Another Round: Influence of Alcohol-Related Conditions and Other Drug Use-Related Disorders in Emergency Department Frequent Use - A Single-Site Matched Case-Control Study in Spain.

INTRODUCTION: Patients who make 5 or more visits per year to hospital emergency departments (EDs) are usually considered ED frequent users (FUs). This study aims to better characterize the influence of alcohol and other drug use-related disorders in this phenomenon in a European Mediterranean country with public, universal, tax-financed healthcare system. METHODS: Matched case-control study. Cases were adults between 18 and 65 years old who consulted 5 or more times the ED of a tertiary hospital in Spain between December 2018 and November 2019. Each case was assigned a control of the same age and gender, who appeared to the ED on the same day, but who made 4 visits or less to the service during the study period. The electronic record of the first ED visit during this period was used to extract the variables of interest: emergency care received, clinical and social characteristics. Predictors of frequent ED use were identified with conditional logistic regression. RESULTS: 609 case-control pairs (total n = 1,218) were selected. History of alcohol-related conditions (adjusted odds ratio [AOR] = 1.82 [95% CI: 1.26-2.64] p = 0.001) and also other drug use-related disorders (AOR = 1.50 [95% CI: 1.11-2.03] p = 0.009) significantly increased the probability of frequent use of emergency services. DISCUSSION/CONCLUSION: Alcohol-related conditions and other drug use-related disorders must be evaluated in all ED FUs. Specific action protocols to concurrently address repeated attendance and addictions in the emergency room could be a good tool to reduce frequent ED use.

Tracking and Profiling Repeated Users Over Time in Text-Based Counseling: Longitudinal Observational Study With Hierarchical Clustering.

BACKGROUND: Due to their accessibility and anonymity, web-based counseling services are expanding at an unprecedented rate. One of the most prominent challenges such services face is repeated users, who represent a small fraction of total users but consume significant resources by continually returning to the system and reiterating the same narrative and issues. A deeper understanding of repeated users and tailoring interventions may help improve service efficiency and effectiveness. Previous studies on repeated users were mainly on telephone counseling, and the classification of repeated users tended to be arbitrary and failed to capture the heterogeneity in this group of users. OBJECTIVE: In this study, we aimed to develop a systematic method to profile repeated users and to understand what drives their use of the service. By doing so, we aimed to provide insight and practical implications that can inform the provision of service catering to different types of users and improve service effectiveness. METHODS: We extracted session data from 29,400 users from a free 24/7 web-based counseling service from 2018 to 2021. To systematically investigate the heterogeneity of repeated users, hierarchical clustering was used to classify the users based on 3 indicators of service use behaviors, including the duration of their user journey, use frequency, and intensity. We then compared the psychological profile of the identified subgroups including their suicide risks and primary concerns to gain insights into the factors driving their patterns of service use. RESULTS: Three clusters of repeated users with clear psychological profiles were detected: episodic, intermittent, and persistent-intensive users. Generally, compared with one-time users, repeated users showed higher suicide risks and more complicated backgrounds, including more severe presenting issues such as suicide or self-harm, bullying, and addictive behaviors. Higher frequency and intensity of service use were also associated with elevated suicide risk levels and a higher proportion of users citing mental disorders as their primary concerns. CONCLUSIONS: This study presents a systematic method of identifying and classifying repeated users in web-based counseling services. The proposed bottom-up clustering method identified 3 subgroups of repeated users with distinct service behaviors and psychological profiles. The findings can facilitate frontline personnel in delivering more efficient interventions and the proposed method can also be meaningful to a wider range of services in improving service provision, resource allocation, and service effectiveness.

A mapping review of interventions to address patients who frequently seek care in the emergency department.

