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• W1983907625 abstract "Recent health policy changes have focused efforts on reducing emergency department (ED) visits as a way to reduce costs and improve quality of care. This was a systematic review of interventions based outside the ED aimed at reducing ED use. This study was designed as a systematic review. We reviewed the literature on interventions in five categories: patient education, creation of additional non-ED capacity, managed care, prehospital diversion, and patient financial incentives. Studies written in English, with interventions administered outside of the ED, and a comparison group where ED use was an outcome, were included. Two independent reviewers screened search results using MEDLINE, Cochrane, OAIster, or Scopus. The following data were abstracted from included studies: type of intervention, study design, population, details of intervention, effect on ED use, effect on non-ED health care use, and other health and financial outcomes. Quality of individual articles was assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines. Of 39 included studies, 34 were observational and five were randomized controlled trials. Two of five studies on patient education found reductions in ED use ranging from 21% to 80%. Out of 10 studies of additional non-ED capacity, four showed decreases of 9% to 54%, and one a 21% increase. Both studies on prehospital diversion found reductions of 3% to 7%. Of 12 studies on managed care, 10 had decreases ranging from 1% to 46%. Nine out of 10 studies on patient financial incentives found decreases of 3% to 50%, and one a 34% increase. Nineteen studies reported effect on non-ED use with mixed results. Seventeen studies included data on health outcomes, but 13 of these only included data on hospitalizations rather than morbidity and mortality. Seven studies included data on cost outcomes. According to the GRADE guidelines, all studies had at least some risk of bias, with four moderate quality, one low quality, and 34 very low quality studies. Many studies have explored interventions based outside the ED to reduce ED use in various populations, with mixed evidence. Approximately two-thirds identified here showed reductions in ED use. The interventions with the greatest number of studies showing reductions in ED use include patient financial incentives and managed care, while the greatest magnitude of reductions were found in patient education. These findings have implications for insurers and policymakers seeking to reduce ED use. Los cambios de política sanitaria recientes han centrado los esfuerzos en reducir las visitas al servicio de urgencias (SU) como una manera de reducir los costes y mejorar la calidad de la atención. Se realiza una revisión sistemática de las intervenciones externas al SU con el objetivo de reducir el uso del SU. Este estudio se diseñó como una revisión sistemática. Se revisó la literatura de las intervenciones en cinco categorías: educación del paciente, creación de capacidad adicional fuera del SU, atención médica, derivación prehospitalaria e incentivos económicos al paciente. Se incluyeron los estudios con intervenciones realizadas fuera del SU, con un grupo comparativo, donde el uso del SU fue un resultado, y que estuviesen escritos en inglés. Dos revisores independientes revisaron los resultados de la búsqueda de MEDLINE, Cochrane, OAIster, y Scopus. Se resumieron los siguientes datos de los estudios incluidos: tipo de intervención, diseño del estudio, población, detalles de la intervención, efecto en el uso del SU, efecto en el uso del sistema sanitario al margen del SU y otros resultados sanitarios y económicos. La calidad individual de los artículos se realizó usando las guías del Grading of Recommendations Assessment, Development, and Evaluation (GRADE). De los 39 estudios incluidos, 34 fueron observacionales y 5 ensayos clínicos aleatorizados. Dos de los cinco estudios en educación del paciente encontraron disminución en el uso del SU en un rango de un 21% a un 80%. De los 10 estudios de la capacidad adicional fuera del SU, cuatro mostraron descenso de un 9% a un 54% y uno un incremento de un 21%. Los dos estudios de la derivación prehospitalaria encontraron reducciones de un 3% a un 7%. De los 12 estudios de la atención médica, 10 tuvieron descensos en un rango de un 1% a un 46%. Nueve de los 10 estudios de incentivos económicos al paciente encontraron descensos de un 3% a un 50%, y uno un incremento de un 34%. Diecinueve estudios documentaron efectos en el uso al margen del SU con resultados mixtos. Diecisiete estudios incluyeron datos en resultados sanitarios, pero 13 de éstos incluyeron sólo datos de hospitalizaciones más que de morbilidad y mortalidad. Siete estudios incluyeron datos de resultados de costes. Según las guías GRADE, todos los estudios tuvieron al menos algún riesgo de sesgo y la calidad fue moderada en 4, baja en 1 y muy baja en 34. Muchos estudios han explorado intervenciones