Improving the use of early follow-up care after emergency department visits. A randomized trial

CONTEXT: Successful care transitions between emergency departments (EDs) and outpatient settings have implications for quality, safety, and cost of care. OBJECTIVE:To investigate the effectiveness of ED-based care transition interventions in achieving outpatient follow-up among pediatric patients.DATA SOURCES: Medline, Embase, CINAHL, Cochrane Library, trial registers, and reference lists of relevant articles. STUDY SELECTION AND DATA EXTRACTION:Eligible studies included randomized controlled trials of ED-based care transition interventions involving pediatric patients (aged ≤18 years). Study selection, data extraction, and risk of bias assessment were performed in duplicate and independent manner. Study results were pooled for meta-analysis by using a random effects model. RESULTS:Sixteen randomized controlled trials, comprising 3760 patients, were included in the study. Most interventions were single-site (n = 14), multicomponent (n = 12), and focused on patients with asthma (n = 8). Pooling data from 10 studies (n = 1965 patients) found moderate-quality evidence for a relative increase of 29% in outpatient follow-up with interventions compared with routine care (odds ratio, 1.58 [95% confidence interval, 1.08-2.31]). Successful interventions included structured telephone reminders, educational counseling on follow-up, and appointment scheduling assistance. There was low-quality evidence when pooling data from 5 studies (n = 1609 participants) that exhibited little or no beneficial effect of interventions on ED readmissions (risk ratio, 1.02 [95% confidence interval, 0.91-1.15]).LIMITATIONS: All studies were conducted in urban US hospitals which makes generalization of the results to rural settings and other countries difficult.CONCLUSIONS: ED-based care transition interventions are effective in increasing follow-up but do not seem to reduce ED readmissions. Further research is required to investigate the mechanisms that affect the success of these interventions.

Section: Populationmentioning

confidence: 99%

Section: Interventionmentioning

confidence: 99%

Section: Interventionmentioning

confidence: 99%

See 1 more Smart Citation

Emergency Department-Based Care Transitions for Pediatric Patients: A Systematic Review

Abraham¹,

Kannampallil²,

Caskey

et al. 2016

“…Telephone care has been used for follow-up after ED visits 17 and was shown to decrease missed appointments, increase compliance with instruction, and ensure appropriateness of follow-up care. 18,19 In the area of chronic illness, telephone care has been shown to reduce medical costs, hospitalization, and ED visits for children with diabetes. 11,20 In a randomized trial of a self-directed parent training program for those with oppositional preschoolers that included weekly telephone encounters as part of a parenting program, investigators found reduced behavior problems in the children, and parents reported lower levels of anxiety, depression, and stress compared with parents in a control group.…”

Section: Clinical Effectiveness Of Telephone Carementioning

confidence: 99%

Payment for Telephone Care

2006

Telephone care in pediatrics requires medical judgment, is associated with practice expense and medical liability risk, and can often substitute for more costly faceto-face care. Despite this, physicians are infrequently paid by patients or thirdparty payors for medical services provided by telephone. As the costs of maintaining a practice continue to increase, pediatricians are increasingly seeking payment for the time and work involved in telephone care. This statement reviews the role of telephone care in pediatric practice, the current state of payment for telephone care, and the practical issues associated with charging for telephone care services, a service traditionally provided gratis to patients and families. Specific recommendations are presented for appropriate documenting, reporting, and billing for telephone care services. BACKGROUNDTelephone care is an increasing component of pediatric practice. Pediatricians are forced to provide more care to children and their families by telephone because of changing consumer and health plan expectations for enhanced access to care, 2-parent employment, the use of cellular phones by a "connected" society, a new focus on chronic disease management, and continued pressure by employers and health plans to reduce the costs of medical services. To address these concerns, pediatricians are required to develop new practice styles and provide more "nonface-to-face" medical services outside the traditional office or hospital setting.Expansion of telephone care has great potential to further decrease health care costs, in part by providing a convenient and safe alternative to more costly in-person services. As a cost-containment strategy, telephone triage and advice, combined with indicated prescriptive therapy, often serves as a substitute for a patient visit to the office, urgent care center, or emergency department (ED). Tools to improve triage, provide advice for acute illnesses, and improve clinical and functional outcomes for the chronically ill patient include guidelines, disease and case management, and patient education. Many of these interventions depend heavily on the telephone.Despite the fact that telephone care involves challenging medical decisionmaking, medicolegal risk, and practice expense and provides convenience and cost benefits to patients and health plans, physicians are rarely paid for providing telephone care. Arguments against payment have included the difficulty in determining appropriate payment without a more exact assessment of physician work than that contained in the Current Procedural Terminology (CPT) telephone codes, the absence of time-based codes as a proxy for work, and the absence of Centers for Medicare and Medicaid Services-published resource-based relative value units (RVUs) for these services. Additional barriers to payment for telephone www.pediatrics.org/cgi

