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The effects of clinical case management on hospital service use among ED frequent users |
Okin R L, Boccellari A, Azocar F, Shumway M, O'Brien K, Gelb A, Kohn M, Harding P, Wachsmuth C |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology The study examined intensive, comprehensive, clinical, case management for high users of an urban emergency department (ED). The patients were assigned to a master's level psychiatric social worker who used a comprehensive, intensive case management model. The case manager was responsible for providing and co-ordinating all required services.
Type of intervention Treatment: clinical management.
Economic study type Cost-effectiveness analysis.
Study population The study population comprised high users of a public urban ED. The inclusion criteria specified that the participants had to have made at least five visits to the San Francisco General Hospital (SFGH) ED during the prior 12 months, be aged at least 18 years, be able to give informed consent and be willing to receive case management services. Patients who were too intoxicated, acutely confused or acutely psychotic to give informed consent were excluded, as were those already receiving case management services.
Setting The practice setting was secondary care. The economic study was carried out in San Francisco (CA), USA.
Dates to which data relate The effectiveness and resource use data were collected during June 1995 and June 1996. The price year was 1997.
Source of effectiveness data The effectiveness data were gathered from a single prospective study.
Link between effectiveness and cost data The costing was undertaken prospectively on the same group of patients as that used in the effectiveness study.
Study sample A total of 174 patients were screened for study admission, of which 53 met the study criteria and were enrolled in the programme. Of those not meeting the inclusion criteria, 47 (39%) patients refused to participate, 42 (35%) were inappropriate referrals and 32 (26%) were unable to give informed consent. The patients were predominantly males (87%). Forty-nine per cent were African American, 23% were Caucasian, 19% Hispanic, 6% Native American and 4% Asian. The mean age at the time of enrolment was 45 years (standard deviation 14.4; range: 19 - 82 years). The majority were homeless (67%), 100% were unemployed, and many were without medical insurance (45%).
Study design The study was conducted using a before-and-after design in which each patient acted as his/her own historical control. The before period was the 12 months before the case management intervention, while the after period was the 12 months post enrolment onto case management.
Analysis of effectiveness The analysis used all those patients for whom the results were available. The primary health outcome used in the analysis was the impact on psychosocial variables (homelessness, alcohol abuse, drug use and having medical insurance).
Effectiveness results In the year after case management enrolment:
homelessness decreased by 57% (McNemar test = 10; p<0.01; 95% confidence interval, CI: -73 - -42);
problem alcohol use decreased by 22% (McNemar test = 4.0; p=0.05; 95% CI: -37 - -10); and
problem drug use decreased by 26% (McNemar test = 3.5; p=0.05; 95% CI: -44 - -11).
The percentage of patients without Medicaid decreased by 54% (McNemar test = -7.0; p<0.01; 95% CI: -76 - -33).
Clinical conclusions The intensive clinical case management programme significantly improved psychosocial outcomes.
Measure of benefits used in the economic analysis The authors did not develop a summary benefit measure. Hence, a cost-consequences analysis was performed. The associated health outcomes are associated with the effectiveness results.
Direct costs The cost/resource boundary of the analysis was that of the hospital (SFGH). The direct costs were for the medical and psychiatric inpatient, outpatient and emergency services, the physicians' professional services and the ambulance. Hospital service utilisation data were obtained from the SFGH administrative databases. The cost-to-charge ratio for the year of service was used. The costs of the programme were calculated as the total wage and fringe costs for the programme's clinical, supervisory and support staff, plus a standard local 29% overhead rate charged for contracted clinical services. All the costs were adjusted for inflation to 1997 dollars using the Medical Care Consumer Price Index.
Statistical analysis of costs Permutation tests and resampling procedures (1,000 times) were used to estimate the statistical significance of observed values for median change against the null hypothesis of no pre-post change. The bootstrap percentile method was used to obtain the CIs.
Indirect Costs No indirect costs were included in the analysis.
Sensitivity analysis No sensitivity analysis was carried out.
Estimated benefits used in the economic analysis See the 'Effectiveness Results' section.
