Association between early returns and frequent ED visits at a rural academic medical center

doi:10.1053/ajem.2003.50017

The American Journal of Emergency Medicine

Volume 21, Issue 1, January 2003, Pages 30-31

https://doi.org/10.1053/ajem.2003.50017 Get rights and content

Abstract

The objective of this study was to examine the influence of frequent emergency department (ED) use on early returns to the ED at a large rural academic medical center. An analysis was done of all 35,440 visits by 22,442 individuals to a large rural academic medical center ED during calendar year 2000. Of 35,440 ED visits, there were 1,992 (5.62%) return visits within 72 hours (early return). Frequent ED visits (visits made by individuals making 4 or more visits per year) was a predictor of early return visits (odds ratio [OR] 3.21, 95% confidence interval [CI] 2.93-3.52; Wald χ², P <.0001). Of 22,442 individuals who came to the ED during the study period, 1,601 (7.13%) returned within 72 hours. Frequency of ED use by a particular individual (4 or more visits per year) was also a predictor of early return for that individual (OR 14.55, 95% CI 12.84-16.48; Wald χ², P <.000001). The high rate of early returns to this rural academic ED was significantly associated with frequent visits (4 or more times per year) to the ED by particular individual. (Am J Emerg Med 2003; 21:30-31. Copyright 2003, Elsevier Science (USA). All rights reserved.)

Section snippets

Materials and methods

Computerized records of all ED visits to the Jon Michael Moore Trauma Center at Ruby Memorial Hospital, at the Robert C. Byrd Health Sciences Center of West Virginia University, for the calendar year 2000 were analyzed for information that included age, gender, primary discharge diagnosis according to the International Classification of Disease, 9th Revision (ICD-9), payer status (type of health insurance), county of residence, month of arrival, day-of-week of arrival, time of arrival, and

Results

During calendar year 2000 there were 35,440 visits to the ED. These 35,440 visits were make by 22,492 different individuals. There were 1356 individuals who made 4 or more visits during the calendar year. These frequent visits (visits made by individuals with 4 or more visits during the year) totaled 7758. There were 1992 visits that were return visits made within 72 h of a previous visit. These early return visits were made by 1601 distinct individuals. Thus, the overall rate of early return

Discussion

Previous studies of early return visits (within 48 to 72 hours) to the ED have identified several contributing factors, including patient-related issues such as leaving against medical advice, disease-related issues such as disease progression, and missed diagnosis.1, 2, 3, 4, 5, 6, 7, 8 Our study, at a rural academic medical center, identified another patient-related factor in that individuals who visited the ED 4 or more times per year were also very significantly more likely (OR > 14) to be

References (8)

B Lerman et al.
Return visits to the emergency department
J Emerg Med
(1987)
JM Pierce et al.
“Bounces”: an analysis of short-term return visits to a public hospital emergency department
Ann Emerg Med
(1990)
LG Graff et al.
Impact on the care of the emergency department chest pain patient from the Chest Pain Evaluation Registry (CHEPER) Study
Am J Cardiol
(1997)
F O'Dwyer et al.
Unscheduled return visits by patients to the accident and emergency department
Arch Emerg Med
(1991)

There are more references available in the full text version of this article.

Cited by (21)

