Case Management for Frequent Users of the Emergency Department

Case Management for Frequent Users of the Emergency Department: A Randomized Controlled Trial

The purpose of this study is to evaluate a specific case management intervention for frequent users (FU) of Emergency Department (ED).

Compared to infrequent or non-users, most of the ED-FU visitors are identified as vulnerable patients because they are more likely to be of low social and economical status, be more isolated and live alone. They report more chronic medical conditions, have a higher mortality rate and consume more healthcare resources.

In the literature, interventions aimed at improving the management of ED-FU have demonstrated several positive outcomes, but there are still some knowledge gaps.

The proposed project tests the hypotheses that case management intervention as compared with standard emergency care

• is a more efficient use of healthcare resources and reduces ED attendance,
• is cost-saving and
• improves quality of life,
• altogether leading to favorable cost-utility ratio.

Study Overview

• Status: Completed
• Conditions: Frequent Users of the Emergency Department; Vulnerable Populations
• Intervention / Treatment: Other: Case Management

• Study Type: Interventional
• Enrollment (Actual): 250
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Switzerland
  • Lausanne, Switzerland, 1011
    • University Hospital of Lausanne

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• 5 or more attendances during the previous 12 months at the Emergency Department of the University Hospital of Lausanne
• Be capable of communicating in any of the languages spoken by the team (i.e. French, English, German, Italian and Spanish) or through a community interpreter

Exclusion Criteria:

• Patients who cannot give informed consent or are ineligible to receive Case Managers services (e.g. acutely confused, acutely psychotic, intoxicated)
• Patients who are in prison
• Patients with a diagnose of cognitive disorders (delirium, dementia, and other cognitive disorders)
• Patients who are not expected to survive at least 18 months after enrollment
• Patients who will not remain in Switzerland for 12 to 18 months after enrollment
• Family members of a participant already included

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Supportive Care
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Case Management; Furnish specific assistance and to provide referrals for the patients: If the social determinants are not adequate, the team will lend assistance for obtaining income entitlements, health insurance coverage if eligible, stable housing, schooling for children, etc.; If there are mental disturbances, the team will refer to mental health departments inside the hospital, and if necessary, to a psychiatrist, psychologist or general practitioner (GP) out in the community.; If the patient presents risk behaviors, the team will refer to substance abuse services and links to community services in order to maintain continuity of care.; In case of somatic problems, the team will find a new GP or make contact with the previous provider, contingent on the patient's consent.	Other: Case Management; Furnish specific assistance and to provide referrals for the patients: If the social determinants are not adequate, the team will lend assistance for obtaining income entitlements, health insurance coverage if eligible, stable housing, schooling for children, etc.; If there are mental disturbances, the team will refer to mental health departments inside the hospital, and if necessary, to a psychiatrist, psychologist or general practitioner (GP) out in the community.; If the patient presents risk behaviors, the team will refer to substance abuse services and links to community services in order to maintain continuity of care.; In case of somatic problems, the team will find a new GP or make contact with the previous provider, contingent on the patient's consent.
No Intervention: Control; Patients randomized to control group (usual care) will receive standard emergency care by physicians (resident or attending physician) and nurses, without the case manager been involved. Nevertheless, the mobile team will take contact with each patient of the control group, giving them short information through a flyer (flyer) which will underline the existence of the mobile team, its addresses and telephone numbers.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
number of Emergency Department visits	12 months after enrollement

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
total costs of the healthcare resource	costs concerning services provided by the University Hospital of Lausanne and cost concerning services used outside the Hospital	12 months after enrollement

Other Outcome Measures

Outcome Measure	Time Frame
Quality of life	Day of enrollement, 2 months, 5.5 months, 9 months and 12 months

Collaborators and Investigators

• Sponsor: University of Lausanne
• Investigators: Principal Investigator: Bodenmann Patrick, PD, MER, MSc, University of Lausanne

Publications and helpful links

General Publications

• Bieler G, Paroz S, Faouzi M, Trueb L, Vaucher P, Althaus F, Daeppen JB, Bodenmann P. Social and medical vulnerability factors of emergency department frequent users in a universal health insurance system. Acad Emerg Med. 2012 Jan;19(1):63-8. doi: 10.1111/j.1553-2712.2011.01246.x. Epub 2012 Jan 5.
• 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 Feb;26(2):155-64. doi: 10.1016/j.ajem.2007.04.021.
• Althaus F, Paroz S, Hugli O, Ghali WA, Daeppen JB, Peytremann-Bridevaux I, Bodenmann P. Effectiveness of interventions targeting frequent users of emergency departments: a systematic review. Ann Emerg Med. 2011 Jul;58(1):41-52.e42. doi: 10.1016/j.annemergmed.2011.03.007.
• Althaus F, Stucki S, Guyot S, Trueb L, Moschetti K, Daeppen JB, Bodenmann P. Characteristics of highly frequent users of a Swiss academic emergency department: a retrospective consecutive case series. Eur J Emerg Med. 2013 Dec;20(6):413-9. doi: 10.1097/MEJ.0b013e32835e078e.
• Iglesias K, Baggio S, Moschetti K, Wasserfallen JB, Hugli O, Daeppen JB, Burnand B, Bodenmann P. Using case management in a universal health coverage system to improve quality of life of frequent Emergency Department users: a randomized controlled trial. Qual Life Res. 2018 Feb;27(2):503-513. doi: 10.1007/s11136-017-1739-6. Epub 2017 Nov 29.
• Bodenmann P, Velonaki VS, Ruggeri O, Hugli O, Burnand B, Wasserfallen JB, Moschetti K, Iglesias K, Baggio S, Daeppen JB. Case management for frequent users of the emergency department: study protocol of a randomised controlled trial. BMC Health Serv Res. 2014 Jun 17;14:264. doi: 10.1186/1472-6963-14-264.

Study record dates

Study Major Dates

• Study Start: June 1, 2012
• Primary Completion (Actual): July 1, 2014
• Study Completion (Actual): July 1, 2014

Study Registration Dates

• First Submitted: August 29, 2013
• First Submitted That Met QC Criteria: September 3, 2013
• First Posted (Estimate): September 4, 2013

Study Record Updates

• Last Update Posted (Estimate): May 27, 2015
• Last Update Submitted That Met QC Criteria: May 26, 2015
• Last Verified: May 1, 2015

More Information

Terms related to this study

• Keywords: quality of life; vulnerable populations; case management; frequent users of the emergency department; cost savings intervention; number of emergency department visits
• Additional Relevant MeSH Terms: Pathologic Processes; Disease Attributes; Emergencies
• Other Study ID Numbers: FNS 30023B_135762/1