Avoiding Clinical Bias: Examine ED Super-Utilizers as You Would Any Other Patient

Posted on Wed, Feb 10, 2016
Avoiding Clinical Bias: Examine ED Super-Utilizers as You Would Any Other Patient

By Michael Lozano, M.D., FACEP
I was skimming the headlines of the day when an article in the Tallahassee Democrat caught my eye. At first, I thought that this was an article about a person removed from a hospital by their family because the authorities wouldn’t take the patient off of life support. As I got more into the details of the story, I then understood that this was about a woman who died after discharge from a hospital while she was still on the property. That, in and of itself, is uncommon. What really catches your interest is that it happened at 4:45 a.m., and that the police were involved in taking her out of the hospital.
Let me stop here to say that I have no particular knowledge about this case outside of what I found online. I don’t want to parse out what may or may not have happened. What I do want is to use this event as a teachable moment. She presented with a given chief complaint, was admitted to the hospital, and then was discharged a few hours later. As I read on, my imagination tries to fill in the blanks – trying to get to the rest of the story so to speak. It’s seemingly automatic, and I suppose that it is human nature after all. Our internal biases try to fill in the blanks. I previously wrote about how our internal biases can affect our clinical decision-making and lead to premature closure. Ask yourself if you have a bias against people who use lots of healthcare resources.
Defining High Utilizers

There are many labels used to describe these patients; “frequent flyer” was the term that was in vogue a while back. What we now see used in the literature is the more descriptive term: high utilizer. The definition varies from study to study, but tends to hover around four or more visits in a year. A recent report looked at 157,818 adult respondents to the 2004–2009 U.S. National Health Interview Survey. [i] The respondents were categorized into groups based on their number of ED visits:

  • Non-users: 0 ED visits
  • Infrequent users: 1 to 3 visits
  • Frequent users: 4 to 9 visits
  • Super-frequent users: 10 or more visits 

Super-frequent use was reported by 0.4 percent of U.S. adults, frequent use by 2 percent and infrequent ED use by 19 percent. After evaluating the different groups for several characteristics, the authors found that frequent and super-frequent users were more likely to be covered by Medicaid, self-reported fair to poor health status, and had co-morbid chronic diseases such as heart disease, stroke or asthma. Although high utilizers were about seven times more likely to say that the ED was their primary source of medical care, they were also 10 to 15 times more likely to have 10 or more outpatient visits in the past 12 months. Lest you think that this is a permanent condition, a group in Denver studied 4,774 publicly insured or uninsured adult super-utilizers over time and found that less than 28 percent of super-users were still in that category at the end of a year. [ii]
Even though they comprise a small percentage of the patients that you see in the ED, high utilizers take out a disproportionate share of your emotional energy as a clinician. If you drill down into this topic, and I certainly invite you to do so, you will find that these are individuals with complex medical and non-medical needs[iii]. Substance abuse is an issue with some, but not all. There also is a greater prevalence of panic disorder, anxiety and depressive symptoms in this group compared with the general population. [iv] [v]Various attempts have been proposed to address this population group, and many have had success. [vi], [vii]
Resist Bias When Treating High Utilizers

The big “take away” point that I want to make is that you’re not going to be able to solve their issues by yourself. Conversely, shutting off your clinical radar to these patients is not going to do any good either. You run the risk of missing a diagnosis if you prematurely cut off your internal debate. The drunken man who fell in the bushes next to city hall, again, may well have a subdural, as did a case that I saw. The patient with sickle cell disease who has been to your ED so many times that you’ve memorized his social security number may have Salmonella sepsis.
Go through your internal checklist to be sure that a given patient is safe to send home. Those vital signs are vital, so insist that they are repeated if initially abnormal. When it comes to super-utilizers, your single rude intervention is not going to stem the overwhelming tide of societal pressure. Worse yet, you may escalate a situation that didn’t need to be escalated. Rather, to be a compassionate, caring clinician you need to manage your biases, avoid premature closure, and make person-to-person connections with these and all of your patients.

Dr. Michael Lozano
Michael Lozano, MD, FACEP, has been an Executive Vice President for EmCare’s South Division since 2009. Prior to his current role, he worked for EmCare as the medical director and chairperson of the Department of Emergency Medicine at Northside Hospital in St. Petersburg, Fla. He also is the medical director for Hillsborough County Fire Rescue in Tampa, Fla. In his role as medical director for Florida’s Urban Search and Rescue System (U.S.A.R.) Task Force 3, Dr. Lozano has responded to several disaster scenes, including the aftermath of hurricanes Charley, Ivan and Katrina. He is a highly skilled physician with over 20 years of medical and leadership experience.
[i] Vinton, D. T., Capp, R., Rooks, S. P., Abbott, J. T., & Ginde, A. A. (2014). Frequent users of US emergency departments: characteristics and opportunities for intervention. Emergency Medicine Journal, 31(7), 526-532.
[ii] Johnson, T. L., Rinehart, D. J., Durfee, J., Brewer, D., Batal, H., Blum, J., ... & Gabow, P. (2015). For Many Patients Who Use Large Amounts Of Health Care Services, The Need Is Intense Yet Temporary. Health Affairs, 34(8), 1312-1319.
[iii] Oberste, A. (2014). Determining Patient Barriers Affecting Emergency Room Overutilization at Northeast Georgia Medical Center (Doctoral dissertation, Emory University).
[iv] Chang, E. T., Wells, K. B., Gilmore, J., Tang, L., Morgan, A. U., Sanders, S., & Chung, B. (2014). Comorbid Depression and Substance Abuse Among Safety-Net Clients in Los Angeles: A Community Participatory Study. Psychiatric Services.
[v] Freeman, E., McGuire, C. A., Thomas, J. W., & Thayer, D. A. (2014). Factors affecting costs in Medicaid populations with behavioral health disorders. Medical care, 52, S60-S66.
[vi] Thomas Bodenheimer, M. D. (2013). Strategies to Reduce Costs and Improve Care for High-Utilizing Medicaid Patients: Reflections on Pioneering Programs.
[vii] Davis, R. (2013). Digital Health Innovations for Medicaid Super-Utilizers: Consumer Feedback to Steer New Technologies. Hamilton, NJ: Center for Health Care Strategies.


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