Mentally Ill, Homeless Patients Are High Intensity Emergency Department Users Interview with:

Paul E Ronksley, PhD Assistant Professor Department of Community Health Sciences Cumming School of Medicine University of Calgary Calgary, AB Canada

Dr. Paul Ronksley

Paul E Ronksley, PhD
Assistant Professor
Department of Community Health Sciences
Cumming School of Medicine
University of Calgary
Calgary, AB Canada

Medical Research: What is the background for this study?

Response: Numerous studies have shown that high users of the emergency department (ED) are often patients with complex medical needs and limited personal and social resources. It is also recognized that high users are a heterogeneous group driven by variability in the operational definition used to define this patient population. “High use” of ED services is often defined by the number of visits per year (namely ≥3 or ≥4 visits to the ED in a 1-year period) with little exploration of the distribution/pattern of these visits over time. The purpose of our study was to examine patient and encounter-level factors and costs related to periods of short-term resource intensity (clustered ED visits) among high users of the ED within a tertiary-care teaching facility. This is important as it may inform interventions that can focus on a more defined group with the goal of providing the needed care in a setting outside of the ED.

Medical Research: What are the main findings?

Response: Our main findings demonstrate that among high  emergency department users (i.e. patients with 3 or more ED visits in a 1-year period), approximately 1 in 7 patients had a period of high-intensity ED use (3 or more visits clustered within a week). These patients with clustered visits were more likely to be homeless, require psychiatric emergency services, and revisit the  emergency department for the same presenting complaints. The high-intensity users were also less likely to be admitted, more likely to leave without being seen and had lower costs per encounter, although their total ED cost across all visits was higher.

Medical Research: What should clinicians and patients take away from your report?

Response: The results of our study could help hospital administrators plan management strategies for a sub-set of high users of the ED. For example, it may be possible for hospital information systems to be used in real-time to flag patients at triage – informing the clinical staff that a patient has visited the ED more than 3 times in a given week. Information from their previous visits could be retrieved to ensure more streamlined care, especially if these patients are presenting with chronic medical conditions. Further, patients with similar medical needs (e.g. symptom or pain management) might benefit from a specialized care pathway that could potentially be identified at triage. This type of specialized care delivery model may increase efficiencies in the  emergency department and reduce the number of visits where patients leave without being seen. While this may be promising, we recognize this methodology would first need to be studied and potentially adapted to different patient needs, and provider and system level factors (e.g. capacity, accessibility, funding structures) that exist across jurisdictions.

Medical Research: What recommendations do you have for future research as a result of this study?

Response: Future research that seeks to isolate specific sub-populations within the heterogeneous group of high emergency department users should account for both the number and pattern of ED visits. Our study demonstrates that patients with periods of high intensity ED use (clustered visits) have pronounced differences in patient and encounter-level characteristics even after adjusting for frequency of visits. Thus, future studies that seek to identify high users need to account for the timing of ED visits. This may be important in the development of interventions to improve care and outcomes for the subset of patients that use the majority of ED services. 


Variations in resource intensity and cost among high users of the emergency department

Paul E. Ronksley PhD1,*, Erin Y. Liu MSc2,Jennifer A. McKay BSc3, Daniel M. Kobewka MD Deanna M. Rothwell MSc2, Sunita Mulpuru MD3,4, Alan J. Forster MD, MSc2,3,4 and Jeffrey Kline

DOI: 10.1111/acem.12939 Academic Emergency Medicine

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Paul E Ronksley, PhD (2016). Mentally Ill, Homeless Patients Are High Intensity Emergency Department Users 

Last Updated on February 19, 2016 by Marie Benz MD FAAD