BACKGROUND: The high utilization of acute care services, particularly emergency departments (ED), continues to be a significant concern for healthcare providers. Numerous approaches have been studied to meet the care needs of patients who frequently seek care in the ED; however, there is no comprehensive review of the current literature base. As such, a current understanding of the interventions initiated within the ED to address the needs of frequent users is required. This mapping review had three objectives: identify the characteristics associated with the need to frequently seek care in the ED; identify interventions implemented to address the needs of this population; and identify gaps in the current evidence base. METHODS: A knowledge map was created by scoping the literature to identify characteristics associated with frequent ED use and interventions implemented to address frequent use. Then, a literature search was conducted to determine what has been implemented by EDs to reduce frequent ED use. The literature was searched from 2013 to January 2023. MeSH terms and keywords were used to identify relevant studies. Studies implementing an intervention for those with characteristics associated with frequent ED use and reporting on ED use were included. RESULTS: Twenty-three (23) controlled trials and 35 observational studies were included. The most common populations were older adults, those with chronic conditions, and generic "frequent users". No studies assessed Indigenous Peoples or racial minorities, and few assessed patients with a disability or patients experiencing homelessness. The most common interventions were referrals, care plans, case management, care coordination, and follow-up phone calls. Most studies reported ED revisits, hospitalization, costs, length-of-stay, or outpatient utilization. Few assessed patient or staff perspectives. About one-third of studies (n = 24) reported significant reductions in ED revisits. CONCLUSIONS: Similar interventions, mainly focused on care coordination and planning, have been implemented to address frequent use of the ED. There are still significant gaps in the populations that have been studied. Efforts now must be undertaken to study more diverse populations whose care needs are not being met elsewhere and thus frequent the ED often.

Utilization patterns, cardiovascular risk, and concomitant serotoninergic medications among triptan users between 2008 and 2018: A gender analysis in one Italian region, Tuscany.

OBJECTIVE: To describe the pattern of triptan use by gender in Tuscany, Italy, focusing on special user populations in which evidence on triptan safety is still not conclusive. BACKGROUND: Growing evidence supports the role of gender differences in migraine pathophysiology and treatment. However, gender impact on triptan real-word utilization has been poorly investigated. METHODS: A retrospective, descriptive, cohort study was performed using the population-based Administrative Healthcare Database of Tuscany region (Italy). Subjects registered in the database on the January 1 of each year between 2008 and 2018 were identified. New users (NU) of triptans (ATC:N02CC*) were patients with one or more triptan dispensation during the year of interest and none in the past. Age, cardiovascular comorbidities representing an absolute or a possible contraindication to triptan utilization, concomitant serotonergic medications, and pattern of triptan use during 1-year follow-up were described by gender. RESULTS: A total of 86,109 patients who received one or more triptan dispensing were identified. Of 64,672 NU (men = 17,039; women = 47,633), 10.2% (6823/64,672) were aged >65 years, who were mostly women (n = 4613). Among NU, men and women with absolute cardiovascular contraindications were 4.3% (740/17,039) and 2.1% (1022/47,633), respectively, while those concomitantly taking serotonergic medications were 17.2% (267/1549) and 21.9% (949/4330), respectively (949/4330). Regular users (two or more dispensing with ≥3 months between first and last observed dispensing) accounted for 26.4% of women (12,597/47,633) and 19.11% of men (3250/17,039); frequent users (≥15 dosage units/month during ≥3 consecutive months) were overall 0.1% (94/64,672) and 62.0% (58/94) of them concomitantly received serotonergic medications. CONCLUSION: Considering gender differences in triptan use highlighted here, large scale observational studies are warranted to better define what populations are safe to use triptans and whether it is appropriate to tighten or relax certain recommendations on triptan use. In the meantime, any suspected adverse drug reaction observed in the special user populations highlighted in this study should be promptly reported.

Identifying facilitators and barriers to integrated and equitable care for community-dwelling older adults with high emergency department use from historically marginalized groups.

BACKGROUND: High rates of emergency department (ED) use by older adults persist despite attempts to improve accessibility of appropriate and comprehensive care. Understanding the drivers of ED visits from the perspective of older adults from historically marginalized groups could help reduce ED use by patients with needs that are preventable or could have been treated in a more appropriate setting. This interpretivist, feminist study aims to explore the unmet care needs of older adults (age 65 +) with high ED use and belonging to historically marginalized groups to better understand how social and structural inequities reinforced by neoliberalism; federal and provincial governance structures and policy frameworks; and regional processes and local institutional practices, shape the experiences of these older adults, particularly those at risk of poor health outcomes based on the social determinants of health (SDH). METHODS/DESIGN: This mixed methods study will employ an integrated knowledge translation (iKT) approach, starting with a quantitative phase followed by a qualitative phase. Older adults self-identifying as belonging to a historically marginalized group, having visited an ED three or more times in the past 12 months, and living in a private dwelling, will be recruited using flyers posted at two emergency care sites and by an on-site research assistant. Data obtained through surveys, short answer questions, and chart review will be used to compile case profiles of patients from historically marginalized groups with potentially avoidable ED visits. Descriptive and inferential statistical analyses and inductive thematic analysis will be conducted. Findings will be interpreted using the Intersectionality-Based Policy Analysis Framework to identify the interconnections between unmet care needs, potentially avoidable ED admissions, structural inequalities, and the SDH. Semi-structured interviews will be conducted with a subset of older adults at risk of poor health outcomes based on SDH, family care partners, and health care professionals to validate preliminary findings and collect additional data on perceived facilitators and barriers to integrated and accessible care. DISCUSSION: Exploring the linkages between potentially avoidable ED visits by older adults from marginalized groups and how their care experiences have been shaped by inequities in the systems, policies, and institutions that structure health and social care provision will enable researchers to offer recommendations for equity-focused policy and clinical practice reforms to improve patient outcomes and system integration.

