ 75 years: 15.7% 15–39 years: 34.5% P = 0.01 40–64 years: 35% > 64 years: 30.5% – –
–
–
–
55 (median)
(b) Studies from other continents Pope et al. [28] 46 Canada Chan and Ovens < 25 years: 18.6% [18] 25–64 years: 62.2% Canada ≥ 65 years: 19.2% Doupe et al. [19] 17–24 years: 9.5% 25–44 years: 31.7% Canada 45–64 years: 27.4% 65–74 years: 11.2% ≥ 75 years: 20.2% Huang et al. [21] 15–39 years: 14% Taiwan 40–64 years: 39.5% > 64 years: 46.5% Phillips et al. [27] 48 Australia
–
–
42.9
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–
– 32
Married: 10.5 (19.7) Single: 78 (71.3)
P < 0.001 37
44.2
52.1
51.3
–
50.0
–
–
–
Socially isolated: 91
Married: 35 (38) Single: 40 (37) Separated: 8 (6) Widowed: 17 (19) Separated: 19.8 (11.1) (P = 0.001) Widowed: 8.6 (9.8) (NS)
–
–
In relationship: 17.1 (35) Single: 42.9 (58.2) –
Married: 53 Living alone: 47 –
–
Marital status (%) (compared with NFUs if available, %)
–
–
–
–
NS
NS
–
–
–
–
–
–
–
P value
P < 0.001
–
–
–
48.1
32
–
–
–
32.4
–
–
–
NFUs
55.1
41.7
33
60.9
47.9
32
–
NS
36
48.7
56
–
45.7
Althaus et al. [7] Switzerland Salazar et al. [14] Spain
44.2
P = 0.02
30.5
36.6
44.7
–
–
–
67.8
43.6
51
FUs
–
–
P value
–
–
NFUs
Sex (female) (%)
0–14 years: 14% 15–44 years: 31% 45–64 years: 23% ≥ 65 years: 32% 54
Bieler et al. [8] Switzerland
Hansagi et al. [12] Sweden Skinner et al. [15] Scotland Williams et al. [17] England Theadom et al. [16] England Moore et al. [13] England Dent et al. [10] England Byrne et al. [9] Ireland
(a) European studies Hansagi et al. [11] Sweden
FUs
Age (mean) (years)a
–
–
Unemployed: 7.1 (6.3) (P < 0.001) Average income: 42 500 (51 200) (P < 0.001) –
–
Unemployed/dependent on government welfare: 82.6 –
Unemployed/dependent on government welfare: 32.3 (14.1) (P < 0.001)
–
–
–
–
–
–
–
–
Income (compared with NFUs if available, %)
Immigrants: 92
–
–
Immigrants: 15.1 (13.1) (P < 0.001)
–
–
Switzerland: 50.7 (53.9) (NS) Europe: 16.7 (23.1) (P = 0.04) Other: 32.6 (23.1) (P = 0.003) –
–
–
–
–
–
–
–
–
Origin (compared with NFUs if available, %)
Demographics and other social-related characteristics for frequent emergency department visitors from European countries (a) and non-European countries (b)
References Countries
Table 2
310 European Journal of Emergency Medicine 2015, Vol 22 No 5
–
–
–
–
–
Married: 41.8 (53.9) (P = 0.0003) Divorced: 13.6 (6.5) (P < 0.0001) Single: 29.1 (29.1) (NS) Widowed: 8.9 (7.3) (NS) Single: 70
– –
–
Triage categories with lower urgencies in FUs than NFUs have been reported [21,24]. For example, 71% of FUs are triaged in a low-urgency group compared with only 39% in the NFUs [21]. However, Markham and Graudins [25] found no difference in acuity by triage category and Moore et al. [13] found that the percentage of most urgent triage categories was highest in FUs visiting 10 times or more per year. The hospital admission rate after ED visits differed between the articles. Three studies found an admission rate of around 25% [7,16,25]. Almost 60% of FUs admitted for a somatic reason have 6 or more hospitalization days. When admitted because of mental problems, 52% stayed at least 1 day [7]. With increasing number of ED visits, admission rates seemed to decrease, starting with 36.6% for patients making 5–9 visits per year, to 12% in patients who attend more than 40 times per year [22]. Salazar et al. [14] found that FUs are 18% less frequently admitted than the general population.
60 –
–
–
41
35
FU, frequent users; NFUs, nonfrequent users. Unless noted otherwise. a
– 35
Discussion
Helliwell et al. [20] New Zealand Kennedy and Ardagh [23] New Zealand Peddie et al. [26] New Zealand
45 (median) 47 (median)
Up to 50% of FUs were transported to the ED by ambulance. This was more common in comparison with NFUs [22,25]. Even when the total number of ED visits by FUs decreased, the percentage of transport by ambulance for frequent attenders remained the same [27]. There was no consensus on the time of presentation to the ED. Although Kirby et al. [24] found that FUs made significantly fewer visits during the weekends, Dent et al. [10] described evenly distributed attendances throughout the week. In Switzerland, FUs appeared to make more attendances during the evening and night (67%) [7].
