Research paper
Frequent emergency department presentations among people who inject drugs: A record linkage study

https://doi.org/10.1016/j.drugpo.2017.03.010Get rights and content

Abstract

Background

People who inject drugs (PWID) have been described as frequent users of health services such as emergency departments (EDs), however few studies have described demographic factors, patterns of substance use and previous health service use associated with frequent use of EDs in this population.

Methods

Using a combination of self-reported data from a cohort of PWID and administrative ED data obtained through record linkage, we identified longitudinal factors associated with the use of ED services. Bivariate and multivariate analyses were conducted using negative binomial regression to identify exposures associated with both cumulative ED presentations, and logistic regression to identify exposures of frequent ED presentations (defined as three or more annual presentations).

Results

Among 612 PWID, over half (58%) presented to EDs at least once and over a third (36%) presented frequently between January 2008 and June 2013. Frequent and cumulative ED presentations were associated with reporting the main drug of choice as cannabis (AOR:1.42, 95%CI:1.07–1.89 and AIRR:2.96, 95%CI:1.44–6.07 respectively) or methamphetamine (AOR:1.62, 95%CI:1.17–2.2 and AIRR:2.42, 95%CI:1.08–5.46 respectively) compared to heroin, and past month use of mental health (AOR:1.42, 95%CI:1.08–1.85 and AIRR:3.32, 95%CI:1.69–6.53 respectively) and outpatient services (AOR:1.47, 95%CI: 1.00–2.16 and AIRR:0.95, 95%CI 1.52–10.28 respectively).

Conclusion

PWID who are frequent users of EDs are likely to have complex health and substance use-related needs. EDs should actively refer people who present with cannabis and methamphetamine dependence to harm reduction services. Harm reduction services should ensure people referred from EDs are screened for co-occurring mental health conditions and receive adequate support.

Introduction

Overcrowding at emergency departments (EDs) is a problem documented in Australia and internationally (Dent, Phillips, Chenhall, & McGregor, 2003; Geelhoed and de Klerk, 2012, Zuckerman and Shen, 2004). One reported driver of overcrowding is frequent ED use by population sub-groups with chronic pain and mental health conditions, and those who may have limited access to primary health care (Pines et al., 2011), such as people with substance use issues (Billings and Raven, 2013, Fuda and Immekus, 2006).

Previous reports show people who inject drugs (PWID) frequently use EDs (Aitken et al., 2012, Kerr et al., 2005; Nambiar, Spelman, Stoove, & Dietze, 2017), typically for injecting-related harms, injuries and mental health conditions (Kerr et al., 2005, Marks et al., 2013; Nambiar et al., submitted). While acute events such as drug overdose and trauma typically require ED services, soft-tissue infections and some mental health conditions can be managed in low acuity settings such as primary health care. Delays in attending primary health care at the onset of some medical conditions may result in ED presentations once the condition has festered. However PWID face a range of barriers to accessing primary health care such as out-of-pocket expenses, inconvenient service opening hours and the stigma associated with injecting drug use (Drumm et al., 2003, Islam et al., 2012; Nambiar, Stoove, & Dietze, 2014). These barriers may encourage the use of relatively anonymous and low threshold services, such as those provided in EDs (Chitwood, McBride, French, & Comerford, 1999).

In a previous study using a cohort of PWID we reported rates of ED utilisation among Australian PWID over three times higher than the general population (Nambiar et al., submitted). This finding was evident despite the availability of free primary health care targeted to PWID that we have shown in a separate study to be widely used by the this cohort (Nambiar et al., 2014). Taken together these findings suggest that there may be sub-populations of PWID whose needs are not met by the targeted primary health care services and may be at greater risk of acute harm and frequent ED presentations. It is therefore important to understand the relationship between use of other health services and ED utilisation, as well as the effect of personal characteristics and patterns of substance use on ED use among PWID to help develop tailored interventions or refine existing targeted services. In the current study we use prospective data from a cohort of PWID to identify longitudinal correlates of cumulative and frequent ED use.

Section snippets

Study population

The study population is drawn from the Melbourne injecting drug user cohort study (MIX), an ongoing community-based cohort of PWID recruited from urban locations in Melbourne, Australia, between 2008 and 2010. Eligible participants had to be residing in Melbourne, aged 18 years or over, reported injecting heroin or amphetamines regularly (at least once a month in the six months prior to baseline) and were able to present a valid Medicare number (used to access the universal healthcare system in

Participants

A total of 688 cohort members from the MIX study were linked to the VEMD. Of these, 76 had incomplete exposure data and so were excluded. There were no significant differences between the excluded and remaining cohort members across demographics and drug use characteristics, although 127 ED presentations and 14 frequent presentation episodes were lost.

At baseline, the remaining 612 participants in the cohort had a median age of 28 years (interquartile range (IQR): 24–29), and 67% were male.

Discussion/Conclusion

We examined the relationship between self-reported exposures in a cohort of PWID and administrative ED data to describe longitudinal correlates of state-wide ED presentations. These findings demonstrate that individual-level factors such as substance use preferences and residing in unstable accommodation, as well as the use of other health services such as mental health and outpatient services, influence patterns of ED presentations among PWID. Accessing primary health care was not associated

Acknowledgements

The authors wish to thank study participants, and community organizations who assisted with recruitment. We would also like to thank the MIX study team who assisted with recruitment, follow-up and interviews. We thank Simon Brown, Katy Greenland, Ying Chen, Likhesh Mahajan and Pradeep Wijayaratne from the Department of Health and Human Services for the VEMD record linkage.

The MIX study is funded by The Colonial Foundation Trust and the National Health and Medical Research Council (NHMRC Grant

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