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A randomized controlled trial testing the effectiveness of a paramedic-delivered care transitions intervention to reduce emergency department revisits.

ABSTRACT: BACKGROUND:Approximately 20% of community-dwelling older adults discharged from the emergency department (ED) return to an ED within 30 days, an occurrence partially resulting from poor care transitions. Prior published interventions to improve the ED-to-home transition have either lacked feasibility or effectiveness. The Care Transitions Intervention (CTI) has been validated to decrease rehospitalization among patients transitioning from the hospital to the home but has never been tested for patients transitioning from the ED to the home. Paramedics, traditionally involved only in emergency care, are well-positioned to deliver the CTI, but have never been previously evaluated in this role. METHODS:This single-blinded randomized controlled trial tests whether the paramedic-delivered ED-to-home CTI reduces community-dwelling older adults' ED revisits in the 30 days after an index visit. We are prospectively recruiting patients aged??60 years at 3 EDs in Rochester, NY and Madison, WI to enroll 2400 patient subjects. Subjects are randomized into control and treatment groups, with the latter receiving the adapted CTI. The intervention consists of the paramedic performing one home visit and up to three follow-up phone calls. During these interactions, the paramedic follows the CTI approach by coaching patients toward their goals, with a focus on their personal health record, medication management, red flags, and primary care follow-up. We follow patient participants for 30 days. All receive a survey during the index ED visit to capture baseline demographic and health information and two telephone-based surveys to assess process objectives and outcomes. We also perform a medical record review. The primary outcome is the odds of ED revisit within 30 days after discharge from the index ED visit. DISCUSSION:This is the first study to test whether the CTI, applied to the ED-to-home transition and delivered by community paramedics, can decrease the rate at which older adults revisit an ED. Outcomes from this research will help address a major emergency care challenge by supporting older adults in the transition from the ED to home, thereby improving health outcomes for this population and reducing potentially avoidable ED visits. TRIAL REGISTRATION:ClinicalTrials.gov Registration: NCT02520661 . Trial registration date: August 13, 2015.

SUBMITTER: Mi R

PROVIDER: S-EPMC5934842 | biostudies-literature | 2018 May

REPOSITORIES: biostudies-literature

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A randomized controlled trial testing the effectiveness of a paramedic-delivered care transitions intervention to reduce emergency department revisits.

Mi Ranran R Hollander Matthew M MM Jones Courtney M C CMC DuGoff Eva H EH Caprio Thomas V TV Cushman Jeremy T JT Kind Amy J H AJH Lohmeier Michael M Shah Manish N MN

BMC geriatrics 20180503 1

<h4>Background</h4>Approximately 20% of community-dwelling older adults discharged from the emergency department (ED) return to an ED within 30 days, an occurrence partially resulting from poor care transitions. Prior published interventions to improve the ED-to-home transition have either lacked feasibility or effectiveness. The Care Transitions Intervention (CTI) has been validated to decrease rehospitalization among patients transitioning from the hospital to the home but has never been teste ...[more]

PMID: 29724172

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Project description:ObjectivesKidney stones affect nearly one in 11 persons in the United States, and among those experiencing symptoms, emergency care is common. In this population, little is known about the incidence of and factors associated with repeat emergency department (ED) visits. The objective was to identify associations between potentially mutable factors and the risk of an ED revisit for patients with kidney stones in a large, all-payer cohort.MethodsThis was a retrospective cohort study of all patients in California initially treated and released from EDs for kidney stones between February 2008 and November 2009. A multivariable regression model was created to identify associations between patient-level characteristics, area health care resources, processes of care, and the risk of repeat ED visits. The primary outcome was a second ED visit within 30 days of the initial discharge from emergent care.ResultsAmong 128,564 patients discharged from emergent care, 13,684 (11%) had at least one additional emergent visit for treatment of their kidney stone. In these patients, nearly one in three required hospitalization or an urgent temporizing procedure at the second visit. On multivariable analysis, the risk of an ED revisit was associated with insurance status (e.g., Medicaid vs. private insurance; odds ratio [OR] = 1.52, 95% confidence interval [CI] = 1.43 to 1.61; p < 0.001). Greater access to urologic care was associated with lower odds of an ED revisit (highest quartile OR = 0.88, 95% CI = 0.80 to 0.97; p < 0.01 vs. lowest quartile). In exploratory models, performance of a complete blood count was associated with a decreased odds of revisit (OR = 0.86, 95% CI = 0.75 to 0.97; p = 0.02).ConclusionsRepeat high-acuity care affects one in nine patients discharged from initial emergent evaluations for kidney stones. Access to urologic care and processes of care are associated with lower risk of repeat emergent encounters. Efforts are indicated to identify preventable causes of ED revisits for kidney stone patients and design interventions to reduce the risk of high-cost, high-acuity, repeat care.

