That is the TLDR from the new Health Services Research paper written by several of my South Carolina colleagues:
Principal Findings
The study included 52,845 ED users, of whom 42,764 were non-frequent, 7677 frequent, and 2404 superfrequent users. Within 2 years from the date of their first ED visit, superfrequent ED users averaged 38.3 ED visits, frequent ED users 10.9 ED visits, and non-frequent ED users 2.6 ED visits (p < 0.001). Compared with non-frequent users, frequent and superfrequent ED users had more comorbidities and chronic conditions on average (1.6 vs. 3.5 vs. 6.4, p < 0.001). Both frequent and superfrequent users had more hospital visits beyond the ED overall (marginal effects: 0.23, 95% CI 0.18–0.27; 0.40, 95% CI 0.29–0.50), and more outpatient office visits overall (marginal effects: 4.39, 95% CI 2.52–6.27; 9.23, 95% CI 5.66–12.81), including primary care and most specialists’ visits, compared with non-frequent users.
People who use the ED a lot compared to people who seldom use the ED have a lot more healthcare utilization. This study does not compare healthcare use of Medicaid beneficiaries who have no initial ED visit during the study period.
Why does this matter?
There is a belief that EDs are used as a treatment center of last resort and that care be diverted to cheaper external locations. But the study is showing that the folks with a lot of ED visits are already using a lot of other care elsewhere. The study indicates that superfrequent ED users are medically complex (6.4 documented comorbidities vs 1.6 for infrequent ED users). We need to think about what we are actually doing with ED diversion programs as the targeted population (5% of ED users) are already getting a lot of care outside of the ED.
Baud
Updated your iphone?
ronno2018
Do we know how many ED users are homeless or economically precarious?
Argiope
I would really like to see this user mix broken down by age and sex. I’m working on a project to improve reproductive care in the ED, since we know that many ED users don’t necessarily have a lot of access to clinic-based care and therefore contraception. Additionally, those multiple comorbidities in frequent users make pregnancy less safe for them. We need data to help guide our efforts. Pregnancy can become a slow-moving emergency that is just as deadly as an MVA for some people—especially in abortion ban states.
Marmot
I think you mean first resort, right?
Adding: That’s how I understood it, back in the day—and the stereotypical case was a homeless drunk who broke his leg weekly walking the railroad tracks.
Also adding: Or it was someone without a PCP who only went to the doctor once some condition got severe, like they needed a foot amputated due to untreated diabetes.
I’m pleased to see these aren’t all that accurate—but how did the previous conception go on so long?
different-church-lady
I’ve been helping a close friend with a number of health issues over the past year. There’s been three trips to the ER, and two of them were a case of the PCP’s office going, “Oh, well that doesn’t sound good, you should just go to the ER now,” only for the ER to find nothing in particular.
So, ancidata for what its worth, but what I’m pointing to here is it’s not always the patient who’s making the decision. The vibe I get from this PCP office is, “It’s gonna be weeks before we can get you in here, we need to hand this off to the ER.”
This is Medicade, by the way.
WeimarGerman
There shouldn’t be a false dichotomy of “just one fix” to this complex problem.
As this study shows there are complex patients who are not well served by a “usual” diversion program. However, there remain people who are on shift work, or in provider deserts, that cannot access 9-5 care who need more access to proper levels of care through other programs. It’s a “both/and” set of recommendations.
Also, like the earlier post on hospice care, it’s extremely hard to predict which patients are in which groups. I recall a program from one insurer to address “super-utilizers” by putting yoga clinics and other wellness offerings into a elder care facility (and open to nearby residents). After a year they analyzed the impact only to find out that most of the super-utilizers were nearly bed ridden and unable to participate in any wellness offering. SMH, this is why the tech bros fail at healthcare.
cmorenc
What is the correlation between frequency of ED use and medical indigence – in the sense that the hospital is less likely to recover more than a fraction of the costs if providing their ED care? If there is a substantial positive correlation, where does the hospital make up the deficit? To what extent do indigent frequent ED users indirectly cause higher insurance costs for everyone else?
Mike E
@different-church-lady: my 1st visit was 5 years ago when my PA saw a ‘blip’ on my EKG that he didn’t like, gave me children’s aspirin and directed me to the ER. I was the least sick person there confirmed by another EKG, blood test and X-ray. A later stress test showed no advanced disease.
Fast forward to this last Dec 15th when I had a temperature of 104° and my visit to the ER confirmed I was positive for covid. More X-rays and OTC fever reducer, my fever broke while I was waiting for a doctor shift change and again I was the least sick patient there. It being a Sunday night took away the urgent care option where any of these procedures could have taken place.
