Heavy users of emergency services: Social construction of a policy problem

doi:10.1016/0277-9536(94)E0116-A

Social Science & Medicine

Volume 40, Issue 4, February 1995, Pages 469-477

https://doi.org/10.1016/0277-9536(94)E0116-A Get rights and content

Abstract

A relatively small subgroup of emergency department (ED) patients is responsible for a disproportionate amount of ED visits and costs. This subgroup, the heavy users of ED services, is identified as a medically and socially vulnerable population. Heavy users of ED services are identified as a ‘problem’ in the United States that opens a ‘window’ on the wider social issues critical to consensus on health care reform. The problem is nested within a complex of larger, interdependent problems including access to care, lack of primary/preventive services, absent or inadequate social services, and fragmented service delivery. This article uses the literature on heavy users of ED services to argue that social constructions of the problem and articulation of solutions by different key players in health care reform are based on divergent and often conflicting premises.

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Care provided in the emergency department (ED) can cost up to five times as much as care received for comparable diagnoses in alternative settings. Small groups of patients, many of whom suffer from an opioid use disorder, often account for a large proportion of total ED visits. We recently conducted, and demonstrated the effectiveness of, the first randomized controlled trial of a citywide ED care-coordination program intending to reduce prescription-opioid-related ED visits. All EDs in the metropolitan study area were connected to a Web-based information exchange system.
The objective of this article was to perform an economic evaluation of the 12-month trial from a third-party-payer perspective.
We modeled the person-period monthly for the 12-month observation period, and estimated total treatment costs and return on investment (ROI) with regard to cost offsets, over time, for all visits where the patient was admitted to and discharged from the ED.
By the end of month 4, the mean cumulative cost differential was significantly lower for intervention relative to treatment-as-usual participants (−$1370; p = 0.03); this figure climbed to −$3200 (p = 0.02) by the end of month 12. The ROI trended upward throughout the observation period, but failed to reach statistical significance by the end of month 12 (ROI = 3.39, p = 0.07).
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Frequent and unnecessary utilization of the emergency department (ED) is often a sign of serious latent patient issues, and the associated costs are shared by many. Helping these patients get the care they need in the appropriate setting is difficult given their complexity, and their tendency to visit multiple EDs.
We analyzed the cost-effectiveness of a multidisciplinary ED-care-coordination program with a regional hospital information system capable of sharing patients’ individualized care plans with cooperating EDs.
ED visits, treatment costs, cost per visit, and net income were assessed pre- and postenrollment in the program using nonparametric bootstrapping techniques. Individuals were categorized as frequent (3–11 ED visits in the 365 days preceding enrollment) or extreme (≥ 12 ED visits) users. Regression to the mean was tested using an adjusted measure of change.
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Of the 25 813 people included in the cohort, 17 020 (65.9%) had 2 emergency department visits within 1 year, 5704 (22.1%) had 3 or 4 visits, and 3089 (12.0%) had 5 or more visits. Males, people aged 45–64 years, and those living in urban centres and lower-income neighbourhoods were more likely to have 3 or 4 visits, or 5 or more visits. The all-cause 1-year mortality rate was 5.4% overall, ranging from 4.7% among patients with 2 visits to 8.8% among those with 5 or more visits. Death due to external causes (e.g., suicide, accidents) was most common. The adjusted mortality rate was 38% higher for patients with 5 or more visits than for those with 2 visits (adjusted hazard ratio 1.38, 95% confidence interval 1.19–1.59). Among 25 298 people aged 16–74 years, this represented 30 607 YPLL.
We observed a high mortality rate among relatively young, mostly urban, lower-income people with frequent emergency department visits for alcohol-related reasons. These visits are opportunities for intervention in a high-risk population to reduce a substantial mortality burden.
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General paperHeavy users of emergency services: Social construction of a policy problem

Abstract

Soc. Sci. Med.

Soc. Sci. Med.

Soc. Sci. Med.

Am. J. Emergency Med.

Ann. Emergency Med.

Soc. Sci. Med.

Ann. Emergency Med.

Ann. Emergency Med.

Texas Med.

Hlth Care Financing Rev.

New York State J. Med.

Int. J. Hlth Serv.

J. Hlth Politics, Policy Law

Am. J. Emergency Med.

The Atlantic Monthly

Yale studies in ambulatory medical care. V. Determinants of use of hospital emergency services

Am. J. Pub. Hlth

The Emergency Department: A Regional Medical Resource

The sagging safety net: Emergency departments on the brink of crisis

Hospitals

Emergency and critical care medicine: Local implementation of national recommendations

Understanding the growth of emergency department utilization

Med. Care

Emergency Services: The Hospital Emergency Department in an Emergency Care System

Utilization of Outpatient Care Resources

Utilization of hospital emergency and outpatient departments: United States, January–June, 1980

Health care indicators

Hlth Care Financing Rev.

High-volume and low-volume users of health services, United States, 1980

High-cost users of medical care

New Engl. J. Med.

High consumers of health care in emergency units: how to improve their quality of care

Quality Assurance Hlth Care

High users of VA emergency room facilities: are outpatients abusing the system or is the system abusing them?

Inquiry

A study of the relationship between social network, perceived ill health and utilization of emergency care

Scand. J. Soc. Med.

Health care utilization after referral from a hospital emergency department

Scand. J. Soc. Med.

Frequency of emergency department attendances as a predictor of mortality: nine-year follow-up of a population-based cohort

J. Publ. Hlth Med.

Neighborhood variations in the use of hospital emergency rooms for primary care

Soc. Sci. Med.

Family use of health care, United States, 1980

Influence of substance abuse and mental disorders on emergency room use by homeless adults

Hosp. Community Psychiat.

An emergency room's patients: their characteristics and utilization of hospital services

Med. Care

The etiology of medical gridlock: causes of emergency department overcrowding in New York City

J. Emergency Med.

Indigent care and overcrowding threaten EDs

Hospitals

Defining and treating “problem patients” in a hospital emergency room

Med. Care

Social problems as collective behavior

Soc. Problems

Toward a sociology of social problems: Social conditions, value-judgments, and social problems

Soc. Problems

Social problems theory: the constructionist view

A. Rev. Sociol.

On cogency, professional bias, and public policy: an assessment of four views of the injury problem

Milbank Q.

Tenacious assumptions in Western medicine

Being-in-the-world: A commentary on Heidegger's Being and Time

Heidegger's hermeneutic realism

The Primacy of Caring: Stress and Coping in Health and Illness

General paper
Heavy users of emergency services: Social construction of a policy problem