Patient education, patient financial incentives and managed care interventions (primary care physician capitation or gatekeeping) are the most successful outside methods to reduce emergency room use, according to a new study published in the journal Academic Emergency Medicine.
The findings have significant implications for insurers and policymakers seeking to reduce the number of visits to the emergency department (ED) as a way to lower costs and improve the quality of care.
The research, led by FierceHealthcare Editorial Advisor Jesse Pines, M.D., director of the Office of Clinical Practice Innovation and professor of emergency medicine at the George Washington University (GW) School of Medicine and Health Sciences, systematically reviewed interventions implemented outside the ED that were designed to reduce ED use. He studied five types of interventions:
- Patient education
- Creation of additional non-ED capacity
- Managed care
- Pre-hospital diversion
- Patient financial incentives
The research team analyzed 39 studies (34 observational and five randomized controlled trials) and found:
- Two of five studies on patient education on medical conditions and healthcare use found reductions in ED use ranging from 21 percent to 80 percent;
- Four out of 10 studies that looked at the creation of additional non-ED capacity found decreases of 9 percent to 54 percent, and one showed a 21 percent increase;
- Both studies on prehospital diversion of low-acuity patients found reductions of 3 percent to 7 percent;
- Of 12 studies on managed care, 10 had decreases ranging from 1 percent to 46 percent;
- Nine out of 10 studies on patient financial incentives found decreases of 3 percent to 50 percent, and one reported a 34 percent increase;
- Nineteen studies reported effects on non-ED use with mixed results;
- Seventeen studies included data on health outcomes, but 13 of these only included data on hospitalizations rather than morbidity and mortality; and
- Seven studies included data on cost outcomes.
Pines found two-thirds of the published interventions actually reduced ED use, but only a handful really looked at patient outcomes. The problem is discouraging people from getting needed care may lead to unintended consequences of sick people staying home instead of heading to the ED, Pines said in a study announcement.
"Furthermore," he said, "some of the interventions, especially those that added non-ED capacity, had the effect of reducing ED use, but increasing overall healthcare consumption. As new programs are rolled out to discourage people from going to EDs, we need to study them carefully to ensure they are safe and look at how they impact big picture costs."
Reducing ED use has become a major priority for many organizations and is an important part of many initiatives included in the Affordable Care Act. Pines said many of the interventions identified in the study can help achieve this goal, but urged providers to think carefully about how initiatives can impact quality and access to care.
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