Characterizing pediatric high frequency users of California emergency departments

Published:December 12, 2018DOI:



      Emergency department (ED) utilization has increased for the last several decades. Despite a focus on adult frequent ED users, little research has examined pediatric frequent ED users. The purpose of this study was to assess pediatric ED utilization in California and to describe those identified as frequent ED users.


      This was a retrospective multi-facility study of ED visits by children 1–17 years of age using statewide data from the California Office of Statewide Health Planning and Development. Patients were classified into utilization groups by the number of ED visits in a one-year period prior to their last visit in 2016: occasional (1–5 visits) vs. frequent (>5 visits). Differences in patient characteristics were compared between occasional and frequent users.


      There were 690,130 patients between 1 and 17 years of age with 1,238,262 visits during the study period. Children with ≥6 visits (2.3%) accounted for 9.3% of all visits. 67% of frequent users had no visits to a pediatric ED. Over 40% (41.4%) of frequent users visited 2 or more hospitals, compared to 7.7% of occasional users. In multivariate analysis, the characteristics with the largest associations with frequent ED use were age, payer, and being admitted/transferred.


      The majority of pediatric frequent users do not seek care in pediatric EDs. Age, prior admission, and Medicare/Medicaid appear to have the largest associations with pediatric patient frequent ED utilization.


      AHRF (Area Health Resource Files), AHRQ (Agency for Healthcare Research and Quality), CCS (Clinical Classifications Software), CI (Confidence Intervals), ED (Emergency Department), HRSA (Health Resources and Services Administration), IBM (International Business Machines Corporation), ID (Identification), ICD-9 (Ninth Revision of the International Classification of Diseases), NCHS (National Center of Health Statistics), OR (Odds Ratio), OSHPD (Office of Statewide Health Planning and Development), PCP (Primary Care Physician), RLN (Record Linkage Number), RUCA (Rural-Urban Commuting Area), SPSS (Statistical Package for the Social Sciences), ZIP Code (Zone Improvement Plan)