Predictors of frequent emergency department visits among hospitalized cancer patients: a comparative cohort study using integrated clinical and administrative data to improve care delivery.

BACKGROUND: Frequent emergency department (FED) visits by cancer patients represent a significant burden to the health system. This study identified determinants of FED in recently hospitalized cancer patients, with a particular focus on opioid use. METHODS: A prospective cohort discharged from surgical/medical units of the McGill University Health Centre was assembled. The outcome was FED use (≥ 4 ED visits) within one year of discharge. Data retrieved from the universal health insurance system was analyzed using Cox Proportional Hazards (PH) model, adopting the Lunn-McNeil approach for competing risk of death. RESULTS: Of 1253 patients, 14.5% became FED users. FED use was associated with chemotherapy one-year pre-admission (adjusted hazard ratio (aHR) 2.60, 95% CI: 1.80-3.70), ≥1 ED visit in the previous year (aHR: 1.80, 95% CI 1.20-2.80), ≥15 pre-admission ambulatory visits (aHR 1.54, 95% CI 1.06-2.34), previous opioid and benzodiazepine use (aHR: 1.40, 95% CI: 1.10-1.90 and aHR: 1.70, 95% CI: 1.10-2.40), Charlson Comorbidity Index ≥ 3 (aHR: 2.0, 95% CI: 1.2-3.4), diabetes (aHR: 1.60, 95% CI: 1.10-2.20), heart disease (aHR: 1.50, 95% CI: 1.10-2.20) and lung cancer (aHR: 1.70, 95% CI: 1.10-2.40). Surgery (cardiac (aHR: 0.33, 95% CI: 0.16-0.66), gastrointestinal (aHR: 0.34, 95% CI: 0.14-0.82) and thoracic (aHR: 0.45, 95% CI: 0.30-0.67) led to a decreased risk of FED use. CONCLUSIONS: Cancer patients with higher co-morbidity, frequent use of the healthcare system, and opioid use were at increased risk of FED use. High-risk patients should be flagged for preventive intervention.

Implementation analysis of a case management intervention for people with complex care needs in primary care: a multiple case study across Canada.

BACKGROUND: Case management is one of the most frequently performed interventions to mitigate the negative effects of high healthcare use on patients, primary care providers and the healthcare system. Reviews have addressed factors influencing case management interventions (CMI) implementation and reported common themes related to the case manager role and activities, collaboration with other primary care providers, CMI training and relationships with the patients. However, the heterogeneity of the settings in which CMI have been implemented may impair the transferability of the findings. Moreover, the underlying factors influencing the first steps of CMI implementation need to be further assessed. This study aimed to evaluate facilitators and barriers of the first implementation steps of a CMI by primary care nurses for people with complex care needs who frequently use healthcare services. METHODS: A qualitative multiple case study was conducted including six primary care clinics across four provinces in Canada. In-depth interviews and focus groups with nurse case managers, health services managers, and other primary care providers were conducted. Field notes also formed part of the data. A mixed thematic analysis, deductive and inductive, was carried out. RESULTS: Leadership of the primary care providers and managers facilitated the first steps of the of CMI implementation, as did the experience and skills of the nurse case managers and capacity development within the teams. The time required to establish CMI was a barrier at the beginning of the CMI implementation. Most nurse case managers expressed apprehension about developing an "individualized services plan" with multiple health professionals and the patient. Clinic team meetings and a nurse case managers community of practice created opportunities to address primary care providers' concerns. Participants generally perceived the CMI as a comprehensive, adaptable, and organized approach to care, providing more resources and support for patients and better coordination in primary care. CONCLUSION: Results of this study will be useful for decision makers, care providers, patients and researchers who are considering the implementation of CMI in primary care. Providing knowledge about first steps of CMI implementation will also help inform policies and best practices.

