Health policy/original research
Comparative Effectiveness of Care Coordination Interventions in the Emergency Department: A Systematic Review

https://doi.org/10.1016/j.annemergmed.2012.02.025Get rights and content

Study objective

To conduct a systematic review on the effectiveness of emergency department (ED)–based care coordination interventions.

Methods

We reviewed any randomized controlled trial or quasi-experimental study indexed in MEDLINE, CINAHL, Web of Science, Cochrane, or Scopus that evaluated the effectiveness of ED-based care coordination interventions. To be included, interventions had to incorporate information from previous visits, provide educational services on continuing care, provide post-ED treatment plans, or transfer information to continuing care providers. Studies had to quantify information transfer or report ED revisits, hospitalizations, or follow-up rates. Randomized controlled trial quality was assessed with the Jadad score.

Results

Of 23 included articles, 14 were randomized controlled trials and 9 were quasi-experimental studies. Randomized controlled trial quality ranged from 2 to 3 on a 5-point scale. The majority of the studies (17) were conducted at a single center. Of nineteen studies that developed post-ED plans, 12 were effective in improving follow-up rates or reducing repeated ED visits. Four studies found paradoxically higher ED visit rates. Of 4 that used educational services for continuing care, 2 were effective. Of the 2 evaluating information transfer, 1 was effective. One study assessed incorporating information from other sites and found higher rates of information transfer, but utilization was not studied.

Conclusion

The majority of ED-based care coordination interventions focus on interfacing with outpatient providers, and about two thirds have been effective in increasing follow-up rates or reducing repeated ED utilization. Other types of interventions have shown similar effectiveness, but fewer have been studied.

Introduction

In the United States, patients commonly are treated by more than 1 medical provider, with care described as “fragmented,” in which there is little or no interaction between providers caring for the same patient.1, 2 Fragmented care leads to higher costs, duplicate testing, and conflicting care plans,1, 3 which is particularly true for populations with greater needs, such as older adults and those with chronic medical conditions.2, 3

In recent years, there has been a greater focus on “care coordination,” in which providers caring for the same patient communicate with each other. Care coordination has been defined as “… the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services.”2 Ideally, coordinated care allows each provider to consider the entire history and plan of care, including previous testing and treatments at every encounter. Preferably, the plan of care should involve a continuity provider who can address ongoing issues.1 Care coordination has received significant attention in the Patient Protection and Affordable Care Act, which has created a variety of incentives to promote care coordination, including accountable care organizations and payment bundling.4

As care coordination becomes more important in health care delivery, the role of the emergency department (ED) has not been clearly defined. Patients frequently come to the ED when outpatient care coordination fails, which can result in a hospital admission or readmission. ED providers are not equipped with the training or facilities to provide continuity care themselves and typically do not have previous knowledge of their patients, the exception being frequent users of ED care. ED providers also frequently lack important medical data about their patients. A 2003 study found that providers did not have access to critical information that could have changed care plans in a third of ED visits. These information gaps were more common for sicker patients, and the missing information was thought to be essential in almost half of the cases.5 Gaps such as this are reflective of a system that is poorly designed to deliver coordinated medical care.3 It is an open question whether the ED will play a central role (ie, with ED-centric care coordination programs) or a more peripheral one (ie, in which programs will be managed by longitudinal care providers). Key to this question is whether ED-based care coordination efforts are effective in improving outcomes. From the perspective of the ED, improving care coordination with outpatient providers may theoretically improve quality by reducing unscheduled return ED visits and improving follow-up with primary care providers. Both are desirable outcomes for many patients, particularly those with chronic illnesses or multiple comorbidities. It is these patients in particular for whom a consistent approach to preventive care, medication adherence, and other issues can ultimately improve health by reducing the rate of avoidable complications. To our knowledge, there have been no systematic reviews of ED-based care coordination interventions.

Our main objective was to synthesize the available evidence on the effectiveness of ED-based interventions for care coordination with outpatient providers, with the goal of identifying common themes about which interventions are more or less effective in improving quality by reducing return visits to the ED and increasing follow-up visits with primary care providers.

Section snippets

Study Design

This was a systematic review of the literature examining the effectiveness of ED-based care coordination interventions. Institutional review board approval was not required because it did not involve the use of human subjects or medical records.

A professional librarian was consulted and a database search strategy was formulated. The following databases were used: MEDLINE (1946 to 2010), CINAHL (1981 to 2010), Web of Science (1980 to 2010), Cochrane Controlled Trials Register, and Scopus. The

Results

The literature search identified 1,353 articles. After duplicates were removed, 1,221 articles remained. Of those, 1,112 articles were excluded on title and abstract review. We retrieved and reviewed the full texts of 109 articles (Figure 1). We included a total of 19 studies from the review. We then reviewed the bibliographies of the included studies and identified 4 additional articles to include in the review, for a total of 23 articles. These included 14 randomized controlled trials and 9

Limitations

This review of the literature has several limitations. First, our definition of care coordination adapted a broad Agency for Healthcare Research and Quality definition of care coordination that crosses all fields of medicine and adjusted it to describe ED care. This narrowed definition may have missed certain studies that could have fit within the broader definition. Our review included only studies conducted for the explicit purpose of evaluating ED-based care coordination and excluded studies

Discussion

We found mixed evidence about the effect of ED-based care coordination interventions on future resource utilization or the quality of subsequent care services. About two thirds of the identified studies described interventions that were effective in improving their primary outcome, of which 8 were randomized controlled studies and 7 were quasi-experimental studies. The studies were of poor to moderate quality partly because we used a standard assessment tool for randomized trials that requires

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    Supervising editor: Michael J. Schull, MD, MSc

    Author contributions: EKL and JMP conceived this study. EBK, ERC, CAU, and JMP conducted reviews of the studies for quality scores. EBK wrote the initial article, tables, and figure, and ERC, CAU, and JMP provided critical revisions. JMP provided overall study supervision. JMP takes responsibility for the paper as a whole.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

    Publication date: Available online April 27, 2012.

    Please see page 13 for the Editor's Capsule Summary of this article.

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