ANTHROPOLOGICAL RESEARCHES AND STUDIES
No: 15

FREQUENT USERS OF EMERGENCY DEPARTMENTS IN TIRANA REGION DURING PANDEMIC

Edmond ZAIMI (1), Artur XHUMARI (2), Elisabeta OSMANAJ (3), Paolo CONTINI (4) , Lucia MONACIS, (5) and  Elizana PETRELA (6)
Keywords: Emergency Department, frequent users, patients’ profile, pandemic.

DOI: https://doi.org/10.26758/15.1.22

(1), (2), (6) University of Medicine, Albania; e-mail:  (1) zaimied@yahoo.com, (2) artur.xhumari@me.com (6) elapetrela@yahoo.com (corresponding author)

(3) “Aleksander Xhuvani” University, Albania; e-mail: eli.osmanaj@gmail.com

(4) University of Bari, Italy; e-mail: contini@uniba.it

(5) University of Foggia, Italy; e-mail: monacis@unifg.it

Address correspondence to: Elizana PETRELA: Statistic Department, University Hospital Center “Mother Teresa”, University of Medicine, Faculty of Medicine, street “Dibres”, Nr 371, Tirana, Albania. Ph.: 00355692440152; E-mail: elapetrela@yahoo.com

Abstract

Objectives. Being given the limited studies on the flow of patients in Albanian emergency departments (EDs), this study made the profile of the frequent patients who attended EDs during the pandemic.  This article aimed to evaluate the weight and the factors which accompanied the frequent ED users even in some unusual situations.

Material and methods. Socio-demographic and clinical characteristics were examined following Andersen’s model. Data were collected from March 9th, 2020 to March 9th, 2021 using the medical registry of the Emergency Service at the University Hospital Center “Mother Teresa” in Tirana.

Results. Data collection included 13,753 patients with 15,314 ED visits; only 0.5% were classified as frequent ED users. They have reported the highest percentages in the Tirana region, in the number of visits and admissions to the ward, and in the diagnoses of hypertension, followed by coronary artery disease (CAD), diabetes (DM), and stroke. Patients with CAD had 4 times the odds of reporting frequent ED use compared to those with no CAD (C.I.95% [2.2, 8.5]); patients with stroke had 11.34 times the odds of reporting frequent ED use compared to those without stroke (C.I.95% [5.2-14.4]). Patients with HTA and with DM had 2.6 times the odds of reporting frequent ED use compared to those without these diseases (C.I.95% [1.4-5.07] and C.I.95% [1.3, 4.3]).

Conclusion. Even during the pandemic, the frequent ED users continue to remain in considerable numbers in the use of the emergency system. A high percentage of frequent users were true emergencies. Results could suggest that the appropriate intervention measures are crucial in order to reduce the occasional ED utilization.

Keywords: Emergency Department, frequent users, patients’ profile, pandemic.

Suggested citation (APA)

Zaimi, E., Xhumari, A., Osmana, E., Contini, P., Monacis, L., & Petrela, E. (2025). Frequent users of emergency departments in Tirana region during pandemic. Anthropological Researches and Studies, 15, 335-347. https://doi.org/10.26758/15.1.22

Introduction

We may speak that the organization, the work mode, the staff and the equipment of the Emergency Departments (EDs) have changed due to health science and technology development. Over the last decades, EDs have faced an ever-increasing flow of patients, leading to the overcrowding of the emergency services, the staff fatigue, and the increased consumption of drugs and medical materials (Pines et al., 2011a; Berchet, 2015). With regard to ED patients, three groups have generally been distinguished (Van den Heede & Van de Voorde, 2016). The first, the so-called inappropriate ED visits, includes patients who do not require urgent attention or specialized input. The reason for this ED attendance is multifaceted, depending on patient’s characteristics and the demographic/societal changes like the aging population, the increasing prevalence of chronic conditions, the loneliness and the lack of family’s support (Naouri et al., 2020). The second group is that of older persons with multiple chronic conditions, functional decline in combination with lack of support. These people experience with a sort of misalignment between their medical needs and their use of healthcare (Dufour et al., 2019). The third covers the frequent ED users, described in the international literature as patients with complex healthcare needs (e.g., exacerbations of patients with chronic conditions, substance abusers, and nursing home residents). Different cut-offs are used in order to determine the most frequent ED users according to the definitions of the frequent use that range from 2 to 20 or more ED visits per year (Pines et al., 2011b). In developed countries, 4.5 – 8% of patients attending the emergency departments are frequent users (with 4 or more yearly ED visits) (LaCalle & Rabin, 2010).

