Review: effectiveness of intensive case management for severe mental illness depends on baseline hospital use and organisation
Correspondence to: Professor T Burns, University of Oxford, Oxford, UK;
In people with severe mental illness, what factors influence the effectiveness of intensive case management in reducing time in hospital?
Medline, CINAHL, EMBASE/Excerpta Medica, and PsycINFO (to January 2007); Cochrane Central Register of Controlled Trials (Issue 4, 2006); and reference lists.
Study selection and assessment:
randomised controlled trials (RCTs) that compared intensive case management with standard care or low-intensity case management in community-dwelling adults with severe mental disorder (schizophrenia, schizophrenia-like disorder, bipolar disorder, or depression with psychotic features). Excluded were trials involving an acute crisis team; a control condition of hospital admission, remaining in hospital, or an alternate form of intensive case management; patients with mean age <18 or >65 years; and patients with organic brain disorder or learning disability. Trials with inadequate concealment of allocation were also excluded. 29 RCTs (n = 5961, mean age 38 y, 63% men) met the selection criteria and had appropriate outcome data. Of these RCTs, 8 were multicentre trials for which each centre was considered separately, for a total of 52 centres analysed.
time in hospital (mean number of d/mo over a 24 mo period), with covariates including degree of low-intensity case management in the control group, country of trial (US or other), baseline hospital use, trial size, and scores on the staffing and organisational subscales of the Index of Fidelity to Assertive Community Treatment (IFACT), which measure the extent to which an intervention adheres to an assertive community treatment model in terms of team membership, and structure and organisation, respectively.
Overall, intensive case management reduced mean time in hospital by 0.46 days/month (95% CI 0.08 to 0.84), but there was significant statistical heterogeneity among centres.
In meta-regression analysis (excluding baseline hospital use as a covariate because it was not available for all centres), the only covariate that explained part of the variation was the IFACT organisational subscale score: the more the case management team was organised like an assertive outreach team, the more effective it was at reducing patient time in hospital (by 0.44 d/mo [CI 0.17 to 0.72] for every 1-point increase in the 7-point subscale). Even with adjustment for this covariate, there was still heterogeneity among trials for treatment effect. The IFACT staffing subscale score was not related to the effectiveness of the intervention.
Data on baseline hospital use were available for 42 of 52 centres. When this covariate was added, meta-regression analysis showed that intensive case management was more effective in centres with higher baseline hospital use (hospital time was reduced by 0.23 d/mo [CI 0.09 to 0.36] for every 1 additional day of baseline hospital use) as well as in centres with higher scores on the IFACT organisational subscale (hospital time was reduced by 0.31 d/mo [CI 0.03 to 0.59] for every 1-point increase in the subscale). With adjustment for these 2 covariates, the effect of intensive case management was similar across trials.
Magnitude of baseline hospital use and extent to which organisation of an intensive case management intervention adheres to an assertive community treatment model determine the effectiveness of the intervention in reducing time in hospital for patients with severe mental illness.
Burns T, Catty J, Dash M, et al. Use of intensive case management to reduce time in hospital in people with severe mental illness: systematic review and meta-regression. BMJ 2007;335:336.
The lack of consistent findings among studies documenting the effect of intensive case management in reducing use of hospital care motivated Burns et al to conduct this meta-analysis. The primary strength of the review is that it proposed several explanations for the inconsistencies and then, through hypothesis-testing, provided data to support or refute each explanation. Because this was a meta-analysis, missing data from the included studies, although minimal, may have affected the strength of the observed associations.
2 important clinical implications of this analysis provide insight into enhancing intensive case management programmes. First, intensive case management provides most benefit to patients with a history of high hospital use. This finding may appear obvious and intuitive. However, when deliberating about what care to provide to whom, evidence-based decisions are fiscally and rationally desirable. As the authors suggest, in settings where hospital use is already low, implementing intensive case management will not further decrease hospital use.
Second, the organisational structure of the management programme has a greater effect on reducing hospital use than staffing characteristics (ie, caseload size, team size, and professional make-up of the team). Intensive case management programmes can create positive changes in organisational structures by implementing some or all of the 7 key items described in the IFACT: (1) team is the primary source of care; (2) service is located away from the hospital; (3) team meets daily; (4) shared responsibility for caseload is the norm; (5) service is available 24 hours/day; (6) team leader is also a case manager; and (7) time available for services is unlimited.1