Is case management of ‘at-risk’ patients in primary care effective? A systematic review and meta-analysis
An ageing population with multimorbidity is putting pressure on high-cost secondary care services. A popular method of managing this pressure is identification of patients at-risk of hospitalisation in primary care, and case management (individual care planning and co-ordination with regular review). However, the effectiveness of this model has not been subjected to rigorous synthesis.
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 initially searched using terms for ‘case management’, ‘primary care’, and a methodology filter (Cochrane EPOC group). Effectiveness compared to usual care was measured across six outcomes: total cost of health services; utilisation of primary care; and utilisation of secondary care; self-reported health status; mortality; and patient satisfaction. Effect size was reported as the standardised mean difference.Secondary subgroup analyses were carried out to assess whether effectiveness was moderated by variation in case management models, context, and study design.
We screened 15,372 titles and abstracts, and included 37 unique studies. Results showed no significant differences for total cost, mortality, and utilisation of primary or secondary care in the short- (0-12 months) or long-term (13+ months). A statistically significant, but clinically trivial 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 benefit of case management was found for patient satisfaction in the short-term (0.26, 0.16 to 0.36), and the trend continued in the long-term (0.35, 0.04 to 0.66).Secondary subgroup analyses suggested that the effectiveness of case management may increase when delivered by a multidisciplinary team, or with social worker involvement, and when case management was delivered in a setting rated as low in initial strength of primary health care.
Results do not support case management as an effective model, especially concerning alleviation on cost or utilisation. The presentation will conclude by considering the reasons for the minimal impact of case management, and methods by which the impact might be improved. We will also consider the applicability of conventional review methods on analysis of complex models of service delivery.
- Jonathan Stokes, NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Maria Panagioti
- Rahul Alam, NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Kath Checkland
- Sudeh Cheraghi-Sohi, NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Peter Bower, NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK