Abstract
BackgroundEmergency department (ED) utilization has dramatically increased in developed countries over the last twenty years. Because it has been associated with adverse outcomes, increased costs, and an overload on the hospital organization, several policies have tried to curb this growing trend. The aim of this study is to systematically review the effectiveness of organizational interventions designed to reduce ED utilization.Methodology/Principal FindingsWe conducted electronic searches using free text and Medical Subject Headings on PubMed and The Cochrane Library to identify studies of ED visits, re-visits and mortality. We performed complementary searches of grey literature, manual searches and direct contacts with experts. We included studies that investigated the effectiveness of interventions designed to reduce ED visits and the following study designs: time series, cross-sectional, repeated cross-sectional, longitudinal, quasi-experimental studies, and randomized trial. We excluded studies on specific conditions, children and with no relevant outcomes (ED visits, re-visits or adverse events). From 2,348 potentially useful references, 48 satisfied the inclusion criteria. We classified the interventions in mutually exclusive categories: 1) Interventions addressing the supply and accessibility of services: 25 studies examined efforts to increase primary care physicians, centers, or hours of service; 2) Interventions addressing the demand for services: 6 studies examined educational interventions and 17 examined barrier interventions (gatekeeping or cost).Conclusions/SignificanceThe evidence suggests that interventions aimed at increasing primary care accessibility and ED cost-sharing are effective in reducing ED use. However, the rest of the interventions aimed at decreasing ED utilization showed contradictory results. Changes in health care policies require rigorous evaluation before being implemented since these can have a high impact on individual health and use of health care resources. Systematic review registration: http://www.crd.york.ac.uk/PROSPERO. Identifier: CRD420111253
Highlights
The use of emergency departments (ED) has increased dramatically in developed countries, with a large portion of this increase attributed to inappropriate or non-urgent visits [1,2]
When patients replace Primary Care with Emergency department (ED) visits there is a lack of continuity and follow-up that limits the provider’s awareness of previous and current illness and treatments and makes it difficult to engage in shared decision making; ED resources may be diverted from life-threatening situations to minor health problems; and the ED requests for ‘‘urgent’’ tests and explorations may generate an overload that can adversely affect the hospital as a whole
Reasons proposed to explain the trend towards an increasing number of patients using the ED as a type of primary care include the progressive aging of the population and the associated increase in chronic conditions, lack of cost awareness, organizational problems in primary care, better ED convenience and accessibility, and patients’ subjective perception of illness severity and greater confidence in the ED compared to primary care services [7]
Summary
The use of emergency departments (ED) has increased dramatically in developed countries, with a large portion of this increase attributed to inappropriate or non-urgent visits [1,2]. Reasons proposed to explain the trend towards an increasing number of patients using the ED as a type of primary care include the progressive aging of the population and the associated increase in chronic conditions, lack of cost awareness, organizational problems in primary care, better ED convenience and accessibility, and patients’ subjective perception of illness severity and greater confidence in the ED compared to primary care services [7]. Emergency department (ED) utilization has dramatically increased in developed countries over the last twenty years. Because it has been associated with adverse outcomes, increased costs, and an overload on the hospital organization, several policies have tried to curb this growing trend. The aim of this study is to systematically review the effectiveness of organizational interventions designed to reduce ED utilization
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