Persistent Emergency Department Use Among Veterans: Longitudinal Patterns and Opportunities for Targeted Intervention.

Introduction: Persistent frequent emergency department (ED) use may signal unmet medical, behavioral, and social needs. Understanding patterns of persistence and associated risk factors can inform ED-based interventions and care coordination strategies. This study aimed to examine patterns of frequent ED use, identify predictors of persistence, and assess frequent community ED users as a policy-relevant subgroup.

Materials and methods: We conducted a national longitudinal cohort study of Veterans Health Administration (VA) enrollees from 2018 to 2022 using administrative data on ED visits across VA and non-VA (community) settings. Frequent ED use was defined as ≥4 visits in a year. We assessed the proportion of frequent users with persistent high utilization over 3 and 5 years, evaluated sociodemographic, clinical, and system-level predictors of persistence, and calculated 5-year mortality rates. Sensitivity analyses examined patterns and outcomes among frequent community ED users.

Results: Annually, 12-13% of VA enrollees met criteria for frequent ED use. Among 174,510 veterans with frequent ED use in 2018, 14% remained frequent utilizers at 3 years and 5% at 5 years, indicating substantial turnover. The most common primary diagnoses among frequent users were chest pain, low back pain, urinary tract infection, suicide/intentional self-harm, and chronic obstructive pulmonary disease. Predictors of persistence included Black race, medical and mental health comorbidities, and higher baseline ED use. Five-year mortality among frequent ED users was 24%. Among frequent community ED users, only 3% remained frequent users, yet their 5-year mortality rate approached 40%.

Conclusions: Although most Veterans cycle out of high ED use, those with persistent use face high mortality. These findings highlight the importance of early identification and risk stratification to guide ED-based care management, behavioral health integration, and end-of-life planning for vulnerable populations.