title: Case Management may Reduce Emergency Department Frequent use in a Universal Health Coverage System: a Randomized Controlled Trial.
abstract: BACKGROUND
  Frequent emergency department (ED) users account for a disproportionately high number of ED visits. Studies on case management (CM) interventions to reduce frequent ED use have shown mixed results, and few studies have been conducted within a universal health coverage system.
  
  
  OBJECTIVE
  To determine whether a CM intervention-compared to standard emergency care-reduces ED attendance.
  
  
  METHODS
  Randomized controlled trial.
  
  
  METHODS
  Two hundred fifty frequent ED users (5 or more visits in the prior 12 months) who visited a public urban ED at the Lausanne University Hospital between May 2012 and July 2013 were allocated to either an intervention (n = 125) or control (n = 125) group, and monitored for 12 months.
  
  
  METHODS
  An individualized CM intervention consisting of concrete assistance in obtaining income entitlements, referral to primary or specialty medical care, access to mental health care or substance abuse treatment, and counseling on at-risk behaviors and health care utilization (in addition to standard care) at baseline and 1, 3, and 5 months.
  
  
  METHODS
  We used a generalized linear model for count data (negative binomial distribution) to compare the number of ED visits during the 12-month follow-up between CM and usual care, from an intention-to-treat perspective.
  
  
  RESULTS
  At 12 months, there were 2.71 (±0.23) ED visits in the intervention group versus 3.35 (±0.32) visits among controls (ratio = 0.81, 95 % CI = 0.63; 1.02). In the multivariate model, the effect of the CM intervention on the number of ED visits approached statistical significance (b = -0.219, p = 0.075). The presence of poor social determinants of health was a significant predictor of ED use in the multivariate model (b = 0.280, p = 0.048).
  
  
  CONCLUSIONS
  CM may reduce ED use by frequent users through an improved orientation to the health care system. Poor social determinants of health significantly increase use of the ED by frequent users.
authors.affiliation: Vulnerable Populations Center, Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland. Patrick.Bodenmann@hospvd.ch.
authors.forename: Patrick
authors.initials: P
authors.lastname: Bodenmann
authors.affiliation: Institute of Higher Education and Research in Healthcare, Department of Community Medicine and Public Health, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
authors.forename: Venetia-Sofia
authors.initials: VS
authors.lastname: Velonaki
authors.affiliation: Vulnerable Populations Center, Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland.
authors.forename: Judith L
authors.initials: JL
authors.lastname: Griffin
authors.affiliation: Life Course and Social Inequality Research Center, Faculty of Social and Political Sciences, University of Lausanne, Lausanne, Switzerland.
authors.forename: Stéphanie
authors.initials: S
authors.lastname: Baggio
authors.affiliation: Center for the Understanding of Social Processes, University of Neuchâtel, Neuchâtel, Switzerland.|Institute of social and preventive medicine, Lausanne University Hospital, Lausanne, Switzerland.
authors.forename: Katia
authors.initials: K
authors.lastname: Iglesias
authors.affiliation: Institute of social and preventive medicine, Lausanne University Hospital, Lausanne, Switzerland.|Technology Assessment Unit, Lausanne University Hospital, Lausanne, Switzerland.|IEMS - Plateforme interfacultaire en économie et management de la santé, University of Lausanne, Lausanne, Switzerland.
authors.forename: Karine
authors.initials: K
authors.lastname: Moschetti
authors.affiliation: Department of Community Medicine and Public Health, Lausanne University Hospital, Lausanne, Switzerland.
authors.forename: Ornella
authors.initials: O
authors.lastname: Ruggeri
authors.affiliation: Institute of social and preventive medicine, Lausanne University Hospital, Lausanne, Switzerland.
authors.forename: Bernard
authors.initials: B
authors.lastname: Burnand
authors.affiliation: Technology Assessment Unit, Lausanne University Hospital, Lausanne, Switzerland.
authors.forename: Jean-Blaise
authors.initials: JB
authors.lastname: Wasserfallen
authors.affiliation: Vulnerable Populations Center, Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland.
authors.forename: Francis
authors.initials: F
authors.lastname: Vu
authors.affiliation: Vulnerable Populations Center, Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland.
authors.forename: Joelle
authors.initials: J
authors.lastname: Schupbach
authors.affiliation: Emergency Department, Lausanne University Hospital, Lausanne, Switzerland.
authors.forename: Olivier
authors.initials: O
authors.lastname: Hugli
authors.affiliation: Alcohol Treatment Center, Lausanne University Hospital, Lausanne, Switzerland.
authors.forename: Jean-Bernard
authors.initials: JB
authors.lastname: Daeppen
mesh_terms: D000328:Adult; D000368:Aged; D019090:Case Management / Q000639:trends*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data* / Q000639:trends*; D005260:Female; D005500:Follow-Up Studies; D006785:Hospitals, University / Q000639:trends; D006801:Humans; D008297:Male; D008875:Middle Aged; D009313:National Health Programs / Q000639:trends*; D010342:Patient Acceptance of Health Care; D016037:Single-Blind Method; D013557:Switzerland / Q000453:epidemiology
keywords: case management; clinical trials; utilization; vulnerable populations