Seaberg David, Elseroad Stanton, Dumas Michael, Mendiratta Sudave, Whittle Jessica, Hyatte Cheryl, Keys Jan
Department of Emergency Medicine, University of Tennessee College of Medicine, Chattanooga, TN.
Erlanger Health System, Chattanooga, TN.
Acad Emerg Med. 2017 Nov;24(11):1327-1333. doi: 10.1111/acem.13280. Epub 2017 Sep 23.
Emergency department (ED) superutilizers (patients with five or more visits/year) comprise only 5% of the patients seen yet comprise 25% of total ED visits. Although the reasons for this are multifactorial, the cost to the patient and the community is exceedingly high. The cost is not just monetary; care of these patients is inappropriately fragmented and their presence in the ED may contribute to overcrowding affecting the community's emergency readiness. Previous studies using staff trained to help patients navigate their care options have had conflicting results.
The objective was to determine whether a trained patient navigator (PN) can reduce ED use and costs in superutilizers over a 1-year period.
Superutilizers were enrolled in a prospective randomized controlled clinical trial. Patients were randomized into the treatment arm and met with a PN who reviewed their diagnosis and associated care plan and identified proper primary care services and community resources for follow-up. The remaining control group was provided standard care. Both groups were given a follow-up call and survey by the PN within 7 days of their visit who assessed primary care follow-up and patient satisfaction using a 4-point Likert scale. After 12 months, the patients' return ED visits and ED costs were compared to the year prior and primary care compliance and satisfaction were measured using Student's t-tests with Bonferroni correction or Mann-Whitney U-tests.
A total of 282 patients were enrolled (148 in navigation treatment group, 134 controls). Patients were similarly matched in age, race, sex, insurance, and chief complaints. Overall ED visits decreased during the 12-month study period, compared to the 12 months prior to enrollment (2,249 visits prior to 2,050 visits during study period, -8.8%). There was a greater decrease in ED visits from the preenrollment year to postenrollment year in the treatment group (1,148 visits to 996 visits, -13.2%) compared to the control group (1,101 visits to 1,054 visits, -4.3%; p < 0.05). Overall health care costs (ED and hospital) for all 282 patients decreased in the year after compared to the 12 months prior to enrollment ($3.9M to $3.1M) with a greater decrease in the navigation treatment group (-26.6%) compared to the control group (-17.5%). Patient surveys found no difference in patient satisfaction in the pre- and postenrollment periods but there was an increase in primary care physician (PCP) use over the 12-month follow-up period in the treatment group (6.42 visits/patient) compared to the control group (4.07 visits/patient; p < 0.05).
Our data showed that the overall number of return ED visits and costs did decrease for both groups, potentially inferring a placebo effect for the use of a PN; however, the decrease in ED visits and costs were greater in the treatment group. One-year follow-up noted an increase in PCP visits in the navigation group. Use of a PN may be cost-effective.
急诊科（ED）的频繁使用者（每年就诊5次或更多次的患者）仅占就诊患者的5%，却占急诊就诊总数的25%。尽管原因是多方面的，但对患者和社区造成的成本却极高。成本不仅是金钱方面的；对这些患者的护理存在不当的碎片化情况，而且他们在急诊科的存在可能导致过度拥挤，影响社区的应急准备。以往使用经过培训以帮助患者选择护理方案的工作人员的研究结果相互矛盾。
目的是确定经过培训的患者导航员（PN）能否在1年时间内减少频繁使用者的急诊就诊次数和成本。
频繁使用者被纳入一项前瞻性随机对照临床试验。患者被随机分为治疗组，与一名PN会面，该PN会审查他们的诊断和相关护理计划，并确定适当的初级保健服务和社区资源以便后续跟进。其余对照组接受标准护理。两组患者在就诊后7天内均会接到PN的随访电话和调查，PN使用4点李克特量表评估初级保健随访情况和患者满意度。12个月后，将患者的急诊复诊次数和急诊成本与上一年进行比较，并使用经Bonferroni校正的学生t检验或Mann-Whitney U检验来衡量初级保健依从性和满意度。
共招募了282名患者（导航治疗组148名，对照组134名）。患者在年龄、种族、性别、保险和主要诉求方面匹配情况相似。与入组前的12个月相比，在12个月的研究期间，急诊就诊总数有所下降（入组前2249次就诊，研究期间2050次就诊，下降8.8%）。与对照组（从1101次就诊降至1054次就诊，下降4.3%；p<0.05）相比，治疗组从入组前一年到入组后一年的急诊就诊次数下降幅度更大（从1148次就诊降至996次就诊，下降13.2%）。与入组前的12个月相比，所有282名患者的总体医疗保健成本（急诊和住院）在入组后的一年有所下降（从390万美元降至310万美元），导航治疗组的下降幅度（-26.