Previous findings emerging from international studies has synthesized the patient characteristics and the contextual factors more prevalent among the frequent compared to the non-frequent ED users in order to provide a picture of the patterns of such frequent patients and to facilitate the informed policy innovations in order to be addressed towards the unwarranted ED utilization (Giannouchos, Kum, Foster, & Ohsfeldt, 2019; Giannouchos, Washburn, Gary, & Foster, 2021; Lee, Park, Kim, Kim, & Lee, 2020; Al-Surimi, Yenugadhati, Shaheen, Althagafi, & Alsalamah, 2021).

Indeed, various initiatives and more accessible interventions involving comprehensive and multidisciplinary services have been implemented worldwide with the aim to reduce the number of emergency department visits and the associated burden on healthcare systems (Mao, Shalaby, & Agyapong, 2023). Nevertheless, more efforts should be made and based on different theoretical frameworks. Among these, the Andersen’s health behavior model (Andersen, 1968) provides a holistic view of understanding patients’ health service use, and it suggests that the health service’s utilization is a function of three sets of factors: predisposing (demographic and social) factors, enabling (economic) factors that may facilitate the access to services, and the need (health outcomes) factors including patients’ self-perceived health, chronic conditions, and restricted activity.

The model was generally applied in the field of mental (Graham, Hasking, Brooker, Clarke, & Meadows, 2017) and dental (Holde, Baker, & Jonsson, 2018) health problems and among different populations (Burokienė, Raistenskis, Burokaitė, Čerkauskienė, & Usonis, 2017; Jiang, Ye, Dai, Zhou, & Li, 2020; Padgett, & Brodsky, 1992; Afilalo, et al., 2004; Kaskie et al., 2011). One study was a mainly theory-based review (Padgett & Brodsky, 1992) while the other studies had a rather limited selection of variables (Afilalo et al., 2004; Kaskie et al., 2011). In addition, a careful inspection of such works shows how only two studies were retrospective and carried out on different populations, Lithuanian children (Burokienė et al., 2017) and Chinese adults (Jiang, Ye, Dai, Zhou, & Li, 2020). The emerging findings indicated that some predisposing demographic factors, like higher educational level, age (under 45 years for young adults and parents with children under seven years) and a closer distance to the ED, and some need factors, like the type of illness and the self-rated health status, were the most significant reasons for ED presentations.

Emergency Department in Albania during the pandemic period

After the declaration of the COVID-19 pandemic, ED attendances were globally reduced due to the fear of the rapid transmissibility of the disease and the perceived risk of infection (Alharthi, Al-Moteri, Plummer, & Al Thobiaty, 2021; Almana & Alharbi, 2022; Barten, Latten, & Van Osch, 2022; Dopfer et al., 2020; Reschen et al., 2021; Westgard, Morgan, Vazquez-Benitez, Erickson, & Zwank, 2020). Nevertheless, the hospitals and the healthcare systems were facing a lack of preparedness, thus negatively impacting ED users’ care (Tuczyńska, Staszewski, Matthews-Kozanecka, Żok, & Baum, 2022), particularly on patients with acute and chronic diseases and comorbidities, such as stroke, diabetes, pulmonary and cardiovascular diseases, and hypertension.

