In adult emergency department patients who are frequent or recurrent users, what evidence exists for biological sex and gender differences in utilization frequency, common presenting complaints, psychiatric and substance‑use comorbidities, chronic disease burden, housing instability, and outcomes such as hospitalization and mortality, including effect sizes and whether sex remains an independent predictor after adjustment for age, comorbidities, insurance status, housing, substance use, and psychiatric illness?

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Sex and Gender Differences in Frequent Emergency Department Use

Women are more likely to be frequent ED users overall, but men with multimorbid chronic disease show a stronger association with frequent ED use and present with higher rates of substance abuse, greater comorbidity burden, and worse outcomes including higher mortality.

Frequency of ED Utilization by Sex

The evidence demonstrates clear sex differences in frequent ED use patterns:

  • Women have higher overall rates of frequent ED use. Among substance-using adults, 58.2% reported past-year ED use, with females significantly more likely than males to report past-year ED utilization after adjustment 1. In a 2024 national analysis of psychiatric emergencies, women comprised 50.1% of ED visits for psychiatric conditions 2.

  • However, the association between multimorbid chronic disease and frequent ED use is substantially stronger in men. In a North Florida community sample, men with 3+ chronic diseases were 4.98 times as likely to be frequent ED users compared to men without chronic disease, whereas women with 3+ chronic diseases were only 2.49 times as likely compared to women without chronic disease 3. This represents a critical sex-based difference where sex remains an independent predictor even after accounting for chronic disease burden.

  • Among young adults (19-25 years), females had 1.77 times the odds of frequent ED use (defined as ≥5 visits/year) compared to males 4.

  • In substance-using populations, being female was independently associated with high-frequency ED use (≥3 visits) with an adjusted OR of 1.88 (95% CI: 1.12-3.17) 5.

Common Presenting Complaints and Diagnoses by Sex

Distinct sex-based patterns emerge in chief complaints:

Women present more frequently with:

  • Anxiety and panic attacks (15.4% vs 10.1% in men, p<0.001) 2
  • Severe depression (11.4% vs 11.1% in men) 2
  • Acute stress reactions (0.9% vs 0.6% in men, p<0.001) 2
  • Eating disorders (0.1% vs 0.07% in men, p<0.001) 2
  • History of abuse (0.53% vs 0.49% in men, p<0.001) 2
  • Complications of pregnancy (13.6% of visits among frequent users vs 6.1% among single users) 4

Men present more frequently with:

  • Acute substance abuse or intoxication (80.3% vs 48.1% in women, p<0.001) 2
  • Bipolar disorder with or without psychosis (24.1% vs 23.9% in women, p<0.001) 2
  • Suicidal ideation (6.7% vs 5.2% in women, p<0.001) 2

Psychiatric and Substance-Use Comorbidity

Sex differences in psychiatric and substance comorbidity are pronounced:

  • Among substance-using adults, the majority were actively using heroin (74.6%), cocaine (62.4%), and alcohol (54.4%), with 53.8% reporting chronic mental health conditions 5. However, sex-specific breakdowns were not provided for these rates.

  • A larger proportion of males with prescription opioid use disorder (POUD) reporting ED use had multiple substance use disorders compared to those without ED use 1.

  • Among females with POUD, major depressive episode was independently associated with increased odds of ED utilization, while this association was not significant for males 1.

  • Treatment history (lifetime or past-year) for alcohol, drugs, or opioid use was associated with increased odds of ED use among both males and females with POUD 1.

  • Among females with POUD, greater POUD severity was associated with increased odds of ED utilization, suggesting a dose-response relationship 1.

Chronic Medical Disease Burden

Men demonstrate higher chronic disease burden among frequent ED users:

  • Men were more likely to have a Charlson Comorbidity Index ≥2 (19.9% vs 16.1% in women, p<0.001) 2.

  • Men were older on average (mean age 45 vs 43 years, p<0.001) when presenting for psychiatric emergencies 2.

  • In the North Florida cohort, 94.8% of substance-using adults had a chronic medical condition, though sex-specific rates were not reported 5.

  • The combination of certain chronic conditions (seizure disorder, hepatitis B, hepatitis C) and accessing ambulatory care was protective against high-frequency ED use, though this was not analyzed by sex 5.

Housing Instability and Social Determinants

Social determinants show clear sex-based patterns:

  • Being homeless was independently associated with high-frequency ED use (≥3 visits) with an adjusted OR of 2.07 (95% CI: 1.08-3.96) in substance-using adults 5. This analysis was not stratified by sex.

