Frequent Users of the ER: Sick, Insured and White - Mar 18, 2010

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Frequent Users of the ER: Sick, Insured and White
Mar 18, 2010

Frequent users of the emergency department are predominantly white, insured and at greater risk for hospitalization due to serious illness, despite public perceptions of them as abusers of the healthcare system with minor complaints and no health insurance. This is the consensus of a systematic review of two dozen published studies of so-called "frequent flyers" ("Frequent Users of Emergency Departments: The Myths, the Data, and the Policy Implications").

"Frequent emergency department users have been proposed as targets of health care reform, but the common assumptions that their visits are frivolous or due to lack of health insurance are not supported by data," said Eduardo LaCalle, M.D., MPH, of the Department of Emergency Medicine at the Mount Sinai School of Medicine in New York "These patients, who represent 4.5 to 8 percent of all emergency patients but 21 to 28 percent of all visits, defy popular assumptions. One example: the uninsured represent only 15 percent of frequent users."

Studies find that a high proportion of frequent emergency department users are insured by Medicare or Medicaid. The majority of frequent emergency department users (defined as visiting the emergency department four or more times per year) are white. Frequent emergency department users tend to be sicker overall than occasional users, and are more likely to be hospitalized. They also have significantly higher mortality rates.

But not all frequent users are the same.

"People lump all frequent users under one label, but there seem to be many distinct groups in this category and we shouldn't direct policy at them without knowing more about who they are and why they are coming," said Elaine Rabin, M.D., also of Mt. Sinai, a co-author of the paper. "An elderly cancer patient with many visits is very different from a young, poorly-controlled asthmatic, yet both may be frequent visitors to the ER. Some frequent users visit the same emergency department all the time; others visit different ERs, depending on their complaint."

The types of complaints vary, from exacerbations of chronic illness to less specific ailments. The connection between mental health problems and frequent emergency department use may also vary geographically: alcohol and psychiatric problems have been shown to be associated with frequent visits at sites in Boston and San Francisco, but not in other areas.

"The stereotype of the uninsured, ethnic minority patient inappropriately seeking basic primary care in the ER pervades, but the picture of frequent users is much more complex," said Dr. LaCalle. "The public health, particularly in light of health care reform, would benefit from further research on frequent emergency department use. We will have to really understand the frequent users before we can address how to improve their access to good quality health care."

Annals of Emergency Medicine is the peer-reviewed scientific journal for the American College of Emergency Physicians, a national medical society. ACEP is committed to advancing emergency care through continuing education, research, and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies. For more information visit

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SOURCE: American College of Emergency Physicians

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