Original Contribution
Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial

Oral presentations include the following: November 2003, APHA, San Francisco, Calif; June 2004, Complexities of Co-Occurring Conditions, Washington, DC; May 2005, CREDO Symposium, Detroit, Mich.
https://doi.org/10.1016/j.ajem.2007.04.021Get rights and content

Abstract

Objective

The objective of the study was to test the hypothesis that clinical case management is more cost-effective than usual care for frequent users of the emergency department (ED).

Methods

The study is a 24-month randomized trial obtaining data on psychosocial problems through interviews and service usage and cost data from administrative records.

Results

Two-hundred fifty-two frequent users were randomized (167 to case management, 85 to usual care). Case management was associated with statistically significant reductions in psychosocial problems common among ED frequent users, including homelessness, alcohol use, lack of health insurance and social security income, and financial need. Case management was associated with statistically significant reductions in ED use and cost. Case management and usual care patients did not differ in use or cost of other hospital services.

Conclusions

Case management appears cost-effective for ED frequent users because it yields statistically and clinically significant reductions in psychosocial problems at a cost similar to that of usual care.

Introduction

Extensive empirical evidence documents that most medical emergency departments (EDs) serve a relatively small number of frequent users who account for a disproportionately large number of ED visits [1], [2]. Frequent users are typically found to be a socially disadvantaged group with multiple medical and psychiatric disorders and myriad social problems [3], [4], [5], [6]. From all perspectives, frequent use of the ED is an undesirable pattern of service use for this vulnerable patient population. Patients receive care that is suboptimal because it is fragmented and episodic, ED health care providers are frustrated by their limited ability to meet frequent users' many complex needs, and health care systems are burdened by the high costs of excess use of expensive acute services. In addition, frequent users contribute to ED overcrowding, which compromises the quality of care for all ED patients and reduces the efficiency of hospital and health system operations [7], [8], [9].

The prevalence and persistence of frequent ED use has increased interest in interventions that reduce overuse of the ED by providing patients with more appropriate and consistent medical and social services. A variety of interventions that differ in complexity and intensity have been evaluated in preliminary studies, with promising results. A randomized trial of 3 modest interventions that provided 16 primary care providers with information about their patients' ED and hospital admissions significantly decreased ED use because providers used the information to monitor and modify their patients' service needs [10]. In a pre-post study on 24 ED frequent users, a case management program designed to involve a range of community care providers in the development of comprehensive care plans markedly reduced ED use [11]. A more comprehensive case management program designed for ED frequent users with substance use disorders was evaluated in a study comparing 10 case-managed patients with 8 similar patients who did not receive case management [12]. Relative to the year before the study, a 58% decrease in ED use was observed in the case management group in the year after study entry, whereas no change in use was observed in the comparison group.

Preliminary evaluations of hospital-based comprehensive clinical case management programs designed for all ED frequent users have yielded varied but promising results. One study examined the impact of hospital-based integrated case management in a pre-post study on 60 ED frequent users, comparing ED use and psychosocial problems in the 12 months before and after initiation of case management [13]. Case management was associated with improvements in housing status and linkages with medical and community services but was also associated with increased ED use. A second study evaluated clinical case management in a pre-post study on 53 patients, comparing hospital use, hospital costs, and psychosocial problems in the 12 months before and after the case management intervention [14]. Statistically significant reductions in ED use, ED costs, medical inpatient costs, homelessness, and substance use were observed in the year after initiation of case management compared with the previous year. When costs were evaluated from the hospital's perspective, the program yielded a net cost savings, with each dollar invested in the program yielding a $1.44 savings in hospital costs. Although these preliminary findings suggest that clinical case management may be cost-effective for frequent ED users, this study shares the limitations of other preliminary intervention studies in that it involved a small convenience sample and used a nonrandomized design.

In this article, we present the results of a 24-month randomized cost-effectiveness trial of clinical case management for ED frequent users. This trial was developed to address the design limitations evident in prior studies and to provide a more rigorous evaluation of the case management intervention. A large, representative sample of frequent ED users was systematically enrolled to avoid the selection biases associated with convenience samples. The randomized design and the 2-year follow-up period were chosen to limit the possibility of attributing natural regression to the mean as a positive intervention effect. Regression to the mean is a concern in any pre-post study where participants are selected based on extreme values on any indicator because such extreme values typically represent a brief, atypical state that will naturally normalize with time. Regression to the mean is of particular concern in studies on ED use because epidemiological data show that only a subset of frequent users remain frequent users for more than 1 year [1]. The trial also explicitly examined the cost-effectiveness of case management in relation to frequency of recent ED visits, a factor associated with patient characteristics and ED costs [15].

Section snippets

Study design

This 24-month prospective randomized trial compared the cost-effectiveness of comprehensive clinical case management with usual care among frequent ED users. The study was designed to test the hypothesis that case management is more cost-effective than usual care because it reduces inappropriate use of the ED and other costly hospital services by addressing psychosocial problems common among frequent ED users. The study also examined whether the cost-effectiveness of case management varies with

Results

Two hundred fifty-two ED frequent users participated in the study; 167 were randomized to case management and 85 to usual care. One hundred forty-one (84%) of the patients randomized to case management enrolled in the program. As summarized in Table 1, the sample was predominantly male and nonwhite, with a mean age of 43 years. The case management and usual care groups did not differ on any demographic characteristics.

At study entry, patients evidenced a considerable level of medical

Discussion

The results of this randomized trial suggest that clinical case management is more cost-effective than usual care for frequent ED users. Comprehensive clinical case management yielded statistically and clinically significant reductions in psychosocial problems common among frequent ED users at a cost similar to that of usual care. Case management was associated with meaningful reductions in homelessness, problem alcohol use, lack of health insurance, lack of social security income support, and

Limitations

The design of this trial is limited in some respects, which may restrict the generalizability of the findings. First, despite our efforts to minimize selection bias and recruit a representative sample of frequent ED users, staffing limitations did constrain recruitment in ways that potentially affect representativeness. Only patients in the ED during standard business hours (between 8 am and 5 pm, Monday through Friday) could be evaluated. Also, clinical demands often prevented the case

Conclusions

Results of a 2-year randomized trial demonstrate that clinical case management is more cost-effective than usual care for frequent users of the ED. Case management was associated with statistically and clinically significant reductions in psychosocial problems common among frequent ED users and with statistically and practically significant reductions in ED use and cost. When the costs of the case management intervention were considered, total hospital service costs were similar for case

Acknowledgments

The authors gratefully acknowledge the many invaluable contributions of the research team members, the clinicians and staff of the ED Case Management Program and the SFGH ED, and the study participants.

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    Financial support was received from the San Francisco Department of Public Health.

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