realizadas fuera del SU para reducir el uso del SU en varias poblaciones, con diversa evidencia. Aproximadamente dos tercios de los aquí identificados mostraron reducciones en el uso del SU. Las intervenciones con el mayor número de estudios que mostraron reducciones en el uso del SU incluyeron los incentivos económicos al paciente y la atención sanitaria, mientras que las mayores magnitudes de reducciones se encontraron en la educación del paciente. Estos resultados tienen implicaciones para las aseguradoras y las estrategias políticas que buscan reducir el uso del SU. Growing health care costs in the United States have made patients, providers, and payers examine the value of services delivered.1 Concepts such as accountable care organizations and medical homes are gaining momentum with the goal of limiting avoidable, redundant, ineffective, or harmful treatments in favor of expanding effective care, access to care, and care coordination. Many programs aimed at improving efficiency focus on the use of hospital-based emergency departments (ED) for care. EDs care for critically ill patients and acute unscheduled conditions and serve as a safety net for those with limited access to health care due to insurance status, the timely availability of clinic-based physicians, and the need for care outside of traditional business hours.2 The focus on the ED as a place to improve efficiency stems from observations that ED care for low-acuity conditions results in higher charges than for similar diagnoses seen in other settings.3 In addition, an ED visit may be a marker of a potentially avoidable injury or illness that could have been prevented with better primary care, patient education, or enhanced public health measures. Studies have examined the effect of interventions to reduce ED use that are performed outside the ED, such as patient education, improved clinic access, care coordination, patient-centered care, and others. While ED-based interventions also exist, they are fundamentally different because of their location and their focus (e.g., follow-up vs. prevention). Our group recently conducted a systematic review of ED-based care coordination interventions.4 Therefore, this review focuses specifically on interventions based outside of the ED looking at systems-level changes, rather than ED-specific changes. Prior reviews of aggregated non-ED interventions have either focused only on one type of intervention or excluded some subsets of visits such as pediatric patients or categories of intervention such as prehospital diversion.5-7 To our knowledge, there has been no broad-based inclusive review of the comparative effectiveness of the myriad interventions tested to reduce ED use. The goal of this investigation was to review the evidence on the effectiveness of interventions based outside of the ED aimed at reducing ED use and, ultimately, to explore themes about which interventions may be most effective, along with any undesired consequences. We systematically reviewed the literature on the effectiveness of non-ED interventions aimed at reducing ED use. Non-ED interventions were defined as those implemented outside of an ED or hospital (e.g., insurance-based, outpatient clinic-based). No human subjects or medical records were reviewed as a part of this study so institutional review board approval was not required. The databases MEDLINE, Cochrane, OAIster, and Scopus were examined from 1966 to the present. Keywords used included emergency department, emergency medical services, utilization, demand, patient education, primary care, capacity, extended hours, advanced access, telephone triage, general practitioner, care coordination, copayment, and payment reform (MEDLINE search terms in Appendix A). Searches were limited to English language publications. Because of the variety in the interventions and outcome measurements in the results, we performed a qualitative rather than quantitative systematic review. Two independent reviewers (MA, SRM) screened search results and excluded those with titles that did not fit inclusion criteria (next section). The two reviewers then screened the abstracts of the remaining citations, again excluding those that did not fit inclusion criteria. The remaining articles underwent full-text review to exclude any remaining studies that did not fit inclusion criteria. Intrarater reliability was measured with a 10% sample of citations, resulting in a kappa of 0.92. Each article with conflicting opinion from reviewers was discussed with a third reviewer (JMP) for a final resolution. The following data were abstracted from all eligible studies: type of intervention, study design, population, details of intervention, effect on ED use, effect on non-ED health care use, and other health and financial outcomes. Reviewers used a standard format to abstract data; this format mirrors the categories in the tables presented here. We attempted to standardize results across studies. In studies with data available for absolute