Reducing Frequent Visits to the Emergency Department: A Systematic Review of Interventions

Abstract

ObjectiveThe objective of this study was to establish the effectiveness of interventions to reduce frequent emergency department (ED) use among a general adult high ED-use population.MethodsSystematic review of the literature from 1950-January 2015. Studies were included if they: had a control group (controlled trials or comparative cohort studies), were set in an ED or acute care facility, and examined the impact of an intervention to reduce frequent ED use in a general adult population. Studies reporting non-original data or focused on a specific patient population were excluded. Study design, patient population, intervention, the frequency of ED visits, and costs of frequent ED use and/or interventions were extracted and narratively synthesized.ResultsAmong 17 included articles, three intervention categories were identified: case management (n = 12), individualized care plans (n = 3), and information sharing (n = 2). Ten studies examining case management reported reductions in mean (-0.66 to -37) or median (-0.1 to -20) number of ED visits after 12-months; one study reported an increase in mean ED visits (+2.79); and one reported no change. Of these, 6 studies also reported reduced hospital costs. Only 1 study evaluating individualized care plans examined ED utilization and found no change in median ED visits post-intervention. Costs following individualized care plans were also only evaluated in 1 study, which reported savings in hospital costs of $742/patient. Evidence was mixed regarding information sharing: 1 study reported no change in mean ED visits and did not examine costs; whereas the other reported a decrease in mean ED visits (-16.9) and ED cost savings of $15,513/patient.ConclusionsThe impact of all three frequent-user interventions was modest. Case management had the most rigorous evidence base, yielded moderate cost savings, but with variable reductions in ED use. Future studies evaluating non-traditional interventions, tailoring to patient subgroups or socio-cultural contexts, are warranted.

“Hospital was the Only Option”: Experiences of Frequent Emergency Department Users in Mental Health

“…In addition, past studies of perceived urgency in the ED have shown that patients and hospital personnel disagree about what constitutes an ''appropriate'' ED visit (Gill et al 1996). We concur with Olthuis et al (2014) that the ''mismatch'' between the ED patient's concerns and the staff's responses requires further investigation, if we are to better understand and meet patient needs and preferences, and design alternative services and supports aimed at curbing frequent ED use (Althaus et al 2011;Kumar and Klein 2013;Soril et al 2015).…”

Patterns of Multiple Emergency Department Visits: Do Primary Care Physicians Matter?

“…3 Numerous interventions have been implemented over the years to reduce discretionary ED utilization rates. 4 Recently, efforts to reduce ED utilization have included redesigning the primary care delivery system (eg, implementation of a patient-centered medical home) 5,6 and introducing financial incentives to primary care physicians (PCPs). [7][8][9] The rationale for both the approaches is that primary care can exert substantial influence on patterns of ED utilization and that altering the current model of primary care delivery can affect ED use by patients.…”

“…4 Second, provision of financial incentives to PCPs has been shown to have no significant impact on ED utilization rates. 4,6,8 In this study, we seek to identify factors associated with multiple ED visits. In particular, we explore to what extent PCPs contribute to the variation in their patients' frequency of ED visits.…”

Case Management in Primary Care for Frequent Users of Health Care Services: A Mixed Methods Study

“…4 Different interventions have been developed and evaluated to improve care for frequent users of health care services, such as case management, individualized care plans, self-management support, and information sharing. 5 Case management is the intervention most supported by evidence on improving appropriate use of health care resources, decreasing undue costs, and increasing patient well-being in this population. [5][6][7] According to the Case Management Society of America, case management is "a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes."…”

“…4 Different interventions have been developed and evaluated to improve care for frequent users of health care services, such as case management, individualized care plans, self-management support, and information sharing. 5 Case management is the intervention most supported by evidence on improving appropriate use of health care resources, decreasing undue Catherine Hudon, MD, PhD, CFPC 1,2 Maud-Christine Chouinard, RN, PhD 3,4,5 Marie RN, MSc(c) 3,4 Fatoumata Diadiou, MA(c) …”