Understanding the Characteristics of Patients who are High Utilizers of Emergency Departments

Background: Patients with high rates of emergency department (ED) and hospital use have attracted increased attention because of the potential to intervene to reduce costs while improving quality of care. The mixed results from various various high utilizer interventions suggest an inadequate understanding of patient needs and the factors that drive high utilization. This study seeks to understand the underlying drivers behind repeated ED use by analyzing patterns in the reasons patients present to the ED. Methods: Patients enrolled at an academically-affiliated general internal medicine clinic were categorized and compared according to patterns of ED use during a 12-month period (July 1, 2014 to June 30, 2015): non-utilizers (0 ED visits, n=2441), non-high utilizers (1-4 ED visits, n=1386), and high utilizers (n≥5, n=260). For all ED visits during the same period, the leading chief complaints, admission rates by complaint, and average number of repeat visits for the same complaint were analyzed for high utilizers and non-high utilizers. Discharge diagnoses associated with leading chief complaints were categorized according to the NYU ED algorithm to assess preventability of visits based on complaint. Charts from ten of the highest utilizers from each of the 3 leading chief complaints (n=30) received an in-depth review to assess the underlying factors behind high patterns of ED use for the same complaints. Results: High utilizers demonstrated a much higher burden of chronic disease, mental illness, and substance abuse than other patients. The presenting chief complaints of high utilizers were statistically similar to non-high utilizers. High utilizers were more likely to present multiple times for the same chief complaints (mean repeat visits 2.4 vs 1.2), especially for specific complaints. Abdominal pain, chest pain, and shortness of breath were the leading chief complaints overall, leading causes of admissions, and leading causes of repeat visits among high utilizers. Around 50% of diagnoses for abdominal pain and chest pain were non-specific, and over 40% were considered primary care-treatable. Shortness of breath was much more likely to be associated with definitive diagnoses and much less likely to be primary care-treatable (24%). Chart review revealed that repeated visits for all 3 chief complaints were often associated with substance abuse, anxiety, and treatment non-adherence. Conclusion: The reasons for high utilization are complex, but can be better understood by examining patterns in ED use. This study suggests that we can target certain patients based on patterns of repeated visits for the same complaint.Master of Public Healt