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Special Report

Health Is Not Just Health Care (Especially for Frequent ED Users)

Shaw, Gina

doi: 10.1097/01.EEM.0000581476.26999.62
Special Report

Frequent emergency department users are sometimes dismissed as frequent fliers, stigmatized as patients with low-acuity medical complaints or manageable chronic conditions who are taking up limited ED bed space and contributing to long waits.

New research, however, found that these patients are at serious risk. Frequent visits to the ED are predictive of mortality among nonelderly patients in the short (seven days) and long terms (two years). (Health Aff [Millwood]. 2019;38[1]:155.) Increased mortality risk remained even after controlling for comorbidities, demographic characteristics, and insurance status. It is the first study to account for deaths in and out of the hospital, and it links multiple years of state health services utilization and death data.

Researchers from the University of California-San Francisco (UCSF) and Mathematica in Oakland, CA, used the 2005-2013 nonpublic data about all ED visits at nonfederal, licensed hospitals from California's Office of Statewide Health Planning and Development. They wrote, “This allowed us to accurately and comprehensively capture ED use even among patients who changed insurance coverage and those who visited multiple EDs.”

Most prior studies looking into the link between mortality and frequent ED use focused only on deaths in the ED or during subsequent hospitalizations, not those outside the hospital after discharge. Many of them were also small, single-center studies, said co-author Hemal Kanzaria, MD, an associate professor of emergency medicine at UCSF and the medical director of care coordination at Zuckerberg San Francisco General Hospital and Trauma Center. “We conducted a statewide analysis, which is particularly important since frequent ED users often visit multiple unique EDs,” he said. “Even accounting for age, gender, race, ethnicity, socioeconomic factors, and comorbidities, we still saw increased odds of mortality among frequent ED users in both the short and long term.”

The researchers separated frequent ED users into those with four to 17 ED visits a year and those with 18 or more visits per year (superusers). Frequent ED use over the past year was associated with a more-than-double mortality odds ratio at 90 days and two years for both groups. Frequent ED use over the past year was also associated with significantly increased mortality within seven days for patients with four to 17 visits but not for superusers.

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More Likely to Die

This means EPs should not write off frequent ED users, said co-author Maria Raven, MD, an associate professor of emergency medicine, the chief of emergency medicine, and the vice chair of emergency medicine at UCSF. “We have to take these patients and the factors that are impacting their use of the health care system very seriously,” she said. “They are sick, and their frequent ED use may be a signal that they are more likely to die. In addition to their medical conditions, there are many other aspects of their life that are impacting their health, including all kinds of other social needs.”

The ED serves as a canary in the coal mine for people at high risk, Dr. Raven said. “When you get to a certain level of ED use, we have to ask why this is happening,” she said. “Clearly, these people are not having their needs met, either elsewhere in the health care system or in the community. There are so many social factors that play into one's ability to control both medical and mental health issues.”

These factors are familiar to almost every EP—poverty, a lack of a social support system, intimate partner violence, adverse childhood experiences, and homelessness and housing insecurity. “These social factors are so important for a person's health, and it manifests in many ways in the ED, leading to patients presenting with anything from exacerbations in chronic obstructive pulmonary disease to experiencing traumatic injuries from violence on the street,” said Dr. Kanzaria. “These are all things we see on a daily basis.”

Levels of ED use also increase with the number of adverse childhood experiences a person has, particularly among younger patients. A Journal of Health Research and Policy study found that ED attendance was 12.2 percent for patients 18 to 29 with no adverse childhood experiences but 28.8 percent of those with four or more. (2017;22[3]:168; “There's a shocking level of trauma,” said Dr. Raven. “Things like social support and history of traumatic events are difficult to account for in research, but in my experience, in terms of implementing interventions for our more extreme frequent users, almost all of them have had some form of [adverse childhood experience] or other life trauma. And many of the very high end of the frequent use spectrum have also burned bridges in some way, or otherwise don't have anyone in their life to support them.”

Emergency physicians as a rule don't study supportive housing programs or childhood trauma counseling, but they still should be aware that these factors prompt ED visits. “Health is not just health care,” said Dr. Kanzaria. “It's all these other things. As an emergency physician, I can't prescribe housing, and the health care system obviously can't be the only place that's addressing such issues, but since these patients are coming to the ED with these needs, and we now know that these frequent ED users are at increased risk of dying, we do need to rethink how we're set up in the acute care system to help patients with things like initiating medication-assisted therapy for substance use disorders and connecting patients to food and housing services.”

