Community Paramedicine Program Research Articles

Paramedic attitudes and experiences working as a community paramedic: a qualitative survey.

Community paramedicine (CP) is an extension of the traditional paramedic role, where paramedics provide non-acute care to patients in non-emergent conditions. Due to its success in reducing burden on hospital systems and improving patient outcomes, this type of paramedic role is being increasingly implemented within communities and health systems across Ontario. Previous literature has focused on the patient experience with CP programs, but there is lack of research on the paramedic perspective in this role. This paper aims to understand the perspectives and experiences, both positive and negative, of paramedics working in a CP program towards the community paramedic role. An online survey was distributed through multiple communication channels (e.g. professional organizations, paramedic services, social media) and convenience sampling was used. Five open-ended questions asked paramedics about their perceptions and experiences with the CP role; the survey also collected demographic data. While the full survey was open to all paramedics, only those who had experience in a CP role were included in the current study. The data was qualitatively analyzed using a comparative thematic analysis. Data was collected from 79 respondents who had worked in a CP program. Three overarching themes, with multiple sub-themes, were identified. The first theme was that CP programs fill important gaps in the healthcare system. The second was that they provide paramedics with an opportunity for lateral career movement in a role where they can have deeper patient connections. The third was that CP has created a paradigm shift within paramedicine, extending the traditional scope of the practice. While paramedics largely reported positive experiences, there were some negative perceptions regarding the slower pace of work and the "soft skills" required in the role that vary from the traditional paramedic identity. CP programs utilize paramedic skills to fill a gap in the healthcare system, can improve paramedic mental health, and also provide a new pathway for paramedic careers. As a new role, there are some challenges that CP program planners should take into consideration, such as additional training needs and the varying perceptions of CP.

Evaluation of the Impact of Discharge Clinic Follow-Up Interventions on 30-Day Readmission Rates.

Care transition programs can result in cost avoidance and decreased resource utilization. This project aimed to determine whether implementation of a discharge clinic, referral to a community paramedicine program, or a second postdischarge call affected 30-day readmission rates. This single-center retrospective exploratory design study included 727 discharged patients without access to a primary care provider who were scheduled for a discharge clinic transitions appointment. Readmission rates were 17.7% for those who completed a discharge appointment and 24.7% for those who did not; 4% for those completing a second postdischarge call and 26% for those who did not; and 11.1% for those referred to a community paramedicine program and 24.9% for those not referred. A completed discharge clinic appointment resulted in 36% lower odds of readmission. A completed discharge clinic appointment was effective in reducing 30-day readmission rates as was a follow-up call.

The Community Paramedicine at Clinic Program: Improving Participant Health while Preserving Healthcare System Resources.

Vulnerable populations such as low-income older adults in social housing suffer from poor quality of life and are impacted by chronic diseases. These populations are also high users of emergency services, which contribute to high healthcare costs. Community-based, patient-centred interventions, such as community paramedicine (CP) programs, can address the healthcare gaps for these underserved populations. Community Paramedicine at Clinic (CP@clinic) is an innovative, evidence-based, chronic disease prevention/management program that improves patient health and quality of life, connects them with health and community services, preserves healthcare resources and yields cost savings for the emergency care system. The program also works with other community organizations, facilitating interprofessional engagement and supporting other disciplines in providing care. Known barriers to implementing CP programs highlight the importance of standard practices and training as exemplified by the CP@clinic program.

Evaluating the Impact of a Mobile Integrated Health‒Community Paramedicine Program on Health-Related Social Needs and Hospital Readmissions

Abstract: Objective. Evaluate a mobile integrated health–community paramedicine program's effect on addressing health-related social needs and their association with hospital readmissions. Methods. This observational study enrolled 1,003 patients from 5/4/2018–7/23/21. Descriptive statistics summarize social needs. A Poisson regression model examined the association of interventions for social needs with 30-day readmissions. Results. Patients who had their medication-related needs fully addressed had a 65% lower rate of total 30-day readmission compared with patients who had no such needs fully addressed (IRR=0.35, 95% CI 0.18–0.68, P=.002). No variables reached statistical significance related to unplanned 30-day readmissions, aside from the HOSPITAL Score. Conclusions. Assisting patients with medication-related needs is associated with reductions in overall 30-day readmissions. Interventions within most domains were not associated with reductions in overall or unplanned 30-day readmissions. This program had greater success addressing needs with one-step interventions, suggesting additional time and resources may be necessary to address complex social needs.

