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Impact of a case-management intervention for reducing emergency attendance on primary care: randomised control trial
Jonathan N Cohen1, An Nguyen2, Meena Rafiq3
1Institute of Health Informatics, University College London, London.
Background:
The impact on primary care workload of case-management interventions to reduce emergency department (ED) attendances is unknown.
Aim:
To examine the impact of a telephone-based case-management intervention targeting people with high ED attendance on primary care use.
Design And Setting:
A single-site data extract from a larger randomised control trial, using the patient-level data from primary care electronic health records (2015-2020), was undertaken.
Method:
A total of 363 patients at high risk of ED usage were randomised to receive a 6-month case-management intervention (253 patients) or standard care (110 patients). Poisson regression models were used to calculate monthly rates of primary care use over time for the 2 years post-randomisation, comparing both arms. Usage was subclassified into face-to-face, telephone, letter, and community and secondary care referrals, stratified by patient demographics.
Results:
No significant difference was found in the mean annual rate of primary care events between the intervention and control arms (P = 0.70). Secondary care referrals saw a 26% reduction in the mean annual referral rate (incident rate ratio [IRR] 0.74, 95% confidence interval [CI] = 0.64 to 0.86, P<0.001) and letters sent increased by 6% in the intervention arm compared with the control arm (IRR 1.06, 95% CI = 1.01 to 1.11, P = 0.01). In the case-managed arm, in patients aged ≥80 years there was a 33% increase in primary care usage (IRR 1.33, 95% CI = 1.28 to 1.40, P<0.001); with a corresponding 10% decrease in patients aged <80 years when compared with controls (IRR 0.90, 95% CI = 0.87 to 0.92, P<0.001).
Conclusion:
A targeted case-management intervention to reduce ED attendances did not increase overall primary care use. Redistribution of usage is seen among some patient groups, particularly older people, which may have important implications for primary healthcare planning.
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