Are you surprised about these instructions from an ER doc?

[vs-eh?]

Do not be afraid to call for an ambulance when indicated. A properly equipped ambulance staffed with trained emergency medicine technicians or paramedics can make a tremendous difference in outcome.

The when "indicated part" and the "make a tremendous difference in outcome" part....Hmmmmm....And who exactly is "afraid" to call an ambulance nowadays?

DRIVE BY CALLERS ARE THE SCURGE OF EMS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ARGH!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! CHECK ON THIS "PATIENT" THAT YOU ARE CALLING ABOUT AND SENDING A FIRE TRUCK AND AN AMBULANCE TO FOR YOUR "UNCONSCIOUS, POSSIBLY NOT BREATHING". A$$HOLE, GET OUT OF YOUR CAR AND WALK UP TO HIM!!!!!!!!!!!!!!!!!!!! AND DON'T BE AT HOME WHEN WE GET THERE (and do a call back for more info) AND CAN'T FIND THIS INDIVIDUAL IN THE 5 MINS IT TOOK FOR US TO GET THERE!!!!!! YOU DON'T KNOW WHERE HE IS???? IT'S BECAUSE HE WAS A DRUNK AND SLEEPING ON THR STREET AND MOVED ON YOU IDIOT. GET OUT OF YOUR CAR IF YOU FEEL THAT MUCH CONCERN!!!!

I often chuckle when people ask "well aren't you going to do anything for me/my father/mother/friend/etc....?" What exactly do you want we to do for your chronic leg pain and the perscribed pain killers are making you "sick".

"Are you going to start an IV or something?" I'm not...But here go ahead, because you obviously know more than me and why exactly this patient needs one.

I hate people.

/thread

[Ridryder 911]

What I love is those that have a pocket full pf prescriptions that has yet to be filled and discharge instructions from the ER and ink is yet not dry with the same c/c. But, alas do something for me!..

Yes, I wish we could have the same radio or whatever communication device they use.. it appears when one call comes in there will be a flood, then peace for a while, only to return in waves.

R/r 911

[Michael]

I hate people.

Gee, they say the nicest things about you... :wink:

[madmedic8522]

we have a frequent flier in our district that actually dislocates her own hip. she was involved in a mvc years ago, and has endured multiple replacement surgeries over the years. we have all run on her, and after about 3 months of the SAME address, as well as updating each other at morning coffee about her, we came to realize that we had a new seeker among us, this was 2 or so years ago.

the last time i picked her up she stated, at 3am, that she had fallen in the bath tub and her head hurt as well as the dislocated hip, of course she was fully dressed/ dry/ and waiting by the front door. upon my assessment i made the statement that nothing was notably wrong with her head, before i could finish she stated that now her back was hurting, and wanted to be transported. we then back boarded her, and transported. on the way in, approx 40 min transport, she stated that the board was painful, i then explained that i would have transported her without the back pain complaint, and she was a little discussed with herself that she ever said that to me. anyways we found out at that hospital alone she has racked up 5.5 pages of er admits in the last 3 years for similar complaints. BTW this isn't the only hospital she goes to, we usually play the "guess what hospital today" game with her, it's a choice of 5. the nurses ask for initials on the phone, and know her when they get them.

she isn't the only one we have, just the best example of wasting medical resources for the other tax payers in my district.

madmedic

[Scaramedic]

I think they have an underground network with enhanced communications when to invade the ER. Ever notice they come set groups... ?I swear, it appears they know exactly when to hit the busiest parts. As well, the physician that wrote the article needs to get back in the ER and quit smelling the potpourri and start smelling a busy ER. Thanks doc for just increasing our waiting time!

R/r 911

Is this the same group that monitors exactly when I get my food so they can call 911 and interrupt my lunch?

Bastards!

Peace,

Marty

:joker:

[Asysin2leads]

My favorite is when the lower economic class comes to the ER in packs. You have the woman with ankle pain, or the kid with the runny nose, or grandma with a cough, and the entourage of about 50 aunts, uncles, cousins, sisters, brothers, and live in boyfriends who accompany them to the hospital. Then you go out to the waiting room and they've pretty much taken over, the kids have their toys out playing, dad's watching some TV with a beer, grandma's cooking some dinner on the range they have installed, its all over.

Some people simply need to be shot. End of story.

[EMT001]

I hope the nurses at his hospital bludgeon him in his sleep. I have a patient that will call 911 for a ride to the ED because she is scared to be home alone when her husband is at work at night.

[Ace844]

(Characteristics of Frequent Users of Emergency Departments

Kelly A. Hunt @ MPPa, Ellen J. Weber, MDb, Jonathan A. Showstack, PhD, MPHc, David C. Colby, PhDa, Michael L. Callaham, MDb

Received 11 October 2005; received in revised form 9 December 2005; accepted 27 December 2005 published online 30 March 2006.)

Editor’s Capsule Summary

What is already known on this topic

Emergency department (ED) utilization has increased more than 26% during 1993 to 2003 and is thought to contribute to the large number of EDs that report crowding. Frequent users are presumed to contribute to the problem of crowding and raise questions about inappropriate use of EDs.

What question this study addressed

To identify frequent users of the ED and determine the characteristics of these patients.

What this study adds to our knowledge

Through use of a national, population-based data source to investigate frequent ED use, 8% of patients were defined as frequent users (those having 4 or more visits in a single year). Most adults who use the ED frequently have insurance and a usual source of care but are more likely to be in poor health and seek frequent medical attention than other ED users.

How might this change clinical practice

Additional support systems and better access to alternative sites of care may contribute to improving the health of these individuals and help to reduce ED use.

Introduction

Background

Emergency department (ED) utilization has risen in recent years, with a 26% increase in the number of visits between 1993 and 2003.1 In fact, the majority of EDs reported that they were at or over capacity for at least 50% of the time in 2003.2 Frequent users of the ED are a much-studied group in the literature,3-30 in part because of the presumption that they contribute substantially to ED crowding and that their use is inappropriate.

Most previous assessments of the contribution of frequent users to ED crowding are limited by the fact that they use patient data from 1 ED, making the results difficult to generalize. Additionally, ED-based studies are not as likely to have access to patient health information, such as their health status, usual source of care, and their use of other health care resources. Finally, there is no widely accepted definition of a frequent user. Definitions of frequent use range from as few as 3 visits annually to 12 or more visits annually, often without a clear rationale for the choice.4,6,7,29,30 Thus, it is difficult to compare or integrate the results of these studies.

Importance

Frequent use is often considered a major contributor to ED crowding. Solutions to crowding that target this group of ED visitors may require significant resources. Understanding the characteristics of frequent ED users and the impact of frequent use on total ED utilization is essential to ensuring that policies are successful in reducing ED crowding and in addressing the needs of these patients.

