Intervention
Portugal has a tax-funded NHS that provides coverage to all residents. Considering the growing health expenditures in Portugal [27], it is necessary to guarantee that the available resources are being optimally used, reducing resource waste, for example, by reducing unnecessary ED visits.
In 2016, Hospital Garcia de Orta (HGO) and the Agrupamento de Centros de Saúde Almada-Seixal (ACES—Almada-Seixal) created a program to provide case management interventions to HGO’s HU. The High Users Resolution Group Program (GRHU) is a multidisciplinary team that identifies and provides care to HU aiming to improve their health status and, consequently, reduce their visits to the ED. GRHU addresses HU's healthcare and social needs by delivering patient-centered case management interventions [28]. The program’s team comprises four social workers, six doctors (three general physicians, two internists, one psychiatrist) and four nurses. Their workflow includes: i) discussing potential patients to include in the program; ii) discussing and planning personalized steps to tackle the needs of each HU included in the program (Integrated Case Plan (ICP)); and iii) assigning a Case Manager (CM) to each HU to implement the ICP through outpatient consultations. CM’s role in the GRHU project is to: i) collaborate with the patient’s primary healthcare center professionals to implement the ICP; ii) collaborate with HGO’s different specialties to implement the ICP; iii) collaborate, when needed, with other healthcare providers or community services; and iv) collaborate with the patients’ informal caregivers; v) monitor the patient to avoid ED visits. GRHU has eleven CMs responsible for a maximum of eight patients each. Between June 2016 and February 2020, the GRHU team performed, on average, five appointments per month where they defined the ICP for the new patients that were included in the GRHU program.
Study setting and population
The study was approved by the HGO’s Ethical Committee. Anonymized data from HU patients (patients with over ten ED visits in a single year at a given time) between June 2016 and February 2020 was made available for the study. This period refers to the beginning of the GRHU program and the date of data the request. Data included demographic and hospital service usage information. We performed a retrospective non-controlled before-after analysis of patients’ ED visits data on 6 and 12-month windows from the intervention. We defined the 6 or 12 months before the first appointment as the before period, while the 6 or 12 months after was the after period. These two periods of analysis were selected as the GRHU team was interested in understanding the results of their intervention in both short- and long-term settings. The study was conducted at HGO, a public hospital in Almada, Portugal, with approximately 164 thousand ED visits in 2020 [29]. Data included the 972 ED patients that were HU since the beginning of the GRHU program. The GRHU team selected 238 patients to participate in the program. To be eligible to participate in this program, patients need to be at least 18 years old, have visited the ED at least 10 times in a single year during the 4-year data collection period, and live in the HGO’s area of influence. Then, if the patient agreed to participate in the study, he signed an informed consent and was interviewed by the GRHU team. During the interview, the GRHU team tried to understand the patient’s needs and involve him in designing his ICP.
Inclusion and exclusion criteria
For our analysis, we included all patients in the GRHU program (238 patients) that had at least one visit to the hospital during the before period. Patients who died during the after period were excluded to prevent being wrongfully considered as positive signals in the reduction of episodes. As reported in the literature there was a significant drop in ED visits in Portugal, after 29th February 2020 [30], coincident with the first COVID-19 lockdown. For this reason, patients that had data after this day were excluded to avoid any misunderstanding in interpreting ED visits’ variation.
Data analysis
All patients that met the inclusion criteria were included in the analysis, independently of the received treatment (intent-to-treat) [31]. We performed one-tailed paired t-tests for the reduction in the mean to compare the utilization of hospital services in the before and after period. Moreover, we assessed the impact of this intervention on the clinical severity of the ED visits using the Manchester Triage System. This system prioritizes patients on five different levels: red (immediate), orange (very urgent), yellow (urgent), green (standard), and blue (non-urgent) [32].
Records of ED visits contained an ICD-9 primary diagnosis [33]. However, ICD-9 diagnoses were not registered for either most outpatient visits or hospitalizations. As such, in order to maintain uniformity, ED visits, outpatient visits and hospitalizations were grouped by the ICD-9 chapters or by clinical specialty. Collapsing individual diagnoses into their logical ICD-9 chapters also significantly reduced the number of diagnoses to a statistically manageable level.
Finally, we also analyzed the demographic characteristics of the patients to profile them: age, gender, and patient charges payment exemption. Despite being a public healthcare system, in Portugal patients must pay user-fees when they visit the ED. However, patients are exempt from paying user-fees if they report economic insufficiency, i.e., if the monthly income, divided by the number of people living in the household, does not exceed €653.64 [34], or patients that have at least 60% of physical or mental disability, declared by an independent medical committee.
We conducted regular meetings with the GRHU team to discuss the obtained results from the data analysis.
Economic analysis
We estimated the GRHU program savings or additional costs as the difference between the costs before and after the intervention per patient, using the hospital perspective, i.e., focusing the analysis on the costs and savings incurred by the hospital, as the hospital was the financier of the GRHU program [35]. The cost categories included ED visits, hospitalizations, and outpatient appointments, their costing information was retrieved from HGO’s Long-term Contract Program (2017–2019). This contract determines the cost of each clinical procedure based on the expected cost for the hospital to treat each diagnosis [36].
Regarding the GRHU intervention costs, the hospital provided the number of hours per week devoted by each GRHU team member (including the time devoted to appointments with patients and the necessary time to prepare them) and their monthly salary. We assumed that the number of weekly hours devoted to the program was the same for every 52 weeks of the year. We computed the cost of each Human Resource (HR) per hour by dividing the number of working hours per month (assumed to be 140 h, 35 h per week) by their monthly salary. However, as it is estimated that costs with HR represent 60% of the total operating costs [37], we added 40% of other costs (that represent other direct and indirect costs) to the HR ones.
We estimated the Return on Investment (ROI) of the GRHU intervention as the ratio between the savings or costs that it generates and its cost [14]. All monetary values are in Euros as of 2020.