–
– – – 43 –
–
– 50 –
–
48.4 P = 0.02
51.8
NS
Australian born: 78.7 (83.9) (P < 0.01) – – – NS 48 39.6 47.7
P < 0.05
28.8% in 40 + FUs 44.6 45 49
Jelinek et al. [22] Australia Kirby et al. [24] Australia Markham and Graudins [25] Australia
One study described data on the ED visitors’ health insurance status. FUs were significantly more often uninsured (11% compared with 3% in the NFUs group) [8]. Other characteristics
P < 0.001
48.4
–
–
–
–
Frequent emergency department users van Tiel et al. 311
In this review, we ascertained the characteristics of frequent visitors of the ED. These characteristics vary considerably, even in studies from the same country. The most important finding is that frequent visitors are a heterogeneous group of patients in terms of demographic, disease, and health characteristics. FUs are responsible for a wide variety of 1–31% of ED visits (according to the applied definition). They are mostly middle aged and older than NFUs, with men and women represented equally, more frequently have chronic diseases than NFUs, and more often have a history of mental disorders. Characteristics
The age group 40–50 years is the highest represented among FUs. There are no sex differences. This is in contrast to frequent ED visitors in the USA, where
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312 European Journal of Emergency Medicine 2015, Vol 22 No 5
Table 3
Disease-related characteristics for frequent emergency department users from European studies (a) and non-European studies (b)
References Countries (a) European studies Hansagi et al. [11] Sweden Hansagi et al. [12] Sweden Skinner et al. [15] Scotland Dent et al. [10] England
Byrne et al. [9] Ireland
Bieler et al. [8] Switzerland Althaus et al. [7] Switzerland Salazar et al. [14] Spain
Somatic disorders and/or affected organ system (%)a Circulatory: 1.4 Respiratory: 32.4 Diabetes: 2.8 Chronic disease(s): 41 Combination of both: 12 –
Collapse: 4.7 Abdominal pain: 15.0 Chest pain: 8.3 Minor injury: 13.7 Gastrointestinal: 14 Circulatory: 23 Respiratory: 12 Musculoskeletal: 17 –
Nervous system: 56.5 Gastrointestinal: 56.5 Multiple significant trauma: 65.2 Surgical: 19.7 Ophthalmic: 9.3 Otolaryngologic: 4.6 Trauma: 4.6
(b) Studies from other continents Pope et al. [28] Chronic pain: 33 Canada Hepatitis B/C of HIV: 17 Chan and Ovens [18] Nervous system: 13.3 Canada Circulatory: 8.0 Respiratory: 11.5 Urogenital: 2.6 Obstetric/gynecologic: 2.4 Endocrine: 2.9 Musculoskeletal: 10.3 Dermatologic: 2.8 Otolaryngologic/ophthalmology: 1.3 Oncologic/hematologic: 3.1 Trauma: 5.0 Doupe et al. [19] Arthritis: 60.1 Canada Asthma: 37.6 Diabetes: 28.4 Circulatory: 31.3 Stroke: 17.4 Huang et al. [21] Gastrointestinal: 14.5 Taiwan Circulatory: 11.0 Respiratory: 5.0 Urogenital: 8.5 Obstetric/gynecologic: 2.0 Oncologic: 19 Trauma: 2.5 Phillips et al. [27] – Australia Jelinek et al. [22] Australia
Kirby et al. [24] Australia
Trauma: 5–9 ED visits/year: 18 > 40 ED visits/year: 13 Circulatory: 5–9 ED visits/year: 9.1 > 40 ED visits/year: 2.4 Chest pain: 5.2 Abdominal pain: 4.5 Dyspnea: 3.8 Minor injury: 2.9 Urogenital: 1.5 Back pain: 1.5 Convulsions: 1.4 COPD: 1.3 Cellulitis: 1.3 Respiratory: 8.1 Gastrointestinal/surgery: 13.9
Mental disease and disorders (%)a 9.9
Mental disease: 16 –
Deliberate self-harm: 9.5
11
Substance abuse (%)a
– –
Alcohol use: 3.1 Overdose: 3.2
87
Alcohol use: 34.8 Cannabis or other drugs: 21.7 –
Anxiety: 34.3 Depression: 60.3 Dementia: 21.6 Personality disorder: 13.3 7.0
– > 40 ED visits/year: 25.9
– Alcohol abuse: 46 Mental disease: 37 Chronic disease: 40 –
–
Alcohol/drug use: 38
–
Personality disorder: 33 Violence and depression: 25 Psychosocial: 24.0
–
Alcohol/drug use: 5.6
–
9.3
Primary ED diagnosis (%)
Injury: 12.0 Substance abuse: 12.3 Mental disorder: 9.4 Either mental health or substance abuse: 60.9 Recurrent medical reason for ED use: 52.3
–
Alcohol use: 33 Drug use: 33 –
–
–
35.9
–
Alcohol use: 5.5
– –
Medical: 27 Mental disease: 30 Substance abuse: 43 –
6.5
–
–
15.7
–
–
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Frequent emergency department users van Tiel et al. 313
Table 3 (continued) References Countries Markham and Graudins [25] Australia
Helliwell et al. [20] New Zealand Kennedy and Ardagh [23] New Zealand Peddie et al. [26] New Zealand
Mental disease and disorders (%)a
Substance abuse (%)a
–
–
–
–
–
–
–
–
Somatic disorders and/or affected organ system (%)a Neurology: 6.3 Renal/urology: 3.6 Cardiovascular: 11.3 Trauma: 15.4 Cancer related: 0.3 Endocrine: 1.2 Hematologic: 1.2 Acute infection: 6.9 Obstetric/gynecologic: 2.6 –
Primary ED diagnosis (%)
Medical: 51 Mental disease: 33 Substance abuse: 16 Medical: 45 Mental disease: 29 Substance abuse: 26 Medical: 49 Mental disease: 49 Substance abuse: 2
COPD, chronic obstructive pulmonary disease; ED, emergency department. a In medical history or as the primary reason for ED visit.
