Factors Contributing to Inappropriate Visits of Frequent Attenders and Their Economic Effects at an Emergency Department in Singapore.
OBJECTIVE
This study aimed to determine which factors contribute to frequent visits at the emergency department (ED) and what proportion were inappropriate in comparison with nonfrequent visits.


METHODS
This study was a retrospective, case-control study comparing a random sample of frequent attenders and nonfrequent attenders, with details of their ED visits recorded over a 12-month duration. Frequent attenders were defined as patients with four or more visits during the study period.


RESULTS
In comparison with nonfrequent attenders (median age = 45.0 years, interquartile range [IQR] = 28.0 to 61.0 years), frequent attenders were older (median = 57.5 years, IQR = 34.0 to 74.8 years; p = 0.0003). They were also found to have more comorbidities, where 53.3% of frequent attenders had three or more chronic illnesses compared to 14% of nonfrequent attenders (p < 0.0001), and were often triaged to higher priority (more severe) classes (frequent 52.2% vs. nonfrequent 37.6%, p = 0.0004). Social issues such as bad debts (12.7%), heavy drinking (3.3%), and substance abuse (2.7%) were very low in frequent attenders compared to Western studies. Frequent attenders had a similar rate of appropriate visits to the ED as nonfrequent attenders (55.2% vs. 48.1%, p = 0.0892), but were more often triaged to P1 priority triage class (6.7% vs. 3.2%, p = 0.0014) and were more often admitted for further management compared to nonfrequent attenders (47.5% vs. 29.6%, p < 0.001). The majority of frequent attender visits were appropriate (55.2%), and of these, 81.1% resulted in admission. For the same number of patients, total visits made by frequent attenders ($174,247.60) cost four times as much as for nonfrequent attenders ($40,912.40). This represents a significant economic burden on the health care system.


CONCLUSIONS
ED frequent attenders in Singapore were associated with higher age and presence of multiple comorbidities rather than with social causes of ED use. Even in integrated health systems, repeat ED visits are frequent and expensive, despite minimal social causes of acute care. EDs in aging populations must anticipate the influx of vulnerable, elderly patients and have in place interventional programs to care for them.
Duke-NUS Graduate Medical School Singapore, Singapore.
Connie
C
Boh
Health Services Research and Biostatistics Unit, Division of Research, Singapore General Hospital, Singapore.
Huihua
H
Li
Health Services & Systems Research Program, Duke-NUS Graduate Medical School Singapore, Singapore.
Eric
E
Finkelstein
Office of Clinical Sciences, Duke-NUS Graduate Medical School Singapore, Singapore.
Benjamin
B
Haaland
Division of Medicine, Singapore General Hospital, Singapore.
Xiaohui
X
Xin
Department of Emergency Medicine, Singapore General Hospital, Singapore.
Susan
S
Yap
Department of Emergency Medicine, Singapore General Hospital, Singapore.
Yogeswary
Y
Pasupathi
Department of Emergency Medicine, Singapore General Hospital, Singapore.|Office of Clinical Sciences, Duke-NUS Graduate Medical School Singapore, Singapore.
Marcus Eh
ME
Ong
D000328:Adult; D000368:Aged; D016022:Case-Control Studies; D002908:Chronic Disease / Q000453:epidemiology; D015897:Comorbidity; D004636:Emergency Service, Hospital / Q000191:economics* / Q000706:statistics & numerical data*; D005260:Female; D015438:Health Behavior; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012846:Singapore / Q000453:epidemiology; D012959:Socioeconomic Factors; D019966:Substance-Related Disorders / Q000453:epidemiology; D014218:Triage