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Case-management DES ‘not supported by evidence’

There is no evidence that case-management can reduce unplanned hospital admissions, concludes an analysis casting doubt over one of the Government’s planned directed enhanced services due to begin this year.

The meta-analysis of 11 trials of case management interventions for older people found that case managing patients did not reduce unplanned hospital admissions.

The review by Bristol University researchers concludes that ‘disappointing’ findings raise doubts about whether case management should be promoted as a mechanism for reducing unplanned hospital admissions.

A new directed enhanced service - that forms part of the Government’s planned GP contract changes in 2013/14 - incentivises practices to go through their lists and case-manage older patients and those with mental health conditions to keep them out of hospital.

There was some suggestion of benefit in reducing length of hospital stays (three vs five days in one study), but the researchers say case management had no significant impact on unplanned admissions in nine of the 11 studies they looked at.

They said that this could be because interventions are provided to patients who are not at sufficiently high risk of hospital admission.

The researchers concluded: ‘The results of this review now provide robust research evidence that does not underpin current policy or practice.’

Study lead Dr Sarah Purdy, reader in primary health care at Bristol University told Pulse: ‘All the evidence to date shows that this [DES] is not going to do what they are hoping it will do. It might not be a message people want to hear but we’re on pretty solid ground.’

Dr Barry Moyse, former head of Somerset LMC says the new review confirms the beliefs held by many GPs that the latest DESs are politically driven rather than based on evidence.

He said: ‘There never has been great evidence for [case management], but that doesn’t stop politicians saying it’s a good idea. And if it’s not working they say it’s because we’re not doing it hard enough.

‘We must have evidence-based policy not policy-based evidence, but what we see all too often is the latter – they cut the evidence to suit the policy, not the other way round.’

Dr Moyse said it was regrettable that GP practices were too ready ‘to sign on the dotted line for almost anything because they are desperately concerned about income.’

He added: ‘I hope more practices will take Dr Richard Vautrey’s  advice, which is to be more businesslike and to look long and hard and see if it is worth the effort – not just in terms of income, but also whether good is being done for patients. We don’t have to jump through the hoops in this way as directed doctrinal policy.’

Readers' comments (6)

  • Harry Longman

    Three years ago I was I worked very hard to show how a case managed service, led by a community NP, might pay for itself. It was clear the assumptions for any benefit could not be supported by the evidence we had. We did nothing. Glad to see that a much higher powered analysis has shown that to be the right decision.

    The value for me in doing that was to keep asking the question, what might work? It was from this, finding practices who had lower use of A&E and emergency admissions, that I found something interesting, and transferable.

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  • Vinci Ho

    The evidences are undeniable now but this government is basically running out of ideas how to run this country . Listen to what Michael Gove said today about the GCSE ,another stupid U turn.
    This case management to cut unplanned hospital admission can be another U turn if we stick to we believe . Unfortunately , the money attached might make some people have second thought . Enforcing this will have the risk of harming our patients , my friends.....

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  • We can all identify individual high risk patients, and we are doing our best to manage them. I believe there is too much resource going into individual case planning - money would be better spent on having a high quality, efficient "reactive" service

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  • Harry Longman - would you be prepared to share what it was that you found 'interesting and transferrable'?

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  • The keys to successful case management are:
    1) selecting the right patients; not just by clinical judgement but with the use of patient stratification tools.
    2) getting full 'buy-in' by the patient as to the objectives of the case management programme. This may mean removing some of the non-cooperative patients from the case-loads.
    3) monitoring the effectiveness of the interventions and changing the processes if the desired results are not achieved. The intervention costs and outcomes can be measured using risk stratification tools.

    As a telehealth consultant with Docobo, I have been involved in many telehealth projects supporting early interventions by community clinicians and most of these have proved cost effective and with high patient ratings.

    Here is just one example:

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  • Ok, case management, EPP! virtual wards, community matrons, telehealth don't have the evidence.

    So researchers, what are we going to offer?

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