A case management intervention targeted to reduce healthcare consumption for frequent Emergency Department visitors: results from an adaptive randomized trial.

BACKGROUND: A small group of frequent visitors to Emergency Departments accounts for a disproportionally large fraction of healthcare consumption including unplanned hospitalizations and overall healthcare costs. In response, several case and disease management programs aimed at reducing healthcare consumption in this group have been tested; however, results vary widely. OBJECTIVES: To investigate whether a telephone-based, nurse-led case management intervention can reduce healthcare consumption for frequent Emergency Department visitors in a large-scale setup. METHODS: A total of 12 181 frequent Emergency Department users in three counties in Sweden were randomized using Zelen's design or a traditional randomized design to receive either a nurse-led case management intervention or no intervention, and were followed for healthcare consumption for up to 2 years. RESULTS: The traditional design showed an overall 12% (95% confidence interval 4-19%) decreased rate of hospitalization, which was mostly driven by effects in the last year. Similar results were achieved in the Zelen studies, with a significant reduction in hospitalization in the last year, but mixed results in the early development of the project. CONCLUSION: Our study provides evidence that a carefully designed telephone-based intervention with accurate and systematic patient selection and appropriate staff training in a centralized setup can lead to significant decreases in healthcare consumption and costs. Further, our results also show that the effects are sensitive to the delivery model chosen.

[Laparoscopic colorectal surgery. Five-year experience at Huddinge University Hospital]. / Laparoskopisk kolorektal kirurgi. Fem års erfarenhet från huddinge universitetssjukhus.

By education of one to two surgeons at the time we limit the learning curve and reduce the complications. 250 patients have been operated for both benign and malignant colorectal diseases. The operation time is still longer than with the open technique. Conversion rate is 18 per cent, no mortality and few serious complications are seen. The blood loss is in mean 150 ml. With shorter time at the operation theatre through optimal education of the hole operation team, the costs for laparoscopic colorectal surgery will diminish. In the future with better laparoscopic technique, we believe there will be increased numbers of total colectomies and operations in the small pelvic.