title: A case management intervention targeted to reduce healthcare consumption for frequent Emergency Department visitors: results from an adaptive randomized trial.
abstract: BACKGROUND
  A small group of frequent visitors to Emergency Departments accounts for a disproportionally large fraction of healthcare consumption including unplanned hospitalizations and overall healthcare costs. In response, several case and disease management programs aimed at reducing healthcare consumption in this group have been tested; however, results vary widely.
  
  
  OBJECTIVE
  To investigate whether a telephone-based, nurse-led case management intervention can reduce healthcare consumption for frequent Emergency Department visitors in a large-scale setup.
  
  
  METHODS
  A total of 12 181 frequent Emergency Department users in three counties in Sweden were randomized using Zelen's design or a traditional randomized design to receive either a nurse-led case management intervention or no intervention, and were followed for healthcare consumption for up to 2 years.
  
  
  RESULTS
  The traditional design showed an overall 12% (95% confidence interval 4-19%) decreased rate of hospitalization, which was mostly driven by effects in the last year. Similar results were achieved in the Zelen studies, with a significant reduction in hospitalization in the last year, but mixed results in the early development of the project.
  
  
  CONCLUSIONS
  Our study provides evidence that a carefully designed telephone-based intervention with accurate and systematic patient selection and appropriate staff training in a centralized setup can lead to significant decreases in healthcare consumption and costs. Further, our results also show that the effects are sensitive to the delivery model chosen.
authors.affiliation: Departments of aMedical Epidemiology and Biostatistics bPublic Health Sciences, Karolinska Institutet cHematology Centre dDepartment of Quality and Patient Safety, Karolinska University Hospital eHealth Navigator fPublic Healthcare Services Committee Administration, Stockholm County Council, Stockholm gHealthcare Administration, Uppsala County Council, Uppsala hHealthcare Administration, Västra Götaland Region, Göteborg iHealthcare Administration, Linköping County Council, Linköping jDepartment of Medicine, Sörmland County Council, Nyköping, Sweden.
authors.forename: Gustaf
authors.initials: G
authors.lastname: Edgren
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Anderson
authors.forename: Anders
authors.initials: A
authors.lastname: Dolk
authors.forename: Jarl
authors.initials: J
authors.lastname: Torgerson
authors.forename: Svante
authors.initials: S
authors.lastname: Nyberg
authors.forename: Tommy
authors.initials: T
authors.lastname: Skau
authors.forename: Birger C
authors.initials: BC
authors.lastname: Forsberg
authors.forename: Joachim
authors.initials: J
authors.lastname: Werr
authors.forename: Gunnar
authors.initials: G
authors.lastname: Öhlen
mesh_terms: D000368:Aged; D019090:Case Management / Q000458:organization & administration; D003695:Delivery of Health Care / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D006300:Health Services Misuse / Q000517:prevention & control*; D006801:Humans; D008297:Male; D008875:Middle Aged; D013548:Sweden