Health mediation does not reduce the readmission rate of frequent users of emergency departments living in precarious conditions: what lessons can be learned from this randomised controlled trial?

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Michel Rotily, Nicolas Persico, Aurore Lamouroux, Ana Cristina Rojas-Vergara, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3870488/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background: Severe overcrowding of emergency departments (EDs) affects the quality of healthcare. One factor of overcrowding is precariousness, but it has rarely been considered a key factor in designing interventions to improve ED care. Health mediation (HM) aims to facilitate access to rights, prevention, and care for the most vulnerable persons and to raise awareness among healthcare providers about obstacles in accessing healthcare. The primary aim of this study was to determine whether HM intervention for frequent users of EDs (FUED) living in precarious conditions could reduce the readmission rate at 90 days. Methods : Between February 2019 and May 2022, we enrolled and interviewed 726 FUED in four EDs of southeastern France in this randomised controlled trial. The HM intervention started in the ED and lasted 90 days. The outcome was measured in the ED information systems. Statistical methods included an intention-to-treat analysis and a per-protocol analysis. Comparisons were adjusted for gender, age, ED, and health mediator. Results : 46% of patients reported attending the ED because they felt their life was in danger, and 42% had been referred to the ED by the emergency medical dispatch centre or their GP; 40% of patients were considered to be in a serious condition by ED physicians. The proportion of patients who were readmitted at 90 days was high but did not differ between the control and the HM intervention groups (31.7% vs 36.3, p=0.23). There was no significant difference in any of the secondary outcome measures between the control and HM intervention groups. Per-protocol analysis also showed no significant difference for the primary and secondary endpoints. Conclusions: Although health mediation seemed to be a promising solution at the end of our qualitative study, this randomised controlled trial did not show that it was effective in reducing the use of emergency services by FUED living in precarious conditions. Interventions should screen these patients and aim to accurately identify their social, psychosocial and medical needs, involve ED staff and train them on the issue of precariousness, with a view to long-term health empowerment. Trial registration : registered on clinicaltrials.gov as NCT03660215 on 4 th September 2018 Figures Figure 1 Background Iterative use of Emergency Departments (EDs) is a global, persistent and important topic in health services research. Many studies have shown its deleterious effects: severe overcrowding resulting in long waits that lead to frustration in patients and staff alike, which in turn can lead to violence, burnout and high turnover of staff in Eds. This then affects the quality and efficiency of care, results in lost opportunities for patients, and creates financial losses for social security systems [1,2]. A small portion of the ED patient population, ranging from as little as 1% to between 4% and 8% contributes from 17–30% of all visits annually [3]. These users likely cost hospitals millions of dollars while decreasing the efficiency of the ED [4]. To address this issue, many researchers have attempted to identify the characteristics of FUED. These characteristics are many and varied, even between studies and study populations: age (younger or older, according to studies), social isolation, chronic diseases and comorbidities, heavy use of general practice services, other primary care services, and other hospital services, psychiatric problems or related to alcohol, economic hardship, being unemployed or dependent on government welfare, being under guardianship, being uninsured, living closer to ED [5–10]. Many of these characteristics affect people living in precarious conditions. Social interventions, personalised and coordinated care, and health education to improve health empowerment could be of benefit to this population as well as to EDs [11]. However, interventional studies in these populations are lacking and the overall effectiveness of strategies to reduce the readmission rate of FUED is still under debate because of the heterogeneity of the definitions of frequent ED use and the modalities of the interventions [12–14]. Health mediation to reduce health inequities In France, improving health policies for persons living in precarious conditions is mainly based on improving social rights to allow these persons to have financial access to healthcare, but this is insufficient in terms of case management, health literacy and inclusivity [15]. Health mediation (HM) is one of the key strategies that the French government has put in place to combat health inequities. HM emerged at the end of the 80s for patients living with AIDS and mental diseases [16]. Here, HM is not intended as an intervention to prevent or solve medical disputes and conflicts [17]. HM is intended to be a proximity interface aimed, on the one hand at providing access to rights, to prevention and to care for populations presenting various factors of vulnerability that distance them from the health systems, and on the other hand at raising awareness in the actors of the health system to the specificities of these populations and to the obstacles they encounter in their healthcare pathways [16]. HM contributes to the opening and continuity of health coverage rights, access to care, and the reception of persons [18]. HM is based on the major principles of “going towards” populations, health and social professionals and institutions and “doing with” in a logic of empowerment of individuals [16,19]. The “going towards” approach has two components: (1) physical movement, “outside the walls”, towards the places frequented by underserved populations and towards health professionals or institutions; (2) openness towards others, towards the person as a whole, without judgement, with respect [19]. In some countries, work has been done with professionals close to health mediators (HMrs), such as community health workers (CHW) or community counsellors (CC) highlighting the benefits of their interventions in hospitals [20, 21]. A systematic review showed that programs involving CHW promote more equitable access and can contribute to improved uptake of referral for health facility services, and underlined the needs for equity during planning and implementation of such programs [21]. In some ways, HMrs are close to CHW, in the sense that they serve as a link between health/social services and the community to facilitate access to services and improve quality-of-service delivery. HMrs also build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, education, informal counselling and social support. On their part, HMrs are not always trusted members of the community served or the neighbourhoods, and they do not provide education, support or advocacy at a community level but only at the individual level. Unlike the community counsellors (CC), HMrs do not offer mental health services or therapy for individuals. Like CC, however, they give support to individuals who have difficulties and low health literacy. In France, several settings have implemented HM to improve the management of chronic and mental illnesses [16,22,23]. Long lacking a legal framework and professional benchmark, HM has been officially recognized in France by the law of modernization of the healthcare system in 2016, and defined in 2017 by the French National Authority for Health [19], as a set of actions to improve access to rights, prevention and care, in order to promote health and thus move towards greater equity. Although HM has been widely promoted by the French Ministry of Health and many actors in the healthcare system, and its implementation has been evaluated in the context of health promotion and access to health in vulnerable people, tangible data are not available on its effectiveness on access to health, and the quality and efficiency of health care in these populations [16,23–25]. An HM intervention targeting deprived FUED, starting in ED and consisting of education actions and help on navigating the care system could reduce readmissions to ED. After the examinations, care and recommendations have been made, patients living in precarious conditions are generally discharged from EDs with a report to their general practitioner (which they do not always have), one or more prescriptions for tests or medication that they do not always understand or that they do not know how to carry out, cannot or do not want to carry out, or do not identify as priorities. Emergency physicians and most nurses do not have specific training or the time to determine psychosocial needs and most do not know what resources are out in the community to fill in the gaps. Social services are attached to EDs but are not sufficiently staffed and trained in empowerment, care pathways, health literacy and outreach techniques [26]. Although HM seems appropriate to reduce iterative ED use in this population, HM has never been evaluated in this context. A need for tools adapted to deprived frequent users of emergency departments The two main strategies tested to reduce iterative ED use are accompaniment by CHWs and, in particular, case management. Very few studies have reported on the impact of CHW on FUED. Yet CHW could help leverage EDs as an entry point into the healthcare system [27]. CHWs implemented in EDs can offer healthcare screenings and education, and care coordination for a vast number of health conditions [27,28]. For ED “super-users” working with CHWs, care coordination intervention led to lower costs per patient for the EDs [29]. Having a CHW service embedded in the ED workflow could allow for patient-centric care to improve overall health outcomes and elevate some of the ED physicians’ responsibility in ensuring proper follow-up to a variety of medical services [27]. Several systematic reviews suggested that case management could reduce ED visits [12,14,30,31] and be cost-effective [32], but few specifically targeted vulnerable patients [13,30,31]. Case management involves multi-disciplinary teams including physicians, nurses, psychologists, social workers and/or housing and community resource liaisons, who develop tailored care strategies and protocols for patients [33]. Such protocols would have to be adapted to the different health systems, especially in the current context of overcrowded EDs that are also facing a shortage of doctors and nurses, in France as in many other countries [34–36]. Little is known about the impact of case management on deprived FUED, and interventional trials in this population are crucial. To address the issue of iterative use of EDs among persons living in precarious conditions, we set up a research project whose main objective was to evaluate the effectiveness of HM in EDs on the readmission rate of this population. We have already shown that HM is well accepted by patients and ED staff alike, but its efficacy remains to be proved [37]. The primary aim of this study was to demonstrate that health mediation intervention for FUED living in precarious conditions can reduce the readmission rate in EDs at 90 days. The secondary objectives were to evaluate the impact of HM on the readmission rates in EDs at 30 and 180 days, and on the number of readmissions in EDs and hospitalisations at 30, 90 and 180 days. Methods Study population This two-arm parallel randomised controlled trial was conducted in four EDs in southeastern France. Two EDs were in densely populated urban areas with high levels of precariousness (North University Hospital, and European Hospital, in northern and central districts of Marseille); the two other EDs were in less urbanized areas characterised by pockets of neo-rural precariousness (Arles and Manosque). Each year, these 4 EDs handle 23% of all ED stays in the counties where they are located; 1,830,495 people aged over 18 live in these counties, with a density of 183 inhabitants per km² and a poverty rate of 17.8% (such as defined by the National Institute for Statistics and Economic studies). The annual use of EDs is 42% (number of ED stays/population aged 18 and over). These four EDs provide mainly medical and surgical health care (95%, including 29% for traumas); psychiatry and toxicology represents 4% of ED stays [38]. Patient enrolment began in February 2019, and the last patient was enrolled in November 2021. The last follow-up was in May 2022. Men and women presenting to one of the participating EDs were eligible to participate if they were at least 18 years old; had visited the same ED once in the 90 days prior to enrolment, or twice in the last 6 months, or three or more times in the last 12 months; were able to communicate in French; understood the purpose of the study; and had an EPICES social precariousness score greater than 30. The EPICES score estimates the level of precariousness using 11 binary items: marital status (one item), health insurance status (one item), economic status (three items), family support (three items) and leisure activity. It can vary from 0 (no precariousness) to 100 (extreme precariousness), with 30 being the cut-off point for classifying people as being in a precarious situation. [39]. Patients were not included if they were unable to give informed consent, could not respond to a face-to-face interview (confused, acutely psychotic, with severe neurodegenerative disorders or intoxicated), were under guardianship, legal protection or imprisonment, were living in a nursing home or other health and social care facility with a care team, or were in a life-threatening emergency situation. Patients living in an area initially considered too remote for the mediator to visit were also excluded. The health mediators (HMrs) (see below) assigned to the study screened all patients attending the ED (including those who had attended the previous evening or during the night and were still present in the ED) for age, place of residence, and whether they had attended the ED during the period used as an inclusion criterion. HMrs were present on weekdays between 7 am and 8 pm, excluding Saturdays, Sundays and public holidays. Each patient with no exclusion criteria was interviewed to complete the EPICES social precariousness questionnaire. If the EPICES score was compatible with the inclusion criterion and the medical staff did not object on medical grounds, the patient was given full information about the study and the intervention procedures, and signed a written consent form. Collected information All patients were interviewed by HMrs to collect socio-demographic characteristics: age, gender, residence, distance to ED, marital status, education level, occupational status, income and migration), public and complementary health insurance coverage, allocation of various allowances, access to general practitioner, quality of life (WHOQOL-Bref) and reason for ED admission. Initial complaints, severity score, main and related pathologies, discharge mode (return home or hospitalisation) and duration of hospitalisation were collected from the hospital information system at baseline, 30, 90 and 180 days. The initial complaints were classified using the thesaurus of the French Society of Emergency Medicine (SFMU), and the final diagnoses were matched according to their International Classification of Diseases (ICD-10) codes. We used the SFMU severity score to classify patients into 5 categories (1-2: