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Case management has no effect on outcomes or costs, find researchers



A new study has cast further doubt on the impact of the unplanned admissions DES by concluding that case management only marginally increases patient satisfaction while having no impact on the cost of secondary care.

The DES, which was renewed for this year’s GP contract, is aimed at reducing unscheduled admissions to hospital of vulnerable patients by closely managing their care but now University of Manchester researchers say all the evidence points to this work being largely in vain.

The team studied 37 papers reviewing the impact of case management pilots focused on patients over 75 with long-term conditions, putting them through systematic review and meta-analysis, and finding no advantage over usual care in terms of overall costs, mortality or use of secondary care services, either in the short (up to a year) or longer term.

There was a small improvement in patient satisfaction both in the short and long term and a suggestion of improvement in patients’ self-reported health status at one year, although the study authors said this was only a ‘clinically trivial’ effect.

Presenting their research, which has been accepted for publication in PLoS ONE, lead author Jonathan Stokes said that ‘the focus on high-risk groups may never alleviate the system pressures alone’, highlighting instead the ‘need for a variety of models to integrate care, taking place across the whole health system and not solely at service delivery’.

Speaking at the recent Society for Academic Primary Care annual conference, he said: ‘Case management has been promoted as a way of reducing health system pressures, but the evidence identified by this review does not… support this promotion.’

GP experts said the findings trigger further questions over the rationale behind the Government’s avoiding unplanned admissions DES, introduced in last year’s GP contract.

The DES, which pays GPs to create a register of their most ‘at risk’ patients, and assign them a lead GP who oversees their written care plan for ongoing management, was renewed for 2015/16 despite warnings from GP experts it is unlikely to work and a rise in unplanned admissions in 2014/15.

Professor Martin Roland, professor of health services research at the University of Cambridge, said the study ‘confirms experience in England of experiments like Evercare and the Integrated Care Pilots, that case management of frail older people is unlikely to reduce hospital admissions’.

He added that this showed the unplanned admissions DES – like earlier schemes including QOF quality and productivity domain indicators – were ‘never likely to impact on emergency admissions even it if improved care for some vulnerable patient groups’.

Dr Richard Vautrey, deputy chair of the GPC, said more work would be needed to research the impact of the unplanned admissions DES specifically, but said that ‘when studies of the DES are done they are unlikely to show a reduction in overall costs as this group of people have complex needs and they will inevitably need hospital care at appropriate times’. 

He added: ‘This research also shows that there is evidence of a rise in patient satisfaction with case management, suggesting patients in this group welcome the attention that clinical teams give them and I suspect that that will be the case with the work done relating to the DES too.’

This year’s LMCs’ conference voted to get the scheme scrapped next year, citing the lack of evidence for the scheme and its failure to reduce hospital pressures in the first year, and warning it was distracting GPs from other vital work and putting them ‘in medico-legal danger’.