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Alternatives to Hospitalization

Drs. Kanzaria and Raven are involved with programs designed to do just that. A large multidisciplinary team from the hospital and the San Francisco Health Network was created to deliver holistic care to emergency department patients with complex social needs who had been admitted for less than two days and later bounced back to the ED.

The group created 10 initiatives that would provide ED patients and emergency physicians with safe alternatives to hospitalization focused on managing social illnesses, ranging from a new social medicine consult service to direct links for transitional housing. The program has served more than 3000 patients and prevented more than 350 admissions and readmissions since it launched in August 2017.

One woman's story exemplifies the way the program works. Homeless for more than a decade, she had been living on San Francisco's Bay Area Rapid Transit (BART) line. “Worried bystanders would call the BART police, and they would bring her to the ED,” said Dr. Kanzaria. “She had over 50 visits at our hospital alone in the last year. One time, the EP called our consult team, and our patient navigator sat down with her to pinpoint her most pressing self-identified needs.” The woman said she was hungry and hadn't eaten in a long time. She had physical pain and feared her belongings in the tattered bags on her wheelchair would be stolen.

“So we got strong bags for her stuff and brought her a meal,” said Dr. Kanzaria. “Gradually we developed trust. After living on the streets, she was a little hesitant, but she finally agreed to talk to a case manager from a community program we partner with, and they bonded over a shared appreciation for certain styles of clothing.” Ultimately, the case manager was able to introduce the idea of living indoors again. The woman was moved first to a respite facility and then to long-term transitional housing after about six months.

The hospitals are also using the Emergency Department Information Exchange (EDIE), a secure communications tool developed by Collective Medical that helps hospitals identify and support vulnerable patients whose complex medical and social needs can't be adequately met in a single care setting. It creates virtual collaboration between participating institutions, where they securely share patient histories, visit summaries, provider data, security events, and care recommendations.



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Lower Inpatient Costs

The nonprofit San Francisco Health Plan, a managed care plan run by Medi-Cal, also receives real-time notifications from EDIE when a client is admitted to the ED, allowing them to help EPs, social workers, and navigators manage a coordinated care plan. “When we get information on a patient's priority status for housing, we can also enter that in EDIE and get someone from the city's supportive housing program to assess the patient, see where they are in the queue, and intervene when possible,” said Dr. Raven. “We have a health care navigator and social worker who work with as many of our frequent users as possible and enter care guidelines on them.”

Dr. Raven described another frequent ED patient who had severe health conditions and was living on the streets of San Francisco. “He was in our observation unit because he didn't want to be admitted to the hospital, but he was too sick to be let go,” she said. “I asked if he'd been assessed for housing, and he had not been. It was clear by the length of time that he had been homeless that he would most likely be priority status. I checked EDIE and saw that he had not been given that status, called the assessment team, and they came within two hours to see what they needed to do for his housing.”

Another patient came to the ED every day, sometimes twice a day, with serious memory issues. “We got him first into a navigation center bed and then into a stepped-up shelter bed,” said Dr. Raven. “Our street medicine team facilitated his taking medications for his seizures, and after three months he was placed into an apartment. His ED use has also decreased drastically.”

You're not alone if you feel like your ED doesn't have the bandwidth to put such programs in place. “It's hard,” said Dr. Raven. “Everywhere has boarding and crowding, and we're all stretched thin. My strategy has been to allocate nonmedical staff to assess and help these individuals, such as social workers and care navigators, to take as much as possible off the physician's plate.”

These efforts are supported based on the recognition that these patients don't need inpatient hospital services but social services, and that having people in the ED who can provide that likely averts inpatient costs, said Dr. Raven. Her program also refers homeless patients with substance use disorders to another UCSF initiative that pays for stays of two days or more at a residential substance treatment facility called Harbor Lights. They have not yet published data on the inpatient costs avoided with this up-front investment in patients' behavioral health and social and housing needs, but Dr. Raven said preliminary research into those numbers suggests positive results.

“These patients are medically sick too, and they're dying, as the new paper makes clear,” she said. “Mortality is of course one of the ultimate outcomes that we as physicians care about, and to make a real difference for these frequent ED users, we need to both take their medical complaints seriously and meet their unmet social needs.”

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Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work

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