Edgren Gustaf, Anderson Jacqueline, Dolk Anders, Torgerson Jarl, Nyberg Svante, Skau Tommy, Forsberg Birger C, Werr Joachim, Öhlen Gunnar
Departments of aMedical Epidemiology and Biostatistics bPublic Health Sciences, Karolinska Institutet cHematology Centre dDepartment of Quality and Patient Safety, Karolinska University Hospital eHealth Navigator fPublic Healthcare Services Committee Administration, Stockholm County Council, Stockholm gHealthcare Administration, Uppsala County Council, Uppsala hHealthcare Administration, Västra Götaland Region, Göteborg iHealthcare Administration, Linköping County Council, Linköping jDepartment of Medicine, Sörmland County Council, Nyköping, Sweden.
Eur J Emerg Med. 2016 Oct;23(5):344-50. doi: 10.1097/MEJ.0000000000000280.
A small group of frequent visitors to Emergency Departments accounts for a disproportionally large fraction of healthcare consumption including unplanned hospitalizations and overall healthcare costs. In response, several case and disease management programs aimed at reducing healthcare consumption in this group have been tested; however, results vary widely.
To investigate whether a telephone-based, nurse-led case management intervention can reduce healthcare consumption for frequent Emergency Department visitors in a large-scale setup.
A total of 12 181 frequent Emergency Department users in three counties in Sweden were randomized using Zelen's design or a traditional randomized design to receive either a nurse-led case management intervention or no intervention, and were followed for healthcare consumption for up to 2 years.
The traditional design showed an overall 12% (95% confidence interval 4-19%) decreased rate of hospitalization, which was mostly driven by effects in the last year. Similar results were achieved in the Zelen studies, with a significant reduction in hospitalization in the last year, but mixed results in the early development of the project.
Our study provides evidence that a carefully designed telephone-based intervention with accurate and systematic patient selection and appropriate staff training in a centralized setup can lead to significant decreases in healthcare consumption and costs. Further, our results also show that the effects are sensitive to the delivery model chosen.
一小部分频繁前往急诊科就诊的患者在医疗保健消费中所占比例过高，包括意外住院和总体医疗费用。作为回应，已经对一些旨在减少该群体医疗保健消费的病例和疾病管理项目进行了测试；然而，结果差异很大。
在大规模环境中研究基于电话的、由护士主导的病例管理干预措施是否可以减少频繁前往急诊科就诊患者的医疗保健消费。
瑞典三个县的总共12181名频繁前往急诊科就诊的患者使用泽伦设计或传统随机设计进行随机分组，以接受由护士主导的病例管理干预或不接受干预，并对其医疗保健消费情况进行长达2年的跟踪。
传统设计显示住院率总体下降了12%（95%置信区间为4%-19%），这主要是由去年的效果推动的。泽伦研究也取得了类似结果，去年住院人数显著减少，但项目早期的结果参差不齐。
我们的研究提供了证据，表明在集中式环境中进行精心设计的基于电话的干预，通过准确、系统地选择患者并进行适当的工作人员培训，可以显著降低医疗保健消费和成本。此外，我们的结果还表明，效果对所选的实施模式很敏感。
