title: Non-emergency department interventions to reduce ED utilization: a systematic review.
abstract: OBJECTIVE
  Recent health policy changes have focused efforts on reducing emergency department (ED) visits as a way to reduce costs and improve quality of care. This was a systematic review of interventions based outside the ED aimed at reducing ED use.
  
  
  METHODS
  This study was designed as a systematic review. We reviewed the literature on interventions in five categories: patient education, creation of additional non-ED capacity, managed care, prehospital diversion, and patient financial incentives. Studies written in English, with interventions administered outside of the ED, and a comparison group where ED use was an outcome, were included. Two independent reviewers screened search results using MEDLINE, Cochrane, OAIster, or Scopus. The following data were abstracted from included studies: type of intervention, study design, population, details of intervention, effect on ED use, effect on non-ED health care use, and other health and financial outcomes. Quality of individual articles was assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines.
  
  
  RESULTS
  Of 39 included studies, 34 were observational and five were randomized controlled trials. Two of five studies on patient education found reductions in ED use ranging from 21% to 80%. Out of 10 studies of additional non-ED capacity, four showed decreases of 9% to 54%, and one a 21% increase. Both studies on prehospital diversion found reductions of 3% to 7%. Of 12 studies on managed care, 10 had decreases ranging from 1% to 46%. Nine out of 10 studies on patient financial incentives found decreases of 3% to 50%, and one a 34% increase. Nineteen studies reported effect on non-ED use with mixed results. Seventeen studies included data on health outcomes, but 13 of these only included data on hospitalizations rather than morbidity and mortality. Seven studies included data on cost outcomes. According to the GRADE guidelines, all studies had at least some risk of bias, with four moderate quality, one low quality, and 34 very low quality studies.
  
  
  CONCLUSIONS
  Many studies have explored interventions based outside the ED to reduce ED use in various populations, with mixed evidence. Approximately two-thirds identified here showed reductions in ED use. The interventions with the greatest number of studies showing reductions in ED use include patient financial incentives and managed care, while the greatest magnitude of reductions were found in patient education. These findings have implications for insurers and policymakers seeking to reduce ED use.
authors.affiliation: Department of Emergency Medicine, Emory University, Atlanta, GA.
authors.forename: Sofie Rahman
authors.initials: SR
authors.lastname: Morgan
authors.forename: Anna Marie
authors.initials: AM
authors.lastname: Chang
authors.forename: Mahfood
authors.initials: M
authors.lastname: Alqatari
authors.forename: Jesse M
authors.initials: JM
authors.lastname: Pines
mesh_terms: D004636:Emergency Service, Hospital / Q000191:economics / Q000706:statistics & numerical data*; D006300:Health Services Misuse / Q000517:prevention & control*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D017063:Outcome Assessment, Health Care