Cost results The patients made fewer visits to the ED in the year after case management enrolment than in the preceding year. The median number of ED visits decreased from 15 to 9 (median change: -5; p<0.01; 95% CI: -7 - -3). The number of medical outpatient clinic visits increased from 2 to 4 (median change: 1; p<0.01; 95% CI: 0 - 3). There was no appreciable change in the use of medical inpatient services or psychiatric inpatient or emergency services.
The mean total hospital service cost decreased from $22,022 in the year before case management enrolment to $14,910 in the year after enrolment (median change: $-2,406; p=0.06; 95% CI: -6,361 - -430).
The median cost of the medical emergency service decreased from $4,124 to $2,195 (median change: $-1,938; p<0.01; 95% CI: -2,459 - -1,013).
The median medical inpatient cost decreased from $8,330 to $2,786 (median change: $-1,082; p<0.01; 95% CI: -8,330 - 0).
The physicians' professional fee cost also decreased significantly (median change: $-270; p=0.03; 95% CI: -464 - -113).
Maintaining or obtaining stable housing may be positively associated with hospital cost-savings.
Synthesis of costs and benefits Authors' conclusions Intensive clinical case management was associated with statistically significant reductions in the use and cost of acute hospital services, and reductions in psychosocial problems. The intervention appears to have been both cost-efficient and cost-effective.
CRD COMMENTARY - Selection of comparators The reason for the choice of the comparator (no intervention) was clear. You should determine if the health technologies examined are appropriate for your own setting.
Validity of estimate of measure of effectiveness The analysis used a before-and-after study design, which was appropriate for the study question. However, selection bias may have existed. For example, the patients were referred at the discretion of the ED staff and the study sample may, therefore, have not been representative of all patients making at least five visits in a year. Confounding variables may also have been present and thus may have affected the outcomes. A randomised controlled trial, where feasible, would have been a more valid study design for the study question. Few details of the method used to measure the effectiveness outcomes were given. However, appropriate statistical analyses were undertaken to estimate the statistical significance. The reporting was clear and concise.
Validity of estimate of measure of benefit There was no summary measure of benefit.
Validity of estimate of costs All the categories of cost relevant to the perspective adopted (hospital) were included in the analysis. The costs and the quantities were reported separately. A statistical analysis of the quantities was performed. However, no sensitivity analysis of the prices was carried out. Discounting was unnecessary since all of the costs were incurred in one year.
Other issues The authors did not compare their findings with those from other studies. In addition, the issue of generalisability to other settings was not specifically addressed. The authors presented their results with accuracy and clarity, and reported a number of limitations to their study. In particular, the before-and-after design, the selection bias, and the fact that the cost analysis was limited to the perspective of a hospital.
Implications of the study The findings suggest that the model of care examined (i.e. intensive case management) can help high users reduce their use of the ED and medical/surgical inpatient services by increasing their use of primary care services, and by decreasing alcohol and substance abuse and homelessness. Future studies need to include a randomised design and more comprehensive measurement of the both costs and outcomes. The characteristics of subgroups for which this intervention would be most effective should also be examined.
Source of funding Supported in part by a foundation award from the Friends of Langley Porter Neuropsychiatric Institute and the San Francisco Department of Public Health.
Bibliographic details Okin R L, Boccellari A, Azocar F, Shumway M, O'Brien K, Gelb A, Kohn M, Harding P, Wachsmuth C. The effects of clinical case management on hospital service use among ED frequent users. American Journal of Emergency Medicine 2000; 18(5): 603-608 Other publications of related interest Spillane LL, Lumb EW, Cobaugh DJ, et al. Frequent users of the emergency department: can we intervene? Academic Emergency Medicine 1997;4:574-80.
Randolph F, Blasinsky M, Leginski W, et al. Creating integrated service system for homeless persons with mental illness: The ACCESS Program. Psychiatric Services 1997;48:369-73.
Indexing Status Subject indexing assigned by NLM MeSH Adult; Aged; Aged, 80 and over; Case Management /economics; Emergency Service, Hospital /economics /utilization; Female; Health Services Misuse; Homeless Persons /psychology /statistics & Hospital Costs; Humans; Male; Mental Disorders /epidemiology /psychology; Middle Aged; Mortality; Pilot Projects; San Francisco /epidemiology; Treatment Outcome; Utilization Review; numerical data AccessionNumber 22000001497 Date bibliographic record published 31/12/2003 Date abstract record published 31/12/2003 |
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