women are over-represented [2]. Many of the FUs do not have a relationship, suggesting a possible association between social isolation and frequent ED use. Little is reported on the number of FUs being homeless, but unemployment, a lower income, or being dependent on government welfare are more common among some frequent ED visitors [7,8,18]. Three studies comparing FUs with NFUs show a significant presence of immigrants in the FUs group (Table 2a and b) [8,18,24]. The presumption that ED visits are mostly based on mental complaints is not substantiated. Chronic somatic complaints seem to be the main reason for ED visits made by FUs. Yet, many FUs also have a history of mental disorders [7,15,18–20,23,26]. The fact that frequent visitors are more often transported to the ED by ambulance suggests that their visits are the result of urgent medical conditions. This is contradicted by the finding that (except for reports of Moore et al. [13]) triage categories for FUs correspond to lower urgencies than for NFUs [21,22,24,25]. The reasons for this discrepancy are not described. Possibly, patients with chronic medical conditions more frequently call the ambulance service as these patients are more familiar with the healthcare and ambulance system. Other options are that these FUs present themselves with potentially serious complaints; however, after a thorough examination in the ED no acute illness is found or the acuity of the medical condition is reduced because of the treatment provided by the ambulance personnel. Most FUs have a GP and make use of these services [9,19,28]. Thus, FUs appear to have concurrent high consumption of primary care and healthcare services in general [11,17–19]. A similar situation was described for FUs in the USA [31–33]. This raises the question of whether encouraging primary care and outpatient visits
would lower the burden that frequent visitors place on EDs.
Subdivision of frequent visitors
As FUs are a heterogeneous patient group, subdivisions are difficult to define. Eight of the included studies include data on patients making 10 or more visits per year [7,10,15,18,20,23,26,28]. These highly FUs show no difference in the primary reasons for ED visits compared with the other FUs. There are also no differences in other social and care-related factors between frequent (≥4 visits) and highly frequent ED users (≥10 visits).
International perspective
This review includes information on frequent ED visitors from six different European countries. The other studies included are from Canada, Australia, New Zealand, and Taiwan. There are no distinct factors for FUs that outline differences between European and non-European FUs (Table 1a and b). Similar to our findings, US FUs account for up to one-third of all ED visits and have a mean age closer to 40 years [2,34]. FUs in the USA also show heterogeneity in the types of complaints and the reasons to visit the ED [2]. Most of the US FUs have GPs and are also heavy consumers of other parts of the healthcare system [31,32]. Frequent visitors in the USA have higher acuity complaints than occasional ED users, whereas Australian, English, and Taiwanese FUs have lower urgencies than NFUs, resembling less serious illnesses [2,21,24]. There is also a difference in the probability of hospital admission. We found that about one-quarter of FUs get admitted, with decreasing admission rates by increasing number of ED visits, whereas LaCalle and Rabin [2]
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314 European Journal of Emergency Medicine 2015, Vol 22 No 5
found that the probability of admission is greater for FUs versus NFUs in the USA.
References 1 2
Limitations
As no standard definition for FUs exists and the studies included applied different thresholds defining FUs, a comparison of their impact on ED's healthcare capacity is difficult. This may be underestimated as only six reviewed studies included patients making four or more ED visits per year. In studies defining FUs with higher visiting rates per year, their contribution toward the burden of care on the ED is small (
Review article
Systematic review of frequent users of emergency departments in non-US hospitals: state of the art Sofie van Tiela, Pleunie P.M. Rooda, Aida M. Bertoli-Avellaa, Vicky Erasmusb, Juanita Haagsmab, Ed van Beeckb, Peter Patkaa and Suzanne Polinderb This review focuses on frequent users (FUs) of the emergency department (ED). Elucidation of the characteristics of frequent ED users will help to improve healthcare services. A systematic review of the literature (from 1999 onwards) on frequent ED users in non-US hospitals was performed. Twenty-two studies were included. FUs are responsible for a wide variety of 1–31% of ED visits depending on the FU definition used. They have a mean age between 40 and 50 years and are older than nonfrequent users. Chronic physical and mental diseases seem to be the main reasons for frequent ED visits. In terms of social characteristics, lacking a partner is more frequently reported among FUs in some studies. The absence of a universal definition for FUs complicates the determination of the burden on emergency healthcare services. FUs are a
Introduction Hospital emergency departments (EDs) worldwide have experienced a sharp increase in patient volume in the past two decades [1]. Increasing interest has focused on a group of patients who contribute toward a disproportionate number of visits and may account for a large part of the resources and healthcare capacity at the ED [2]. To adapt healthcare facilities for the special needs of frequent users (FUs), the characteristics of these patients and their differences from nonfrequent users (NFUs) of the ED should be known. It is often assumed that FUs unfairly use EDs for primary care complaints and create unnecessary return visits for a variety of medical, mental, and social problems [3,4]. European literature supporting or refuting these assumptions is currently scarce. In 2010, LaCalle and Rabin [2] reviewed the literature on frequent ED visitors in hospitals across the USA. They concluded that FUs are a heterogeneous group and subgroups have not yet been sufficiently defined to allow clearly directed policy decisions. In this review, we aim to summarize patient characteristics of frequent ED visitors in non-US hospitals and describe how frequent ED use is influenced by social, disease, and care-related factors.
