Clinical Reviews
Effectiveness of Case Management Strategies in Reducing Emergency Department Visits in Frequent User Patient Populations: A Systematic Review

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Abstract

Background

Case management (CM) is a commonly cited intervention aimed at reducing Emergency Department (ED) utilization by “frequent users,” a group of patients that utilize the ED at disproportionately high rates. Studies have investigated the impact of CM on a variety of outcomes in this patient population.

Objectives

We sought to examine the evidence of the effectiveness of the CM model in the frequent ED user patient population. We reviewed the available literature focusing on the impact of CM interventions on ED utilization, cost, disposition, and psychosocial variables in frequent ED users.

Discussion

Although there was heterogeneity across the 12 studies investigating the impact of CM interventions on frequent users of the ED, the majority of available evidence shows a benefit to CM interventions. Reductions in ED visitation and ED costs are supported with the strongest evidence.

Conclusion

CM interventions can improve both clinical and social outcomes among frequent ED users.

Introduction

As the United States continues to attempt to control the debt crisis, increasing attention has turned to health care costs to achieve fiscal discipline. Drivers of health care costs in the United States are heterogeneous and include technological innovation, increased administrative expenditures, lack of strong cost-containment measures, increased provider market power, and increased use of health care services 1, 2, 3, 4, 5.

One area of health care expenditure that has been under the microscope has been Emergency Department (ED) utilization and cost. From 1997 to 2007, the annual number of visits to EDs increased by 23%, from 96 million to 117 million visits, respectively (6). Given this, there is mounting interest in the group of patients that utilize the ED at disproportionately high rates. These individuals, termed “frequent attenders” or “high utilizers” are frequent users of the ED, with ED visit rates that range anywhere from more than two to as many as 20 visits in any given year 7, 8. Approximately 4.5–8% of patients visiting the ED are frequent users. Yet, this small group accounts for 21–28% of all ED visits (7). ED utilization by this group of patients is often viewed as non-emergent and inappropriate 8, 9. This contributes to ED overcrowding, compromises quality of care for other patients, and reduces efficiency of health care systems 10, 11.

Frequent ED users tend to be more ill, face greater social problems, are more frequently admitted to the hospital, have higher overall mortality rates, have greater psychiatric morbidity, and incur higher health care costs 8, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26. This subset of patients places a significant financial strain on health care resources. Frequent users represent about 50% of the Medicaid dollars spent on ED care (27). Compared with patients who are less frequent users, patients visiting the ED between three and 20 times a year incur higher overall costs as well as higher costs across all categories such as laboratory, pharmacy, radiology, catheterization, operating room, and other costs (8).

Interventions aimed at these patients have the potential to reduce ED utilization rates and reduce costs associated with these patients. Studies have employed different strategies to affect ED utilization by these patients, including individualized care plans and case management, patient education, primary care partnerships, and managed care level interventions. Case management is the most frequently cited approach and has been shown to reduce ED utilization and costs 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42.

Case management (CM) is defined as a “collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes” (43). In this approach, case managers identify appropriate providers and services for individual patients while simultaneously ensuring that available resources are being used in a timely and cost-effective manner. This intervention can benefit patients as well as their support systems, the health care systems, and reimbursement sources. CM is based on a model of continuous, integrated medical and psychosocial care, which is markedly different from the episodic and often fragmented care that occurs in the ED setting.

Given the potential benefit of the CM model, studies have investigated the impact of CM on a variety of outcomes such as ED utilization rates and costs. We systematically reviewed the CM literature to determine the proven effectiveness of this model in the frequent ED user patient population. This review focuses on the evidence of impact of CM as an intervention in improving outcomes of frequent users of ED care. The primary outcome of interest was ED utilization, although some studies did report cost analyses and psychosocial outcomes as well.

Section snippets

Materials and Methods

We performed a systematic review of the literature designed to capture relevant primary studies for inclusion in our review (44). Figure 1 details the search strategy employed to obtain our results and is based on the PRISMA guidelines (45).

We conducted a comprehensive search of MEDLINE and EMBASE databases. The search was performed in May 2010 and included studies dating from 1990 to April 2010. A verification search was performed in July 2010.

We combined three main search themes—frequent use,

Results

The structured search strategy yielded 12 unique studies meeting criteria as described above 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39. Figure 1 reveals the flow chart of the search strategy used to obtain the relevant results. Table 1 displays details extracted from the studies 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39.

Of the 12 studies included, two were randomized control trials, eight were pre- and post-intervention studies using historical controls, and two employed age-matched

Discussion

Although there were noted differences in results across studies, the majority of the studies included in this review noted a reduction in ED visits after CM implementation. This reduction was found in different patient populations, including both uninsured, unemployed, homeless patients, and insured patients with stable housing, access to care, and an identifiable PCP.

Although the descriptions of the CM programs varied across studies, we are generally able to note that the intensity of the CM

Conclusion

From our review, CM seems to be successful in improving both clinical and social outcomes among frequent ED users. Reductions in ED visitation and ED costs are supported with the strongest evidence. The breadth of resources and intensity of intervention seems to correlate with better outcomes. Although the current literature supports the benefits of CM interventions, additional investigation is needed to determine what specific aspects of CM are most successful and cost effective. In addition,

Acknowledgements

The authors thank Dominique L. Cosco, md, and Carmen Mohan, md, for their assistance with reviewing and editing the article.

References (45)

  • A. Gelijns et al.

    The dynamics of technological change in medicine

    Health Aff (Millwood)

    (1994)
  • M.E. Chernew et al.

    Managed care, medical technology, and health care cost growth: a review of the evidence

    Med Care Res Rev

    (1998)
  • S. Woolhandler et al.

    Costs of health care administration in the United States and Canada

    N Engl J Med

    (2003)
  • R.G. Evans et al.

    The 20-year experiment: accounting for, explaining, and evaluating health care cost containment in Canada and the United States

    Annu Rev Public Health

    (1991)
  • K. Davis et al.

    Health care cost containment

    (1990)
  • Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary (2010)....
  • J.P. Ruger et al.

    Analysis of costs, length of stay, and utilization of emergency department services by frequent users: implications for health policy

    Acad Emerg Med

    (2004)
  • A.W. Murphy et al.

    Characteristics of attenders and their attendances at an urban accident and emergency department over a one year period

    J Accid Emerg Med

    (1999)
  • S. Trzeciak et al.

    Emergency department overcrowding in the United States: an emerging threat to patient safety and public health

    Emerg Med J

    (2003)
  • R.M. Cowan et al.

    Clinical review: emergency department overcrowding and the potential impact on the critically ill

    Crit Care

    (2005)
  • J.H. Mandelberg et al.

    Epidemiologic analysis of an urban, public emergency department’s frequent users

    Acad Emerg Med

    (2000)
  • K.J. Rask et al.

    Ambulatory health care use by patients in a public hospital emergency department

    J Gen Intern Med

    (1998)
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