Data mining techniques utilizing latent class models to evaluate emergency department revisits
2020, Journal of Biomedical Informatics
The use of machine learning techniques is especially pertinent to the composite and challenging conditions of emergency departments (EDs). Repeat ED visits (i.e. revisits) are an example of potentially inappropriate utilization of resources that can be forecasted by these techniques.
To track the ED revisit risk over time using the hidden Markov model (HMM) as a major latent class model. Given the HMM states, we carried out forecasting of future ED revisits with various data mining models.
Information integrated from four distributed sources (e.g. electronic health records and health information exchange) was integrated into four HMMs which capture the relationships between an observed and a hidden progression that shift over time through a series of hidden states in an adult patient population.
Assimilating a pre-analysis of the various patients by applying latent class models and directing them to well-known classifiers functioned well. The performance was significantly better than without utilizing pre-analysis of HMM for all prediction models (classifiers(.
These findings suggest that one prospective approach to advanced risk prediction is to leverage the longitudinal nature of health care data by exploiting patients’ between state variation.
Sex differences in frequent ED use among those with multimorbid chronic diseases
2016, American Journal of Emergency Medicine
Citation Excerpt :
Observations with reported number of ED visits exceeding 40 in the last 6 months (n = 4) skewed the distribution and were not included in this analysis. The literature varies on the definition of frequent ED use, but it generally defines frequent ED use as 4 or more visits annually [6,7,14,19,22]. We define frequent ED use as 2 or more visits in the last 6 months, roughly equivalent to 4 visits annually.
The objectives were to examine the association between multimorbid chronic disease and frequency of past 6 months emergency department (ED) visits, by sex, in a community sample of adults from North Florida (N = 7143).
Data came from HealthStreet, a community engagement program at the University of Florida which uses the Community Health Worker Model to assess community member health conditions and concerns, and willingness to participate in health research. Using logistic regression, we estimated associations between multimorbid chronic disease and frequent ED use using sex as an effect modifier.
Multimorbid chronic disease was associated with frequent ED use overall, with a stronger association among men. Of the 7143 respondents, 14.4% were frequent ED users, 58.0% were female, and 61.5% were black non-Hispanic. Major findings included that women with 3+ chronic diseases were 2.49 (95% confidence interval, 1.7-3.6) times as likely as women without chronic diseases to report frequent ED use, compared with men with 3+ chronic diseases, who were 4.98 (95% confidence interval, 2.9-8.6) times as likely as men without chronic disease to report frequent ED use.
Multimorbid chronic disease is very strongly associated with frequent ED use among all, but the association is especially strong among men. Future research is needed to further understand this association and its implication for health care.
Short-term unscheduled return visits of adult patients to the emergency department
2014, Journal of Emergency Medicine
Citation Excerpt :
An unscheduled return visit is defined as a patient presentation for the same chief complaint within 72 h of discharge from the ED (4). Previous studies observed revisit rates between 0.4% and 15.8% (2,5–18). Patients who return to the ED within 72 h not only contribute to ED crowding, but also have been described as a population at high risk for errors in diagnosis or physician judgment in their management (5,19).
Emergency department (ED) crowding is a major international concern that affects patients and providers.
We describe the characteristics of patients who had an unscheduled related return visit to the ED and investigate its relation to ED crowding.
Retrospective medical record review of all unscheduled related ED return visits by patients older than 16 years of age over a 1-year period. The top quartile of ED occupancy rates was defined as ED crowding.
Eight hundred thirty-seven patients (1.9%) made an unscheduled related return visit. Length of stay (LOS) at the ED for the index visit and the LOS for the return visit (5 h, 54 min vs. 6 h, 51 min) were significantly different, as were the percent admitted (11.6% vs. 46.1%). Of these patients, 85.1% and 12.0% returned due to persistence or a wrong initial diagnosis, of their initial illness, respectively, and 2.9% returned due to an adverse event related to the treatment initially received. Patients presented the least frequently with an alcohol-related complaint during the index visit (480 patients), but they had the highest number of unscheduled return visits (45 patients; 9.4%). Unscheduled related return visits were not associated with ED crowding.
Return visits impose additional pressure on the ED, because return patients have a significantly longer LOS at the ED. However, the rate of unscheduled return visits and ED crowding was not related. Because this parameter serves as an essential quality assurance tool, we can assume that the studied hospital scores well on this particular parameter.
The rise of the frequent attender
2012, African Journal of Emergency Medicine
Frequent Users of Emergency Departments: The Myths, the Data, and the Policy Implications
2010, Annals of Emergency Medicine
Citation Excerpt :
However, no study has shown a threshold number at which striking differences in resources, demographics, or clinical import are observed. When defined as 4 or more ED visits per year, frequent users accounted for 4.5% to 8% of all ED patients.10,18,22,25,27 These patients contribute 21% to 28% of all ED visits.10,18,22,25,27
Frequent emergency department (ED) users have been the targets of health care reform proposals and hospital crowding interventions, but it is not clear that common assumptions about this group are supported by data. We review the literature pertaining to frequent ED users, their demographics, acuity of illness, and patterns of health care utilization. We seek to inform development of policies directed at frequent ED use and to highlight potential related challenges.
A systematic review of the literature on frequent ED users was performed.
Frequent users comprise 4.5% to 8% of all ED patients but account for 21% to 28% of all visits. Most frequent ED users are white and insured; public insurance is overrepresented. Age is bimodal, with peaks in the group aged 25 to 44 years and older than 65 years. On average, these patients have higher acuity complaints and are at greater risk for hospitalization than occasional ED users. However, the opposite may be true of the highest-frequency ED users. Frequent users are also heavy users of other parts of the health care system. Only a minority of frequent ED users remain in this group long term. Complaints vary with age, location, and usage patterns.
Frequent ED users are a heterogeneous group along many dimensions and defy popular assumptions. The subgroups have not yet been sufficiently defined to allow clearly directed policy design, and many frequent users present with true medical needs, which may explain why existing attempts to address the phenomena have had mixed success at best.
Characteristics and Predictors of Frequent Utilization of Emergency Services
2009, Journal of Emergency Nursing
Although frequent ED users account for a small percentage of ED visits, these patients can drain the system, contributing to overcrowding and lowered quality of care.
This retrospective descriptive correlational study explored characteristics of frequent ED users at a large Midwestern urban hospital and factors predictive of high ED utilization. The sample included adult patients with at least 6 visits in 2005-2006 (N = 201). For each, 6 visits were randomly chosen for chart review (N = 1200 visits) of demographic, health history, and clinical factors such as chief complaints.
Frequent users were commonly female, 35 years old, white, single, unemployed, living alone, with private insurance/Medicaid and a primary care physician. Top chief complaints were abdominal pain, headache, chest pain, low back pain, and lower extremity pain. However, a Poisson regression found that the following characteristics were associated with a higher number of ED visits: male, non-Black race, part-time employment, retired/unemployed, having Medicare, and having a chief complaint of upper respiratory infection. Headache approached significance as an independent predictor of more visits.
Almost 95% had fewer than 10 ED visits per year, with pain the overall top chief complaint. Seventy percent of frequent visits occurred during either the evening or night shift, perhaps indicating access issues to primary physicians or urgent care clinics. The rate of frequent users was comparable with other investigations, yet few similarities in patient characteristics and predictors of high ED utilization were found, partly because of the retrospective design, but certainly reinforcing limited generalizability of ED utilization patterns across centers in different metropolitan and geographic regions.

View all citing articles on Scopus

^☆: Address reprint requests to Jack E. Riggs, MD, Department of Neurology, West Virginia University Health Sciences Center, Morgantown, WV 26506-9180. E-mail: [email protected]

^☆☆: 0735-6757/03/2101-0005$35.00/0

View full text

Brief ReportsAssociation between early returns and frequent ED visits at a rural academic medical center☆,☆☆

Abstract

Section snippets

Materials and methods

Results

Discussion

J Emerg Med

Ann Emerg Med

Am J Cardiol

Unscheduled return visits by patients to the accident and emergency department

Arch Emerg Med

Brief Reports
Association between early returns and frequent ED visits at a rural academic medical center☆,☆☆