Emergency department utilization among adult patients diagnosed with chronic pain and depression from an urban safety-net patient population
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BACKGROUND: Patients visit the emergency department (ED) for life-threatening conditions, such as broken bones or chest pain, and non-life threatening conditions such as medication refills and pain management. Patients may make ED visits for non-life threatening conditions because they lack access to primary care. Research has shown that patients who are low-income, have chronic conditions, such as pain, and have depression are among those most likely to use the ED at a high rate. One of the most common reasons for visiting the ED is for pain relief, and therefore an intervention on patient self-management might prevent ED visits. The Program for Integrative Medicine and Health Care Disparities at Boston Medical Center (BMC) developed the Integrative Medicine Group Visit (IMGV) model to address chronic pain and depression among low-income patients, with the goal to improve patient’s adherence to self-management of pain and depression. The IMGV model consists of three non-pharmacologic components: evidence-based complementary medicine, mindfulness-based stress reduction, and group medical visits – all of which have been used to manage pain and depression. In a pre-post study of IMGV conducted in 2014, IMGV was associated with a significant decrease in ED utilization. Currently, the Program is conducting a randomized clinical trial (RCT) to compare a number of outcomes between the IMGV model and standard of care. The aim of this study was to determine if IMGV affects ED utilization in adult patients diagnosed with chronic pain and depression from an urban safety-net hospital population. METHODS: We conducted a secondary database analysis of participants enrolled in the IMGV RCT. The RCT is a two-armed study, and the medical chart review is part of the RCT. The study had patients who sought primary care at BMC and two affiliated outpatient urban community clinics. Only emergency visits made at BMC’s Emergency Department were included in our analysis. The inclusion criteria included reporting a pain level score > 4 on a 0-10 scale and having a score > 5 on the Patient Health Questionnaire-9. The intervention consisted of 10 IMGV sessions over 21 weeks. The control was standard treatment of care. Data extraction was completed in two ways: (1) the BMC Clinical Data Warehouse was extracted from Epic and (2) hand review took place by research assistant. The primary outcomes included ED encounters at two different time points: (1) 90 days before Session 1 and (2) Session 1 to Session 9. The extracted information also included information about patients’ chief complaints and discharge diagnoses. A visit was categorized as being a preventable emergency visit (PEV) or a non-preventable emergency visit (NEPV). Descriptive statistics and two-sample T-tests were used to analyze outcomes. RESULTS: At baseline, 22 of the 31 participants made at least one ED visit in the 90 days before Session 1. At 9-weeks, 14 of the 26 participants made at least ED visit. From baseline to 9-weeks, the number of participants who had at least one ED visit decreased for the intervention group (13 to 4), but increased for the control group (9 to 10). From baseline to 9-weeks, the number of visits decreased among intervention participants (16 to 5) but increased among control participants (11 to 12). The two-sample T-test, which compared the ED utilization among the intervention and control, resulted in the mean values of -0.7333 and 0.0625, respectively. This result indicated that intervention participants had overall lower ED visit use from baseline to 9-weeks. Emergency visits were also analyzed by whether they were PEV or NPEV. Of the 27 ED visits at baseline, 21 were classified as being a PEV, and 6 were classified as being a NPEV. Of the 17 ED visits at 9-weeks, the number of visits decreased for both PEVs (21 to 13) and NPEV (6 to 4). CONCLUSION: We wanted to determine if the IMGV reduces ED utilization in patients with chronic pain and depression. Our results suggest that the IMGV model may be associated with reduced overall ED utilization and reduced preventable ED visits. However, one limitation is that we have a very small sample size. This finding needs to be produced in an adequately powered clinical trial. Further research might explore the mechanisms for how the IMGV model can lead to lower ED utilization among patients with chronic pain and depression.