It has often been said that the most frequent users of overburdened hospital emergency departments are mentally ill substance abusers. But a new study has found that this belief is unfounded—an urban legend.

Coauthored by John Billings of the Robert F. Wagner Graduate School of Public Service and Maria C. Raven of the University of California, San Francisco, and published in the journal Health Affairs, the new analysis of hospital emergency department use in New York City by Medicaid patients reveals that conditions related to substance abuse and mental illness are actually responsible for only a small share of the emergency department visits by frequent users, and that emergency department use accounts for a small portion of these patients’ total Medicaid expenditures.

In fact, according to the study, frequent emergency department users are those who have a substantial burden of disease, often having multiple chronic conditions and many hospitalizations.

The article, “Dispelling an Urban Legend: Frequent Emergency Department Users Have Substantial Burden of Disease,” analyzes data on emergency department visits by 212,259 New York City residents who received their first emergency department care in 2007. The authors write that “contrary to urban legend, most repeat ED users in the study did appear to have relatively strong linkage to ambulatory care, at least as evidenced by their high rates of primary and specialty care visits. Except for ED users with 10 or more visits in the [initial] year, ambulatory care visit rates actually exceeded ED visit rates.”

While hospital emergency department use is not a major cost driver for the Medicaid program, an improved understanding of Medicaid beneficiaries who frequently obtain emergency department care could help inform the current policy debate over how to meet the significant needs of this population and how to contain Medicaid expenditures, the study states.

Importantly, the analysis indicates that “predictive modeling” based on information provided at a patient’s initial ED visit could be used to identify individuals likely to return to the emergency department frequently. Billings and Raven write that the predictive modeling approach, coupled with an understanding of the characteristics of frequent ED users, offers healthcare institutions an opportunity to design targeted, cross-system healthcare interventions to keep future frequent users from having to return to the hospital for emergency care.

“It is also important to note that only a small number of ‘frequent fliers’ are ultra-high ED users or serial high ED users, with frequent ED use year after year,” they write. “To date, most thinking by providers and policymakers about the problem of frequent ED users has focused on these serial users, but the overwhelming majority of frequent users have only episodic periods of high ED use, instead of consistent use over multiple years. More needs to be learned about these patients, and predictive modeling and quick intervention will probably be critical since their repeat ED use is unlikely to continue over time.”


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