heterogeneous group of patients with genuine medical needs and high consumption of other healthcare services. European Journal of Emergency Medicine 22:306–315 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. European Journal of Emergency Medicine 2015, 22:306–315 Keywords: emergency department, frequent users, patient characteristics Departments of aEmergency Medicine and bPublic Health, Erasmus University Medical Centre, Rotterdam, The Netherlands Correspondence to Sofie van Tiel, MD, PO Box 2040, 3000 CA Rotterdam, The Netherlands Tel: + 31 10 703 8430; fax: + 31 10 703 5004; e-mail: [email protected] Received 7 October 2014 Accepted 22 December 2014
(1) Studies describing patients making four or more ED visits per year, which is the threshold used commonly in studies on FUs [2,4–6]. The study population comprises patients 18 years or older. (2) Studies describing one or more of the following information on the population of FUs: (a) Social history-related factors (age, sex, ethnicity, and marital status). (b) Disease-related factors (type and severity of illness). (c) Care-related factors [general practitioner (GP) or insurance status]. (3) Articles written in English and published after 1999 as we aimed to identify frequent ED users in the 21th century. Exclusion criteria were as follows: (1) Studies describing only one specific patient population who frequently visit the ED – for example, HIV patients, or homeless people. (2) Studies carried out in the USA as a recently published systematic review described the characteristics of frequent ED users in this country [2]. Search strategy
Methods Study selection
We included studies describing patient characteristics of frequent ED visitors. The inclusion criteria were as follows: 0969-9546 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
A systematic review of the literature was performed. As no standardized terms for this topic have been established, MEDLINE, Embase, and PubMed were searched (14 August 2013) using the following keywords: ‘emergency health service’ OR ‘emergency ward’ OR DOI: 10.1097/MEJ.0000000000000242
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Frequent emergency department users van Tiel et al. 307
(emergen* OR trauma OR acute OR accident* OR urgenc* OR department* OR ward* OR service* OR unit* OR center* OR room) AND (frequent OR return* OR patient* OR attend* OR user* OR usage OR use OR utili* OR presenter* OR visit* OR frequent us* OR returning patient OR frequent attend* OR frequent utili* OR frequent present*).
Data extraction
Two reviewers (S.v.T. and S.P.) independently examined the results retrieved through the database search to identify potentially relevant papers. Relevant papers were selected by screening the titles (first step), abstracts (second step), and entire articles (third step) to ensure that they fulfilled the selection criteria listed above. Fulltext articles were appraised critically, including methodological details and relevant outcomes, using data extraction forms, including information on study characteristics, the definition for frequent ED use, and different FU characteristics.
Results The database search identified 1233 titles of potentially relevant articles, of which 22 papers fulfilled the inclusion criteria (Fig. 1). Eleven of the studies included were carried out in European hospitals [7–17]. They all represented data from single hospitals, mostly university or teaching hospitals. The rest of the studies had been carried out in Australia, Canada, New Zealand, and Taiwan [18–28]. Four of these studies reviewed data from multiple hospitals. Only one study comprised patients 17 years and older, with an age range from 17 to 93 years [26]. A summary of the studies is presented in Table 1a and b. Six studies used the threshold of four or more ED visits per year to define FU [8,9,11,12,21,24]. All other studies set a higher number of visits of up to 12 or more ED visits per year [7,18].
Proportion of emergency department patients and emergency department visits
When FUs were defined as making four or more ED visits per year, they accounted for 3.5–7.7% of all ED patients during the study period [8,21,24]. They were responsible for 12.1–18% of all ED visits [8,11,21]. When the definition of 10 to 18 or more visits per year was used, FUs represented 0.1–0.3% of ED visitors [7,13,18–20]. These patients contributed to 0.8–3.6% of all ED visits [7,10,13,14,23]. Pope et al. [28] did not compose a definition for frequent ED use, but the 24 patients described made a total of 616 ED visits during the study period, with a median of 26.5 ED visits per FU during 1 year (Table 1a and b).
