A Randomized Controlled Trial of a Citywide Emergency Department Care-Coordination Program to Reduce Prescription Opioid-Related Visits: An Economic Evaluation.

BACKGROUND: Care provided in the emergency department (ED) can cost up to five times as much as care received for comparable diagnoses in alternative settings. Small groups of patients, many of whom suffer from an opioid use disorder, often account for a large proportion of total ED visits. We recently conducted, and demonstrated the effectiveness of, the first randomized controlled trial of a citywide ED care-coordination program intending to reduce prescription-opioid-related ED visits. All EDs in the metropolitan study area were connected to a Web-based information exchange system. OBJECTIVE: The objective of this article was to perform an economic evaluation of the 12-month trial from a third-party-payer perspective. METHODS: We modeled the person-period monthly for the 12-month observation period, and estimated total treatment costs and return on investment (ROI) with regard to cost offsets, over time, for all visits where the patient was admitted to and discharged from the ED. RESULTS: By the end of month 4, the mean cumulative cost differential was significantly lower for intervention relative to treatment-as-usual participants (-$1370; p = 0.03); this figure climbed to -$3200 (p = 0.02) by the end of month 12. The ROI trended upward throughout the observation period, but failed to reach statistical significance by the end of month 12 (ROI = 3.39, p = 0.07). CONCLUSION: The intervention produced significant cost offsets by the end of month 4, which continued to accumulate throughout the trial; however, ROI was not significant. Because the per-patient administrative costs of the program are incurred at the time of enrollment, our results highlight the importance of future studies that are able to follow participants for a period beyond 12 months to more accurately estimate the program's ROI.

A Randomized Controlled Trial of a Citywide Emergency Department Care Coordination Program to Reduce Prescription Opioid Related Emergency Department Visits.

BACKGROUND: Increasing prescription overdose deaths have demonstrated the need for safer emergency department (ED) prescribing practices for patients who are frequent ED users. OBJECTIVES: We hypothesized that the care of frequent ED users would improve using a citywide care coordination program combined with an ED care coordination information system, as measured by fewer ED visits by and decreased controlled substance prescribing to these patients. METHODS: We conducted a multisite randomized controlled trial (RCT) across all EDs in a metropolitan area; 165 patients with the most ED visits for complaints of pain were randomized. For the treatment arm, drivers of ED use were identified by medical record review. Patients and their primary care providers were contacted by phone. Each patient was discussed at a community multidisciplinary meeting where recommendations for ED care were formed. The ED care recommendations were stored in an ED information exchange system that faxed them to the treating ED provider when the patient presented to the ED. The control arm was subjected to treatment as usual. RESULTS: The intervention arm experienced a 34% decrease (incident rate ratios = 0.66, p < 0.001; 95% confidence interval 0.57-0.78) in ED visits and an 80% decrease (odds ratio = 0.21, p = 0.001) in the odds of receiving an opioid prescription from the ED relative to the control group. Declines of 43.7%, 53.1%, 52.9%, and 53.1% were observed in the treatment group for morphine milligram equivalents, controlled substance pills, prescriptions, and prescribers, respectively. CONCLUSION: This RCT showed the effectiveness of a citywide ED care coordination program in reducing ED visits and controlled substance prescribing.

A comprehensive approach to address the prescription opioid epidemic in Washington State: milestones and lessons learned.

An epidemic of morbidity and mortality has swept across the United States related to the use of prescription opioids for chronic noncancer pain. More than 100,000 people have died from unintentional overdose, making this one of the worst manmade epidemics in history. Much of health care delivery in the United States is regulated at the state level; therefore, both the cause and much of the cure for the opioid epidemic will come from state action. We detail the strong collaborations across executive health care agencies, and between those public agencies and practicing leaders in the pain field that have led to a substantial reversal of the epidemic in Washington State.

Cost-effective: emergency department care coordination with a regional hospital information system.

BACKGROUND: Frequent and unnecessary utilization of the emergency department (ED) is often a sign of serious latent patient issues, and the associated costs are shared by many. Helping these patients get the care they need in the appropriate setting is difficult given their complexity, and their tendency to visit multiple EDs. STUDY OBJECTIVE: We analyzed the cost-effectiveness of a multidisciplinary ED-care-coordination program with a regional hospital information system capable of sharing patients' individualized care plans with cooperating EDs. METHODS: ED visits, treatment costs, cost per visit, and net income were assessed pre- and postenrollment in the program using nonparametric bootstrapping techniques. Individuals were categorized as frequent (3-11 ED visits in the 365 days preceding enrollment) or extreme (≥12 ED visits) users. Regression to the mean was tested using an adjusted measure of change. RESULTS: Both frequent and extreme users experienced significant decreases in ED visits (5 and 15, respectively; 95% confidence intervals [CI] 2-5 and 13-17, respectively) and direct-treatment costs ($1285; 95% CI $492-$2364 and $6091; 95% CI $4298-$8998, respectively), leading to significant hospital cost savings and increased net income ($431; 95% CI $112-$878 and $1925; 95% CI $1093-$3159, respectively). The results further indicate that fewer resources were utilized per visit. Regression to the mean did not seem to be an issue. CONCLUSIONS: When examined as a whole, research on the program suggests that expanding it would be an efficient allocation of hospital, and possibly societal, resources.