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The American Journal of Managed Care May 2018
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Impact of Emergency Physician–Provided Patient Education About Alternative Care Venues
Pankaj B. Patel, MD; David R. Vinson, MD; Marla N. Gardner, BA; David A. Wulf, BS; Patricia Kipnis, PhD; Vincent Liu, MD, MS; and Gabriel J. Escobar, MD
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Characteristics and Medication Use of Veterans in Medicare Advantage Plans
Talar W. Markossian, PhD, MPH; Katie J. Suda, PharmD, MS; Lauren Abderhalden, MS; Zhiping Huo, MS; Bridget M. Smith, PhD; and Kevin T. Stroupe, PhD
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Keith Kranker, PhD; Linda M. Barterian, MPP; Rumin Sarwar, MS; G. Greg Peterson, PhD; Boyd Gilman, PhD; Laura Blue, PhD; Kate Allison Stewart, PhD; Sheila D. Hoag, MA; Timothy J. Day, MSHP; and Lorenzo Moreno, PhD
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Impact of Emergency Physician–Provided Patient Education About Alternative Care Venues

Pankaj B. Patel, MD; David R. Vinson, MD; Marla N. Gardner, BA; David A. Wulf, BS; Patricia Kipnis, PhD; Vincent Liu, MD, MS; and Gabriel J. Escobar, MD
Postvisit phone education from an emergency physician and/or mailed information about alternative venues of care reduced subsequent emergency department (ED) utilization for low-acuity treat-and-release adult ED patients.

Objectives: Interventions that focus on educating patients appear to be the most effective in directing healthcare utilization to more appropriate venues. We sought to evaluate the effects of mailed information and a brief scripted educational phone call from an emergency physician (EP) on subsequent emergency department (ED) utilization by low-risk adults with a recent treat-and-release ED visit. 

Study Design: Patients were randomized into 3 groups for post-ED follow-up: EP phone call with mailed information, mailed information only, and no educational intervention. Each intervention group was compared with a set of matched controls. 

Methods: We undertook this study in 6 EDs within an integrated healthcare delivery system. Overall, 9093 patients were identified; the final groups were the phone group
(n = 609), mail group (n = 771), and matched control groups for each (n = 1827 and n = 1542, respectively). Analysis was stratified by age (<65 and ≥65 years). Patients were educated about available venues of care delivery for their future medical needs. The primary outcome was the rate of 6-month ED utilization after the intervention compared with the 6-month utilization rate preceding the intervention.

Results: Compared with matched controls, subsequent ED utilization decreased by 22% for patients 65 years or older in the phone group (P = .04) and by 27% for patients younger than 65 years in the mail group (P = .03).

Conclusions: ED utilization subsequent to a low-acuity ED visit decreased after a brief post-ED education intervention by an EP explaining alternative venues of care for future medical needs. Response to the method of communication (phone vs mail) varied significantly by patient age.

Am J Manag Care. 2018;24(5):225-231
Takeaway Points

Emergency department (ED) crowding, especially for low-acuity visits, is a significant public health issue. We studied the impact of providing patients with simple nonmedical education about alternative venues of care following a recent ED visit.
  • Patients 65 years or older had a 22% reduction in future ED utilization after phone follow-up by an emergency physician (EP).
  • Patients younger than 65 years had a 27% reduction in future ED utilization after receiving mailed educational information.
  • Phone follow-up by EPs may be a valuable tool to affect future ED utilization.
  • Targeting interventions based upon age-specific responses warrants further study.
Emergency department (ED) crowding is a public health problem that compromises patient care and adversely affects clinical outcomes.1-3 Low-acuity ED visits place a strain on already crowded EDs and are an expensive source of healthcare utilization and patient cost sharing, especially for conditions that can be managed appropriately in an ambulatory setting.4,5 Attempts to reduce ED utilization have had variable success,6-15 although most successful programs emphasize patient education delivered through care coordination and management.10,12,13,15-17 Simply providing generic nonmedical information about alternative venues of care other than the ED appears to be effective.4,6,10,14,18-20 Most studies have utilized nonphysicians, such as nurses, case managers, discharge planners, and pharmacists, to provide this information to patients.6,8,10,12,13,15-17,19,21,22

We hypothesized that providing patients with a simple educational intervention on available resources and venues of care within our organization could lead to reductions in future ED utilization for low-acuity problems. Our primary goal was to evaluate the impact of a brief educational phone call by an emergency physician (EP) and/or mailed information following a treat-and-release ED visit on subsequent 6-month ED utilization in a randomized population of low-risk, low-acuity adult patients.23 We also sought to assess the impact of these interventions on utilization of the organization’s Advice and Appointment Call Center (AACC) and outpatient visits. We made an a priori hypothesis that the effects of these interventions might differ by age group (<65 vs ≥65 years).



