Too much focus on ED “frequent flyers”

AUSTRALIAN experts agree with a UK report that most interventions aimed at reducing hospital emergency admissions are focusing on the wrong patients — frequent flyers.

The authors of the BMJ article said the assumption that efforts should be focused on these so-called frequent flyers was widespread, yet these high-risk patients did not actually account for the most admissions. (1)

“Most admissions come from low risk patients, and the greatest effect on admissions will be made by reducing risk factors in the whole population rather than in a small group of high risk people”, they wrote.

Emergency admissions were a popular target to improve quality of care and save money, but there was a lack of evidence about what was effective and misconceptions could lead to naive or unrealistic expectations, they wrote.

Another danger was the assumption that all interventions aimed at reducing emergency admissions were beneficial.

“For example, two recently published high quality randomised controlled trials of interventions designed to keep people out of hospital showed increased deaths among the intervention groups …”, they wrote. (2, 3)

Australian research published in 2008 also found there was a common misperception that “frequent attenders” were time-consuming, “illegitimate” users of emergency department resources. (4)

It found these patients were sicker than other patients and often required more inpatient management, but comprised only a small percentage of emergency department patients.

The workload associated with their attendances was relatively “inconsequential”, the researchers wrote.

Professor Peter Cameron, head of the critical care division at Monash University, said the science behind many Australian efforts to boost emergency department efficiency by avoiding admissions was “very rubbery”.

“A lot of these policies have been introduced to save money because hospital admissions are so expensive, but when you analyse how much these programs cost and their effect on hospital admissions, most don’t result in cost savings in the end”, he said.

However he noted that this has been much bigger issue in the UK.

“There’s some good data in UK on how much ‘churn’ is created by these quick-fix changes [to emergency department admissions] that ostensibly save money by avoiding something in the short term, but which in long term, actually create more work”, he said.

Professor Gordian Fulde, director of accident and emergency at St Vincent’s Hospital, Sydney, agreed that money was not as well spent when the focus was on frequent flyers.

“The big word is prevention: where it really has to start is to prevent people becoming homeless, mentally ill and drug affected. That’s where the money is in utopia, but you and I don’t live there”, Professor Fulde said.

Dr Sally McCarthy, Australasian College for Emergency Medicine president, said frequent presenters were often patients who found it hard maintain contact with their usual care provider. She also noted they tended not to be admitted.

A broader system-wide approach was needed if efficiencies were to be made. “If we looked at particular local health districts that are performing better and investigated why that might be and apply it across system, that may possibly be a more robust way to go than just focusing on small groups”, Dr McCarthy said.

The UK authors have called for a more considered approach and suggested five guidelines for those focusing on this aspect of health care:

• Don’t assume reductions in admissions in a high-risk group are due to your intervention

• Don’t assume there is a correct level of admission or referral

• Don’t assume that fewer admissions or referrals are necessarily better

• Be cautious about using data for short time periods or referrals to single specialties

• Choose interventions that are evidence based.

– Amanda Bryan

1. BMJ 2012; Online 18 September
2. Ann Intern Med 2012; 156: 673-683
3. Arch Intern Med 2012; 172: 773-779
4. MJA 2008; 189: 552-556

Posted 24 September 2012