NIHR Signal “Case management” can prevent people with heart failure being admitted again

Published on 30 August 2016

Case management that is initiated in hospital and led by specialist nurses may reduce unplanned hospital readmissions and length of hospital stay for adults with heart failure.

Case management is specific, intensive one-to-one care that involves many components to do with planning, coordinating and reviewing the care of people with long-term conditions.

This NIHR review of organisational type research found quite a lot of studies: 17 trials and five other studies, including three from the UK. The interventions used by the individual studies in this review varied widely, which highlights some need for caution in interpreting the pooled findings. There was limited evidence that hospital-initiated case management is cost effective – particularly in relation to the NHS. A few studies examined case management that was started in the community.

The findings are promising and may lead to further studies that confirm these findings in the UK setting. Commissioners would also need to know other things too, such as the components of case management that are most beneficial and the costs.

“Case management” can prevent people with heart failure being admitted again

Why was this study needed?

Heart failure is a condition where the heart is unable to pump blood to meet the needs of the body. It can have various causes such as high blood pressure or damaged heart muscle from a past heart attack. It typically affects older people and causes symptoms including breathlessness, swollen legs and fatigue. Over half a million people are living with heart failure in the UK and this figure is expected to rise.

Heart failure in England costs about 2% of the total NHS budget and about 70% of this is spent on hospital stays for people with heart failure. People with heart failure spend on average 12 days in hospital, and about one in four are readmitted within three months of discharge.

The NHS provides case management for some long-term conditions, to prevent hospitalisation and improve care for patients. Previous evidence has suggested that case management doesn’t reduce unplanned admissions in the general elderly population. This review aimed to see whether it is clinically and cost effective for people with heart failure.

What did this study do?

This systematic review of 17 randomised controlled trials and five non-randomised controlled studies included 8,626 people with heart failure living in Organisation for Economic Co-operation and Development countries. Three studies were based in the UK.

Trials compared unplanned hospital admissions and length of hospital stay in people receiving case management with those receiving usual care. In nine studies, researchers also collected any cost information. Studies were divided into hospital-initiated and community-initiated case management. In nearly all the studies case management was led by specialist nurses.

The review was conducted using best practice methods to source the studies, extract data and assess the risk of bias. However, the interventions differed widely between studies and were poorly described in some. There were few community-initiated trials and these were of low quality. Only the results of 13 hospital-initiated case management trials were pooled in meta-analysis.

What did it find?

  • People receiving hospital-initiated case-management were less likely to be readmitted to hospital compared to those who received usual care (rate ratio [RR] 0.74, 95% confidence interval [CI] 0.60 to 0.92; 12 trials). However, there was significant variability between the results of the individual trials.
  • Sub-analysis found that the effect of case management was the same regardless of the duration of intervention (three months, six months, or 12 to 18 months).
  •  People receiving hospital-initiated case management had slightly shorter hospital stay than those receiving usual care (mean difference [MD] -1.28 days, 95% CI -2.04 to -0.52 days; 8 trials). Removing one trial with a high risk of bias increased the strength of this finding (MD -1.76, 95% CI -2.29 to -1.23; 7 trials). Sub-analysis revealed that this effect was greatest for re-admissions within three months.
  • Hospital-initiated case management involving family support appeared to be more effective in reducing hospital readmissions compared with interventions that did not include a family component (RR 0.56, 95% CI 0.34 to 0.92), though there was some uncertainty around this effect.
  • Nine trials of hospital-initiated case management reported cost data. Six found no difference between interventions, but three trials reported statistically significant cost savings favouring case management. None of these trials were UK-based.

What does current guidance say on this issue?

NICE guidance on chronic heart failure (2010) does not mention case management, but gives recommendations on monitoring. It says that people who wish to be involved in monitoring their condition should receive the necessary education and support from healthcare professionals. New NICE guidance on the management of chronic heart failure is due to be published March 2018.

What are the implications?

This review provides some evidence that hospital-initiated case management may be effective in reducing hospital readmissions and length of stay in people with heart failure. However, there were limitations to the evidence. Few studies have addressed community-initiated care, and evidence for cost-effectiveness is lacking – particularly as related to the NHS.

The review highlights the diverse nature of case management interventions and the need for more specific research about which components are most beneficial. This includes questions about cost, skill-mix and workforce, including the role of specialist nurses and others.

