Moe Jessica, Kirkland Scott W, Rawe Erin, Ospina Maria B, Vandermeer Ben, Campbell Sandy, Rowe Brian H
Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada.
Emergency Medicine Research Group, University of Alberta, Edmonton, Alberta, Canada.
Acad Emerg Med. 2017 Jan;24(1):40-52. doi: 10.1111/acem.13060.
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.
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 were from a comprehensive search that included seven databases and the gray literature. Eligibility criteria for selecting studies included experimental studies assessing the effect of interventions on frequent users' ED visits and patient-oriented outcomes.
A total of 6,865 citations were identified and 31 studies included. Designs were noncontrolled (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 comorbidities, chronic disease, or 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 (interquartile range = 0.41 to 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 analyses 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, interstudy heterogeneity was high.
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.
频繁就诊于急诊科（ED）的患者是高风险且高资源消耗型患者。本系统评价评估了针对成年频繁就诊于急诊科患者的干预措施在降低就诊频率和改善患者结局方面的有效性。
预先制定的方案已在国际前瞻性系统评价注册库（PROSPERO）中发表。两名独立的评审人员进行筛选、选择、质量评级并提取数据。第三方裁决解决分歧。计算干预后与干预前急诊科就诊的率比。数据来源包括全面检索七个数据库和灰色文献。选择研究的纳入标准包括评估干预措施对频繁就诊患者急诊科就诊及以患者为导向的结局影响的实验性研究。
共识别出6865条引文，纳入31项研究。研究设计包括非对照研究（n = 21）、前后对照研究（n = 4）和随机对照试验（n = 6）。频繁就诊患者的定义差异很大，偏倚风险为中度至高度。研究对象包括一般频繁就诊患者或合并精神疾病、慢性病、社会经济地位低的患者或老年人。干预措施包括病例管理（n = 18）、护理计划（n = 8）、分流策略（n = 3）、打印病例记录（n = 1）和社会工作访视（n = 1）。对25项研究计算了干预后与干预前的率比，其中21项（84%）研究显示就诊次数显著减少。中位数率比为0.63（四分位间距 = 0.41至0.71），表明所述干预措施的总体效果是干预后减少急诊科就诊次数。在基于6个月或12个月随访、定义阈值、临床频繁就诊患者亚组和干预类型的亚组分析中，大多数研究发现就诊次数显著减少。报告无家可归情况的研究发现稳定住房状况持续改善。总体而言，研究间异质性较高。
针对频繁就诊于急诊科患者的干预措施似乎可减少急诊科就诊次数，并可能改善稳定住房状况。未来研究应考察成本效益并采用标准化定义。