Goals of This Investigation

We studied a national, population-based data source to investigate frequent ED use. The goals of this study were to describe the frequency of visits among adults who report ED visits and to characterize frequent users.

Materials and methods

Study Design

The Community Tracking Study Household Survey, conducted by the Center for Studying Health System Change, is designed to measure health care use and the characteristics associated with use, such as income, education, insurance, and health status.31 Data for the current analysis were collected from July 2000 through June 2001. Community Tracking Study estimates of population ED use, which are based on self-reported data, are similar to estimates from the hospital-based National Hospital Ambulatory Medical Care Survey.32,33

A family informant provided basic sociodemographic and health insurance information about the family unit. Each adult in the family (including the informant) then responded to questions about personal habits; health status; visits to physicians, EDs, and hospitals in the last year; satisfaction with medical care, including satisfaction with physician choice; and unmet medical needs. Health status was measured by administering the SF-12™ Health Survey (standard US version 1.0, 1994), which contains components for both physical and mental health.34,35 Interviewers queried up to 8 members of the household. The study excluded households that could not complete the interview in either Spanish or English.

Selection of Participants

The sampling methods for the Community Tracking Study are described extensively elsewhere.31,36,37 Briefly, interviewers surveyed households by telephone in 60 randomly selected communities and in a national supplemental sample. Random-digit dialing was used to select households within these communities for interviews. To include families and individuals who do not have telephones, interviewers conducted field surveys. The base sample includes standard epidemiologic weights to estimate trends at the national, civilian, noninstitutionalized, US population level.31 A weight is assigned to each respondent to characterize the number of people in the country he or she represents. All analyses used survey weights that account for probability of selection and nonresponse.

The 2001 Community Tracking Study survey used 67,255 telephone numbers to obtain responses for 59,725 individuals in 32,669 households, for a weighted response rate of 56.2%. Lack of response included refusals to be interviewed and dialed telephone numbers that were not answered or were not working. A language barrier accounted for 0.3% of households not interviewed. Individuals younger than 18 years were excluded from the present analysis because children were not interviewed directly and are not the primary decisionmakers about health care use. In addition, many of the variables of interest (eg, SF-12 scores) were not asked of children. The resulting study sample consisted of 49,603 adults.

Primary Data Analysis

Using the Community Tracking Study data, we determined who used the ED in the adult population and how many visits per year each ED user made. We grouped ED users by level of use (1 to 7 or more visits) and calculated the percentage of overall visits ED users represented within each level and the proportion of overall ED visits accounted for within each level (Figure 1). We then determined the proportion of individuals within each level of use who possessed certain demographic or health-related characteristics, including health status, usual source of care, and family income. No particular level of visits demonstrated an obvious breakpoint in these characteristics. For example, as visits increased, so did the proportion of individuals in poor physical and mental health (Figure 2).

Figure 1. Frequency of visits to EDs among adults, United States, 2000 to 2001.

Figure 2. Poor physical and mental health among ED visitors, United States, 2000 to 2001. *Poor health is defined as the lowest 20% of SF-12 scores within each group (physical health and mental health).48

As described above, definitions of “frequent use” vary widely in the literature. To create policies that effectively address ED crowding, frequent use should be defined according to the size and impact of this group of patients. Therefore, we determined whether a particular group of individuals account for a disproportionate percentage of all ED visits. This group would have to be large enough to warrant the expenditure of resources required for policy interventions to improve health care outcomes for these individuals and reduce ED crowding. With the understanding that interventions are not likely to completely eliminate all visits, targeting a group that accounts for approximately 25% of ED visits would likely have a substantial impact on total ED visits.1 Therefore, a group of patients was identified whose level of use accounted for approximately 25% of annual ED visits and are referred to as “frequent users,” whereas individuals with fewer visits are referred to as “less frequent” users.

Logistic regression techniques were used to test the association between patient characteristics and the likelihood of being a frequent user. To avoid capitalizing on chance associations, the models included a set of independent variables entered simultaneously according to a priori hypotheses; stepwise techniques were not used. These characteristics were chosen by their likelihood of affecting frequency of use and included age, sex, education, race, poverty level, risk-taking preferences, usual source of care, smoking habits, insurance type and changes, health maintenance organization (HMO) enrollment, health status, number of overnight hospital stays, and number of primary care visits.33 Health status was based on respondents’ physical component summary scores and mental component summary scores, which are calculated from SF-12 question responses. Using these scores, we identified the 20% of the population that was in poorest health.34 Usual source of care was based on the respondent’s answer to the following questions: “Is there a place that you usually go to when you are sick or need advice about your health? What kind of place is it: a doctor’s office, an HMO, a hospital outpatient clinic, some other clinic or health center, an emergency room, or some other place?” For the analysis, usual source of care was grouped into 4 categories: (1) physician’s office, (2) “clinic/other location” (HMO, hospital outpatient clinic, some other clinic or health center, and “other”), (3) ED, and (4) no usual source of care (similar to groupings used in the National Ambulatory Medical Care Survey).38,39 Other independent variables included exogenous geographic characteristics (size of metropolitan area [>200,000 population, ≤200,000 population, nonmetropolitan area]), degree of HMO penetration in the area, and the area’s physician-population ratio. The rationale for the selection of independent variables was described previously.33

Because individuals’ experience with their usual source of care may be associated with frequency of ED use, we computed additional equations to test variables characterizing an individual’s outpatient encounters. Given that many of these variables were correlated with each other, each was added separately to the equation that included the above set of core independent variables. These variables included whether the individual was treated by the same or a different provider at each visit to the usual source of care, whether the place of usual source of care had changed in the past year, and responses to the following: “Are you satisfied or dissatisfied with the choice you personally have for primary care doctors?” and “I trust my doctor to put my medical needs above all other considerations when treating my medical problems.” Persons whose last outpatient visit had been to their usual source of care were also asked to estimate the time between calling for the appointment and being treated by a physician and for their rating of how well their physician listened. Satisfaction with health care was assessed by responses to the questions, “During the past 12 months, was there any time when you didn’t get the medical care you needed?” and “Have you been satisfied or dissatisfied with the health care you have received during the last 12 months?” The association of the total number of outpatient (nonemergency) visits with frequent use was also tested. Statistical significance was defined as a probability of a type I error of less than 5% (2-tailed). Results are expressed as odds ratios (ORs) with 95% confidence intervals (CIs). Standard errors were calculated using the statistical package SUDAAN (Research Triangle Institute, Research Triangle Park, NC).40

This study was approved by the Committee on Human Research at the University of California, San Francisco.

Results

An estimated 23% of US adults (45.2 million persons) reported at least 1 visit to the ED during the study period, for a total of 79.5 million visits. The percentage of adults who reported 1 to 7 or more annual ED visits and the proportion of total ED visits made by individuals with each level of use are shown in Figure 1. Overall, 92% of individuals made 3 or fewer visits and accounted for 72% of all adult ED visits. The 8% of users with 4 or more visits were responsible for 28% of visits. Therefore, according to our previously described rationale, we defined frequent users as those with 4 or more ED visits.