153 Social Domains of Needs Score on Predicting Hospital Admissions for Patients in a Community Paramedicine Program

153 Social Domains of Needs Score on Predicting Hospital Admissions for Patients in a Community Paramedicine Program

Select, route and schedule: optimizing community paramedicine service delivery with mandatory visits and patient prioritization.

Healthcare delivery in the United States has been characterized as overly reactive and dependent on emergency department care for safety net coverage, with opportunity for improvement around discharge planning and high readmissions and emergency department bounce-back rates. Community paramedicine is a recent healthcare innovation that enables proactive visitation of patients at home, often shortly after emergency department and hospital discharge. We establish the first optimization-based framework to study efficiencies in the management and operation of a community paramedicine program. The collective innovations of our modeling include i) a novel hierarchical objective function with the goals of fairly increasing patient welfare, lowering hospital costs, and reducing readmissions and emergency department visits, ii) a new constraint set that ensures priority same-day visits for emergent patients, and iii) a further extension of our model to determine the minimum supplemental resources necessary to ensure feasibility in a single optimization formulation. Our medical-need based objective function prioritizes patients based on their clinical features and seeks to select and schedule patient visits and route healthcare providers to maximize overall patient welfare while favoring shorter tours. We use our methods to develop managerial insights via computational experiments on a variety of test instances based on real data from a hospital system in Upstate New York. We are able to identify optimal and nearly optimal tours that efficiently select, route, and schedule patients in reasonable timeframes. Our results lead to insights that can support managerial decisions about establishing (and improving existing) community paramedicine programs.

Goals, Services, and Target Patient Populations of Community Paramedicine in Rural United States

Introduction: Rural areas contain one-fifth of the US population and only 10% of the nation’s physicians. Community paramedicine (CP) is a growing healthcare delivery model in which emergency medical personnel provide non-emergent medical care. Community paramedics may help fill the primary healthcare gap for rural residents. This literature review provides an overview of the common goals, services, target populations, and setbacks of rural CP programs in the US.
 Methods: A systematic search following PRISMA protocols was completed on PubMed and Google scholar using the search terms: “community paramedicine/paramedic” and “rural, remote, frontier” between 2000-2021.
 Results: Rural CP program goals are to aid patients in chronic disease management and reduce emergency department visits, hospital admissions/readmissions, and healthcare costs. Programs target services toward patients who are chronically ill, post-hospital discharge, and frequent EMS users.
 Conclusion: CP provision of preventative and primary care services has improved health outcomes for patients with chronic disease. Programs report cost savings for the healthcare payer and patient and a reduction in ED transports and hospital readmissions. The problems identified are acquiring sustainable funding to develop CP programs and reimburse CP services, lack of consistency between CP scope of practice and educational requirements across states, role tensions with other healthcare professions, and lack of research about the safety of CP programs for patients. Future research is needed to investigate patient outcomes secondary to CP preventative and primary care services, which may identify if CPs are an effective means of helping fill the primary care gap for rural communities.

Factors Associated With Successful Enrollment in a Community Paramedicine Program for Heart Failure.

Introduction Participation in community paramedicine (CP) programs, sometimes referred to as Mobile Integrated Healthcare (MIH), may improve patient-centered outcomes and reduce hospital readmissions. The objective of this study was to correlate patient and system-specific factors with successful enrollment in a CP program for heart failure. Methods We conducted a retrospective review of patients enrolled in a CP program after hospitalization for a heart failure-related diagnosis. All patients greater than 18 years of age referred to the CP program with a heart-failure-related diagnosis were included. Factors including age, sex, hospital length of stay, enrollment method, concurrent use of transitional care services, care team, and service line referral were collected. The primary outcome was successful enrollment which led to an initial home visit. Chi-square and t-tests were performed to determine if the outcome differed between cohorts. Results A total of 908 patients met the inclusion criteria, and 677 (74.7%) received home visits. Increased participation was noted in patients enrolled in person (81.1% vs. 66%, p<0.01) and those also receiving transitional care services (78.9% vs. 62.5%, p<0.01). Conclusion We conclude that efforts should be made to contact patients in person, prior to hospital discharge, who are eligible for CP services.

