Psychiatric status, somatisation, and health care utilization of frequent attenders at the emergency department: A comparison with routine attenders

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Abstract

Seventy-seven frequent attenders at an emergency department (ED) in an inner-city hospital in the UK (defined as seven or more visits in the previous 12 months) were compared with 182 patients who were attending the same department on a routine basis. Patients completed the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and the Short Form (SF)-36. Information was obtained on 64% of the frequent attenders and 45% underwent a detailed psychiatric assessment. Of the frequent attenders, 45% had psychiatric disorder and 49% had some form of an alcohol-related disorder. Compared with routine attenders, frequent attenders reported lower health status, had more psychiatric disorder (odds ratio: OR=8.2, 95% confidence interval: CI=3.8–18.1), had more general hospital admissions (OR=19.9, 95% CI=8.3–47.8), more psychiatric admissions (OR=167.5, 95% CI=9.5–2959.0), and more GP visits (95% CI for difference=−10.2 to −5.7). There was no evidence that frequent attenders had more somatisation than routine attenders. Specific treatment and management strategies need to be developed for this group of patients, although a substantial proportion may be difficult to engage in the treatment process.

Introduction

Since 1981, emergency departments (EDs) have experienced a progressive rise in the overall number of new attendances by approximately 2% per year [1]. Several descriptive reports have suggested that a relatively small group of patients account for a large proportion of the overall total of ED attendances [2], [3], [4], as they make repeated unscheduled visits. These patients have been characterised as often being vagrants [5], or having high rates of alcohol problems or social difficulties [3], [4]. It has also been suggested that they may use EDs in preference to seeking care from the primary sector. A recent study from Ireland [6] has shown that increasing frequency of attendance at an ED was significantly associated with increasing age, being male, and not being married. There have been no studies, however, which have examined the psychiatric profiles and health status of frequent attenders at EDs.

The phenomenon of frequent attendance has been studied most in the primary care setting. Several studies from around the world [6], [7], [8], [9], [10], [11], [12], [13], [14] have shown that frequent attenders in primary care have high rates of psychiatric disorder in comparison with normal attenders, in particular, they have high rates of anxiety, depression, and somatisation. A recent study of frequent attendance at a medical out-patient clinic [15] has shown that frequent attenders in the secondary care sector are also high users of primary care services.

The main goal of this study was to determine the health status and prevalence of psychiatric disorder, including somatisation, of patients who attend the ED on a frequent basis in comparison with routine attenders. A secondary goal was to establish whether ED frequent attenders use emergency services instead of primary care, or as an addition to primary care.

Section snippets

Patients and method

The study was conducted at Manchester Royal Infirmary. The ED serves a deprived inner-city area and treated approximately 67,500 new patients in 1997. It has a computerised register that records every attendance and enables frequent attenders to be easily identified.

Frequent attendance at the ED has been defined as four or more visits within a 12-month period [3]. For the purposes of this study, we chose a more conservative figure of seven or more visits as we wished to focus upon patients who

Results

Of the 77 patients who were identified as frequent attenders, 23 (29.9%) could not be traced (i.e. were of no fixed abode or gave a false address), 13 (16.9%) refused to be interviewed, 3 (3.9%) had died, 2 (2.6%) had learning difficulties, and 1 man was deaf and mute. Several patients on whom assessments were completed required up to four home visits before face-to-face contact could be established. A total of 35 (45.5%) frequent attenders were finally interviewed and data from psychiatric

Discussion

This is the first study in the UK that has focused upon patients who make repeated visits to the ED. Its findings are strengthened by the use of a detailed interview as opposed to reliance upon a self-report questionnaire. Out of the 77 frequent attenders identified for inclusion in the project, however, only 35 could be interviewed face-to-face, although further data was obtained on 64% of the original sample. This limits the potential representativeness of the study, but it may also reflect

Acknowledgements

This work was funded by the North West Regional Health Authority.

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