Descriptive results are displayed in Table 1. An estimated 3.5 million frequent users accounted for 22.2 million ED visits, compared with 41.7 million less frequent users who accounted for 57.3 million visits. Sixty-five percent of the frequent user population were women, 83% were younger than 65 years, and 60% were white. Thirty-three percent of frequent users had family incomes below the federal poverty level, whereas 16% were at or above 400% of the federal poverty level. Eighty-four percent of frequent users had some form of health insurance, and 81% had a usual source of care. About half of frequent users with a usual source of care were under the care of a private physician. Sixty-one percent of frequent users reported poor physical health, and 50% reported poor mental health. Sixty-eight percent of frequent users had 5 or more outpatient visits in the previous year.

Table 1. Total adult ED visitors and visits by characteristics of less frequent and frequent users, United States, 2000 to 2001.

Characteristic Less Frequent Users (1–3 ED Visits) Frequent Users (≥4 ED Visits)

Persons Visits Persons Visits

No.(Millions) % No. (Millions) % No. (Millions) % No. (Millions) %

Total 41.7 100 57.3 100 3.5 100 22.2 100

Sex

Male 18.8 45 25.2 44 1.2 35 7.4 33

Female 22.9 55 32.1 56 2.3 65 14.8 67

Age, y

18–34 14.8 36 20.6 36 1.3 36 7.9 35

35–64 19.5 47 26.5 46 1.7 47 11.0 49

65–79 5.6 13 7.7 13 ISD ISD ISD ISD

≥80 1.8 4 2.6 5 ISD ISD ISD ISD

Income by Poverty threshold⁎

≥400% 14.2 34 18.2 32 0.6 16 3.2 14

200–399% 13.5 32 18.4 32 0.9 26 5.8 26

100–199% 8.3 20 12.2 21 0.9 24 4.9 22

<Poverty threshold 5.7 14 8.6 15 1.2 33 8.2 37

Race/ethnicity

White 30.0 72 40.4 70 2.1 60 13.3 60

Black 5.6 13 8.5 15 0.8 22 5.2 23

Other 1.7 4 2.2 4 ISD ISD ISD ISD

Latino 4.5 11 6.3 11 ISD ISD ISD ISD

Physical health status†

Good 28.4 68 37.4 65 1.4 39 8.0 36

Poor 13.3 32 19.9 35 2.1 61 14.1 64

Mental health status†

Good 30.4 73 40.6 71 1.7 50 10.3 46

Poor 11.3 27 16.7 29 1.8 50 11.9 54

Insurance

Private 23.1 55 30.5 53 1.2 35 7.5 34

Medicare 9.1 22 12.7 22 1.0 30 6.3 28

Medicaid/other public 2.8 7 4.3 7 0.7 19 5.0 23

Military 0.6 1 0.9 2 ISD ISD ISD ISD

Uninsured 6.1 15 9.0 16 0.5 15 3.1 14

Enrolled in HMO

Yes 14.9 36 20.1 35 1.1 32 7.2 32

No 20.0 48 27.2 47 1.9 53 11.8 53

Usual source of care

Physician’s office 24.6 59 33.1 58 1.7 49 10.5 47

Clinic/other location‡ 10.1 24 14.6 26 1.1 32 7.4 33

ED 1.9 5 3.0 5 ISD ISD ISD ISD

No usual source of care 5.0 12 6.5 11 ISD ISD ISD ISD

Outpatient visits

past 12 mo

None 5.9 14 7.6 13 ISD ISD ISD ISD

1–4 19.4 47 25.6 45 0.8 23 4.4 20

≥5 16.4 39 24.1 42 2.4 68 15.8 71

ISD, Insufficient data (<100 respondents in this category). The numbers and percentages may not add to totals because of rounding and missing values.

⁎

In the 2000–2001 Community Tracking Study Household file, the poverty threshold is based on the US Census Bureau 2000 family income poverty threshold, and it varies with family size. In 2000, the federal poverty threshold was an income of $17,661 per year for a family of 4.

†

Poor health is defined as the lowest 20% of SF-12 scores within each group (physical health and mental health).48

‡

Clinic/other location includes individuals who identified an HMO, hospital outpatient clinic, other clinic or health center, or “some other place” as their usual source of care.

The results of the multivariate analysis are shown in Table 2. Poverty, poor physical health, poor mental health, and having 5 or more outpatient visits were all independently associated with the likelihood of frequent ED use in the adult population. Compared to persons with private insurance, Medicaid and Medicare enrollees were more likely to report frequent use (Medicaid OR 1.64; 95% CI 1.17 to 2.31; Medicare OR 1.85; 95% CI 1.26 to 2.73), and there was a trend toward uninsured individuals being more likely to report frequent use (OR 2.38; 95% CI 0.99 to 5.74).

Table 2. Likelihood of 4 or more ED visits per year among adult ED users,⁎ United States, 2000 to 2001.

Population Characteristic OR (95% CI)

Income by poverty threshold†

≥400% 1.00(Referencegroup)

200–399% 1.43(1.07–1.91)

100–199% 1.65(1.22–2.23)

<Poverty threshold 2.36(1.70–3.28)

Race/ethnicity

White 1.00(Referencegroup)

Black 1.27(0.98–1.64)

Hispanic/Latino 1.02(0.73–1.43)

Other 1.31(0.87–1.97)

Physical health status‡

Good 1.00(Referencegroup)

Poor 2.54(2.08–3.10)

Mental health status‡

Good 1.00(Referencegroup)

Poor 1.70(1.42–2.02)

Insurance

Private 1.00(Referencegroup)

Medicare 1.85(1.26–2.73)

Medicaid/other public 1.64(1.17–2.31)

Military 0.67(0.32–1.38)

Uninsured 2.38(0.99–5.74)

Enrolled in HMO

Yes 1.00(Referencegroup)

No 1.03(0.83–1.28)

Usual source of care

Physician’s office 1.00(Referencegroup)

Clinic/other location§ 1.26(1.03–1.54)

ED 2.34(1.62–3.39)

No usual source of care 0.67(0.49–0.93)

Outpatient visits past 12 mo

None 1.00(Referencegroup)

1–4 1.05(0.68–1.60)

≥5 3.02(1.94–4.71)

Change in usual source of care last 12 mo

Change 1.00(Referencegroup)

No change 0.75(0.62–0.91)

Satisfied with choice of physician

No 1.00(Referencegroup)

Yes 0.78(0.61–1.00)

Treated by same provider at usual source of care

No 1.00(Referencegroup)

Yes 0.67(0.53–0.84)

Did not get or put off needed care

No, did not have unmet need 1.00(Referencegroup)

Yes, had unmet need 1.17(0.81–1.70)

Satisfaction with care received in past 12 mo

No, not satisfied 1.00(Referencegroup)

Yes, satisfied 0.75(0.60–0.94)

⁎

Selected ORs for having ≥4 annual ED visits vs 1–3 visits, adjusted for all of the characteristics included in the table, plus the following variables: age, sex, education, number in household, risk taking, smoking, percentage of population enrolled in HMO, physician to patient ratio in geographic area, location in a metropolitan statistical area (SMA) (>200,000 population, ≤200,000 population, not in SMA), and missing values. Trust in primary physician, physician listening skills, or whether the patients waited ≥7 days for their last appointment were not associated with frequent use.