number of ED visits before and after the intervention was implemented (as opposed to, for example, number of visits per person, etc.), we calculated a percentage reduction of ED visits. When visit numbers were reported, the difference between number of visits before and after the intervention was divided by the number of ED visits prior to intervention to standardize the comparison of study results. We followed guidelines created in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement to create a four-phase flow diagram (Data Supplement S1, available as supporting information in the online version of this paper) showing the number of records included and excluded at each phase.8 Studies were included if they had interventions administered outside of the ED, had a comparison group where ED use was an outcome, and were in English. While studies in other languages were excluded, studies were included regardless of country and health care system if published in English. Five categories of interventions were included: 1) patient education on medical conditions and appropriate medical care use for low-acuity conditions, 2) creation of additional capacity in non-ED settings (e.g., expanded hours or same-day access), 3) managed care (e.g., primary care physician capitation or gatekeeping), 4) prehospital diversion, and 5) patient financial incentives (e.g., copayments or deductibles). Two other interventions, telephone triage and case management, were initially searched for but because recent systematic reviews have compiled the results of those topics; these were excluded.5, 6 Studies with ED-based interventions were excluded, as were studies without measurable objective outcomes. Studies with outcomes assessed through patient or provider subjective surveys were also excluded. Quality assessment was done using the portion of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria aimed at assessing the risk of bias in individual articles.9 Because of the heterogeneity in study designs, other components of the GRADE criteria, including the formal overall evaluation of the body of literature, were not used. Additionally, studies with risk-adjusted results and where significance was measured are reported. The search yielded 793 titles. After removing duplicates and exclusions based on title or abstract, 62 studies remained and underwent full-text review (Data Supplement S1). An additional 19 references were identified and also underwent full-text review, which resulted in a total number of included studies of 39 that ranged from publication dates of 1986 to 2011. The number of included studies per category is as follows: patient education on medical conditions and health care use, five studies10-14; creation of additional non-ED capacity, 10 studies15-24; prehospital diversion of low-acuity patients, two studies25, 26; managed care, 12 studies27-38; and patient financial incentives, 10 studies.39-47 Two out of five studies found significant reductions in the use of the ED after interventions, with reductions ranging from 21% to 80% (Table 1).10-14 All studies were based in the United States. Interventions included use of booklets or in-person educational sessions. Both pediatric and adult patients are included. Three studies reported data on non-ED use with one finding 0.03 fewer clinic visits per person.10-12 Three articles reported health outcomes and no significant adverse events were noted.11-13 No studies reported risk-adjusted data. Pre–post interventional study United States 6 months Air Force base Intervention group: 1,555 subjects Control group: 972 subjects Intervention group: reduction in ED use rate per person from 0.353 to 0.279 (p = 0.02) Control group: increase in ED use rate per person from 0.386 to 0.421 Intervention group: reduction in clinic use rate per person from 1.072 to 1.038 Control group: increase in clinic visits rate per person from 1.040 to 1.168 Randomized, parallel group study United States January–July 1998 Two urban Medicaid health plans (Plan A and B) Intervention group: households sent educational brochure Control group: households not sent educational brochure Retrospective cohort-control study, difference-in-difference model United States 12 months Primary care practices at academic health center Intervention group: 191 patients in practice Control groups: Nurses provided standardized education along with prescription for pain relieving ear drops Parents reminded of 24-hour medical advice telephone access Reduction in ED use for ear pain by 80.3% (p = 0.009) at intervention site. Concurrent control site had 25% nonsignificant increase in ED use Randomized controlled trial United States One year Multiple home health nursing agencies Intervention group: 180 diabetic patients Control group: 193 diabetic patients Nonsignificant changes in hospitalization rates/1,000 members/year in intervention group vs. control group: Pre–post interventional study United States Primary health care centers recruited through