As in all countries, Albania, a small and middle-income country, was affected by the COVID-19 sanitary crisis with the following reduction in pressure on hospitals. Till 2023, its health system recorded 334,380 cases of coronavirus (Elflein, 2023) and 3,596 deaths (Elflein, 2023). To the authors’ knowledge, there is a little evidence of the number of patients visiting EDs in this country. Indeed, only the ED of the Vlora regional hospital was investigated to provide empirical evidence on hospital visits and mortality rates by comparing data from 2020 with those from the last three years (2017–2019). Findings showed a decrease in patients in 2020 (n = 9,266) compared to the number recorded in 2017 (n = 12,407) and an increase in patients with cardiovascular, psychiatric, and renal/urinary tract compared to those having been reported in 2019. In short, patients decreased over time, with an average annual percent decrease of 7%, while the mortality rate increased (Bucaj et al., 2022). However, this retrospective study collected data without taking into account any theoretical models, and it highlighted that not only during the COVID-19 period but in general, there was a lack of prevention culture among the Albanians.

In light of the paucity of the empirical data concerning the Albanian ED users, the present study sought to provide a further evidence on this issue by exploring the flow of ED users in the Tirana region during the pandemic period and identifying the demographic and clinical profile of the non-Covid patients. In this period, all the attention was focused on COVID-19 cases, while other patients were also suffering from different diseases.

The underlying theoretical model is Andersen’s perspective. Being given the exploratory nature of this study, the main research questions were: (i) how many patients were seeking for ED care during the pandemic period; and (ii) the significant differences between the frequent vs. the non-frequent ED users in terms of predisposing, enabling, and need factors.

The findings could be helpful in designing the appropriate intervention measures that are crucial to reducing ED utilization and improving the relevant healthcare outcomes.

Materials and Methods

Study design

A retrospective observational study was conducted for one year from March 9th, 2020, to March 9th, 2021, using anonymous aggregated data extracted from the electronic medical registry of the Emergency Service for Internal Disease at the University Hospital Center “Mother Teresa” (UHCT) in Tirana. UHCT is a tertiary hospital in Albania, and it also serves as a secondary hospital for Tirana residents. The registry was drawn up according to a progressive number, and it has included information on the time (hour) of submission, patients’ names and surnames, sex, age, place of residence (rural/urban, Tirana/other districts), type of referral, and diagnosis.

The emergency medical service in Albania is an integral part of the health care system, offered continuously for 24 hours at all the levels of the health care provision. The medical emergency service is organized and offered at four levels: a) primary, b) hospital, c) university hospital, and d) university trauma hospital. (Albanian Law nr. 147/2014 “for emergency medical service”. Emergency medical service at the primary level is provided in health care centers. The hospital emergency service consists of the network of emergency services in regional and university hospitals, as well as the network of 24-hour emergency services in the municipal hospitals. During this study, the UHC “Mother Teresa” had a fragmented emergency service with customized services including pediatric, psychiatric, infectious disease, surgical emergency, and emergency service for internal diseases.

Variables and measurements

Patients with four or more ED visits over the past year were classified as frequent ED users, whereas a score below 4 visits classified patients as non-frequent ED users in line with the most commonly reported definition (Hunt, Weber, Showstack, Colby, & Callaham, 2006). Information on age and sex as predisposing factors, region, and the urban or the rural residence as the enabling factors, the date of ED visit, and the disease category or the medical problems, factors which indicated the most frequent pathologies recorded in non-Covid patients during the pandemic, as need factors, was collected.

Statistical analysis

Categorical data were presented as frequencies and percentages, and continuous variables were presented as mean (standard deviation; SD). Descriptive statistics were expressed in frequencies and percentages were used for socio-demographic and clinical variables. The comparison of patients’ characteristics between frequent and non-frequent ED users was tested using the post hoc Mann-Whitney U and chi-square tests for continuous and categorical variables, respectively. Logistic regression analyses were used to find random relationships between variables. The odds ratio and CI 95% were calculated for each variable. A p-value of < .05 was considered statistically significant. The statistical software IBM SPSS 25.0 (Statistics Package for Social Sciences) was used to analyze the data.

Ethical approval

This study was approved by the Institutional Review Board of the University of Tirana (Albania) with the protocol code P2430/1 on 09/09/2020 and was carried out in conformity with the regulations on data management with the Albanian law on privacy. The dataset analysed in the current study is the property of the University Hospital Center “Mother Teresa” (UHCT). Each patient was assigned a unique identifier that did not allow tracing of his/her identity or other sensitive data. All procedures performed in this study comply with the 1964 Helsinki Declaration and its revisions.

