NIHR Signal Case management might not improve health outcomes or reduce costs

Published on 7 September 2015

This systematic review of trials found that case management in primary care of people at risk of unplanned hospital admission did not improve health outcomes, mortality, use of healthcare services, or save money. Patient satisfaction improved, but only a little. Case management was defined as the identification, assessment and care-coordination of people at risk of unplanned hospitalisation. The trials mainly involved older, frail people based in the US, lessening direct applicability to the NHS, which has a stronger primary care orientated system. The authors suggest that case management may be more effective in a system without a strong universal primary care base, but even in these countries the effects were small.

Case management is widespread in the NHS but this NIHR-funded review and meta-analysis suggests it isn’t very effective. This confirms findings from earlier studies. This review has updated that evidence, giving more details of impact and trying to look and see if some ways of delivering case management are better than others. 

Share your views on the research.

Why was this study needed?

Case management has been implemented in the NHS for people at greatest risk of unplanned hospital admission. Though it has been promoted and adopted as a way of improving outcomes and reducing costs, evidence of effectiveness has been described as “promising but mixed”. This NIHR-funded systematic review is the first to use meta-analysis to establish the effectiveness of case management.

Case management can take many different forms, but the researchers’ defined it as having three main components. The first is “case finding”, the process of identifying people “at risk” who could benefit from case management. The second is “assessment” of the needs of the at risk individual, which may include the writing of an individualised care plan. The third is “care co-ordination”, where a case manager or team works to navigate the individual through the most effective care pathway suitable for them. Case management may be done by a team or individual, often a nurse such as a community matron is involved.

What did this study do?

This was a systematic review of 36 trials, 28 of which were randomised control trials, comparing case management in primary care with usual care. The vast majority of trials involved the frail elderly. Case management was delivered in different ways and by different people across the trials. Outcomes included patient self-assessed health status, patient satisfaction, mortality, health service costs and utilisation. Outcomes were measured over the short (up to 12 months) and long term (13 months or more). Results were combined using meta-analysis.

Trials mainly including people with mental health problems, or trials of hospital discharge planning, were excluded from the review.

The review methods were reliable and the included trails were good quality - only 6% of trials were assessed to be at high risk of bias. However only one of the trials was based in the UK, limiting direct UK relevance; over half were based in the US.

What did it find?

  • Compared to usual care, case management made no difference in health service costs, utilisation of primary or secondary care services care, mortality, or self-reported health status in the long term.
  • Case management showed a small increase in patient satisfaction in the short term (standardised mean difference (SMD) 0.26, 95% confidence interval (CI) 0.16 to 0.36) and long term (SMD 0.35, 95% CI 0.04 to 0.66). It also resulted in a very small improvement in self-reported health status in the short term (SMD 0.07, 95% CI 0.00 to 0.14).

What does current guidance say on this issue?

NICE has not published guidance on using case management for at risk patients in primary care. However it does recommend case management for specific populations or conditions, such as people with alcohol dependency or tuberculosis in hard-to-reach groups.

The 2015 General Practitioner contract has introduced a new “unplanned admissions Enhanced Service” in England to try and reduce unnecessary emergency admissions to hospitals. The main component of the Enhanced Service is proactive case management of at risk patients, and in participating practices this will require coverage of 2% of the practice population over 18 years of age.

What are the implications?

This review suggests that case management is unlikely to reduce NHS costs, demand on primary or secondary care, or lead to better health outcomes. It improved patient satisfaction, but the difference was very small. The findings came mainly from studies based in the US reducing their direct applicability to the UK, as primary care services are arranged differently to the US.

Case management programmes are complex interventions, often provided as part of wider integrated service models. Reducing hospital re-admissions for the frail elderly remains a priority in the NHS. This review included a wide range of interventions. Some of the more detailed analyses in this review suggested delivery by multidisciplinary teams rather than single case managers may be more effective. It also highlighted the importance of including social workers. The design of case management components in alternative models of care need careful consideration to ensure that value to patients and value for money can be demonstrated in the local community.

Citation

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 Jul 17;10(7):e0132340.

This project was funded by the National Institute for Health Research Greater Manchester Primary Care Patient Safety Translational Research Centre (NIHR GM PSTRC).

Bibliography

BMA. General practice contract changes 2014–2015: Unplanned admissions Enhanced Service 2014. London: British Medical Association; 2015.

Hutt R, Rosen R, McCauley J. Case-managing long-term conditions: What impact does it have in the treatment of older people? London: The King’s Fund; 2004.

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

NICE. Identifying and managing tuberculosis among hard-to-reach groups. PH37. London: National Institute for Health and Care Excellence; 2012.

NICE. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. CG115. London: National Institute for Health and Care Excellence; 2011.

Why was this study needed?

Case management has been implemented in the NHS for people at greatest risk of unplanned hospital admission. Though it has been promoted and adopted as a way of improving outcomes and reducing costs, evidence of effectiveness has been described as “promising but mixed”. This NIHR-funded systematic review is the first to use meta-analysis to establish the effectiveness of case management.

Case management can take many different forms, but the researchers’ defined it as having three main components. The first is “case finding”, the process of identifying people “at risk” who could benefit from case management. The second is “assessment” of the needs of the at risk individual, which may include the writing of an individualised care plan. The third is “care co-ordination”, where a case manager or team works to navigate the individual through the most effective care pathway suitable for them. Case management may be done by a team or individual, often a nurse such as a community matron is involved.

What did this study do?

This was a systematic review of 36 trials, 28 of which were randomised control trials, comparing case management in primary care with usual care. The vast majority of trials involved the frail elderly. Case management was delivered in different ways and by different people across the trials. Outcomes included patient self-assessed health status, patient satisfaction, mortality, health service costs and utilisation. Outcomes were measured over the short (up to 12 months) and long term (13 months or more). Results were combined using meta-analysis.