Mobile integrated health-community paramedicine programs' effect on emergency department visits: An exploratory meta-analysis

IntroductionMobile Integrated Health Community Paramedicine (MIH-CP) programs are designed to increase access to care and reduce Emergency Department (ED) and Emergency Medical Services (EMS) usage. Previous MIH-CP systematic reviews reported varied interventions, effect sizes, and a high prevalence of biased methods. We aimed to perform a meta-analysis on MIH-CP effect on ED visits, and to evaluate study designs' effect on reported effect sizes. We hypothesized biased methods would produce larger reported effect sizes. MethodsWe searched Pubmed, Embase, CINAHL, and Scopus databases for peer-reviewed MIH-CP literature from January 1, 2000, to July 24, 2021. We included all full-text English studies whose program met the National Associations of Emergency Medical Technicians definition, reported ED visits, and had an MIH-CP related intervention and outcome. We established risk ratios for each included study through interpreting the reported data. We performed a random-effects and cumulative meta-analysis of ED visit data, tests of heterogeneity, and a moderator analysis to assess for factors influencing the magnitude of observed effect. ResultsWe identified 16 studies that reported ED visit data and included 12 in our meta-analysis. All studies were observational; 3 used matched controls, 6 pre-post controls, and 3 without controls. 7 studies' intervention were diversion/triage while 5 studies intervened with health education/home primary care services.Pooled risk ratio for our data set was 0.56 (95% confidence interval 0.42–0.74). Cumulative meta-analysis revealed that as of 2018 MIH-CP programs began to show consistent reductions in ED visits. Significant heterogeneity was seen among studies, with I-squared >90%. Moderator analysis showed reduced heterogeneity for matched-control studies. ConclusionOur data revealed MIH-CP programs were associated with a reduced risk of ED visits. Study design did not have a statistically significant influence on effect size, though it did influence heterogeneity. We would recommend future studies continue to use high levels of control to produce reliable data with lower heterogeneity.

Impact of a mobile integrated healthcare and community paramedicine program on improving medication adherence in patients with heart failure and chronic obstructive pulmonary disease after hospital discharge: A pilot study

BackgroundThe mobile integrated health-community paramedicine (MIH-CP) program affiliated with the University of Maryland Medical Center focuses on improving patient transitions from hospital to home by addressing both medical and social determinants of health. Until recently, only self-contained health systems could integrate inpatient and outpatient medication data. Without some means to track patients in transition, there is a significant risk of medication-related problems and errors. ObjectiveTo evaluate the impact of the MIH-CP program on medication adherence among patients with congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD). MethodsThis is a pilot observational study designed to compare adherence to drug regimens prescribed at hospital discharge (measured by the proportion of days covered [PDC]) between patients enrolled in the MIH-CP program and a propensity-matched control group. Propensity scores were calculated using 11 demographic, diagnostic, third-party payer, and patient care-associated variables. Discharge medication details were obtained from electronic medical records. PDC for each of the medications were calculated from pharmacy claims data. ResultsEighty-three patients were included in the study; forty-three patients were placed in the intervention group and 40 were propensity-matched controls. After adjusting for age, sex, and third-party payer, findings indicated that medication adherence was higher among patients enrolled in the MIH-CP program compared with control during the first 30 days post-discharge, specifically among patients diagnosed with CHF (8% difference in PDC, 95% confidence interval [CI], ‐0.12-0.28%) and COPD (14% difference, 95% CI, ‐0.15-0.43%), although neither result achieved statistical significance. The differences in medication adherence between patients who were enrolled and those who were not enrolled in the MIH-CP program diminished after 30 days post-discharge. ConclusionThis pilot study demonstrated a trend toward improved medication adherence among patients enrolled in the MIH-CP program. Future research involving a larger patient cohort will be required to confirm these preliminary findings.

Evaluating Social Determinants of Health in a Mobile Integrated Healthcare-Community Paramedicine Program.

