Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland.
Acad Emerg Med. 2012 Jan;19(1):63-8. doi: 10.1111/j.1553-2712.2011.01246.x. Epub 2012 Jan 5.
The objectives were to identify the social and medical factors associated with emergency department (ED) frequent use and to determine if frequent users were more likely to have a combination of these factors in a universal health insurance system.
This was a retrospective chart review case-control study comparing randomized samples of frequent users and nonfrequent users at the Lausanne University Hospital, Switzerland. The authors defined frequent users as patients with four or more ED visits within the previous 12 months. Adult patients who visited the ED between April 2008 and March 2009 (study period) were included, and patients leaving the ED without medical discharge were excluded. For each patient, the first ED electronic record within the study period was considered for data extraction. Along with basic demographics, variables of interest included social (employment or housing status) and medical (ED primary diagnosis) characteristics. Significant social and medical factors were used to construct a logistic regression model, to determine factors associated with frequent ED use. In addition, comparison of the combination of social and medical factors was examined.
A total of 359 of 1,591 frequent and 360 of 34,263 nonfrequent users were selected. Frequent users accounted for less than a 20th of all ED patients (4.4%), but for 12.1% of all visits (5,813 of 48,117), with a maximum of 73 ED visits. No difference in terms of age or sex occurred, but more frequent users had a nationality other than Swiss or European (n = 117 [32.6%] vs. n = 83 [23.1%], p = 0.003). Adjusted multivariate analysis showed that social and specific medical vulnerability factors most increased the risk of frequent ED use: being under guardianship (adjusted odds ratio [OR] = 15.8; 95% confidence interval [CI] = 1.7 to 147.3), living closer to the ED (adjusted OR = 4.6; 95% CI = 2.8 to 7.6), being uninsured (adjusted OR = 2.5; 95% CI = 1.1 to 5.8), being unemployed or dependent on government welfare (adjusted OR = 2.1; 95% CI = 1.3 to 3.4), the number of psychiatric hospitalizations (adjusted OR = 4.6; 95% CI = 1.5 to 14.1), and the use of five or more clinical departments over 12 months (adjusted OR = 4.5; 95% CI = 2.5 to 8.1). Having two of four social factors increased the odds of frequent ED use (adjusted = OR 5.4; 95% CI = 2.9 to 9.9), and similar results were found for medical factors (adjusted OR = 7.9; 95% CI = 4.6 to 13.4). A combination of social and medical factors was markedly associated with ED frequent use, as frequent users were 10 times more likely to have three of them (on a total of eight factors; 95% CI = 5.1 to 19.6).
Frequent users accounted for a moderate proportion of visits at the Lausanne ED. Social and medical vulnerability factors were associated with frequent ED use. In addition, frequent users were more likely to have both social and medical vulnerabilities than were other patients. Case management strategies might address the vulnerability factors of frequent users to prevent inequities in health care and related costs.
确定与急诊科（ED）频繁使用相关的社会和医学因素，并确定在全民健康保险制度下，频繁使用者是否更有可能同时存在这些因素。
这是一项回顾性图表审查病例对照研究，比较了瑞士洛桑大学医院随机选择的频繁使用者和非频繁使用者样本。作者将频繁使用者定义为在过去 12 个月内有 4 次或以上 ED 就诊的患者。研究期间，纳入了在 2008 年 4 月至 2009 年 3 月期间访问 ED 的成年患者，并排除了离开 ED 而未接受医疗出院的患者。对于每位患者，研究期间的第一个 ED 电子记录被视为数据提取的依据。除了基本人口统计学特征外，还包括了社会（就业或住房状况）和医学（ED 主要诊断）特征等感兴趣的变量。使用显著的社会和医学因素构建逻辑回归模型，以确定与 ED 频繁使用相关的因素。此外，还比较了社会和医学因素的组合。
共选择了 1591 名频繁使用者中的 359 名和 34263 名非频繁使用者中的 360 名。频繁使用者占所有 ED 患者的不到 20%（4.4%），但占所有就诊次数的 12.1%（5813 次就诊，占 48117 次就诊的 12.1%），最多就诊次数为 73 次。在年龄或性别方面没有差异，但更多的频繁使用者来自瑞士或欧洲以外的国籍（n=117[32.6%]vs.n=83[23.1%]，p=0.003）。调整后的多变量分析表明，社会和特定的医学脆弱性因素最增加了 ED 频繁使用的风险：受监护（调整后的优势比[OR] = 15.8；95%置信区间[CI] = 1.7 至 147.3），居住在 ED 附近（调整后的 OR = 4.6；95% CI = 2.8 至 7.6），没有保险（调整后的 OR = 2.5；95% CI = 1.1 至 5.8），失业或依赖政府福利（调整后的 OR = 2.1；95% CI = 1.3 至 3.4），精神科住院次数（调整后的 OR = 4.6；95% CI = 1.5 至 14.1），12 个月内使用五个或更多临床科室（调整后的 OR = 4.5；95% CI = 2.5 至 8.1）。有四个社会因素中的两个增加了 ED 频繁使用的几率（调整后的 OR = 5.4；95% CI = 2.9 至 9.9），对于医学因素也有类似的结果（调整后的 OR = 7.9；95% CI = 4.6 至 13.4）。社会和医学因素的组合与 ED 频繁使用明显相关，因为频繁使用者有 10 倍的可能性有三个因素（共 8 个因素；95% CI = 5.1 至 19.6）。
频繁使用者占洛桑 ED 就诊的中等比例。社会和医学脆弱性因素与 ED 频繁使用相关。此外，频繁使用者比其他患者更有可能同时存在社会和医学脆弱性。病例管理策略可能会针对频繁使用者的脆弱性因素进行干预，以防止医疗保健和相关费用的不平等。
