Frequent users of the emergency department: improving services

Development of an implementation framework of 'ideal' models of service delivery tailored for the different types of frequent user services with a focus on specific interventions for particular subgroups of frequent users. The researchers will use the Consolidated Framework for Implementation Research for systematically examining how interventions are implemented and the TIDieR template as a formal framework for identifying and describing components of the included interventions. Timeline: 31-36 months of the programme.

Timeline: 18-30 months of the programme:
1. Individual patient-level analysis of attendances to identify frequent use within years and over multiple years. Examination of how features relating to patients (e.g. age, gender, deprivation) and attendances (e.g. occasional bursts vs more regular in time or reason for attendance) predict further emergency department (ED) use. Time to next ED attendance and time in frequent user status will be modelled using survival trees. These analyses will be developed in the CUREd database which covers the acute services in the Yorkshire and Humber region and then repeated on a national basis using data derived from Hospital Episode Statistics (HES) to investigate the generalizability of findings. HES data will also enable the tracking of ED use across multiple sites. Analysis within CUREd will also focus on pre-hospital urgent and emergency care use (NHS 111, 999) and compare patterns in ED frequent users compared to others.
2. Costs: Using both HES and CUREd datasets, established costing methods will be applied using national reference costs to HES A&E and inpatient healthcare resource groups (HRGs) (including high-cost unbundled HRGs) and exploring micro-costing approaches to more detailed CUREd data to determine the costs associated with frequent use of urgent and emergency care services and the distribution of costs across users and trusts. Comparison will be made between HES and CUREd to consider the consistency of each source. Determining the distribution of frequent attendance at Urgent and Emergency Care and associated costs for the Yorkshire and Humber region (CUREd dataset) and for the whole of England (HES dataset).
3. An interrupted time series analysis of the impact on ED frequent attendance of frequent user services will be conducted with ED attendance as the main outcome measure. For each current service with a clear confirmed start date, a 12-month implementation phase following the date the service was launched, will be identified. Frequent use over all years prior to implementation and all years (and part years) after the implementation year will be examined. A comparison between EDs with a frequent user service and without will also be carried out with EDs being matched on general characteristics (e.g. pre-service annual throughput, urban/rural). A similar analysis, over shorter time periods, to examine the impact of the COVID-19 pandemic on both total ED use and ED use by frequent users will be undertaken, if sufficient HES data post-pandemic is available.
4. An understanding of the lived experience of people who frequently attend including their reasons for attending, their experience of treatment in urgent and Emergency Care settings, their experience of frequent user services and what interventions they find helpful or unhelpful.