In 2018, the University of Maryland Medical Center and the Baltimore City Fire Department implemented a community paramedicine program to help medically or socially complex patients transition from hospital to home and avoid hospital utilization. This study describes how patients' social determinants of health (SDoH) needs were identified, and measures the association between needs and hospital utilization.SDoH needs were categorized into ten domains. Multinomial logistic regression was used to measure association between identified SDoH domains and predicted risk of readmission. Poisson regression was used to measure association between SDoH domains and actual 30-day hospital utilization.The most frequently identified SDoH needs were in the Coordination of Healthcare (37.7%), Durable Medical Equipment (18.8%), and Medication (16.3%) domains. Compared with low-risk patients, patients with an intermediate risk of readmission were more likely to have needs within the Coordination of Healthcare (RRR [95% CI] 1.12 [1.01, 1.24], p = 0.032) and Durable Medical Equipment (RRR = 1.13 [1.00, 1.27], p = 0.046) domains. Patients with the highest risk for readmission were more likely to have needs in the Utilities domain (RRR = 1.76 [0.97, 3.19], p = 0.063). Miscellaneous domain needs, such as requiring a social security card, were associated with increased 30-day hospital utilization (IRR = 1.23 [0.96, 1.57], p = 0.095).SDoH needs within the Coordination of Healthcare, Durable Medical Equipment, and Utilities domains were associated with higher predicted 30-day readmission, while identification documentation and social services needs were associated with actual readmission. These results suggest where to allocate resources to effectively diminish hospital utilization.

A Systematic Review of Methodologies and Outcome Measures of Mobile Integrated Health - Community Paramedicine Programs

Introduction: Mobile integrated health – community paramedicine (MIH-CP) uses patient-centered, mobile resources in the out-of-hospital environment to increase access to care and reduce unnecessary emergency department (ED) usage. The objective of this systematic review is to characterize the outcomes and methodologies used by MIH-CP programs around the world and assess the validity of the ways programs evaluate their effectiveness. Methods: The PubMed, Embase, CINAHL, and Scopus databases were searched for peer-reviewed literature related to MIH-CP programs. We included all full-length studies whose programs met the National Association of Emergency Medical Technicians definition, had MIH-CP–related interventions, and measured outcomes. We excluded all non-English papers, abstract-only, and incomplete studies. Our initial literature review identified 6434 titles. We screened 178 full-text studies to assess for eligibility and identified 33 studies to include in this review. These 33 include four randomized controlled trials, 17 cohort studies, eight 8 case series, and four 4 cross-sectional studies. Of the 29 non-randomized trials, five used matched controls, 13 used pre-post, and 11 used no controls. Outcomes measured were hospital usage (24 studies), ED visits (15), EMS usage (23), patient satisfaction (8), health-related outcomes (8), and cost (9). Studies that evaluated hospital usage reported one of several outcome measures: hospital admissions (11), ED length of stay (3), and hospital readmission rate (2). EMS usage was measured by ambulance transports (12) and EMS calls (10). Cost outcomes observed were ambulance transport savings (7), ED visit savings (4), hospital admission savings (3), and cost per quality-adjusted life year (2). Most studies assessing MIH-CP programs reported success of their interventions. However, significant heterogeneity of outcome measures and varying quality of study methodologies exist among studies. Future studies designed with adequately matched controls and applying uniform core metrics for cost savings and health care usage are needed to better evaluate the effectiveness of MIH-CP programs.

Empowering Patient Self-Management: A Community Paramedicine Model of Care in Ontario

Community Paramedicine Remote Patient Monitoring (CPRPM) was launched in Ontario in April 2015 to address high health system usage in vulnerable patients living with chronic disease. CPRPM expands on the home visit model of community paramedicine (CP) to bridge gaps in patient care and address inefficiencies in resource utilization. At patient and systems levels, CPRPM aims to promote patient self-management of chronic diseases. Several reports driving the development of the Ontario Seniors Strategy, which include key recommendations for expanding CP programs, provided the impetus for government to deliver on their electoral platform promise to increase health care spending. The Local Health System Integration Act, 2006 gave Local Health Integration Networks the authority to make home and community care services accessible to Ontario residents, including the supplies and equipment required by patients and their caregivers to support their care at home. Outcome measures of CPRPM point to positive benefits for encouraging patient self-management of chronic diseases and reducing health system strain, with a return on investment of 542%. The variety of options for patient interaction and ability to lessen health system burden makes CPRPM a desirable model of care.

Automated referral to community paramedicine during 9-1-1 fall calls for resource activation.

We sought to improve the referral process to a community paramedicine (CP) program following a 9-1-1 encounter. An electronic health record (EHR) for CP records with the ability to link to emergency EHR was identified and implemented with a single-click referral to the CP program. Referrals were tracked for 15 months before and after implementation. Referral capacity increased from an average of 14.2 referrals per month to 44.9 referrals per month. The results of this study suggest an EHR is a useful investment for CP programs and may be integral to efficient program operations.

