["Active health management" can provide support for vulnerable patients. New model for the prevention of unplanned healthcare]. / ¼Aktiv hälsostyrning« kan ge utsatta patienter stöd - Ny modell för prevention av oplanerad sjukvård.

A small group of frequent emergency department visitors account for a disproportionally large fraction of health care consumption, including unplanned hospitalizations and overall healthcare costs. In response, case and disease management programs aimed at reducing health care consumption in this group have been tested, however results vary widely. In this study, we aimed to investigate if a telephone-based, nurse led case management intervention can reduce health care consumption for frequent emergency department visitors in a large-scale set-up. A total of 12,181 frequent emergency department users in three counties in Sweden were randomized either using Zelen's design or a traditional randomized design to receive a nurse led case management intervention or no intervention. Patients were followed for health care consumption for up to 2 years. The results of the study with traditional design showed an overall 12% (95% confidence interval [CI], 4-19%) decreased rate of hospitalization, which was mostly driven by effects among patients included in the last year. Similar results were achieved in the Zelen studies, with significant reduction of hospitalization, again in the last year, but mixed results in the early development of the project. Our study provides evidence that a carefully designed telephone-based intervention with accurate and systematic patient selection and appropriate staff training in a centralized set-up can lead to significant decreases in health care consumption and costs. However, we also demonstrate that the effects are sensitive to the delivery model chosen.

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.

Clinical process analysis and activity-based costing at a heart center.

Cost studies, productivity, efficiency, and quality of care measures, the links between resources and patient outcomes, are fundamental issues for hospital management today. This paper describes the implementation of a model for process analysis and activity-based costing (ABC)/management at a Heart Center in Sweden as a tool for administrative cost information, strategic decision-making, quality improvement, and cost reduction. A commercial software package (QPR) containing two interrelated parts, "ProcessGuide and CostControl," was used. All processes at the Heart Center were mapped and graphically outlined. Processes and activities such as health care procedures, research, and education were identified together with their causal relationship to costs and products/services. The construction of the ABC model in CostControl was time-consuming. However, after the ABC/management system was created, it opened the way for new possibilities including process and activity analysis, simulation, and price calculations. Cost analysis showed large variations in the cost obtained for individual patients undergoing coronary artery bypass grafting (CABG) surgery. We conclude that a process-based costing system is applicable and has the potential to be useful in hospital management.