A Randomized Controlled Trial of a Citywide Emergency Department Care Coordination Program to Reduce Prescription Opioid Related Emergency Department Visits

Abstract

Background Increasing prescription overdose deaths have demonstrated the need for safer ED prescribing practices for patients who are frequent ED users. Objectives We hypothesized that the care of frequent ED users would improve using a citywide care coordination program combined with an ED care coordination information system, as measured by fewer ED visits by and decreased controlled substance prescribing to these patients. Methods We conducted a multi-site randomized controlled trial (RCT) across all EDs in a metropolitan area. 165 patients with the most ED visits for complaints of pain were randomized. For the treatment arm, drivers of ED use were identified by medical record review. Patients and their primary care providers were contacted by phone. Each patient was discussed at a community multidisciplinary meeting where recommendations for ED care were formed. The ED care recommendations were stored in an ED information exchange system that faxed them to the treating ED provider when the patient presented to the ED. The control arm was subjected to treatment as usual. Results The intervention arm experienced a 34% decrease (IRR = 0.66, p < 0.001; 95% CI: 0.57 – 0.78) in ED visits and an 80% decrease (OR = 0.21, p = 0.001) in the odds of receiving an opioid prescription from the ED relative to the control group. Declines of 43.7%, 53.1%, 52.9%, and 53.1% were observed in the treatment group for morphine milligram equivalents, controlled substance pills, prescriptions, and prescribers. Conclusion This RCT showed the effectiveness of a citywide ED care coordination program in reducing ED visits and controlled substance prescribing.

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

“…29 The program is designed to reduce “unnecessary” use of the ED, while also ensuring that patients get the care they need in the appropriate setting. An individualized ED care plan is created for each participant by a team of healthcare providers, including the patient’s primary care physician, ED physicians and nurses, and mental health and substance-use-disorder professionals, among others.…”

“…The framework and day-to-day administration of the program have been described in detail elsewhere. 29,31 …”

“…The final randomized sample consisted of 165 participants; 82 who were enrolled in the care-coordination program, and 83 in the control group. See Neven et al 29 for full details of the study rationale and design.…”

“…29 Participants in the care-coordination intervention had fewer visits to the ED, received fewer opioids and opioid prescriptions in the ED, and had fewer prescribers over the 12-month observation period. However, evidence of effectiveness is often not sufficient for implementation of such programs, given the resource constraints faced by payers of healthcare services.…”

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 .…”