Objective The objective of this study was to establish the effectiveness of interventions to reduce frequent emergency department (ED) use among a general adult high ED-use population. Methods Systematic review of the literature from 1950-January 2015. Studies were included if they: had a control group (controlled trials or comparative cohort studies), were set in an ED or acute care facility, and examined the impact of an intervention to reduce frequent ED use in a general adult population. Studies reporting non-original data or focused on a specific patient population were excluded. Study design, patient population, intervention, the frequency of ED visits, and costs of frequent ED use and/or interventions were extracted and narratively synthesized. Results Among 17 included articles, three intervention categories were identified: case management (n = 12), individualized care plans (n = 3), and information sharing (n = 2). Ten studies examining case management reported reductions in mean (-0.66 to -37) or median (-0.1 to -20) number of ED visits after 12-months; one study reported an increase in mean ED visits (+2.79); and one reported no change. Of these, 6 studies also reported reduced hospital costs. Only 1 study evaluating individualized care plans examined ED utilization and found no change in median ED visits post-intervention. Costs following individualized care plans were also only evaluated in 1 study, which reported savings in hospital costs of $742/patient. Evidence was mixed regarding information sharing: 1 study reported no change in mean ED visits and did not examine costs; whereas the other reported a decrease in mean ED visits (-16.9) and ED cost savings of $15,513/patient. Conclusions The impact of all three frequent-user interventions was modest. Case management had the most rigorous evidence base, yielded moderate cost savings, but with variable reductions in ED use. Future studies evaluating non-traditional interventions, tailoring to patient subgroups or socio-cultural contexts, are warranted.

/pdf/reducing-frequent-visits-to-the-emergency-department-a-11y6xccie3.pdf

Reducing frequent visits to the emergency department: a systematic review of interventions.

Objectives
Frequent emergency department (ED) users are high-risk and high-resource-utilizing patients. This systematic review evaluates effectiveness of interventions targeting adult frequent ED users in reducing visit frequency and improving patient outcomes.

Methods
An a priori protocol was published in PROSPERO. Two independent reviewers screened, selected, rated quality, and extracted data. Third-party adjudication resolved disagreements. Rate ratios of post- versus pre-intervention ED visits were calculated. Data sources were from a comprehensive search that included seven databases and the gray literature. Eligibility criteria for selecting studies included experimental studies assessing the effect of interventions on frequent users’ ED visits and patient-oriented outcomes.

Results
A total of 6,865 citations were identified and 31 studies included. Designs were noncontrolled (n = 21) and controlled (n = 4) before–after studies and randomized controlled trials (n = 6). Frequent user definitions varied considerably and risk of bias was moderate to high. Studies examined general frequent users or those with psychiatric comorbidities, chronic disease, or low socioeconomic status or the elderly. Interventions included case management (n = 18), care plans (n = 8), diversion strategies (n = 3), printout case notes (n = 1), and social work visits (n = 1). Post- versus pre-intervention rate ratios were calculated for 25 studies and indicated a significant visit decrease in 21 (84%) of these studies. The median rate ratio was 0.63 (interquartile range = 0.41 to 0.71), indicating that the general effect of the interventions described was to decrease ED visits post-intervention. Significant visit decreases were found for a majority of studies in subgroup analyses based on 6- or 12-month follow-up, definition thresholds, clinical frequent user subgroups, and intervention types. Studies reporting homelessness found consistent improvements in stable housing. Overall, interstudy heterogeneity was high.

Conclusions
Interventions targeting frequent ED users appear to decrease ED visits and may improve stable housing. Future research should examine cost-effectiveness and adopt standardized definitions.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/acem.13060

Effectiveness of Interventions to Decrease Emergency Department Visits by Adult Frequent Users: A Systematic Review.

Community hospital stays in 12 states during 2008-2009 were analyzed to determine predictors of 12-month hospital readmission and emergency department (EDs) revisits among persons with a mental health or substance abuse diagnosis. Probabilities of hospital readmission and of ED revisits were modeled as functions of patient demographics, insurance type, number of prior-year hospital stays, diagnoses and other characteristics of the initial stay, and hospital characteristics. Alcohol or drug dependence, dementias, psychotic disorders, autism, impulse control disorders, and personality disorders were most strongly associated with future inpatient admission or ED revisits within 12 months of initial encounter. Insurance type, including uninsured status, were highly significant (p<.01) predictors of both readmission and ED revisits.