lesion status and/or functional prognosis judged stable, without (1) or with (2) further diagnostic or therapeutic action required; 3: lesion status and/or functional prognosis judged likely to deteriorate in the ED, but not life-threatening; 4-5: life-threatening pathological situation, without (4) or with (5) resuscitation techniques). The REDCAP software was used to enter all the information collected [40]. Health mediation intervention Enrolled patients were randomised to one of two arms at the time of their ED visit: 'control' (usual care) or 'experimental' (HM), by the HMrs according to a randomisation list generated by an independent statistician using a 4-block randomisation prior to the start of the study, for each of the four EDs [41]. In the experimental arm, the patient was managed by an HMr from the time of admission to the ED and followed up for 90 days, in accordance with the recommendations of the French High Authority for Health [19]; examples of HM are displayed in Table 1. The five HMrs were full-time paid staff with 2-5 years post-baccalaureate education and a diploma in social work, with some experience in the health sector; medical background was not required. Qualified applicants were selected on the basis of good communication skills, good knowledge of social rights and procedures and common health care pathways, ability/experience in teamwork and networking with health/social professionals inside and outside the EDs, and in managing relationships with disadvantaged people in an ethical and equitable manner. They were initially trained and supervised by a senior HMr (for attitudes and behaviour towards these people) and a general practitioner, with routine group or individual meetings to present challenging cases. The tasks of HMrs consisted of (1) administering a questionnaire on socio-demographics, quality of life, health literacy, and reasons of admission to ED; (2) evaluating the socio-medical needs of patients according to ad hoc guidelines; (3) defining objectives corresponding to activities and resources of the services requested; (4) accompanying persons towards prevention and care, and helping them understand how to access social and health care; (5) acting as an interpreter and bridge to the persons concerned but also to health professionals and social workers; (6) adopting a benevolent stance and active listening in order to detect individual and collective problems that might require specific information or prevention. All of these tasks were carried out with a view to improving the capacity for health empowerment of the patients. Measurements – outcomes Primary outcome: first readmission in ED at 90 days after inclusion. Secondary outcomes: ED readmission at 30 and 180 days, number of ED readmissions at 30, 90 and 180 days, number of hospitalisations after ED readmission at 90 days, admission to ED at 30, 90 and 180 days for the same reason as the first admission. Sample size The sample size was calculated to detect an efficacy of the intervention on the primary endpoint: 4% in the intervention group versus 10% in the control group, with an attrition rate of 15%, a significance level of 0.05 and power of 0.80. Based on these assumptions, the total required sample size was estimated to be 726 patients (363 subjects per group). Statistical methods Groups were compared from their initial allocation, regardless of adherence to the HM intervention (intention-to-treat analysis); a second analysis was performed (per-protocol analysis) comparing the primary and secondary endpoints in the control group to those in patients who met the HMrs at least once face-to-face after inclusion, at least three times by phone, and did not abandon the intervention during the 90-day follow up by the HM. A subgroup analysis in per-protocol patients was performed on patients with low severity scores (CCMU 1-2), and then on patients living in very precarious conditions (EPICES score 60+). Continuous variables are expressed as means and SDs or as median with range (min-max), and categorical variables are reported as count and percentages. Comparisons of mean values between two groups were performed using student t-test or Mann-Whitney U. Comparisons of percentages were performed using Chi-Square test or (Fisher’s exact test, as appropriate). Ordinal and binomial multivariable logistic regression analyses were performed to analyse the effect of health mediation intervention, to take into account age, gender, HMr and ED. All the tests were two-sided, the statistical significance was defined as p<.05. Statistical analysis was performed using IBM SPSS Statistics version 20 (IBM SPSS Inc., Chicago, IL, USA). Results Figure 1 displays the flow diagram. Table 2 presents the socio-demographic characteristics. Table 3 shows access to health care prior to first ED admission and quality of life at enrolment. With regard to precariousness, it is noteworthy that 30% had no qualifications, 14% were illiterate, 33% had not always lived in France, 34.5% lived alone, 53% were unemployed and 56% were in a very precarious situation (Table 2). With regard to healthcare, 49% had full health insurance coverage for a chronic illness and 12% received a disability allowance, 13% did not have a GP, 75% had consulted their GP in the previous three months, 71% had reported having no difficulty in contacting their GP (Table 3). All domains of quality of life estimated by the WHO-QOL-BREF were below the average measured in a representative sample of the French population [42]: physical health (51.7 vs.76.9), psychological health (61.3 vs. 67), social relationships (67.6 vs. 74.5) (Table 4). Half of the patients lived less than 15 minutes from the ED, 42% had travelled by ambulance and 16% had walked or used public transportation (Table 4). The main reason given by patients for attending the ED was that they felt their life was in danger (46%), followed by the fact that they had been referred to the ED by the emergency medical dispatch centre or their GP (42%). On arrival in ED, more than 40% of patients were considered by the medical staff to be in a serious condition (injury status and/or functional prognosis deemed likely to worsen in the ED, but not life-threatening, life-threatening pathological situation with or without immediate resuscitation) (Table 4). Cardiovascular events (26%) and traumatic/rheumatologic disorders (21%) were the most frequent causes (Table 4). Approximately 20% of patients were hospitalised following their first admission to the ED (at enrolment). The proportion of patients with low severity score (CCMU 1) at admission in our sample was lower than in the regional average (6.4% vs 9.4%). The per-protocol and intent-to-treat populations did not differ in any of the characteristics measured. The proportion of patients who were readmitted at 90 days was high but did not differ between the control and the HM intervention groups (31.7% vs 36.3, p=0.23) (Table 5). There was no significant difference between the control and HM intervention groups for any of the secondary outcome measures (Table 5). The per-protocol analysis also did not identify any significant difference for the primary and secondary endpoints (Table 5). The same analyses, performed only in patients with a low severity score at enrolment, and then in those with a high severity score (EPICES score 60+) showed no significant differences between the control and HM intervention groups for any of the outcomes measured. Discussion While our previous social-psychological analysis showed that both FUED living in precarious conditions and ED professionals recognised the needs to address bio-psycho-social distress and the utility of HM [37], the results of our randomised trial showed no effect of HM on 90-day readmission rates or any of the secondary outcomes. We compared the characteristics of the patients enrolled in our randomised trial with the available data from the EDs of the same region [38], and when not available to the national data, with the caveat that the enrolment period included the Covid pandemic and the lockdown periods. First, the proportion of women and the mean age were higher in our sample than those reported by the EDs in the same region, 53.8% vs 48.4%, 47.8 vs 45 years respectively [38]. The proportion of patients with a low admission severity score (CCMU 1) in our sample was lower than the regional average (6.4% vs 9.4%). In contrast, the proportion of patients with a high severity score (CCMU 4–5) was higher in our sample than in the region (5% vs 2.0%) while ours were less likely to be admitted to hospital at ED discharge (19.8% vs 24.9%). We also found that the proportion of patients admitted to the EDs for trauma was lower in our sample than in the region (11.5% vs 29%), while the proportion of patients admitted for psychiatric or toxicological reasons was higher (9.4% vs 4%). All domains of quality of life estimated by the WHO-QOL-BREF were below the average in a representative sample of the French population [42]. Relative to regional and national observations, the FUED in our sample were more likely to be women, older, have psychiatric disorders and a poorer quality of life, more likely to be admitted for serious health and vital conditions, and less likely to be admitted for trauma. Gender, age, psychiatric disorders and chronic diseases have also been identified as related to iterative use of EDs in the literature [5–10]. It is interesting to note that most FUED in our sample had a GP and had consulted a GP in the last three months, indicating a precarious state of health rather than difficulties in accessing healthcare. Two main methodological issues should be discussed to explain the lack of effect of HM on the readmission rates at 30, 90 and 180 days, the first concerning the characteristics of the patients enrolled in the trial and the second concerning the HM intervention. Patient profile may help explain why HM did not work A recurring methodological issue in the evaluation of interventions is how to define a FUED [13]. The definition generally varies between 3 and 5 admissions per year [9,43–45]. Our study used a rather low criterion (at least 3 ED admissions per year). However, 44.3% of the patients enrolled in our trial were readmitted at least once at 180 days (including 21.6% at least twice). Another issue that needs to be addressed is the heterogeneity of patients and their reasons for presenting to the ED. Raven et al. raised the question of “distinguishing between users who go to ED 40 times a year and those who go only 5 times a year”, or “between a 27-year-old woman being treated for asthma who has just lost her job and benefits and lives near the ED and a 42-year-old man with chronic alcoholism, lung cancer and cirrhosis of the liver who is taken to the ED by a health mobile team” [13]. In our sample, the reasons for ED re-use were very diverse: 25.6% had returned to the ED for cardiovascular reasons, while 21.7% had come for trauma or rheumatological problems. It should also be noted that 42% of the patients had been referred by an emergency medical regulation department or a general practitioner, 44.9% had felt in danger on first presentation and 49.7% had long-term care insurance. It is uncertain whether an HM intervention can be effective in these patients who already have a GP, are being followed up for a chronic condition and feel their life is at risk. Rather than using this criterion alone (being a FUED and living in precarious conditions), interventions should start with a thorough social, psychosocial and health assessment of whether and how an intervention is likely to prevent repeat admissions, as a result of an accurate joint medical and social assessment, and therefore to target only these FUED. Another issue is the definition of precariousness and its use to attribute an intervention to a FUED. Several terms or dimensions have often been used in papers investigating the factors related to iterative ED use: social vulnerability, deprivation, unemployment, economic hardship.... Precariousness can be defined as "a state of social instability characterised by the absence of one or more guarantees that allow persons [...] to enjoy their fundamental rights" [46]. The causes and dimensions of precariousness are multiple and affect heterogeneous populations [47]. Precariousness appears to be a multidimensional dynamic process, the result of a series of events experienced in different areas of an individual's life (housing, employment, culture, education, family and social relations, physical and mental health…) [48,49]. In our trial, we chose the EPICES score as a multidimensional indicator of precariousness because it is recognised to be more strongly associated with lifestyle and health indicators than the administrative definition of precariousness. The EPICES score has demonstrated its value in identifying people in precarious situations who are at increased risk of health problems and are not recognised by the criteria of the socio-administrative definition [50]. Based on the EPICES score, we enrolled patients with varied vulnerabilities [social and material deprivation, health and financial difficulties), some of which can be reached only by a long-term HM, and/or accepted by patients. Even if the diagnosis of needs made by the HMs allowed the intervention to be tailored, it is likely that some patients did not feel sufficiently concerned or motivated by an intervention offered during their visit to the ED. Half of the patients in the intervention arm did not accept more than one face-to-face meeting, had fewer than three telephone contacts and/or did not follow up with the HM, which highlights the difficulty of engaging a majority of patients in HM. While the EPICES score seems useful for screening FUEDs living in precarious conditions, HM should be offered only to patients who are able or fully willing to benefit from it. Therefore, the concept of precariousness does not seem to be the only criterion to be used in the evaluation of interventions aimed at reducing the use of emergency services. In the light of our results, the EPICES score seems to be more a tool for identifying people at risk. A detailed assessment of the components of precariousness would be more appropriate for selecting FUED who could be helped by an intervention aimed at reducing the risk of repeated use of ED. Is health mediation an appropriate tool to reduce the iterative use of EDs? Initially, HM focused on persons living with AIDS and mental health diseases, with the aim of facilitating the access to rights, prevention and care for populations with various factors of precariousness that distance them from the health systems, and of making health system actors aware of the specificities of these populations and the obstacles they encounter in their health care navigation. [16]. In our trial, 13.4% reported not having a GP, a slightly higher proportion than in the general population, and 24.3% had not seen a GP in the last three months, despite a higher prevalence of chronic diseases and a poorer quality of life than the general population. These findings mean that less than a quarter of our sample needed strong support. In future evaluations, HMs should focus their attention and resources on the most vulnerable patients, who are the hardest to reach. In the qualitative analysis of the intervention, we noticed that many deprived persons discontinued their telephone subscription because of financial issues, had technical difficulties to listen to their voice messages, and faced constraints/barriers to respect their appointments [37]. The COVID 19 pandemic and its lockdown periods also affected the organisation and the burden of EDs and HM, and enhanced the isolation of patients