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Targeted Letters to Reduce Avoidable Emergency Department Attendances
Last registered on January 06, 2015

Pre-Trial

Trial Information
General Information
Title
Targeted Letters to Reduce Avoidable Emergency Department Attendances
RCT ID
AEARCTR-0000600
Initial registration date
January 05, 2015
Last updated
January 06, 2015 9:31 AM EST
Location(s)
Primary Investigator
Affiliation
The Behavioural Insights Team
Other Primary Investigator(s)
Additional Trial Information
Status
In development
Start date
2015-01-13
End date
2015-12-01
Secondary IDs
NHS REC reference 14/YH/1280
Abstract
The study aims to test whether it is possible to reduce pressure on Emergency Departments by sending a personal feedback letter to people who have recently attended an Emergency Department and whose health issues could likely have been dealt with elsewhere. These attendances clearly have many causes. However, it is likely that some attendances are due to behavioural factors – in other words, the various ways in which users interact with services. This study focuses on one particular behavioural factor: lack of feedback to users making avoidable visits.

The study will take place in collaboration with an NHS hospital trust. Each week during the trial, the hospital trust will identify those Emergency Department attendances in the last seven days which, according to clinical judgement, could have been dealt with elsewhere. Patients will then be randomly selected to receive a letter containing information on alternative healthcare options for non-emergency health concerns. Patient records will be analysed to determine whether the patients who received the letter are less likely to make an avoidable repeat visit to the Emergency Department in the future, compared with patients who received no letter.
External Link(s)
Registration Citation
Citation
Behrendt, Hannah. 2015. "Targeted Letters to Reduce Avoidable Emergency Department Attendances." AEA RCT Registry. January 06. https://doi.org/10.1257/rct.600-2.0.
Former Citation
Behrendt, Hannah. 2015. "Targeted Letters to Reduce Avoidable Emergency Department Attendances." AEA RCT Registry. January 06. https://www.socialscienceregistry.org/trials/600/history/3364.
Experimental Details
Interventions
Intervention(s)
The intervention aims to reduce avoidable Emergency Department attendances by sending a personal letter to people who have recently attended an Emergency Department, but whose health concerns could likely have been dealt with elsewhere.

Several trials in the US have evaluated the effect of information and mailing interventions on emergency department visits. A trial in a paediatric emergency department gave families receiving Medicaid information about the importance of primary care provision and helped families make appointments. (Grossman, Rich, & Johnson, 1998) This decreased emergency department attendances by 11.1% over the six months following the intervention, however, there was no difference in utilisation between six and 24 months after the intervention. In a different trial, nearly 7000 households receiving Medicaid were randomly selected to be sent a booklet with information about common non-urgent conditions, encouraging the use of alternatives to emergency care, such as GPs, telephonic nurse advice, and self-care (Rector, Venus, & Laine, 1999). The intervention did not significantly reduce attendance at emergency departments. Both studies look at quite specific populations and the results may not be applicable in the UK NHS system. This trial presents information in a more concise and targeted way in order to avoid information overload.

To date, there have been various attempts to provide general information to NHS users about the alternatives to emergency departments. The most obvious examples are the regional ‘Choose Well’ programmes. The ‘Choose Well’ campaign is a national NHS initiative which aims to give people information so that they know where to go to find help with their health concerns, and how to care for themselves if they have a common illness or ailment. However, the campaign merely provides general information that is not linked to individual behaviour. This trial aims to provide patients who have recently made an avoidable visit to A&E with clear and simple information about what to do when an urgent care problem arises.


Grossman, L. K., Rich, L. N., & Johnson, C. (1998). Decreasing nonurgent emergency department utilization by Medicaid children. Pediatrics, 102(1), 20–24.
Rector, T. S., Venus, P. J., & Laine, A. J. (1999). Impact of mailing information about nonurgent care on emergency department visits by medicaid beneficiaries enrolled in managed care. American Journal of Managed Care, 5, 1505–1512.
Intervention Start Date
2015-01-13
Intervention End Date
2015-07-07
Primary Outcomes
Primary Outcomes (end points)
The outcome measure for this trial is the number of avoidable re-attendances over four months following attendance.
Primary Outcomes (explanation)
Discussions with the hospital trust have identified a process for classifying attendances as avoidable, using the ‘No Investigation No Significant Treatment’ code.
Secondary Outcomes
Secondary Outcomes (end points)
Secondary Outcomes (explanation)
Experimental Design
Experimental Design
This is a between groups randomised controlled trial with one treatment and one control arm. Each week during the 6 month trial the hospital trust will identify Emergency Department attendances in the last seven days which, according to clinical judgement, could have been dealt with elsewhere. A process for identifying these appointments has been determined using the ‘No Investigation No Significant Treatment’ code.

Patients will then be randomly assigned to either the treatment or control group. Those who are in the treatment group will be sent a letter giving information about local nonemergency health services. Patients randomly assigned to the control group will receive no letter (this is the usual care).

Patient records will be analysed to determine whether the patients who received the letter are less likely to make an avoidable repeat visit in the future.
Experimental Design Details
Randomization Method
Randomization done in office by a computer (Excel).
Randomization Unit
Simple randomization at the individual level.
Was the treatment clustered?
No
Experiment Characteristics
Sample size: planned number of clusters
1 Hospital Trust (randomization is at the individual level)
Sample size: planned number of observations
25,000 hospital attendances
Sample size (or number of clusters) by treatment arms
12,500 attendances receiving letter; 12,500 attendances control
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
Analysis of past data indicates that if letters are sent out for approximately 6 months, this will allow us to detect a 6.3% reduction in re-attendance rates (i.e. a reduction in re-attendance rates from 25.9% to 24.3%). The power calculations were based on data from April 2013 to March 2014, including all adult A&E Attendances that could potentially have been seen in Primary Care, or who may not have needed to come to A&E (as determined by the code ‘No Investigation No Significant Treatment’). In this data set there are a total of 42,657 attendances. Out of these, 30,720 are first attendances and 11,937 are re-attendances. Around 25.9% of avoidable first attendances are followed by a further avoidable attendance. The calculations are run for a size of test of 5% and a power of 80%. Two trial arms are assumed (one treatment, one control).
IRB
INSTITUTIONAL REVIEW BOARDS (IRBs)
IRB Name
NRES Committee Yorkshire & The Humber - South Yorkshire
IRB Approval Date
2014-11-28
IRB Approval Number
14/YH/1280
Post-Trial
Post Trial Information
Study Withdrawal
Intervention
Is the intervention completed?
No
Is data collection complete?
Data Publication
Data Publication
Is public data available?
No
Program Files
Program Files
Reports and Papers
Preliminary Reports
Relevant Papers