Factors related to the frequent use of emergency department services in Korea.

BACKGROUND: Frequent Emergency Department (ED) visitors are identified by the policymakers to reduce avoidable ED visits and lessen the financial and operational burden. This study aimed to identify the factors related to the frequent use of ED services. METHODS: This nationwide, cross-sectional observational study was conducted using information obtained from the 2019 National Emergency Department Information System (NEDIS) database. Frequent ED users were defined as patients with four or more ED visits a year. We performed multiple logistic regression analyses to verify the relationship among sociodemographic characteristics, residential characteristics, clinical characteristics, and frequency of ED visits. RESULTS: Among 4,063,640 selected patients, 137,608 patients visited the ED four or more times a year (total number of visits = 735,502 times), which accounted for 3.4% and 12.8% of the total number of ED users and ED visits, respectively. A high ED visit frequency was associated with male sex, age < 9 or ≥ 70 years, Medical Aid (based on the insurance type), lower number of medical institutions and beds compared with that of the national average, and conditions, such as cancer, diabetes, renal failure, and mental illness. A low ED-visit frequency was associated with residence in regions vulnerable to emergency medical care and regions with high income. The possibility of frequent ED visits was high for patients with level 5 severity (non-emergent) and those with an increased need for medical treatment, including older patients and patients with cancer or mental illness. The possibility of frequent ED visits was low for patients aged > 19 years with level 1 severity (resuscitation). CONCLUSIONS: Health service accessibility factors, including low income and medical resource imbalance, were associated with frequent ED visits. Future large-scale prospective cohort studies are warranted to establish an efficient emergency medical system.

How to reduce erroneous Emergency Department admissions for the frail elderly.

Background: Readmission after a first hospitalization is a common occurrence. It may be due to incomplete treatment, poor care for underlying problems or reflect bad coordination with health services at the time of discharge. The aim of this study was to identify the factors and classify the pathologies that expose elderly patients to erroneous access to the Emergency/Urgency Department (EUD). Study design: Retrospective observational study. Materials and methods: From January 2016 to December 2019 we studied patients who had at least one readmission to the EUD in the six months following discharge. All EUD accesses of the same patient that occurred for the problem treated during the previous hospitalization were identified. Data was provided by the University Hospital of Siena. Patients were stratified by age, gender, and municipality of residence. We used an ICD-9-CM coding system to describe health problems. Statistical analysis was carried out with Stata software. Results: We studied 1,230 patients (46.6% females) the mean age was 78.2 ± 14.3. Most of them, 721 (58.6%) were ≥80 years old, 334 (27.1%) were 65-79, 138 (11.2%) were 41-64, and only 37 (3.0%) were ≤40. Patients who lived in Municipality of Siena had a lower probability to return than to those living in other municipalities (OR 0.76; 95%CI: 0.62-0.93; p<0,05). The main causes of readmission for ≥65 years old were "symptoms, signs and ill-defined conditions" (18.3%), "respiratory diseases" (15.0%), "injury and poisoning" (14.1%), "cardiovascular diseases" (11.8%), "classification of factors influencing health status and contact with health services" (9.8%), "genitourinary diseases" (6.6%) and "digestive diseases (5.7%). Conclusions: We observed that patients residing a greater distance from the hospital facilitates the risk of readmission. The factors that were exposed could be used to identify frequent users and initiate measures to reduce their access.

Better understanding care transitions of adults with complex health and social care needs: a study protocol.