      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Neuman M.I.
        • Alpern E.R.
        • Hall M.
        • et al.
        Characteristics of recurrent utilization in pediatric emergency departments.
        Pediatrics. 2014; 134: e1025-e1031
        • Alpern E.R.
        • Clark A.E.
        • Alessandrini E.A.
        • et al.
        Recurrent and high-frequency use of the emergency department by pediatric patients.
        Acad Emerg Med. 2014; 21: 365-373
        • LeDuc K.
        • Rosebrook H.
        • Rannie M.
        • Gao D.
        Pediatric emergency department recidivism: demographic characteristics and diagnostic predictors.
        J Emerg Nurs. 2006; 32: 131-138
        • McDonnell W.M.
        • Guenther E.
        Challenging assumptions about uninsured children in the pediatric emergency department.
        Pediatr Emerg Care. 2012; 28: 436-439
        • Yamamoto L.G.
        • Zimmerman K.R.
        • Butts R.J.
        • et al.
        Characteristics of frequent pediatric emergency department users.
        Pediatr Emerg Care. 1995; 11: 340-346
        • Castillo E.M.
        • Brennan J.J.
        • Killeen J.P.
        • Chan T.C.
        Identifying frequent users of emergency department resources.
        J Emerg Med. 2014; 47: 343-347
        • Bourgeois F.T.
        • Shannon M.W.
        Emergency care for children in pediatric and general emergency departments.
        Pediatr Emerg Care. 2007; 23: 94-102
        • Brennan J.J.
        • Chan T.C.
        • Hsia R.Y.
        • Wilson M.P.
        • Castillo E.M.
        Emergency department utilization among frequent users with psychiatric visits.
        Acad Emerg Med. 2014; 21: 1015-1022
        • California Office of Statewide Health Planning and Development
        MIRCal - Medical information reporting for California.
        Date accessed: June 12, 2018
        • Griswold S.K.
        • Nordstrom C.R.
        • Clark S.
        • Gaeta T.J.
        • Price M.L.
        • Camargo Jr., C.A.
        Asthma exacerbations in North American adults: who are the “frequent fliers” in the emergency department?.
        Chest. 2005 May; 127: 1579-1586
        • Arfken C.L.
        • Zeman L.L.
        • Yeager L.
        • White A.
        • Mischel E.
        • Amirsadri A.
        Case-control study of frequent visitors to an urban psychiatric emergency service.
        Psychiatr Serv. 2004 Mar; 55: 295-301
        • Quilty S.
        • Shannon G.
        • Yao A.
        • Sargent W.
        • McVeigh M.F.
        Factors contributing to frequent attendance to the emergency department of a remote Northern Territory hospital.
        Med J Aust. 2016; 204111.e111-117
        • Injury Prevention & Control: Data & Statistics (WISQARS)
        Centers for disease control and prevention.
        Date accessed: June 12, 2018
      1. Rural urban commuting area codes data. Washington University - Rural Health Research Center.
        • Area Health Resources Files
        Health resources and services administration.
        Date accessed: June 12, 2018
        • Elixhauser A.
        • Steiner C.
        • Palmer L.
        Clinical classifications software (CCS).
        U.S. Agency for Healthcare Research and Quality, 2014 (Available)
        • Fuda K.K.
        • Immekus R.
        Frequent users of Massachusetts emergency departments: a statewide analysis.
        Ann Emerg Med. 2006; 48: 16.e1-16.e8
        • Lyons T.W.
        • Olson K.L.
        • Palmer N.P.
        • Horwitz R.
        • Mandl K.D.
        • Fine A.M.
        Patients visiting multiple emergency departments: patterns, costs, and risk factors.
        Acad Emerg Med. 2017 Nov; 24: 1349-1357
        • Hunt K.A.
        • Weber E.J.
        • Showstack J.A.
        • Colby D.C.
        • Callaham M.L.
        Characteristics of frequent users of emergency departments.
        Ann Emerg Med. 2006; 48: 1-8
        • Cook L.J.
        • Knight S.
        • Junkins E.P.
        • Mann N.C.
        • Dean J.M.
        • Olson L.M.
        Repeat patients to the emergency department in a statewide database.
        Acad Emerg Med. 2004; 11: 256-263
        • Lucas R.H.
        • Sanford S.M.
        An analysis of frequent users of emergency care at an urban university hospital.
        Ann Emerg Med. 1998; 32: 563-568
        • Ruger J.P.
        • Richter C.J.
        • Spitznagel E.L.
        • Lewis L.M.
        Analysis of costs, length of stay, and utilization of emergency department services by frequent users: implications for health policy.
        Acad Emerg Med. 2004; 11: 1311-1317
        • Bedford H.E.
        • Jenkins S.M.
        • Shore C.
        • Kenny P.A.
        Use of an east end children's accident and emergency department for infants: a failure of primary health care?.
        Qual Health Care. 1992; 1: 29-33
        • Yoffe S.J.
        • Moore R.W.
        • Gibson J.O.
        • et al.
        A reduction in emergency department use by children from a parent educational intervention.
        Fam Med. 2011; 43: 106
        • Wier L.
        • Yu H.
        • Owens P.
        • Washington R.
        Overview of children in the emergency department, 2010.
        (Agency for Healthcare Research and Quality)
        Date: 2013
        Date accessed: June 12, 2018
        • Mandelberg J.H.
        • Kuhn R.E.
        • Kohn M.A.
        Epidemiologic analysis of an urban, public emergency department's frequent users.
        Acad Emerg Med. 2000; 7: 637-646
        • Griswold S.K.
        • Nordstrom C.R.
        • Clark S.
        • Gaeta T.J.
        • Price M.L.
        • Camargo C.A.
        Asthma exacerbations in North American adults: who are the “frequent fliers” in the emergency department?.
        Chest J. 2005; 127: 1579-1586
        • Haggerty J.L.
        • Roberge D.
        • Pineault R.
        • Larouche D.
        • Touati N.
        Features of primary healthcare clinics associated with patients' utilization of emergency rooms: urban–rural differences.
        Health Policy. 2007; 3: 72-85
        • Hines A.L.
        • Fraze T.
        • Stocks C.
        Emergency department visits in rural and non-rural community hospitals, 2008.
        Agency for Healthcare Research and Quality, Rockville, MD2011
        • LaCalle E.
        • Rabin E.
        Frequent users of emergency departments: the myths, the data, and the policy implications.
        Ann Emerg Med. 2010; 56: 42-48
        • Gindi R.M.
        • Jones L.I.
        Reasons for emergency room use among US children: National Health Interview Survey, 2012.
        NCHS Data Brief. 2014; 160: 1-8