This study consisted of a retrospective chart review performed at a 205-bed community hospital that receives approximately 55,000 ED visits each year. The hospital is located in a suburban area, in a city of approximately 30,000 people. The hospital also serves several neighboring cities, serving a total of approximately 100,000 people in the area. This study was given Institutional Review Board (IRB) exemption by the hospital committee on research
The hospital ED has a case management program that functions to assist in the care and management of difficult patients in the ED, particularly those patients frequently seeking emergency care for problems related to prescription medication addiction. Patients may be considered for enrollment in this program if they are identified as having 5 or more visits in a 1-month period or if any member of the ED staff is concerned about repetitive use of the ED for drug-seeking behavior. Furthermore, any patient identified by the California Bureau of Narcotic Enforcement as having committed prescription forgery or fraud is automatically enrolled in the program. As the criteria for enrollment in the program are not strictly defined, the reason for enrollment is not kept in the patients’ case management files. While not all patients in the case management program are enrolled for problems related to substance abuse, nearly 95% of the patients have a case management care plan that limits the prescription of controlled substances or referral to chemical dependency.15
The goal of the case management program is not to capture all drug-seeking patients in the ED; rather, it is to address the patients with excessive ED use secondary to drug-seeking behavior and other issues.
Inclusion criteria for patients in our study were the following: any patient enrolled in the case management program that was given a referral to chemical dependency and any patient enrolled in the case management program that had a care plan involving limitation of narcotics, benzodiazepines, or muscle relaxants.
Exclusion criteria for patients in our study were the following: all patients enrolled in the case management program whose care plans did not involve either a chemical dependency evaluation or limitation of narcotics, benzodiazepines, or muscle relaxants. We did not exclude patients with known painful chronic medical conditions.
For each of the patients that met our inclusion criteria, we reviewed all visits to the ED for a 1-year period prior to enrollment in the case management program. Patient medical records were accessed using the hospital’s medical record system, Horizon Patient Folder (McKesson, 2002), and all physician and nurse documentation for each visit was carefully reviewed. For each patient, we recorded the number of times that patients exhibited any of the 10 behaviors listed in . As this study was a retrospective chart review, physicians and nurses treating these patients were not expected to look for or document the presence or absence of these behaviors; rather, we recorded the number of times these behaviors were documented in the medical record. If 2 (or more) behaviors occurred at a single visit, then both (or more, if present) behaviors were recorded as individual events. Furthermore, we only looked at each drug-seeking behavior in isolation. We did not record the number of visits at which a patient demonstrated multiple behaviors.
These 10 behaviors were chosen for assessment as they represent drug-seeking behaviors frequently reported in the literature, and are often described as being “classic” for such behavior.10–12,25,30–32
While certain behaviors commonly associated with drug-seeking behavior, such as headache and reporting a non-narcotic allergy, are easy to assess in a chart review, behaviors such as exaggeration of symptoms are not. We thus chose to look for complaining of 10/10 pain and complaining of greater than 10/10 pain as measurable equivalents to assess for exaggeration of symptoms.
Due to limitations on access to the hospital’s medical record system, each chart was reviewed by a single physician reviewer. To standardize the chart review and data collection process, we collected and entered data into a pre-formatted Excel spreadsheet (Microsoft, 2007) consisting of 1 column for patient medical record number followed by 10 columns (one for each studied behavior).
Once data collection was complete, we analyzed the data using Excel (Microsoft, 2007). For each of the 10 behaviors studied, we tallied the total number of times each behavior was exhibited. We then calculated the percentage of total visits at which patients in our study demonstrated each behavior, as well as a 95% confidence interval for each calculated percentage.