BACKGROUND: Adults with chronic conditions who also suffer from mental health comorbidities and/or social vulnerability require services from many providers across different sectors. They may have complex health and social care needs and experience poorer health indicators and high mortality rates while generating considerable costs to the health and social services system. In response, the literature has stressed the need for a collaborative approach amongst providers to facilitate the care transition process. A better understanding of care transitions is the next step towards the improvement of integrated care models. The aim of the study is to better understand care transitions of adults with complex health and social care needs across community, primary care, and hospital settings, combining the experiences of patients and their families, providers, and health managers. METHODS/DESIGN: We will conduct a two-phase mixed methods multiple case study (quantitative and qualitative). We will work with six cases in three Canadian provinces, each case being the actual care transitions across community, primary care, and hospital settings. Adult patients with complex needs will be identified by having visited the emergency department at least three times over the previous 12 months. To ensure they have complex needs, they will be invited to complete INTERMED Self-Assessment and invited to enroll if positive. For the quantitative phase, data will be obtained through questionnaires and multi-level regression analyses will be conducted. For the qualitative phase, semi-structured interviews and focus groups will be conducted with patients, family members, care providers, and managers, and thematic analysis will be performed. Quantitative and qualitative results will be compared and then merged. DISCUSSION: This study is one of the first to examine care transitions of adults with complex needs by adopting a comprehensive vision of care transitions and bringing together the experiences of patients and family members, providers, and health managers. By using an integrated knowledge translation approach with key knowledge users, the study's findings have the potential to inform the optimization of integrated care, to positively impact the health of adults with complex needs, and reduce the economic burden to the health and social care systems.

Characterizing people with frequent emergency department visits and substance use: a retrospective cohort study of linked administrative data in Ontario, Alberta, and B.C., Canada.

BACKGROUND: Substance use is common among people who visit emergency departments (EDs) frequently. We aimed to characterize subgroups within this cohort to better understand care needs/gaps, and generalizability of characteristics in three Canadian provinces. METHODS: This was a retrospective cohort study (April 1st, 2013 to March 31st, 2016) of ED patients in Ontario, Alberta, and British Columbia (B.C.) We included patients ≥ 18 years with substance use-related healthcare contact during the study period and frequent ED visits, defined as those in the top 10% of ED utilization when all patients were ordered by annual ED visit number. We used linked administrative databases including ED visits and hospitalizations (all provinces); mental heath-related hospitalizations (Ontario and Alberta); and prescriptions, physician services, and mortality (B.C.). We compared to cohorts of people with (1) frequent ED visits and no substance use, and (2) non-frequent ED visits and substance use. We employed cluster analysis to identify subgroups with distinct visit patterns and clinical characteristics during index year, April 1st, 2014 to March 31st, 2015. RESULTS: In 2014/15, we identified 19,604, 7,706, and 9,404 people with frequent ED visits and substance use in Ontario, Alberta, and B.C (median 37-43 years; 60.9-63.0% male), whose ED visits and hospitalizations were higher than comparison groups. In all provinces, cluster analyses identified subgroups with "extreme" and "moderate" frequent visits (median 13-19 versus 4-6 visits/year). "Extreme" versus "moderate" subgroups had more hospitalizations, mental health-related ED visits, general practitioner visits but less continuity with one provider, more commonly left against medical advice, and had higher 365-day mortality in B.C. (9.3% versus 6.6%; versus 10.4% among people with frequent ED visits and no substance use, and 4.3% among people with non-frequent ED visits and substance use). The most common ED diagnosis was acute alcohol intoxication in all subgroups. CONCLUSIONS: Subgroups of people with "extreme" (13-19 visits/year) and "moderate" (4-6 visits/year) frequent ED visits and substance use had similar utilization patterns and characteristics in Ontario, Alberta, and B.C., and the "extreme" subgroup had high mortality. Our findings suggest a need for improved evidence-based substance use disorder management, and strengthened continuity with primary and mental healthcare.

The analysis of the geographical distribution of emergency departments' frequent users: a tool to prioritize public health policies?

BACKGROUND: The individual factors associated to Frequent Users (FUs) in Emergency Departments are well known. However, the characteristics of their geographical distribution and how territorial specificities are associated and intertwined with ED use are limited. Investigating healthcare use and territorial factors would help targeting local health policies. We aim at describing the geographical distribution of ED's FUs within the Paris region. METHODS: We performed a retrospective analysis of all ED visits in the Paris region in 2015. Data were collected from the universal health insurance's claims database. Frequent Users (FUs) were defined as having visited ≥3 times any ED of the region over the period. We assessed the FUs rate in each geographical unit (GU) and assessed correlations between FUs rate and socio-demographics and economic characteristics of GUs. We also performed a multidimensional analysis and a principal component analysis to identify a typology of territories to describe and target the FUs phenomenon. RESULTS: FUs accounted for 278,687 (11.7%) of the 2,382,802 patients who visited the ED, living in 232 GUs. In the region, median FUs rate in each GU was 11.0% [interquartile range: 9.5-12.5]. High FUs rate was correlated to the territorial markers of social deprivation. Three different categories of GU were identified with different profiles of healthcare providers densities. CONCLUSION: FUs rate varies between territories and is correlated to territorial markers of social deprivation. Targeted public policies should focus on disadvantaged territories.

