Ambulatory health care use by patients in a public hospital emergency department

Abstract

OBJECTIVE:To describe primary care clinic use and emergency department (ED) use for a cohort of public hospital patients seen in the ED, identify predictors of frequent ED use, and ascertain the clinical diagnoses of those with high rates of ED use. DESIGN: Cohort observational study.SETTING: A public hospital in Atlanta, Georgia.PATIENTS: Random sample of 351 adults initially surveyed in the ED in May 1992 and followed for 2 years. MEASUREMENTS AND MAIN RESULTS:Of the 351 patients from the initial survey, 319 (91%) had at least one ambulatory visit in the public hospital system during the following 2 years and one third of the cohort was hospitalized. The median number of subsequent ED visits was 2 (mean 6.4), while the median number of visits to a primary care appointment clinic was 0 (mean 1. CONCLUSIONS:All subgroups of patients in this study relied heavily on the ED for ambulatory care, and high ED use was positively correlated with appointment clinic visits and inpatient hospitalization rates, suggesting that high resource utilization was related to a higher burden of illness among those patients. The prevalence of chronic medical conditions and substance abuse among these most frequent emergency department users points to a need for comprehensive primary care. Multidisciplinary case management strategies to identify frequent ED users and facilitate their use of alternative care sites will be particularly important as managed care strategies are applied to indigent populations who have traditionally received care in public hospital EDs.KEY WORDS: emergency department; public hospitals; ambulatory care; primary care clinic. J GEN INTERN MED 1998;13:614-620.T here are growing efforts to restrict access to emergency departments (EDs) on the premise that care can be more appropriately provided in alternative sites, such as primary care clinics. 1 These efforts may particularly affect indigent communities, in which many consider the ED to be their main health care provider. 2,3 A 1993 General Accounting Office report showed a 34% increase in ED visits by patients with Medicaid and a 15% increase in visits by uninsured patients between 1985 and 1990. 4 To reverse this trend, Medicaid managed care programs use gatekeepers, preauthorization, and payment denials to decrease ED use. Case management strategies have been limited to small groups of patients with a chronic disease, such as asthma.There is considerable evidence of the benefit of continuity care with a primary care provider; however, imposing financial and administrative barriers to ED use on indigent populations without workable alternatives may have undesirable outcomes. 5 Indigent patients receiving care in public hospital EDs represent a potentially highrisk population that is increasingly subject to managed care restrictions despite a paucity of clinical information about the type and necessity of care being received. The appropriate managed care strategy for this population, from case management to cost sharing, will depend on the prevalence of u...

Predictors and Outcomes of Frequent Emergency Department Users

“…3,5,8,9,14 Our study excluded intoxicated patients. Prior studies suggest that alcoholism is a predictor of heavy ED use, 3,8,10 so our study population may not be comparable to those of other investigations.…”

“…They suggest a high chronic physical and psychological disease burden in this population, and this relationship has been previously noted. 3,5,8,10,13,14 These findings provide a context for understanding the higher rates of hospitalization, illness severity, and use of other services by frequent ED visitors.…”

“…Other studies of heavy use have used definitions ranging from four to 12 visits per year. 2,3,5,7,10,12,14,41 Our results may be dependent on how frequent use is defined; our survey was structured so that we could perform only a limited sensitivity analysis. However, our model continues to demonstrate robust predictive power when we redefine ''frequent use'' as three or more prior ED visits.…”

“…1 Of particular interest is a small group of patients who account for a disproportionate number of ED visits. [2][3][4][5][6][7][8][9][10] Prior studies suggest that 3-4% of patients may account for 12-20% of total ED visits. 8,9 Understanding the characteristics of these patients may help to improve their medical care in both the ED and primary care settings, and potentially ease ED overcrowding.…”

“…8 -11,12 These patients have high rates of chronic physical illness as well as psychiatric distress, including depression, loneliness, and substance abuse. 3,5,10,13 Heavy ED users are disproportionately covered by Medicare or Medicaid insurance, are more likely to use the ED as their primary site of care, and tend to have access to a primary care physician. 5,8,10,14 Furthermore, high ED use has been correlated with adverse clinical outcomes, such as increased mortality, 4,13 admission rates, 10,14 and use of other health care resources.…”