Effectiveness of Interventions to Decrease Emergency Department Visits by Adult Frequent Users: A systematic review

Abstract

Introduction

Frequent emergency department (ED) users are high-risk and high-resource-utilizing patients. This systematic review evaluates effectiveness of interventions targeting adult frequent ED users in reducing visit frequency and improving patient outcomes.

Methods

An a priori protocol was published in PROSPERO. Two independent reviewers screened, selected, rated quality and extracted data. Third party adjudication resolved disagreements. Rate ratios of post- versus pre-intervention ED visits were calculated.

Data sources: A comprehensive search included seven databases and the grey literature.

Eligibility criteria for selecting studies:Experimental studies assessing the effect of interventions on frequent users’ ED visits and patient-oriented outcomes were included.

Results

6,865 citations were identified and 31 studies included. Designs were non-controlled (n=21) and controlled (n=4) before-after studies, and randomized controlled trials (n=6). Frequent user definitions varied considerably and risk of bias was moderate to high. Studies examined general frequent users or those with psychiatric co-morbidities, chronic disease, low socioeconomic status, or the elderly. Interventions included case management (n=18), care plans (n=8), diversion strategies (n=3), printout case notes (n=1), and social work visits (n=1). Post- versus pre-intervention rate ratios were calculated for 25 studies and indicated a significant visit decrease in 21 (84%) of these studies. The median rate ratio was 0.63 (IQR 0.41, 0.71), indicating that the general effect of the interventions described was to decrease ED visits post-intervention. Significant visit decreases were found for a majority of studies in subgroup analysis based on 6- or 12-month follow-up, definition thresholds, clinical frequent user subgroups and intervention types. Studies reporting homelessness found consistent improvements in stable housing. Overall, inter-study heterogeneity was high.

Conclusions

Interventions targeting frequent ED users appear to decrease ED visits and may improve stable housing. Future research should examine cost-effectiveness and adopt standardized definitions.

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