Citation and Funding

Huntley AL, Johnson R, King A, et al. Does case management for patients with heart failure based in the community reduce unplanned hospital admissions? A systematic review and meta-analysis. BMJ Open. 2016; 6(5): e010933.

This project was funded by the NIHR National School of Primary Health Care Project no. 238.

Bibliography

BACPR. The BACPR Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation 2012 (2nd edition). London: British Association for Cardiovascular Prevention and Rehabilitation; 2012.

BHF. Cardiovascular disease statistics 2015. Oxford: British Heart Foundation; 2015.

National Institute for Cardiovascular Outcomes Research, Mitchell P, Marle D, Donkor A, et al. National Heart Failure Audit; April 2013 – March 2014. London; 2014.

NICE. Chronic heart failure in adults: management. CG108. London: National Institute for Health and Care Excellence; 2010.

Stokes J, Panagioti M, Alam R, et al. Effectiveness of Case Management for 'At Risk' Patients in Primary Care: A Systematic Review and Meta-Analysis. PLoS One. 2015;17;10(7):e0132340.

The King’s Fund. Case management. What it is and how it can best be implemented. London: The King’s Fund; 2011.

Why was this study needed?

Heart failure is a condition where the heart is unable to pump blood to meet the needs of the body. It can have various causes such as high blood pressure or damaged heart muscle from a past heart attack. It typically affects older people and causes symptoms including breathlessness, swollen legs and fatigue. Over half a million people are living with heart failure in the UK and this figure is expected to rise.

Heart failure in England costs about 2% of the total NHS budget and about 70% of this is spent on hospital stays for people with heart failure. People with heart failure spend on average 12 days in hospital, and about one in four are readmitted within three months of discharge.

The NHS provides case management for some long-term conditions, to prevent hospitalisation and improve care for patients. Previous evidence has suggested that case management doesn’t reduce unplanned admissions in the general elderly population. This review aimed to see whether it is clinically and cost effective for people with heart failure.

What did this study do?

This systematic review of 17 randomised controlled trials and five non-randomised controlled studies included 8,626 people with heart failure living in Organisation for Economic Co-operation and Development countries. Three studies were based in the UK.

Trials compared unplanned hospital admissions and length of hospital stay in people receiving case management with those receiving usual care. In nine studies, researchers also collected any cost information. Studies were divided into hospital-initiated and community-initiated case management. In nearly all the studies case management was led by specialist nurses.

The review was conducted using best practice methods to source the studies, extract data and assess the risk of bias. However, the interventions differed widely between studies and were poorly described in some. There were few community-initiated trials and these were of low quality. Only the results of 13 hospital-initiated case management trials were pooled in meta-analysis.

What did it find?

  • People receiving hospital-initiated case-management were less likely to be readmitted to hospital compared to those who received usual care (rate ratio [RR] 0.74, 95% confidence interval [CI] 0.60 to 0.92; 12 trials). However, there was significant variability between the results of the individual trials.
  • Sub-analysis found that the effect of case management was the same regardless of the duration of intervention (three months, six months, or 12 to 18 months).
  •  People receiving hospital-initiated case management had slightly shorter hospital stay than those receiving usual care (mean difference [MD] -1.28 days, 95% CI -2.04 to -0.52 days; 8 trials). Removing one trial with a high risk of bias increased the strength of this finding (MD -1.76, 95% CI -2.29 to -1.23; 7 trials). Sub-analysis revealed that this effect was greatest for re-admissions within three months.
  • Hospital-initiated case management involving family support appeared to be more effective in reducing hospital readmissions compared with interventions that did not include a family component (RR 0.56, 95% CI 0.34 to 0.92), though there was some uncertainty around this effect.
  • Nine trials of hospital-initiated case management reported cost data. Six found no difference between interventions, but three trials reported statistically significant cost savings favouring case management. None of these trials were UK-based.

What does current guidance say on this issue?

NICE guidance on chronic heart failure (2010) does not mention case management, but gives recommendations on monitoring. It says that people who wish to be involved in monitoring their condition should receive the necessary education and support from healthcare professionals. New NICE guidance on the management of chronic heart failure is due to be published March 2018.

What are the implications?

This review provides some evidence that hospital-initiated case management may be effective in reducing hospital readmissions and length of stay in people with heart failure. However, there were limitations to the evidence. Few studies have addressed community-initiated care, and evidence for cost-effectiveness is lacking – particularly as related to the NHS.

The review highlights the diverse nature of case management interventions and the need for more specific research about which components are most beneficial. This includes questions about cost, skill-mix and workforce, including the role of specialist nurses and others.