Hospital readmission rates and emergency department visits for mental health and substance abuse conditions

Objective Frequent users of healthcare services are a vulnerable population, often socioeconomically disadvantaged, who can present multiple chronic conditions as well as mental health problems. Case management (CM) is the most frequently performed intervention to reduce healthcare use and cost. This study aimed to examine the evidence of the effectiveness of CM interventions for frequent users of healthcare services.

Design Scoping review.

Data sources An electronic literature search was conducted using the MEDLINE, Scopus and CINAHL databases covering January 2004 to December 2015. A specific search strategy was developed for each database using keywords ‘case management’ and ‘frequent use’.

Eligibility criteria for selecting studies To be included in the review, studies had to report effects of a CM intervention on healthcare use and cost or patient outcomes. Eligible designs included randomised and non-randomised controlled trials and controlled and non-controlled before–after studies. Studies limited to specific groups of patients or targeting a single disease were excluded. Three reviewers screened abstracts, screened each full-text article and extracted data, and discrepancies were resolved by consensus.

Results The final review included 11 articles evaluating the effectiveness of CM interventions among frequent users of healthcare services. Two non-randomised controlled studies and 4 before–after studies reported positives outcomes on healthcare use or cost. Two randomised controlled trials, 2 before–after studies and 1 non-randomised controlled study presented mitigated results. Patient outcomes such as drug and alcohol use, health locus of control, patient satisfaction and psychological functioning were evaluated in 3 studies, but no change was reported.

Conclusions Many studies suggest that CM could reduce emergency department visits and hospitalisations as well as cost. However, pragmatic randomised controlled trials of adequate power that recruit the most frequent users of healthcare services are still needed to clearly confirm its effectiveness.

https://bmjopen.bmj.com/content/bmjopen/6/9/e012353.full.pdf

Effectiveness of case management interventions for frequent users of healthcare services: a scoping review.

PURPOSE Case management (CM) interventions are effective for frequent users of health care services, but little is known about which intervention characteristics lead to positive outcomes. We sought to identify characteristics of CM that yield positive outcomes among frequent users with chronic disease in primary care. METHODS For this systematic review of both quantitative and qualitative studies, we searched MEDLINE, CINAHL, Embase, and PsycINFO (1996 to September 2017) and included articles meeting the following criteria: (1)population: adult frequent users with chronic disease, (2)intervention: CM in a primary care setting with a postintervention evaluation, and (3)primary outcomes: integration of services, health care system use, cost, and patient outcome measures. Independent reviewers screened abstracts, read full texts, appraised methodologic quality (Mixed Methods Appraisal Tool), and extracted data from the included studies. Sufficient and necessary CM intervention characteristics were identified using configurational comparative methods. RESULTS Of the 10,687 records retrieved, 20 studies were included; 17 quantitative, 2 qualitative, and 1 mixed methods study. Analyses revealed that it is necessary to identify patients most likely to benefit from a CM intervention for CM to produce positive outcomes. High-intensity intervention or the presence of a multidisciplinary/interorganizational care plan was also associated with positive outcomes. CONCLUSIONS Policy makers and clinicians should focus on their case-finding processes because this is the essential characteristic of CM effectiveness. In addition, value should be placed on high-intensity CM interventions and developing care plans with multiple types of care providers to help improve patient outcomes.

https://www.annfammed.org/content/annalsfm/17/5/448.full.pdf

Characteristics of Case Management in Primary Care Associated With Positive Outcomes for Frequent Users of Health Care: A Systematic Review.

Background: Patients with complex behavioral health and medical problems can have a disproportionate impact on emergency departments. Methods: We identified a cohort of 255 low-income, uninsured patients who had used inpatient or emergency department services more than 6 times in the previous 12 months. Between July 2010 and June 2011 we enrolled 36 of these high-risk patients to participate in a twice-weekly drop-in group medical appointment staffed by an interdisciplinary team of a family physician, behavioral health professional, and nurse case manager. The team provided 705 patient visits in a group setting (a total of 108 group sessions) and 652 case manager phone calls. The average number of clients per drop-in group medical appointment was 6.5. Results: Emergency department use dropped from a rate of 0.58 per patient per month to 0.23 (P Conclusions: Team-based drop-in group medical appointments coupled with case management seem to be a cost-effective model to reduce emergency department visits by some patients with complex behavioral health and medical needs.

/pdf/reducing-utilization-by-uninsured-frequent-users-of-the-21eukadkym.pdf

James Hall

Papers

Reducing utilization by uninsured frequent users of the emergency department: combining case management and drop-in group medical appointments