ER ‘frequent flyers’ need more care, not less

By Katie Kerwin McCrimmon

Frequent flyers at hospital ERs sought emergency care at least four times a year and accounted for anywhere from 11 to 40 percent of total emergency room visits around the U.S., according to seven new studies unveiled this week at the annual meeting of the American College of Emergency Physicians in Denver.

In one of the studies, researchers in San Diego identified a group of super users, each of whom visited an ER 21 or more times in a single year. These patients bounced from hospital to hospital. While they represented just .2 percent of all patients, they accounted for 4.5 percent of all emergency department visits in the region.

The new studies found that frequent users typically have serious medical issues.

Many have mental health and substance abuse problems. Most are likely to have government health insurance through Medicare or Medicaid. Its a misconception that most ER users are uninsured. And while some are addicted to pain medications, many have other health problems.

The studies which sprang up separately and were not coordinated defined frequent users differently, ranging from those who came to ERs at least four times a year to those who came seven times. The studies did not analyze the total costs that the patients incurred, but emergency physicians say the patients clearly need more, better-coordinated care, not less access to care.

Dr. Andy Sama, president of the American College of Emergency Physicians, left, and Dr. Robert E. OConnor, an emergency physician at the University of Virginia, share findings from seven studies on ER frequent flyers during the annual meeting of emergency physicians in Denver.

This is a finite number of people, said Dr. Robert OConnor, an emergency physician at the University of Virginias Medical Center in Charlottesville and author of one of the abstracts unveiled Tuesday. In Wisconsin, the extreme high-end users (amounted) to 39 patients. You can come up with 39 individual treatment plans so patients receive the best care. Its not as if were trying to bar these people from coming in to emergency departments. Were trying to optimize their care.

OConnor attributed the burst of new research to digital health records that make it easier to track frequent users. Cost for care is also critical. As of Oct. 1, hospitals face penalties if patients are readmitted within 30 days of release. The fines do not apply to emergency departments if patients show up seeking care, but do not need to be admitted. Even so, health policy experts are keenly focused on learning about frequent users and reducing their visits and costs to health systems.

The trend has come to be known as hotspotting after Dr. Atul Gawande highlighted the work of pioneering New Jersey family doctor, Jeffrey Brenner, in the New Yorker in 2011. (Related: Hotspotting health revolution comes to Denverand Saving the mentally ill, saving taxpayers.Throughout health care systems, researchers are now trying to use sophisticated data-mining to identify the most expensive patients and find better ways to care for them while cutting costs.

As more elements of the Affordable Care Act get implemented, emergency doctors expect use of ERs to increase since as many as 40 million previously uninsured people may flow into the system. In Massachusetts, after the state required all individuals to get health insurance, ER usage increased, OConnor said.

In his own study in Virginia, OConnor found frequent users who were admitted to the hospital were significantly more likely to be readmitted after 30 days. His study and the one from Wisconsin found, however, that patients who were frequent users did so for a relatively brief period only a year or two. Results were mixed on whether repeat users were more or less likely to be admitted to the hospital from the ER.

OConnor said ER doctors want to be able to work with health partners in the community who could reduce hospitalizations and help patients for less cost. But, when patients show up in the ER late on a Friday night and the ER staff cant coordinate with home health providers or ensure that patients will get the medication they need, doctors sometimes have little choice but to admit them.

OConnor and Dr. Andy Sama, an emergency physician from New York and president of the American College of Emergency Physicians (ACEP), said frequent ER users are often demonized as abusers of the system when in fact they represent a small percentage of the total number of emergency patients and most seek care when they need it.

Despite the widespread belief that these patients can be directed elsewhere, these patients for the most part need to be treated when they come in, OConnor said.

Whats more, the people showing up now in ERs may be the sickest of the sick since a raft of new urgent care centers may be attracting people with easily treatable respiratory infections or broken bones.

If you have a sick population, its unfair to the patients and the hospital to penalize them for readmission rates, OConnor said.

As policymakers struggle to cut costs in health care, ERs and hospitals receive the most blame for giving patients inefficient, high-cost care. But Sama said ER costs amount to just 2 percent of all health care costs in the U.S., according to an ACEP study.

When you consider that we have 136 million contacts a year, only spending 2 percent is a pretty good return on investment, Sama said. These frequent users have complex medical problems, limited access to primary care, significant psychiatric complaints and are often dependent individuals with limited access to funds, poor living circumstances and difficulty in getting care.

Our charge is to find better solutions for these patients. Our job is to solve their problems, Sama said.

Potential solutions are springing up across the country. Among the most promising are home visits from nurses and health coaches who can help people with chronic problems stay healthy. New technology may also enable home health workers to transmit patients vital signs directly to their doctors to better track them and avoid unnecessary hospital visits.

OConnor said he and his colleagues need much better coordination with community programs and 24/7 access to digital health records. For instance, if a patient arrives at 3 a.m. and says a recent x-ray taken outside the hospital shows a problem, but OConnor cant access images, he has to order another x-ray in the hospital. That takes time and costs money. He also said it would be tremendously helpful to have instant access to a patients entire list of current and past medications along with notes from other providers.

ER doctors often have to start from scratch every time a patient comes in for care even if that patient is a frequent flyer.

OConnor said the most promising improvements may come from viewing ERs as a hub and spoke model. The ER is the hub at the center of care, but spokes must reach out to various community partners who will help ensure that fewer people need full-fledged ER services.

If we had better access to immediate resources, I think we could save the health system significant amounts of money, OConnor said.

Sama said much better mental health care systems would be a huge help to emergency physicians since so many patients come in with severe psychiatric problems.

Throughout the country, some new promising programs are coming through coordination with ambulance services.

In Colorados Eagle County, for instance, paramedics are not waiting for the sick to call them. They are working with doctors to arrange house calls to check up on patients and cut ER visits.

In Fort Worth, Texas, EMTs are identifying their frequent callers.

A small percentage call 15 or 20 times a year. That becomes an issue for EDs (emergency departments) and ambulances, tying up services, said Dr. David Ross, an emergency doctor at Penrose-St. Francis Health Systems in Colorado Springs who is also medical director for an ambulance company there.

Ross said in Fort Worth, paramedics found that people sometimes call for an ambulance when theyre depressed and dont have an actual medical problem.

Sometimes the (paramedics) will just go and visit them, Ross said.

In Colorado Springs, paramedics are experimenting with a checklist that can reduce the number of alcohol abusers who end up in ERs. In the past, paramedics routinely took people who were drunk directly to the ER. They needed a medical checkup before they could be transported to a less-expensive detox center.

Starting in 2003, paramedics used a simple checklist to determine if patients really needed medical care or if they just needed to dry out. The two most important items on the checklist were whether a patient could walk and if the patient would consent to a physical exam. Paramedics found that they could safely bypass ERs for patients who could walk on their own and cooperated with care in the field.

In Colorado Springs, Ross said paramedics are now able to transport about 150 patients a month directly to detox rather than sending them all to ERs.

Ross said health experts in Colorado Springs are trying to develop similar systems for psychiatric patients. Colorado has a severe shortage of space in community programs for people with psychiatric problems, so many end up in ERs. If hospitals can work with outpatient clinics to create more space, they may be able to develop a checklist to evaluate psychiatric patients in the field and bypass ERs.

Our model would maybe be to pair a paramedic with a psychiatric evaluator who would go to a scene and determine if a person could go straight to a behavioral health system, said Ross. There are solutions already in progress.