ER Focus on Immediate Medical Issues Can Miss the Bigger Picture

Frequent visitors to emergency departments often have complex social needs, such as homelessness, substance abuse, unemployment and mental illness, yet both medical providers and policymakers tend to focus on their immediate or recent medical issues without examining such other factors.

In what is believed to be one of the first analyses of frequent emergency department (ED) users to include integrated medical, behavioral and social service data, a new UC San Francisco study comprehensively examined these patients’ use of both medical and nonmedical services. This included homeless shelters, jail health services, sobering centers and ambulatory mental health care facilities. 

Health is more than health care. Our findings point to an urgent need for care coordination and communication across multiple sectors.

The authors found that frequent and “superfrequent” emergency department (ED) users – those who visit an ED four to 17 times per year, or more than 17 times per year, respectively – are generally sicker than infrequent patients and sought a wide range of medical, mental health, substance use and social services in San Francisco. 

“Focusing only on acute-care use provides a limited view of patients’ lives and the ways in which patients access health and social services,” said lead author Hemal K. Kanzaria, MD, associate professor in the UCSF Department of Emergency Medicine. “Health is more than health care. Our findings point to an urgent need for care coordination and communication across multiple sectors."  

This includes looking beyond emergency services to understand how best to improve health outcomes for frequent ED users and to accurately evaluate the full effect of interventions, the authors said.

“Clinicians in behavioral health, medical health and social services must share data to identify and address the needs of this population, which can range from poorly controlled diabetes to housing instability, and from addiction to unemployment, in an integrated, coordinated, and comprehensive manner,” said Kanzaria, an affiliated faculty member at the Philip R. Lee Institute for Health Policy Studies.

The paper is published in Health Affairs.     

Over the last decade, researchers and policymakers have increasingly focused on identifying the frequent and superfrequent ED users, who represent a disproportionate share of total ED visits and costs with the intention of intervening to reduce avoidable visits.  

In their investigation, the authors examined Medicaid claims data in fiscal years 2013-2015 that were linked to records from San Francisco County’s Coordinated Care Management System, a county-level integrated data system. 

Altogether, 20,667 patients in San Francisco County were included in the study, which focused on adults under age 65. Of those, 1,823 visited the ED four to 17 times annually, and 173 had 18 or more annual visits. 

The researchers found that a higher proportion of frequent users (28 percent) and superfrequent users (54 percent) sought substance use disorder services, compared to nonfrequent ED users (8 percent). Similarly, 46 percent of frequent ED users and 67 percent of superfrequent ED users sought mental health services, compared to 22 percent of nonfrequent ED users. This group also had more sobering center visits, a disproportionate use of housing and jail health services, and a higher prevalence of coexisting medical, mental health and substance use disorders. 

“Integrated health and social data can help identify patients who might benefit from care management, and be used to measure the impact of interventions that target this vulnerable population,” said senior author Maria C. Raven, MD, MPH, associate professor and chief of the UCSF Department of Emergency Medicine.

“We believe that policymakers should prioritize improvements in data sharing and the development of integrated medical, behavioral, and social care systems.” 

The authors note that their study accounted only for mental health, substance abuse and social services within a single safety-net health system, and might not apply outside of San Francisco County or to non-safety-net health systems. They also noted that the study did not include elderly patients, or other important populations, including undocumented patients and those supported by private insurance.

Authors: Co-authors are Caroline L. Cawley, MPH, and Sarah H. Sabbagh, MPH, from UCSF. 

Funding: Hemal Kanzaria received support from a Hellman Family Award for Early Career Faculty to conduct the study. No disclosures are reported.

The University of California, San Francisco (UCSF) is exclusively focused on the health sciences and is dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. UCSF Health, which serves as UCSF’s primary academic medical center, includes top-ranked specialty hospitals and other clinical programs, and has affiliations throughout the Bay Area.