Breakthrough Series Collaborative Intervention group: three sites with 109 patients Control group: two sites with 76 patients Of 10 studies, three examined interventions that expanded capacity through new community clinics, while the remainder involved existing physician practices expanding appointments and/or hours of care. Four studies found significant decreases in the use of the ED after increases in non-ED capacity, with reductions ranging from 9% to 54%, while five were nonsignificant and one found an increase of 21% (Table 2).15-24 Four studies were based in the United States and the remaining six in Canada or Europe. Regarding effect on non-ED use, five studies reported data with four showing increases in non-ED use ranging from 1% to 102%.16, 17, 20-23 Of these, one article reported that while there was an increase in primary care use, there was a concurrent decrease in urgent care use.20 Two articles reported health outcomes.20, 21 Three studies reported cost data showing 10% to 20% savings with the intervention.15, 18, 20 Two studies risk-adjusted data.20, 21 Matched time-series analysis England One year before and after NHS developed walk-in centers with drop-in service Intervention group: 10 towns with walk-in center Control group: 10 similar size towns in same region without walk-in centers Before-and-after observational study with control group England 6 months before and after NHS developed walk-in centers with drop-in service Intervention group: one town with walk-in center Control group: one nearby town in the same region without walk-in center Retrospective study Ireland 1999–2007 Single, large ED and out-of-hours general practice emergency service clinic associated with same hospital Intervention group: Dubdoc patients Control group: low-triage-level ED patients Cohort study United States 2003–2005 Rural counties in state of Georgia Intervention group: counties with CHCs (n = 24) Control group: counties without federally funded CHCs (n = 93) Case-comparison study before-and-after advance access implementation Canada 3 months Four family physician practices Intervention group: patients of general practice with advanced access booking Control group: patients of three general practices with traditional booking 7% revenue increase for practice Improved self-reported patient satisfaction (p < 0.05) Before-and-after observational study with control group Belgium 2006–2007 Formation of GPCs Intervention group: city (Turnhout) that implemented GPC Control group: two other large cities that did not have GPC (Ghent and Antwerp) Retrospective pre–post study United States 1999–2001 Risk adjusted Large, multispecialty medical group Patients with three select chronic conditions (heart disease, diabetes, depression) Intervention group: 17,376 patients in 2001 after implementation of open access Control group: 16,099 patients in 1999 before implementation of open access Increase in primary care visits (all p < 0.01) Significant decrease in risk-adjusted proportion of patients visiting urgent care (all p < 0.001) Total cost per patients increased 10%–20% depending on condition Significant reduction of proportion of patients with hospitalizations (1%) and length of stay >3 days (4%) for heart disease patients only (nonsignificant changes for other conditions) Retrospective pre–post study United States 1999–2001 Risk adjusted Large, multispecialty medical group owned by health plan Intervention group: 6,609 patients with depression in 2001 after implementation of open access Control group: 7,284 patients with depression in 1999 before implementation of open access 1% increase in primary care visits (p < 0.01) 2% increase in hospitalizations (p < 0.05) 17.6% reduction in proportion of patients with no follow-up after starting new medication (p = 0.001) Majority of visits with one physician (continuity of care) increased by 6.7% (p < 0.001) Retrospective pre–post cohort study Limburg, the Netherlands Regional general practitioner cooperatives Intervention group: 12,319 patient contacts after implementation of GPCs Control group: 11,781 patient contacts before implementation of GPCs 9% decrease in ED visits after hours 13.7% absolute reduction number of self-referrals to ED 10% increase in primary care visits after hours 4.6% increase in overall patient contacts after hours 3.6% shift in use from ED to primary care (p < 0.001) Pre–post intervention study with comparison group United States 12 months Large, private, primary care pediatric practice with Medicaid patients Intervention group: 17,382 children in the enhanced access program Control group: 26,066 Medicaid-eligible children who received services from other local community primary care providers Both studies examining the effects of emergency medical services (EMS) diversion of low-acuity patients away from the ED found significant decreases in the use of the ED after interventions, with reductions ranging from 3% to 7% (Table 3).25, 26 One study was conducted in the United