Project description:BACKGROUND: Emergency department (ED) utilization has dramatically increased in developed countries over the last twenty years. Because it has been associated with adverse outcomes, increased costs, and an overload on the hospital organization, several policies have tried to curb this growing trend. The aim of this study is to systematically review the effectiveness of organizational interventions designed to reduce ED utilization. METHODOLOGY/PRINCIPAL FINDINGS: We conducted electronic searches using free text and Medical Subject Headings on PubMed and The Cochrane Library to identify studies of ED visits, re-visits and mortality. We performed complementary searches of grey literature, manual searches and direct contacts with experts. We included studies that investigated the effectiveness of interventions designed to reduce ED visits and the following study designs: time series, cross-sectional, repeated cross-sectional, longitudinal, quasi-experimental studies, and randomized trial. We excluded studies on specific conditions, children and with no relevant outcomes (ED visits, re-visits or adverse events). From 2,348 potentially useful references, 48 satisfied the inclusion criteria. We classified the interventions in mutually exclusive categories: 1) Interventions addressing the supply and accessibility of services: 25 studies examined efforts to increase primary care physicians, centers, or hours of service; 2) Interventions addressing the demand for services: 6 studies examined educational interventions and 17 examined barrier interventions (gatekeeping or cost). CONCLUSIONS/SIGNIFICANCE: The evidence suggests that interventions aimed at increasing primary care accessibility and ED cost-sharing are effective in reducing ED use. However, the rest of the interventions aimed at decreasing ED utilization showed contradictory results. Changes in health care policies require rigorous evaluation before being implemented since these can have a high impact on individual health and use of health care resources. Systematic review registration: http://www.crd.york.ac.uk/PROSPERO. Identifier: CRD420111253.

Project description:BackgroundImproving care transitions following emergency department (ED) visits may reduce post-ED adverse events among older adults (e.g., ED revisits, decreased function). The Care Transitions Intervention (CTI) improves hospital-to-home transitions; however, its effectiveness at improving post-ED outcomes is unknown. We tested the effectiveness of the CTI with community-dwelling older adult ED patients, hypothesizing that it would reduce revisits and increase performance of self-management behaviors during the 30 days following discharge.MethodsWe conducted a randomized controlled trial among patients age ≥ 60 discharged home from one of three EDs in two states. Intervention participants received a minimally modified CTI, with a home visit 24 to 72 h postdischarge and one to three phone calls over 28 days. We collected demographic, health status, and psychosocial data at the initial ED visit. Medication adherence and knowledge of red flag symptoms were assessed via phone survey. Care use and comorbidities were abstracted from medical records. We performed multivariate regressions for intention-to-treat and per-protocol (PP) analyses.ResultsParticipant characteristics (N = 1,756) were similar across groups: mean age 72.4 ± 8.6 years and 53% female. Of those randomized to the intervention, 84% completed the home visit. Overall, 12.4% of participants returned to the ED within 30 days. The CTI did not significantly affect odds of 30-day ED revisits (adjusted odds ratio [AOR] = 0.97, 95% confidence interval [CI] = 0.72 to 1.30) or medication adherence (AOR = 0.89, 95% CI = 0.60 to 1.32). Participants receiving the CTI (PP) had increased odds of in-person follow-up with outpatient clinicians during the week following discharge (AOR = 1.24, 95% CI = 1.01 to 1.51) and recalling at least one red flag from ED discharge instructions (AOR = 1.34 95% CI = 1.05 to 1.71).ConclusionsThe CTI did not reduce 30-day ED revisits but did significantly increase key care transition behaviors (outpatient follow-up, red flag knowledge). Additional research is needed to explore if patients with different conditions benefit more from the CTI and whether decreasing ED revisits is the most appropriate outcome for all older adults.

Project description:ImportanceMobile integrated health care (MIH) is a new model of community-based health care to provide on-site urgent or nonurgent care. Niagara emergency medical services (NEMS) started MIH in 2018 to serve the Niagara region of Ontario, Canada. However, its economic impact is unknown.ObjectiveTo compare time on task and cost between MIH and ambulance delivered by NEMS from a public payer's perspective.Design, setting, and participantsThis economic evaluation was an analysis of the NEMS databases regarding responses to emergency calls by the NEMS from 2016 to 2019. Emergency calls serviced by MIH in 2018 to 2019 were used as an intervention cohort. Propensity score matching was used to identify a 1:1 matched cohort of calls serviced by regular ambulance response for the same period and 2 years prior. Statistical analyses were performed from January to April 2020.ExposuresMIH compared with matched ambulance services.Main outcomes and measuresThe main outcomes were the time on task (including time on scene and time at hospital) and costs. Costs were calculated in 2019 Canadian dollars using cost per minute and compared with the 3 ambulance cohorts.ResultsIn 2018 to 2019, there were 1740 calls serviced by MIH for which a matched ambulance cohort was identified for the same period and 2 years prior. The mean (SD) time on task was 72.7 (51.0) minutes for MIH, compared with 84.1 (52.0) minutes, 84.3 (54.1) minutes, and 79.4 (42.0) minutes for matched ambulance in 2018 to 2019, 2017 to 2018, and 2016 to 2017, respectively. Of calls serviced by MIH, 498 (28.6%) required ED transport (ie, after MIH team assessment, transport to ED was deemed to be necessary or demanded by the patient), compared with 1300 (74.7%) calls serviced by ambulance in 2018 to 2019, 1294 (74.4%) in 2017 to 2018, and 1359 (78.1%) in 2016 to 2017. The mean (SD) total cost per 1000 calls was $122 760 ($78 635) for MIH compared with $294 336 ($97 245), $299 797 ($104 456), and $297 269 ($81 144) for regular ambulance responses in the 3 matched cohorts, respectively.Conclusions and relevanceCompared with regular ambulance response, MIH was associated with a substantial reduction in the proportion of patients transported to the ED, leading to a substantial saving in total costs. This finding suggests that the MIH model is a promising and viable solution to meeting urgent health care needs in the community, while substantially improving the use of scarce health care resources.

Dataset Information

A randomized controlled trial testing the effectiveness of a paramedic-delivered care transitions intervention to reduce emergency department revisits.

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A randomized controlled trial testing the effectiveness of a paramedic-delivered care transitions intervention to reduce emergency department revisits.

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