Alce _e_ardillo
As usual,there are a lot of reasons for this. Inadequate primary care slots,where people cannot be seen in PC to head-off an ER visit; poor adherence to treatment, and postponing care until they’re too sick to be seen in PC. Falls due to poor balance or weakness, injuries caused by alcohol or substance use. When I was working in primary care, we could accommodate only a fraction of the people who needed care. And if you magically doubled our clinic size, it would do no good, people would come out from the “woodwork “ to absorb the care. The ratio of PC to ER/UC always teeters between not enough and too much…
beckya57
Psych provider here: I’d love to see this data broken down by medical vs psych disorders (though I suspect a lot of frequent ED users have a lot of both). EDs are often overflowing these days with psych patients, as the psych system is horribly underfunded and inadequate, and some of them are very high utilizers. EDs are not well-equipped to handle them, as their mandate is treating high-acuity medical conditions/serious injuries, and the results are bad for everyone (both med and psych patients, ED staff, and the taxpayers).
satby
One of my friends and her granddaughter both are frequent flyers at the local ER in their town. The granddaughter is severely allergic and asthmatic and seems poorly managed (IMO) by her health care team, since she ends up hospitalized 3-4 or more times a year. My friend is an extreme migraine sufferer who’s actually quite stoic, but will go once or twice a year when her multiple medications don’t make a dent in multiple day migraines. They both have excellent insurance, in fact my friend is covered by once of those gold level union plans. They do both often end up at urgent care too, so that’s not really deflecting ER visits by much.
Ohio Mom
@Mike E: After a bad experience in an urgent care office, and a couple of friends having bad experiences, it’s straight the emergency room for me.
Now the nearby hospital’s ED has built-in urgent care — if you are having an escalating emergency, you are sent to a different side of the department— so I don’t feel bad about about going there. They are set up for me.
Though I sometimes chuckle that it’s not urgent care I’m getting, it’s the least urgent care. When I was there for stitches last year, there were patients on the other side who (I think) had been in a car accident. The staff all left the urgent care side to help out on the other side, leaving us urgent care patients unattended for an hour. Underlining just how un-urgent we really were.
Alce _e_ardillo
@Marmot: Either fortunately or unfortunately, that has never really been the case. While homeless and or substance using people have always been a thing, the majority of the super utilizers have been people with complex medical problems, frequently elderly, who need help at home, getting around,going to multiple appointments,not able to get the good food or medicines or assistance with ambulating…
PatrickG
@different-church-lady: For my father in law, can add my anecdata to confirm. HALF of his encounters in 2024 were the ER, including things like mechanical device troubleshooting (metered G-tube) that weren’t emergencies but — like your experience — we couldn’t get a standard appointment for weeks, by which point it definitely would be an emergency!
Frustrated note: for the last one the PCP refused to call us back on a Friday morning. We learned Monday it was not because of appointment availability but because they were trying to figure out if insurance would allow a second-in-a-year appointment. So my wife got to spend six hours in the ER on a holiday weekend for something that took 30 mins to resolve but absolutely could not wait over the weekend.
what a system
Ohio Mom
@Alce _e_ardillo: It probably has something to do with the hospital’s location. The ED in the general hospital inside the City of Cincinnati definitely gets lot of low-income people arriving by city ambulance, often for complaints that could have been handled by a PCP, as well as the homeless people and drug abusers. Some of them are known as frequent fliers by the firefighters manning the EMS vehicles.
But yes, elderly people like my 93 y.o. MIL get taken to the ED by because they fell down and the independent living facility she lives in won’t pick her up, they call the fire department, who takes her to the hospital.
Wapiti
@different-church-lady: I’ve had that happen with my father. His PCP is located in a clinic that does
acuteurgent care, but the PCP has just sent us to the ER when he had a possible concussion or such. This is on Medicare.rikyrah
@Ohio Mom:
I really like this idea. It makes so much sense. Wish this was the norm.
Starfish (she/her)
@cmorenc: Some hospital systems track THOSE patients and assign them social workers.
rikyrah
@Ohio Mom:
I don’t blame the facility. Falls are very tricky with the elderly.
Barbara
@rikyrah: They are also all set up to charge you a big fat facility fee for a non-emergent service.
Barbara
@satby: A lot of the thinking here is based on the assumption that people are going to the ED for non-emergent conditions because they don’t have access to primary care resources. That can be the case — but there are also people whose conditions are poorly managed and are experiencing actual, life threatening emergencies. One of my clients said that addressing this issue with asthmatic children was their number one priority. Emergencies like this can lead to death, and frequent ED visits are often a sign of a poorly controlled condition — inadequate medication, or misunderstanding about how to use medication.
Barbara
@Ohio Mom: Medicare won’t pay for an ambulance visit unless you go to a facility for care or treatment. So even if she doesn’t need that level of care, they take her so they can get reimbursed.
DFH
The last several years of her life my mom hit the hospital-to-rehab-to-home triangle so often, she became familiar with the local volunteer ambulance EMT people. Local farmers and residents, appearing at all hours, blizzard and sunshine. “Will it be my regular crew?” was the topper. IOW, elderly folks can pile up the visits.
Ruckus
Old fartitus brings the fun of getting to know your doctor(s) just a tad better. More things go wrong for most old farts. And that is with healthy old farts, (and yes – I am one – basically anyway) If you aren’t a healthy old fart, a lot of things can, and often do, go wrong.
I use the VA because the care is good, I earned it, and there is never a question of can you afford this. Now some do pay for their care but it depends on income and military history. When I worked, I had copays. I believe they will pay for emergency care if you live far enough away from a VA hospital.
Ohio Mom
@Barbara: Oh. Now I see.