Patient Demographic and Health Factors Associated With Frequent Use of Emergency Medical Services in a Midsized City

To optimize health care utilization, health outcomes, and costs, research is needed to improve an understanding of frequent users of emergency health services. Frequent use of emergency services is associated with high costs of health care and may be indicative of challenges accessing, or poor outcomes of, health care. Patient demographics and health factors related to frequent use of the emergency medical services (EMS) system of a midsized city were identified. Study findings will aid in the development of targeted interventions to improve population health. The authors reviewed 9-1-1 call dispatch data and Baltimore City Fire Department (BCFD) EMS records from 2008 through 2010. Frequent use was defined as six or more EMS incidents in the 23-month period. Analyses used census data to compare demographics of EMS users to their population distribution and examined differences in demographics and health problems of frequent EMS users compared to nonfrequent users. Frequent EMS users (n = 1,969) had a range of six to 199 EMS incidents (mean = 11.2) during the observation period, and although they accounted for only 1.5% of EMS users, they were involved in 12.0% of incidents. Frequent users, compared to nonfrequent users and to the population, were more likely to be male, African American, and 45 years of age or older. Of frequent users, the modal age group was 45 to 54 years, accounting for 29.7% of frequent users, which represented twice this age group's population distribution. Furthermore, this age group had the greatest overrepresentation of males (63.0% of frequent users) and was the peak age group for incidents related to substance abuse (28.0% of frequent users' incidents in this age group). Frequent users, compared to nonfrequent users, had lower levels of incidents related to trauma (5.1% vs. 16.7%) and higher levels of medical incidents (94.8% vs. 82.9%). As proportions of EMS incidents among frequent versus nonfrequent users, respiratory, mental health, and seizure-related incidents were highest in the youngest age groups; substance abuse–related incidents were highest in those middle-aged (35 to 44 and 45 to 54 years). Of health problems, behavioral health (mental health or substance use) contributed most to frequent EMS use (23.4% of frequent users' incidents). Across all incidents, 65.8% of frequent users had indications of behavioral health problems, representing 6.6-fold higher odds than nonfrequent users (22.5%). Frequent compared to nonfrequent users also had higher levels of select chronic conditions (diabetes, 39.9% vs. 14.6%; asthma, 40.9% vs. 13.4%; and HIV, 9.1% vs. 2.4%), with unadjusted odds almost four to seven times higher. The study findings revealed the major role of chronic somatic and behavioral health problems in frequent EMS use and that rates of frequent use were highest among those middle-aged, African American, and male. These results suggest the need for coordination of EMS with community-based, integrated medical and behavioral health services to improve access and use of preventive services, with implications for health outcomes and costs. This study demonstrates the value of EMS patient data in identifying at-risk populations and informing novel, targeted approaches to public health interventions. Para optimizar la utilización de la atención sanitaria, los resultados sanitarios y los costes, se necesita investigar para mejorar la comprensión de los usuarios frecuentes de los servicios sanitarios urgentes. El uso frecuente de los servicios de emergencias se asocia con costes elevados de la atención sanitaria y puede ser indicativo de oportunidades de acceso o de malos resultados de la atención sanitaria. Se identificaron los factores sanitarios y demográficos del paciente relacionados con el uso frecuente del sistema de los servicios de emergencias médicas (SEM) de una ciudad de tamaño medio. Los hallazgos del estudio ayudarán en el desarrollo de intervenciones dirigidas para mejorar la salud de la población. Se revisaron los datos de las llamadas atendidas al 9–1-1 y las historias clínicas del SEM del Baltimore City Fire Department desde 2008 a 2010. El uso frecuente se definió como seis o más episodios de uso del SEM en un periodo de 23 meses. Los análisis utilizaron datos del censo para comparar las características demográficas de los usuarios del SEM con la distribución de su población; y examinaron las diferencias demográficas y en los problemas de salud entre los usuarios frecuentes del SEM y los usuarios no frecuentes. Los usuarios frecuentes del SEM (n = 1.969) tuvieron un rango de episodios del SEM de 6 a 199 (media 11,2) durante el periodo de observación; y aunque contabilizaron sólo un 1,5% de los usuarios del SEM, estuvieron involucrados en un 12% de los episodios. Los usuarios frecuentes, cuando se compararon con los usuarios no frecuentes y la población, fueron más frecuentemente hombres, afroamericanos, y de 45 años de edad o más. De los usuarios frecuentes, el grupo de edad modal fue de 45 a 54 años, que suposo un 29,7% de los usuarios frecuentes, lo que representó el doble de la distribución de la población de este grupo de edad. Además, este grupo de edad tuvo la mayor representación de hombres (63,0% de los usuarios frecuentes) y fue el grupo de edad pico para los episodios relacionados con el abuso de sustancias (28,0% de los episodios de usuarios frecuentes en este grupo de edad). Los usuarios frecuentes, en comparación con los usuarios no frecuentes, tuvieron menos episodios relacionados con traumatismo (5.1% vs. 16.7%) y más episodios médicos (94.8% vs. 82.9%). Como proporciones de episodios del SEM entre los usuarios frecuentes frente a los no frecuentes, los episodios relacionados con problemas respiratorios, de salud mental y episodios relacionados con crisis fueron mayores en los grupos de edad más jóvenes; los episodios relacionados con el abuso de sustancias fueron mayores en aquéllos de mediana edad (35 a 44 años y 45 a 54 años). De los problemas de salud, los trastornos del comportamiento (salud mental o