ObjectivesThis study aimed to determine which factors contribute to frequent visits at the emergency department (ED) and what proportion were inappropriate in comparison with nonfrequent visits. MethodsThis study was a retrospective, case-control study comparing a random sample of frequent attenders and nonfrequent attenders, with details of their ED visits recorded over a 12-month duration. Frequent attenders were defined as patients with four or more visits during the study period. ResultsIn comparison with nonfrequent attenders (median age=45.0 years, interquartile range [IQR]=28.0 to 61.0 years), frequent attenders were older (median=57.5 years, IQR=34.0 to 74.8 years; p=0.0003). They were also found to have more comorbidities, where 53.3% of frequent attenders had three or more chronic illnesses compared to 14% of nonfrequent attenders (p<0.0001), and were often triaged to higher priority (more severe) classes (frequent 52.2% vs. nonfrequent 37.6%, p=0.0004). Social issues such as bad debts (12.7%), heavy drinking (3.3%), and substance abuse (2.7%) were very low in frequent attenders compared to Western studies. Frequent attenders had a similar rate of appropriate visits to the ED as nonfrequent attenders (55.2% vs. 48.1%, p=0.0892), but were more often triaged to P1 priority triage class (6.7% vs. 3.2%, p=0.0014) and were more often admitted for further management compared to nonfrequent attenders (47.5% vs. 29.6%, p<0.001). The majority of frequent attender visits were appropriate (55.2%), and of these, 81.1% resulted in admission. For the same number of patients, total visits made by frequent attenders ($174,247.60) cost four times as much as for nonfrequent attenders ($40,912.40). This represents a significant economic burden on the health care system. ConclusionsED frequent attenders in Singapore were associated with higher age and presence of multiple comorbidities rather than with social causes of ED use. Even in integrated health systems, repeat ED visits are frequent and expensive, despite minimal social causes of acute care. EDs in aging populations must anticipate the influx of vulnerable, elderly patients and have in place interventional programs to care for them. (C) 2015 by the Society for Academic Emergency Medicine Resumen Factores que Contribuyen a las Visitas Inapropiadas de los Hiperfrecuentadores y su Impacto Economico en un Servicio de Urgencias en Singapur ObjetivosDeterminar que factores contribuyen a las hiperfrecuentaciones en el Servicio de Urgencias (SU) y que proporcion fueron inadecuadas en comparacion con las no hiperfrecuentaciones. MetodologiaEstudio de casos y controles retrospectivo que comparo una muestra aleatoria de hiperfrecuentadores (HF) y no hiperfrecuentadores (NHF) con datos de sus visitas recogidos durante 12 meses. Los HF se definieron como pacientes con cuatro o mas visitas durante el periodo del estudio. ResultadosEn comparacion con los NHF (edad mediana=45,0 anos, RIC=28,0 a 61,0), los HF fueron de mayor edad (mediana=57,5 anos, RIC=34,0 a 74,8) (p=0,0003). Ademas, se hallo que tenian mayor grado de comorbilidad, donde un 53,3% de los HF tenia 3 o mas enfermedades cronicas en comparacion con un 14% de los NHF (p<0,0001), y a menudo se les clasifico con mayores niveles de prioridad (mayor gravedad) (HF 52,2% frente NHF 37,6%, p=0,0004). Los problemas sociales como la falta de recursos economicos (12,7%), el alcoholismo (3,3%), y el abuso de sustancias (2,7%) fueron bastante menores en HF en comparacion con los estudios occidentales. Los HF tendieron a realizar mas visitas apropiadas al SU que los NHF (55,2% frente 48,1%, p=0,0892), y fueron clasificados a nivel de triaje comoe prioridad 1, y mas frecuentemente ingresados para un posterior manejo en comparacion con los NHF (6,7% frente 3,2%, p=0,0881; y 47,5% frente 29,6%, p<0,001, respectivamente). La mayoria de las visitas de HF fueron claramente apropiadas (55,2%), y de estas, un 81,1% resultaron en un ingreso. Para el mismo numero de pacientes, el total de visitas realizadas por los HF tuvo un coste cuatro veces mayor que los NHF (174.247,60 frente a 40.912,40 dolares, respectivamente). Esto representa un carga economica significativa en el sistema sanitario de salud. ConclusionesLos HF del SU en Singapur se asociaron con mayor edad y la presencia de multiples enfermedades asociadas mas que con una atencion en el SU de causa social. Incluso en los sistemas sanitarios integrados, las visitas al SU repetidas son frecuentes y caras, a pesar de que es escasa la atencion aguda por causa social. Los SU en las poblaciones envejecidas debe anticipar el flujo de pacientes ancianos vulnerables y tener en implantados programas de intervencion para manejarlos.