Identifying Frequent Health Care Users and Care Consumption Patterns: Process Mining of Emergency Medical Services Data.

BACKGROUND: Tracing frequent users of health care services is highly relevant to policymakers and clinicians, enabling them to avoid wasting scarce resources. Data collection on frequent users from all possible health care providers may be cumbersome due to patient privacy, competition, incompatible information systems, and the efforts involved. OBJECTIVE: This study explored the use of a single key source, emergency medical services (EMS) records, to trace and reveal frequent users' health care consumption patterns. METHODS: A retrospective study was performed analyzing EMS calls from the province of Drenthe in the Netherlands between 2012 and 2017. Process mining was applied to identify the structure of patient routings (ie, their consecutive visits to hospitals, nursing homes, and EMS). Routings are used to identify and quantify frequent users, recognizing frail elderly users as a focal group. The structure of these routes was analyzed at the patient and group levels, aiming to gain insight into regional coordination issues and workload distributions among health care providers. RESULTS: Frail elderly users aged 70 years or more represented over 50% of frequent users, making 4 or more calls per year. Over the period of observation, their annual number and the number of calls increased from 395 to 628 and 2607 to 3615, respectively. Structural analysis based on process mining revealed two categories of frail elderly users: low-complexity patients who need dialysis, radiation therapy, or hyperbaric medicine, involving a few health care providers, and high-complexity patients for whom routings appear chaotic. CONCLUSIONS: This efficient approach exploits the role of EMS as the unique regional "ferryman," while the combined use of EMS data and process mining allows for the effective and efficient tracing of frequent users' utilization of health care services. The approach informs regional policymakers and clinicians by quantifying and detailing frequent user consumption patterns to support subsequent policy adaptations.

Does Case Management Provide Support for Staff Facing Frequent Users of Emergency Departments? A Comparative Mixed-Method Evaluation of ED Staff Perception.

OBJECTIVE: Frequent users of emergency departments (FUED) account for a disproportionate number of emergency department (ED) visits and contribute to a wide range of challenges for ED staff. While several research has documented that case management (CM) tailored to FUED leads to a reduction in ED visits and a better quality of life (QoL) among FUED, whether there is added value for ED staff remains to be explored. This study aimed to compare, among staff in two academic EDs in Switzerland (one with and one without CM), the FUED-related knowledge, perceptions of the extent of the FUED issue, FUED-related work challenges and FUEDs' legitimacy to use ED. METHOD: Mixed methods were employed. First, ED physicians and nurses (N = 253) of the two EDs completed an online survey assessing their knowledge and perceptions of FUEDs. Results between healthcare providers working in an ED with CM to those working in an ED without CM were compared using independent two-sided T-tests. Next, a sample of participants (n = 16) took part in a qualitative assessment via one-to-one interviews (n = 6) or focus groups (n = 10). RESULTS: Both quantitative and qualitative results documented that the FUED-related knowledge, the extent FUED were perceived as an issue and perceived FUEDs' legitimacy to use ED were not different between groups. The level of perceived FUED-related challenges was also similar between groups. Quantitative results showed that nurses with CM experienced more challenges related to FUED. Qualitative exploration revealed that lack of psychiatric staff within the emergency team and lack of communication between ED staff and CM team were some of the explanations behind these counterintuitive findings. CONCLUSION: Despite promising results on FUEDs' QoL and frequency of ED visits, these preliminary findings suggest that CM may provide limited support to ED staff in its current form. Given the high burden of FUED-related challenges encountered by ED staff, improved communication and FUED-related knowledge transfer between ED staff and the CM team should be prioritized to increase the value of a FUED CM intervention for ED staff.

Case Management in Primary Care for Frequent Users of Health Care Services: A Realist Synthesis.