Trials mainly including people with mental health problems, or trials of hospital discharge planning, were excluded from the review.

The review methods were reliable and the included trails were good quality - only 6% of trials were assessed to be at high risk of bias. However only one of the trials was based in the UK, limiting direct UK relevance; over half were based in the US.

What did it find?

  • Compared to usual care, case management made no difference in health service costs, utilisation of primary or secondary care services care, mortality, or self-reported health status in the long term.
  • Case management showed a small increase in patient satisfaction in the short term (standardised mean difference (SMD) 0.26, 95% confidence interval (CI) 0.16 to 0.36) and long term (SMD 0.35, 95% CI 0.04 to 0.66). It also resulted in a very small improvement in self-reported health status in the short term (SMD 0.07, 95% CI 0.00 to 0.14).

What does current guidance say on this issue?

NICE has not published guidance on using case management for at risk patients in primary care. However it does recommend case management for specific populations or conditions, such as people with alcohol dependency or tuberculosis in hard-to-reach groups.

The 2015 General Practitioner contract has introduced a new “unplanned admissions Enhanced Service” in England to try and reduce unnecessary emergency admissions to hospitals. The main component of the Enhanced Service is proactive case management of at risk patients, and in participating practices this will require coverage of 2% of the practice population over 18 years of age.

What are the implications?

This review suggests that case management is unlikely to reduce NHS costs, demand on primary or secondary care, or lead to better health outcomes. It improved patient satisfaction, but the difference was very small. The findings came mainly from studies based in the US reducing their direct applicability to the UK, as primary care services are arranged differently to the US.

Case management programmes are complex interventions, often provided as part of wider integrated service models. Reducing hospital re-admissions for the frail elderly remains a priority in the NHS. This review included a wide range of interventions. Some of the more detailed analyses in this review suggested delivery by multidisciplinary teams rather than single case managers may be more effective. It also highlighted the importance of including social workers. The design of case management components in alternative models of care need careful consideration to ensure that value to patients and value for money can be demonstrated in the local community.

Citation

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 Jul 17;10(7):e0132340.

This project was funded by the National Institute for Health Research Greater Manchester Primary Care Patient Safety Translational Research Centre (NIHR GM PSTRC).

Bibliography

BMA. General practice contract changes 2014–2015: Unplanned admissions Enhanced Service 2014. London: British Medical Association; 2015.

Hutt R, Rosen R, McCauley J. Case-managing long-term conditions: What impact does it have in the treatment of older people? London: The King’s Fund; 2004.

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

NICE. Identifying and managing tuberculosis among hard-to-reach groups. PH37. London: National Institute for Health and Care Excellence; 2012.

NICE. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. CG115. London: National Institute for Health and Care Excellence; 2011.

Effectiveness of Case Management for 'At Risk' Patients in Primary Care: A Systematic Review and Meta-Analysis

Published on 18 July 2015

Stokes, J.,Panagioti, M.,Alam, R.,Checkland, K.,Cheraghi-Sohi, S.,Bower, P.

PLoS One Volume 10 , 2015

BACKGROUND: An ageing population with multimorbidity is putting pressure on health systems. A popular method of managing this pressure is identification of patients in primary care 'at-risk' of hospitalisation, and delivering case management to improve outcomes and avoid admissions. However, the effectiveness of this model has not been subjected to rigorous quantitative synthesis. METHODS AND FINDINGS: We carried out a systematic review and meta-analysis of the effectiveness of case management for 'at-risk' patients in primary care. Six bibliographic databases were searched using terms for 'case management', 'primary care', and a methodology filter (Cochrane EPOC group). Effectiveness compared to usual care was measured across a number of relevant outcomes: Health - self-assessed health status, mortality; Cost - total cost of care, healthcare utilisation (primary and non-specialist care and secondary care separately), and; Satisfaction - patient satisfaction. We conducted secondary subgroup analyses to assess whether effectiveness was moderated by the particular model of case management, context, and study design. A total of 15,327 titles and abstracts were screened, 36 unique studies were included. Meta-analyses showed no significant differences in total cost, mortality, utilisation of primary or secondary care. A very small significant effect favouring case management was found for self-reported health status in the short-term (0.07, 95% CI 0.00 to 0.14). A small significant effect favouring case management was found for patient satisfaction in the short- (0.26, 0.16 to 0.36) and long-term (0.35, 0.04 to 0.66). Secondary subgroup analyses suggested the effectiveness of case management may be increased when delivered by a multidisciplinary team, when a social worker was involved, and when delivered in a setting rated as low in initial 'strength' of primary care. CONCLUSIONS: This was the first meta-analytic review which examined the effects of case management on a wide range of outcomes and considered also the effects of key moderators. Current results do not support case management as an effective model, especially concerning reduction of secondary care use or total costs. We consider reasons for lack of effect and highlight key research questions for the future. REVIEW PROTOCOL: The review protocol is available as part of the PROSPERO database (registration number: CRD42014010824).

The King’s Fund has defined case management as “… a well-established way of integrating services around the complex needs of people with long-term conditions. It is a targeted, community-based and pro-active approach that identifies individuals at high risk of hospital admission, assesses their needs, produces a personal care plan, and ensures co-ordination of that plan.”

Expert commentary

This systematic review is a very useful addition to the evidence base around case management of high-risk patients in primary care. In line with previous work it shows that case management has small benefits in terms of patient satisfaction. However, in health care systems with strong primary care there is no benefit from case management of high risk patients on mortality, service utilisation or costs. In order to address pressures on primary and secondary care we need to think about alternative models of care and addressing the needs of wider population groups.

Professor Sarah Purdy, Associate Dean, University of Bristol