and the difficulties of remaining in contact with them. The HMrs were obliged to favour phone contacts instead of face-to-face meetings, and several patients were lost to follow up. Our experience highlights the need for a very high level of investment in human resources and the need to identify and focus on the most vulnerable patients, which also raises the issue of stigma and the need for clear explanations to patients when HM is offered [45]. Another difficulty we encountered was working with the medical and social staff of the ED. The HMrs were present in the ED, in contact with the ED staff and very well accepted [37]. However, the HMrs did not always manage to involve the ED medical and social staff sufficiently in the discharge care plan, mainly because of the work overload. The ED staff showed high expectations of HMrs, but several ED professionals reported that they were faced with intense assignments and a high psycho-emotional load on a daily basis, which led to feelings of dissatisfaction when caring for the FUED living in precarious conditions. A great deal of training and support is needed for ED staff, and it is essential that HMrs are fully integrated into the ED staff so that decisions about treatment take into account precariousness and social vulnerability. In their scoping review, Richard et al. identified the conditions for the success of HM, in particular the status and training of HMrs, They also noted that most papers took the effectiveness of HM for granted and only presented an analysis of the conditions [25]. It is now essential to define the profile of patients who can benefit from HM in order to improve the health care indicators, including ED use, as well as the methods and duration of HM. Our intervention was designed for a maximum support period of 90 days to achieve our main objective of reducing ED readmission. Our qualitative analysis showed that some patients would have liked a longer period of support, which would have allowed them to be better managed in the long term in outpatient settings [37]. The lack of evidence that HM reduces the number of ED re-use highlights the difficulty to involve patients living in precarious conditions. A longer-term intervention based on a more holistic approach and targeting both the capacities of individuals and the environmental conditions in which they find themselves may be more effective in reducing the frequent use of emergency departments in the long term [51,52]. Conclusion Although health mediation seemed to be a promising solution at the end of our qualitative study [37], our study did not show that it was effective in reducing the use of emergency services by vulnerable frequent users of ED. Interventions targeting this population living in precarious conditions should aim to accurately identify their social, psychosocial and medical needs, involve ED staff and train them on the issue of precariousness, with a view to long-term health empowerment. Abbreviations AIDS Acquired Immune Deficiency Syndrome CC Community counsellor CHW Community Health Worker CM Case Management COVID COronaVIrus Disease ED Emergency Department EPICES Evaluation de la Précarité et des Inégalités de santé dans les Centres d'Examens de Santé (Evaluation of precariousness and health inequalities in health examination centers) HM Health Mediation HMrs Health Mediators WHOQOL-BREF World Health Organization Quality Of Life Declarations Ethics approval and consent to participate Ethical approval and consent to participate in this study were granted by the Ile de France III personal protection committee on 24/07/2018 (Reference Am8211-1-3621-RM, EUDRACT 2018-A01851-54), and amended on 02/07/2019. All methods were conducted in accordance with the relevant guidelines and regulations. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests I declare that the authors have no competing interests as defined by BMC Emergency Medicine, or other interests that might be perceived to influence the results and/or discussion reported in this paper. Funding Research reported in this manuscript was funded by PREPS 17-0633/Ministère de la Santé (Programme de Recherche sur la Performance du système de Soins (PREPS) Authors' contributions MR planned and designed this study. ALa, ACRV, TA, SO, CC and PA amended the study design and the health mediation intervention. MR, ALo and MB performed the statistical analysis. MR drafted the paper. NP, ALa, ACRV, TA, SO, CC and PA reviewed and approved this manuscript. Acknowledgements We thank all the patients and professionals in the emergency departments of Hôpital Nord, Marseille (Dr, Aurélia Bordais, Pr Antoine Roch and the staff); Hôpital Européen, Marseille (Dr Aymeric Vasseur, Jeremy Pavon and the staff), Centre Hospitalier Louis Raffalli, Manosque (Dr Anne-Sophie Peron, Dr Pierre Mingasson, Dr Nicole Morati, Marie-Helene Mandaroux and the staff), and Centre Hospitalier Joseph Imbert, Arles (Dr François Daltroff, Dr Maurice Saidi, Alexandra Ferrand, Arnaud Duret and the staff). We also thank the health mediators (Ella Ragot, Fatima Hassani, Jean Michel Amata, Dalila Soudjay, Ana-Cristina Rojas-Vergara); the In Citta Association for the training in health mediation (Julien Perrin and Valeria Mantello); all the APHM staff who supported the project: Dr Karine Baumstarck, Dr Anne Galinier, Olivier Gauche, Margaux Vieille, Claire Morando, Richard Malkoun, Frédérique Durieux, Mariola Klimkowska. 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(Health Evidence Network report). http://www.euro.who.int/Document/E88086.pdf Tables Table 1: Examples of health mediation (HMr: Health Mediator; ED: Emergency Department) Case 1: Mrs X., 74 years old, came to the ED several times in the last six months for the same reason, a high blood pressure. She reported regular meetings with the GP and the cardiologist, with a nurse visiting every day to check her blood pressure and medications. Mrs X. and her husband were both on full social security coverage. The couple live on a small pension. At the time of the initial interview by the HM, Mrs X. stated that she had been having financial problems for 3 months due to the suspension of housing allowances. The husband had been to the family benefits fund office several times, but had not been able to resolve the problem. The loss of support meant that the couple's resources were significantly reduced, making it difficult for them to pay the rent or buy food. This situation was a great source of stress for Mrs X. The HM put the couple in touch with a social worker to look for a solution regarding housing benefits and to find social housing. After several weeks, the couple recovered their housing benefit. In the meantime, the HM informed Mrs X. about the various food distribution associations near her home and called her regularly to check on her and reassure her. Mrs X. did not return to the ED in the following months. CASE 2: Mr X., aged 58, regularly returns to the ED for several reasons (chronic bronchitis, depressive syndrome, alcohol abuse). He is very isolated, out of touch with the health care system, has neither a regular general practitioner, nor complementary medical insurance, nor exemption from fees for a long-term illness. Mr X. does not receive housing benefits because he has no rental agreement and pays low rent in an unhealthy dwelling in danger of collapsing. Mr X. has a very low income, receiving financial allowance for his disability. He has a large debt with the hospital and refuses any contact with a social worker. The mediation lasted 90 days. Several meetings took place at home and at the hospital, with dozens of telephone calls. The patient was reintegrated into a care programme with a GP in his neighbourhood, obtained recognition of his chronic pathologies for full healthcare insurance, and the hospital's litigation department was informed in order to regularise his debts. He obtained help with the payment of supplementary health insurance and was able to start dental and ophthalmic treatment. Finally, he was evacuated from his home and rehoused, and a social follow-up with an association was launched. A neighbourhood citizens' association keeps in touch with Mr X. to break his isolation. The HM had to call on several structures outside the hospital to find the best alternatives for his complex situation. Mr X. reduced the number of ED admissions from 15 in the 6 months prior to inclusion to 4 in the 90 days following inclusion. Table 2: Socio-demographic characteristics in the intent-to-treat and per-protocol groups (at enrolment) Intent-to-treat (n=720) Per-Protocol (n=540) n % n % Women 387 53.8 295 54.6 Age n % First quartile (18-29 y.) 183 25.5 129 23.9 Second quartile (30-47 y.) 175 24.3 137 25.4 Third quartile (48-63 y.) 180 25.0 138 25.6 Fourth quartile (64-96 y.) 181 25.2 135 25.0 Education General training - Baccalaureate (A-level) 267 37.6 199 37.4 Professional training 226 31.8 169 31.8 Without any degree 217 30.6 164 30.8 Illiterate 95 13.4 75 14.1 Resident in France 5 y. 37 5.2 29 5.4 > 5y. 199 27.7 157 29.1 Always 482 67.1 353 65.5 Living Alone 243 33.9 185 34.5 With family or friends 207 28.9 199 28.5 With a partner 266 37.2 153 37.1 Occupation (time) Full-time Occupation 156 30.8 115 30.0 Part-time occupation 59 11.6 47 12.3 No occupation 270 53.3 221 57.7 Occupation (type ) Agriculture 74 10.4 48 9.0 Employee 360 50.7 283 53.1 Blue-collar worker 106 14.9 79 14.8 Retired or unemployed 170 23.9 123 23.1 Level of precariousness Precarious (EPICES Score 30-59) 409 56.8 303 56.1 Very precarious (EPICES Score 60+) 311 43.2 237 43.9 Table 3: Access to health care prior to first ED admission and quality of life, in the intent-to-treat and per-protocol groups (at enrolment). Intent-to-treat (n=720) Per-Protocol (n=540) n %* n %* Receives disability allowance 86 12.0 70 13.0 Has a complete insurance coverage for chronic illnesses 320 49.3 240 49.7 Difficulty to reach the attending physician Very easy 326 45.7 250 46.6 Easy 157 22.0 118 22.0 Not easy 135 18.9 96 17.9 No attending physician 96 13.4 72 13.4 Time since the last visit to the attending physician < 3months 529 74.8 401 75.7 Difficulty to ask questions to the attending physician Always or sometimes difficult 104 19.8 75 19.0 Never difficult 375 71.4 288 72.9 Don’t know or no answer 46 8.8 32 8.1 Mean (std) Mean (std) WHO-QOL domains Physical Health 51.7(16.7) 52.0(17.2) Psychological Health 61.3(20.4) 61.6(20.4) Social Relations 67.6(28.4) 67.8(29.2) *(%) among respondents only Table 4: Admission to emergency departments (ED) in the intent-to-treat and per-protocol groups (at enrolment) Intent-to-treat (n=720) Per-Protocol (n=540) n % n % Admitted to ED during night hours 161 22.4 113 20.9 Distance between ED and housing 30 min 101 14.8 81 15.7 Means of transportation to ED By foot or public transport 120 16.7 86 16.0 Personal vehicle 295 41.0 225 41.8 Ambulance 303 42.2 227 42.2 Arrived to ED alone 443 62.0 331 61.6 Reason for coming to ED Called the medical emergency dispatch centre and was told to come to the ED (or were sent a vehicle to be picked up). 225 31.5 168 31.5 Don't have a GP 12 1.7 8 1.5 GP told you to go to the ED 76 10.6 57 10.7 GP was not available or was unreachable 20 2.8 17 3.2 Thought your health was in danger 326 45.7 240 44.9 Needed a test that you couldn't get quickly 24 3.4 21 3.9 Lived near the ED 8 1.1 6 1.1 Other reason 29 4.9 23 4.1 ED severity score at ED admission 1- Clinical condition considered stable. No additional diagnostic or therapeutic procedures. Simple clinical examination. 45 6.4 37 7.0 2- Stable lesion status and/or functional prognosis. Decision to perform additional diagnostic or therapeutic procedures in an ED 358 50.9 259 49.0 3- Injury status and/or functional prognosis deemed likely to worsen in the ED, but not life-threatening. 266 37.8 203 38.4 4-5 - Life-threatening pathological situation with or without immediate resuscitation. 35 5.0 30 5.7 Organic apparatus concerned Gastro-intestinal and Genito-Urinary 131 18.2 85 15.7 Cardiovascular 188 26.1 139 25.7 Respiratory 82 11.8 67 12.4 Trauma and rheumatology 152 21.1 117 21.7 Psychiatric/Intoxication 68 9.4 51 9.4 Hospitalised after discharge from the ED 142 19.8 115 21.3 Table 5: Readmissions and re-hospitalisations to ED according to the health mediation intervention Intent-to-treat Per-Protocol Control group Health Mediation intervention p Health Mediation intervention p n 362 358 178 Admitted to ED at 30 days 0.24 0.29 No 295 (81.5%) 279 (77.9 %) 136 (76.4%) Once 47 (13%) 49 (13.7%) 25 (14.0%) Twice or more 20 (5.5%) 30 (8.4%) 17 (9.6%) Admitted to ED at 30 days for the same reason 25 (6.9%) 38 (10.6%) 19 (10.7%) Number of readmissions at 30 days 0.30 (0.94) 0.37 (0.88) 0.32 0.39 (0.85) 0.32 Admitted to ED at 90 days No 247 (68.2) 228 (63.7%) 0.23 111 (62.4%) 0.33 Once 66 (18.2) 81 (22.6%) 38 (21.3%) Twice or more 49 (13.5) 49 (13.7%) 29 (16.3%) Admitted to ED at 90 days for the same reason 25 (6.9) 23 (6.4%) 0.79 11 (6.2%) 0.80 ED severity score at ED admission at 90 days 0.99 0.37 1- Clinical condition considered stable. No additional diagnostic or therapeutic procedures. Simple clinical examination Or 2- Stable lesion status and/or functional prognosis. Decision to perform additional diagnostic or therapeutic procedures in an ED 47 (65.3%) 50 (65.8%) 26 (61.9 %) 3- Injury status and/or functional prognosis deemed likely to worsen in the ED, but not life-threatening. 23 (31.9%) 23 (30.3%) 14 (33.3%) 4-5 - Life-threatening pathological situation with or without immediate resuscitation. 2 (2.8%) 3 (3.9% 2 (4.8%) Number of readmissions at 90 d. 0.67 (1.6) 0.71 (1.5) 0.69 0.80 (1.6) 0.37 Number of hospitalisations at 90 d. 15 (4.1) 16 (4.5) 0.83 11 (6.2%) 0.29 Admitted to ED at 180 days 0.18 0.25 No 207 (57.2%) 194 (54.2%) 95 (53.4) Once 80 (22.1%) 83 (23.2%) 38 (21.3) Twice or more 75 (20.7%) 81 (22.6%) 45 (25.3) Admitted to ED at 180 days for the same reason 7 (1.9%) 14 (3.9%) 0.12 8 (4.5) 0.09 P-adjusted for age, gender, emergency department and health mediator. