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• Reduced frequent attendance: could it be seasonal?
  Elizabeth D Bateman
  Published on: 24 March 2009

• Published on: 24 March 2009

  Reduced frequent attendance: could it be seasonal?

  • Elizabeth D Bateman, Emergency Medicine StR

  Dear Editor,

  I read with interest the article by Skinner, Carter and Haxton assessing whether case management of frequent attenders to an urban emergency department reduces frequency of subsequent attendances.1 The case for multidisciplinary management of frequent attenders is well-made and the reported practice of case review and implementation of care plans highly commendable.

  However, a possible c...

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  Dear Editor,

  I read with interest the article by Skinner, Carter and Haxton assessing whether case management of frequent attenders to an urban emergency department reduces frequency of subsequent attendances.1 The case for multidisciplinary management of frequent attenders is well-made and the reported practice of case review and implementation of care plans highly commendable.

  However, a possible considerable limitation to this study is not fully elucidated in the authors’ discussion. While mention is made that the reduction seen in attendances by frequent attenders following case review “may be due to the natural ebb and flow in the presentations of these patients”1, comment is not made on the potential substantial effects of the differing seasons in which the study was conducted (October 2006 to March 2007 control, compared to April 2007 to September 2007 post- intervention).

  Watters et al have previously observed that the number of patient attendances to the Emergency Department at the Royal Infirmary Edinburgh is subject to monthly variation.2 Chi-squared analysis of the total numbers of patients presenting each month presented by Watters et al confirms variation in numbers of patients by month (chi2 = 105.24, p <0.001) even when the varying numbers of days in each month is taken into account (chi2 = 57.03, p <0.001).

  Further to this variation in total attendances is the seasonal variation in presentations of different clinical conditions. The most common documented diagnoses in this group of frequent attenders was stated to include “alcohol-related problems (46%), mental health problems (37%) and chronic complaints such as abdominal or chest pain (40%)”. Other diagnoses included COPD / asthma and drug abuse. However, the presentations of many of these conditions have been shown to be subject to seasonal variation. Arkfen et al’s study of frequent visitors to psychiatric emergency services found that admission was more frequent in inclement weather 3; Halpern et al observed a seasonal variation in emergency department “psychiatric visits” with results supporting the “existence of a Christmas effect”, they also noted that substance abusers were more likely to attend the emergency department during the weeks surrounding Christmas 4.

  It is also known that patients with ischaemic heart disease are more likely to become severely symptomatic during colder temperatures, and “cold stress” contributes to a higher mortality rate from this condition during the winter 5. Winter predominance seasonal variation in presentation rates for abdominal pain is also suspected, and has been demonstrated in children 6. Ballester et al observed “clear temporal patterns of COPD emergency” with more emergencies in winter 7.

  With more than half of the frequent attenders’ documented diagnoses subject to seasonal variation with increased presentations during winter months, it would appear that there is an as yet unaddressed confounding bias in the observed decreased number of subsequent attendances in the (summer) months following case management intervention. I eagerly await the mentioned follow-up study, and will be interested to ascertain whether the results seen so far are indeed sustainable over time.

  E Bateman

  Competing interests: None

  REFERENCES

  1. Skinner J, Carter L, Haxton C. Case management of patients who frequently present to a Scottish emergency department. Emerg Med J 2009; 26: 103-105.

  2. Watters DA, Brooks S, Elton RA, et al. Sports injuries in an accident and emergency department. Emerg Med J 1984; 1: 105 -111.

  3. Arfken C, Zeman LL, Yeager L, et al. Frequent visitors to psychiatric emergency services: staff attitudes and temporal patterns. J Behav Health Serv Res 2002; 29(4): 490-496.

  4. Halpern SD, Doraiswamy PM, Tupler LA, et al. Emergency department patterns in psychiatric visits during the holiday season. Ann Emerg Med 1994; 24(5): 939-943.

  5. Houdas Y, Deklunder G, Lecroart JL. Cold exposure and ischemic heart disease. Int J Sports Med 1992; 13 Suppl1: S179-81.

  6. Saps M, Blank C, Khan S, et al. Seasonal variation in the presentation of abdominal pain. J Pediatr Gastroenterol Nutr 2008; 46(3): 279-84.

  7. Ballester F, Pérez-Hoyos S, Rivera ML, et al. [The patterns of use and factors associated with the patient admission of hospital emergencies for asthma and chronic obstructive pulmonary disease]. Arch Bronconeumol 1999; 35(1): 20-26.

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  Conflict of Interest:
  None declared.

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