Results

Study participants’ characteristics

In the period March 9th, 2020-March 9th, 2021, 13,766 patients were registered in the electronic data register at University Hospital Centre “Mother Theresa” (PENTAHO), with a total of 15,327 visits made to the ED. Of these, 13 patients were registered in the system as unidentified and were excluded from the analysis of the data. Results emerged from the analysis of the data of 13,753 patients with 15,314 ED visits. The study flow chart is shown in Figure 1. Based on the number of ED visits, 91.2% of users (n = 12548) attended the ED once annually, 7.2% (n = 989) two times, 1.1% (n = 147) three times, and only 0.5% (n = 69) four or more times. Of the last category, 38 patients visited the ED four times, and 31 patients more than four times. Demographic, behavioral, and clinical information were reported in Table 1. Around 43% (n = 5847) of ED users were women, 98.1% (n = 13487) were living in urban areas, and more than half of patients (66.9%, n = 9207) came from the Tirana region. The mean age was 62.12 (SD = 15.99), with an age range between 15 and 101 years old. The average number of ED visits was equal to 1.11. In addition, more than one-third of the total sample, i.e., 38.2% (n = 5257), consisted of current smokers, followed by hypertensive subjects, 23.6% (n = 3247), whereas a very small proportion identified subjects with diabetes, 8.3% (n = 1147), coronary artery disease, 5.5% (n = 758), and stroke, 0.9% (n = 120).

Figure 1

ED users from the University Hospital Center “Mother Teresa” (UHCT), (March 9, 2020-March 2021) (to see Figure 1, please click here)

Table 1

General characteristics of the total sample (n = 13753) (to see Table 1, please click here)

A more detailed description of ED users’ demographic and clinical characteristics categorized into visit counts is reported in Table 2. Of the total population, the findings provided evidence for significant differences among the five groups concerning the number of ED visits in all observed factors except for the residence and the gender variables. Indeed, although high percentages of male ED users from the urban districts were observed across all the groups, data indicated no significant differences among them.

Table 2

General, behavioral and clinical characteristics of the study-population categorized into the number of ED visits (to see Table 2, please click here)

It was also noticed that the differences emerged in the following factors: (i) region [χ2 (4, N = 13.753) = 74.329, p < 0.001] with a high rate of ED users from the Tirana region across all groups; (ii) age (F(4, 13.753) = 101.3, p < 0.010) with a sharp increase of the mean value in the category of the most frequent users (M age = 69.16), followed by a slight decrease in the categories of non-frequent users (Mage = 64.4 and 65.76 for two and three visits, respectively) and an equal mean age in one and four visits group (Mage = 61.88 and 61.74); (iii) in the number of visits (F(4, 13.753) = 326.83, p < 0.001), with a mean value for the most frequent ED users group equal to 6.29 ranging from 5 to 17 visits; (iv) in the time slot of ED visits [χ2 (4, N = 1614) = 15.40, p < 0.010] with the highest percentage in the most frequent ED users (>4 visits) followed by the group with 3, 4, 1 and 2 visits; (v) in current smokers [χ2 (4, N = 1614) = 15.363, p < 0.010]: patients belonged to the group of more than 4 ED visits obtained the highest percentage in comparison with the other ED users; (vi) in all factors of the diagnosis established in ED, hypertension [χ2 (4, N = 1614) = 23.872, p < 0.001] coronary artery disease [χ2 (4, N=757) = 87.122, p < 0.010] diabetes [χ2 (4, N=1147) = 13.49, p < 0.010] and stroke [χ2 (4, N = 119) = 61.69, p < 0.001]. In both categories of four and more than four visits, the highest percentage of ED users were affected by hypertension, coronary artery disease, and diabetes, followed by the users affected by stroke.

Significant differences were also confirmed when comparing patients’ characteristics between the frequent and the non-frequent ED users (Table 3). Regarding the general characteristics, the frequent ED users reported a higher percentage in the region, number of visits and admissions to the ward, and diagnosis of chronic illness. Indeed, the frequent ED users were from the Tirana region [χ2 (1, N = 13.753) = 3.80, p < 0.050], with more than 6 visits [U = 0.00, z = -29.286, p < 0.001, r = .249], admitted to the ward within a year [χ2 (1, N = 4015) = 16.448, p < 0.001] and diagnosed with chronic illness [χ2 (1, N = 5958) = 23.71, p < 0.001].

