Here one year, gone the next? Investigating persistence of frequent emergency department attendance: a retrospective study in Australia

Abstract

ObjectivesPatients are presenting to emergency departments (EDs) with increasing complexity at rates beyond population growth and ageing. Intervention studies target patients with 12 months or less of frequent attendance. However, these interventions are not well targeted since most patients do not remain frequent attenders. This paper quantifies temporary and ongoing frequent attendance and contrasts risk factors for each group.DesignRetrospective population-based study using 10 years of longitudinal data.SettingAn Australian geographic region that includes metropolitan and rural EDs.Participants332 100 residents visited any ED during the study period.Main outcome measureFrequent attendance was defined as seven or more visits to any ED in the region within a 12-month period. Temporary frequent attendance was defined as meeting this threshold only once, and ongoing more than once. Risk factors for temporary and ongoing frequent attenders were identified using logistic regression models for adults and children.ResultsOf 8577 frequent attenders, 80.1% were temporary and 19.9% ongoing (12.9% repeat, 7.1% persistent). Among adults, ongoing were more likely than temporary frequent attenders to be young to middle aged (aged 25–64 years), and less likely to be from a high socioeconomic area or be admitted. Ongoing frequent attenders had higher rates of non-injury presentations, in particular substance-related (OR=2.5, 99% CI 1.1 to 5.6) and psychiatric illness (OR=2.9, 99% CI 1.8 to 4.6). In comparison, children who were ongoing were more likely than temporary frequent attenders to be aged 5–15 years, and were not more likely to be admitted (OR=2.7, 99% CI 0.7 to 10.9).ConclusionsFuture intervention studies should distinguish between temporary and ongoing frequent attenders, develop specific interventions for each group and include rigorous evaluation.

Understanding emergency department frequent attenders

“…Alcohol and other drug use also correlate with frequent presentation. An Australian study examined over 8500 regular ED attenders finding that frequent attendance was associated with alcohol/drug abuse (OR 6.4, 99% CI 4.3–9.7) compared with a control group 5 . Almost 1 in 10 ED presentations have alcohol as a factor, 6 this can be up to one in eight in peak times, based on the Australasian College for Emergency Medicine's annual Alcohol Harm Snapshot Survey 7 .…”

“…It is clear from the literature this is a heterogeneous group, albeit with some common characteristics. FA are more likely to be older than non‐frequent presenters, 5,10 with one study reporting a significant increase in presentations in the 70–79 years age group 2 . FA are more likely to be male, Aboriginal or Torres Strait Islander, be single 2,5 and often have complex social needs 1 .…”

“…FA are more likely to be older than non‐frequent presenters, 5,10 with one study reporting a significant increase in presentations in the 70–79 years age group 2 . FA are more likely to be male, Aboriginal or Torres Strait Islander, be single 2,5 and often have complex social needs 1 . They are more likely to live in lower socio‐economic areas with insecure housing and have alcohol as a contributing factor to their presentation 5,11 …”

“…FA are more likely to be male, Aboriginal or Torres Strait Islander, be single 2,5 and often have complex social needs 1 . They are more likely to live in lower socio‐economic areas with insecure housing and have alcohol as a contributing factor to their presentation 5,11 …”

High use of the emergency department shows typical features of complex systems: analysis of multicentre linked data

“…High use of the emergency department (ED) is a ubiquitous phenomenon 14 but harbours a paradox: while high use is consistently found, the population of high-using patients is constantly changing. Studies in emergency medicine 15 16 have demonstrated that high use by an individual is a relatively unstable state: many high users in one time period become infrequent users in the next, and vice versa.…”