Effectiveness of Interventions Targeting Frequent Users of Emergency Departments: A Systematic Review

Althaus, Fabrice; Paroz, Sophie; Hügli, Olivier; Ghali, William A.; Daeppen, Jean‐Bernard; Peytremann‐Bridevaux, Isabelle; Bodenmann, Patrick

doi:10.1016/j.annemergmed.2011.03.007

Cited by 281 publications

(328 citation statements)

References 57 publications

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“…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.…”

Section: Discussionmentioning

confidence: 99%

“…Based on results from a systematic review of the literature, 7 the sample size estimate was calculated to detect an average difference of two ED visits annually between the two groups (i.e. four fewer intervention group visits compared to two fewer control group visits, with an anticipated standard deviation of four in both groups).…”

Section: Sample Sizementioning

confidence: 99%

“…6 Case management (CM) is an intervention designed to assist frequent ED users in reducing their ED utilization. 7,8 CM aims to meet patients' individual needs and to optimize resource allocation for the frequent user and payer. 9,10 To our knowledge, only…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2016

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BACKGROUND: Frequent emergency department (ED) users account for a disproportionately high number of ED visits. Studies on case management (CM) interventions to reduce frequent ED use have shown mixed results, and few studies have been conducted within a universal health coverage system. OBJECTIVE: To determine whether a CM intervention--compared to standard emergency care-reduces ED attendance. DESIGN: Randomized controlled trial. PARTICIPANTS: Two hundred fifty frequent ED users (5 or more visits in the prior 12 months) who visited a public urban ED at the Lausanne University Hospital between May 2012 and July 2013 were allocated to either an intervention (n = 125) or control (n = 125) group, and monitored for 12 months. INTERVENTIONS: An individualized CM intervention consisting of concrete assistance in obtaining income entitlements, referral to primary or specialty medical care, access to mental health care or substance abuse treatment, and counseling on at-risk behaviors and health care utilization (in addition to standard care) at baseline and 1, 3, and 5 months. MAIN MEASURES: We used a generalized linear model for count data (negative binomial distribution) to compare the number of ED visits during the 12-month follow-up between CM and usual care, from an intention-to-treat perspective.KEY RESULTS: At 12 months, there were 2.71 (±0.23) ED visits in the intervention group versus 3.35 (±0.32) visits among controls (ratio = 0.81, 95 % CI = 0.63; 1.02). In the multivariate model, the effect of the CM intervention on the number of ED visits approached statistical significance (b = −0.219, p = 0.075). The presence of poor social determinants of health was a significant predictor of ED use in the multivariate model (b = 0.280, p = 0.048). CONCLUSIONS: CM may reduce ED use by frequent users through an improved orientation to the health care system. Poor social determinants of health significantly increase use of the ED by frequent users.

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Section: Discussionmentioning

confidence: 99%

Section: Sample Sizementioning

confidence: 99%

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

et al. 2016

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“…3 Numerous interventions have been implemented over the years to reduce discretionary ED utilization rates. 4 Recently, efforts to reduce ED utilization have included redesigning the primary care delivery system (eg, implementation of a patient-centered medical home) 5,6 and introducing financial incentives to primary care physicians (PCPs). [7][8][9] The rationale for both the approaches is that primary care can exert substantial influence on patterns of ED utilization and that altering the current model of primary care delivery can affect ED use by patients.…”

Section: Introductionmentioning

confidence: 99%

Patterns of Multiple Emergency Department Visits: Do Primary Care Physicians Matter?