“…7,8 A variety of strategies have been found to improve the rate of post-ED care follow-up, including scheduling of follow-up appointments at the ED visit, postdischarge telephone reminders, assistance with scheduling an appointment after ED discharge, assistance with child care, and transportation assistance. 7,[9][10][11] However, none of these studies investigated the impact of such follow-up care on longer-term, patient-oriented asthma outcomes. In 1 study, adults with acute asthma who were given an appointment for primary care follow-up during the ED visit were less likely to relapse than those not given an appointment, suggesting that primary care follow-up may result in improved short-term outcomes; however, the impact on long-term outcomes and disease control is unknown.…”

mentioning

confidence: 99%

Emergency Department Allies: A Controlled Trial of Two Emergency Department–Based Follow-up Interventions to Improve Asthma Outcomes in Children

Gorelick¹,

Meurer²,

Walsh‐Kelly³

et al. 2006

OBJECTIVE. We sought to study the impact of emergency department (ED)-based intensive primary care linkage and initiation of asthma case management on long-term, patient-oriented outcomes for children with an asthma exacerbation.METHODS. Our study was a randomized, 3-arm, parallel-group, single-blind clinical trial. Children aged 2 through 17 years treated in a pediatric ED for acute asthma were randomly assigned to standard care (group 1), including patient education, a written care plan, and instructions to follow up with the primary care provider within 7 days, or 1 of 2 interventions. Group 2 received standard care plus assistance with scheduling follow-up, while group 3 received the above interventions, plus enrollment in a case management program.OUTCOMES. The primary outcome was the proportion of children having an ED visit for asthma within 6 months. Other outcomes included change in quality-of-life score and controller-medication use.RESULTS. Three hundred fifty-two children were enrolled; 78% completed followup, 69% were black, and 70% had persistent asthma. Of the children, 37.8% had a subsequent ED visit for asthma, with no difference among the treatment groups (group 1: 38.4%; group 2, 39.2%; group 3, 35.8%). Children in all groups had a substantial, but similar, increase in their quality-of-life score. Controller-medication use increased from 69.4% to 81.4%, with no difference among the groups.CONCLUSION. ED-based attempts to improve primary care linkage or initiate case management are no more effective than our standard ED care in improving subsequent asthma outcomes over a 6-month period. A STHMA, WHICH AFFECTS Ͼ6 million US children, is a chronic disease marked by acute exacerbations that account for much of the associated morbidity. 1-3 Much of the care of these acute flare-ups is provided in emergency departments (EDs), with Ͼ728 000 ED visits for childhood asthma in 2000. 1 Because the ED is a frequent source of care for patients with asthma, it may have a role in chronic disease management as well. 4 A 2002 publication by an expert panel outlined multiple policy recommendations to improve childhood asthma outcomes. 5 Three of these recommendations focused on improving access to and quality of asthma health care services, improving primary asthma care, and providing case management (CM) for high-risk asthmatic children.Linkage between the ED and the source of primary asthma care has been the subject of some investigation. In 1997, the National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 2 6 emphasized the importance of ongoing preventive care and follow-up with a primary care provider (PCP) after acute care treatment in reducing asthma morbidity. However, although NAEPP guidelines recommend follow-up with a PCP within 3 to 5 days of an acute asthma exacerbation, numerous studies have demonstrated low rates of compliance with this recommendation. 7,8 A variety of strategies have been found to improve the rate of post-ED care follow-up, including scheduling of fo...