Reducing frequent visits to the emergency department: a systematic review of interventions

Abstract

Objective: The 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.

Methods: Systematic 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.

Results: Among 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.

Conclusions: The 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.

Fig 1. PRISMA Flow Diagram.

A total of 1491 abstracts were identified from the electronic database search. After removal of duplicate records, 1029 abstracts were reviewed and 952 were excluded. Hand-searching of the references lists of relevant systematic reviews identified 4 additional full-text articles. Eighty-one articles in all were assessed in full-text, of which 64 were excluded and 17 studies (4 randomized controlled trials; 13 comparative cohort studies), within 3 intervention categories (care or case management; individualized care plans; information sharing), were included for final qualitative synthesis. Heterogeneity in the reported outcomes prohibited pooling of data for meta-analysis.