Impact of COVID-19 on emergency department attendance in an Australia hospital: a parallel convergent mixed methods study

ObjectivesThe COVID-19 pandemic has changed the way people are accessing healthcare. The aim of this study was to examine the impact of COVID-19 on emergency department (ED) attendance for frequent attenders and to explore potential reasons for changes in attendance.DesignThis convergent parallel mixed methods study comprised two parts.SettingAn interrupted time-series analysis evaluated changes in ED presentation rates; interviews investigated reasons for changes for frequent ED users in a culturally and linguistically diverse setting.ParticipantsA total of 4868 patients were included in the time series. A subgroup of 200 patients were interviewed, mean age 66 years (range 23–99).ResultsInterrupted time-series analysis from 4868 eligible participants showed an instantaneous decrease in weekly ED presentations by 36% (p<0.001), with reduction between 45% and 67% across emergency triage categories. 32% did not know they could leave home to seek care with differences seen in English versus non-English speakers (p<0.001). 35% reported postponing medical care. There was a high fear about the health system becoming overloaded (mean 4.2 (±2) on 6-point scale). Four key themes emerged influencing health-seeking behaviour: fear and/or avoidance of hospital care; use of telehealth for remote assessment; no fear or avoidance of hospital care; not leaving the house for any reason.ConclusionsThis study demonstrated reduced ED use by a vulnerable population of previously frequent attenders. COVID-19 has resulted in some fear and avoidance of hospitals, but has also offered new opportunity for alternative care through telehealth.

Consultation patterns and frequent attenders in UK primary care from 2000 to 2019: a retrospective cohort analysis of consultation events across 845 general practices

ObjectiveTo describe the distribution of consultations at the practice level and examine whether increases are uniform or driven by people who consult more frequently.DesignRetrospective cohort study.SettingUK general practice data from the Clinical Practice Research Datalink (CPRD) GOLD database.Participants1 699 709 314 consultation events from 12 330 545 patients, in 845 general practices (1 April 2000 to 31 March 2019).MethodsConsultation information was aggregated by financial year into: all consultations/all staff; all consultations/general practitioners (GPs); face-to-face consultations/all staff; face-to-face consultations/GPs. Patients with a number of consultations above the 90th centile, within each year, were classified as frequent attenders. Negative binomial regressions examined the association between available practice characteristics and consultation distribution.ResultsAmong frequent attenders, all consultations by GPs increased from a median (25th and 75th centile) of 13 (10 and 16) to 21 (18 and 25) and all consultations by all staff increased from 27 (23–30) to 60 (51–69) over the study period. Approximately four out of ten consultations of any type concerned frequent attenders and the proportion of consultations attributed to them increased over time, particularly for face-to-face consultations with GPs, from a median of 38.0% (35.9%–40.3%) in 2000–2001 to 43.0% (40.6%–46.4%) in 2018–2019. Regression analyses indicated decreasing trends over time for face-to-face consultations and increasing trends for all consultation types, for both GPs and all staff. Frequent attenders consulted approximately five times more than the rest of the practice population, on average, with adjusted incidence rate ratios ranging between 4.992 (95% CI 4.917 to 5.068) for face-to-face consultations with all staff and 5.603 (95% CI 5.560 to 5.647) for all consultations with GPs.ConclusionsFrequent attenders progressively contributed to increased workload in general practices across the UK from 2000 to 2019. Important knowledge gaps remain in terms of the demographic, social and health characteristics of frequent attenders and how UK general practices can be prepared to meet the needs of these patients.

Sociodemographic characteristics and disability pensions of frequent attenders in occupational health primary care – a follow-up study in Finland