States, and the other, in the United Kingdom. One intervention involved EMS offering either home or clinic care to low-acuity patients.25 The other involved transportation of such patients to clinic care without home care as an option.26 Regarding effect on non-ED use, both studies found increases in use of other care settings. No studies directly addressed other health or cost outcomes. No data were risk adjusted. Cohort study with matched historical controls United States August 2000–January 2001 Two EMS Intervention group: 1,016 patients Control (historical) group: 2,617 patients Clinic use: there was 3.5% more clinic use by the intervention group compared to the control group (8% vs. 4.5%) (p = 0.001) No transport (home care): there was 3.7% more home care (no transport) by the intervention group compared to the control group (47.4% vs. 4.5) (p = 0.043) Cluster randomized controlled trial United Kingdom 6 months Two EMS. Intervention group: 409 patients Control group: 425 patients Of the 12 studies examining the effects of managed care on ED use, six had interventions with capitated payment of primary care physician, five had a requirement of primary care physician approval or gatekeeping, and one was a hybrid of these two (Table 4).27-38 Ten studies were based in the United States, one in Canada, and one in Ireland. The majority of U.S. studies were in Medicaid populations and included pediatric patients. Overall, nine studies (six with capitation and four with gatekeeping as interventions) found significant decreases in the use of the ED after managed care interventions, with reductions ranging from 1% to 46%, while two did not find any significant difference.27-31, 33-38 The final study found mixed results with no change in ED use when comparing physicians pre- and postcapitation, but with an increase in ED use among physicians compensated through capitation versus fee-for-service.32 Before-and-after study United States 3 years 1983–1985 Single, pediatric ED Intervention group: patients assigned to PCP under AFDC recipients, estimated ~40,000 Control group: same group of patients, 1 year prior to start of program Total ED visits: Pre: 35,704 During: 25,543 Post: 31,248 Total ED use decreased 23% during the study period compared to period after end of program, for patients enrolled in AFDC program, ED use decreased 46% Total hospital admissions from ED (no significant change): Pre: 3,545 During: 3,555 Post: 3,922 Single, university-based pediatric clinic. Medicaid patients. Intervention group: 4,766 patients (July 1–August 30, 1991) Control group: 2,798 patients (July 1–Augist 30, 1981) ED visits declined 2.4% (p = 0.00005) Inappropriate ED visits declined 33% (p < 0.00001) Four Medicaid demonstration programs Intervention group: AFDC in program requiring gatekeeper approval Control group: recipients of traditional Medicaid programs Before-and-after study Ireland 1993–1995 Large, single ED Intervention group: Patients were GMS ineligible did not qualify for free care in Ireland Control group: all patients who visited ED Randomized control trial United States 1997–1998 Single, university-affiliated primary care practice Intervention group: 1,121 patients Control group: 1,172 patients PCP visits: nonsignificant increase in intervention group (0.27 visits/patient/year, p = 0.14) Specialty visits: significant reduction in visits in intervention group (0.57 visits/patient/year, p = 0.04) Pediatric Medicaid patients, single state Intervention group: recipients in areas with capitation Control group: recipients in areas without capitation Decrease in inpatient psychiatric admission Increase in outpatient visits in for for-profit capitated areas Single-state, Medicaid patients year prior and after intervention Intervention group: recipients in areas with capitation Control group: recipients in areas without capitation Single-state, Medicaid patients Intervention group: 10,685 patients (1993) 7,541 patients (1994) Control group: 6,614 patients (1991) 7,295 patients (1992) Nonquantified increase in outpatient visits Inpatient admission decreased by 4% Median length-of-stay decreased by 3.3 days Increase in 30-day readmissions by 1.9% Reduction in expenditures per beneficiary $420 Retrospective cohort study Canada 2005–2006 Single province in country with universal health care system Intervention group: 487,131 patients in primary care practices of physicians who chose capitated system Control group: 2,517,527 patients in primary care practices of physicians who chose fee-for-service system No change in ED visits in capitation group vs. same physicians precapitation Increase likelihood of OR = 1.20, 95% CI = 1.15 to 1.25) for capitation group vs. fee-for-service group (4% more patients in capitation group made visits to ED Higher ratio of low-acuity visits among capitation (1.6) vs. control (0.9) groups Members of five insurers in one city Intervention groups: 22,316 patients in fully capitated HMO 38,030 patients in any of three IPA Control