This study was approved by the Kaiser Permanente Northern California (KPNC) Institutional Review Board for the Protection of Human Subjects, which has jurisdiction over all facilities included in this report.

We conducted this multicenter, randomized, controlled trial from October 2014 through July 2015 within KPNC, an integrated healthcare delivery system. Under KPNC’s mutual exclusivity agreement, approximately 9500 physicians in The Permanente Medical Group, Inc, care for 4.1 million Kaiser Foundation Health Plan (KFHP), Inc, members at 21 hospitals and more than 200 outpatient clinics.24-26 The Epic (Epic Systems; Verona, Wisconsin) electronic health record, known internally as Kaiser Permanente HealthConnect, was fully deployed in all KPNC facilities in 2010. Members account for approximately 33% of the insured population in Northern California and are representative of the geographic areas served.24 KPNC’s secure online services allow patients to access their medical information, refill prescriptions, make appointments, and communicate with their providers via email.25-27 The KPNC AACC, which includes staffing by EPs, handles approximately 12 million calls per year.28 The AACC provides healthcare advice, appointment scheduling, and messaging with primary care providers. Patients who need additional medical evaluation are directed to the most appropriate venue of care, including the ED. KPNC has 21 EDs that receive more than 1 million visits per year. We included patients with treat-and-release visits to 6 EDs with a range of annual censuses: 2 higher-census EDs (63,000 and 81,000 visits/year), 2 medium-census EDs (46,000 and 49,000 visits/year), and 2 lower-census EDs (26,000 and 27,000 visits/year).

Physician Selection

Two EPs from each of 6 KPNC EDs volunteered to participate in the study. Study EPs received standardized training from the principal investigator (PBP) about the study, its goals, and their roles in contacting patients by phone. Training included reviews of a standardized phone script (eAppendix A [eAppendices available at]), a phone log (eAppendix B), and postcontact letters (eAppendices C and D) and an information pamphlet that were mailed to each intervention group. The principal investigator fielded queries from the EPs and oversaw the entire enrollment process with the project manager (MNG).

Patient Identification and Selection

We identified patients who met the following inclusion criteria: (1) 18 years or older, (2) KFHP membership, and (3) a low-acuity treat-and-release ED visit during October-November 2014 but without AACC contact in the 24 hours prior to their ED visit in 1 of the 6 KPNC EDs (eAppendix E). We defined low-acuity as 1) having a Laboratory-based Acute Physiology Score, version 2 (LAPS2) score—an acute physiology score based on 16 laboratory tests, vital signs, pulse oximetry, and neurological status in the preceding 72 hours—less than 50 at the time of the ED index visit, a score associated with a 30-day mortality risk less than 1.5%29; and 2) being discharged directly home from the ED. Patients who left against medical advice, were discharged to a skilled nursing facility or long-term acute care facility, or were transferred to a non–health plan facility were excluded. We also excluded non–English-speaking patients, those who could not respond on their own or through a family member or guardian, and those who died during the 6-month postintervention period (eAppendix E). We conducted separate analyses for patients younger than 65 years and those 65 years or older. Lastly, in our capitated prepaid healthcare system, patients are not obligated to follow recommended care paths and there are no sanctions (economic or otherwise) for patients who choose different venues of care.


We identified 3 arms for this study: phone and mail intervention (phone group), mail intervention only (mail group), and no intervention (control group). Prior to the start of this study, our study statistician (PK) identified a target of 600 patients for each of the 2 intervention arms. From a previous pilot study,23 we had learned that we were successful in reaching 50% of patients by phone in a short time frame (within 2 weeks). Additionally, we needed to sample enough patients so that study physicians would reach 50% of patients who were younger than 65 years and 50% of patients who were 65 years or older. To ensure we would be successful in reaching 600 patients, we needed to sample twice that number. For the first arm, each study EP received a weekly list of 25 eligible patients seen at their medical center ED who were randomly assigned to the phone group. EPs contacted patients by phone within 2 weeks of their index ED visit. EPs worked their way through the list of patients until they had enrolled half of these patients each week to a total of 50 patients contacted for the study period. If a patient did not consent to be interviewed, was unavailable to talk, or could not be reached by phone, the EP moved on to the next patient on the list, a method of patient selection previously described.30 The target was for 50% of contacted patients to be younger than 65 years and 50% of contacted patients to be 65 years or older. This weighting of patients was part of the study design because we postulated that older patients (≥65 years) utilized the ED at a different rate than younger ones.

For arm 1 (phone group), we developed a detailed phone script that described services available through the organization’s AACC and online services.27,28 The conversation opened with patient consent and closed with an opportunity for feedback and questions. Each EP maintained a phone log of their calls to document basic information about their encounter. We mailed information about the organization’s AACC and online services to this phone group. We mailed information to arm 2 patients (mail group) who had no phone contact with a study EP. The third arm (no-intervention group) was not called or sent mailed information.

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