Evidence is weak for case management for the elderly
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《英国医生杂志》
Limited evidence exists for the effectiveness of case management—a process of planning, coordinating, managing, and reviewing the care of an individual across different services—for older people, and the NHS should proceed with caution before introducing any particular model based on this approach, warned a report published this week.
The report found little evidence from available research studies that case management reduced hospital admissions or that it was cost effective.
The authors, from the King抯 Fund, a charitable foundation doing healthcare policy research, cautioned against the NHS adopting any single approach to case management, which is currently being developed across the service as part of a plan to reduce emergency hospital bed days by 5% by improving the coordination of services for people with severe complex health problems.
Several primary care trusts are currently piloting a nurse led model developed by Evercare, imported from America抯 United Health Group, others are piloting schemes developed by US healthcare provider Kaiser Permanente and UK pharmaceutical company Pfizer.
The report抯 authors reviewed the published literature on case management for older people and assessed its impact on hospital admissions, length of inpatient stay, use of emergency facilities, healthcare costs, and patients?functional ability. An electronic search of key research databases from 1996 to 2004 identified 19 papers that met the inclusion criteria and which were of high methodological quality, from a total of 415 peer reviewed papers on case management.
The papers showed only weak evidence for the effectiveness of case management in preventing admissions of elderly patients to acute care. Five studies (only two of which were randomised controlled trials) showed significant reductions in admissions, seven found no difference, and four found reductions in admissions that did not reach statistical significance. No consistent effect was found on the use of emergency departments after case management.
Most studies showed decreases in hospital bed days associated with case management and improved functional status or prevention of deterioration. Evidence for the cost effectiveness of case management was limited and the report called for further evaluation to establish whether the costs of providing case management were offset by savings from reduced use of services.
Ruth Hutt, visiting fellow in health policy at the King抯 Fund, and one of the report抯 authors, said, "In the absence of evidence for any specific model of case management, primary care trusts should clarify the needs that they are trying to address and then consider how to organise services in order to address these needs. This may be possible by adapting existing services or may require the development of new systems and services."
She acknowledged that case management might improve patients?quality of life, but she considered that primary care trusts should be given flexibility to develop their own arrangements to improve care for those with long term conditions, taking into account existing local services and local needs. "Case management is unlikely to provide an 憃ff the shelf?solution to achieving the required reductions in emergency admissions," she concluded.(London Susan Mayor)
The report found little evidence from available research studies that case management reduced hospital admissions or that it was cost effective.
The authors, from the King抯 Fund, a charitable foundation doing healthcare policy research, cautioned against the NHS adopting any single approach to case management, which is currently being developed across the service as part of a plan to reduce emergency hospital bed days by 5% by improving the coordination of services for people with severe complex health problems.
Several primary care trusts are currently piloting a nurse led model developed by Evercare, imported from America抯 United Health Group, others are piloting schemes developed by US healthcare provider Kaiser Permanente and UK pharmaceutical company Pfizer.
The report抯 authors reviewed the published literature on case management for older people and assessed its impact on hospital admissions, length of inpatient stay, use of emergency facilities, healthcare costs, and patients?functional ability. An electronic search of key research databases from 1996 to 2004 identified 19 papers that met the inclusion criteria and which were of high methodological quality, from a total of 415 peer reviewed papers on case management.
The papers showed only weak evidence for the effectiveness of case management in preventing admissions of elderly patients to acute care. Five studies (only two of which were randomised controlled trials) showed significant reductions in admissions, seven found no difference, and four found reductions in admissions that did not reach statistical significance. No consistent effect was found on the use of emergency departments after case management.
Most studies showed decreases in hospital bed days associated with case management and improved functional status or prevention of deterioration. Evidence for the cost effectiveness of case management was limited and the report called for further evaluation to establish whether the costs of providing case management were offset by savings from reduced use of services.
Ruth Hutt, visiting fellow in health policy at the King抯 Fund, and one of the report抯 authors, said, "In the absence of evidence for any specific model of case management, primary care trusts should clarify the needs that they are trying to address and then consider how to organise services in order to address these needs. This may be possible by adapting existing services or may require the development of new systems and services."
She acknowledged that case management might improve patients?quality of life, but she considered that primary care trusts should be given flexibility to develop their own arrangements to improve care for those with long term conditions, taking into account existing local services and local needs. "Case management is unlikely to provide an 憃ff the shelf?solution to achieving the required reductions in emergency admissions," she concluded.(London Susan Mayor)