Demographic and social characteristics
In 13 out of 22 studies, more than 50% of the FUs were men [8–10,13,14,17,21–25,27,28]. This percentage seemed to increase with an increasing number of ED attendances (Table 2a and b) [13,22]. Doupe et al. [19] found that the majority of FU ED visits (54.3%) were made by men in the high-frequency visiting group (≥18 ED visits/year). Conversely, several other studies reported a percentage of female FU of 60% or more [7,12,26]. FUs had a mean age between 40 and 50 years [7,8,10,15, 16,22–24,27,28]. They were older than NFUs. All except one of the studies comparing the mean age of FUs with NFUs found that FUs are significantly older than NFUs. For example, Jelinek et al. [22] reported a mean age for FUs of 49 years whereas the mean age for NFUs was 45 years (P < 0.001). Several studies indicated that FUs are mainly not in a relationship as they are single, separated, divorced, or widowed [7–9,12,17,21,25,27]. In Canada, Australia, and Switzerland, it appeared that FU are significantly more often immigrants [2,15,29]. Unemployment or being dependent on government welfare applied to 82.6% of FUs in Switzerland [30]. Two other studies found that this percentage was significantly higher in FUs compared with NFUs [8,18]. In Edinburgh, Scotland, they found that 12% of frequent ED visitors are homeless [26]. This is the only study that discussed a relationship of homelessness and FU. Disease characteristics
There was considerable diversity in the primary diagnosis of FUs (Table 3a and b). FUs presented with somatic or mental health complaints or a combination of both. There was a wide variety of somatic complaints. Although a study from Taiwan reported that 19% of the frequent visitors are oncologic patients, studies from Canada reported arthritis (60%) and chronic pain (33.1%) as the reasons for FUs visiting the ED [19,21,28]. Respiratory problems seemed to be an important medical reason for FUs to visit the ED (11.5–37.6%) [11,18,19]. Nervous system problems were another common somatic cause [7,15,18]. Chronic diseases accounted for up to 40% of the ED visits, but few studies specified the chronic medical conditions of their patients. Congestive heart failure, ischemic heart disease, chronic obstructive pulmonary disease, renal insufficiency, diabetes, and cerebral vascular disease were the most mentioned examples [7,12,19]. FUs visits were rarely related to traumatic problems [2]. In Spain, only 4.6% of all ED attendances by FUs were the result of trauma [14]. Many FUs had a medical history of, or presented to, the ED with mental health conditions. The proportion of mental problems was higher in the FUs group in
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308
European Journal of Emergency Medicine 2015, Vol 22 No 5
Fig. 1
Literature search (MEDLINE, Embase, and PubMed)
Titles and abstracts reviewed N =1233 possible relevant articles
Exclusion based on title and abstract N =1192 excluded n=169
Published before 2000
n=880
Not relevant
n=133
Matched exclusion criteria
n=10
Systematic review articles
n=2
No abstract available
Full articles reviewed N = 41 Possible relevant articles
Exclusion based on full article N =19 excluded n =14
Matched exclusion criteria
n=5
No full text available
Articles included in systematic review N =22
Search strategy, results of literature search and reason for exclusion.
comparison with NFUs in all studies [8,9,18,21,22,24,25]. In three studies from Canada, mental diseases or psychiatric disorders were the main health problem of frequent ED visitors, ranging from 24 to 60% (Table 3b) [18,19,28]. Doupe et al. [19] calculated a significant higher odds ratio for personality disorders in this group. Another study found that the higher the number of ED visits per year, the larger the difference in the percentage
of mental health problems between the FUs and NFUs groups, with higher numbers of mental health problems in the FU group [22]. Often-presented mental conditions were anxiety and panic disorders, depression, schizophrenia, and somatoform syndromes [7,12,17,18]. Substance abuse was a common problem among FUs (Table 3a and b). Studies from Ireland, Switzerland, and
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Frequent emergency department users van Tiel et al. 309
Table 1
Summary of European (a) and non-European (b) studies included in the literature review
References Countries (a) European studies Hansagi et al. [11] Sweden Hansagi et al. [12] Sweden Skinner et al. [15] Scotland Williams et al. [17] England Theadom et al. [16] England Moore et al. [13] England
Sample size (of FUs)
Sample represents >1 hospital
Percentage of ED visits by FUs (%)b
Described patient characteristics
4
1894
No
18
1–3
4
1799
No
–
1, 2
10 ED visits/6 months
57
No
1.4
1–3
7
77
No
–
1–3
350
No
–
1, 3
Categorized: Single (or 1), 2, 3, 4, 5–9 and ≥ 10 attendances 10
2951
No
2
44
No
4 times/year: 5.1 5–9 times/year: 6.5 ≥ 10 times/year: 2.3 1.9
1, 2
4
1070
No
–
1, 2
4
1591
No
12.1
1–3
12
23
No
0.8
1–3
10
86
No
1.1
1,2
Not specified Median of 26.5 12
24
No
–
1, 2
6839
Yes
–
1–3
7–17
2177
Yes
9.9
1, 2
4
1096
No
14.3
1, 2
6
150
No
–
1–3
5
–
Yes
–
1, 2
4
1222
No
–
1, 2
8
540
Yes
4.2
1, 2
10
1996: 69 1997: 80 1998: 72 1999: 85 77
No
1, 2
No
1996: 1.4 1997: 1.8 1998: 1.8 1999: 2.1 1.7
No
2.3c
2
4 ED visits/6 months
Dent et al. [10] England Byrne et al. [9] Ireland Bieler et al. [8] Switzerland Althaus et al. [7] Switzerland Salazar et al. [14] Spain (b) Studies from other continents Pope et al. [28] Canada Chan and Ovens[18] Canada Doupe et al. [19] Canada Huang et al. [21] Taiwan Phillips et al. [27] Australia Jelinek et al. [22] Australia Kirby et al. [24] Australia Markham and Graudins [25] Australia Helliwell et al. [20] New Zealand
Kennedy and Ardagh [23] New Zealand Peddie et al. [26] New Zealand
Definition of FUs (≥ visits/year)a
10 10
87
1, 2
1, social; 2, disease; 3, care; ED, emergency department; FU, frequent users. a Unless noted otherwise. b Of all ED visits made during the study period. c Includes a small number of pediatric patients.
