Elsevier

Health Policy

Volume 120, Issue 5, May 2016, Pages 452-461
Health Policy

Review
Characteristics of frequent users of the emergency department in the general adult population: A systematic review of international healthcare systems

https://doi.org/10.1016/j.healthpol.2016.02.006Get rights and content

Highlights

  • Small proportion of frequent emergency department users account for high healthcare costs.

  • We performed a systematic review of the published literature characterizing frequent users.

  • Twenty cohort studies characterizing frequent users in 5 healthcare systems were identified.

  • Similar demographic, clinical and resource use characteristics were observed across systems.

  • International knowledge translation may help development of interventions and health policies.

Abstract

Objectives

The objectives of this study were to synthesize and compare population characteristics associated with frequent emergency department (ED) use within and across healthcare systems.

Methods

A systematic review of literature published between 1950 and 2015 was conducted. Healthcare systems of included studies were categorized using the Rothgang–Wendt typology. Demographic, clinical and health service utilization characteristics of frequent ED users in the general adult population were identified within each healthcare system. Pooled estimates, stratified by healthcare system, were calculated to compare the association of each characteristic with frequent, compared to non-frequent, emergency room use.

Results

Twenty moderate to high quality comparative cohort studies were included. Among these, five healthcare systems were identified: National Health Insurance; Private Healthcare; National Health Service; Social Health Insurance and Etatist Social Health Insurance. Many similar characteristics were observed: in most healthcare systems, frequent ED users were more likely to be older, female, and have a mental health diagnosis. Previous hospitalizations and high primary care use (>3 visits/year) were associated with future frequent ED use in the NHIS and NHS systems.

Conclusions

Observed similarities suggest that frequent ED use may not differ from one healthcare system to the next. With increasing need to develop solutions for high ED utilization world-wide, targeted efforts must be made to bolster dissemination and uptake of effective interventions across healthcare contexts.

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.

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