ReviewCharacteristics of frequent users of the emergency department in the general adult population: A systematic review of international healthcare systems
Introduction
Individuals that frequent the emergency department (ED) on multiple occasions within a specified timeframe comprise a small proportion of the overall ED patient population (∼5%), yet account for 21–28% of all ED visits and associated costs [1], [2], [3], [4], [5]. With increasing pressure to control healthcare costs, many healthcare jurisdictions are considering adoption of interventions and programmes that may provide more efficient and more effective care for this patient group [6]. However, design, implementation, and sustainability of such interventions is challenging without sufficient understanding of the specific patient composition and/or reasons underlying frequent ED use. Understanding the differences in frequent user populations across healthcare systems is essential for the assessment of transferability of potentially effective interventions to reduce frequent ED use.
Only one published systematic review, to date, has specifically examined the characteristics of frequent ED users in the United States (US); thus limiting its generalizability to the US private healthcare system [1]. There have been few other attempts to characterize frequent ED users in the international literature [2], [7]. Of those conducted, most have tended to focus on broad syntheses across multiple healthcare systems [2], [3]. Yet given the diversity in how healthcare systems are structured internationally [8], the usefulness of such pooled, cross-system syntheses is unclear. Not only may there be limited generalizability in the determinants and forces underlying frequent ED use, but also in the capacity and resources to intervene.
Thus, the specific objective of this research is to synthesize and compare population characteristics associated with frequent ED use in the general adult population within and across healthcare systems. This research will inform decision-makers seeking to develop relevant, appropriate system interventions or adopt interventions developed in other contexts.
Section snippets
Methods
A systematic review of the published literature was completed. The World Health Organization definition of a health care system was adopted to ensure the work remained broad in its scope [9]. Healthcare systems were classified using the Rothgang and Wendt (R-W) typology [10], [11] and study-reported demographic, clinical and health service utilization characteristics were then compared within and across healthcare system category. As this research includes only published findings, institutional
Results
One thousand one hundred and twenty six citations were identified. Of those, 1034 were excluded during abstract review. The remaining 92 studies proceeded to full-text review. Systematic reviews were also hand-searched and four additional relevant articles were identified, totalling 96 studies for full-text review. Seventy-six articles were excluded following full-text review, leaving 20 articles included in the final analysis [4], [5], [7], [14], [15], [16], [17], [18], [19], [20], [21], [22],
Discussion
This systematic review identified 20 moderate to high-quality prospective, comparative cohort studies characterizing the general adult population who frequently use the ED. Interestingly, comparing patient characteristics across healthcare system types revealed a number of commonalities. Among the five systems identified, adult frequent ED users were more likely to be over the age of 65, have previous in-patient acute care admissions, psychiatric hospitalizations, and have been a previous
Conclusions
Frequent use of the ED has been documented in small cohorts of individuals across multiple countries and healthcare systems. Use of a healthcare system typology identified common frequent ED user characteristics both within and between healthcare systems, suggesting that frequent ED users may not differ across healthcare systems. A focus on international knowledge translation of effective interventions should be developed and facilitated.
Conflict of interest statement
The authors have no conflicts of interest to declare.
Acknowledgement
LJJS is supported by an Alberta Innovates-Health Solutions (AI-HS) Graduate Studentship Award.
References (36)
- et al.
Frequent users of emergency departments: the myths, the data, and the policy implications
Annals of Emergency Medicine
(2010) - et al.
Effectiveness of case management strategies in reducing Emergency Department visits in frequent user patient populations: a systematic review
Journal of Emergency Medicine
(2013) - et al.
Frequent use of the hospital emergency department is indicative of high use of other health care services
Annals of Emergency Medicine
(2001) - et al.
Five types of OECD healthcare systems: empirical results of a deductive classification
Health Policy
(2013) - et al.
A descriptive study of heavy emergency department users at an academic emergency department reveals heavy ED users have better access to care than average users
Journal of Emergency Nursing
(2005) - et al.
Frequent attenders to an emergency department: a study of primary health care use, medical profile, and psychosocial characteristics
Annals of Emergency Medicine
(2003) - et al.
Frequent users of emergency departments: developing standard definitions and defining prominent risk factors
Annals of Emergency Medicine
(2012) - et al.
Resource utilization and health care charges associated with the most frequent ED users
American Journal of Emergency Medicine
(2014) - et al.
Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial
American Journal of Emergency Medicine
(2008) - et al.
The effects of clinical case management on hospital service use among ED frequent users
American Journal of Emergency Medicine
(2000)