Capsule Commentary on Bodenmann et al., Case Management May Reduce Emergency Department Frequent Use in a Universal Health Coverage System: a Randomized Controlled Trial

Journal of General Internal Medicine, May 2017

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Capsule Commentary on Bodenmann et al., Case Management May Reduce Emergency Department Frequent Use in a Universal Health Coverage System: a Randomized Controlled Trial

Capsule Commentary on Bodenmann et al., Case Management May Reduce Emergency Department Frequent Use in a Universal Health Coverage System: a Randomized Controlled Trial Blake Gregory 0 1 0 Compliance with Ethical Standards: 1 Department of Internal Medicine, Division of Primary Care, Highland General Hospital and Alameda Health System , Oakland, CA , USA - his study by Bodenmann et al.1 examined the impact of a T case management (CM) intervention on frequent Emergency Department (ED) users (≥5 ED visits in 12 months). The randomized controlled trial took place at a single site in Switzerland, which has universal health coverage. Patients were randomized to individualized case management versus standard care and followed for 12 months. By the end of the study period, there were 2.71 ED visits in the intervention group compared to 3.35 visits in the control group, a 19 % reduction in the group receiving CM. The effect of the intervention did not achieve statistical significance (ratio = 0.81, 95 % CI = 0.63 to 1.02). The authors conclude that individualized CM may reduce ED utilization in the population studied. Case management programs aim to support medically and psychosocially complex patients through needs assessments and care coordination. The consensus is mixed in the literature on whether ED-based CM programs reduce ED utilization: one RCT from 19972 did not show an impact of a CM intervention on ED use, but two more recent RCTs3, 4 demonstrated statistically significant reductions in ED use through the implementation of ED-based CM programs. The conflicting conclusions of the above studies may be related to heterogeneity of design. There is no universal agreement in the literature of what constitutes a frequent ED user. Moreover, CM interventions vary in duration (from 12 to 24 months) and scope (telephone versus in-person visits). Differences in location and patient population may also influence outcomes. Nevertheless, compelling evidence suggests that case management helps these complex patients. The subjects in Bodenmann’s study had the benefit of universal health coverage and only 14 % did not have a PCP. PCPs likely helped coordinate care for many of these patients, which may have lessened the impact of the intervention. In more fragmented health systems where fewer patients have access to a PCP,5 it is not unreasonable to posit that ED-based CM services could play a significant role in care coordination and reduce utilization. For complex patients who frequent the ED, it is likely that more support, not less, is the key to better resource utilization. Conflict of Interest: The author has no conflicts of interest with the material in this article. 1. Bodenmann P , Velonaki VS , Griffin JL , Baggio S , Iglesias I , Moschettin K , Ruggeri O , Burnand B , Wasserfallen JB , Vu F , Schupbach J , Hugli JO , Daeppen JB . Case management may reduce emergency department frequent use in a universal health coverage system: a randomized controlled trial . J Gen Intern Med . 2016 . doi: 10 .1007/s11606-016-3789-9. 2. Spillane LL , Lumb EW , Cobaugh DJ , Wilcox SR , Clark JS , Schneider SM . Frequent users of the emergency department: can we intervene? Acad Emerg Med . 1997 ; 4 ( 6 ): 574 - 580 . 3. Shumway M , Boccellari A , O'Brien K , Okin RL . Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial⋆ . Am J Emerg Med . 2008 ; 26 ( 2 ): 155 - 164 . 4. Reinius P , Johansson M , Fjellner A , Werr J , Öhlén G , Edgren G. A telephone-based case-management intervention reduces healthcare utilization for frequent emergency department visitors . Eur J Emerg Med . 2013 ; 20 ( 5 ): 327 - 334 . 5. Weisz D , Gusmano MK , Wong G , Trombley J . Emergency department use: a reflection of poor primary care access? Am J Manag Care . 2015 ; 21 ( 2 ): e152 - 60 .


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Capsule Commentary on Bodenmann et al., Case Management May Reduce Emergency Department Frequent Use in a Universal Health Coverage System: a Randomized Controlled Trial, Journal of General Internal Medicine, 2017, DOI: 10.1007/s11606-016-3829-5