Moreover, a trend towards significant differences between the two groups emerged in the time slot of the visit [χ2 (1, N = 1614) = 3.38, p = 0.056] and in the current smokers [χ2 (1, N = 5257) = 3.25, p = 0.051], as the higher percentages were found in frequent ED users. Conversely, there were no significant differences between the two groups in residence [χ2 (1, N = 13.753) = 1.368, p > 0.050], gender [χ2 (1, N = 13.753) = 0.106, p > 0.050], and age [U = 442807.500, z = 0.701, p > 0.050]. It is noteworthy that, for gender, a higher—even though not significant—a percentage was recorded in non-frequent ED females and frequent ED males. Finally, significant differences between the two groups were found in each chronic illness established in ED: coronary artery disease (CAD) [χ2 (1, N = 757) = 14.69, p < 0.010], hypertension (HTA) [χ2 (1, N = 3248) = 17.46, p < 0.001], diabetes (DM) [χ2 (1, N = 1147) = 10.03, p < 0.010], and stroke [χ2 (1, N = 120) = 49.57, p < 0.001]. Frequent ED users showed higher percentages in diagnoses: hypertension was the most frequent diagnosis, followed by coronary artery disease, diabetes (DM) with an equal percentage, and stroke. In non-frequent ED users, findings confirmed hypertension as the most frequent diagnosis, followed by diabetes, coronary artery disease, and stroke (all percentages are reported in Table 3).

Table 3

Comparison between frequent vs non-frequent ED users (to see Table 3, please click here)

The logistic regression analysis was performed to predict the categorical variable (non-frequent vs. frequent ED users) from a set of independent variables, i.e., diagnoses established in ED visits. The model explained that number of 53.1% of the variance in frequent ED users’ group. Patients with CAD had 4 times the odds of reporting frequent ED use compared to those with no CAD (CI 95% [2.2-8.5]), while patients with stroke had 11.34 times the odds of reporting frequent ED use compared to those without stroke (CI 95% [5.2-14.4]), after controlling for confounders. Patients with HTA and with DM had 2.6 times the odds of reporting frequent ED use compared to those without these diseases (CI 95% [1.4-5.07] and CI 95% [1.3-4.3]). Table 4 reports all values of the OR-odds ratios with the confidence interval.

Table 4

Odds ratios and 95% confidence intervals for the association between the diagnoses established in ED and frequent users (to see Table 4, please click here)

Discussion

In light of the international findings showing a significant decrease in the utilization of the emergency medical services during the COVID-19 pandemic (Alharthi et al., 2021; Barten et al., 2022; Reschen et al., 2021; Cummins et al., 2022; Molina et al., 2022; Chou, Yen, Chu, & Hu, 2021; Işık, & Çevik, 2021), the current study followed the Andersen’s behaviour model in order to reveal the number of Albanian ED users which was silenced so far and the significant differences in profile between frequent vs non-frequent ED users.

In line with the first research question, the descriptive statistics revealed that the total number of patients visiting the emergency department may be aligned with the amount reported in the Albanian region of Vlora (Bucaj et al., 2022), whose geographic area—it should be kept in mind—is smaller than the area considered in this study. Hence, it could be inferred a decrease in such population during the pandemic period. This is in line with the international trend (Al-Surimi et al., 2021; Bucaj et al., 2022; Chou et al., 2021; Işık & Çevik, 2021) showing the reduction of non-urgent visits due to the implementation of the lockdown restrictions, and it is also related to the so-called inappropriate ED visits (Islam, Freeman, Chadwick, & Martiniuk, 2022). Anyway, further data on this issue should be provided to confirm this explanation.

