Reducing emergency visits in older adults with chronic illness. A randomized, controlled trial of group visits.

CONTEXT

Emergency department utilization by chronically ill older adults may be an important sentinel event signifying a breakdown in care coordination. A primary care group visit (i.e., several patients meeting together with the provider at the same time) may reduce fragmentation of care and subsequent emergency department utilization.

OBJECTIVE

To determine whether primary care group visits reduce emergency department utilization in chronically ill older adults.

DESIGN

Randomized trial conducted over a 2-year period.

SETTING

Group-model HMO in Denver, Colorado.

PATIENTS

295 older adults (> or = 60 years of age) with frequent utilization of outpatient services and one or more chronic illnesses.

INTERVENTION

Monthly group visits (generally 8 to 12 patients) with a primary care physician, nurse, and pharmacist held in 19 physician practices. Visits emphasized self-management of chronic illness, peer support, and regular contact with the primary care team.

MEASURES

Emergency department visits, hospitalizations, and primary care visits.

RESULTS

On average, patients in the intervention group attended 10.6 group visits during the 2-year study period. These patients averaged fewer emergency department visits (0.65 vs. 1.08 visits; P = 0.005) and were less likely to have any emergency department visits (34.9% vs. 52.4%; P = 0.003) than controls. These differences remained statistically significant after controlling for demographic factors, comorbid conditions, functional status, and prior utilization. Adjusted mean difference in visits was -0.42 visits (95% CI, -0.13 to -0.72), and adjusted RR for any emergency department visit was 0.64 (CI, 0.44 to 0.86).

CONCLUSION

Monthly group visits reduce emergency department utilization for chronically ill older adults.