Case management for frequent users of the emergency department: study protocol of a randomised controlled trial

Abstract

BackgroundWe devised a randomised controlled trial to evaluate the effectiveness and efficiency of an intervention based on case management care for frequent emergency department users. The aim of the intervention is to reduce such patients’ emergency department use, to improve their quality of life, and to reduce costs consequent on frequent use. The intervention consists of a combination of comprehensive case management care and standard emergency care. It uses a clinical case management model that is patient-identified, patient-directed, and developed to provide high intensity services. It provides a continuum of hospital- and community-based patient services, which include clinical assessment, outreach referral, and coordination and communication with other service providers.Methods/DesignWe aim to recruit, during the first year of the study, 250 patients who visit the emergency department of the University Hospital of Lausanne, Switzerland. Eligible patients will have visited the emergency department 5 or more times during the previous 12 months. Randomisation of the participants to the intervention or control groups will be computer generated and concealed. The statistician and each patient will be blinded to the patient’s allocation. Participants in the intervention group (N = 125), additionally to standard emergency care, will receive case management from a team, 1 (ambulatory care) to 3 (hospitalization) times during their stay and after 1, 3, and 5 months, at their residence, in the hospital or in the ambulatory care setting. In between the consultations provided, the patients will have the opportunity to contact, at any moment, the case management team. Participants in the control group (N = 125) will receive standard emergency care only. Data will be collected at baseline and 2, 5.5, 9, and 12 months later, including: number of emergency department visits, quality of life (EuroQOL and WHOQOL), health services use, and relevant costs. Data on feelings of discrimination and patient’s satisfaction will also be collected at the baseline and 12 months later.DiscussionOur study will help to clarify knowledge gaps regarding the positive outcomes (emergency department visits, quality of life, efficiency, and cost-utility) of an intervention based on case management care.Trial registrationClinicalTrials.gov Identifier: NCT01934322.

Case Management may Reduce Emergency Department Frequent use in a Universal Health Coverage System: a Randomized Controlled Trial

“…regression to the mean), even without intervention. 7,19 Finally, the Hawthorne effect-that people have a tendency to change their behavior when under observation-may have influenced ED use among these participants. In the Reinius study, 13 control participants were passively observed in a Zelen's design, adopted in part to avoid a Hawthorne effect.…”

“…19 Briefly, we conducted an RCT with a parallel design to compare CM with standard care among frequent ED users of the Lausanne University Hospital (Switzerland) ED between May 2012 and July 2013. The Lausanne University Hospital is one of five EDs in the canton (state) of Vaud, and serves 770,000 people, with over 35,000 ED visits annually.…”

“…Eighty-five participants were needed in both groups using a significance level of 0.05 and power of 0.9. We anticipated a dropout rate of 30 %, based on the increased mortality rate of frequent ED users, 21 past research 19,22 and clinical experience of the CM team (serving populations including forced migrants and homeless persons), due to the instability in this population. Thus, we aimed to enroll 250 frequent ED users (125 in each group).…”

“…19 The research nurse, CM team, ED staff and data collection manager were not blinded to participant allocation, due to their activities and contacts. We informed study participants that they might receive CM services, without informing them of their group allocation.…”

Associations between perceived discrimination and health status among frequent Emergency Department users

“…Data were part of a larger study, a randomized-controlled trial designed to improve frequent users' quality of care [18]. This study was carried out with baseline data.…”