Concerning the second research question on the differences between the frequent vs. the non-frequent ED users in terms of predisposing, enabling, and need factors, findings from the first set of factors showed a general predominance of males among patients, in accordance with studies carried out in Ireland (Cummins et al., 2022), in the USA (Molina et al., 2022), and in the category of the Taiwanese frequent users (Chou et al., 2021), but in contrast with the data reported in Turkey (Işık & Çevik, 2021) and in the Vlora region (Bucaj et al., 2022), although these Albanian findings referred to the period 2017-2020. However, no significant gender differences emerged across the five groups categorized by the number of visits and between frequent and occasional ED users. The absence of the significant differences was in line with the Irish study (Cummins et al., 2022) but not with the Turkish research (Işık & Çevik, 2021) and the Taiwanese study (Chou et al., 2021) that reported differences in the category of the occasional users. Furthermore, no data on gender differences were recorded by the other Albanian (Bucaj et al., 2022) and American (Molina et al., 2022) studies.

With regard to the age, the ED patients’ mean age was 62.12, therefore higher than the datum from the Vlora region (52.80) (Bucaj et al., 2022) and from the USA population (46.70) (Molina et al., 2022). In addition, when comparing findings among patients across age groups identified by the number of ED visits, these indicated the highest mean value in ED patients with more than 4 visits (Mage = 69.16). By contrast, data revealed no significant difference in age between non-frequent vs. frequent ED users (62.10 vs 65.02). Finally, the obtained mean value of the frequent ED users was equal to the value reported by Taiwanese frequent ED users (Mage = 65.00) (Chou et al., 2021).

Taken into account the second set of factors, the region of patients’ provenience proved to be a significant factor in determining the use of health services. Indeed, living in the Tirana region and, therefore, the proximity which offers the use of the emergency department at the Hospital Centre “Mother Teresa” in Tirana, has represented a key factor. From the comparisons across all categories of ED visits and between frequent vs. non-frequent ED users, data indicated a higher incidence of patients from the Tirana region with more than 4 visits in seeking access to the health care. By contrast, living in urban or rural areas did not play a significant role among ED patients.

Concerning behavioral and needs factors (clinical characteristics), data indicated that more than one-third of ED users were current smokers. Although this tendency was consistent with previous research (Giannouchos et al., 2019), no significant differences emerged between the frequent vs the non-frequent ED patients, even if a trend toward a statistical significance resulted. Given the lack of prior information on this feature in the pandemic period, no comparisons could be made with data from other countries.

As for clinical diseases, findings showed that the hypertension was the most prevalent diagnosed condition, followed by diabetes, and that significant differences were found between frequent vs non frequent groups, where the higher prevalence was yielded in the category of patients with more than four visits. Since such diseases were differently categorized across studies, this prevalence could be not compared with other findings. Conversely, the significant differences between frequent vs. non-frequent ED users who was affected by cardiovascular complaints and stroke could be compared with the Albanian study: the higher prevalence for both diseases in the frequent ED users was in line with data reported in the Vlora region (Bucaj et al., 2022). Patients suffering from such diseases were at the greater risk, thus leading to infer that these diagnoses seemed to be the likely determinants of frequent ED users.

Limitations and conclusion

Although this study provided further data on Albanian ED users, the results are not easily to be compared with those that has been reported in other contexts, due to different disease categorizations and factors taken into account across studies and to the non-representative sample, thus making any generalization difficult. Another limitation of this study is the lack of data before the pandemic period, thus providing no accurate overview of the impact of the COVID-19 pandemic on ED users.

Despite these general limitations, the observed results showed that the percentage of the frequent ED users –around 0.05% of the total number of visits – even if not in line with the international data from the developed countries (4.5 – 8% of the patients attending emergency departments), highlights the need of those policy measures that could plain appropriate interventions able to reduce the flow of inappropriate ED users and to strengthen the primary care.

Based on Anderson’s model, the demographic and clinical characteristics of frequent ED patients were profiled: the patient from the research was a male, smoker, affected by cardiovascular complaints and stroke, and aged over 60 years. These patients could be considered as appropriate visitors according to Van den Heed’s (Van den Heede & Van de Voorde, 2016) classification. Notably, the mean age in this group is higher than the one which has been noticed in other countries. This raises the question: do seniors perceive a limited availability of care services and support? Further studies are needed to clarify this issue.

Competing interests

The authors declare no competing interests.

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