Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland.
Technology Assessment Unit, Lausanne University Hospital, Lausanne, Switzerland.
PLoS One. 2018 Sep 24;13(9):e0199691. doi: 10.1371/journal.pone.0199691. eCollection 2018.
In most emergency departments (EDs), few patients account for a relatively high number of ED visits. To improve the management of these patients, the university hospital of Lausanne, Switzerland, implemented an interdisciplinary case management (CM) intervention. This study examined whether the CM intervention-compared with standard care (SC) in the ED-reduced costs generated by frequent ED users, not only from the hospital perspective, but also from the third-party payer perspective, that is, from a broader perspective that takes into account the costs of health care services used outside the hospital offering the intervention.
In this randomized controlled trial, 250 frequent ED users (>5 visits during the previous 12 months) were allocated to either the CM or the SC group and followed up for 12 months. Cost data were obtained from the hospital's analytical accounting system for the entire sample and from health insurance companies for a subgroup (n = 140). Descriptive statistics and multivariate regressions were used to make comparisons between groups and assess the contribution of patient characteristics to the main cost components.
At the end of the 12-month follow-up, 115 patients were in the CM group and 115 in the SC group (20 had died). Despite differences in economic costs between patients in the CM intervention and the SC groups, our results do not show any statistically significant reduction in costs associated with the intervention, either for the hospital that housed the intervention or for the third-party payer. Frequent ED users were big users of health services provided by both the hospital and community-based services, with 40% of costs generated outside the hospital that housed the intervention. Higher age, Swiss citizenship, and having social difficulty increased costs significantly.
As the role of the CM team is to guide patients through the entire care process, the intervention location is not limited to the hospital but often extends into the community.
在大多数急诊科（ED）中，少数患者占相对较高数量的 ED 就诊次数。为了改善这些患者的管理，瑞士洛桑大学医院实施了一种跨学科的病例管理（CM）干预措施。本研究考察了与 ED 中的标准护理（SC）相比，CM 干预措施是否降低了频繁 ED 使用者的成本，不仅从医院的角度，而且从第三方支付者的角度来看，这是从更广泛的角度考虑到了医院提供干预措施之外的医疗服务的成本。
在这项随机对照试验中，250 名频繁的 ED 使用者（在过去 12 个月中就诊次数超过 5 次）被分配到 CM 或 SC 组，并随访 12 个月。从医院的分析会计系统获得了整个样本的成本数据，从健康保险公司获得了一个亚组（n=140）的成本数据。使用描述性统计和多元回归比较了组间差异，并评估了患者特征对主要成本构成的贡献。
在 12 个月的随访结束时，115 名患者在 CM 组，115 名在 SC 组（20 名死亡）。尽管 CM 干预组和 SC 组患者的经济成本存在差异，但我们的结果并没有显示出干预措施与医院或第三方支付者相关的成本有任何统计学意义的降低。频繁的 ED 用户是医院和社区服务提供的医疗服务的大量使用者，其中 40%的费用是在提供干预措施的医院之外产生的。较高的年龄、瑞士公民身份和社会困难显著增加了成本。
由于 CM 团队的作用是指导患者完成整个护理过程，因此干预地点不仅限于医院，而且经常延伸到社区。