Maeng

Hao

Bulger

2017

TPJ

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Context: Overutilization and overreliance on Emergency Departments (EDs) as a usual source of care can lead to unnecessarily high costs and undesirable consequences, such as a gap in care coordination and inadequate provision of preventive care.Objective: To identify factors associated with multiple ED visits by patients, in particular, the impact of primary care physicians (PCPs) on their patients' multiple ED visit rates.Design: Geisinger Health Plan claims data among adult patients who averaged more than 1 ED visit within a 12-month period between 2013 and 2014 were obtained (N = 20,351).Main Outcome Measures: Rate of ED visits. Three linear regression models using patient characteristics and utilization patterns as covariates along with PCP fixed effects were estimated to explain the variation in the multiple ED visit rates.Results: Multiple ED visits were significantly associated with younger age (18-39 years), having Medicaid insurance, and greater comorbidity. Higher rates of physician office visits and inpatient admissions were also associated with higher rates of multiple ED visits. Accounting for PCP characteristics only marginally improved the explained variation (R 2 increased from 0.14 to 0.16).Conclusions: Multiple ED visit patterns are likely driven by patients' health conditions and care needs rather than by their PCPs. Multiple ED visits also appear to be complementary, rather than substitutionary, to PCP visits, suggesting that PCP-focused interventions aimed at reducing ED use are unlikely to have a major impact.

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“…8 Many reviews have documented the positive impacts of case management among frequent users of health care services. Althaus et al 9 concluded that case management decreased emergency department use and costs, and improved clinical and social outcomes. Reviews by Kumar and Klein 6 and Soril et al 5 also reported that the majority of evidence pointed to the benefits of case management interventions for frequent users.…”

Section: Introductionmentioning

confidence: 99%

Case Management in Primary Care for Frequent Users of Health Care Services: A Mixed Methods Study

et al. 2018

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PURPOSE This study aimed to evaluate the effects of the V1SAGES case management intervention (Vulnerable Patients in Primary Care: Nurse Case Management and Self-management Support) for frequent users of health care services with chronic disease and complex care needs on psychological distress and patient activation. METHODSWe used a 2-phase sequential mixed methods design. The first phase was a pragmatic randomized controlled trial with intention-to-treat analysis that measured the effects of the intervention compared with usual care on psychological distress and patient activation before and after 6 months. The second phase had a qualitative descriptive design and entailed thematic analysis of in-depth interviews (25 patients, 6 case management nurses, 9 health managers) and focus groups (8 patients' spouses, 21 family physicians) to understand stakeholders' perceived effects of the intervention on patients. RESULTSA total of 247 patients were randomized into the intervention group (n = 126) or the control group (n = 121). Compared with usual care, the intervention reduced psychological distress (odds ratio = 0.43; 95% CI, 0.19-0.95, P = .04), but did not have any significant effect on patient activation (P = .43). Qualitative results suggested that patients and their spouses benefitted from the case management intervention, gaining a sense of security, and stakeholders noted better patient self-management of health.CONCLUSIONS Together, our study's quantitative and qualitative results suggest that case management reduces psychological distress, making patients and caregivers feel more secure, whereas impact on self-management is unclear. Case management is a promising avenue to improve outcomes among frequent users of health care with complex needs. Ann Fam Med 2018;16:232-239. https://doi.org/10.1370/afm.2233. INTRODUCTIONF requent use of health care services is often driven by the complex health and social care needs of individuals having chronic physical conditions and, often, mental health comorbidities, sometimes accompanied by social vulnerability.1,2 Frequent users with chronic disease and complex care needs often experience fragmented, uncoordinated, and ineffective health care, resulting in poor health outcomes at considerable costs to the health care system. 3 Although high use may be defined from either a frequency or cost perspective, the former is more convenient and easier to measure when identifying this population in a pragmatic context. Given that primary care is a first point of contact with the health and social care system, it may play a strong role in allowing the implementation of innovations to provide more coordinated care. 4 Different interventions have been developed and evaluated to improve care for frequent users of health care services, such as case management, individualized care plans, self-management support, and information sharing. 5 Case management is the intervention most supported by evidence on improving appropriate use of health care resources, decreasing undue C...

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Effectiveness of Interventions Targeting Frequent Users of Emergency Departments: A Systematic Review

Cited by 281 publications

References 57 publications

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

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

Patterns of Multiple Emergency Department Visits: Do Primary Care Physicians Matter?

Case Management in Primary Care for Frequent Users of Health Care Services: A Mixed Methods Study

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