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Received Jun 5, 2017; Revised Sep 6, 2017; Accepted Oct 25, 2017
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1. Introduction
The Pareto principle [1], as applied to health care, is exhibited in the tremendous use of resources by a small percentage of users. For example, while comprising just 4.5%–8% of patients, high frequency visitors (HFVs) of the emergency department (ED) (definitions vary from ≥3 to ≥12 visits per year) account for 21%–28% of all visits [2]. HFVs of the ED have been characterized as having psychosocial challenges, chronic medical conditions, and low socioeconomic status [3]. While heterogeneity among HFVs of the ED has been reported [2], pain is ubiquitous across medical diagnoses, mental health disorders, and socioeconomic states and may represent a common factor underlying ED visits by HFVs [4]. Indeed, chronic pain was reported as the most common chief complaint among patients with ≥6 annual visits to the ED at a large urban centre [5], and 36% of patients with ≥12 annual ED visits at our center reported chronic pain as the driving factor [6].
Many pain complaints are nonemergent and inappropriate for the ED [7, 8]. This is generally the case for chronic pain, defined as recurrent or persistent pain lasting for more than 3 to 6 months or beyond normal duration of healing [9]. Chronic pain is best managed in the primary care environment [10] using a chronic disease model [11]. Despite this, patients with chronic pain account for 11–16% of visits to the ED [4, 11, 12], with 7% of these patients visiting multiple times per year [13].
Acute exacerbations of chronic pain can be costly [14], and focusing healthcare reform on a small number of HFVs who present with chronic pain may reduce overall costs and yield rapid improvements in treatment outcomes [15]. Inappropriate use of the ED for nonemergent conditions, such as chronic pain, increases the risk for a multitude of operational and care-related outcomes, including overcrowding [16, 17], increased waiting times [18], negative effects on patients, staff and caregiver satisfaction [19], and increased risk of subsequent adverse events [5, 20–22]. Targeting healthcare reform on...