Frequent Flyers in the ED

ACEP LAC 2016

Frequent Flyers in the Emergency Department-

Rachel Solnick, Yale EM

What is a Frequent Flyer?•Recent cost cutting and continued increase in ED volume by 34% from 1995 to 2010 visits have brought FF to the forefront of the debate as a target for cost savings, due to concerns for overuse or inappropriate use

•Various studies use quantify FF as 3 - 12 ED visits / year, it is most commonly > 4 visit /year

•Studies that define a frequent visitor as a patient who makes a minimum of 4 visits in the prior year have found that 4% of ED patients are

responsible for 20–30% of annual visits (Sandoval 2010)

•ED care itself only constitutes approximately 4 percent of all health care spending, the amount allocated to frequent users is not significant

LaCalle, 2013

Adverse impact of FF•PATIENTS: FF often present with acute exacerbations of chronic problems ore more less specific symptomatology and pain. (LaCalle 2010) Repeat ED care puts them at risk for suboptimal care• fragmented and episodic care ,• less attention to prevention • multiple providers differently diagnose • risk of overtreatment ( Olsson , 2001)

•PROVIDERS: frustrated by their limited ability to meet frequent users‘ complex social / medical needs

•PUBLIC: FF constitute 25-30% of patient load, thus contribute in part to overcrowding which can result in:• longer wait times, • increase left without being seen, • ambulance diversion,• worse clinical outcomes

Adverse impact of FF-Counterpoints

•Overcrowding less the fault of FF and mainly due to inadequate inpatient capacity ( beds/ staff) for increasingly ill patients (Trzeciak 2003) also other causes :• overburdened inpatient facilities• insufficient staffing and ED space • increase in seriously ill patients,• influx of nonemergent patients.

•The portion of FF that are low complexity matter less to overcrowding . low-complexity ED patients are associated with negligible increase in ED length of stay and time to first physician contact for other ED patients ( Shumway 2008)

•It is a misconception that most FF are inappropriately using the ED and can be more efficiently served outpatient, a small but visible number of very frequent of FF are less sick

• Majority of FF have only episodic periods of high ED use. 28.4% of FF in one urban study found they remained FF in following year ( Fuda 2006)

Most FF have substantial burden of disease

•FF have higher adjusted mortality rates (standardized mortality ratio 1.55 (Hansagi 2001) and more likely to die at their last visit (2.6% vs 1.1%) (Fuda 2006)

•They are generally hospitalized at higher rates (18.8% vs 14.2% of visits) at any given visit and throught the year ( Fuda 2006)

•FF are sicker than general population and have more chronic health problems. (Hunt 2006) (LaCalle 2010)

Most FF have substantial burden of disease

Is insurance an issue?•Increase in overall ED visits by 28% from 1992 to 2005, attributed not to increase in uninsured but incr use by nonpoor with PCP access. (Weber 2008)

•In a nationally representative sample, Most FF had health insurance (84%) and usual source of care (81%) . Pt without a usual source of care were less likely to be FF ( Hunt 2006) • more commonly have Medicaid (53% vs 39%)

or Medicare • less likely to be uninsured ( 12% vs 24%)

(sandoval 2010)

•More ED visits seen with change in insurance and dissatisfaction with usual healthcare. Long wait times for an appt (>7 days) wasn’t assoc iate with more ED visits (Weber 2005)

•Due to nonstandard use of frequency , many studies have combined highly FF with less FF, but studies parsing them show the highest of FF to be less sick

Highly FF ( >18 visits) represented 3.6 % of all visits, were substantially more likely to have substance abuse issues ( 67% vs 35%) and to have been FF for a long period of time then less frequent ( 7-17 vists/yr) (Doupe 2012)

FF are a mixed group

Ruger 2004

Highly FF did not use proportionally more of other health care services, suggesting reliance on the ED as a primary source of care (Doupe 2012)

•The lowest acuity visits are more often in highest frequency of FF ( > 20 visit/yr) constituting only 1.1% of all patients / year ( Ruger 2004) • more likely to elope• less often hospitalized• if admitted their stay was less than half as long• visit cost 1/3 of other patients• Differing studies vary on their insurance coverage

•High FF more often with psych and social comorbidities ( LaCalle 2013)

FF are a mixed group

•FF indicator of increased use of other health care / government resources• more likely to make any PCP visits than rare users

(72% vs 57% ) • more likely to make >5 PCP visits (OR 3.43)

(Hansagi 2001)

•Only 27% of FF said they had difficulty in seeing a PCP, instead they visit the ED bc what they perceive as moderate or very serious conditions (28% vs 16%) (Lucas 1998)

•A study from Massachusetts General Hospital found that FF were NOT more likely to make non emergent or PCP treatable visits to the ED (Liu 2012)

Not a lack of primary care access

Most adults who use the ED frequently have insurance and a usual source of care but are more likely to be in poor health and thus seek frequent medical attention than other ED users(Hunt 2006)

PCP not always the answer

FF were more likely to have a PCP, and even have one that was at the ED hospital compared to non FF ( 45% vs 23%) ( Sandoval 2010)

Frequent users have higher odds of coming to the ER for mental health related (5.8% versus 3.9%, p0.0001), drug related (0.7% versus 0.3%, 0.0004), and alcohol-related visits (9.5% versus 1.6%, p.0.0001) ( Liu 2012)

More likely to report higher levels of stress, lower social support, screen positive for depression ( Sandoval, 2010)

Psychosocial /economic issues

One study of In South Carolina, showed 23% of visits by frequent users have a primary, secondary, or tertiary behavioral health diagnosis (compared to 14% for non-frequent users). ( South Carolina Public Health Institute , 2011)

A study of 5 million VA ED found homelessness, schizophrenia, opiod rx, CHF were stronly correlated with FF, similar to standard EDs despite the VAs access to coordinated care ( Doran 2013)

Psychosocial /economic issues

When addressing issue of FF, must take into account the necessary service they provide for chronically ill people. Reducing FF use should take a comprehensive approachMedicare and Medicaid awarded funds from the Emergency Diversion Grant Program to 20 state medical agencies in April 2008. 30 projects have been funded and are ongoing. Even with a patient-centered medical homes and coordinate care approach, a subset of FF with homelessness would benefit much more from help with housing for lasting health improvement and reduced costs (Doran 2013)

Next steps

Next steps: Reducing use when possible

•A systematic review found that non ED interventions have been effective in reducing ED use, but with widely varying rates even within intervention category (Alqatari 2012) • capacity increase in non -ED settings (3 of 5 studies decr

by 12-52%)• education on healthcare use ( 4 of decreased by 2-500%) • managed care (capitation or gatekeeping) ( 8 of 11 decr

by 12-85%)• patient financial incentives ( 5 of 9 decr by 8-66% ) with

the adverse effect of higher death rate in the $1-$5 copay group

Next steps- Hot Spotters• Dr Jeffrey Brenner hot spotting of high users

• Insurance claims to map health care• Pt management program to transition hospital to outpatient care

• Care management team• social worker, nurse, community health worker and health coach

• Visits the patient in the hospital, reviews meds, helps plan discharge • Visit home after discharge, support 2-9 mo., transport for appt, help initiate social services

• Pt in program reduced their ED visit frequency, and total fell from a monthly average of $1.2 million to just over $500,000

Next steps- Targeted approaches

• In MD 2014 reforms pays hospitals set amounts, hospitals started providing in home care managers for top 400 pt • A MD low income senior housing facility with disproportionately high volume ambulance had a one doctor clinic built directly in the building, saw a 50% reduction in 911 calls

Thank You!

www.emra.org

Questions? Rachel Solnick

[email protected]