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 06 Mar, 2024 Reviews received at journal 03 Mar, 2024 Reviewers agreed at journal 15 Feb, 2024 Reviewers invited by journal 13 Feb, 2024 Editor invited by journal 24 Jan, 2024 Editor assigned by journal 24 Jan, 2024 Submission checks completed at journal 24 Jan, 2024 First submitted to journal 16 Jan, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Santé","correspondingAuthor":false,"prefix":"","firstName":"Celia","middleName":"","lastName":"Chischportich","suffix":""},{"id":269511617,"identity":"c06f2f42-d2c3-4bda-9682-c8e450d96ea4","order_by":8,"name":"Anderson Loundou","email":"","orcid":"","institution":"Aix-Marseille University","correspondingAuthor":false,"prefix":"","firstName":"Anderson","middleName":"","lastName":"Loundou","suffix":""},{"id":269511618,"identity":"34837af0-b6b3-4e59-9e8e-34221c44ce73","order_by":9,"name":"Mohamed Boucekine","email":"","orcid":"","institution":"Aix-Marseille University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"","lastName":"Boucekine","suffix":""}],"badges":[],"createdAt":"2024-01-16 16:59:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3870488/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3870488/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50330524,"identity":"7b26ebe5-693d-4daf-abfe-43454f2d5b35","added_by":"auto","created_at":"2024-01-29 21:42:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":275308,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-3870488/v1/af2d3971ad57a1a8ca392b3d.png"},{"id":50331819,"identity":"87380e82-6dfc-413c-9a12-2ec724454b70","added_by":"auto","created_at":"2024-01-29 21:50:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":680576,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3870488/v1/983a29f1-7a18-42cc-a0e9-489aeb0944c2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Health mediation does not reduce the readmission rate of frequent users of emergency departments living in precarious conditions: what lessons can be learned from this randomised controlled trial?","fulltext":[{"header":"Background","content":"\u003cp\u003eIterative use of Emergency Departments (EDs) is a global, persistent and important topic in health services research. Many studies have shown its deleterious effects: severe overcrowding resulting in long waits that lead to frustration in patients and staff alike, which in turn can lead to violence, burnout and high turnover of staff in Eds. This then affects the quality and efficiency of care, results in lost opportunities for patients, and creates financial losses for social security systems [1,2]. A small portion of the ED patient population, ranging from as little as 1% to between 4% and 8% contributes from 17\u0026ndash;30% of all visits annually [3]. These users likely cost hospitals millions of dollars while decreasing the efficiency of the ED [4]. To address this issue, many researchers have attempted to identify the characteristics of FUED. These characteristics are many and varied, even between studies and study populations: age (younger or older, according to studies), social isolation, chronic diseases and comorbidities, heavy use of general practice services, other primary care services, and other hospital services, psychiatric problems or related to alcohol, economic hardship, being unemployed or dependent on government welfare, being under guardianship, being uninsured, living closer to ED [5\u0026ndash;10]. Many of these characteristics affect people living in precarious conditions. Social interventions, personalised and coordinated care, and health education to improve health empowerment could be of benefit to this population as well as to EDs [11]. However, interventional studies in these populations are lacking and the overall effectiveness of strategies to reduce the readmission rate of FUED is still under debate because of the heterogeneity of the definitions of frequent ED use and the modalities of the interventions [12\u0026ndash;14].\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eHealth mediation to reduce health inequities\u003c/h2\u003e \u003cp\u003eIn France, improving health policies for persons living in precarious conditions is mainly based on improving social rights to allow these persons to have financial access to healthcare, but this is insufficient in terms of case management, health literacy and inclusivity [15]. Health mediation (HM) is one of the key strategies that the French government has put in place to combat health inequities. HM emerged at the end of the 80s for patients living with AIDS and mental diseases [16]. Here, HM is not intended as an intervention to prevent or solve medical disputes and conflicts [17]. HM is intended to be a proximity interface aimed, on the one hand at providing access to rights, to prevention and to care for populations presenting various factors of vulnerability that distance them from the health systems, and on the other hand at raising awareness in the actors of the health system to the specificities of these populations and to the obstacles they encounter in their healthcare pathways [16]. HM contributes to the opening and continuity of health coverage rights, access to care, and the reception of persons [18]. HM is based on the major principles of \u0026ldquo;going towards\u0026rdquo; populations, health and social professionals and institutions and \u0026ldquo;doing with\u0026rdquo; in a logic of empowerment of individuals [16,19]. The \u0026ldquo;going towards\u0026rdquo; approach has two components: (1) physical movement, \u0026ldquo;outside the walls\u0026rdquo;, towards the places frequented by underserved populations and towards health professionals or institutions; (2) openness towards others, towards the person as a whole, without judgement, with respect [19]. In some countries, work has been done with professionals close to health mediators (HMrs), such as community health workers (CHW) or community counsellors (CC) highlighting the benefits of their interventions in hospitals [20, 21]. A systematic review showed that programs involving CHW promote more equitable access and can contribute to improved uptake of referral for health facility services, and underlined the needs for equity during planning and implementation of such programs [21]. In some ways, HMrs are close to CHW, in the sense that they serve as a link between health/social services and the community to facilitate access to services and improve quality-of-service delivery. HMrs also build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, education, informal counselling and social support. On their part, HMrs are not always trusted members of the community served or the neighbourhoods, and they do not provide education, support or advocacy at a community level but only at the individual level. Unlike the community counsellors (CC), HMrs do not offer mental health services or therapy for individuals. Like CC, however, they give support to individuals who have difficulties and low health literacy. In France, several settings have implemented HM to improve the management of chronic and mental illnesses [16,22,23]. Long lacking a legal framework and professional benchmark, HM has been officially recognized in France by the law of modernization of the healthcare system in 2016, and defined in 2017 by the French National Authority for Health [19], as a set of actions to improve access to rights, prevention and care, in order to promote health and thus move towards greater equity. Although HM has been widely promoted by the French Ministry of Health and many actors in the healthcare system, and its implementation has been evaluated in the context of health promotion and access to health in vulnerable people, tangible data are not available on its effectiveness on access to health, and the quality and efficiency of health care in these populations [16,23\u0026ndash;25].\u003c/p\u003e \u003cp\u003eAn HM intervention targeting deprived FUED, starting in ED and consisting of education actions and help on navigating the care system could reduce readmissions to ED. After the examinations, care and recommendations have been made, patients living in precarious conditions are generally discharged from EDs with a report to their general practitioner (which they do not always have), one or more prescriptions for tests or medication that they do not always understand or that they do not know how to carry out, cannot or do not want to carry out, or do not identify as priorities. Emergency physicians and most nurses do not have specific training or the time to determine psychosocial needs and most do not know what resources are out in the community to fill in the gaps. Social services are attached to EDs but are not sufficiently staffed and trained in empowerment, care pathways, health literacy and outreach techniques [26]. Although HM seems appropriate to reduce iterative ED use in this population, HM has never been evaluated in this context.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eA need for tools adapted to deprived frequent users of emergency departments\u003c/h3\u003e\n\u003cp\u003eThe two main strategies tested to reduce iterative ED use are accompaniment by CHWs and, in particular, case management. Very few studies have reported on the impact of CHW on FUED. Yet CHW could help leverage EDs as an entry point into the healthcare system [27]. CHWs implemented in EDs can offer healthcare screenings and education, and care coordination for a vast number of health conditions [27,28]. For ED \u0026ldquo;super-users\u0026rdquo; working with CHWs, care coordination intervention led to lower costs per patient for the EDs [29]. Having a CHW service embedded in the ED workflow could allow for patient-centric care to improve overall health outcomes and elevate some of the ED physicians\u0026rsquo; responsibility in ensuring proper follow-up to a variety of medical services [27]. Several systematic reviews suggested that case management could reduce ED visits [12,14,30,31] and be cost-effective [32], but few specifically targeted vulnerable patients [13,30,31]. Case management involves multi-disciplinary teams including physicians, nurses, psychologists, social workers and/or housing and community resource liaisons, who develop tailored care strategies and protocols for patients [33]. Such protocols would have to be adapted to the different health systems, especially in the current context of overcrowded EDs that are also facing a shortage of doctors and nurses, in France as in many other countries [34\u0026ndash;36]. Little is known about the impact of case management on deprived FUED, and interventional trials in this population are crucial.\u003c/p\u003e \u003cp\u003eTo address the issue of iterative use of EDs among persons living in precarious conditions, we set up a research project whose main objective was to evaluate the effectiveness of HM in EDs on the readmission rate of this population. We have already shown that HM is well accepted by patients and ED staff alike, but its efficacy remains to be proved [37]. The primary aim of this study was to demonstrate that health mediation intervention for FUED living in precarious conditions can reduce the readmission rate in EDs at 90 days. The secondary objectives were to evaluate the impact of HM on the readmission rates in EDs at 30 and 180 days, and on the number of readmissions in EDs and hospitalisations at 30, 90 and 180 days.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy population\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis\u0026nbsp;two-arm parallel randomised\u0026nbsp;controlled\u0026nbsp;trial\u0026nbsp;was conducted in four EDs in southeastern France. Two EDs were in densely populated urban areas with high levels of precariousness (North University Hospital, and European Hospital, in northern and central districts of Marseille); the two other EDs were in less urbanized areas characterised by pockets of neo-rural precariousness (Arles and Manosque). Each year, these 4 EDs handle 23% of all ED stays in the counties where they are located; 1,830,495 people aged over 18 live in these counties, with a density of 183 inhabitants per km\u0026sup2; and a poverty rate of 17.8% (such as defined by the National Institute for Statistics and Economic studies). The annual use of EDs is 42% (number of ED stays/population aged 18 and over). These four EDs provide mainly medical and surgical health care (95%, including 29% for traumas); psychiatry and toxicology represents 4% of ED stays\u0026nbsp;[38].\u003c/p\u003e\n\u003cp\u003ePatient enrolment began in February 2019, and the last patient was enrolled in November 2021. The last follow-up was in May 2022. Men and women presenting to one of the participating EDs were eligible to participate if they were at least 18 years old; had visited the same ED once in the 90 days prior to enrolment, or twice in the last 6 months, or three or more times in the last 12 months; were able to communicate in French; understood the purpose of the study; and had an EPICES social precariousness score greater than 30. The EPICES score estimates the level of precariousness using 11 binary items: marital status (one item), health insurance status (one item), economic status (three items), family support (three items) and leisure activity. It can vary from 0 (no precariousness) to 100 (extreme precariousness), with 30 being the cut-off point for classifying people as being in a precarious situation.\u0026nbsp;[39].\u003c/p\u003e\n\u003cp\u003ePatients were not included if they were unable to give informed consent, could not respond to a face-to-face interview (confused, acutely psychotic, with severe neurodegenerative disorders or intoxicated), were under guardianship, legal protection or imprisonment, were living in a nursing home or other health and social care facility with a care team, or were in a life-threatening emergency situation. Patients living in an area initially considered too remote for the mediator to visit were also excluded.\u003c/p\u003e\n\u003cp\u003eThe health mediators (HMrs) (see below) assigned to the study screened all patients attending the ED (including those who had attended the previous evening or during the night and were still present in the ED) for age, place of residence, and whether they had attended the ED during the period used as an inclusion criterion. HMrs were present on weekdays between 7\u0026nbsp;am and 8 pm, excluding Saturdays, Sundays and public holidays. Each patient with no exclusion criteria was interviewed to complete the EPICES social precariousness questionnaire. If the EPICES score was compatible with the inclusion criterion and the medical staff did not object on medical grounds, the patient was given full information about the study and the intervention procedures, and signed a written consent form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCollected information\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients were interviewed by HMrs to collect socio-demographic characteristics: age, gender, residence, distance to ED, marital status, education level, occupational status, income and migration), public and complementary health insurance coverage, allocation of various allowances, access to general practitioner, quality of life (WHOQOL-Bref) and reason for ED admission. Initial complaints, severity score, main and related pathologies, discharge mode (return home or hospitalisation) and duration of hospitalisation were collected from the hospital information system at baseline, 30, 90 and 180 days. The initial complaints were classified using the thesaurus of the French Society of Emergency Medicine (SFMU), and the final diagnoses were matched according to their International Classification of Diseases (ICD-10) codes. We used the SFMU severity score to classify patients into 5 categories (1-2: lesion status and/or functional prognosis judged stable, without (1) or with (2) further diagnostic or therapeutic action required; 3: lesion status and/or functional prognosis judged likely to deteriorate in the ED, but not life-threatening; 4-5: life-threatening pathological situation, without (4) or with (5) resuscitation techniques). The REDCAP software was used to enter all the information collected\u0026nbsp;[40].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHealth mediation intervention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEnrolled patients were randomised to one of two arms at the time of their ED visit: \u0026apos;control\u0026apos; (usual care) or \u0026apos;experimental\u0026apos; (HM), by the HMrs according to a\u0026nbsp;randomisation list\u0026nbsp;generated by an independent statistician using a 4-block randomisation prior to the start of the study, for each of the four EDs\u0026nbsp;[41]. In the experimental arm, the patient was managed by an HMr from the time of admission to the ED and followed up for 90 days, in accordance with the recommendations of the French High Authority for Health\u0026nbsp;[19]; examples of HM are displayed in Table 1.\u003c/p\u003e\n\u003cp\u003eThe five HMrs were full-time paid staff with 2-5 years post-baccalaureate education and a diploma in social work, with some experience in the health sector; medical background was not required. Qualified applicants were selected on the basis of good communication skills, good knowledge of social rights and procedures and common health care pathways, ability/experience in teamwork and networking with health/social professionals inside and outside the EDs, and in managing relationships with disadvantaged people in an ethical and equitable manner. They were initially trained and supervised by a senior HMr (for attitudes and behaviour towards these people) and a general practitioner, with routine group or individual meetings to present challenging cases.