Higher mortality among frequent ED users compared to non-frequent users

1. This systematic review showed increased mortality in frequent emergency department (ED) users compared to non-frequent users.

2. While it was unclear whether frequent ED users had more hospital admissions, this group had increased outpatient visits compared to non-frequent ED users.

Evidence Rating Level: 2 (Good)       

Study Rundown: Increasing volume of emergency department (ED) visits has been a major cause of concern in many healthcare systems. However, it has been estimated that a small fraction of ED users (~5%) may account for nearly 25% of ED visits. This systematic review was designed to study the mortality and hospital admission patterns of this group. This study showed an increase in mortality and outpatient visits among high frequency ED users compared to non-frequent users. Though suggestive of a difference, it was unclear whether this population also had a higher rate of hospital admissions.

However, there were many obstacles to clearly interpreting the data from this review. First, there was great heterogeneity in the definition of frequent users among studies, and heterogeneous outcomes precluded pooling individual data sets, weakening the results. In addition, it was not clear whether the finding of increased mortality was driven by a few outliers, such as those in the last 6 months of a terminal disease, or was more homogenous. Such distinction would better define a vulnerable group that could have targeted interventions. Finally, the findings of these studies were from many places around the world, and so heterogeneity in the findings may be specific to certain health care systems.

Click to read the study in the Emergency Medicine Journal

Relevant Reading: Frequent users of emergency departments: the myths, the data, and the policy implications.

In-Depth [systematic review]: This review conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and quality of the studies included were assessed using the Newcastle-Ottawa Scale. A total of 5980 citations were identified and 31 articles satisfied criteria for inclusion. These studies consisted of retrospective cohorts, prospective cohorts, and cross-sectional studies that described frequent ED users without a specific disease. Four only described those with psychiatric disorders. Most were conducted in urban areas and conducted in the US, though 7 other industrialized nations were represented. From 1990 to 2013, this study showed that frequent ED users had a higher rate of mortality (median OR 2.2; IQR 1.1 to 2.7) and more frequent outpatient visits (median OR 2.65; IQR 1.47 to 6.29) than non-frequent ED users. Though suggestive of an increase, high variability made it unclear whether more frequent ED users also had higher hospital admission rates (median OR 1.16; IQR 0.94 to 1.63) or admission events upon ED visit (median OR 2.58; IQR 0.97 to 9.06).

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