Background Work disability is a complex issue that requires preventive efforts from healthcare systems and individuals, and that too often results in disability pensions (DP). While many studies have attempted to characterize risk factors of work disability, many showing for example a link between socioeconomic positions, working conditions and frequent attendance to OH primary care it is not known if frequent attendance is associated with DP despite the sociodemographic factors. This study aims to address this gap and examine the association between frequent attendance to OH primary care and DP, when adjusted by sociodemographic factors. Methods This study combines routine medical record data of an occupational health service provider with comprehensive national registers. Medical record data were used to define groups of frequent attenders to OH primary care (FA) (1-year-FA, 2-year-FA, persistent-FA and non-FA) from 2014 to 2016. The sociodemographic factors (including i.e. educational level, occupational class, unemployment periods) were derived from Statistic Finland and DP decisions were derived from Finnish Centre for Pensions. Association of frequent attendance to OH primary care with DP decisions were analyzed and adjusted by sociodemographic factors. Results In total, 66,381 patients were included. Basic and intermediate education along with manual and lower non-manual work predicted frequent attendance to OH primary care. Unemployment in 2013 did not predict frequent attendance to OH primary care. Frequent attendance to OH primary care was associated with DP within next two years, even when adjusted for sociodemographic factors. The association of frequent attendance to OH primary care with DP grew stronger as high service use persisted over time. Conclusions Frequent attendance to OH primary care is associated with DP risk in the near future despite the underlying sociodemographic differences. Patients using OH primary care services extensively should be identified and rehabilitative needs and measures necessary to continue in the work force should be explored. Sociodemographic issues that co-exist should be explored and considered when planning interventions.

Developing and validating a prediction model for frequent attenders at a Swedish emergency department using an electronic medical record system, a retrospective observational study

Background: Frequent attenders (FA) account for a significant number of emergency department (ED) visits but to date there is no prediction model to identify patients at risk of becoming a FA. The aim of this research was to identify and describe FA using readily available data provided by electronic medical records and create a prediction model to identify future FA Method: Adults ≥18 years that visited the ED during 2015 were included. Patients with ≥4 visits were defined as FA, and patients with ≤3 visits were placed in the control group. Numerous variables were analyzed and differences between the groups compared. Logistic regression analysis was used to determine the predictor variables and the model validated using Receiver Operating Characteristic (ROC) on an independent sample. Results: 6635 patients were included in developing the model: 15.3 (n=1012) were classified as FA and 15.4 (n=1011) as the control group. Variables associated with at risk of becoming a FA were the following: age above 60 years OR 1.52 [CI 1.27 – 1.82], ED arrival by ambulance or helicopter OR 1.31 [CI 1.08 – 1.58], sheltered living OR 3.82 [CI 2.37 – 6.17], previous contact with psychiatric department OR 1.52 [CI 1.23 – 1.89], 10 outpatient care visits or more OR 4.81 [CI 3.81 – 6.08] and 10 outpatient care physician visits or more OR 3.94 [CI 3.25 – 4.78]. The ROC in the validation set had an area under the curve of 0.85 [CI 0.84 – 0.86]. Conclusion: Data from electronic medical record software can be used to create and validate the risk of becoming a FA in the ED. We found that age over 60 years, ED arrival by ambulance or helicopter, sheltered living, previous contact with psychiatric departments, and frequent visits at outpatient care together predict the risk of becoming a FA.

Heterogeneity of reasons for attendance in frequent attenders of emergency departments and its relationship to future attendance

BackgroundEDs globally are under increasing pressure through rising demand. Frequent attenders are known to have complex health needs and use a disproportionate amount of resources. We hypothesised that heterogeneity of patients’ reason for attendance would be associated with multimorbidity and increasing age, and predict future attendance.MethodWe analysed an anonymised dataset of all ED visits over the course of 2014 in Yorkshire, UK. We identified 15 986 patients who had five or more ED encounters at any ED in the calendar year. Presenting complaint was categorised into one of 14 categories based on the Emergency Care Data Set (ECDS). We calculated measures of heterogeneity (count of ECDs categories and entropy of categories) and examined their relationship to total number of ED visits and to patient characteristics. We examined the predictive value of these and other features on future attendance.ResultsMost frequent attenders had more than one presenting complaint type. Heterogeneity increased with number of attendances, but heterogeneity adjusted for number of attendances did not vary substantially with age or sex. Heterogeneity was associated with the presence of one or more contacts for a mental health problem. For a given number of attendances, prior mental health contact but not heterogeneity was associated with further attendance.ConclusionsHeterogeneity of presenting complaint can be quantified and analysed for ED use: it is increased where there is a history of mental disorder but not with age. This suggests it reflects more than the number of medical conditions.

