Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA.
Department of Surgery, Uniformed Services University, Bethesda, MD, USA.
Mil Med. 2021 Jul 1;186(7-8):e819-e825. doi: 10.1093/milmed/usaa399.
Super-utilizers (patients with 4 or more emergency department [ED] visits a year) account for 10% to 26% of all ED visits and are responsible for a growing proportion of healthcare expenditures. Patients recognize the ED as a reliable provider of acute care, as well as a timely resource for diagnosis and treatment. The value of ED care is indisputable in critical and emergent conditions, but in the case of non-urgent conditions, ED utilization may represent an inefficiency in the healthcare system. We sought to identify patient and clinical characteristics associated with ED super-utilization in a universally insured population.
We performed a retrospective cohort study using TRICARE claims data from the Military Health System Data Repository (2011-2015). We reviewed the claims data of all adult patients (aged 18-64 years) who had at least one encounter at the ED for any cause. Multivariable logistic regression was used to determine independent factors associated with ED super-utilization.
Factors associated with increased odds of ED super-utilization included Charlson Score ≥2 (adjusted odds ratio [aOR] 1.98, 95% confidence interval [CI]: 1.90-2.06), being eligible for Medicare (aOR 1.95, 95% CI: 1.90-2.01), and female sex (aOR 1.35, 95% CI: 1.33-1.37). Active duty service members (aOR 0.69, 95% CI 0.68-0.72) and beneficiaries with higher sponsor-rank (Officers: aOR 0.50, 95% CI: 0.55-0.57; Senior enlisted: aOR 0.82, 95% CI: 0.81-0.83) had lower odds of ED super-utilization. The most common primary diagnoses for ED visits among super-utilizers were abdominal pain, headache and migraine, chest pain, urinary tract infection, nausea and vomiting, and low back pain.
Risk of ED super-utilization appears to increase with age and diminished health status. Patient demographic and clinical characteristics of ED super-utilization identified in this study can be used to formulate healthcare policies addressing gaps in primary care in diagnoses associated with ED super-utilization and develop interventions to address modifiable risk factors of ED utilization.
超级使用者（每年急诊就诊 4 次或以上的患者）占所有急诊就诊的 10%至 26%，并负责越来越多的医疗保健支出。患者认为急诊是急性护理的可靠提供者，也是及时诊断和治疗的资源。在危急和紧急情况下，急诊护理的价值是无可争议的，但在非紧急情况下，急诊就诊可能代表医疗系统的效率低下。我们试图确定普遍参保人群中与急诊就诊过度使用相关的患者和临床特征。
我们使用来自军事医疗系统数据存储库（2011-2015 年）的 TRICARE 索赔数据进行了回顾性队列研究。我们审查了至少因任何原因在急诊就诊一次的所有成年患者（18-64 岁）的索赔数据。多变量逻辑回归用于确定与急诊就诊过度使用相关的独立因素。
与急诊就诊过度使用几率增加相关的因素包括 Charlson 评分≥2（调整后的优势比 [aOR] 1.98，95%置信区间 [CI]：1.90-2.06）、有资格参加医疗保险（aOR 1.95，95% CI：1.90-2.01）和女性（aOR 1.35，95% CI：1.33-1.37）。现役军人（aOR 0.69，95% CI 0.68-0.72）和赞助商级别较高的受益人（军官：aOR 0.50，95% CI：0.55-0.57；高级士官：aOR 0.82，95% CI：0.81-0.83）急诊就诊过度使用的几率较低。超级使用者急诊就诊最常见的主要诊断是腹痛、头痛和偏头痛、胸痛、尿路感染、恶心和呕吐以及下腰痛。
急诊就诊过度使用的风险似乎随着年龄的增长和健康状况的恶化而增加。本研究确定的急诊就诊过度使用患者的人口统计学和临床特征可用于制定医疗保健政策，以解决与急诊就诊过度使用相关的初级保健诊断差距，并制定干预措施以解决急诊就诊可改变的风险因素。
