Health policy/review article
Effectiveness of Interventions Targeting Frequent Users of Emergency Departments: A Systematic Review

Presented as an abstract at the 33rd annual meeting of the Society of General Internal Medicine, May 2010, Minneapolis, MN; and as a poster at the 78th annual meeting of the Swiss Society of Internal Medicine, May 2010.
https://doi.org/10.1016/j.annemergmed.2011.03.007Get rights and content

Study objective

Frequent users of emergency departments (EDs) are a relatively small group of vulnerable patients accounting for a disproportionally high number of ED visits. Our objective is to perform a systematic review of the type and effectiveness of interventions to reduce the number of ED visits by frequent users.

Methods

We searched MEDLINE, EMBASE, CINAHL, PsychINFO, the Cochrane Library, and ISI Web of Science for randomized controlled trials, nonrandomized controlled trials, interrupted time series, and controlled and noncontrolled before-and-after studies describing interventions targeting adult frequent users of EDs. Primary outcome of interest was the reduction in ED use. We also explored costs analyses and various clinical (alcohol and drug use, psychiatric symptoms, mortality) and social (homelessness, insurance status, social security support) outcomes.

Results

We included 11 studies (3 randomized controlled trials, 2 controlled and 6 noncontrolled before-and-after studies). Heterogeneity in both study designs and definitions of frequent users precluded meta-analyses of the results. The most studied intervention was case management (n=7). Only 1 of 3 randomized controlled trials showed a significant reduction in ED use compared with usual care. Six of the 8 before-and-after studies reported a significant reduction in ED use, and 1 study showed a significant increase. ED cost reductions were demonstrated in 3 studies. Social outcomes such as reduction of homelessness were favorable in 3 of 3 studies, and clinical outcomes trended toward positive results in 2 of 3 studies.

Conclusion

Interventions targeting frequent users may reduce ED use. Case management, the most frequently described intervention, reduced ED costs and seemed to improve social and clinical outcomes. It appears to be beneficial to patients and justifiable for hospitals to implement case management for frequent users in the framework of a clear and consensual definition of frequent users and standardized outcome measures.

Introduction

Frequent use of hospital emergency departments (EDs) by specific patient subgroups has been reported in several countries, irrespective of the details of the health care system in use.1, 2, 3, 4, 5, 6, 7, 8 Frequent users are patients who use EDs on multiple occasions. Definitions and visit number thresholds vary across studies; according to Locker et al,9 a frequency of more than 4 attendances per year corresponds to nonrandom events, and use of this threshold may improve comparisons between studies.

Frequent users represent a relatively small group of patients accounting for a disproportionally high number of visits to hospital EDs.10, 11, 12 For more than 30 years, this patient group has been the focus of interest and concern in emergency medicine and health policy for at least 4 reasons.13, 14, 15 First, the high number of visits leads to concerns about their appropriateness.16, 17 In the context of chronically crowded EDs18 not designed to provide longitudinal patient care over repeated visits,19, 20 frequent users are often considered time-consuming “illegitimate” users of ED resources.21, 22 This impression of frequent users has the potential to negatively influence the quality of care that they receive.23, 24 Second, frequent use of EDs generates high health care costs.25, 26 Third, frequent users are often vulnerable individuals27: compared with infrequent or nonusers of EDs, they are more likely to be of low socioeconomic status,28, 29 isolated, and living alone.3, 30, 31 They are also more likely to report chronic medical conditions,28, 32, 33, 34 have a higher mortality rate,35, 36 and consume more health care resources.28, 37 Fourth, it is unclear why some patients overuse EDs.38 Although some studies point to the lack of a primary care physician,39, 40 other reports show that the majority of frequent users have a primary care provider.26, 28, 29, 41 Other possible reasons include unmet medical and nonmedical needs42 or the attractiveness of free ED care.37

In this context, ED teams have attempted to develop interventions aimed at reducing the number of ED visits by frequent users and at responding to their medical and psychosocial needs. Several primary studies have assessed the effect of specific interventions on the use of EDs by adult frequent users. However, no clear consensus exists on the optimal intervention and what effect may be expected from any interventions that are implemented. To address these questions, we have conducted a systematic review.

The purpose of our systematic review was to critically evaluate experimental and observational studies describing interventions targeting frequent users of hospital EDs. The primary outcome of interest was the reduction in ED use. We also explored cost analyses and various clinical (alcohol and drug use, psychiatric symptoms, mortality) and social (homelessness, insurance status, social security support, basic financial needs, need for a primary care practitioner) outcomes. The use of ambulatory care services and satisfaction of patients or staff were also examined.

Section snippets

Study Design

The protocol (Appendix E1, available online at http://www.annemergmed.com) and extraction form were prepared according to the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions.43 The reporting of this systematic review is based on the PRISMA statement for systematic reviews of health care interventions.44

We conducted a systematic literature search (inception to June 2009) of MEDLINE, EMBASE, PsychINFO, CINAHL, the Cochrane Library, and Web of Science (Conference

Results

Of a total of 8,794 references, 7,696 and 850 references were discarded after the title and abstract were read, respectively. We fully reviewed 248 articles and finally included a total of 11 studies in the systematic review (Figure).4, 10, 23, 47, 48, 49, 51, 52, 53, 54, 55

Characteristics of the 11 selected studies are shown in Table 1. Three were randomized controlled trials,48, 51, 52 2 controlled before-and-after studies,10, 47 and 6 noncontrolled before-and-after studies.4, 23, 49, 53, 54,

Limitations

Our systematic review has some limitations. First, we included study designs other than randomized controlled trials (namely, controlled and uncontrolled before-and-after studies). This strategy was chosen a priori because we recognized that few pertinent randomized controlled trials have been published, possibly reflecting the ethical and practical difficulties in the implementation of randomized controlled trials evaluating complex interventions for vulnerable populations. Second, we have

Discussion

This systematic review identified 11 studies assessing the effectiveness of interventions targeting frequent users of hospital EDs. Most interventions were case management (n=7) or based on partial components of case management (n=3). One study tested an intervention based on the provision to emergency physicians of patients' case notes from their last 3 visits. A reduction in the number of ED visits was observed in 7 of the 11 selected studies.

Cost analyses conducted in 3 studies have

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