Canada reported the highest percentages of alcohol/drugs use as the reason for ED visits by FUs (22–38%) [7,9,19,28]. Dent et al. [10] reported concurrent alcohol use or long-term alcohol dependence in 55% of FUs, and 16% had documented use of illicit drugs including heroine, methadone, and cannabis. This was much higher than the 4% drug-dependent FUs described in a Canadian study [18]. Healthcare characteristics of frequent users
Seven studies described data on primary care. In total, 2–33% of FUs had no (registered) GP [7,8,15]. If
possible, FUs attended their GP on a regular basis. Hansagi et al. [11] reported that 72% of FUs made at least one GP visit per year and Chan and Ovens [18] found that more than 50% of their FUs made 12 or more GP visits per year. Williams et al. [17] reported that FUs made significantly more GP visits than NFUs. One study reported that of FUs almost 15% made one outpatient visit to a medical specialist and 49% made three or more visits during the study period [19]. Hansagi et al. [11] showed that 26% of FUs have made at least one visit to another hospital during the study period.
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– –
– – – 53
48
33.1
–
57
–
< 25 years: 40.2% P < 0.001 25–64 years: 45.2% P < 0.001 ≥ 65 years: 14.6% P < 0.001 17–24 years: 15.7% – 25–44 years: 33.1% 45–64 years: 26.2% 65–74 years: 9.2% ≥ 75 years: 15.7% 15–39 years: 34.5% P = 0.01 40–64 years: 35% > 64 years: 30.5% – –
–
–
–
55 (median)
(b) Studies from other continents Pope et al. [28] 46 Canada Chan and Ovens < 25 years: 18.6% [18] 25–64 years: 62.2% Canada ≥ 65 years: 19.2% Doupe et al. [19] 17–24 years: 9.5% 25–44 years: 31.7% Canada 45–64 years: 27.4% 65–74 years: 11.2% ≥ 75 years: 20.2% Huang et al. [21] 15–39 years: 14% Taiwan 40–64 years: 39.5% > 64 years: 46.5% Phillips et al. [27] 48 Australia
–
–
42.9
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–
– 32
Married: 10.5 (19.7) Single: 78 (71.3)
P < 0.001 37
44.2
52.1
51.3
–
50.0
–
–
–
Socially isolated: 91
Married: 35 (38) Single: 40 (37) Separated: 8 (6) Widowed: 17 (19) Separated: 19.8 (11.1) (P = 0.001) Widowed: 8.6 (9.8) (NS)
–
–
In relationship: 17.1 (35) Single: 42.9 (58.2) –
Married: 53 Living alone: 47 –
–
Marital status (%) (compared with NFUs if available, %)
–
–
–
–
NS
NS
–
–
–
–
–
–
–
P value
P < 0.001
–
–
–
48.1
32
–
–
–
32.4
–
–
–
NFUs
55.1
41.7
33
60.9
47.9
32
–
NS
36
48.7
56
–
45.7
Althaus et al. [7] Switzerland Salazar et al. [14] Spain
44.2
P = 0.02
30.5
36.6
44.7
–
–
–
67.8
43.6
51
FUs
–
–
P value
–
–
NFUs
Sex (female) (%)
0–14 years: 14% 15–44 years: 31% 45–64 years: 23% ≥ 65 years: 32% 54
Bieler et al. [8] Switzerland
Hansagi et al. [12] Sweden Skinner et al. [15] Scotland Williams et al. [17] England Theadom et al. [16] England Moore et al. [13] England Dent et al. [10] England Byrne et al. [9] Ireland
(a) European studies Hansagi et al. [11] Sweden
FUs
Age (mean) (years)a
–
–
Unemployed: 7.1 (6.3) (P < 0.001) Average income: 42 500 (51 200) (P < 0.001) –
–
Unemployed/dependent on government welfare: 82.6 –
Unemployed/dependent on government welfare: 32.3 (14.1) (P < 0.001)
–
–
–
–
–
–
–
–
Income (compared with NFUs if available, %)
Immigrants: 92
–
–
Immigrants: 15.1 (13.1) (P < 0.001)
–
–
Switzerland: 50.7 (53.9) (NS) Europe: 16.7 (23.1) (P = 0.04) Other: 32.6 (23.1) (P = 0.003) –
–
–
–
–
–
–
–
–
Origin (compared with NFUs if available, %)
Demographics and other social-related characteristics for frequent emergency department visitors from European countries (a) and non-European countries (b)
References Countries
Table 2
310 European Journal of Emergency Medicine 2015, Vol 22 No 5
–
–
–
–
–
Married: 41.8 (53.9) (P = 0.0003) Divorced: 13.6 (6.5) (P < 0.0001) Single: 29.1 (29.1) (NS) Widowed: 8.9 (7.3) (NS) Single: 70
– –
–
Triage categories with lower urgencies in FUs than NFUs have been reported [21,24]. For example, 71% of FUs are triaged in a low-urgency group compared with only 39% in the NFUs [21]. However, Markham and Graudins [25] found no difference in acuity by triage category and Moore et al. [13] found that the percentage of most urgent triage categories was highest in FUs visiting 10 times or more per year. The hospital admission rate after ED visits differed between the articles. Three studies found an admission rate of around 25% [7,16,25]. Almost 60% of FUs admitted for a somatic reason have 6 or more hospitalization days. When admitted because of mental problems, 52% stayed at least 1 day [7]. With increasing number of ED visits, admission rates seemed to decrease, starting with 36.6% for patients making 5–9 visits per year, to 12% in patients who attend more than 40 times per year [22]. Salazar et al. [14] found that FUs are 18% less frequently admitted than the general population.
