Background
Methods
Results
Study (Yr) | Country | Setting | Number of subjects in the study | Intervention period | Comparator |
---|---|---|---|---|---|
Crane (2012) | USA | 200 bed not for profit hospital. | 36 (from initial group of 255) | July 2009–June 2010 | Pre and post |
DeHaven (2012) | USA | 1 ED in Dallas | 574 (265 intervention and 309 controls) | April 2003–July 2004 | Controls |
Edgren (2016) | Sweden | 5 counties in Sweden. | Group One used Zelen’s design and had 7280 in intervention group and 3508 in control group. Group two used RCT design and had 934 in intervention group and 459 in control group. | 2010- March2014. | Controls |
Enard (2013) | USA | Nine Memorial Hermann EDs in the Houston area | 13,642 participants (1905 in intervention and 11,373 in control group). | Nov 2008- April 2011 | Pre and post |
Grimmer-Somers (2010) | Australia | One metropolitan health region | 37 patients | 18 months from 2007 to 2009 | Pre and post |
Grover (2018) | USA | ED community hospital with 225 bed hospital in suburban area. | 158 in intervention. | Oct 2013- June 2015 | Pre and post. |
Hardin (2017) | USA | Inner city tertiary hospital. 80,000 annual ED visits. | 339 in intervention | Nov 2012-Dec 2015 | Pre and post |
Lin (2017) | USA | Brigham and Women’s hospital. Large urban acaedemic medical centre | 72 (36 in intervention and 36 in control) | Oct 2014-April 2015 | Controls. |
Murphy (2013) | USA | Regional medical and trauma centre. 644 beds and 80,000 ED visits per yr. | 141 (76 extreme and 65 frequent ED users) | Jan 2008- Dec 2010 | Pre and post. |
Navratil-Strawn (2014) | USA | Patients enrolled in an insurance scheme. | 14,140 (7070 participants and an equal number of controls) | June-Nov 2011 | Controls. |
Okin (2000) | USA | San Francisco General Hospital. | 53 patients. | June 1995–June 1996 | Pre and post . |
Reinius (2012) | Sweden | Karolinska University Hospital with 90,000 visits per yr. | 268 patients (211 in intervention and 57 in control group). | Sep 2010- Sep 2011 | Controls |
Seaberg (2017) | USA | Urban ED with 57,000 presentations per yr. | 318 (184 in intervention and 134 controls). | Jan- June 2015 | Controls. |
Shumway (2008) | USA | San Francisco General Hospital. Sole Level 1 trauma hospital in the county. | 252 (167 in intervention and 85 to usual care) | March 1997 to Feb 1999 | Controls. |
Stokes-Buzzelli (2010) | USA | Urban hospital with 95,000 ED presentations per yr. | 36 patients | June 2005–July 2007 | Pre and post |
Tadros (2012) | USA | One urban hospital. | 51 patients | Dec 2006-June 2009 | Pre and post |
Study characteristics
Definitions
Author | Year | Frequent Presenter’ Definition |
---|---|---|
Crane | 2012 | ≥6 visits/ year |
DeHaven | 2012 | ≥2 visits/ year |
Edgren | 2016 | ≥3 visits in previous 6 months |
Enard | 2013 | Extracted data from > 5 visits pre intervention period. |
Grimmer-Somers | 2010 | Individuals known to use public hospital ED services in an unplanned manner. |
Grover | 2018 | ≥10 visits in 12 months, ≥6 visits in 6 months, ≥4 visits in 1 month or concerned ED use. |
Hardin | 2017 | ≥3visit/ year |
Lin | 2017 | Patients with the most ED visits in the previous month and previous year. |
Murphy | 2013 | Frequent = 3–11 visits per year, Extreme = ≥12 visits/year preceding year of enrolment. |
Navratil-Strawn | 2014 | ≥3 visits/ year in the previous 12 months |
Okin | 2000 | ≥5 visits/ year |
Reinius | 2012 | ≥3 visits during 6 months before inclusion. |
Seaberg | 2017 | ≥5 visits/ year |
Shumway | 2008 | ≥5 visits/ year |
Stokes-Buzzelli | 2010 | Patients with the most ED visits. |
Tadros | 2012 | ≥10 visits/ year |
Intervention outcomes
Intervention | Crane (2012) | DeHaven (2012) | Edgren (2016) | Enard (2013) | Grimmer-Somers (2010) | Grover (2018) | Hardin (2017) | Lin (2017) | Murphy (2013) | Navratil-Strawn (2014) | Okin (2000) | Reinius (2012) | Seaberg (2017) | Shumway (2008) | Stokes-Buzzelli (2010) | Tadros (2012) |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Case management/ care coordination/ acute care plans | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X |
Financial assistance (social security) | X | |||||||||||||||
Goal setting | X | |||||||||||||||
Group therapy | X | X | X | |||||||||||||
Harm reduction services | X | |||||||||||||||
