Frequent Users of Emergency Department Services: Gaps in Knowledge and a Proposed Research Agenda

Authors

  • Jesse M. Pines MD, MBA, MSCE,

    1. From the Departments of Emergency Medicine and Health Policy, George Washington University Medical Center (JMP), Washington, DC; the Department of Emergency Medicine, Mayo Clinic College of Medicine (BRA), Rochester, MN; the Department of Emergency Medicine, Harbor-UCLA Medical Center, David Geffen School of Medicine, University of California (AHK), Los Angeles, CA; the Department of Emergency Medicine, Oregon Health Sciences University (RAL), Portland, OR; the Institute for Health Research, Kaiser Permanente Colorado and the Departments of Emergency Medicine and Preventive Medicine and Biometrics, University of Colorado Health Sciences Center (DJ), Denver, CO; the Department of Emergency Medicine, New York University School of Medicine (MR), New York, NY; the Department of Emergency Medicine, University of California at San Francisco (EJW), San Francisco, CA; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine (DMY), Pittsburgh, PA. Dr. Asplin is currently at the Fairview Medical Group, St. Paul, MN.
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  • Brent R. Asplin MD, MPH,

    1. From the Departments of Emergency Medicine and Health Policy, George Washington University Medical Center (JMP), Washington, DC; the Department of Emergency Medicine, Mayo Clinic College of Medicine (BRA), Rochester, MN; the Department of Emergency Medicine, Harbor-UCLA Medical Center, David Geffen School of Medicine, University of California (AHK), Los Angeles, CA; the Department of Emergency Medicine, Oregon Health Sciences University (RAL), Portland, OR; the Institute for Health Research, Kaiser Permanente Colorado and the Departments of Emergency Medicine and Preventive Medicine and Biometrics, University of Colorado Health Sciences Center (DJ), Denver, CO; the Department of Emergency Medicine, New York University School of Medicine (MR), New York, NY; the Department of Emergency Medicine, University of California at San Francisco (EJW), San Francisco, CA; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine (DMY), Pittsburgh, PA. Dr. Asplin is currently at the Fairview Medical Group, St. Paul, MN.
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  • Amy H. Kaji MD, PhD,

    1. From the Departments of Emergency Medicine and Health Policy, George Washington University Medical Center (JMP), Washington, DC; the Department of Emergency Medicine, Mayo Clinic College of Medicine (BRA), Rochester, MN; the Department of Emergency Medicine, Harbor-UCLA Medical Center, David Geffen School of Medicine, University of California (AHK), Los Angeles, CA; the Department of Emergency Medicine, Oregon Health Sciences University (RAL), Portland, OR; the Institute for Health Research, Kaiser Permanente Colorado and the Departments of Emergency Medicine and Preventive Medicine and Biometrics, University of Colorado Health Sciences Center (DJ), Denver, CO; the Department of Emergency Medicine, New York University School of Medicine (MR), New York, NY; the Department of Emergency Medicine, University of California at San Francisco (EJW), San Francisco, CA; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine (DMY), Pittsburgh, PA. Dr. Asplin is currently at the Fairview Medical Group, St. Paul, MN.
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  • Robert A. Lowe MD, MPH,

    1. From the Departments of Emergency Medicine and Health Policy, George Washington University Medical Center (JMP), Washington, DC; the Department of Emergency Medicine, Mayo Clinic College of Medicine (BRA), Rochester, MN; the Department of Emergency Medicine, Harbor-UCLA Medical Center, David Geffen School of Medicine, University of California (AHK), Los Angeles, CA; the Department of Emergency Medicine, Oregon Health Sciences University (RAL), Portland, OR; the Institute for Health Research, Kaiser Permanente Colorado and the Departments of Emergency Medicine and Preventive Medicine and Biometrics, University of Colorado Health Sciences Center (DJ), Denver, CO; the Department of Emergency Medicine, New York University School of Medicine (MR), New York, NY; the Department of Emergency Medicine, University of California at San Francisco (EJW), San Francisco, CA; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine (DMY), Pittsburgh, PA. Dr. Asplin is currently at the Fairview Medical Group, St. Paul, MN.
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  • David J. Magid MD,

    1. From the Departments of Emergency Medicine and Health Policy, George Washington University Medical Center (JMP), Washington, DC; the Department of Emergency Medicine, Mayo Clinic College of Medicine (BRA), Rochester, MN; the Department of Emergency Medicine, Harbor-UCLA Medical Center, David Geffen School of Medicine, University of California (AHK), Los Angeles, CA; the Department of Emergency Medicine, Oregon Health Sciences University (RAL), Portland, OR; the Institute for Health Research, Kaiser Permanente Colorado and the Departments of Emergency Medicine and Preventive Medicine and Biometrics, University of Colorado Health Sciences Center (DJ), Denver, CO; the Department of Emergency Medicine, New York University School of Medicine (MR), New York, NY; the Department of Emergency Medicine, University of California at San Francisco (EJW), San Francisco, CA; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine (DMY), Pittsburgh, PA. Dr. Asplin is currently at the Fairview Medical Group, St. Paul, MN.
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  • Maria Raven MD,

