A Randomized Controlled Trial of a Citywide Emergency Department Care-Coordination Program to Reduce Prescription Opioid-Related Visits: An Economic Evaluation

Abstract

Background Care provided in the emergency department (ED) can cost up to 5 times as much as care received for comparable diagnoses in alternative settings. Small groups of patients, many of whom suffer from an opioid use disorder, often account for a large proportion of total ED visits. We recently conducted, and demonstrated the effectiveness of, the first randomized controlled trial of a citywide ED care-coordination program intending to reduce prescription-opioid-related ED visits. All EDs in the metropolitan study area were connected to a web-based information exchange system. Objective The objective of this paper was to perform an economic evaluation of the 12-month trial from a third-party-payer perspective. Methods We modeled the person period monthly for the 12-month observation period, and estimated total treatment costs and return on investment (ROI) with regard to cost offsets, over time, for all visits where the patient was admitted to, and discharged from the ED. Results By the end of month 4 the mean cumulative cost differential was significantly lower for intervention relative to TAU participants (−$1,370; p=0.03); this figure climbed to −$3,200 (p=0.02) by the end of month 12. The ROI trended upward throughout the observation period, but failed to reach statistical significance by the end of month 12 (ROI=3.39, p=0.07). Conclusion The intervention produced significant cost offsets by the end of month 4, which continued to accumulate throughout the trial; however, ROI was not significant. Since the per-patient administrative costs of the program are incurred at the time of enrollment, our results highlight the importance of future studies that are able to follow participants for a period beyond 12 months in order to more accurately estimate the program’s ROI.

The Characteristics and Effectiveness of Interventions for Frequent Emergency Department Utilizing Patients With Chronic Noncancer Pain: A Systematic Review

“…Each of the studies that measured the frequency of ED visits (n = 12) reported a decrease in the number of visits following the implementation of an intervention. [19][20][21][22][23][24][25][26][28][29][30][31] Nine of the studies reported statistically significant reductions in the frequency of ED visits (from p < 0.0001 to p < 0.05), 19,22,23,[26][27][28][29][30][31] one reported a nonsignificant reduction (p = 0.68), 21 and two studies did not report a p value. 19,24 • Patients referred to taper-to-abstinence pain management clinic run by a pain management and addiction specialist;…”

“…As detailed in Table 1, a total of four RCTs [19][20][21][22] and nine noncontrolled before-after studies (NCBAS) [23][24][25][26][27][28][29][30][31] were included, involving the assessment of 609 patients and 1,070 patients, respectively (total N = 1,679). The sample sizes of the RCTs ranged from 40 to 406 patients while the sample sizes for the NCBAS were slightly smaller ranging from 14 to 314.…”

“…Eight of the included studies implemented multifaceted interventions that included two or more of the identified components, 19,20,[22][23][24][25][26]30 and the remaining five studies implemented interventions that were focused around a singular component. 21,[27][28][29]31 Study Quality Assessment Four randomized studies were assessed using the Cochrane RoB 2.0 tool and nine nonrandomized studies were assessed using the ROBINS-I tool.…”

The associations between query‐based and directed health information exchange with potentially avoidable use of health care services

“…Despite its importance to state and federal health policy, the evidence base for HIE as an effective intervention to improve quality while reducing utilization and costs has been criticized as insufficient . The most consistent evidence in support of HIE as a stand‐alone intervention to positively affect health care delivery comes largely from emergency department settings and from studies of specific use cases, such as provider use of repeat and/or appropriate imaging, medication reconciliation, or prescribing behavior . In contrast, studies in ambulatory care settings have been less consistent, ranging from no impact, to mixed results, to some observed improvements in outcomes for specific patient populations .…”

“…[6][7][8] The most consistent evidence in support of HIE as a standalone intervention to positively affect health care delivery comes largely from emergency department settings [9][10][11][12][13] and from studies of specific use cases, such as provider use of repeat and/or appropriate imaging, [14][15][16] medication reconciliation, 17 or prescribing behavior. 18,19 In contrast, studies in ambulatory care settings have been less consistent, ranging from no impact, 20 to mixed results, 21,22 to some observed improvements in outcomes for specific patient populations. 23,24 Absence of strong evidence of its effectiveness has been a barrier to broader HIE adoption.…”