• Christopher Burton, Tony Stone, Phillip Oliver, Jon M Dickson, Jen Lewis, and Suzanne M Mason.
• The Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, UK chris.burton@sheffield.ac.uk.
• Emerg Med J. 2022 Jan 1; 39 (1): 3-9.

ObjectiveFrequent attendance at the ED is a worldwide problem. We hypothesised that frequent attendance could be understood as a feature of a complex system comprising patients, healthcare and society. Complex systems have characteristic statistical properties, with stable patterns at the level of the system emerging from unstable patterns at the level of individuals who make up the system.MethodsAnalysis of a linked dataset of routinely collected health records from all 13 hospital trusts providing ED care in the Yorkshire and Humber region of the UK (population 5.5 million). We analysed the distribution of attendances per person in each of 3 years and measured the transition of individual patients between frequent, infrequent and non-attendance. We fitted data to power law distributions typically seen in complex systems using maximum likelihood estimation.ResultsThe data included 3.6 million attendances at EDs in 13 hospital trusts. 29/39 (74.3%) analyses showed a statistical fit to a power law; 2 (5.1%) fitted an alternative distribution. All trusts' data fitted a power law in at least 1 year. Differences over time and between hospital trusts were small and partly explained by demographics. In contrast, individual patients' frequent attendance was unstable between years.ConclusionsED attendance patterns are stable at the level of the system, but unstable at the level of individual frequent attenders. Attendances follow a power law distribution typical of complex systems. Interventions to address ED frequent attendance need to consider the whole system and not just the individual frequent attenders.© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

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