Analyzing the use of multiple emergency departments

Visits to emergency departments (EDs) have consistently been on the rise throughout the United States, with the number of ED visits reaching 136.9 million in 2015. Within this number lies a subset of patients who are labeled as frequent emergency department users (FEDUs), who account for 14 to 47 percent of the total ED visits.

There is also a category of patients who are not only FEDUs, but also FEDUs who don’t return to the same hospital, choosing instead to utilize the services of different EDs.

While existing research indicates that 32 percent of revisits to the ED within three days occur at a different hospital, less is known about the profile of what has been termed frequent multisite emergency department users (FMEDUs), patients who return to the ED but not the same one where their first visit occurred.

A group of researchers at the Texas A&M School of Public Health recently found that multisite users were more likely to have diagnoses related to mental health, substance use and other urgent critical conditions.

Theodoros V. Giannouchos, MS, MPharm, a PhD candidate in the Department of Health Policy & Management at the School of Public Health, is the lead author on the study titled “Predictors of Multiple Emergency Department Utilization Among Frequent Emergency Department Users in 3 States,” which was published recently in the journal Medical Care, the official journal of the Medical Care Section of the American Public Health Association.

“Multiple health care delivery models and interventions are currently being explored throughout the United States to provide the needed and appropriate care to frequent users,” Giannouchos said. “However, if these remain hospital specific without taking into account that some of these patients seek subsequent or similar care from other providers, then such initiatives will not be as effective.”

For the study, Giannouchos and his co-authors analyzed a four-year period (2011–2014) of outpatient ED visits by all adult ED users with more than five visits in a year in New York, Massachusetts and Florida. The team chose these states because they have a consistent and unique patient identifier that enabled researchers to track patients across different ED sites for each of the calendar years.

The researchers defined frequent use as greater than five visits to the ED in one year, which is a commonly used threshold. The team eliminated patients with less than five visits in a given year as well as children because they are less likely to be responsible for deciding when and where to seek care.

The researchers found that across the three states, 1,033,626 patients were frequent users and accounted for 7,613,077 ED visits. Of these frequent users, 25 percent were multisite users and they accounted for 30 percent of all ED visits.

The team also found that frequent users with at least one visit for a mental health or substance use related diagnosis were more likely to use multiple sites, accounting for 15 percent of the FMEDU population in New York, 18 percent in Massachusetts and 6 percent in Florida.

“The association between significant physical illness and complex medical needs with the use of multiple hospitals indicates the importance of helping patients navigate through a complex and fragmented system, while also addressing social determinants of health at multiple levels,” Giannouchos said.

The research team’s findings shine the spotlight on the need to implement integrated mental health and substance use treatment programs across health systems in an effort to curb the number of frequent, duplicate, and sometimes, unnecessary ED visits.

To do this, the team suggests that a population health perspective should be applied and that multiple hospitals should be engaged in the effort. Additionally it suggests a community-level preventative approach that might include the use of health information exchange (HIE) data as stronger infrastructure for mental health and substance abuse.

“Quality reporting tools and measures, such as those including re-admissions and return rates within a few days, will be incomplete and only partially valid without considering the use of multiple hospitals among these individuals,” Giannouchos said.

Giannouchos’ co-authors on the study include, from the School of Public Health: David J. Washburn, ScD, SM, assistant professor; Hye-Chung Kim, PhD, associate professor; and Robert L. Ohsfeldt, PhD, Regents professor and PhD program chair. Also co-authoring the study is William M. Sage, MD, JD, a faculty fellow at the Texas A&M University Hagler Institute for Advanced Study, professor in the Department of Surgery and Perioperative Care at the University of Texas at Austin Dell Medical School, and James R. Dougherty Chair for Faculty Excellence at the University of Texas at Austin School of Law.