PURPOSE: Case management (CM) is a promising intervention for frequent users of health care services. Our research question was how and under what circumstances does CM in primary care work to improve outcomes among frequent users with chronic conditions? METHODS: We conducted a realist synthesis, searching MEDLINE, CINAHL, Embase, and PsycINFO (1996 to September 2017) for articles meeting the following criteria: (1) population: adult frequent users with chronic disease, (2) intervention: CM in a primary care setting with a postintervention evaluation, and (3) primary outcomes: integration of services, health care system use, cost, and patient outcome measures. Academic and gray literature were evaluated for relevance and robustness. Independent reviewers extracted data to identify context, mechanism, and outcome (CMO) configurations. Analysis of CMO configurations allowed for the modification of an initial program theory toward a refined program theory. RESULTS: Of the 9,295 records retrieved, 21 peer-reviewed articles and an additional 89 documents were retained. We evaluated 19 CM interventions and identified 11 CMO configurations. The development of a trusting relationship fostering patient and clinician engagement in the CM intervention was recurrent in many CMO configurations. CONCLUSION: Our refined program theory proposes that in the context of easy access to an experienced and trusted case manager who provides comprehensive care while maintaining positive interactions with patients, the development of this relationship fosters the engagement of both individuals and yields positive outcomes when the following mechanisms are triggered: patients and clinicians feel supported, respected, accepted, engaged, and committed; and patients feel less anxious, more secure, and empowered to self-manage.

Frequent Emergency Department Visitors Associated With a Pain-Discharge Diagnosis.

BACKGROUND: Emergency departments (EDs) have experienced an increase in annual patient visits and length of stay over the past decade. Management of frequent-user patients with pain-related diagnoses are challenging in a time-limited setting. OBJECTIVE: The purpose of this study was to describe characteristics of frequent ED users with pain-related diagnoses. METHODS: This was a retrospective longitudinal cohort study of hospital ED visits from two EDs in using encounters from September 2016 to August 2018. Frequent users were characterized as having four or more visits in a 1-year period and were further classified into three categories based on the number of pain-related visits in the study period. Descriptive statistics and regression analysis results are reported for all demographic and clinical characteristics for index encounters, patient level data, and pain subgroups. RESULTS: Of all patients, 11.3% (n = 5174) were identified as frequent users, accounting for 38.9% (n = 91,114) of all ED visits. Overall, frequent pain users were more likely to be of middle age (odds ratio [OR] 1.70, 95% confidence interval [CI] 0.80-1.72), female (OR 2.43, 95% CI 1.79-3.29), have commercial insurance (OR 1.91, 95% CI 1.37-2.66), and have 10 or more ED encounters (super user status) in a 12-month period (OR 23.66, 95% CI 17.12-32.71). CONCLUSION: Understanding characteristics of ED frequent users with pain-related diagnoses may inform community-based interventions designed to reduce episodic care and thereby improve care coordination and management.

Characteristics of Case Management in Primary Care Associated With Positive Outcomes for Frequent Users of Health Care: A Systematic Review.

PURPOSE: Case management (CM) interventions are effective for frequent users of health care services, but little is known about which intervention characteristics lead to positive outcomes. We sought to identify characteristics of CM that yield positive outcomes among frequent users with chronic disease in primary care. METHODS: For this systematic review of both quantitative and qualitative studies, we searched MEDLINE, CINAHL, Embase, and PsycINFO (1996 to September 2017) and included articles meeting the following criteria: (1)population: adult frequent users with chronic disease, (2)intervention: CM in a primary care setting with a postintervention evaluation, and (3)primary outcomes: integration of services, health care system use, cost, and patient outcome measures. Independent reviewers screened abstracts, read full texts, appraised methodologic quality (Mixed Methods Appraisal Tool), and extracted data from the included studies. Sufficient and necessary CM intervention characteristics were identified using configurational comparative methods. RESULTS: Of the 10,687 records retrieved, 20 studies were included; 17 quantitative, 2 qualitative, and 1 mixed methods study. Analyses revealed that it is necessary to identify patients most likely to benefit from a CM intervention for CM to produce positive outcomes. High-intensity intervention or the presence of a multidisciplinary/interorganizational care plan was also associated with positive outcomes. CONCLUSIONS: Policy makers and clinicians should focus on their case-finding processes because this is the essential characteristic of CM effectiveness. In addition, value should be placed on high-intensity CM interventions and developing care plans with multiple types of care providers to help improve patient outcomes.

Impact of an individual plan of care for frequent and high utilizers in a large healthcare system.