Housing | X | X | X | |||||||||||||
Individual visits / CHW/ Nurse | X | X | X | X | X | X | X | X | ||||||||
Mentoring | X | |||||||||||||||
Monetary assistance with pharmacy, lab tests and other medical costs | X | |||||||||||||||
Multidisciplinary | X | X | X | X | X | X | ||||||||||
Problem solving | X | |||||||||||||||
Referral to specialists and other services including social services | X | X | X | X | X | X | X | X | X | X | X | |||||
Telephone | X | X | X | X | X | X | X | X | X | |||||||
Transportation | X | X | ||||||||||||||
Change in ED use | ↓ | ↓ | Mixed | ↓ | ↓ | ↓ | ↓ | ↓ | ↓ | ↓ | ↓ | ↓ | ↓ | ↓ ED use but not in inpatient | ↓ | ↓ |
Magnitude of change | ED use dropped from a rate of 0.58 per patient per month to 0.23** | Fewer ED visits, 0.93 vs 1.44** | 12% decrease in hospitalisation (95%CI 4–19%) | V | 30 ED presentations by 11 users in 2006 dropped to 22 presentations by 9 users in 2009. | 830 fewer ED visits and a 49.26% change** | Mean difference of 5.5 and a 37.4% change** | 35% fewer ED visits | frequent users decreased by 5 visits (95% CI of 2–5); extreme users decreased by 15 visits (95% CI of 13–17)* | ED visits decreased by 178/1000 visits; hospital admission by 53/1000 visits* | Median number of visits decreased from 15 to 9 visits (95% CI of 3–7 visits)** | RR 0.77 (95% CI of 0.69–0.86) | 13.2% decrease in ED use from 1148 to 996 visits** | V | Visits decreased by 25% from 67.4 to 50.5 (95% CI 0.3 to 33)* | Visits decreased by 28.1% from 199 to 143** |
Change in cost | ↓ | ↓ | Mixed | ↓ | ↑ outpatient clinic use. ↓ crisis ED use. | ↓ | ↓ | ↓ | ↓ | ↓ | ↓ | ↓ | ↓ | Effective but not cost saving | ↓ | ↓ |
Magnitude of change | Hospital charges dropped from $1167 per patient per month to $230** | $1188 vs $446** | V | V | NR | $2,785,690 absolute change and 47.81% change** | Mean difference of $6290 and 47.9%** | ED costs were 15% lower | Decrease in frequent ED use by $1285 (95% CI of $492–$2364); extreme ED use decreased by $6091 (95% CI of $4298–$8998)* | A saving of $21 per member per month for ED visits or $59 per member per month on admissions. | ED costs decreased from $4124 to $2192 (95% CI $1013 to $2459 to); and inpatient costs decreased from $8330 to $2786 (95% CI $0 to $8330).** | 45% decrease in total cost per patient** | 26.6% decrease (95% CI 26.1 to 27%)** | V | decreased by 24% from $64,721 to $49,208 (95% CI $83 to -$30,943)* | 12.7% decrease in costs from $413,410 to $360,779 |
Economic outcomes
Study (Yr) | Country | Social Economic Background | Perspective | Cost variable included in analysis | Type of economic evaluation | Outcome |
---|---|---|---|---|---|---|
Crane (2012) | USA | Low income, uninsured. | Healthcare | Hospital charges ($1167 per month pre-intervention, $230 post-intervention); cost of program ($66 K) | Cost analysis | ED use dropped by 0.25 per patient per month 0.23 and hospital charges dropped from $1167 per patient per month to $230. |
DeHaven (2012) | USA | Uninsured | Healthcare | Indirect costs (sum of costs for all ED visits for the year, includes fixed costs related to building maintenance, staffing and utilities) | Cost analysis | Intervention enrolees of the PAD program had significantly fewer ED visits (0.93 vs 1.44). Direct hospital costs around 60% less ($1188 vs 446). Indirect costs 50% less ($313 vs $692). |
Edgren (2016) | Sweden | “Screening aimed to identify patients who seemed to be lacking in health literacy, sought care at an improper level, or from too many providers”. | Healthcare | Costs of conducting maintenance activities ($13,950.42), total program cost ($54,284.31). Per-client discretionary costs for transport, equipment, medications and interpreters ($250 per person). | Cost analysis | The traditional design showed an overall 12% decreased rate of hospitalization, which was mostly driven by effects in the last year. |
Enard (2013) | USA | Publically insured (Medicaid), uninsured (self pay), or covered by a local public health benefit that subsidises medical costs for eligible residents. | Healthcare | Prior to enrolment: ED charges ($8,453,761), inpatient charges ($8,453,761). Post-intervention: ED charges ($3,041,473) and inpatient charges ($5,405,175). | Cost analysis | The savings associated with reduced PCR-ED visits were greater than the cost to implement the navigation program. |