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe tasks of HMrs consisted of (1) administering a questionnaire on socio-demographics, quality of life, health literacy, and reasons of admission to ED; (2) evaluating the socio-medical needs of patients according to ad hoc guidelines; (3) defining objectives corresponding to activities and resources of the services requested; (4) accompanying persons towards prevention and care, and helping them understand how to access social and health care; (5) acting as an interpreter and bridge to the persons concerned but also to health professionals and social workers; (6) adopting a benevolent stance and active listening in order to detect individual and collective problems that might require specific information or prevention. All of these tasks were carried out with a view to improving the capacity for health empowerment of the patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMeasurements \u0026ndash; outcomes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrimary outcome: first readmission in ED at 90 days after inclusion.\u003c/p\u003e\n\u003cp\u003eSecondary outcomes: ED readmission at 30 and 180 days, number of ED readmissions at 30, 90 and 180 days, number of hospitalisations after ED readmission at 90 days, admission to ED at 30, 90 and 180 days for the same reason as the first admission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSample size\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sample size was calculated to detect an efficacy of the intervention on the primary endpoint: 4% in the intervention group versus 10% in the control group, with an attrition rate of 15%, a significance level of 0.05 and power of 0.80. Based on these assumptions, the total required sample size was estimated to be 726 patients (363 subjects per group).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStatistical methods\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGroups were compared from their initial allocation, regardless of adherence to the HM intervention (intention-to-treat analysis); a second analysis was performed (per-protocol analysis) comparing the primary and secondary endpoints in the control group to those in patients who met the HMrs at least once face-to-face after inclusion, at least three times by phone, and did not abandon the intervention during the 90-day follow up by the HM. A subgroup analysis in per-protocol patients was performed on patients with low severity scores (CCMU 1-2), and then on patients living in very precarious conditions (EPICES score 60+). Continuous variables are expressed as means and SDs or as median with range (min-max), and categorical variables are reported as count and percentages. Comparisons of mean values between two groups were performed using student t-test or Mann-Whitney U. Comparisons of percentages were performed using Chi-Square test or (Fisher\u0026rsquo;s exact test, as appropriate). Ordinal and binomial multivariable logistic regression analyses were performed to analyse the effect of health mediation intervention, to take into account age, gender, HMr and ED. All the tests were two-sided, the statistical significance was defined as p\u0026lt;.05. Statistical analysis was performed using IBM SPSS Statistics version 20 (IBM SPSS Inc., Chicago, IL, USA).\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFigure 1 displays the flow diagram. Table 2 presents the socio-demographic characteristics. Table 3 shows access to health care prior to first ED admission and quality of life at enrolment. With regard to precariousness, it is noteworthy that 30% had no qualifications, 14% were illiterate, 33% had not always lived in France, 34.5% lived alone, 53% were unemployed and 56% were in a very precarious situation (Table 2). With regard to healthcare, 49% had full health insurance coverage for a chronic illness and 12% received a disability allowance, 13% did not have a GP, 75% had consulted their GP in the previous three months, 71% had reported having no difficulty in contacting their GP (Table 3). All domains of quality of life estimated by the WHO-QOL-BREF were below the average measured in a representative sample of the French population [42]: physical health (51.7 vs.76.9), psychological health (61.3 vs. 67), social relationships (67.6 vs. 74.5) (Table 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHalf of the patients lived less than 15 minutes from the ED, 42% had travelled by ambulance and 16% had walked or used public transportation (Table 4). The main reason given by patients for attending the ED was that they felt their life was in danger (46%), followed by the fact that they had been referred to the ED by the emergency medical dispatch centre or their GP (42%). On arrival in ED, more than 40% of patients were considered by the medical staff to be in a serious condition (injury status and/or functional prognosis deemed likely to worsen in the ED, but not life-threatening, life-threatening pathological situation with or without immediate resuscitation) (Table 4). Cardiovascular events (26%) and traumatic/rheumatologic disorders (21%) were the most frequent causes (Table 4). Approximately 20% of patients were hospitalised following their first admission to the ED (at enrolment). The proportion of patients with low severity score (CCMU 1) at admission in our sample was lower than in the regional average (6.4% vs 9.4%). The per-protocol and intent-to-treat populations did not differ in any of the characteristics measured.\u003c/p\u003e\n\u003cp\u003eThe proportion of patients who were readmitted at 90 days was high but did not differ between the control and the HM intervention groups (31.7% vs 36.3, p=0.23) (Table 5). There was no significant difference between the control and HM intervention groups for any of the secondary outcome measures (Table 5). The per-protocol analysis also did not identify any significant difference for the primary and secondary endpoints (Table 5). The same analyses, performed only in patients with a low severity score at enrolment, and then in those with a high severity score (EPICES score 60+) showed no significant differences between the control and HM intervention groups for any of the outcomes measured.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWhile our previous social-psychological analysis showed that both FUED living in precarious conditions and ED professionals recognised the needs to address bio-psycho-social distress and the utility of HM [37], the results of our randomised trial showed no effect of HM on 90-day readmission rates or any of the secondary outcomes.\u003c/p\u003e \u003cp\u003eWe compared the characteristics of the patients enrolled in our randomised trial with the available data from the EDs of the same region [38], and when not available to the national data, with the caveat that the enrolment period included the Covid pandemic and the lockdown periods. First, the proportion of women and the mean age were higher in our sample than those reported by the EDs in the same region, 53.8% vs 48.4%, 47.8 vs 45 years respectively [38]. The proportion of patients with a low admission severity score (CCMU 1) in our sample was lower than the regional average (6.4% vs 9.4%). In contrast, the proportion of patients with a high severity score (CCMU 4\u0026ndash;5) was higher in our sample than in the region (5% vs 2.0%) while ours were less likely to be admitted to hospital at ED discharge (19.8% vs 24.9%). We also found that the proportion of patients admitted to the EDs for trauma was lower in our sample than in the region (11.5% vs 29%), while the proportion of patients admitted for psychiatric or toxicological reasons was higher (9.4% vs 4%). All domains of quality of life estimated by the WHO-QOL-BREF were below the average in a representative sample of the French population [42]. Relative to regional and national observations, the FUED in our sample were more likely to be women, older, have psychiatric disorders and a poorer quality of life, more likely to be admitted for serious health and vital conditions, and less likely to be admitted for trauma. Gender, age, psychiatric disorders and chronic diseases have also been identified as related to iterative use of EDs in the literature [5\u0026ndash;10]. It is interesting to note that most FUED in our sample had a GP and had consulted a GP in the last three months, indicating a precarious state of health rather than difficulties in accessing healthcare.\u003c/p\u003e \u003cp\u003eTwo main methodological issues should be discussed to explain the lack of effect of HM on the readmission rates at 30, 90 and 180 days, the first concerning the characteristics of the patients enrolled in the trial and the second concerning the HM intervention.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePatient profile may help explain why HM did not work\u003c/h2\u003e \u003cp\u003eA recurring methodological issue in the evaluation of interventions is how to define a FUED [13]. The definition generally varies between 3 and 5 admissions per year [9,43\u0026ndash;45]. Our study used a rather low criterion (at least 3 ED admissions per year). However, 44.3% of the patients enrolled in our trial were readmitted at least once at 180 days (including 21.6% at least twice). Another issue that needs to be addressed is the heterogeneity of patients and their reasons for presenting to the ED. Raven et al. raised the question of \u0026ldquo;distinguishing between users who go to ED 40 times a year and those who go only 5 times a year\u0026rdquo;, or \u0026ldquo;between a 27-year-old woman being treated for asthma who has just lost her job and benefits and lives near the ED and a 42-year-old man with chronic alcoholism, lung cancer and cirrhosis of the liver who is taken to the ED by a health mobile team\u0026rdquo; [13]. In our sample, the reasons for ED re-use were very diverse: 25.6% had returned to the ED for cardiovascular reasons, while 21.7% had come for trauma or rheumatological problems. It should also be noted that 42% of the patients had been referred by an emergency medical regulation department or a general practitioner, 44.9% had felt in danger on first presentation and 49.7% had long-term care insurance. It is uncertain whether an HM intervention can be effective in these patients who already have a GP, are being followed up for a chronic condition and feel their life is at risk. Rather than using this criterion alone (being a FUED and living in precarious conditions), interventions should start with a thorough social, psychosocial and health assessment of whether and how an intervention is likely to prevent repeat admissions, as a result of an accurate joint medical and social assessment, and therefore to target only these FUED.\u003c/p\u003e \u003cp\u003eAnother issue is the definition of precariousness and its use to attribute an intervention to a FUED. Several terms or dimensions have often been used in papers investigating the factors related to iterative ED use: social vulnerability, deprivation, unemployment, economic hardship.... Precariousness can be defined as \"a state of social instability characterised by the absence of one or more guarantees that allow persons [...] to enjoy their fundamental rights\" [46]. The causes and dimensions of precariousness are multiple and affect heterogeneous populations [47]. Precariousness appears to be a multidimensional dynamic process, the result of a series of events experienced in different areas of an individual's life (housing, employment, culture, education, family and social relations, physical and mental health\u0026hellip;) [48,49]. In our trial, we chose the EPICES score as a multidimensional indicator of precariousness because it is recognised to be more strongly associated with lifestyle and health indicators than the administrative definition of precariousness. The EPICES score has demonstrated its value in identifying people in precarious situations who are at increased risk of health problems and are not recognised by the criteria of the socio-administrative definition [50]. Based on the EPICES score, we enrolled patients with varied vulnerabilities [social and material deprivation, health and financial difficulties), some of which can be reached only by a long-term HM, and/or accepted by patients. Even if the diagnosis of needs made by the HMs allowed the intervention to be tailored, it is likely that some patients did not feel sufficiently concerned or motivated by an intervention offered during their visit to the ED. Half of the patients in the intervention arm did not accept more than one face-to-face meeting, had fewer than three telephone contacts and/or did not follow up with the HM, which highlights the difficulty of engaging a majority of patients in HM. While the EPICES score seems useful for screening FUEDs living in precarious conditions, HM should be offered only to patients who are able or fully willing to benefit from it. Therefore, the concept of precariousness does not seem to be the only criterion to be used in the evaluation of interventions aimed at reducing the use of emergency services. In the light of our results, the EPICES score seems to be more a tool for identifying people at risk. A detailed assessment of the components of precariousness would be more appropriate for selecting FUED who could be helped by an intervention aimed at reducing the risk of repeated use of ED.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eIs health mediation an appropriate tool to reduce the iterative use of EDs?\u003c/h2\u003e \u003cp\u003eInitially, HM focused on persons living with AIDS and mental health diseases, with the aim of facilitating the access to rights, prevention and care for populations with various factors of precariousness that distance them from the health systems, and of making health system actors aware of the specificities of these populations and the obstacles they encounter in their health care navigation. [16]. In our trial, 13.4% reported not having a GP, a slightly higher proportion than in the general population, and 24.3% had not seen a GP in the last three months, despite a higher prevalence of chronic diseases and a poorer quality of life than the general population. These findings mean that less than a quarter of our sample needed strong support. In future evaluations, HMs should focus their attention and resources on the most vulnerable patients, who are the hardest to reach. In the qualitative analysis of the intervention, we noticed that many deprived persons discontinued their telephone subscription because of financial issues, had technical difficulties to listen to their voice messages, and faced constraints/barriers to respect their appointments [37]. The COVID 19 pandemic and its lockdown periods also affected the organisation and the burden of EDs and HM, and enhanced the isolation of patients and the difficulties of remaining in contact with them. The HMrs were obliged to favour phone contacts instead of face-to-face meetings, and several patients were lost to follow up. Our experience highlights the need for a very high level of investment in human resources and the need to identify and focus on the most vulnerable patients, which also raises the issue of stigma and the need for clear explanations to patients when HM is offered [45].