    1. From the Departments of Emergency Medicine and Health Policy, George Washington University Medical Center (JMP), Washington, DC; the Department of Emergency Medicine, Mayo Clinic College of Medicine (BRA), Rochester, MN; the Department of Emergency Medicine, Harbor-UCLA Medical Center, David Geffen School of Medicine, University of California (AHK), Los Angeles, CA; the Department of Emergency Medicine, Oregon Health Sciences University (RAL), Portland, OR; the Institute for Health Research, Kaiser Permanente Colorado and the Departments of Emergency Medicine and Preventive Medicine and Biometrics, University of Colorado Health Sciences Center (DJ), Denver, CO; the Department of Emergency Medicine, New York University School of Medicine (MR), New York, NY; the Department of Emergency Medicine, University of California at San Francisco (EJW), San Francisco, CA; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine (DMY), Pittsburgh, PA. Dr. Asplin is currently at the Fairview Medical Group, St. Paul, MN.
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  • Ellen J. Weber MD,

    1. From the Departments of Emergency Medicine and Health Policy, George Washington University Medical Center (JMP), Washington, DC; the Department of Emergency Medicine, Mayo Clinic College of Medicine (BRA), Rochester, MN; the Department of Emergency Medicine, Harbor-UCLA Medical Center, David Geffen School of Medicine, University of California (AHK), Los Angeles, CA; the Department of Emergency Medicine, Oregon Health Sciences University (RAL), Portland, OR; the Institute for Health Research, Kaiser Permanente Colorado and the Departments of Emergency Medicine and Preventive Medicine and Biometrics, University of Colorado Health Sciences Center (DJ), Denver, CO; the Department of Emergency Medicine, New York University School of Medicine (MR), New York, NY; the Department of Emergency Medicine, University of California at San Francisco (EJW), San Francisco, CA; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine (DMY), Pittsburgh, PA. Dr. Asplin is currently at the Fairview Medical Group, St. Paul, MN.
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  • Donald M. Yealy MD

    1. From the Departments of Emergency Medicine and Health Policy, George Washington University Medical Center (JMP), Washington, DC; the Department of Emergency Medicine, Mayo Clinic College of Medicine (BRA), Rochester, MN; the Department of Emergency Medicine, Harbor-UCLA Medical Center, David Geffen School of Medicine, University of California (AHK), Los Angeles, CA; the Department of Emergency Medicine, Oregon Health Sciences University (RAL), Portland, OR; the Institute for Health Research, Kaiser Permanente Colorado and the Departments of Emergency Medicine and Preventive Medicine and Biometrics, University of Colorado Health Sciences Center (DJ), Denver, CO; the Department of Emergency Medicine, New York University School of Medicine (MR), New York, NY; the Department of Emergency Medicine, University of California at San Francisco (EJW), San Francisco, CA; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine (DMY), Pittsburgh, PA. Dr. Asplin is currently at the Fairview Medical Group, St. Paul, MN.
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  • Funding for this conference was made possible (in part) by 1R13HS018114–01 from the Agency for Healthcare Research and Quality (AHRQ). The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services, nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

  • The authors have no potential conflicts of interest to disclose.

  • Supervising Editor: Lawrence M. Lewis, MD.

Address for correspondence and reprints: Jesse M. Pines, MD, MBA, MSCE; e-mail: jesse.pines@gmail.com.

Abstract

ACADEMIC EMERGENCY MEDICINE 2011; 18:e64–e69 © 2011 by the Society for Academic Emergency Medicine

Abstract

Frequent use of emergency department (ED) services is often perceived to be a potentially preventable misuse of resources. The underlying assumption is that similar and more appropriate care can be delivered outside of EDs at a lower cost. To reduce costs and incentivize more appropriate use of services, there have been efforts to design interventions to transition health care utilization of frequent users from EDs to other settings such as outpatient clinics. Many of these efforts have succeeded in smaller trials, but wider use remains elusive for varying reasons. There are also some fundamental problems with the assumption that all or even the majority of frequent ED use is misuse and invoking reasons for that excessive use. These tenuous assumptions become evident when frequent users as a group are compared to less frequent users. Specifically, frequent users tend to have high levels of frequent ED use, have a higher severity of illness, be older, have fewer personal resources, be chronically ill, present for pain-related complaints, and have government insurance (Medicare or Medicaid). Because of the unique characteristics of the population of frequent users, we propose a research agenda that aims to increase the understanding of frequent ED use, by: 1) creating an accepted categorization system for frequent users, 2) predicting which patients are at risk for becoming or remaining frequent users, 3) implementing both ED- and non–ED-based interventions, and 4) conducting qualitative studies of frequent ED users to explore reasons and identify factors that are subject to intervention and explore specific differences among populations by condition, such as mental illness and heart failure.

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