Capsule Commentary on Bodenmann et al., Case Management May Reduce Emergency Department Frequent Use in a Universal Health Coverage System: a Randomized Controlled Trial

Abstract

T his study by Bodenmann et al.1 examined the impact of a case management (CM) intervention on frequent Emergency Department (ED) users (≥5 ED visits in 12 months). The randomized controlled trial took place at a single site in Switzerland, which has universal health coverage. Patients were randomized to individualized case management versus standard care and followed for 12 months. By the end of the study period, there were 2.71 ED visits in the intervention group compared to 3.35 visits in the control group, a 19 % reduction in the group receiving CM. The effect of the intervention did not achieve statistical significance (ratio = 0.81, 95 % CI = 0.63 to 1.02). The authors conclude that individualized CM may reduce ED utilization in the population studied.Case management programs aim to support medically and psychosocially complex patients through needs assessments and care coordination. The consensus is mixed in the literature on whether ED-based CM programs reduce ED utilization: one RCT from 1997 2 did not show an impact of a CM intervention on ED use, but two more recent RCTs 3, 4 demonstrated statistically significant reductions in ED use through the implementation of ED-based CM programs.The conflicting conclusions of the above studies may be related to heterogeneity of design. There is no universal agreement in the literature of what constitutes a frequent ED user. Moreover, CM interventions vary in duration (from 12 to 24 months) and scope (telephone versus in-person visits). Differences in location and patient population may also influence outcomes.Nevertheless, compelling evidence suggests that case management helps these complex patients. The subjects in Bodenmann's study had the benefit of universal health coverage and only 14 % did not have a PCP. PCPs likely helped coordinate care for many of these patients, which may have lessened the impact of the intervention. In more fragmented health systems where fewer patients have access to a PCP, 5 it is not unreasonable to posit that ED-based CM services could play a significant role in care coordination and reduce utilization. For complex patients who frequent the ED, it is likely that more support, not less, is the key to better resource utilization.Corresponding Author: Blake Gregory, MD; Department of Internal Medicine, Division of Primary Care, Highland General Hospital and Alameda Health System, Oakland, CA, USA (e-mail: bgregory@alamedahealthsystem.org). Compliance with Ethical Standards:Conflict of Interest: The author has no conflicts of interest with the material in this article.