What happens to frequent attenders when they attend psychiatric liaison services? a clinical and demographic profile

AimsWe aimed to describe the demographic and clinical profile, and management of frequent attenders to a psychiatric liaison service.BackgroundFrequent Attenders to emergency departments contribute significantly to the burden on health services and by definition are subjectively highly stressed. It is therefore important that mental health services develop effective responses to this group of patients. A systematic literature search indicated a paucity of information on this group of patients.MethodWe conducted a case series of 49 frequently attending patients to the Psychiatric Liaison service in Tower Hamlets, East London NHS Foundation Trust.We defined frequent attenders as seeing the Psychiatric Liaison Service 5 or more times in 2018. We excluded 4 patients aged <18 years or >65 years.For each patient we collected data regarding their demographics; the details of each attendance to the Psychiatric Liaison Service; and their use of other psychiatric services.We then conducted a multivariate analysis, including stratification of patients based on number of attendances to identify correlation between frequency of attendance and the other information.ResultDemographic: The 45 patients reviewed had a mean age of 37 and a mean of 7 attendances during the study period.Clinical: 89% had a history of emotional trauma, 71% of substance misuse, and 49% of any personality disorder. Only 9% of the patients were under the care of the locality Personality Disorder Service.73% of the patients were under the care of any other psychiatric service. There was no correlation between being under other services and the frequency of attendance.Only 31% had contact with the locality Frequent Attenders Service during the study period, as this was established recently.ConclusionPsychiatric Frequent Attenders have complex needs, which do not fit neatly into existing psychiatric diagnoses and services.The high frequency of emotional trauma, substance misuse and personality disorder indicates a need for training of clinicians in these services to manage these patients, as well as planning for referral pathways for this group of patients who provide services with major challenges in appropriate pathways to care and follow-up

Measuring the impact of an acute visiting scheme on emergency department attendances – a pre-post cohort design

Background Emergency department (ED) attendances are contributing to rising costs of the National Health Service (NHS) in England. Critically assessing the impact of new services to reduce emergency department use can be difficult as new services may create additional access points, unlocking latent demand. The study evaluated an Acute Visiting Scheme (AVS) in a primary care context. We asked if AVS reduces overall ED demand and whether or not it changed utilisation patterns for frequent attenders. Method The study used a pre post single cohort design. The impact of AVS on all-cause ED attendances was hypothesised as a substitution effect, where AVS duty doctor visits would replace emergency department visits. Primary outcome was frequency of ED attendances. End points were reduction of frequency of service use and increase of intervals between attendances by frequent attenders. Results ED attendances for AVS users rose by 47.6%. If AVS use was included, there was a more than fourfold increase of total service utilisation, amounting to 438.3%. It shows that AVS unlocked significant latent demand. However, there was some reduction in the frequency of ED attendances for some patients and an increase in time intervals between ED attendances for others. Conclusion The study demonstrates that careful analysis of patient utilisation can detect a differential impact of AVS on the use of ED. As the new service created additional access points for patients and hence introduces an element of choice, the new service is likely to unlock latent demand. This study illustrates that AVS may be most useful if targeted at specific patient groups who are most likely to benefit from the new service.

Frequent attendance at the emergency department shows typical features of complex systems: analysis of multicentre linked data

ObjectiveFrequent attendance at the ED is a worldwide problem. We hypothesised that frequent attendance could be understood as a feature of a complex system comprising patients, healthcare and society. Complex systems have characteristic statistical properties, with stable patterns at the level of the system emerging from unstable patterns at the level of individuals who make up the system.MethodsAnalysis of a linked dataset of routinely collected health records from all 13 hospital trusts providing ED care in the Yorkshire and Humber region of the UK (population 5.5 million). We analysed the distribution of attendances per person in each of 3 years and measured the transition of individual patients between frequent, infrequent and non-attendance. We fitted data to power law distributions typically seen in complex systems using maximum likelihood estimation.ResultsThe data included 3.6 million attendances at EDs in 13 hospital trusts. 29/39 (74.3%) analyses showed a statistical fit to a power law; 2 (5.1%) fitted an alternative distribution. All trusts’ data fitted a power law in at least 1 year. Differences over time and between hospital trusts were small and partly explained by demographics. In contrast, individual patients’ frequent attendance was unstable between years.ConclusionsED attendance patterns are stable at the level of the system, but unstable at the level of individual frequent attenders. Attendances follow a power law distribution typical of complex systems. Interventions to address ED frequent attendance need to consider the whole system and not just the individual frequent attenders.