Background Frequent attenders (FAs) at emergency department (ED) in Singapore hospitals have been increasing over the years. More than half of the FAs are reported to be alcohol-related frequent attenders (ARFA) and they were found to be using EDs unnecessarily. We aim to assess if there will be a difference in patient outcomes in terms of ED usage and cost-effectiveness by implementing an assertive community treatment (ACT) program to manage AFRAs.
Methods This is a prospective, multi-centre, before-and-after, superiority and cohort study to assess the impact of ACT from 4 study sites. 200-300 patients will be recruited and followed up for 12 months. The primary objective of the study is to investigate whether there will be a reduction in AFRA ED attendances. The secondary objective is to estimate the change in total cost utilization.
Conclusion/Significance All patients who are on ACT programme will be enrolled in this study. The study intervention will be used as a new mode of care at participating hospitals. We expect to see reduced alcohol addiction level, reduced isolation level, improved motivation and better overall health. With reduced alcohol-related hospital visits, we would also expect to see improved healthcare utilization by ARFAs which will lead to increased cost savings to the healthcare systems and decreased social costs.
• Patients who are not on active follow-up at the National Addictions Management Service at the Institute of Mental Health (IMH).
Patients who speak English or Mandarin.
Patients who are 21 years of age or older.
≧2 SNOMED alcohol-related ED visits in last 12 months AND ≧5 Emergency Department visits (All-cause)
• Patients who are on active follow-up at the NAMS at the Institute of Mental Health (IMH).
Patients who are uncontactable by phone AND through opportunistic recruitment.
Patients who do not give consent.
Patients who do not speak English or Mandarin.
Singapore has a population of 5.7 million, served by 7 adult EDs. Based on unpublished data, we estimate a population of 200-300 patients who would meet the criteria to be classified as ARFA in Singapore. Our study will implement the community-based intervention in ARFAs from 4 adult EDs. Once patients are recruited, individual, identifiable 5-year historical data from the point of study enrolment will be obtained from the electronic medical records system. This data will include dates of ED visits and ED diagnosis. Each intervention site will recruit up to 32 patients per year. The ACT teams will see a maximum of 16 patients over a period of 6 months (Appendix 1). Four hospitals will participate in the study over a period of 4 years with different initiation dates at each site. The setting up of such a service requires on-site specialist guidance and the specialist addictions team from NAMS is only able to guide one hospital's ACT team at a time for a period of 12 months.
Cohort
Prospective
Assertive Community Treatment (ACT)
BehavioralAssertive Community Treatment (ACT) is part of a 6-month program ARFAs will undergo. ACT teams will engage with ARFAs on a dedicated schedule. Each visit would last an average of 60 minutes. There will not be a re-arrangement of no-show visits. ACT teams will re-engage the ARFA over the phone to plan for the next visit as per the schedule. In keeping with principles of ACT, ARFA's will be assertively sought out in the community and provided intensive engagement, with holistic and supportive care alongside a harm reduction approach. Care will also involve case management and involvement of SSA's. Each interaction during the treatment period will focus on various aspects covering physical health, mental health, and addiction
Emergency Department (ED) attendance
The primary outcome will be the rate of ED visits when comparing the pre-intervention period (12 months) with the post-intervention period (12 months). We anticipate a 25% reduction because of the ACT intervention.
Emergency Medical Services (EMS) 995 calls
The secondary outcome will be a change in the rate of calls to our EMS system when comparing the pre-intervention period (12 months) and the post-intervention period (12 months). We anticipate a 25% reduction in the rate of calls to EMS by those who met the criteria for a patient.
Sustained reduction in ED attendance and EMS calls
Decrease in mean ED and EMS visits by 25% when comparing the pre-intervention 12-month period with the post-intervention 13-24 month period. During the post-intervention period, there would not be any active follow-up. This outcome would demonstrate the sustained effect of this intervention.
Level of Alcohol Dependence by Christo Inventory of Substance-misuse services (CISS score)
Christo Inventory of Substance-misuse services (CISS) scores are a validated marker of the severity of alcohol dependence. It is a quantitative, outcome evaluation tool to be completed by a trained healthcare professional from direct patient interviews. It consists of 10 items reflecting patients' problems with social functioning, general health, sexual/injecting risk behavior, psychological functioning, occupation, criminal involvement, drug/alcohol use, ongoing support, compliance and working relationships. The simplicity, brevity and flexibility of CISS make it a useful tool to allow comparison before, during and after treatment. The minimum score is 0 while the maximum score is 20. Lower scores indicate better outcomes. Improvement in Christo Inventory of Substance-misuse services (CISS) scores by 25% at the end of up to 6 months of treatment when compared to pre-intervention.
UCLA 3-point Loneliness Scale
The University of California Los Angeles (UCLA) 3-point Loneliness Scale is a validated, interviewer-administered questionnaire developed from the Revised UCLA Loneliness Scale. It provides a quick and succinct method to collect information about social isolation. The minimum score is 3 and the maximum score is 9. Lower scores indicate better outcomes. Improvement in UCLA 3-point Loneliness Scale by 2 points at the end of up to 6 months of treatment when compared to pre-intervention.
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