  • Men were more likely to be uninsured (17.9% vs 12.5% in women, p<0.001) 2.

  • Among females with POUD, lower income was associated with increased odds of ED utilization, while this was not a significant predictor for males 1.

  • Among males with POUD, public insurance was associated with ED utilization, while among females, insurance status was not a significant predictor 1.

  • African American race was independently associated with high-frequency ED use (adjusted OR 2.36; 95% CI: 1.30-4.29) in substance-using populations 5, though sex-stratified analyses were not provided.

Hospitalization, Mortality, and Other Outcomes

Outcomes differ substantially by sex:

Women have:

  • Lower mortality rates (0.7% vs 1.6% in men, p<0.001) 2
  • Lower mean ED costs (adjusted mean difference: $1,189 less than men, p<0.001) 2
  • Fewer in-hospital admissions (30.3% vs 36.5% in men, p<0.001) 2
  • Higher number of prolonged hospitalizations (36.1% vs 30% in men, p<0.001) 2

Men have:

  • Higher mortality rates (1.6% vs 0.7% in women, p<0.001) 2
  • Higher healthcare costs 2
  • More frequent inpatient admissions (36.5% vs 30.3% in women, p<0.001) 2

Independent Predictors After Adjustment

Sex remains an independent predictor of frequent ED use after adjustment for multiple confounders:

  • In substance-using populations, female sex remained independently associated with high-frequency ED use (adjusted OR 1.88) after controlling for race, homelessness, substance abuse treatment history, and ambulatory care visits 5.

  • In the multimorbid chronic disease analysis, the interaction between sex and chronic disease burden was significant, with men showing a much stronger association (OR 4.98 vs 2.49 for women) after accounting for the presence of chronic diseases 3.

  • Among young adults, female sex remained an independent predictor (OR 1.77) after adjustment for insurance status, diagnosis categories, and other demographic factors 4.

Stigma and "Frequent Flyer" Labeling

The provided evidence does not directly address whether stigma or labeling patients as "frequent flyers" has known sex or gender implications. This represents a significant gap in the emergency medicine literature. The studies focus on utilization patterns and clinical characteristics but do not examine clinician attitudes, implicit bias, or differential treatment based on sex among frequent ED users.

Key Clinical Implications

Common Pitfalls to Avoid:

  1. Do not assume women are frequent ED users solely due to pregnancy-related issues. While pregnancy complications account for 13.6% of visits among young adult frequent users 4, women present with diverse psychiatric conditions including anxiety, depression, and stress reactions that require distinct management approaches.

  2. Do not overlook the dramatically higher substance abuse burden in male frequent ED users. With 80.3% of male psychiatric ED visits involving substance abuse or intoxication 2, screening and intervention for substance use disorders must be prioritized in this population.

  3. Recognize that men with multimorbid chronic disease represent an especially high-risk group. The nearly 5-fold increased odds of frequent ED use in men with 3+ chronic diseases 3 demands aggressive care coordination and chronic disease management.

  4. Account for sex-specific social determinants. Homelessness, lack of insurance, and lower income affect ED utilization differently by sex and require tailored interventions 5, 1.

Algorithmic Approach to Frequent ED Users by Sex:

For Male Frequent ED Users:

  • Screen aggressively for polysubstance use (heroin, cocaine, alcohol)
  • Assess for multiple chronic medical conditions (CCI ≥2)
  • Evaluate insurance status and facilitate enrollment
  • Address suicidal ideation (6.7% prevalence)
  • Coordinate care for chronic disease management given higher admission rates and mortality

For Female Frequent ED Users:

  • Screen for anxiety, depression, and acute stress reactions
  • Assess for history of abuse (present in 0.53%)
  • Evaluate for pregnancy-related complications in reproductive-age women
  • Address lower income as barrier to care
  • Focus on outpatient mental health linkage given lower admission rates but longer hospitalizations

For Both Sexes:

  • Assess substance use treatment history (associated with ED use in both)
  • Evaluate for major depressive episodes
  • Screen for homelessness
  • Coordinate ambulatory care access (protective when combined with chronic disease management)

References

3
Research

Sex differences in frequent ED use among those with multimorbid chronic diseases.

The American journal of emergency medicine, 2016

4
Research

Characterization of Young Adult Emergency Department Users: Evidence to Guide Policy.

The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 2016

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.