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Target Long-Term Emergency Room Frequent Users to Curb Visits and Cut Costs

Analysis  |  By Christopher Cheney  
   January 14, 2020

Long-term ED frequent users use emergency rooms on a chronic basis and have relatively high costs, researchers find.

There are four primary subgroups of emergency department (ED) frequent users, which can help guide hospital treatment of these patients, a recent research article shows.

ED frequent users are associated with a disproportionately large share of emergency room visits and spending on services. Earlier research found that ED frequent users make up about 4.5% to 8% of the ED patient population nationwide but account for 21% to 28% of all ED visits.

The recent research article, which was published in The American Journal of Emergency Medicine, identified four subgroups of ED frequent users: short-term, heart-related, long-term, and minor care. Frequent ED users were defined as making at least four emergency room visits in a year-long period.

"This taxonomy of ED frequent users allows healthcare organizations to tailor interventions to specific subgroups of ED frequent users who can be targeted with tailored interventions. Cost data suggest intervention for long-term ED frequent users offers the greatest cost-avoidance benefit from a hospital perspective," the research article's co-authors wrote.

The researchers collected data from more than 5,731 ED frequent users at a single urban tertiary hospital-based ED in 2014. There was a total of nearly 80,000 ED patients at the hospital in 2014.

ED frequent user subgroups

1. Short-term ED frequent users were unlikely to be admitted as inpatients from an emergency room. The researchers found only 4.26% ED frequent users were likely to be chronic ED users, which were defined as being ED frequent users two years in a row. Short-term ED frequent users were the youngest on average (43 years old), and they did not have one prevalent diagnosis. The average cost of care per patient was $1,196. Short-term ED frequent users were the largest subgroup at 3,383 patients.

"This group may not be a good use of resources [for intervention] as they appear to naturally resolve on their own within one year," the researchers wrote.

2. Heart-related ED frequent users had circulatory disorders as their primary reason for emergency room visits. For this group, a high percentage (66%) of emergency room visits resulted in an inpatient admission. The average cost of care per patient was $5,609. Heart-related ED frequent users were the smallest subgroup at 249 patients.

"Given the small size of the heart-related group (249 patients), effective interventions could lead to relatively fast cost-avoidance benefits. However, given the advanced age and medical complexity of this group, some level of ED and inpatient hospital utilization will likely be unavoidable," the researchers wrote.

3. Long-Term ED frequent users had the highest percentage of chronic ED users (89%), highest percentage of patients insured by Medicaid (50%), and highest percentage of patients who visited the emergency room for mental health disorders (10%). The average cost of care per patient was $2,807. Long-term ED frequent users were the second-largest subgroup at 1,713 patients.

"[The] combination of chronic use and high costs suggests that it would be the optimal subgroup to target with intervention(s)," the researchers wrote.

4. Minor care ED frequent users had the lowest percentage (9%) of inpatient admissions after emergency room visits, had the lowest percentage (39%) of patients insured by Medicaid, and had a low percentage (19%) of chronic ED users. The average cost of care per patient was $922. Minor care ED frequent users were the second-smallest subgroup at 386 patients.

"These patients may not be an optimal group to target with intervention given their relatively low costs and high prevalence of self-resolution in a short period of time," the researchers wrote.

Targeting long-term ED frequent users for interventions

There are several interventions that could benefit long-term ED frequent users and the hospitals that serve them, says Lauren Birmingham, PhD, MA, who is currently working as a senior statistician at General Dynamics Information Technology and served as the lead author of the recently published ED frequent users article while working as a research fellow at Akron, Ohio-based Summa Health.

"We know that frequent users of the ED prefer the ED over other care locations, so it makes it an optimal place to get these patients connected to the right resources," Birmingham recently told HealthLeaders. Some emergency rooms are already staffed with care managers, social workers, and substance abuse counselors that can connect patients with valuable resources, she says.

Earlier research led by Birmingham found that ED frequent users can benefit from navigations services or discussing their health issues with a nurse. "A navigator could help these patients unravel the complexities of the healthcare system and social service system to put together a plan to get the right resources for the patient. There are many resources available to patients, but they often don't know about them and can't figure out how to access them alone," she says.

Connections to community health workers have produced good outcomes in low socioeconomic status, post-discharge populations, and they may be a good strategy for long-term ED frequent users, Birmingham says. "What's great about community health workers or other navigators is that they can learn more about what the patient needs and can further tailor interventions to their needs, which is not often something an ED care provider can do in a busy ED."

Christopher Cheney is the CMO editor at HealthLeaders.


Dividing ED frequent users into distinct subgroups gives hospitals an opportunity to tailor interventions for frequent users of emergency rooms.

In recent research, characteristics of long-term ED frequent users included a high prevalence of chronic emergency room utilization.

From a hospital perspective, cost of care data indicate that long-term ED frequent user interventions could generate the highest cost avoidance.

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