abuso de sustancias) son los que más contribuyeron al uso frecuente del SEM (23,4% de los episodios de los usuarios frecuentes). De todos los episodios, un 65,8% de los usuarios frecuentes tuvieron una indicación de problemas de trastornos del comportamiento, lo que supuso 6,6 veces más probabilidad que los usuarios no frecuentes (22,5%). Los usuarios frecuentes, en comparación con los no frecuentes, también tuvieron mayor frecuencia de ciertas enfermedades crónicas (diabetes: 39,9% frente 14,6%, respectivamente; asma: 40,9% frente 13,4%; y VIH: 9,1% frente 2,4%) con una probabilidad no ajustada de casi 4 a 7 veces mayor. Los hallazgos del estudio revelaron el papel principal de los problemas de trastorno del comportamiento y somáticos crónicos en el uso frecuente del SEM; y que los porcentajes de uso frecuente fueron mayores entre aquellos pacientes de mediana edad, afroamericanos y hombres. Estos resultados sugieren la necesidad de coordinación del SEM con la comunidad y de integrar los servicios sanitarios médicos y del comportamiento para mejorar el acceso y el uso de los servicios preventivos, con las implicaciones en los resultados sanitarios y los costes. Este estudio demuestra el valor de los datos del paciente del SEM en la identificación de las poblaciones en riesgo e informan de aproximaciones novedosas dirigidas a intervenciones de salud pública. As health care policymakers seek to improve patient outcomes and reduce health care costs, research is needed to understand patient factors associated with high utilization of emergency health services.1, 2 Studies indicate increased demand for both emergency medical services (EMS) and emergency department (ED) care in recent years.3-7 Previous studies of frequent users of emergency health services have focused on ED users.5, 8-16 Research indicates important differences in EMS users compared to other ED patient populations, suggesting the need for greater research attention to EMS users. EMS users, compared to other ED patients, tend to be older and more disadvantaged; have higher levels of mental health visits; and have higher acuity status, more frequent hospital admissions, and longer lengths of stay and therefore higher health care costs.17-22 In this study we sought to identify patient demographics and health problems associated with frequent use of an EMS system in a midsized U.S. city with a demographic profile suggestive of high propensity for EMS use. The few prior studies on frequent users of EMS have focused on geriatric and pediatric subpopulations.23-25 To our knowledge, this study represents one of the first to examine patient factors associated with frequent use of EMS on a population level. The study findings have implications for methodologic approaches to understanding population patterns of high-cost acute services utilization and for informing the development of interventions to optimize frequent EMS users' health outcomes and decrease health care costs. Early study findings indicated that frequent ED use was associated with African American ethnicity; public health care coverage, lack of health insurance, or other indicators of low socioeconomic status; and mental illness, substance abuse, and other vulnerabilities.5, 14-16 Current research suggests growing heterogeneity among frequent ED users.10 While it remains that persons with Medicaid or Medicare coverage are overrepresented among frequent ED users, results of a recent systematic review indicate that the majority of frequent ED users are white and female, and that there is a bimodal age distribution, with peak ages of 25 to 44 years and over 65 years.9, 10, 26 Study findings suggest that the recent rise in ED utilization rates is attributable to the increasing use of EDs among persons who are not poor, have health insurance, and have chronic somatic conditions.4, 11, 12, 15 Indeed, rates of chronic conditions such as diabetes, asthma, and HIV have soared in the past two decades, especially among but not limited to poor, urban, African Americans; and these conditions are associated with high levels of ED use and health care costs.27-34 Most research on EMS use is derived from studies of EMS-transported ED patients. Although they comprise only a minority (approximately one sixth) of ED patients, EMS transports, compared to ED patients transported by other means, are disproportionately older, urban, African American, and socioeconomically disadvantaged; and, unlike as is the case for other health services, EMS users are more likely to be male than female.17-19, 27 In a recent study of the National Hospital Ambulatory Medical Care Survey (NHAMCS), Meisel and colleagues28 found that even among adults < 65 years old, EMS use was associated with traditional indicators of low socioeconomic status. Previous research on health problems of EMS users has focused on trauma, cardiovascular events, and other acute health problems of pediatric and geriatric populations.23-25 Recent studies indicate that EMS plays a major and growing role in the care of persons with behavioral health (mental health and substance use) problems.17, 21, 27 A study of NHAMCS data from 1997 to 2003 found that among ED patients, EMS transport was associated with problems related to mental health, and of those ED patients with visits related to mental health, a disproportionately high proportion (31%) arrived by EMS.19 In a population-level study of use of New York City's EMS system, Munjal and colleagues27 found that EMS utilization rates (not limited to transports) increased and incidents related to behavioral health accounted for of EMS incidents and, of all health problems, had the greatest of in the period. and found that in in a U.S. in through behavioral health problems accounted for of all EMS In this study we sought to identify patient demographics and health problems associated with frequent utilization of EMS in a midsized U.S. city with a population demographic and health profile suggestive of a high to EMS use. In we sought to by the to which behavioral and other health problems, select chronic somatic contributed to frequent EMS use. 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