Repeat visitors crowd ERs

A state study has found that about 4 percent of the people who used Massachusetts health emergency departments in 2003 accounted for 17.5 percent of total visits.

The Division of Health Care Finance and Policy study represented the first time the state examined data on those who frequent emergency rooms. Officials said gathering the information was the first step in figuring out how to provide better treatment for people who may regularly need immediate care.

''We first wanted to know who are these people and why is this a regular source of care," said Amy Lischko, the division's assistant commisioner. ''Then we can look at how to get people a real medical home and better-coordinated care."

The patients went to emergency rooms even though the facilities are more expensive and often less comfortable than a physician's office. In addition to excessive costs, healthcare analysts said, quality of care can be compromised when patients visit emergency departments instead of their regular doctors, especially if they do so frequently.

''If a patient comes in and you don't have a medical record, there is a possibility for redundant lab work, CAT scans or MRIs, and specialist consultations," said Alan Sager, a professor of healthcare finance at Boston University's School of Public Health. ''This delays services by consuming resources and time that would otherwise be able to treat all of us."

Contrary to the belief that people who frequently use an emergency room are indigent and lack health insurance, between 75 percent and 85 percent of frequent emergency-department users had some kind of health coverage, mostly through Medicaid or private coverage, the research found.

Cherita Jackson, 36, of Dorchester, has already taken her children to hospital emergency departments three times this year, even though she has a family doctor at a clinic near her home.

"What am I supposed to do when my child has an asthma attack or a fever in the middle of the night?" she asked.

The study looked at frequent users, or those who were emergency room patients at least five times during 2003, and so-called traveling frequent users -- people who went to at least four different facilities. Some had been to an emergency department up to 254 times during those 12 months, and to as many as 43 of the state's 75 emergency departments.

Hospital administrators say many frequent users go to emergency departments for the right reasons. Jackson, for example, said she brought her children because of incidents such as an asthma attack and a broken wrist.

Though most patients go for real emergencies, Dr. Alasdair Conn, chief of the emergency department at Massachusetts General Hospital, said that ''there are those people who are addicted to [medication] and ran out. We call them frequent fliers."

The state report paid particular attention to frequent users who complained of back pain, mouth pain, or migraines. Nearly 8 percent of those who went to more than one emergency department complained of back pain, compared with 3.5 percent of patients who usually go to the same facility.

Similarly, about 4.5 percent of the traveling users of emergency departments complained of toothaches, nearly triple the 1.7 percent of nontraveling patients.

''If a person comes with a migraine, back pain, or a toothache, I look into our system to see if they've been here before," Conn said. ''If I see they've had three episodes like this in the last three months, my antenna goes up."

''Some are legit, but some overuse or are addicted to narcotics," he added. ''And the biggest reasons they ask for more are back pain, toothaches, and migraines."

People between ages 25 and 44 made up 34 percent of patients who frequent emergency departments, more than any other age group, the state research found. Three of four patients were white, and 55 percent were female.

Traveling frequent users, those who visit multiple facilities, had similar demographics, according to the study. People between 25 to 44 made up 56 percent of that group, and whites 82 percent. At 55 percent, men made up a higher percentage of those who traveled to different emergency rooms.

Some hospital administrators pointed out that a variety of factors increase the use of emergency departments.

Boston Medical Center takes in more emergency visitors than any other emergency department in the state. Frequent users accounted for 25 percent of the department's 106,000 users in 2003.

''Most of the people we see are urgent and can't get into primary care," said Dr. Jonathan Olshaker, chairman of BMC's emergency department. ''If they call their doctor to say they have chest pain or trouble breathing, they'll be told to go to the emergency room."

Most of these people have chronic conditions that are best managed with primary care, Olshaker said, but when that condition becomes acute and they can't see a doctor for days, an emergency room offers the best care.