Health policy/original researchWhat Drives Frequent Emergency Department Use in an Integrated Health System? National Data From the Veterans Health Administration
Introduction
Health system administrators, policymakers, and providers have an increasing interest in and concern about emergency department (ED) use. Rather than being equally distributed across the population, approximately 5% of patients are responsible for a quarter of all ED visits.1 These so-called superusers or frequent users are of concern because their needs seem to be poorly met by standard care systems, their costs are high, and they have drawn the attention of the popular media, which portrays them as a wasteful indication of health system failure.2
The existing research on frequent ED users has raised doubts about commonly held assumptions. Frequent ED users are sicker than the general population, with multiple chronic health problems,1, 3, 4 and most are insured.1, 5, 6, 7, 8 In addition, rather than being disengaged from other sources of care, frequent ED users have been found to utilize the outpatient primary and specialty clinic system heavily.1, 3, 4, 9, 10, 11, 12
There is still much we do not understand about frequent ED use, including how to best define it. Most previous studies have defined frequent ED use as either present or absent according to fixed and often arbitrary utilization thresholds.13 There is no consensus on what the threshold should be, and studies have used a wide range of numbers, from 2 to 20 visits per year.13 In addition to being arbitrarily defined, binary cutoffs may obscure important differences that exist among patients associated with different areas on the broad continuum of ED use.14
Most previous studies of frequent ED users have focused on single EDs, which limits their generalizability. Those studies that have examined ED use on a state,15, 16, 17 regional,18, 19 or national4, 6, 12, 20, 21 level are generally based either on self-reported ED use of uncertain accuracy or on large administrative databases that have limited information on important patient-level characteristics. Administrative data from the Veterans Health Administration (VHA) provide more detailed and accurate information about frequent ED users than has been previously available, including diagnostic data on specific mental and physical illnesses, precise measures of VHA outpatient health services use, psychotropic and opioid medication use, and homelessness status. In addition, the national scope and size of the VHA allows for an analysis of multiple levels of ED use. Finally, the VHA in many ways functions like an accountable care organization in its provision of coordinated and comprehensive care for eligible veterans within an integrated care network. As such, it can serve as an interesting lens through which to view health care use as the Patient Protection and Affordable Care Act is implemented and as accountable care organizations, along with other reforms to improve access to health care, become both more necessary and commonplace.
In this study, we aim to determine what multidimensional patient-level factors are most strongly associated with a 6-level gradient of VHA ED use.
Section snippets
Study Design
We conducted a cross-sectional analysis of data obtained from national VHA databases for fiscal year 2010 (October 1, 2009, to September 30, 2010). Sociodemographic and clinical data were obtained from the Outpatient Encounter File, which contains data on all VHA outpatient clinic and ED visits nationwide, and the Patient Treatment File, which documents all episodes of VHA inpatient care. The Decision Support System pharmacy file contains data on all prescriptions filled at VHA pharmacies
Results
Of 5,531,379 patients who had received VHA services in fiscal year 2010, 4,600,667 (83.2%) had no VHA ED visit, 493,391 (8.9%) had 1 ED visit, 356,258 (6.4%) had 2 to 4 visits, 70,741 (1.3%) had 5 to 10 visits, 9,705 (0.2%) had 11 to 25 visits, and 617 (0.01%) had greater than 25 visits. A disproportionate number of the overall VHA ED visits were made by patients who visited the ED more than once per year (Table 1).
Patient sociodemographic and medical characteristics, divided by ED use
Limitations
The primary limitation of this study is that it includes only VHA patients and thus may not be generalizable to other health care systems or to the US population generally. VHA EDs vary across VHA facilities nationally but are generally less likely to be major trauma centers and serve fewer female patients and no children compared with other EDs.22 On the other hand, VHA EDs have many similarities with non-VHA EDs. For example, VHA EDs have similar proportions of “nonurgent” patients and report
Discussion
We examined a comprehensive set of factors associated with different levels of ED use among patients in the VHA system. To our knowledge, ours is the first national study that uses well-documented administrative data rather than patient self-reported ED use and includes multiple factors that influence care-seeking behaviors, many of which have not been available in previously studied administrative data sets. Using the Gelberg-Andersen Behavioral Model for Vulnerable Populations as a framework,
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Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. Support was provided by the VA New England Mental Illness Research and Education Center. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and the preparation, review, or approval of the article.
Please see page 152 for the Editor's Capsule Summary of this article.
Supervising editor: Debra E. Houry, MD, MPH
Author contributions: All authors conceived of and designed the study, interpreted the data, and contributed substantially to the article's revision. KMD and RAR analyzed the data and drafted the article. RAR had full access to all of the data in the study and takes responsibility for the paper as a whole.
Publication date: Available online April 9, 2013.