Predictive Model-Driven Hotspotting to Decrease Emergency Department Visits: a Randomized Controlled Trial

Abstract

Background: Emergency department (ED) visits contribute substantially to health care expenditures. Case management has been proposed as a strategy to address the medical and social needs of complex patients. However, strong research designs to evaluate the effectiveness of such interventions are limited.

Objectives: To evaluate whether a community-based case management program was associated with reduced ED utilization among complex patients.

Design: Patients whose risk exceeded a threshold were randomly assigned to a group offered case management or to the control group. Assignment occurred at five intervals between November 2017 and January 2019. Program effectiveness for all assigned patients was assessed using an intention-to-treat effect. Program effectiveness among those who received treatment was assessed using a local average treatment effect, estimated using instrumental variables. Both estimators were adjusted for baseline characteristics using linear models.

Participants: Adults over age 18 with at least one health care encounter with Michigan Medicine or St. Joseph Mercy Health System between June 2, 2016, and November 27, 2018.

Interventions: Intervention arm participants (n = 486) were offered coordinated case management across medical, mental health, and social service organizations. Control arm participants (n = 409) received usual care.

Main measures: The primary outcome was the number of ED visits in the 6 months following randomization into the study. Secondary outcomes were 6-month counts of inpatient and outpatient visits.

Key results: Of the 486 patients assigned to the intervention, 131 (27%) consented to receive case management. The intention-to-treat effect on ED visits was + 0.14 (95% CI: - 0.27 to + 0.55). The local average treatment effect among those who consented and received case management was + 0.53 (95% CI: - 1.00 to + 2.05). Intention-to-treat and local average treatment effects were not significant for secondary outcomes.

Conclusions: The community case management intervention targeting ED visits was not associated with reduced utilization. Future case management interventions may benefit from additional patient engagement strategies and longer evaluation time periods.

Trial registration: Clinicaltrials.gov Identifier: NCT03293160.

Keywords: Prior Presentations: None; case management; emergency department; patient; utilization.

Conflict of interest statement

The authors declare that they do not have a conflict of interest.

© 2021. Society of General Internal Medicine.

Figures

Fig. 1

Sample flow diagram.

Fig. 2

Estimates of the Effect of Case Management on Patient Utilization. Panel a Intention-to-treat estimates. Panel b Local average treatment effect estimates.