title: What drives frequent emergency department use in an integrated health system? National data from the Veterans Health Administration.
abstract: OBJECTIVE
  There is widespread concern about patients with frequent emergency department (ED) use. We identify sociodemographic and clinical factors most strongly associated with frequent ED use within the Veterans Health Administration (VHA) nationally.
  
  
  METHODS
  We conducted a cross-sectional analysis of national VHA databases (N=5,531,379) in 2010. The primary outcome measure was the number of VHA ED visits categorized into 6 frequency levels.
  
  
  RESULTS
  In 2010, 4,600,667 (83.2%) VHA patients had no ED visit, whereas 493,391 (8.9%) had 1 visit, 356,258 (6.4%) had 2 to 4 visits, 70,741 (1.3%) had 5 to 10 visits, 9,705 (0.2%) had 11 to 25 visits, and 617 (0.01%) had greater than 25 visits. Increasing ED use frequency was associated with homelessness, medical diagnoses, substance abuse and psychiatric diagnoses, receipt of psychotropic and opioid prescriptions, and more frequent use of outpatient medical and mental health services. In multivariable analyses, factors most strongly associated with all levels of ED use were schizophrenia (odds ratio [OR] range 1.44 [95% confidence interval {CI} 1.41 to 1.47] to 6.86 [95% CI 5.55 to 8.48] across categories of increasing ED use), homelessness (OR range 1.41 [95% CI 1.38 to 1.43] to 6.60 [95% CI 5.36 to 8.12]), opioid prescriptions filled (OR range 2.09 [95% CI 2.07 to 2.10] to 5.08 [95% CI 4.16 to 6.19]), and heart failure (OR range 1.64 [95% CI 1.63 to 1.66] to 3.53 [95% CI 2.64 to 4.72]).
  
  
  CONCLUSIONS
  Frequent ED use occurs even in a coordinated health care system that provides ready access to outpatient care. Frequent ED users are characterized by traits that represent high levels of psychosocial and medical needs. The correlates we identified for frequent ED use were consistent across multiple distinct levels of ED use.
authors.affiliation: Robert Wood Johnson Foundation Clinical Scholars Program, Yale School of Medicine and U.S. Department of Veterans Affairs, New Haven, CT, USA. kelly.doran@yale.edu
authors.forename: Kelly M
authors.initials: KM
authors.lastname: Doran
authors.forename: Maria C
authors.initials: MC
authors.lastname: Raven
authors.forename: Robert A
authors.initials: RA
authors.lastname: Rosenheck
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D016208:Databases, Factual; D019033:Delivery of Health Care, Integrated / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D019538:Health Care Surveys; D006787:Hospitals, Veterans / Q000706:statistics & numerical data*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D014481:United States; D014493:United States Department of Veterans Affairs; D058014:Veterans Health / Q000706:statistics & numerical data*