The effect of brief case management on emergency department use of frequent users in mental health: Findings of a randomized controlled trial.

Vicky Stergiopoulos,Stephen W Hwang,Ashley Cohen,Agnes Gozdzik,Paul Kurdyak,Tim Guimond,Molyn Leszcz,Donald Wasylenki,Jacobus P Van Wouwe

doi:10.1371/journal.pone.0182157

Abstract

Frequent users of hospital emergency departments (EDs) are a medically and socially vulnerable population. The Coordinated Access to Care from Hospital EDs (CATCH-ED) study examined the effectiveness of a brief case management intervention in reducing ED use and improving health outcomes among frequent ED users with mental health or addiction challenges in a large urban centre. Adults (≥18 years of age) who had five or more ED visits in the past 12-months, with at least one visit for mental health or addictions problems were randomized to either brief case management (N = 83) or usual care (N = 83) and followed for 12 months. The primary outcome of effectiveness was the frequency of ED visits during 12 months after study enrolment. Secondary outcomes included days in hospital, mental health and addiction symptom severity and health-related quality of life, measured by the SF-12. Compared to usual care, CATCH-ED participants saw a 14% reduction in frequency of ED visits during the 12-month post-randomization period [rate ratio (RR) = 0.86, 95% CI 0.64–1.15)], however, this finding did not reach statistical significance. There were also no statistically significant differences between the groups at 12 months in the number of days spent in hospital (RR = 1.16, 95% CI 0.59–2.29), physical (1.50, 95% CI -2.15–5.15) or mental (-3.97, 95% CI -8.13–0.19) component scores of the SF-12, severity of psychiatric symptoms (-0.41, 95% CI -2.30–1.49), alcohol (0.053 95% -0.017–0.12) or drug (-0.0027, 95% CI -0.0028–0.023) use. Compared to usual care, a brief case management intervention did not result in significantly reduced ED use or improved health outcomes among frequent ED users with mental health or addictions challenges in a large urban centre in Canada. Future studies need to evaluate the availability and accessibility of community-based resources for individuals with frequent ED use.

Highlights

Frequent users of emergency departments (EDs), often defined as those with four or more visits in a year [1], comprise a small proportion of Emergency department (ED) users (4.5–8%), but account for 21–28% of all ED visits [2]
Our study found that after 12 months, frequent ED users with mental health conditions who received a brief intensive case management intervention had a 14% decrease in ED visits compared to those who received usual care, this decrease was not statistically significant
The finding of a reduction in disease specific quality of life, which decreased in the intervention compared to usual care group, should be interpreted with caution given the extent of missing data for this outcome

Summary

Introduction

Frequent users of emergency departments (EDs), often defined as those with four or more visits in a year [1], comprise a small proportion of ED users (4.5–8%), but account for 21–28% of all ED visits [2]. While several studies have shown that frequent ED use is mostly episodic in nature, with only approximately 25–30% of frequent users in a given year maintaining similar levels of ED use in the following year [12, 13], a recent study observed that among the group of most frequent ED users (those with 18 or more ED visits/year) in the province of Manitoba, 70% had the same level of ED use in the calendar year prior to the study [10] This most frequent ED user group had the highest rate of a physician-based diagnosis of a mental illness, compared to less frequent users [10], suggesting that the highest frequency ED users comprise a population with high rates of mental illness, addiction and complex unmet needs

Methods

Results

Conclusion