†

In the 2000–2001 Community Tracking Study Household file, the poverty threshold is based on the US Census Bureau 2000 family income poverty threshold, and it varies with family size. In 2000, the federal poverty threshold was an income of $17,661 per year for a family of 4.

‡

Poor health is defined as the lowest 20% of SF-12 scores within each group (physical health and mental health).48

§

Clinic/other location includes individuals who identified an HMO, hospital outpatient clinic, other clinic or health center, or “some other place” as their usual source of care.

Individuals who stated that they had no usual source of care were less likely to be frequent users (OR 0.67, 95% CI 0.49 to 0.93) than individuals who reported a private physician’s office as their usual source of care. Not surprisingly, individuals who stated that the ED was their usual source of care were more likely to be frequent users (OR 2.34; 95% CI 1.62 to 3.39). Individuals who visited a clinic for their usual care were more likely than those who were treated by a private physician to be frequent users (OR 1.26; 95% CI 1.03 to 1.54). Individuals who were treated by the same physician at every visit were less likely than those who were treated by different physicians to report frequent use (OR 0.67; 95% CI 0.53 to 0.84). Individuals who stated that they were satisfied with their choice of physicians were less likely than those who were not satisfied to be frequent users, although this was only marginally significant (OR 0.78; 95% CI 0.61 to 1.00). Individuals who were satisfied with their health care were less likely to report frequent use than those who were dissatisfied with their care (OR 0.75; 95% CI 0.60 to 0.94). Unmet need, changes in insurance status, HMO enrollment, longer waits for appointments, and trust in one’s physician or physician listening skills were not associated with frequent use.

Limitations

Similar to other survey data, our findings may be limited by recall bias and lack of response. However, the sampling and weighting methods of the Community Tracking Study were designed to include a nationally representative sample and to account for differences in the likelihood of selection and differential response rates. The study sample could also potentially underrepresent homeless persons, who might account for a disproportionate share of frequent ED visits.41 It is unlikely that our inferences and conclusions would be substantially changed if the sample included a larger proportion of the estimated 2.3 to 3.5 million persons who are homeless.42 Our estimates of total ED visits and payer mix have been published previously and are similar to estimates from the 2001 National Hospital Ambulatory Medical Care Survey.32,33 Because no diagnostic information was available in the Community Tracking Study Household Survey, this study could not assess the reason for or the urgency of the ED visit. However, previous studies attempting to assess appropriate use of care using clinical data are contradictory, with poor interrater reliability and poor ability to predict outcome.43-46 Because the analysis was confined to the responses of surveyed adults, these results cannot be applied to children.

As we demonstrated, the proportion of individuals who possess a particular characteristic changes gradually as the number of visits increases, with no distinct cutoff. Thus, defining frequent use as a specific number of visits is necessarily arbitrary. This is an important finding as much as it is a limitation of this study. We chose to use a level of visits that accounted for a predetermined proportion of all ED visits because of the potential impact on ED crowding. Studies of other issues and questions might, however, select a different visit level or define frequent use by other criteria.

Discussion

Most adults who use the ED frequently have insurance and a usual source of care but are more likely to be in poor health than other users. Adults who use the ED more frequently are also more likely to be poor, heavy users of other parts of the health care system, and dissatisfied with their medical care. Contrary to common perceptions, individuals who lack a usual source of care are actually less likely to be frequent users than those who have usual source of care. The absolute number of frequent users who are poor, lack a usual source of care or are uninsured is small relative to the number of less frequent users with similar characteristics.

There is no commonly agreed-on definition of frequent use. Frequent use could mean more than the 1 visit per year made by the majority of visitors,47 anything beyond reasonable use,4,6 or a number of visits beyond the 99th percentile of use.7,29,30 Definitions of frequent use must depend on the reasons for studying that particular population and, most appropriately, should be based on criteria that can inform cost-effective policy decisions. Focusing on the very small group of patients who have an extraordinary level of use but account for a tiny proportion of visits is not likely to affect either population health or ED visits.

Although a number of other studies have assessed frequent use of the ED, their utility has been limited because most were not population-based or nationally representative, often included only a subgroup of ambulatory ED visitors, and reported on a limited number of patient characteristics.3-30 No studies reviewed the overall distribution of visits in their population to define a cutoff for frequent visits, and only a few studies provided a rationale for their definition of frequent use. Zuckerman and Shen 4 characterized frequent users as those with 3 or more visits, according to the rationale that the need for a small number of visits can happen to anyone, but “having three or more visits is more likely to reflect a pattern of dependence on the ED as a source of care.” Chan and Ovens 7 used 12 visits on the basis of identifying outliers in behavior and the ability of ED physicians to “recognize one visit per month.”

The study by Zuckerman and Shen 4 is the only other study of frequent ED users we are aware of using population-based data that can be generalized to the entire United States. This study pooled data from the Urban Institute’s 1997 and 1999 National Survey of America’s Families and defined frequent use as 3 or more visits. Although the authors provide a rationale for the definition of frequent use, the distribution of visits was not assessed in determining this definition, and the number of visits frequent users account for was not reported. The authors found that frequent users were more likely than less frequent users to be poor and near-poor, in fair or poor health, to have public insurance, and to have more outpatient visits to physicians and a perception of unmet medical needs. These results are similar to ours. Of note, the National Survey of America’s Families samples children and nonelderly adults, whereas our analysis included all adults but excluded children.

Other studies that used definitions of frequent users similar to ours but were conducted at single institutions also support our findings that patients with more frequent use are a sicker and more vulnerable population. Using a convenience sample of patients from an ED in Ireland, Byrne et al 6 defined frequent users as those with greater than or equal to 4 visits. Frequent users reported more visits to the physician, more hospital visits, and greater use of other health care services (eg, social work services, addiction counseling, and psychiatric services) than less frequent users. They also reported poorer mental health than less frequent visitors. Ruger et al 29 reviewed the ED population at an urban academic ED in the United States, grouping patients in 1, 2, 3 to 20, and 20 or more visits annually. Patients with 3 to 20 visits were as likely to present with acute illnesses and be admitted to the hospital as those with only 1 visit.

