• Emergency Care Systems

It was Greg Henry, that preeminent emergency physician from Michigan, who once said “The ED has become the bottom of the societal birdcage…. All social problems have become diseases. If your mother no longer loves you and the police don't want you, you can always come and see us”. In truth it often feels that way when we arrive onto a shift, and especially feels that way when we have a visit from one of our ‘friends’ of the emergency department (ED). It is recognised that a small number of patients make frequent use of the ED and account for a disproportionate amount of the total ED workload.1 Recent press coverage has highlighted the problem of frequent attenders with the public by identifying those Emergency Departments in the UK who rank highest in having a frequently attending patient.2 The study by Vinton3 et al has shed more light on the profile of these patients through a large population-based study in the USA. The study used the US National Health Interview Survey to compare characteristics of US adults by frequency of ED use, specifically the prevalence of chronic diseases and primary care and mental health use. The survey is a self-report household survey that gathers information about healthcare use among other things. The analysis compared baseline characteristics of non-frequent, frequent and super-frequent users of EDs in order to understand the profile of the frequent and super-frequent attender groups. The study found that the characteristics associated with higher ED use included non-Hispanic race/ethnicity, Medicaid insurance, lower socioeconomic status, lower self-reported health status and several common chronic diseases. In addition, both patients reporting the ED as their usual source of care and those with ≥10 outpatient visits in the past 12 months were more likely to report frequent ED use.

Perhaps these findings will not come as a great surprise to readers, and in fact the results do agree with many of the papers published on this topic in the past, despite the fact that studies have been undertaken in different health economies. First, there is general disagreement about the definition of a frequent user. In the past it has been rather arbitrarily based upon the number of attendances within a given time frame. The definitions used vary, ranging from 3 to 12 attendances within a year, with no clear consensus on what the actual value should be. Second, there is strong evidence that frequent users are more likely to have chronic disease conditions, have a lower socioeconomic status, be less well educated, more likely to present with medical complaints, have higher rates of psychiatric morbidity and also be frequent users of other health services (both emergency and routine).4–16

We should also remember that this is not just a problem for EDs, but for all urgent care services. Ambulance services in particular are challenged by some patients who call frequently and have introduced a number of strategies for managing this workload and reducing subsequent calls.17 One service estimates the costs of such callers to be £11 million per annum.18