Interventions to Decrease Use in Prehospital and Emergency Care Settings Among Super-Utilizers in the United States: A Systematic Review

Overview

In health care policy circles, the term “super-utilizer” has come to define a small population of patients with complex health and social needs whose acute care is responsible for disproportionately high health care spending. This group has been the subject of much attention as health care systems work to reduce costs and provide better care.

As part of their work to understand best practices for addressing the medical and social needs of high-need/high-cost patients, Samantha Iovan, Paula Lantz, Katie Allan, and Mahshid Abir, representing P4A’s University of Michigan Research Hub, published a systematic review examining interventions that are being implemented to address these patients in prehospital and emergency care settings in the U.S. The article in Medical Care Research and Review includes studies from the peer-reviewed and grey literature from 2000-2017.

Findings

The systematic review included 46 evaluations of interventions in the U.S. The most common intervention evaluated was case management, followed by medical care plans and care coordination. Notably, most interventions were tailored to provide personalized care, including social services, based on patients’ individual needs.

The analysis revealed several flaws in the current evaluation research literature on this population of patients:

• Out of 46 evaluations, eight (17%) were randomized controlled trials and nine (20%) used a quasi-experimental design. This means that 29 evaluations (63%) had no control group.
• Most studies (89%) evaluated outcomes over 12 months or less, making it difficult to gauge the lasting impact of the interventions.
• Definitions of "super-utilizers" varied significantly across studies, ranging from patients having more than two ED visits in six months, to patients with more than 25 ED visits in one year.

Of the eight randomized controlled trials, only three demonstrated significant reductions in emergency department and/or emergency services use; five of the nine quasi-experimental designs showed some positive findings for reducing emergency department and/or emergency services use.

Implications for Policy and Practice

Although some of the interventions are promising, weak study designs—including the likelihood of regression to the mean—make it difficult to draw conclusions about effectiveness. The lack of high-quality studies in the literature is very concerning given the enthusiasm for these programs in the health care community. It is imperative that additional rigorous evaluations be conducted to establish evidence for these programs and to ensure vulnerable populations are not receiving interventions that are ineffective. Until additional strong evaluations indicate such effectiveness, health care systems should be cautious about using these types of interventions with these unique populations.