Frequent use is often equated with inappropriate use. Our data do not support this assumption. The health status and patterns of health care use of frequent users found in our study and others using similar definitions strongly suggest that these individuals have greater health care needs than the rest of the population. Therefore, it appears that frequent users may be using the ED appropriately or perhaps in lieu of other forms of care that are unavailable to them. In contrast, in the ED-based study by Ruger et al,29 individuals who had 20 or more annual ED visits presented with less acute problems and were more likely to be discharged from the ED than those with 3 to 20 visits, which appears to be inappropriate use. However, only 23 patients had 20 or more visits and accounted for only 1% of total ED visits. Focusing efforts on this small group of patients would have minimal impact on ED use overall.

In a previous study, we assessed the characteristics of users and nonusers of the ED (without regard to visit frequency) and determined that the majority of all adults who use the ED have a usual source of care, are insured, and are not poor.33 The results of the current study demonstrate that the majority of frequent users also have a usual source of care, have insurance, and are not poor. Thus, frequent ED users are similar to less frequent users and, in fact, to the general population with regard to these characteristics.

Our previous study also demonstrated that individuals in poor physical and mental health and those who had 5 or more outpatient visits were more likely to have had an ED visit. This study extends these findings by showing that poor health and high use of outpatient care is also associated with increasing use of the ED. Thus, there appears to be a continuum of ED use in which individuals in poor health are more likely to use the ED, and those in poorest health are more likely to be frequent visitors. Lack of insurance did not predict overall ED use in our first study; insurance status was marginally associated with frequent use in the current analysis. Although having a usual source of care actually appeared to increase the likelihood of ED use in the previous study and frequent use in this study, the current analysis demonstrated that individuals who visited clinics rather than private physicians’ offices or who were treated by different physicians at an outpatient visit were more likely to be frequent users. Taken together, these 2 studies suggest that ED use, regardless of the number of visits, is more closely associated with health status and health care delivery than with having a usual source of care or insurance.

In conclusion, frequent users are more likely to be in poor health and heavy users of all types of care, which suggests that frequent ED use may be appropriate, particularly if support services and alternative sites for care are insufficient. Policies to decrease ED utilization by frequent users should focus on improving health care delivery services and are likely to benefit less frequent users with similar needs.

The authors wish to thank Kathryn Muessig, BA, for her expert research assistance.

References

1. 1McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2003 emergency department summary: advance data from vital and health statistics, No 358. Hyattsville, MD: National Center for Health Statistics; 2005;Available at: http://www.cdc.gov/nchs/data/ad/ad358.pdf. Accessed July 15, 2005..

2. 2The Lewin Group. American Hospital Association Trendwatch Chartbook. Chicago, IL: American Hospital Association; 2004;.

3. 3Cunningham PJ, May JH. Insured Americans Drive Surge in Emergency Department Visits (Issue Brief No. 70). Washington, DC: Center for Studying Health System Change; 2003;.

4. 4Zuckerman S, Shen YC. Characteristics of occasional and frequent emergency department users (do insurance coverage and access to care matter?). Med Care. 2004;42:176–182. MEDLINE

5. 5Andren KG, Rosenqvist U. Heavy users of an emergency department (a two year follow-up study). Soc Sci Med. 1987;25:825–831.

6. 6Byrne M, Murphy AW, Plunkett PK, et al.. Frequent attenders to an emergency department (a study of primary health care use, medical profile and psychosocial characteristics). Ann Emerg Med. 2003;41:309–318. Abstract | Full Text | PDF (91 KB) | MEDLINE | CrossRef

7. 7Chan BTB, Ovens HJ. Frequent users of emergency departments (do they also use family physicians’ services?). Can Fam Phys. 2002;48:1654–1660. MEDLINE

8. 8Cook LJ, Knight S, Junkins EP, et al.. Repeat patients to the emergency department in a statewide database. Acad Emerg Med. 2004;11:256–263. MEDLINE | CrossRef

9. 9Dent A, Phillips G, Chenhall A, et al.. The heaviest repeat users of an inner city emergency department are not general practice patients. Emerg Med. 2003;15:322–329.

10. 10Hansagi H, Olsson M, Sjoberg S, et al.. Frequent use of the hospital emergency department is indicative of high use of other health care services. Ann Emerg Med. 2001;37:561–567. Abstract | Full Text | PDF (99 KB) | MEDLINE | CrossRef

11. 11Helliwell PE, Hider PN, Ardagh MW. Frequent attenders at Christchurch Hospital’s emergency department. N Z Med J. 2001;114:160–161. MEDLINE

12. 12Huang J, Tsai W, Chen Y, et al.. Factors associated with frequent users of emergency services in a medical center. J Formos Med Assoc. 2003;102:222–228. MEDLINE

13. 13Jacoby LE, Jones SL. Factors associated with ED use by “repeater” and “nonrepeater” patients. J Emerg Nurs. 1982;8:243–247. MEDLINE

14. 14Kennedy D, Ardagh M. Frequent attenders at Christchurch Hospital’s emergency department (a 4-year study of attendance patterns). N Z Med J. 2004;117:1193.

15. 15Kne T, Young R, Spillane L. Frequent ED users (patterns of use over time). Am J Emerg Med. 1998;16:648–652. MEDLINE | CrossRef

16. 16Lucas RH, Sanford SM. An analysis of frequent users of emergency care at an urban university hospital. Ann Emerg Med. 1998;32:563–568. Abstract | Full Text | PDF (62 KB) | MEDLINE | CrossRef

17. 17Mandelberg JH, Kuhn RE, Kohn MA. Epidemiological analysis of an urban, public emergency department’s frequent users. Acad Emerg Med. 2000;7:637–646. MEDLINE

18. 18Okin RL, Boccellari A, Azocar F, et al.. The effects of clinical case management on hospital service use among ED frequent users. Am J Emerg Med. 2000;18:603–608. Abstract | Full Text | PDF (47 KB) | MEDLINE | CrossRef

19. 19Okuyemi KS, Frey B. Describing and predicting frequent users of an emergency department. J Assoc Acad Minor Phys. 2001;12:119–123. MEDLINE

20. 20Olsson M, Hansagi H. Repeated use of the emergency department (qualitative study of the patient’s perspective). Emerg Med J Online. 2001;18:430–434.

