Wednesday, January 23, 2013

Who Uses the Emergency Room Most? The Answers May Surprise You

There is a stereotype that the most frequent users of emergency rooms (ERs) are those who do not have health insurance and/or who present for non-urgent reasons. While the uninsured do use the ER often, the best way to determine who uses it the most and why is to do a formal research study on the topic.

In an upcoming article in the American Journal of Emergency Medicine, researchers presented the results of such a study.

In the study, frequent use of the ER was defined as 9 or more visits in a one year period. This represented the top 1% of ER use. The researchers administered questionnaires to adults in this group. Of note, patients excluded were those who presented to the ER intoxicated, with altered mental status, or acute (sudden) psychosis (detachment from reality).

Over a one year period from 2009 to 2010, the researchers identified 115 frequent ER users. Twenty three percent had a psychiatric condition (usually presenting for suicidal thoughts). The average patient presented to the ER 22 times. The average age was 44. Regarding gender, 57% were male and 47% were female. Regarding education, 44% had a high school education or GED, 43% had less than a high school education, and 11% had a college education. Lower educational level was not correlated with higher ER use. Regarding race, 92% were black, 11% were white, and 1% were Hispanic.

In terms of annual income, 69% earned less than $10,000 a year. Only 5% earned more than $40,000 a year. Patients used the ER more frequently if they had lower income, transportation problems, problems with shelter, and high prescription costs (32% could not afford prescriptions). Twenty-seven percent reported being unable to afford a clinic visit. Seventy-eight percent reported having adequate health insurance whereas 22% did not. The number of ER visits between insured and uninsured patients was comparable.

Seventy-five percent of patients had one or more chronic medical conditions and identified the ER as the primary place they went for health care. Of the ER users, 63% were admitted to the hospital and 50% were admitted more than once. The most frequent reason for admission was end stage renal disease. Four hundred and sixty hospital admissions were for medical reasons and 22 were for psychiatric reasons.

In terms of the most frequent medical diagnoses, 59% had high blood pressure, 19% had congestive heart failure, 19% had diabetes mellitus, 16% had end stage renal (kidney disease), 12% had coronary artery disease, and 9% had chronic obstructive pulmonary disease (COPD). Congestive heart failure is an imbalance in the pumping action of the heart that causes inadequate blood circulation. In diabetes mellitus, the body is not able to effectively use a natural chemical called insulin, which quickly absorbs glucose (a type of sugar) from the blood into cells for their energy needs and into the fat and liver cells for storage. Coronary artery disease is a narrowing of coronary arteries, which are blood vessels that supply the heart with blood. COPD is a general term for diseases that are characterized by long-term or permanent narrowing of small airways (known as bronchi) connected to the lungs.

The authors noted that their findings echoed prior studies that found that the most frequent ER users have some form of health insurance and access to a primary care provider, but used the ER as their primary source of health care despite such access. The authors noted that it is plausible that the primary health care providers may not be able to meet the needs of these patients which is why they go to the ER. The authors noted that future studies should examine if a medical home may be a better place for these patients to meet their needs to ease the strain on the ER. A medical home (or patient-centered medical home) is a team-centered health care system led by a medical doctor, nurse practitioner, or physician assistant to provide comprehensive and continuous health care. At present, there are not many medical homes in the U.S.

Suggested reading: Confessions of Emergency Room Doctors

Related blog entry: Decreased Child ER Visits after LA Lakers Title Games

Reference: Miller JB, Brauer E, Rao H, Wickenheiser K, Dev S, Omino R, Stokes-Buzzelli S. (2013). The most frequent ED patients carry insurance and a significant burden of disease. Am J Emerg Med. 31(1):16-9.

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