group: 14,110 patients in a traditional indemnity insurance plan (estimated) ED use rates (p < 0.05): 70 per 1000 members in capitated panel, 363 per 1000 members in IPA panel, 466 per 1000 members in indemnity panel (85% lower ED use rates in capitated vs. indemnity panel) Admission for five ambulatory sensitive conditions 0.8 per 1000 members in capitated panel, 2.7 per 1000 members in IPA panel, 2.9 per 1000 members in indemnity panel Before-and-after study United States 1995–1997 Pediatric visits at two community EDs over 2 year, determined rates of ED visits after implementation of managed care plan Intervention group: Medicaid-managed care with 20,663 ED visits Control group: non-Medicaid group: 34,079 ED visits Medicaid group: 24% reduction in overall ED visits (p < 0.001) (33.5 [SD ± 5.3] reduced to 25.6 [SD ± 2.3] monthly ED visit per 1,000 enrollees); 37% reduction in nonurgent ED visits (p < 0.001) Non–Medicaid-insured group: 8% increase in overall ED visits (p < 0.001) 8% increase in nonurgent ED visits (p not given) Retrospective cohort study United States One year Three asthmatic pediatric patients groups based on their type of insurance Fee-for-service group: 47 patients Capitated (HMO) group: 24 patients Medicaid group: 22 patients ED use: Fee for service, 2/47 (4%); Capitated, 6/24 (25%); Medicaid, 7.5/22 (34%); p = 0.038 Physician visits Fee for service, 12/47 (25%); Capitated, 12/24 (50%); Medicaid, 9.5/22 (43%); p = 0.56 Specialist visits Fee for service, 6/47 (12.7%); Capitated, 7.5/24 (31%); Medicaid, 3/22 (13.6%); p = 0.118 Hospital visits Fee for service, 2/47 (4%); Capitated, 2/24 (8.3%); Medicaid, 3/22 (13.6%); p = 0.14 Regarding the effect on non-ED use, six studies did report data, with only four reporting significance and mixed results.28, 30, 32, 35, 37, 38 Six articles included health outcome data, five in the form of effect on hospitalizations and one on morbidity indices; results were mixed and did not always assess for significance.27, 30, 32, 34, 37, 38 Two studies reported cost data with both showing decreases with capitation.28, 30 No studies reported risk-adjusted data. Of the 10 studies using costs to influence patients to use certain sites for care, or to use care efficiently, nine studies found significant decreases in the use of the ED after implementation of the intervention, with reductions ranging from 3% to 50% (Table 5).39-47 The remaining study found a significant relative increase of 34% in ED visits.48 All studies took place in the United States. The intervention in seven studies was the requirement for patient copayment or coinsurance, and in three it was the implementation of a high deductible. Half of the studies were in Medicaid populatons, with the majority of those single-state interventions, while the others involved commercial insurers. Quasi-experimental, longitudinal, concurrent controls United States 1999–2001 Risk adjusted Prepaid integrated delivery system, 19 medical center Intervention group: commercially insured, 2,257,445 patients (copayment levels: $0, $1–$5, $10–$15, $20–$35, and $50–$10 per ED visit) Control group: Medicare, with employer supplementation, 261,091 patients (copayment levels: $0, $1–$15, and $20–$50 per ED visit) Before-and-after observational study United States 48 months 26 EDs, purposive sample of the state Intervention group: post–Oregon health plan cutbacks Control group: pre–Oregon health plan cut-backs Five groups of patients based on the class of payer: Hospitalization from ED visit (adjusted ORs): Before-and-after study United States 2001–2004 State population study Intervention group: Medicaid enrollees with the standard plan Control group: Medicaid enrollees with the plus plan (not affected by cutbacks) Medicaid cutback, Oregon: The beneficiaries of the Oregon health plan receive new policy changes that include copayment for most of the health services (PCP visits, ED use, and hospitalization and eliminated outpatient behavioral health services Decrease in ED use rates (RR = 0.84; 95% CI = 0.83–0.86). Compared to Plus Plan members, use also decreased (RR = 0.82; 95% CI = 0.80–0.84) Injury-related visits also decreased (p < 0.001). Quasi experimental, pre–post design (differences-in-differences methodology) 24 months Risk adjusted State-level study among Medicaid enrollees in 29 states. Intervention group: Medicaid enrollees in states with copayment increase (nine states) Control group: Medicaid enrollees in states without no copayment or no copayment change (20 states) Randomized controlled trial United States State-level among six geographic areas in four states Intervention group: 3,973 persons were assigned randomly to different fee-for-service insurance plans with copayment rates of 0, 25, 50, or 95% The pro" @default.
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• W1983907625 title "Non-Emergency Department Interventions to Reduce ED Utilization: A Systematic Review" @default.
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