The effect of brief case management on emergency department use of frequent users in mental health: Findings of a randomized controlled trial

Abstract

Frequent users of hospital emergency departments (EDs) are a medically and socially vulnerable population. The Coordinated Access to Care from Hospital EDs (CATCH-ED) study examined the effectiveness of a brief case management intervention in reducing ED use and improving health outcomes among frequent ED users with mental health or addiction challenges in a large urban centre. Adults (≥18 years of age) who had five or more ED visits in the past 12-months, with at least one visit for mental health or addictions problems were randomized to either brief case management (N = 83) or usual care (N = 83) and followed for 12 months. The primary outcome of effectiveness was the frequency of ED visits during 12 months after study enrolment. Secondary outcomes included days in hospital, mental health and addiction symptom severity and health-related quality of life, measured by the SF-12. Compared to usual care, CATCH-ED participants saw a 14% reduction in frequency of ED visits during the 12-month post-randomization period [rate ratio (RR) = 0.86, 95% CI 0.64–1.15)], however, this finding did not reach statistical significance. There were also no statistically significant differences between the groups at 12 months in the number of days spent in hospital (RR = 1.16, 95% CI 0.59–2.29), physical (1.50, 95% CI -2.15–5.15) or mental (-3.97, 95% CI -8.13–0.19) component scores of the SF-12, severity of psychiatric symptoms (-0.41, 95% CI -2.30–1.49), alcohol (0.053 95% -0.017–0.12) or drug (-0.0027, 95% CI -0.0028–0.023) use. Compared to usual care, a brief case management intervention did not result in significantly reduced ED use or improved health outcomes among frequent ED users with mental health or addictions challenges in a large urban centre in Canada. Future studies need to evaluate the availability and accessibility of community-based resources for individuals with frequent ED use.

Interventions to manage use of the emergency and urgent care system by people from vulnerable groups: a mapping review

“…The full texts of 28 papers were screened, with 16 included in the mapping review. [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28] Full details of these papers are included in Report Supplementary Material 1.…”

“…The primary study papers that met the inclusion criteria all used an evaluative design. There were four randomised controlled trials (RCTs), 14,22,26,28 three non-randomised trials 19,23,24 and three cohort studies. 15,17,21 The majority of the literature was from North America, with three studies from the UK, 13,15,21 a single study from Australia 28 and a single study from Switzerland.…”

“…None of the study populations was described in terms of being 'vulnerable'. Included studies referred to participants as being frequent users or frequent callers, 14,15,17,[20][21][22][23][24][25][26][27] young people with alcohol-related presentations, 28 people with high opioid use, 22 people at high risk of drug-seeking behaviour 16 or people on a low income. 18 The interventions evaluated in the primary studies included provision of a link worker for young people with an alcohol-related presentation, combined with a brief intervention and referral, 28 and introduction of a system for people on a low income or who were uninsured whereby hospital EDs were linked to local primary care providers and ED staff referred patients to these clinics 18 (both subsequently classified under 'outreach services and teams').…”

“…16 Case management, which could include offering additional social support to patients, was described in four studies. 14,15,24,26 The difference between interventions described as case management and those referred to as care plans was not always clearly distinguishable, as establishing a plan was often a main component of management.…”

“…A RCT evaluating case management for frequent attenders who had mental health or addiction difficulties found a 14% reduction in frequency of ED visits during the post-randomisation process; however, in line with the studies described above, this reduction did not reach statistical significance. 26 A pilot study of frequent ambulance callers suggested that case management was promising as a method to reduce the median call volume, although the authors highlighted the complex range of needs of patients. 15 Of the 16 included studies, there was overall uncertainty regarding the effectiveness of interventions aiming to reduce UEC use, with five studies indicating a reduction in service use 16,17,20,21,23 and six studies suggesting no significant reduction in service use.…”