60 –
–
–
41
35
FU, frequent users; NFUs, nonfrequent users. Unless noted otherwise. a
– 35
Discussion
Helliwell et al. [20] New Zealand Kennedy and Ardagh [23] New Zealand Peddie et al. [26] New Zealand
45 (median) 47 (median)
Up to 50% of FUs were transported to the ED by ambulance. This was more common in comparison with NFUs [22,25]. Even when the total number of ED visits by FUs decreased, the percentage of transport by ambulance for frequent attenders remained the same [27]. There was no consensus on the time of presentation to the ED. Although Kirby et al. [24] found that FUs made significantly fewer visits during the weekends, Dent et al. [10] described evenly distributed attendances throughout the week. In Switzerland, FUs appeared to make more attendances during the evening and night (67%) [7].
–
– – – 43 –
–
– 50 –
–
48.4 P = 0.02
51.8
NS
Australian born: 78.7 (83.9) (P < 0.01) – – – NS 48 39.6 47.7
P < 0.05
28.8% in 40 + FUs 44.6 45 49
Jelinek et al. [22] Australia Kirby et al. [24] Australia Markham and Graudins [25] Australia
One study described data on the ED visitors’ health insurance status. FUs were significantly more often uninsured (11% compared with 3% in the NFUs group) [8]. Other characteristics
P < 0.001
48.4
–
–
–
–
Frequent emergency department users van Tiel et al. 311
In this review, we ascertained the characteristics of frequent visitors of the ED. These characteristics vary considerably, even in studies from the same country. The most important finding is that frequent visitors are a heterogeneous group of patients in terms of demographic, disease, and health characteristics. FUs are responsible for a wide variety of 1–31% of ED visits (according to the applied definition). They are mostly middle aged and older than NFUs, with men and women represented equally, more frequently have chronic diseases than NFUs, and more often have a history of mental disorders. Characteristics
The age group 40–50 years is the highest represented among FUs. There are no sex differences. This is in contrast to frequent ED visitors in the USA, where
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312 European Journal of Emergency Medicine 2015, Vol 22 No 5
Table 3
Disease-related characteristics for frequent emergency department users from European studies (a) and non-European studies (b)
References Countries (a) European studies Hansagi et al. [11] Sweden Hansagi et al. [12] Sweden Skinner et al. [15] Scotland Dent et al. [10] England
Byrne et al. [9] Ireland
Bieler et al. [8] Switzerland Althaus et al. [7] Switzerland Salazar et al. [14] Spain
Somatic disorders and/or affected organ system (%)a Circulatory: 1.4 Respiratory: 32.4 Diabetes: 2.8 Chronic disease(s): 41 Combination of both: 12 –
Collapse: 4.7 Abdominal pain: 15.0 Chest pain: 8.3 Minor injury: 13.7 Gastrointestinal: 14 Circulatory: 23 Respiratory: 12 Musculoskeletal: 17 –
Nervous system: 56.5 Gastrointestinal: 56.5 Multiple significant trauma: 65.2 Surgical: 19.7 Ophthalmic: 9.3 Otolaryngologic: 4.6 Trauma: 4.6
(b) Studies from other continents Pope et al. [28] Chronic pain: 33 Canada Hepatitis B/C of HIV: 17 Chan and Ovens [18] Nervous system: 13.3 Canada Circulatory: 8.0 Respiratory: 11.5 Urogenital: 2.6 Obstetric/gynecologic: 2.4 Endocrine: 2.9 Musculoskeletal: 10.3 Dermatologic: 2.8 Otolaryngologic/ophthalmology: 1.3 Oncologic/hematologic: 3.1 Trauma: 5.0 Doupe et al. [19] Arthritis: 60.1 Canada Asthma: 37.6 Diabetes: 28.4 Circulatory: 31.3 Stroke: 17.4 Huang et al. [21] Gastrointestinal: 14.5 Taiwan Circulatory: 11.0 Respiratory: 5.0 Urogenital: 8.5 Obstetric/gynecologic: 2.0 Oncologic: 19 Trauma: 2.5 Phillips et al. [27] – Australia Jelinek et al. [22] Australia
Kirby et al. [24] Australia
Trauma: 5–9 ED visits/year: 18 > 40 ED visits/year: 13 Circulatory: 5–9 ED visits/year: 9.1 > 40 ED visits/year: 2.4 Chest pain: 5.2 Abdominal pain: 4.5 Dyspnea: 3.8 Minor injury: 2.9 Urogenital: 1.5 Back pain: 1.5 Convulsions: 1.4 COPD: 1.3 Cellulitis: 1.3 Respiratory: 8.1 Gastrointestinal/surgery: 13.9
Mental disease and disorders (%)a 9.9
Mental disease: 16 –
Deliberate self-harm: 9.5
11
Substance abuse (%)a
– –
Alcohol use: 3.1 Overdose: 3.2
87
Alcohol use: 34.8 Cannabis or other drugs: 21.7 –
Anxiety: 34.3 Depression: 60.3 Dementia: 21.6 Personality disorder: 13.3 7.0
– > 40 ED visits/year: 25.9
– Alcohol abuse: 46 Mental disease: 37 Chronic disease: 40 –
–
Alcohol/drug use: 38
–
Personality disorder: 33 Violence and depression: 25 Psychosocial: 24.0
–
Alcohol/drug use: 5.6
–
9.3
Primary ED diagnosis (%)
Injury: 12.0 Substance abuse: 12.3 Mental disorder: 9.4 Either mental health or substance abuse: 60.9 Recurrent medical reason for ED use: 52.3
–
Alcohol use: 33 Drug use: 33 –
–
–
35.9
–
Alcohol use: 5.5
– –
Medical: 27 Mental disease: 30 Substance abuse: 43 –
6.5
–
–
15.7
–
–
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Frequent emergency department users van Tiel et al. 313