21. 21O’Shea J, Collins EW, Pezzullo JC. An attempt to influence health care visits of frequent hospital emergency facility users. Clin Pediatr. 1984;23:559–562. MEDLINE

22. 22Pope D, Fernandes CMB, Bouthillette F, et al.. Frequent users of the emergency department (a program to improve care and reduce visits). CMAJ. 2000;162:1017–1020. MEDLINE

23. 23Purdie FRJ, Honigman B, Rosen P. The chronic emergency department patient. Ann Emerg Med. 1981;10:298–301. Abstract | Abstract + References | PDF (383 KB) | MEDLINE | CrossRef

24. 24Schneider KC, Dove HG. High users of VA emergency room facilities (are outpatients abusing the system or is the system abusing them?). Inquiry. 1983;20:57–64. MEDLINE

25. 25Spillane L, Lumb EW, Cobaugh DJ, et al.. Frequent users of the emergency department (can we intervene?). Acad Emerg Med. 1997;4:574–580. MEDLINE

26. 26Sun BC, Burstin HR, Brennan TA. Predictors and outcomes of frequent emergency department users. Acad Emerg Med. 2003;10:320–328. MEDLINE | CrossRef

27. 27Ullman R, Block JA, Stratmann WC. An emergency room’s patients (their characteristics and utilization of hospital services). Med Care. 1975;13:1011–1020. MEDLINE

28. 28Yamamoto LG, Zimmerman KR, Butts RJ, et al.. Characteristics of frequent pediatric emergency department users. Pediatr Emerg Care. 1995;11:340–346. MEDLINE

29. 29Ruger JP, Richter CJ, Spitznagel EL, et al.. Analysis of costs, length of stay, and utilization of emergency department services by frequent users (implications for health policy). Acad Emerg Med. 2004;11:1311–1317. MEDLINE | CrossRef

30. 30Blank FS, Li H, Smithline HA, et al.. A descriptive study of heavy emergency department users at an academic emergency department reveals heavy ED users have better access to care than average users. J Emerg Nurs. 2005;31:139–134.

31. 31Strouse R, Carlson B, Hall J. Center for Studying Health System Change (Household Survey Methodology Report 2000-01 (Round Three)). Washington, DC: Center for Studying Health System Change; 2003;.

32. 32McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey (2001 emergency department summary). Adv Data. 2003;1–29.

33. 33Weber EJ, Showstack JA, Hunt KA, et al.. Does lack of a usual source of care or health insurance increase the likelihood of an emergency department visit? results of a national population-based study. Ann Emerg Med. 2005;45:4–12. Abstract | Full Text | PDF (192 KB) | CrossRef

34. 34Ware J, Kosinski M, Keller SD. A 12-item short-form health survey (construction of scales and preliminary tests of reliability and validity). Med Care. 1996;34:220–233. MEDLINE | CrossRef

35. 35Center for Studying Health System Change. Community Tracking Study Household Survey (Survey Methodology Report (Round One)). Washington, DC: Center for Studying Health System Change; 1998;.

36. 36Cunningham PJ, Kemper P. Ability to obtain medical care for the uninsured (how much does it vary across communities?). JAMA. 1998;280:921–927. MEDLINE | CrossRef

37. 37Kemper P, Blumenthal D, Corrigan JM, et al.. The design of the community tracking study (a longitudinal study of health system change and its effects on people). Inquiry. 1996;33:195–206. MEDLINE

38. 38Cherry DK, Burt CW, Woodwell DA. National Ambulatory Medical Care Survey (2001 summary). Adv Data. 2003;1–44.

39. 39Hing E, Middleton K. National Hospital Ambulatory Medical Care Survey (2001 outpatient department summary). Adv Data. 2003;1–26.

40. 40Brogan D. Software for survey data (misuse of standard packages). In: Armitage P, Colton T editor. Encyclopedia of Biostatistics. Boston, MA: John Wiley and Sons; 1998;.

41. 41Kushel MB, Perry S, Bangsberg D, et al.. Emergency department use among the homeless and marginally housed (results from a community-based study). Am J Public Health. 2002;92:778–784. MEDLINE

42. 42Burt M. What will it take to end homelessness?. Washington, DC: Urban Institute; 2001;Available at http://www.urban.org/UploadedPDF/end_homelessness.pdf. Accessed June 17, 2005..

43. 43Afilalo M, Guttman A, Colacone A, et al.. Emergency department use and misuse. J Emerg Med. 1995;13:259–264. Abstract | Abstract + References | PDF (602 KB) | MEDLINE | CrossRef

44. 44Liu T, Sayre MR, Carleton SC. Emergency medical care (types, trends, and factors related to nonurgent visits). Acad Emerg Med. 1999;6:1147–1152. MEDLINE

45. 45Gill JM, Reese CL, Diamond JJ. Disagreement among health care professionals about the urgent care needs of emergency department patients. Ann Emerg Med. 1996;28:474–479. Abstract | Full Text | PDF (603 KB) | MEDLINE | CrossRef

46. 46Lowe RA, Bindman AB. Judging who needs emergency department care (a prerequisite for policy-making). Am J Emerg Med. 1997;15:133–136. MEDLINE | CrossRef

47. 47National Center for Health Statistics. Health, United States 2001 With Urban and Rural Health Chartbook. Hyattsville, MD: National Center for Health Statistics; 2001;.

48. 48Reschovsky JD. Do HMOs make a difference? access to health care. Inquiry. 2000;36:390–399Winter 1999. MEDLINE

a Research & Evaluation, Robert Wood Johnson Foundation, Princeton, NJ

b Division of Emergency Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA

c Institute for Health Policy Studies and Department of Medicine, University of California, San Francisco, San Francisco, CA

Address for correspondence: Kelly Hunt, The Robert Wood Johnson Foundation, Route 1 and College Road East, PO Box 2316, Princeton, NJ 08543-2316; 609-627-5994, fax 609-514-7992

Supervising editor: Robert K. Knopp, MD

Author contributions: KAH, EJW, JAS, DCC, and MLC conceived the study, determined the theoretical model, and interpreted the results. EJW, JAS, and KAH designed the analyses. KAH and JAS provided statistical consultation; KAH programmed the data. KAH drafted the manuscript, with contributions from EJW and JAS. All authors contributed substantially to its revision. KAH takes responsibility for the paper as a whole.

The interpretations and opinions are those of the authors and may not necessarily reflect those of the Robert Wood Johnson Foundation or the University of California, San Francisco.

Funding and support: The authors report this study did not receive any outside funding or support.

Disclaimer: Michael Callaham, MD, recused himself from the editorial decision process for this article.

Reprints not available from the authors.

PII: S0196-0644(06)00068-0

doi:10.1016/j.annemergmed.2005.12.030

© 2006 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

.

(Frequent Emergency Department Visitors: The End of Inappropriateness

Steven L. Bernstein @ MD

published online 22 May 2006.

Article Outline

• References

• Copyright

SEE RELATED ARTICLES, P. 1 and 9

[Ann Emerg Med. 2006;48:18-20.)

]

In 1992, a 4-month-old boy with fever and irritability was taken by his parents to the local emergency department (ED) late at night. The emergency physician on duty diagnosed otitis media and prescribed antibiotics and analgesics, and the child recovered without incident. His parents, both physicians, spent the next year in a losing battle with the insurance company, which denied payment because of the “inappropriateness” of the visit. The insurance company claimed that because the baby’s fever was less than 103°, the visit was unnecessary. The boy’s father (and author of this editorial) was impressed with the insurer’s creativity in denying the claim.

