title: Reducing frequent visits to the emergency department: a systematic review of interventions.
abstract: OBJECTIVE
  The objective of this study was to establish the effectiveness of interventions to reduce frequent emergency department (ED) use among a general adult high ED-use population.
  
  
  METHODS
  Systematic review of the literature from 1950-January 2015. Studies were included if they: had a control group (controlled trials or comparative cohort studies), were set in an ED or acute care facility, and examined the impact of an intervention to reduce frequent ED use in a general adult population. Studies reporting non-original data or focused on a specific patient population were excluded. Study design, patient population, intervention, the frequency of ED visits, and costs of frequent ED use and/or interventions were extracted and narratively synthesized.
  
  
  RESULTS
  Among 17 included articles, three intervention categories were identified: case management (n = 12), individualized care plans (n = 3), and information sharing (n = 2). Ten studies examining case management reported reductions in mean (-0.66 to -37) or median (-0.1 to -20) number of ED visits after 12-months; one study reported an increase in mean ED visits (+2.79); and one reported no change. Of these, 6 studies also reported reduced hospital costs. Only 1 study evaluating individualized care plans examined ED utilization and found no change in median ED visits post-intervention. Costs following individualized care plans were also only evaluated in 1 study, which reported savings in hospital costs of $742/patient. Evidence was mixed regarding information sharing: 1 study reported no change in mean ED visits and did not examine costs; whereas the other reported a decrease in mean ED visits (-16.9) and ED cost savings of $15,513/patient.
  
  
  CONCLUSIONS
  The impact of all three frequent-user interventions was modest. Case management had the most rigorous evidence base, yielded moderate cost savings, but with variable reductions in ED use. Future studies evaluating non-traditional interventions, tailoring to patient subgroups or socio-cultural contexts, are warranted.
authors: The Department Community Health Sciences, Teaching Research and Wellness Building, 3280 Hospital Drive NW, Calgary, Alberta, Canada; Institute for Public Health, Teaching Research and Wellness Building, 3280 Hospital Drive NW, Calgary, Alberta, Canada.
authors: Lesley J J
authors: LJ
authors: Soril
authors: The Department Community Health Sciences, Teaching Research and Wellness Building, 3280 Hospital Drive NW, Calgary, Alberta, Canada; Institute for Public Health, Teaching Research and Wellness Building, 3280 Hospital Drive NW, Calgary, Alberta, Canada.
authors: Laura E
authors: LE
authors: Leggett
authors: The Department Community Health Sciences, Teaching Research and Wellness Building, 3280 Hospital Drive NW, Calgary, Alberta, Canada; Institute of Health Economics, 1200, 10405 Jasper Avenue, Edmonton, Alberta, Canada.
authors: Diane L
authors: DL
authors: Lorenzetti
authors: The Department Community Health Sciences, Teaching Research and Wellness Building, 3280 Hospital Drive NW, Calgary, Alberta, Canada; Institute for Public Health, Teaching Research and Wellness Building, 3280 Hospital Drive NW, Calgary, Alberta, Canada.
authors: Tom W
authors: TW
authors: Noseworthy
authors: The Department Community Health Sciences, Teaching Research and Wellness Building, 3280 Hospital Drive NW, Calgary, Alberta, Canada; Institute for Public Health, Teaching Research and Wellness Building, 3280 Hospital Drive NW, Calgary, Alberta, Canada.
authors: Fiona M
authors: FM
authors: Clement
mesh_terms: D000328:Adult; D019090:Case Management / Q000191:economics / Q000458:organization & administration*; D017046:Cost Savings / Q000191:economics; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D017721:Hospital Costs; D006801:Humans; D010347:Patient Care Planning; D011785:Quality Assurance, Health Care; D016032:Randomized Controlled Trials as Topic