Editor’s Note: Read Dr. Cedric Dark’s commentary on this EMRA + PolicyRx Health Policy Journal Club article.

Working in any emergency department, over time clinicians will notice some familiar faces. Patients characterized as frequent emergency department users (FEDUs) have more than five visits per year. The implications of their frequent visits can be significant. While FEDUs are a small portion of all ED users (4 to 16 percent), they account for up to half of total ED visits, contributing to crowding and health care costs.¹ Previous work has characterized FEDUs as patients with lower socioeconomic status and educational levels who are often sicker at baseline due to a complex constellation of medical comorbidities. But for FEDUs using multiple sites, are there other factors driving their visits?

A recent study addressed this question by determining how many FEDUs sought care at multiple sites (more than three sites per year), identifying the social, clinical, and contextual factors associated with these patterns.² The study used Health Cost and Utilization Project data from 2011 to 2014 for all outpatient ED visits in New York, Massachusetts, and Florida.

The study found that across all three states, 1,033,626 FEDUs accounted for more than 7 million visits. Nearly one-quarter of all FEDUs were also multisite users, accounting for 30 percent of the overall ED visits. Moreover, multisite frequent users were more likely to have diagnoses related to mental health and substance abuse than single-site frequent users. This correlation highlights that, in order to mitigate multisite ED use, there is a need for the implementation of integrated mental health and substance abuse treatment programs across health systems targeting high utilizers, expanding beyond the scope of a single emergency department.³ Policies must address the lack of cohesive infrastructure leading to high utilization by multisite FEDUs since a fragmented health care system creates challenges in addressing the medical, social, and psychological needs of frequent utilizers.

As we witness our health system’s shortcomings through the lens of the COVID-19 pandemic, let us acknowledge the need for supportive community infrastructure for FEDUs. Advocacy by emergency physicians for community-wide approaches to coordinated mental health and substance abuse counseling and support as well as chronic disease prevention and treatment is paramount to improve the systems of care that affect our most frequent visitors

Ms. Gujaran is a medical student at the University of Maryland School of Medicine in Baltimore.

References

1. Trueger S. On “unnecessary” ED visits: background reading. MDaware website. Accessed Jan. 9, 2020. 
2. Giannouchos TV, Washburn DJ, Kum HC, et al. Predictors of multiple emergency department utilization among frequent emergency department users in 3 states. Med Care. 2020;58(2):137-145.