\u003c/p\u003e \u003cp\u003eAnother difficulty we encountered was working with the medical and social staff of the ED. The HMrs were present in the ED, in contact with the ED staff and very well accepted [37]. However, the HMrs did not always manage to involve the ED medical and social staff sufficiently in the discharge care plan, mainly because of the work overload. The ED staff showed high expectations of HMrs, but several ED professionals reported that they were faced with intense assignments and a high psycho-emotional load on a daily basis, which led to feelings of dissatisfaction when caring for the FUED living in precarious conditions. A great deal of training and support is needed for ED staff, and it is essential that HMrs are fully integrated into the ED staff so that decisions about treatment take into account precariousness and social vulnerability.\u003c/p\u003e \u003cp\u003eIn their scoping review, Richard et al. identified the conditions for the success of HM, in particular the status and training of HMrs, They also noted that most papers took the effectiveness of HM for granted and only presented an analysis of the conditions [25]. It is now essential to define the profile of patients who can benefit from HM in order to improve the health care indicators, including ED use, as well as the methods and duration of HM. Our intervention was designed for a maximum support period of 90 days to achieve our main objective of reducing ED readmission. Our qualitative analysis showed that some patients would have liked a longer period of support, which would have allowed them to be better managed in the long term in outpatient settings [37]. The lack of evidence that HM reduces the number of ED re-use highlights the difficulty to involve patients living in precarious conditions. A longer-term intervention based on a more holistic approach and targeting both the capacities of individuals and the environmental conditions in which they find themselves may be more effective in reducing the frequent use of emergency departments in the long term [51,52].\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAlthough health mediation seemed to be a promising solution at the end of our qualitative study [37], our study did not show that it was effective in reducing the use of emergency services by vulnerable frequent users of ED. Interventions targeting this population living in precarious conditions should aim to accurately identify their social, psychosocial and medical needs, involve ED staff and train them on the issue of precariousness, with a view to long-term health empowerment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAIDS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAcquired Immune Deficiency Syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity counsellor\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCHW\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity Health Worker\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCase Management\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCOVID\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCOronaVIrus Disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eED\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmergency Department\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEPICES\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEvaluation de la Pr\u0026eacute;carit\u0026eacute; et des In\u0026eacute;galit\u0026eacute;s de sant\u0026eacute; dans les Centres d'Examens de Sant\u0026eacute; (Evaluation of precariousness and health inequalities in health examination centers)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Mediation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHMrs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Mediators\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHOQOL-BREF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization Quality Of Life\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval and consent to participate in this study were granted by the Ile de France III personal protection committee on 24/07/2018 (Reference Am8211-1-3621-RM, EUDRACT 2018-A01851-54), and amended on 02/07/2019. All methods were conducted in accordance with the relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI declare that the authors have no competing interests as defined by BMC Emergency Medicine, or other interests that might be perceived to influence the results and/or discussion reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch reported in this manuscript was funded by PREPS 17-0633/Minist\u0026egrave;re de la Sant\u0026eacute; (Programme de Recherche sur la Performance du syst\u0026egrave;me de Soins (PREPS)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMR planned and designed this study. ALa, ACRV, TA, SO, CC and PA amended the study design and the health mediation intervention. MR, ALo and MB performed the statistical analysis. MR drafted the paper. NP, ALa, ACRV, TA, SO, CC and PA reviewed and approved this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all the patients and professionals in the emergency departments of H\u0026ocirc;pital Nord, Marseille (Dr, Aur\u0026eacute;lia Bordais, Pr Antoine Roch and the staff); H\u0026ocirc;pital Europ\u0026eacute;en, Marseille (Dr Aymeric Vasseur, Jeremy Pavon and the staff), Centre Hospitalier Louis Raffalli, Manosque (Dr Anne-Sophie Peron, Dr Pierre Mingasson, Dr Nicole Morati, Marie-Helene Mandaroux and the staff), and Centre Hospitalier Joseph Imbert, Arles (Dr Fran\u0026ccedil;ois Daltroff, Dr Maurice Saidi, Alexandra Ferrand, Arnaud Duret and the staff). We also thank the health mediators (Ella Ragot, Fatima Hassani, Jean Michel Amata, Dalila Soudjay, Ana-Cristina Rojas-Vergara); the In Citta Association for the training in health mediation (Julien Perrin and Valeria Mantello); all the APHM staff who supported the project:\u0026nbsp;Dr Karine Baumstarck,\u0026nbsp;Dr\u0026nbsp;Anne Galinier, Olivier Gauche, Margaux Vieille, Claire Morando, Richard Malkoun, Fr\u0026eacute;d\u0026eacute;rique Durieux, Mariola Klimkowska. We are grateful to the two territorial support platforms APPORT-Sant\u0026eacute; and PRATIC-Sant\u0026eacute; for their backing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information (optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eCameron PA. Hospital overcrowding: a threat to patient safety? 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Rev M\u0026eacute;decine Interne. 2020;41(10):693\u0026ndash;9. https://linkinghub.elsevier.com/retrieve/pii/S0248866320302149\u003c/li\u003e\n \u003cli\u003evon Allmen M, Grazioli VS, Kasztura M, Chastonay O, Moullin JC, Hugli O, et al. Does Case Management Provide Support for Staff Facing Frequent Users of Emergency Departments? A Comparative Mixed-Method Evaluation of ED Staff Perception. BMC Emerg Med. 2021;21(1):92. https://bmcemergmed.biomedcentral.com/articles/10.1186/s12873-021-00481-9\u003c/li\u003e\n \u003cli\u003eNa\u0026iuml;t Salem R, Rotily M, Apostolidis T, Odena S, Lamouroux A, Chischportich C, et al. Health mediation: an intervention mode for improving emergency department care and support for patients living in precarious conditions. BMC Health Serv Res. 2023;23(1):495.\u003c/li\u003e\n \u003cli\u003ePanorama 2019 des structures d\u0026rsquo;urgence de la r\u0026eacute;gion PACA. Region PACA: IESS; 2019 p. 136. https://ies-sud.fr/wp-content/uploads/2021/01/Panorama_2019_iess.pdf\u003c/li\u003e\n \u003cli\u003eLabbe E, Blanquet M, Gerbaud L, Poirier G, Sass C, Vendittelli F, et al. A new reliable index to measure individual deprivation: the EPICES score. Eur J Public Health. 2015;25(4):604\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eGarcia KKS, Abrah\u0026atilde;o AA. Research Development Using REDCap Software. Healthc Inform Res. 2021;27(4):341\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eEfird J. Blocked Randomization with Randomly Selected Block Sizes. Int J Environ Res Public Health. 2010;8(1):15\u0026ndash;20. http://www.mdpi.com/1660-4601/8/1/15\u003c/li\u003e\n \u003cli\u003eBaumann C, Erpelding ML, R\u0026eacute;gat S, Collin JF, Brian\u0026ccedil;on S. The WHOQOL-BREF questionnaire: French adult population norms for the physical health, psychological health and social relationship dimensions. Rev D\u0026Eacute;pid\u0026eacute;miologie Sant\u0026eacute; Publique. 2010;58(1):33\u0026ndash;9. https://linkinghub.elsevier.com/retrieve/pii/S0398762009005227\u003c/li\u003e\n \u003cli\u003eBobashev G, Warren L, Wu LT. Predictive model of multiple emergency department visits among adults: analysis of the data from the National Survey of Drug Use and Health (NSDUH). BMC Health Serv Res. 2021;21(1):280. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-06221-w\u003c/li\u003e\n \u003cli\u003eMalebranche M, Grazioli VS, Kasztura M, Hudon C, Bodenmann P. Case management for frequent emergency department users: no longer a question of if but when, where and how. Can J Emerg Med. 2021;23(1):12\u0026ndash;4. http://link.springer.com/10.1007/s43678-020-00024-4\u003c/li\u003e\n \u003cli\u003eSchaad L, Graells M, Kasztura M, Schmutz E, Moullin J, Hugli O, et al. Perspectives of Frequent Users of Emergency Departments on a Case Management Intervention: A Qualitative Study. Inq J Med Care Organ Provis Financ. 2023;60:469580231159745.\u003c/li\u003e\n \u003cli\u003eWrezinski J. Grande pauvret\u0026eacute; et pr\u0026eacute;carit\u0026eacute; \u0026eacute;conomique et sociale. 1987 p. 118. (Avis et rapports du Conseil Economique et Social). https://www.lecese.fr/sites/default/files/pdf/Rapports/1987/Rapport-WRESINSKI.pdf\u003c/li\u003e\n \u003cli\u003eHan C. Precarity, Precariousness, and Vulnerability. Annu Rev Anthropol. 2018;47(1):331\u0026ndash;43. https://www.annualreviews.org/doi/10.1146/annurev-anthro-102116-041644\u003c/li\u003e\n \u003cli\u003eB\u0026eacute;guinet S. La repr\u0026eacute;sentation sociale du risque de pr\u0026eacute;carit\u0026eacute; chez les \u0026eacute;tudiants. Commun Organ. 2013;(43):227\u0026ndash;52. http://journals.openedition.org/communicationorganisation/4236\u003c/li\u003e\n \u003cli\u003ePierret R. Qu\u0026rsquo;est-ce que la pr\u0026eacute;carit\u0026eacute; ? Socio. 2013;(2):307\u0026ndash;30. http://socio.revues.org/511\u003c/li\u003e\n \u003cli\u003eSass C, Gu\u0026eacute;guen R, Moulin JJ, Abric L, Dauphinot V, Dupr\u0026eacute; C, et al. Comparaison du score individuel de pr\u0026eacute;carit\u0026eacute; des Centres d\u0026rsquo;examens de sant\u0026eacute;, EPICES, \u0026agrave; la d\u0026eacute;finition socio-administrative de la pr\u0026eacute;carit\u0026eacute;. Sant\u0026eacute; Publique. 2006;18(4):513. http://www.cairn.info/revue-sante-publique-2006-4-page-513.htm\u003c/li\u003e\n \u003cli\u003eMaton KI. Empowering community settings: agents of individual development, community betterment, and positive social change. Am J Community Psychol. 2008;41(1\u0026ndash;2):4\u0026ndash;21.\u003c/li\u003e\n \u003cli\u003eWallersteing N. What is the evidence on effectiveness of empowerment to improve health. Copenhagen: WHO Regional Office for Europe; 2006 p. 37. (Health Evidence Network report). http://www.euro.who.int/Document/E88086.pdf\u003cstrong\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1: Examples of health mediation (HMr: Health Mediator; ED: Emergency Department)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003eCase 1: Mrs X., 74 years old, came to the ED several times in the last six months for the same reason, a high blood pressure. She reported regular meetings with the GP and the cardiologist, with a nurse visiting every day to check her blood pressure and medications. Mrs X. and her husband were both on full social security coverage.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eThe couple live on a small pension. At the time of the initial interview by the HM, Mrs X. stated that she had been having financial problems for 3 months due to the suspension of housing allowances. The husband had been to the family benefits fund office several times, but had not been able to resolve the problem. The loss of support meant that the couple\u0026apos;s resources were significantly reduced, making it difficult for them to pay the rent or buy food. This situation was a great source of stress for Mrs X.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eThe HM put the couple in touch with a social worker to look for a solution regarding housing benefits and to find social housing. After several weeks, the couple recovered their housing benefit. In the meantime, the HM informed Mrs X. about the various food distribution associations near her home and called her regularly to check on her and reassure her. Mrs X. did not return to the ED in the following months.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003eCASE 2: Mr X., aged 58, regularly returns to the ED for several reasons (chronic bronchitis, depressive syndrome, alcohol abuse). He is very isolated, out of touch with the health care system, has neither a regular general practitioner, nor complementary medical insurance, nor exemption from fees for a long-term illness. Mr X. does not receive housing benefits because he has no rental agreement and pays low rent in an unhealthy dwelling in danger of collapsing. Mr X. has a very low income, receiving financial allowance for his disability. He has a large debt with the hospital and refuses any contact with a social worker.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eThe mediation lasted 90 days. Several meetings took place at home and at the hospital, with dozens of telephone calls. The patient was reintegrated into a care programme with a GP in his neighbourhood, obtained recognition of his chronic pathologies for full healthcare insurance, and the hospital\u0026apos;s litigation department was informed in order to regularise his debts. He obtained help with the payment of supplementary health insurance and was able to start dental and ophthalmic treatment. Finally, he was evacuated from his home and rehoused, and a social follow-up with an association was launched. A neighbourhood citizens\u0026apos; association keeps in touch with Mr X. to break his isolation. The HM had to call on several structures outside the hospital to find the best alternatives for his complex situation. Mr X. reduced the number of ED admissions from 15 in the 6 months prior to inclusion to 4 in the 90 days following inclusion.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2: Socio-demographic characteristics in the intent-to-treat and per-protocol groups (at enrolment)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.710843373493976%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eIntent-to-treat (n=720)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.19449225473322%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePer-Protocol (n=540)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003eWomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e387\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e53.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e295\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e54.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eFirst quartile (18-29 y.)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e183\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e25.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e129\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e23.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSecond quartile (30-47 y.)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e24.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e25.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eThird quartile (48-63 y.)