Grimmer-Somers (2010) | Australia | Unplanned ED use, crisis inpatient admission, poor attendance at primary health and/ or outpatient clinics, unmanaged chronic disease, medication misuse, vulnerable social circumstances. | Healthcare | Gross charges and expenses, ED service charges and expenses, IP service charges and expenses, outpatient service charges and expenses. | Cost analysis | Staff spent 34 h with each client, costing $1700 each. Crisis ED and inpatient admissions decreased. Planned outpatient clinic use increased. |
Grover (2018) | USA | Patients who demonstrated a propensity for future problematic ED encounters such as violence in the ED or prescription forgery. | Healthcare | Average direct costs per patient for intervention and control groups. | Cost analysis | ED and hospital charges decreased by 5.8 million dollars (41% reduction) |
Hardin (2017) | USA | Patients who would benefit from a Complex Care Map | Healthcare | Direct treatment costs (wages, salaries, materials); indirect costs (those incurred as part of the production process (e.g. admin costs, maintenance costs) | Cost analysis | ED mean visits decreased 43%, inpatient admission decreased 44%. Gross charges decreased 45%, direct expenses decreased 47%. |
Lin (2017) | USA | NR | Healthcare | Hospital service costs | Cost analysis | Average ED direct costs 15% lower for intervention patients. Average inpatient costs per patient 8% lower. |
Murphy (2013) | USA | NR | Healthcare and fire department | Health care system costs - total costs for transport or non-transport responses based on predicted or actual call volume. | Cost analysis | Frequent and extreme users decreased in ED visits (5 and 15 respectively) and direct treatment costs ($1285) leading to significant hospital cost savings. |
Navratil-Strawn (2014) | USA | Insurance scheme | Healthcare | Hospital inpatient and outpatient Medicare costs (not charges). ED physician costs not included in this study. | Cost analysis and ROI | Participants had greater reduction in ED visits (p = 0.003) and hospital admissions (p = 0.002) and increased office visits (p = < 0.001). ROI of 1.24. |
Okin (2000) | USA | Program aimed to decrease homelessness, decrease alscohol and substance use and improve linkages to primary care providers, reduce health care utilisation and enrol patients without meical insurance to medicaid. | Healthcare | Medical inpatient costs, psychiatric emergency costs, psychiatric inpatient costs, medical outpatient costs, physicians’ professional fee costs, non EDCM costs | Cost analysis and ROI | Median number of ED visits decreased from 15 to 9 (p < 0.1) and median inpatient costs decreased from $4330 to $2786 (p < 0.1). ROI of $1.44. |
Reinius (2012) | Sweden | NR | Healthcare | Ambulance and hospital charges as proxy for cost of care. No evaluation of individual insurance status or reimbursements. | Cost analysis | Intervention reduced the total healthcare costs for per person hospital admissions by 45%. |
Seaberg (2017) | USA | NR | Healthcare | Total healthcare cost, primary and secondary care visit costs for outpatient care | Cost analysis | ED visits decreased overall with a larger decrease in the intervention group (by 13.2%) compared to the control group (by 4.5%). |
Shumway (2008) | USA | Subjects had psychosocial problems that could be addressed with case management (problems with housing, medical care, substance abuse, mental health disorders or financial entitlements). | Healthcare | Total costs of the intervention and total cost per person | Cost analysis | Reductions in ED use and cost did not translate to reductions in inpatient use, which represent a larger proportion of total hospital service use. |
Stokes-Buzzelli (2010) | USA | 89% of the study population had substance abuse issues. | Healthcare | ED charges | Cost analysis | ED charged decreased by 24% (from $64,721 to $49,208). The number of lab studies ordered decreased by 28%. The number of average ED visits decreased by 25%. |
Tadros (2012) | USA | NR | Healthcare | Total healthcare costs for hospital admissions | Cost analysis | Pre-hospital based case management system is effective in decreasing transport by frequent presenters but had only a limited impact on use of hospital services. |