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

Abstract

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. The authors have no potential conflicts to disclose. PROSPERO registration number CRD42014015058. Study group authorship: Jessica Moe conceptualized and drafted the protocol, screened abstracts and articles for inclusion, extracted data, analyzed data, and wrote the manuscript; Scott Kirkland helped to draft the protocol, screened abstracts and articles for inclusion, analyzed data, assessed study quality, and wrote sections of the manuscript; Erin Rawe drafted the protocol and extracted data; Maria Ospina helped to draft the protocol, assessed study quality, and provided third-party adjudication for inclusion screening and quality assessment; Ben Vandermeer helped to plan and perform the statistical analysis; Sandy Campbell developed and ran the search strategy; Brian H. Rowe conceptualized the protocol, provided third-party adjudication for inclusion screening and quality assessment, analyzed data, and wrote a section of the manuscript. All authors reviewed, edited, and approved the final manuscript. Existing evide...

Review article: Interventions for people presenting to emergency departments with a mental health problem: A systematic scoping review

“…A second concern regarding the focus on the patient is that few studies involved patients’ family, carers and significant others, despite increasing recognition that family‐centred care provides a holistic and efficient care experience, achieving better health outcomes for people who present to the ED with mental health problems . Further research is required to understand the dynamics between people with mental health problems who attend the ED and their social support networks (or lack thereof).…”

“…A second concern regarding the focus on the patient is that few studies involved patients' family, carers and significant others, despite increasing recognition that family-centred care provides a holistic and efficient care experience, achieving better health outcomes for people who present to the ED with mental health problems. [23][24][25] Further research is required to understand the dynamics between people with mental health problems who attend the ED and their social support networks (or lack thereof). This is particularly critical as interventions that are likely to have longer-term positive patient impacts, such as behaviour modification techniques and substance misuse reduction, might be initiated in the ED but typically also include specialist mental health team, outpatient or community care continuity 26 that can be supported by engagement and partnership with family.…”

Association of the frequent users profile with the characteristics of using an emergency service

“…21 Outras intervenções têm sido implementadas, como gestão dos casos desses UFs por equipes multiprofissionais, realizadas por contatos telefônicos e nomeação de uma enfermeira de referência da rede básica na alta do SUE. 22 No entanto, algumas estratégias são difíceis de serem viabilizadas em grandes centros urbanos.…”

From ED overcrowding to jail overcrowding: a cautionary tale of a Serial Inebriate Programme (SIP)

“…However, our findings also suggest that reductions in EMS and police arrests come at a services cost with a sharp increase in the use of jail for SIP participants. Prior analyses of programmes targeting frequent ED users have found reduced ED costs after implementation,12 but others have found either no change in costs13 or a subsequent increase in outpatient costs14 that could be related to patients being connected to services. It is important to note that the impact of SUD programmes transcends costs associated with incarceration and ED.…”