Incidents such as this sparked a new focus in the 1990s on examining visit appropriateness and crowding as key policy issues in emergency medicine.1–7 ED visit volume grew sharply during the decade,8 along with denials of payment by managed care organizations, leading in part to the adoption of the prudent layperson standard at the federal and state levels.

The earliest reports of ED crowding cited myriad causes, including the inability to move admitted patients upstairs to inpatient wards1 and, in urban areas, a growing number of mentally ill and substance-abusing patients.5 These disparate causes would later be explicated nicely in the input-throughput-output conceptual model of crowding.9

In 1993, the General Accounting Office (now known as the Government Accountability Office) issued an influential report that asserted the growth in ED use was largely due to uninsured, elderly, and seriously ill patients.10 The report also noted that 43% of ED patients had nonurgent conditions, many of which could have been treated elsewhere in the community. This latter statistic received considerable attention and became the basis for much of the conversation about “inappropriate” ED use. More recent data showing that most of the growth in ED visit volume came from patients insured privately or by Medicare11 did not quell the discussions about “inappropriate” ED visits.

Subsequent policy debates about ED crowding have been muddied by the confusion of separate but related phenomena and lack of clear definitions. These include:

•ED crowding: A condition in which the demand for ED services, including personnel and beds, exceeds the available supply. The input-throughput-output model outlines the various factors that contribute to each of the 3 components of crowding. Studying ED crowding has been difficult because of the lack of a single metric applicable to all EDs.12,13 Several recently developed omnibus indexes of crowding, if validated, may provide a reproducible way to measure the phenomenon.14,15

•Inappropriate ED use: Generally defined as an ED visit by someone with a nonurgent or less-urgent condition treated more efficiently and cheaply in an office or clinic setting. In its more malignant form, inappropriate ED use has been characterized as visits by people of lower socioeconomic status who are “gaming” the system by claiming benefits and services to which they are not entitled.

•Frequent ED use: A subset of inappropriate use, typically refers to patients who visit the ED 3 or more times annually. Every ED has a panel of patients, well known to the staff as “frequent flyers,” who visit regularly because of complications of homelessness, alcoholism, sickle cell disease, asthma, migraine, and the like.

In this issue of Annals, 2 articles provide compelling evidence that the “inappropriate” ED visit is nothing of the kind.16,17 Hunt et al16 analyzed the Community Tracking Study Household Survey, a nationally representative sample of more than 32,000 households, and found that 8% of adults accounted for 28% of all ED visits in 2000 to 2001. In this study, factors independently associated with frequent ED use (defined as 4 or more annual visits) were poor physical or mental health, 5 or more annual outpatient visits, and a family income below the poverty threshold. It is worth noting that most patients in this national dataset had insurance (84%) and a regular source of care (81%). This study did not include information about specific diagnoses.

Fuda and Immekus17 examined a set of Massachusetts databases for 2003 and found that 1% of all state residents accounted for 17.6% of all ED visits. In the Fuda and Immekus17 study, frequent ED users (defined as 5 or more annual visits) were more likely to be admitted and received a higher intensity of services at each visit. Of note, more than half (54.5%) of frequent users had a primary or secondary International Classification of Diseases, Ninth Revision code associated with a mental health or substance use disorder compared with 12.0% of the infrequent ED users. Interestingly, only 28% of frequent users remained so in a second year of observation. Fuda and Immekus17 did not perform multivariate modeling to determine which variables were independently associated with frequent ED use.

From these articles, several themes emerge about frequent ED users:

•they are sicker than infrequent or nonusers;

•they use more health care in general, including more non-ED ambulatory visits;

•they suffer disproportionately from mental illness and substance use; and

•their insurance status, race, and ethnicity are minor determinants of ED use.

What interventions are available to reduce the prevalence of frequent ED use? The most likely approaches involve expanding office hours for primary care and mental health services and providing case management for frequent users. Both approaches entail a multidisciplinary effort by ambulatory care providers, mental health providers, social services, health care systems, and payers. These are not efforts that can be confined to the ED. As far as efficacy goes, data are sparse, and the evidence is suggestive but not definitive.

Lowe et al18 recently found that patients enrolled in primary care practices with more than 12 hours of evening coverage a week were 20% less likely to use the ED. The implication of this observational study, that expanding office hours reduce ED use, is less clear. A brief 6-week study from the Netherlands, using a pre-post design, found that extended evening and weekend hours in one small city’s primary care settings reduced ED usage 53%.19 Solberg et al20 found that open-access scheduling, without expanding hours, increased the proportion of scheduled office visits to the primary care provider and reduced the number of urgent-care visits to the primary care provider but did not affect ED usage. Neither study specifically studied or targeted frequent ED users.

Two studies of case management for frequent ED users yielded conflicting results. At San Francisco General Hospital, Okin et al21 reduced ED visits during 1 year from a median of 15 to 9 for patients who had made at least 5 annual visits before case management. In Rochester, case management did not reduce ED use for patients with more than 10 annual visits.22 Both studies offered mental health services and counseling for drugs and alcohol.

Last, one may reasonably conclude that, although frequent ED users make a disproportionate number of ED visits, they do not contribute in a substantive way to ED crowding. In fact, the Government Accountability Office acknowledged as much in their 2003 report that reexamined ED crowding and concluded that high inpatient occupancy and an inability to move admitted patients upstairs (particularly to telemetry and critical care beds) was the main cause of ED crowding.23 To a great extent, this confirmed what most emergency physicians had already known, but its appearance in a federal report was nonetheless important.

In regard to frequent ED visitors, language matters. Describing ED recidivism as a problem or as inappropriate stigmatizes the patients who make those visits. The deeper problem is that there are substantial numbers of Americans, particularly those with mental illness and substance use disorders, with unmet health needs who use the ED because of its convenience, accessibility, and affordability. For these patients, the ED represents an “affirmative choice” for care, rather than a provider of last resort.24 Viewed this way, the ED visit then becomes an epiphenomenon related to the unmet health need.

The notion of the “inappropriate” ED user is largely apocryphal. Fuda and Immekus17 and Hunt et al16 convincingly demonstrate that frequent ED users are sicker, with considerable mental illness and substance use, than infrequent or nonusers. Frequent ED users come to the hospital because they need care. Infrequent users may avoid the ED with expanded access to primary care, but this is not at all clear. Constructive policy change will not result from a blame-the-victim analysis.

Perhaps a wiser health policy goal would be to focus on the delivery of high-quality, convenient, accessible care to all patients in all clinical settings, ambulatory, emergency, and inpatient.25 Intensive case management of frequent ED users and expanded off-hours access to facilities delivering primary care, especially mental health and substance use treatment, may decrease the frequency of ED recidivism, but additional work is needed to test the efficacy of these interventions. In health care’s current political climate, which emphasizes cost containment and personal responsibility, it is difficult to see this happening. But for now, let us put to rest future conversations about “inappropriate” ED use.