Citation and Funding

Huntley AL, Johnson R, King A, et al. Does case management for patients with heart failure based in the community reduce unplanned hospital admissions? A systematic review and meta-analysis. BMJ Open. 2016; 6(5): e010933.

This project was funded by the NIHR National School of Primary Health Care Project no. 238.

Bibliography

BACPR. The BACPR Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation 2012 (2nd edition). London: British Association for Cardiovascular Prevention and Rehabilitation; 2012.

BHF. Cardiovascular disease statistics 2015. Oxford: British Heart Foundation; 2015.

National Institute for Cardiovascular Outcomes Research, Mitchell P, Marle D, Donkor A, et al. National Heart Failure Audit; April 2013 – March 2014. London; 2014.

NICE. Chronic heart failure in adults: management. CG108. London: National Institute for Health and Care Excellence; 2010.

Stokes J, Panagioti M, Alam R, et al. Effectiveness of Case Management for 'At Risk' Patients in Primary Care: A Systematic Review and Meta-Analysis. PLoS One. 2015;17;10(7):e0132340.

The King’s Fund. Case management. What it is and how it can best be implemented. London: The King’s Fund; 2011.

Does case management for patients with heart failure based in the community reduce unplanned hospital admissions? A systematic review and meta-analysis

Published on 12 May 2016

Huntley, A. L.,Johnson, R.,King, A.,Morris, R. W.,Purdy, S.

BMJ Open Volume 6 , 2016

OBJECTIVES: The aim of this systematic review of randomised controlled trials (RCTs) and controlled trials (non-RCTs, NRCTs) is to investigate the effectiveness and related costs of case management (CM) for patients with heart failure (HF) predominantly based in the community in reducing unplanned readmissions and length of stay (LOS). SETTING: CM initiated either while as an inpatient, or on discharge from acute care hospitals, or in the community and then continuing on in the community. PARTICIPANTS: Adults with a diagnosis of HF and resident in Organisation for Economic Co-operation and Development countries. INTERVENTION: CM based on nurse coordinated multicomponent care which is applicable to the primary care-based health systems. PRIMARY AND SECONDARY OUTCOMES: Primary outcomes of interest were unplanned (re)admissions, LOS and any related cost data. Secondary outcomes were primary healthcare resources. RESULTS: 22 studies were included: 17 RCTs and 5 NRCTs. 17 studies described hospital-initiated CM (n=4794) and 5 described community-initiated CM of HF (n=3832). Hospital-initiated CM reduced readmissions (rate ratio 0.74 (95% CI 0.60 to 0.92), p=0.008) and LOS (mean difference -1.28 days (95% CI -2.04 to -0.52), p=0.001) in favour of CM compared with usual care. 9 trials described cost data of which 6 reported no difference between CM and usual care. There were 4 studies of community-initiated CM versus usual care (2 RCTs and 2 NRCTs) with only the 2 NRCTs showing a reduction in admissions. CONCLUSIONS: Hospital-initiated CM can be successful in reducing unplanned hospital readmissions for HF and length of hospital stay for people with HF. 9 trials described cost data; no clear difference emerged between CM and usual care. There was limited evidence for community-initiated CM which suggested it does not reduce admission.

Case management is a multi-component approach towards planning, coordinating and reviewing the care of individuals with long term conditions. The King’s Fund describes the key aims of UK-based case management: “to reduce expensive hospital utilisation (principally in terms of emergency admissions but also in terms of length of stay), to improve care outcomes for patients and to enhance the patient experience”.

This review divides trials into hospital-initiated and community-initiated case management, depending on whether the interventions were started while the participant was being treated in hospital or at home.

Expert commentary

As well as being a major cause of morbidity and mortality, heart failure is also one of the commonest causes of unplanned hospital admissions. Hence, there is growing interest in the use of case management to reduce the risk of hospital admission in people with heart failure. In this systematic review, the authors reported that hospital-initiated case management can reduce the risk of unplanned hospital admissions in this group of patients. The authors did not find any significant effect of community-initiated case management on hospital admissions. However, the community-based studies were at high risk of bias; and the review highlighted the need for better designed and implemented studies to answer this important health policy question.

Azeem Majeed, Professor of Primary Care and Head of the Department of Primary Care & Public Health at Imperial College London

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  •   Cardiovascular system disorders, Health management, Nursing, Acute and general medicine