AEM Early Access 07: Patterns and Costs of Patients Visiting Multiple EDs

Welcome to the seventh episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an AEM Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

Discussing: (click on title for full text, open access through November 30, 2017)

Patients Visiting Multiple Emergency Departments: Patterns, Costs and Risk Factors

Todd W. Lyons MD, MPH, Karen L. Olson PhD,Nathan P. Palmer PhD, Reed Horwitz, Kenneth D. Mandl MD, MPH, Andrew M. Fine MD, MPH


Dr Todd Lyons

Dr. Todd Lyons, MD MPH

Clinical Instructor, Harvard Medical School

Staff Physician, Boston Children's Hospital

Article Summary

Objective: The authors of this study investigated the prevalence and impact of ED care fragmentation by characterizing the population of patients seeking care at multiple EDs and quantifying costs associated with this patient population.


Methods: This is a retrospective cohort study of insured patients who had one or more ED visit between 2010 and 2016. Outcomes investigated included number of EDs visited by each patient, the costs associated with this subset of patients, and factors associated with visiting multiple EDs.


Results: The study included 53,015,427 patients belonging to a single for-profit payer. Of this group, 8,651,716 patients had at least 1 ED visit and accounted for 16,390,676 ED visits resulting in  $26,102,831,740 in ED costs.

  • 20.5% of patients visited more than one ED but accounted for 41.4% of visits and 39.2% of costs

  • A small proportion (0.4%) of patients visited 5 or more EDs but accounted for 2.8% of ED visits and costs

  • Factors most strongly associated with visiting multiple EDs included age, living in the South, total years of enrollment and higher visit complexity

  • Diagnoses most strongly associated with visiting multiple EDs included alcohol and drug diagnoses and mental health disorders


Conclusion: A minority of patients seek care at multiple EDs but account for a significant cost burden. Characterization of this population suggests they represent higher complexity visits and are more likely to suffer from comorbid substance abuse and mental health conditions. The authors recommend further work to evaluate the impact of ED care fragmentation of care utilization and outcomes and recommend improving access to patient records to mitigate its effects.


1.  Bourgeois FC, Olson KL, Mandl KD. Patients treated at multiple acute health care facilities: Quantifying information fragmentation. Arch Intern Med. 2010;170(22):1989-1995. 

2.  Cook LJ, Knight S, Junkins EP, Mann NC, Dean JM, Olson LM. Repeat Patients to the Emergency Department in a Statewide Database. Acad Emerg Med. 2004;11(3):256-263. 

3.  Fertel, Baruch S., Hart, Kimberly W., Lindsell, Christopher J., Ryan, Richard J., Lyons MS. Patients Who Use Multiple EDs: Quantifying the Degree of Overlap Between ED Populations. West J Emerg Med. 2015;49(2):229.