Severely compromised life circumstances cause frequent ER use by vets

Even with health insurance, ready access to preventive, specialty and behavioral health care and comprehensive electronic medical records, nearly 8 percent of patients in the Veterans Health Administration (VHA) visit the emergency department two or more times per year, according to a study published online Tuesday in Annals of Emergency Medicine ("What Drives Frequent Emergency Department Use in an Integrated Health System: National Data from the Veterans Health Administration"). The study, along with an accompanying editorial ("How Frequent Emergency Department Use by U.S. Veterans Can Inform Good Public Policy"), casts doubt that any simplistic solution to frequent ER use exists.

"Just as we see in the , frequent users of the ER in the VHA generally have severely compromised and high levels of psychosocial dysfunction in addition to medical needs," said lead study author Kelly Doran, MD, of the Robert Wood Johnson Foundation Clinical Scholars Program at the Yale University School of Medicine and the U.S. Department of Veterans Affairs in New Haven, Conn. "Our findings defy the common assumption that once patients have ongoing medical care and health insurance their ER use will drop off. Instead, it appears that improved health outcomes may be realized through increased spending on social services, such as housing subsidies and income supplements."

Researchers analyzed more than four million records from 2010 for patients enrolled in the Veterans Health Administration. Most (83.2 percent) had no VHA visit, while 8.9 percent had one ER visit. Patients who visited the ER two to four times made up 6.4 percent of the patient population. Those who visited five to 10 times made up 1.3 percent of the population, and patients with 11-25 visits made up 0.2 percent of the population. A tiny percentage, 0.01 percent, had more than 25 visits.

Factors most consistently and strongly associated with all levels of emergency department use were schizophrenia, homelessness, opiate prescriptions being filled and heart failure.

"This isn't a problem of insufficient medical care– providing access to more of the same outpatient care is unlikely to eliminate frequent ER use," said Dr. Doran.

Jesse Pines, MD, MBA, of the George Washington University in Washington D.C., the author of the accompanying editorial, wrote that the VHA "is an integrated delivery system that operates in many ways like an accountable care organization, a major cornerstone of the [Affordable Care Act]."

"Even accountable care organizations will have frequent ER users," said Dr. Pines. "Therefore efforts should focus on enhancing the quality of emergency care, rather than policies intended to undermine emergency departments. For example, non-payment for ER care for specific conditions is often discussed as a way to reduce costs. This study makes it even clearer that non-payment programs focused on emergency departments are just not good public policy."

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