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e25.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eFourth quartile (64-96 y.)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e181\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e25.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e135\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eGeneral training - Baccalaureate \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; (A-level)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\"\u003e\n \u003cp\u003e267\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\"\u003e\n \u003cp\u003e37.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\"\u003e\n \u003cp\u003e199\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\"\u003e\n \u003cp\u003e37.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eProfessional training\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e226\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e31.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e169\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e31.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eWithout any degree\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e217\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e30.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e164\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e30.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003eIlliterate \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e13.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e14.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003eResident in France\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e5 y.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026gt; 5y.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e199\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e27.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e29.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAlways\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e482\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e67.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e353\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e65.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003eLiving\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAlone\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e243\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e33.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e185\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e34.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eWith family or friends\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e207\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e28.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e199\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e28.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eWith a partner\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e266\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e37.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e153\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e37.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003eOccupation (time)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eFull-time Occupation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e156\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e30.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e30.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;Part-time occupation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e11.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e12.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eNo occupation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e270\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e53.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e221\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e57.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003eOccupation (type\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAgriculture\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e10.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e9.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eEmployee\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e360\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e50.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e283\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e53.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eBlue-collar worker\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e14.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e14.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eRetired or unemployed\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e170\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e23.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e23.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003eLevel of precariousness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePrecarious (EPICES Score 30-59)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e409\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e56.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e303\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e56.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.09466437177281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eVery precarious (EPICES Score 60+)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e311\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.629948364888124%\" valign=\"top\"\u003e\n \u003cp\u003e43.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.080895008605852%\" valign=\"top\"\u003e\n \u003cp\u003e237\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.113597246127366%\" valign=\"top\"\u003e\n \u003cp\u003e43.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Table 3: Access to health care prior to first ED admission and quality of life, in the intent-to-treat and per-protocol groups (at enrolment).\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.97292069632495%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56092843326886%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eIntent-to-treat (n=720)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.46615087040619%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePer-Protocol (n=540)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.97292069632495%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.79497098646035%\" valign=\"top\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e%*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.700193423597678%\" valign=\"top\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e%*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.97292069632495%\" valign=\"top\"\u003e\n \u003cp\u003eReceives disability allowance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.79497098646035%\" valign=\"top\"\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.700193423597678%\" valign=\"top\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e13.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.97292069632495%\" valign=\"top\"\u003e\n \u003cp\u003eHas a complete insurance coverage for chronic illnesses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.79497098646035%\" valign=\"top\"\u003e\n \u003cp\u003e320\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e49.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.700193423597678%\" valign=\"top\"\u003e\n \u003cp\u003e240\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e49.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.97292069632495%\" valign=\"top\"\u003e\n \u003cp\u003eDifficulty to reach the attending physician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.79497098646035%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.700193423597678%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.97292069632495%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eVery easy\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.79497098646035%\" valign=\"top\"\u003e\n \u003cp\u003e326\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e45.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.700193423597678%\" valign=\"top\"\u003e\n \u003cp\u003e250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e46.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.97292069632495%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eEasy\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.79497098646035%\" valign=\"top\"\u003e\n \u003cp\u003e157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e22.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.700193423597678%\" valign=\"top\"\u003e\n \u003cp\u003e118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e22.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.97292069632495%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eNot easy\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.79497098646035%\" valign=\"top\"\u003e\n \u003cp\u003e135\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e18.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.700193423597678%\" valign=\"top\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e17.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.97292069632495%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eNo attending physician\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.79497098646035%\" valign=\"top\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e13.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.700193423597678%\" valign=\"top\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e13.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.97292069632495%\" valign=\"top\"\u003e\n \u003cp\u003eTime since the last visit to the attending physician \u0026lt; 3months\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.79497098646035%\" valign=\"top\"\u003e\n \u003cp\u003e529\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e74.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.700193423597678%\" valign=\"top\"\u003e\n \u003cp\u003e401\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e75.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.97292069632495%\" valign=\"top\"\u003e\n \u003cp\u003eDifficulty to ask questions to the attending physician\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.79497098646035%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.700193423597678%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.97292069632495%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAlways or sometimes difficult\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.79497098646035%\" valign=\"top\"\u003e\n \u003cp\u003e104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e19.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.700193423597678%\" valign=\"top\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e19.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.97292069632495%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eNever difficult\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.79497098646035%\" valign=\"top\"\u003e\n \u003cp\u003e375\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e71.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.700193423597678%\" valign=\"top\"\u003e\n \u003cp\u003e288\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e72.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.97292069632495%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eDon\u0026rsquo;t know or no answer\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.79497098646035%\" valign=\"top\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e8.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.700193423597678%\" valign=\"top\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.76595744680851%\" valign=\"top\"\u003e\n \u003cp\u003e8.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.97292069632495%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56092843326886%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eMean (std)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.46615087040619%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eMean (std)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.97292069632495%\" valign=\"top\"\u003e\n \u003cp\u003eWHO-QOL domains\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56092843326886%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.46615087040619%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.97292069632495%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePhysical Health\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56092843326886%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e51.7(16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.46615087040619%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e52.0(17.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.97292069632495%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePsychological Health\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56092843326886%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e61.3(20.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.46615087040619%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e61.6(20.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.97292069632495%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSocial Relations\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56092843326886%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e67.6(28.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.46615087040619%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e67.8(29.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;*(%) among respondents only\u003c/p\u003e\n\u003cp\u003eTable 4: Admission to emergency departments (ED) in the intent-to-treat and per-protocol groups (at enrolment)\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" style=\"margin-right: calc(26%); width: 74%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"60.07067137809187%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.964664310954063%\" colspan=\"2\" valign=\"top\" style=\"width: 20.2604%;\"\u003e\n \u003cp\u003eIntent-to-treat\u003c/p\u003e\n \u003cp\u003e(n=720)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.964664310954063%\" colspan=\"2\" valign=\"top\" style=\"width: 44.4405%;\"\u003e\n \u003cp\u003ePer-Protocol (n=540)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003eAdmitted to ED during night hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e161\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e22.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e20.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003eDistance between ED and housing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026lt;15 min\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e334\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e48.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e251\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e48.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003e15-30 min\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e249\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e36.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e183\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e35.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026gt; 30 min\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e14.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e15.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003eMeans of transportation to ED\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003eBy foot or public transport\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e16.