Improving Hospice and Palliative Care Through Nurse Practitioner Engagement in a Community Paramedicine Program

More than 80% of Americans would prefer to die at home, but only 20% do. Paramedics have a role in caring for terminally ill patients, especially when involved in a community setting. A knowledge gap was noted with community paramedics (CPs) regarding end-of-life questions and palliative care for paramedics. This evidence-based quality improvement project aimed to provide structured, evidence-based palliative and hospice education to CPs. Nurse practitioners can provide education and training on palliative and hospice care to CPs and help patients remain at home.

Diabetes Rescue, Engagement and Management (D-REM): rationale and design of a pragmatic clinical trial of a community paramedicine programme to improve diabetes care

IntroductionDiabetes is one of the most common serious chronic health conditions in the USA. People living with diabetes face multiple barriers to optimal diabetes care, including gaps in access to...

\u201cThey\u2019re very passionate about making sure that women stay healthy\u201d: a qualitative examination of women\u2019s experiences participating in a community paramedicine program

BackgroundCommunity paramedicine programs (i.e., physician-directed preventive care by emergency medical services personnel embedded in communities) offer a novel approach to community-based health care. Project Swaddle, a community paramedicine program for mothers and their infants, seeks to address (directly or through referrals) the physical, mental, social, and economic needs of its participants. The objective of this process evaluation was to describe women’s experiences in Project Swaddle. By understanding their experiences, our work begins to build the foundation for similar programs and future examinations of the efficacy and effectiveness of these approaches.MethodsWe completed 21 interviews with women living in Indiana (July 2019–February 2020) who were currently participating in or had graduated from Project Swaddle. Interviews were audio-recorded, transcribed, and analyzed using a six-phase approach to thematic analysis.ResultsProgram enrollment was influenced by the community paramedics’ experience and connections, as well as information received in the community from related clinics or organizations. Participants viewed the community paramedic as a trusted provider who supplied necessary health information and support and served as their advocate. In their role as physician extenders, the community paramedics enhanced patient care through monitoring critical situations, facilitating communication with other providers, and supporting routine healthcare. Women noted how community paramedics connected them to outside resources (i.e., other experts, tangible goods), which aimed to support their holistic health and wellbeing.ConclusionsResults demonstrate Project Swaddle helped women connect with other healthcare providers, including increased access to mental health services. The community paramedics were able to help women establish care with primary care providers and pediatricians, then facilitate communication with these providers. Women were supported through their early motherhood experience, received education on parenting and taking control of their health, and gained access to resources that met their diverse needs.

Analysis of Readmissions in a Mobile Integrated Health Transitional Care Program Using Root Cause Analysis and Common Cause Analysis.

Mobile integrated health and community paramedicine (MIH-CP) programs are gaining popularity in the United States as a strategy to address the barriers to healthcare access and appropriate utilization. After one year of operation, leadership of Baltimore City's MIH-CP program was interested in understanding the circumstances surrounding readmission for enrolled patients and to incorporate quality improvement tools to direct program development. Retrospective chart review was performed to determine preventable versus unpreventable readmissions with a hypothesis that deficits in social determinants of health would play a more significant role in preventable readmissions. In the studied population, at least one root cause that can be considered a social determinant of health was present in 75.8% of preventable readmissions versus only 15.2% of unpreventable readmissions. Root Cause Analysis highlighted health literacy, functional status, and behavioral health issues among the root causes that most heavily influence preventable readmissions. Common Cause Analysis results suggest our MIH-CP program should focus its resources on mitigating poor health literacy and functional status. This project's findings successfully directed leadership of the city's MIH-CP program to modify program processes and advocate for the use of these quality improvement tools for other MIH-CP programs.

