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

ABSTRACT: 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.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.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.The review protocol is available as part of the PROSPERO database (registration number: CRD42014010824).

SUBMITTER: Stokes J

PROVIDER: S-EPMC4505905 | biostudies-literature | 2015

REPOSITORIES: biostudies-literature

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

Stokes Jonathan J Panagioti Maria M Alam Rahul R Checkland Kath K Cheraghi-Sohi Sudeh S Bower Peter P

PloS one 20150717 7

<h4>Background</h4>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.<h4>Methods and findings</h4>We carried out a systematic review and meta-analysis of the effectiveness of case ...[more]

PMID: 26186598

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Project description:BackgroundChronic obstructive pulmonary disease (COPD) is widely underdiagnosed, but the most effective approach for identifying these patients is unknown.AimsThe aim of this study was to summarise and compare the effectiveness of different case finding approaches for undiagnosed COPD in primary care.MethodsA systematic review of primary studies of any design evaluating case finding strategies for COPD in primary care among individuals aged ⩾35 years with no prior diagnosis was conducted. Medline, Embase and other bibliographic databases were searched from 1997 to 2013, and methodological quality was assessed using standard tools. Results were described and meta-analysis of the uptake and yield from different approaches was performed where there was sufficient homogeneity.ResultsThree randomised controlled trials (RCTs), 1 controlled trial and 35 uncontrolled studies were identified that assessed the identification of new cases of COPD through systematic case finding. A range of approaches were used including pre-screening with questionnaires (n=13) or handheld flow meters (n=5) or direct invitation to diagnostic spirometry (n=30). Overall, any approach identified more undiagnosed COPD compared with usual care. Targeting those at higher risk (e.g., smokers) and pre-screening (e.g., using questionnaires) is likely to increase the yield. However, studies were heterogeneous and were limited by a lack of comparison groups, inadequate reporting and diversity in the definition of COPD, which limited our ability to draw firm conclusions.ConclusionsThere is extensive heterogeneity among studies evaluating case finding strategies for COPD, with few RCTs. Well-conducted RCTs comparing case finding approaches are needed to identify the most effective target population, recruitment strategy and screening tests, using a clinical definition of COPD, and addressing the limitations highlighted in this review. There is also a need to evaluate the impact of case finding on clinical care and patient outcomes.

Project description:ObjectiveTo examine the effectiveness of behavioural weight management interventions for adults with obesity delivered in primary care.DesignSystematic review and meta-analysis of randomised controlled trials.Eligibility criteria for selection of studiesRandomised controlled trials of behavioural weight management interventions for adults with a body mass index ≥25 delivered in primary care compared with no treatment, attention control, or minimal intervention and weight change at ≥12 months follow-up.Data sourcesTrials from a previous systematic review were extracted and the search completed using the Cochrane Central Register of Controlled Trials, Medline, PubMed, and PsychINFO from 1 January 2018 to 19 August 2021.Data extraction and synthesisTwo reviewers independently identified eligible studies, extracted data, and assessed risk of bias using the Cochrane risk of bias tool. Meta-analyses were conducted with random effects models, and a pooled mean difference for both weight (kg) and waist circumference (cm) were calculated.Main outcome measuresPrimary outcome was weight change from baseline to 12 months. Secondary outcome was weight change from baseline to ≥24 months. Change in waist circumference was assessed at 12 months.Results34 trials were included: 14 were additional, from a previous review. 27 trials (n=8000) were included in the primary outcome of weight change at 12 month follow-up. The mean difference between the intervention and comparator groups at 12 months was -2.3 kg (95% confidence interval -3.0 to -1.6 kg, I2=88%, P<0.001), favouring the intervention group. At ≥24 months (13 trials, n=5011) the mean difference in weight change was -1.8 kg (-2.8 to -0.8 kg, I2=88%, P<0.001) favouring the intervention. The mean difference in waist circumference (18 trials, n=5288) was -2.5 cm (-3.2 to -1.8 cm, I2=69%, P<0.001) in favour of the intervention at 12 months.ConclusionsBehavioural weight management interventions for adults with obesity delivered in primary care are effective for weight loss and could be offered to members of the public.Systematic review registrationPROSPERO CRD42021275529.

Project description:BackgroundCollaborative care interventions have been proposed as a promising strategy to support patients with multimorbidity. Despite this, the effectiveness of collaborative care interventions requires further evaluation. Existing systematic reviews describing the effectiveness of collaborative care interventions in multimorbidity management tend to focus on specific interventions, patient subgroups, and settings. This necessitates a comprehensive review that will provide an overview of the effectiveness of collaborative care interventions for adult patients with multimorbidity.ObjectiveThis systematic review aims to systematically assess the effectiveness of collaborative care interventions in comparison to usual care concerning health-related quality of life (HRQoL), mental health, and mortality among adult patients with multimorbidity.MethodsRandomized controlled trials evaluating collaborative care interventions designed for adult patients (18 years and older) with multimorbidity compared with usual care will be considered for inclusion in this review. HRQoL will be the primary outcome. Mortality and mental health outcomes such as rating scales for anxiety and depression will serve as secondary outcomes. The systematic search will be conducted in the CENTRAL, PubMed, CINAHL, and Embase databases. Additional reference and citation searches will be performed in Google Scholar, Web of Science, and Scopus. Data extraction will be comprehensive and include information about participant characteristics, study design, intervention details, and main outcomes. Included studies will be assessed for limitations according to the Cochrane Risk of Bias tool. Meta-analysis will be conducted to estimate the pooled effect size. Meta-regression or subgroup analysis will be undertaken to explore if certain factors can explain the variation in effect between studies, if feasible. The certainty of evidence will be evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach.ResultsThe preliminary literature search was performed on February 16, 2024, and yielded 5255 unique records. A follow-up search will be performed across all databases before submission. The findings will be presented in forest plots, a summary of findings table, and in narrative format. This systematic review is expected to be completed by late 2024.ConclusionsThis review will provide an overview of pooled estimates of treatment effects across HRQoL, mental health, and mortality from randomized controlled trials evaluating collaborative care interventions for adults with multimorbidity. Furthermore, the intention is to clarify the participant, intervention, or study characteristics that may influence the effect of the interventions. This review is expected to provide valuable insights for researchers, clinicians, and other decision-makers about the effectiveness of collaborative care interventions targeting adult patients with multimorbidity.Trial registrationInternational Prospective Register of Systematic Reviews (PROSPERO) CRD42024512554; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=512554.International registered report identifier (irrid)DERR1-10.2196/58296.

Dataset Information

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

Publications

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

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