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003ePersonal vehicle\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e295\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e41.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e225\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e41.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003eAmbulance\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e303\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e42.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e227\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e42.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003eArrived to ED alone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e443\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e62.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e331\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e61.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003eReason for coming to ED\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003eCalled the medical emergency dispatch centre and was told to come to the ED (or were sent a vehicle to be picked up).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e225\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e31.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e168\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e31.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003eDon\u0026apos;t have a GP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003eGP told you to go to the ED\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e10.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e10.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003eGP was not available or was unreachable\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003eThought your health was in danger\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e326\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e45.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e240\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e44.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003eNeeded a test that you couldn\u0026apos;t get quickly\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003eLived near the ED\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003eOther reason\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003eED severity score at ED admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003e1- Clinical condition considered stable. No additional diagnostic or therapeutic procedures. Simple clinical examination.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003e2- Stable lesion status and/or functional prognosis. Decision to perform additional diagnostic or therapeutic procedures in an ED\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e358\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e50.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e259\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e49.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003e3- Injury status and/or functional prognosis deemed likely to worsen in the ED, but not life-threatening.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e266\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e37.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e203\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e38.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003e4-5 - Life-threatening pathological situation with or without immediate resuscitation.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003eOrganic apparatus concerned\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003eGastro-intestinal and Genito-Urinary\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e131\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e18.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e15.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003eCardiovascular\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e188\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e26.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e25.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003eRespiratory\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e11.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e12.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003eTrauma and rheumatology\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e21.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e21.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003e\u003cem\u003ePsychiatric/Intoxication\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e9.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e9.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.859154929577464%\" valign=\"top\" style=\"width: 35.3205%;\"\u003e\n \u003cp\u003eHospitalised after discharge from the ED\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.0507%;\"\u003e\n \u003cp\u003e142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 10.1749%;\"\u003e\n \u003cp\u003e19.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 8.6124%;\"\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.035211267605634%\" valign=\"top\" style=\"width: 35.7466%;\"\u003e\n \u003cp\u003e21.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;Table 5: Readmissions and re-hospitalisations to ED according to the health mediation intervention\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"654\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.053435114503817%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eIntent-to-treat\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.580152671755727%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePer-Protocol\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003eHealth Mediation intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003eHealth Mediation intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e362\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e358\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e178\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdmitted to ED at 30 days\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e295 (81.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e279 (77.9 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e136 (76.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eOnce\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e47 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e49 (13.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e25 (14.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eTwice or more\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e20 (5.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e30 (8.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e17 (9.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003eAdmitted to ED at 30 days for the same reason\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e25 (6.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e38 (10.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e19 (10.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003eNumber of readmissions at 30 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e0.30 (0.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e0.37 (0.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e0.39 (0.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdmitted to ED at 90 days\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e247 (68.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e228 (63.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e111 (62.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eOnce\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e66 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e81 (22.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e38 (21.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eTwice or more\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e49 (13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e49 (13.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e29 (16.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003eAdmitted to ED at 90 days for the same reason\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e25 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e23 (6.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e11 (6.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003eED severity score at ED admission at 90 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e1- Clinical condition considered stable. No additional diagnostic or therapeutic procedures. Simple clinical examination\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eOr\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;2- Stable lesion status and/or functional prognosis. Decision to perform additional diagnostic or therapeutic procedures in an ED\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e47 (65.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e50 (65.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e26 (61.9 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e3- Injury status and/or functional prognosis deemed likely to worsen in the ED, but not life-threatening.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e23 (31.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e23 (30.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e14 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e4-5 - Life-threatening pathological situation with or without immediate resuscitation.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e2 (2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e3 (3.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e2 (4.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003eNumber of readmissions at 90 d.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e0.67 (1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e0.71 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e0.80 (1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003eNumber of hospitalisations at 90 d.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e15 (4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e16 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e11 (6.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdmitted to ED at 180 days\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e207 (57.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e194 (54.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e95 (53.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eOnce\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e80 (22.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e83 (23.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e38 (21.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eTwice or more\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e75 (20.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e81 (22.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e45 (25.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.86259541984733%\" valign=\"top\"\u003e\n \u003cp\u003eAdmitted to ED at 180 days for the same reason\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.50381679389313%\"\u003e\n \u003cp\u003e7 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e14 (3.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.175572519083969%\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.877862595419847%\"\u003e\n \u003cp\u003e8 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.702290076335878%\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;P-adjusted for age, gender, emergency department and health mediator.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3870488/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3870488/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Severe overcrowding of emergency departments (EDs) affects the quality of healthcare. One factor of overcrowding is precariousness, but it has rarely been considered a key factor in designing interventions to improve ED care. Health mediation (HM) aims to facilitate access to rights, prevention, and care for the most vulnerable persons and to raise awareness among healthcare providers about obstacles in accessing healthcare. The primary aim of this study was to determine whether HM intervention for frequent users of EDs (FUED) living in precarious conditions could reduce the readmission rate at 90 days.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Between February 2019 and May 2022, we enrolled and interviewed 726 FUED in four EDs of southeastern France in this randomised controlled trial. The HM intervention started in the ED and lasted 90 days. The outcome was measured in the ED information systems. Statistical methods included an intention-to-treat analysis and a per-protocol analysis. Comparisons were adjusted for gender, age, ED, and health mediator.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: 46% of patients reported attending the ED because they felt their life was in danger, and 42% had been referred to the ED by the emergency medical dispatch centre or their GP; 40% of patients were considered to be in a serious condition by ED physicians. The proportion of patients who were readmitted at 90 days was high but did not differ between the control and the HM intervention groups (31.7% vs 36.3, p=0.23). There was no significant difference in any of the secondary outcome measures between the control and HM intervention groups. Per-protocol analysis also showed no significant difference for the primary and secondary endpoints.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Although health mediation seemed to be a promising solution at the end of our qualitative study, this randomised controlled trial did not show that it was effective in reducing the use of emergency services by FUED living in precarious conditions. Interventions should screen these patients and aim to accurately identify their social, psychosocial and medical needs, involve ED staff and train them on the issue of precariousness, with a view to long-term health empowerment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e: registered on clinicaltrials.gov as NCT03660215 on 4\u003csup\u003eth\u003c/sup\u003e September 2018\u003c/p\u003e","manuscriptTitle":"Health mediation does not reduce the readmission rate of frequent users of emergency departments living in precarious conditions: what lessons can be learned from this randomised controlled trial?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-29 21:42:11","doi":"10.21203/rs.3.rs-3870488/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-03-06T08:36:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-03T10:59:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1f0b5935-3563-4a05-8b13-97c14c501f60","date":"2024-02-15T21:58:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-13T21:56:36+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-01-24T11:06:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-01-24T11:05:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-01-24T11:05:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Emergency Medicine","date":"2024-01-16T16:52:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"aa8b2b87-fc6d-40de-823a-56247e4a2a3d","owner":[],"postedDate":"January 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-05-06T05:52:04+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-29 21:42:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3870488","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3870488","identity":"rs-3870488","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}