341 All Over the Road: A Systematic Review of Mobile Integrated Health, Community Paramedicine Programs

Mobile Integrated Health Community Paramedicine (MIHCP) expands the scope of EMS clinicians to provide patient-centered, mobile resources in the out-of-hospital environment to increase access to care and reduce ED usage. Prior MIHCP reviews have been limited in breadth or focused on characterizing interventions. This systematic review aims to characterize the outcomes and methodology that programs used to evaluate their effectiveness. We searched Pubmed, Embase, CINAHL, and Scopus databases for peer-reviewed literature related to MIHCP programs from January 1, 2000, through July 2020. We included all full-text English studies whose program met the National Association of Emergency Medical Technicians (NAEMT) definition, had an MIH- CP-related intervention and measured outcome, and was implemented through emergency medical services. We excluded all non-English papers, abstract-only, and incomplete studies. We identified 22 studies in our literature review. Study populations ranged from 14 to 2315 subjects and lasted from 4 to 48 months. There were three randomized controlled trials, 13 cohort studies (8 retrospective, 5 prospective), three case series, and three cross-sectional studies. Of the 13 cohort studies, 8 used a pre-post control, 2 statistically matched controls, 1 non-statistically matched control, 1 combined statistically matched and pre-post controls, and 1 did not feature a control. Case series and cross-sectional studies did not feature controls. 14 studies included ED usage as an outcome, measured by: ED visits (9), hospital admissions (8), ED length of stay (3), ED visits avoided (2), readmission rate (3), and ED transport rate (5). 12 studies included at least one Center for Medicare & Medicaid Innovation (CMMI) healthcare utilization core outcome. 4 studies reported cost-related outcomes, measured by: ambulance transport savings (2), ED visit savings (2), hospital admissions savings (1), and cost per quality adjusted life year increase (1). Three studies used at least one NAEMT core cost outcome. The NAEMT laid out a uniform set of measures (eg. health care utilization and cost) for MIHCP to optimize resource utilization and achievement of the triple aim. No individual study reported all CMMI healthcare utilization core outcomes nor NAEMT cost core outcomes. Our review of MIHCP studies revealed significant heterogeneity in study designs, control groups, and outcome measurements. Importantly, 6/22 (27%) studies used appropriate controls, while the rest were subject to selection bias, and only 9/22 (41%) were prospective, leaving the others more subject to information bias. Future MIHCP studies should focus on appropriate study designs to reduce bias and report core outcome measures to improve consistency across investigations and adherence to national organizations' recommendations.

163 Study Design Influences Effect Size: Systematic Review and Meta-Analysis of Mobile Integrated Health Community Paramedicine Programs’ Effect on Emergency Department Visits

Mobile Integrated Health Community Paramedicine (MIH-CP) programs are designed to reduce emergency department (ED) usage and increase access to care for vulnerable, underserved populations. Multiple MIH-CP systematic reviews have reported wide ranges of interventions, effect sizes, and a high prevalence of biased methods. The objectives of this study were to review MIH-CP interventions and perform a meta-analysis with a focus on the impact of study design on the magnitude of the observed effect. We hypothesized study design would influence effect size. We queried Pubmed, Embase, CINAHL, and Scopus databases for peer-reviewed MIH-CP literature from January 1, 2000, to July 31, 2020. We included all full-text English studies whose program met the National Association of Emergency Medical Technicians definition, had an MIH-CP related intervention and outcome, and was implemented through Emergency Medical Services. Our primary outcome was ED visits. We interpreted data to establish risk ratios for each study and performed a random-effects meta-analysis. We further performed a cumulative meta-analysis, tests of heterogeneity, and a moderator analysis to assess for factors influencing the magnitude of the observed effect. We included eight studies in our meta-analysis. All studies were observational; two used matched controls, two pre-post, and four no controls. Five studies’ interventions were diversion/triage: three provided acute care visits upon EMS activation and transported patients as indicated, one provided acute care “after- hours,” and one performed health clearance for mental health calls with direct transport to a mental health facility when appropriate. Three studies intervened with health education/home primary care services: two provided resources and regular follow-up for post-discharge patients, one provided similar service to patients with high ED utilization. Pooled risk ratio (RR) was 0.46 (95% confidence interval [CI] 0.25-0.83, I-square = 99%). Cumulative meta-analysis revealed MIH-CP programs began to show reductions in ED visits as of 2018. Moderator analysis revealed difference in effect size as a function of study design: matched controls RR 0.45 (95% CI 0.12-1.7), pre-post RR 1.03 (95% CI 0.27-4.0), uncontrolled RR 0.29 (95% 0.11-0.77). Study design has a major influence on the magnitude of observed effect in MIH-CP studies. While our pooled meta-analysis appeared to suggest a reduced risk of ED visits for patients engaged in MIH-CP programs, there was high heterogeneity among studies, and moderator analysis revealed a significant effect was observed only in uncontrolled studies. Non-significance may be due in part to small sample sizes. Future studies can focus on using appropriate controls to identify interventions’ effects more accurately.