INTRODUCTION: "Frequent or High Utilizers" are significant stressors to Emergency Departments (EDs) and Inpatient Units across the United States (US). These patients incur higher healthcare costs with ED visits and inpatient admissions. Our aims were to determine whether implementation of individualized care plans (ICPs) could 1) reduce costs, 2) reduce inpatient length of stay (LOS), and 3) reduce ED encounters throughout a large healthcare system. METHODS: 13 EDs were included including academic, community, Free-standing and pediatric EDs. Data was collected from January 1, 2014 through December 31, 2017. ICPs were created for high ED utilizers, as recommended by staff input through multidisciplinary care committees at each site. The ICP consisted of 1) specific symptom-related information with approaches in management, 2) recent assessment from specialists, 3) social work summary, and 4) psychiatry summary. A Best Practice Alert was placed in the electronic medical record that could be seen at all hospitals within the system. ICP's were updated annually. RESULTS: 626 ICPs were written; 452 initial ICPs and 174 updates. The 452 ICP patients accounted for 23,705 encounters during the four-year period; on average, an ICP patient visited the ED 52 times (14.75 encounters/year). Overall indirect and direct costs decreased 42% over first 6 months, inpatient LOS improved from 1.9 to 0.97 days/month, and ED encounters decreased from 1.96 to 1.14. All cost and LOS data significantly improved at 24 months post-ICP inception. CONCLUSION: Implementation of individualized care plan can reduce cost, inpatient LOS, and ED encounters for high utilizers.

Characterizing pediatric high frequency users of California emergency departments.

OBJECTIVE: Emergency department (ED) utilization has increased for the last several decades. Despite a focus on adult frequent ED users, little research has examined pediatric frequent ED users. The purpose of this study was to assess pediatric ED utilization in California and to describe those identified as frequent ED users. METHODS: This was a retrospective multi-facility study of ED visits by children 1-17 years of age using statewide data from the California Office of Statewide Health Planning and Development. Patients were classified into utilization groups by the number of ED visits in a one-year period prior to their last visit in 2016: occasional (1-5 visits) vs. frequent (>5 visits). Differences in patient characteristics were compared between occasional and frequent users. RESULTS: There were 690,130 patients between 1 and 17 years of age with 1,238,262 visits during the study period. Children with ≥6 visits (2.3%) accounted for 9.3% of all visits. 67% of frequent users had no visits to a pediatric ED. Over 40% (41.4%) of frequent users visited 2 or more hospitals, compared to 7.7% of occasional users. In multivariate analysis, the characteristics with the largest associations with frequent ED use were age, payer, and being admitted/transferred. CONCLUSIONS: The majority of pediatric frequent users do not seek care in pediatric EDs. Age, prior admission, and Medicare/Medicaid appear to have the largest associations with pediatric patient frequent ED utilization.

Implementing a case management intervention for frequent users of the emergency department (I-CaM): an effectiveness-implementation hybrid trial study protocol.

BACKGROUND: ED overcrowding represents a significant public health problem in developed countries. Frequent users of the emergency departments (FUEDs; reporting 5 or more ED visits in the past year) are often affected by medical, psychological, social, and substance use problems and account for a disproportionately high number of ED visits. Past research indicates that case management (CM) interventions are a promising way to reduce ED overcrowding and improve FUEDs' quality of life. There is, however, very limited knowledge about how to disseminate and implement this intervention on a large scale to diverse clinical settings, including community hospitals and non-academic centers. This paper describes the protocol of a research project aiming to implement a CM intervention tailored to FUEDs in the public hospitals with ED in the French-speaking region of Switzerland and evaluate both the implementation process and effectiveness of the CM intervention. METHODS: This research project uses a hybrid study design assessing both implementation and clinical outcomes. The implementation part of the study uses mixed methods a) to describe quantitatively and qualitatively factors that influence the implementation process, and b) to examine implementation effectiveness. The clinical part of the study uses a within-subject design (pre-post intervention) to evaluate participants' trajectories on clinical variables (e.g., quality of life, ED use) after receiving the CM intervention. We designed the study based on two implementation science frameworks. The Generic Implementation Framework guided the overall research protocol design, whereas the RE-AIM (reach, efficacy, adoption, implementation and maintenance) framework guided the implementation and effectiveness evaluations. DISCUSSION: This research project will contribute to implementation science by providing key insights into the processes of implementing CM into broader practice. This research project is also likely to have both clinical and public health implications. TRIAL REGISTRATION: NCT03641274 , Registered 20 August 2018.