Study Dispels 'Urban Legends' About Frequent ED Users

Miriam E. Tucker

December 04, 2013

Washington, DC — Contrary to "urban legend," frequent users of emergency care actually have high rates of primary care use and only a small proportion of their emergency department (ED) visits are for substance abuse and mental health problems, a new study of Medicaid ED users in New York City shows.

The results of the study, involving administrative data for more than 200,000 Medicaid beneficiaries, counters the notion that frequent users of ED services are people who try to avoid visiting primary care physicians who could treat their conditions more easily and less expensively. Moreover, the study also found that visits for substance abuse and mental health comprised just 5% of total visits in a single year.

"We found that a lot of the tenets that underlie the urban legend of frequent ED use are unfounded," Maria C. Raven, MD, assistant professor in the Department of Emergency Medicine at the University of California, Los Angeles, said at a briefing here sponsored by the journal Health Affairs. The study was among several published in the journal's December theme issue, devoted to the future of emergency medicine.

The study findings point to the need for better care coordination, Dr. Raven told Medscape Medical News.

"Placing all the burden on primary physicians to decrease this [ED] use might be unrealistic because these patients are really sick...I think we need better care coordination programs in place, and we need to provide [primary care providers] with more resources. In the current 15-minute visit it's probably very difficult to address all the needs of these complex patients," she said.

Lemeneh Tefera, MD, an emergency physician who was not involved in the research, told Medscape Medical News that the study findings also serve to dispel the concern that the expansion of Medicaid under the Affordable Care Act (ACA) will create an exceptionally onerous burden on EDs.

"I think the ED is already being used excessively by multiple types of patient populations, so the uninsured are not the sole reason that EDs are busy. In fact, the very well insured use the ED for different reasons that also impact crowding and overutilization," said Dr. Tefera, adjunct associate professor of Health Policy and Health Economics in the Department of Emergency Medicine at George Washington School of Medicine, Washington, DC.

Who's Using the ED?

The investigators analyzed Medicaid claims data for a total of 212,259 patients aged 18 to 62 years in New York City, including an "index visit" to the ED in 2007 and claims data for 3 years prior and 3 years after that visit. They found that ED use contributed to just 2.1% of overall Medicaid spending. Even the "ultra-high" ED users, with 15 or more visits per year, contributed just 4.6% to total costs, Dr. Raven reported.

Half of all ED users (50.4%) had 1 or more chronic illnesses, with rates increasing from 45.5% for patients with just 1 ED visit to 84.5% for the ultra-high users, meaning that the more they used the ED, the more likely they were to have a chronic illness. Overall burden of disease, as measured by the Charlson Comorbidity Index, also increased with ED use, from 1.15 for patients with a single visit to 3.20 for ultra-high users.

Rates of mental health and substance abuse were also high, at 23% and 35.1%, respectively, among ED users. However, substance abuse and mental health as reasons for the ED visit comprised just 5.2% and 4.9%, respectively.

The number of primary care visits the patient had made in both the index year and the year prior to the index ED visit increased with the number of ED visits, from 3.80 in the year prior and 3.89 in the index year for those with just one ED visit in 2007 to 6.72 and 7.45 primary care visits, respectively, for the ultra-high ED users.

The number of ED visits also predicted the number of nonobstetric inpatient admissions, from 0.24 for those with just 1 ED visit in the previous or index year, to 5.39 hospital admissions in the prior year and 7.34 in the index year for the ultra-high ED users. This suggests, Dr. Raven noted, that inpatient costs rather than the ED costs are responsible for the bulk of the overall encounter costs for Medicaid patients.

She acknowledged that these data are limited by factors that aren't captured in administrative data, such as housing situation, social support, and the quality of the primary care received.

Nonetheless, she said that the data clearly demonstrate that "ED use is not a major Medicaid cost driver, and frequent ED users often suffer from a substantial burden of illness that can require emergency care. The primary care delivery system must find ways to be more responsive to these patients, and the narrow focus on ED use seems misguided."

Better Coordination Seen as Solution

Dr. Tefera told Medscape Medical News that patients with restrictive insurance plans will often come to the ED because their plans don't cover care at nearby health clinics, or require hefty co-pays. “I feel primary care physicians are doing their best to provide access, but are limited by the number of hours in a day and the coverage their patients have…It's not that they don't want to see the patient in their office, but the patient gets told that their Medicaid type isn't accepted. Instead of [traveling far] to another clinic where it is accepted, they'll go to the ED."

He predicted that the recent "medical home" concept, promoted in the ACA as "Accountable Care Organizations" that care for populations will help alleviate the access problem over time. Such integrated systems are envisioned to incorporate ED visits, clinic referrals, follow-up and medical record harmonization all under one roof.

"I think this is the direction we're going, but it will happen over years. It won't happen in the next 6 months, but in the next decade hopefully. I think there will be incremental change and improvement,” Dr. Tefera said.

"I think ACAs are certainly going to be part of the solution, but integration, coordination, improving the medical record, and sharing information will all contribute. But this will not be a quick fix. It will be an ongoing effort over the next decade.... But it's great that we're starting."

Dr. Raven and Dr. Tefera have disclosed no relevant financial relationships.

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