References

1. 1Feferman I, Cornell C. How we solved the overcrowding problem in our emergency department. CMAJ. 1989;140:273–276. MEDLINE

2. 2Dickinson G. Emergency department overcrowding. CMAJ. 1989;140:270–271. MEDLINE

3. 3Koska MT. Indigent care and overcrowding threaten EDs. Hospitals. 1989;63:66–70. MEDLINE

4. 4American College of Emergency Physicians. Measures to deal with emergency department overcrowding (American College of Emergency Physicians). Ann Emerg Med. 1990;19:944–945. PDF (140 KB) | MEDLINE | CrossRef

5. 5Gallagher EJ, Lynn SG. The etiology of medical gridlock (causes of emergency department overcrowding in New York City). J Emerg Med. 1990;8:785–790. MEDLINE | CrossRef

6. 6Andrulis DP, Kellermann A, Hintz EA, et al.. Emergency departments and crowding in United States teaching hospitals. Ann Emerg Med. 1991;20:980–986. Abstract | Abstract + References | PDF (715 KB) | MEDLINE | CrossRef

7. 7Lynn SG, Kellermann AL. Critical decision making (managing the emergency department in an overcrowded hospital). Ann Emerg Med. 1991;20:287–292. Abstract | Abstract + References | PDF (684 KB) | MEDLINE | CrossRef

8. 8Burt CW, McCaig LF. Trends in Hospital Emergency Department Utilization (United States, 1992–99). Hyattsville, MD: National Center for Health Statistics; 2001;Advance Data From Vital and Health Statistics, No. 150..

9. 9Asplin BR, Magid DJ, Rhodes KV, et al.. A conceptual model of emergency department crowding. Ann Emerg Med. 2003;42:173–180. Abstract | PDF (73 KB) | MEDLINE | CrossRef

10. 10General Accounting Office. Emergency Departments (Unevenly Affected by Growth and Change in Patient Use). Washington, DC: US General Accounting Office; 1993;.

11. 11Cunningham P, May J. Insured Americans Drive Surge in Emergency Department Visits. Washington, DC: Center for Studying Health System Change; 2003. Issue Brief No. 70.

12. 12Hwang U, Concato J. Care in the emergency department (how crowded is overcrowded?). Acad Emerg Med. 2004;11:1097–1101. MEDLINE | CrossRef

13. 13Solberg LI, Asplin BR, Weinick RM, et al.. Emergency department crowding (consensus development of potential measures). Ann Emerg Med. 2003;42:824–834. Abstract | Full Text | PDF (131 KB) | MEDLINE | CrossRef

14. 14Bernstein SL, Verghese V, Leung W, et al.. Development and validation of a new index to measure emergency department crowding. Acad Emerg Med. 2003;10:938–942. MEDLINE | CrossRef

15. 15Weiss SJ, Derlet R, Arndahl J, et al.. Estimating the degree of emergency department overcrowding in academic medical centers (results of the National ED Overcrowding Study (NEDOCS)). [erratum appears in Acad Emerg Med. 2004;11:408. Fernandez-Frankelton M corrected to Fernandez-Frackelton M]Acad Emerg Med. 2004;11:38–50. MEDLINE | CrossRef

16. 16Hunt KA, Weber EJ, Showstack JA, et al.. Characteristics of frequent users of emergency departments. Ann Emerg Med. 2006;48:1–8. Abstract | Full Text | PDF (157 KB) | CrossRef

17. 17Fuda KK, Immekus R. Frequent users of Massachusetts emergency departments (a statewide analysis). Ann Emerg Med. 2006;48:9–16.

18. 18Lowe RA, Localio AR, Schwarz DF, et al.. Association between primary care practice characteristics and emergency department use in a Medicaid managed care organization. Med Care. 2005;43:792–800. MEDLINE | CrossRef

19. 19van Uden CJT, Winkens RAG, Wesseling G, et al.. The impact of a primary care physician cooperative on the caseload of an emergency department (the Maastricht integrated out-of-hours service). J Gen Intern Med. 2005;20:612–617. CrossRef

20. 20Solberg LI, Maciosek MV, Sperl-Hillen JM, et al.. Does improved access to care affect utilization and costs for patients with chronic conditions?. Am J Managed Care. 2004;10:717–722. MEDLINE

21. 21Okin RL, Boccellari A, Azocar F, et al.. The effects of clinical case management on hospital service use among ED frequent users. Am J Emerg Med. 2000;18:603–608. Abstract | Full Text | PDF (47 KB) | MEDLINE | CrossRef

22. 22Spillane LL, Lumb EW, Cobaugh DJ, et al.. Frequent users of the emergency department (can we intervene?). Acad Emerg Med. 1997;4:574–580. MEDLINE

23. 23US Government Accountability Office. Hospital Emergency Departments (Crowded Conditions Vary among Hospitals and Communities). Washington, DC: General Accounting Office; 2003;.

24. 24Ragin DF, Hwang U, Cydulka RK, et al.. Reasons for using the emergency department (results of the EMPATH Study). Acad Emerg Med. 2005;12:1158–1166.

25. 25Institute of Medicine. Crossing the Quality Chasm (A New Health System for the 21st Century). Washington, DC: National Academy Press; 2001;.

Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY.

Address for correspondence: Steven L. Bernstein, MD, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, 111 East 210th St., Bronx, NY 10467; 718-920-2068, fax 718-798-0730

Supervising editor: Brent R. Asplin, MD, MPH

Funding and support: The author reports this study did not receive any outside funding or support.

Publication dates: Available online May 18, 2006.

Reprints not available from the author.

PII: S0196-0644(06)00489-6

doi:10.1016/j.annemergmed.2006.03.033

© 2006 American College of Emergency Physicians. Published by Elsevier

[Michael]

* Whew! * I'm so glad we had this little chat! :wink:

[Riblett]

Ah the pet peeve of nearly every EMSer...stupid people. And it should come as no surprise that they make up a disproportionately large number of our 'customer base'. I guess all is fair in love, war, and any job where you are fighting the process of natural selection on a daily basis.

Two nights ago I had a lady call 911 that was EMDed as a respiratory distress. Okay so we get up from our dinner (good chinese, by the way) and run lights and sirens. We are met at the front steps of the trailer by a 24 y/o woman saying that she needs to go to the hospital. She looked fine, no obvious distress, six year old daughter underfoot. When asked why she says that she thinks she may have pneumonia or something. She seemed to have the same damn cold that my partner did and he had even less sympathy for her than I did. She also proceeds to tell us that her daughter was sick too and needed to be seen also. She told my partner enroute that she KNEW she would get seen "like, much faster" since she came to the ED on an ambulance. Plus her husband was inside asleep and did want to have to drive her.

I hate people.