Case Management may Reduce Emergency Department Frequent use in a Universal Health Coverage System: a Randomized Controlled Trial

Abstract

BACKGROUND: Frequent emergency department (ED) users account for a disproportionately high number of ED visits. Studies on case management (CM) interventions to reduce frequent ED use have shown mixed results, and few studies have been conducted within a universal health coverage system. OBJECTIVE: To determine whether a CM intervention--compared to standard emergency care-reduces ED attendance. DESIGN: Randomized controlled trial. PARTICIPANTS: Two hundred fifty frequent ED users (5 or more visits in the prior 12 months) who visited a public urban ED at the Lausanne University Hospital between May 2012 and July 2013 were allocated to either an intervention (n = 125) or control (n = 125) group, and monitored for 12 months. INTERVENTIONS: An individualized CM intervention consisting of concrete assistance in obtaining income entitlements, referral to primary or specialty medical care, access to mental health care or substance abuse treatment, and counseling on at-risk behaviors and health care utilization (in addition to standard care) at baseline and 1, 3, and 5 months. MAIN MEASURES: We used a generalized linear model for count data (negative binomial distribution) to compare the number of ED visits during the 12-month follow-up between CM and usual care, from an intention-to-treat perspective.KEY RESULTS: At 12 months, there were 2.71 (±0.23) ED visits in the intervention group versus 3.35 (±0.32) visits among controls (ratio = 0.81, 95 % CI = 0.63; 1.02). In the multivariate model, the effect of the CM intervention on the number of ED visits approached statistical significance (b = −0.219, p = 0.075). The presence of poor social determinants of health was a significant predictor of ED use in the multivariate model (b = 0.280, p = 0.048). CONCLUSIONS: CM may reduce ED use by frequent users through an improved orientation to the health care system. Poor social determinants of health significantly increase use of the ED by frequent users.

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

“…The high heterogeneity between studies, most importantly in how frequent users are defined, but also in participant demographic and clinical characteristics, the nature of the intervention (type and quality of case management) and system level-factors such as availability and accessibility of usual care services, may contribute to the lack of consistent findings and certainly limits the ability to compare findings between studies. Similar to our study, the most recent trial used the same definition of frequent users (≥5 ED visits in past 12 months), was held in a country with universal health insurance coverage and privately delivered health care (Switzerland) and showed a trend towards reduced ED use which did not reach statistical significance [33]. In comparison, of the two case management trials which showed a statistically significant reduction in ED among frequent ED users, the first took place in the US [15], while the second, conducted in a country with universal health insurance (Sweden), used telephone-based case management, an arguably different intervention [16].…”

How to Reduce Excessive Use of the Health Care Service in Medical Aid Beneficiaries: Effectiveness of Community-Based Case Management

“…Several studies reported that case management for medical aid beneficiaries was effective in reducing healthcare use [11][12][13][14]. However, most of these studies focused on reducing healthcare use to demonstrate the effectiveness of case management.…”

Frequent emergency department use by older adults with ambulatory care sensitive conditions: A population‐based cohort study

“…As an example, adequate case management interventions could lead to fewer ED visits by frequent users by improving ACSC management, as well as through the orientation and coordination of healthcare services. 30 The present study has some notable strengths. First, it was carried out with an exhaustive medico-administrative database of older adults in Quebec, Canada, making the results generalizable to our whole population of interest.…”

“…To control costs and ensure the highest quality of care, we must meet the needs of geriatric patients in the ED and also across the care continuum. As an example, adequate case management interventions could lead to fewer ED visits by frequent users by improving ACSC management, as well as through the orientation and coordination of healthcare services …”