A Pilot Project Targeting Frequent Attenders at the Emergency Department With Medically Unexplained Symptoms

Abstract

Objectives & Background We identified that there is a cohort of people who attend our Emergency Department (ED) extremely frequently (>24 times per year) or who have frequent admissions (>12 per year). Analysing hospital clinical records identified that in many cases medically unexplained symptoms (MUS) drive the frequent presentation. The needs of these patients were not being met by a traditional dualistic approach in which people are seen in either physical or mental health settings. Indeed, despite frequent medical investigations/treatments, their symptoms persist, their problems are not resolved, they frequently complain and they keep coming back. This carries risk and distress for the patients, and heavy use of resources for the hospitals involved. Methods Each month we looked at attendance data for the previous 3 months (this identified people who in an acute phase of repeat presentations). By accessing patients clinical records we determined the main factors which appeared to drive their frequent attendance and admissions and identified those who presented with MUS. Care plans were developed and each patient was contacted and offered weekly Cognitive Behavioural Therapy (CBT) sessions to help them manage their symptoms. This was part of a case management approach in which coordinated, multidisciplinary reviews were undertaken resulting in an individualised care plan. Results Thus far the pilot has seen a reduction in attendances at ED for 100% of patients included in study (N=20). Crucially, all now attend less than once per month. In total 245 attends were saved after the CBT interventions Conclusion Providing a psychological intervention to this patient cohort is effective in reducing hospital costs by containing the most frequent attenders. CBT and care plans have reduced attendance to under once per month and subsequently reduced medical interventions and prescribing costs. 866Emerg Med J 2013;30(10):866-880

Effectiveness of Interventions to Decrease Emergency Department Visits by Adult Frequent Users: A Systematic Review

“…Quality assessments of two currently ongoing studies 42,43 were not performed as only published protocols were available. The risk of bias of NCBA studies ranged from high (n = 7) 14,30,[32][33][34]37,40 to moderate (n = 14). 12,13,15,16,[25][26][27][28][29]31,35,36,38,39 Quality issues related to the study participants' representativeness, enrollment of all eligible participants into the study, adequate sample size, outcome assessor blinding, and lack of multiple outcome measurements were identified.…”

“…Twenty-one NCBA studies, [12][13][14][15][16][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40] six RCTs, 17,[41][42][43][44][45] and four CBA studies [46][47][48][49] examined interventions targeting adult frequent ED users. The studies were published between 1985 and 2014 (median publication year = 2010; IQR = 2006 to 2013).…”

“…The studies were published between 1985 and 2014 (median publication year = 2010; IQR = 2006 to 2013). Most (n = 23) were published in peer-reviewed journals, [12][13][14][15][16][17][25][26][27][28][29][30][35][36][37][38][39]41,[44][45][46][47][48][49] five were scientific conference abstracts, [31][32][33][34]40 and two were protocols for planned RCTs. 42,43 Authors of primary studies were mainly from the United States.…”

“…42,43 Authors of primary studies were mainly from the United States. 12,13,15,25,27,31,32,34,36,37,[39][40][41]45,46,48,49 Other countries represented were Canada, 38,43 the United Kingdom, 16,26,33 Australia, 14,30 Sweden, 17,28,44,47 Scotland, 35 Taiwan, 29 and Switzerland. 42 Overall, studies included a general frequent user population; however, some focused their inclusion on subgroups with psychiatric, mental health or substance abuse comorbidities, 25,26,36,39,43 homeless, low income, unemployed or uninsured/underinsured patients, 13 41 Additional definitions were more than three visits in 6 months, 44 10 visits in 6 months, 35 three visits in 1 month, 37 and three or more visits in 72 hours.…”

“…42 Overall, studies included a general frequent user population; however, some focused their inclusion on subgroups with psychiatric, mental health or substance abuse comorbidities, 25,26,36,39,43 homeless, low income, unemployed or uninsured/underinsured patients, 13 41 Additional definitions were more than three visits in 6 months, 44 10 visits in 6 months, 35 three visits in 1 month, 37 and three or more visits in 72 hours. 29 Other studies considered the top 30, 33 50, 15 or 100 attendees 36 to be frequent users or allowed staff or investigators to determine inclusion without specified thresholds 16,30,34 or based on clinical parameters. 38 One study identified frequent users using the hospital billing system but did not specify the thresholds applied.…”