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

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.

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.

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%.

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.