Health Policy and Clinical Practice/Original Research
Frequent attenders to an emergency department: A study of primary health care use, medical profile, and psychosocial characteristics*,**,*

Presented to the Faculty of Public Health Medicine at the Royal College of Physicians in Ireland at the summer scientific meeting, 2000.
https://doi.org/10.1067/mem.2003.68Get rights and content

Abstract

Study objective: We describe, in comparison with a control group, frequent attenders to an emergency department in terms of their general health service use and their clinical, psychological, and social profiles. Methods: One hundred frequent attenders (those who had made ≥4 visits in the previous year) and 100 nonfrequent attenders matched for sex, age, and triage category were interviewed in the ED. Data were gathered on health service use, mental health (by using the General Health Questionnaire–12 item), and perceived social support (by using the Multidimensional Scale of Perceived Social Support). Patients' general practitioners were contacted to validate attendance data. Medical charts were searched for evidence of psychological problems and alcohol or drug abuse. Results: In the overall sample of 200 patients, 32% were female, and the mean age was 55 years (SD 20). Frequent attenders had made more visits to their general practitioner in the past year compared with control patients (median 12 versus 3 visits); a higher proportion of frequent attenders had used public health nursing services, community welfare services, social work services, addiction counseling, and psychiatric services in the past year. Frequent attenders had made more other hospital visits and had spent more nights in the hospital than control patients. General Health Questionnaire–12 item scores were higher for frequent attenders than control patients, indicating poorer mental health. Frequent attenders had lower levels of perceived social support. Conclusion: Frequent attenders to the ED are also heavy users of general practice services, other primary care services, and other hospital services. General Medical Services–eligible patients (84% of frequent attenders) frequently attend the ED, even though they have free access to primary care. Frequent attenders are a psychosocially vulnerable group, and service providers and policy makers need to take account of this vulnerable patient profile as they endeavor to meet their service needs. [Ann Emerg Med. 2003;41:309-318.]

Introduction

There are considerable but separate literatures regarding what are termed “frequent attenders” to emergency departments1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 or general practices.14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26 Studies of frequent attenders to EDs show consistently similar patient characteristics, even when performed in very different health care systems, such as those in France,5 the United States,8 Ireland,11 Canada,27 Sweden,28 or the United Kingdom.29 Such patients tend to be men from poor socioeconomic backgrounds with marked psychosocial problems who experience significantly increased morbidity and even mortality. Apart from sex, this description also aptly describes frequent attenders to general practice offices.

The literature in both disciplines discusses differing methodologic approaches to defining frequent attenders.9, 20 Different definitions, which have been based on arbitrary numeric definitions or upper percentiles over varying time periods, have caused difficulties in comparing work from different centers. There is also a parallel volume of qualitative literature highlighting the effect of frequent attendance on both patients and providers.10, 23 However, with one significant recent exception,2 there has been remarkably little evaluation to determine whether frequent attenders to EDs also consult frequently with general practice and other primary care providers or vice versa. This is important because some commentators, especially in the United States, have suggested that access to free primary care will reduce ED use.12 An examination of the other health service use of frequent attenders to the ED would appear essential in providing an understanding of frequent attenders and in developing initiatives to ensure that they receive coordinated optimal care.

Those few studies that have attempted to cross the emergency and general practice interface have been mainly from the United States.4, 8, 12, 30 Interpretation of their findings is limited because EDs in the United States provide access to many patients who have no other source of primary care12, 17, 31, 32; thus, their generalizability to Europe is limited. Hansagi et al,2 however, used the remarkable Swedish national health database, which tracks health care use among almost the entire population by using unique patient identifiers. They identified a group of frequent attenders to an ED and found that, in comparison with other attenders to the ED, they were more likely to visit general practitioners, attend outpatient departments, and be admitted to the hospital. This is an important study from a country with a well-funded health care system and universal health care access. We thought it appropriate to replicate this study in a mixed health care system, to extend the study to involve other providers of primary care, and to review patient psychosocial profiles.

The most dominant model of use of health care services in the health services literature is the Andersen-Aday model.33 Within this model, the major domains that affect service use are environmental factors, such as financial, social, and political influences and organization of services; outcomes, such as patient satisfaction and perceived and actual health status; and population characteristics. Population characteristics include predisposing characteristics, such as age, sex, and occupation; enabling factors, such as income, insurance, and social support; and need, as it is perceived by the patient and evaluated by the provider. In this study, we have examined some of the variables of this model in an attempt to further our knowledge of frequent users of the ED.

The aim of this study was to describe health service use and the clinical, psychological, and social profiles of a sample of frequent ED attenders. The same data were obtained for a matched control group to allow comparison. Health service use examined included general practice attendance, other primary care health services, and hospital services.

Section snippets

Materials and methods

This was a cross-sectional study in which 100 consecutive frequent attenders to an ED and 100 consecutive matched control patients were interviewed in the ED to obtain information on their use of health services and clinical, social, and psychological variables. Each patient's general practitioner was subsequently contacted to provide information on their attendance to general practice.

About one third of the population in the Republic of Ireland has access to free primary care and medications;

Results

Between August and November 1999, 200 patients were interviewed: 100 frequent attenders and 100 control patients. The flowchart in the Figure shows the number of patients at each stage of the study.

Figure. Flowchart showing recruitment and follow-up of patients. GP, General practitioner.

Of the 23 frequent attenders deemed unsuitable by hospital staff to take part in the study interview, 4 were deemed too ill, 6 were deemed too intoxicated or under the influence of drugs to take part, 8 were

Dscussion

The study confirms Hansagi et al's2 central finding that frequent attenders to EDs complement such use with heavy use of primary care and other hospital services. It is noteworthy that replication of this finding was performed in a mixed health care system without universal access. The Irish health system is also relatively underfunded in comparison with that of Sweden; the relative proportions of 1998 gross domestic product spent on health care are 6.4% and 8.4%, respectively.40 In line with

Acknowledgements

We acknowledge the invaluable assistance of the ED nursing and reception staff of St. James's Hospital, Dublin, without whose patience and support this study would not have been possible. We also thank general practitioners for responding to our requests in this study. We acknowledge Mary Smith, SRN, BSc (Royal College of Surgeons in Ireland), for her valuable practical advice arising from previous work in this setting. We acknowledge Geraldine McMahon, FFAEM (St. James's Hospital), for her

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    *

    Supported by the Health Research Board and General Medical Services Payments Board, Ireland.

    **

    Address for reprints: Molly Byrne, BA, MSc, Department of General Practice, National University of Ireland, Galway, Ireland; 00 353 91 512106, fax 00 353 91 750559; E-mail [email protected].

    *

    Author contributions: AWM, PKP, HMM, and GB conceived and designed the study and obtained research funding. These authors monitored the progress of the study and supported the researcher throughout the duration of the study. MB recruited and interviewed participants. MB also designed the data collection tools and the study data set; she collected, managed, and analyzed all study data. AM coded data and searched patient medical charts for psychologic and social data. MB and AWM drafted the manuscript, and PKP, HMM, PKP, and GB contributed substantially to its revision. MB and AWM take responsibility for the paper as a whole.

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