Table 3 (continued) References Countries Markham and Graudins [25] Australia
Helliwell et al. [20] New Zealand Kennedy and Ardagh [23] New Zealand Peddie et al. [26] New Zealand
Mental disease and disorders (%)a
Substance abuse (%)a
–
–
–
–
–
–
–
–
Somatic disorders and/or affected organ system (%)a Neurology: 6.3 Renal/urology: 3.6 Cardiovascular: 11.3 Trauma: 15.4 Cancer related: 0.3 Endocrine: 1.2 Hematologic: 1.2 Acute infection: 6.9 Obstetric/gynecologic: 2.6 –
Primary ED diagnosis (%)
Medical: 51 Mental disease: 33 Substance abuse: 16 Medical: 45 Mental disease: 29 Substance abuse: 26 Medical: 49 Mental disease: 49 Substance abuse: 2
COPD, chronic obstructive pulmonary disease; ED, emergency department. a In medical history or as the primary reason for ED visit.
women are over-represented [2]. Many of the FUs do not have a relationship, suggesting a possible association between social isolation and frequent ED use. Little is reported on the number of FUs being homeless, but unemployment, a lower income, or being dependent on government welfare are more common among some frequent ED visitors [7,8,18]. Three studies comparing FUs with NFUs show a significant presence of immigrants in the FUs group (Table 2a and b) [8,18,24]. The presumption that ED visits are mostly based on mental complaints is not substantiated. Chronic somatic complaints seem to be the main reason for ED visits made by FUs. Yet, many FUs also have a history of mental disorders [7,15,18–20,23,26]. The fact that frequent visitors are more often transported to the ED by ambulance suggests that their visits are the result of urgent medical conditions. This is contradicted by the finding that (except for reports of Moore et al. [13]) triage categories for FUs correspond to lower urgencies than for NFUs [21,22,24,25]. The reasons for this discrepancy are not described. Possibly, patients with chronic medical conditions more frequently call the ambulance service as these patients are more familiar with the healthcare and ambulance system. Other options are that these FUs present themselves with potentially serious complaints; however, after a thorough examination in the ED no acute illness is found or the acuity of the medical condition is reduced because of the treatment provided by the ambulance personnel. Most FUs have a GP and make use of these services [9,19,28]. Thus, FUs appear to have concurrent high consumption of primary care and healthcare services in general [11,17–19]. A similar situation was described for FUs in the USA [31–33]. This raises the question of whether encouraging primary care and outpatient visits
would lower the burden that frequent visitors place on EDs.
Subdivision of frequent visitors
As FUs are a heterogeneous patient group, subdivisions are difficult to define. Eight of the included studies include data on patients making 10 or more visits per year [7,10,15,18,20,23,26,28]. These highly FUs show no difference in the primary reasons for ED visits compared with the other FUs. There are also no differences in other social and care-related factors between frequent (≥4 visits) and highly frequent ED users (≥10 visits).
International perspective
This review includes information on frequent ED visitors from six different European countries. The other studies included are from Canada, Australia, New Zealand, and Taiwan. There are no distinct factors for FUs that outline differences between European and non-European FUs (Table 1a and b). Similar to our findings, US FUs account for up to one-third of all ED visits and have a mean age closer to 40 years [2,34]. FUs in the USA also show heterogeneity in the types of complaints and the reasons to visit the ED [2]. Most of the US FUs have GPs and are also heavy consumers of other parts of the healthcare system [31,32]. Frequent visitors in the USA have higher acuity complaints than occasional ED users, whereas Australian, English, and Taiwanese FUs have lower urgencies than NFUs, resembling less serious illnesses [2,21,24]. There is also a difference in the probability of hospital admission. We found that about one-quarter of FUs get admitted, with decreasing admission rates by increasing number of ED visits, whereas LaCalle and Rabin [2]
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314 European Journal of Emergency Medicine 2015, Vol 22 No 5
found that the probability of admission is greater for FUs versus NFUs in the USA.
References 1 2
Limitations
As no standard definition for FUs exists and the studies included applied different thresholds defining FUs, a comparison of their impact on ED's healthcare capacity is difficult. This may be underestimated as only six reviewed studies included patients making four or more ED visits per year. In studies defining FUs with higher visiting rates per year, their contribution toward the burden of care on the ED is small (
