Use of intensive case management to reduce time in hospital in people with severe mental illness: Systematic review and meta-regression. British Medical Journal, 335, 336-340

University of Oxford, Oxford, England, United Kingdom
BMJ (online) (Impact Factor: 16.38). 09/2007; 335(7615):336. DOI: 10.1136/bmj.39251.599259.55
Source: PubMed

ABSTRACT To explain why clinical trials of intensive case management for people with severe mental illness show such inconsistent effects on the use of hospital care.
Systematic review with meta-regression techniques applied to data from randomised controlled trials.
Cochrane central register of controlled trials, CINAHL, Embase, Medline, and PsychINFO databases from inception to January 2007. Additional anonymised data on patients were obtained for multicentre trials.
Included trials examined intensive case management compared with standard care or low intensity case management for people with severe mental illness living in the community. We used a fidelity scale to rate adherence to the model of assertive community treatment. Multicentre trials were disaggregated into individual centres with fidelity data specific for each centre. A multivariate meta-regression used mean days per month in hospital as the dependent variable.
We identified 1335 abstracts with a total of 5961 participants. Of these, 49 were eligible and 29 provided appropriate data. Trials with high hospital use at baseline (before the trial) or in the control group were more likely to find that intensive case management reduced the use of hospital care (coefficient -0.23, 95% confidence interval -0.36 to -0.09, for hospital use at baseline; -0.44, -0.57 to -0.31, for hospital use in control groups). Case management teams organised according to the model of assertive community treatment were more likely to reduce the use of hospital care (coefficient -0.31, -0.59 to -0.03), but this finding was less robust in sensitivity analyses and was not found for staffing levels recommended for assertive community treatment.
Intensive case management works best when participants tend to use a lot of hospital care and less well when they do not. When hospital use is high, intensive case management can reduce it, but it is less successful when hospital use is already low. The benefits of intensive case management might be marginal in settings that have already achieved low rates of bed use, and team organisation is more important than the details of staffing. It might not be necessary to apply the full model of assertive community treatment to achieve reductions in inpatient care.

Download full-text


Available from: Tom Patrick Burns, Aug 18, 2015
  • Source
    • "When community services are poor, it is comparatively more common for patients to spend long periods of time in hospitals, and a case manager may find it easier to reduce hospitalization . Thus, low levels of hospital use can be seen as a proxy for good community services, which has been shown to modify the effects of case management interventions for individuals experiencing severe mental illnesses (Burns et al., 2007). In short, the services environment may produce ceiling and floor effects in outcomes measures, which have relevance for the way the effectiveness of ESIs is interpreted across cultural contexts. "
    [Show abstract] [Hide abstract]
    ABSTRACT: The spread of evidence-based practice throughout the world has resulted in the wide adoption of empirically supported interventions (ESIs) and a growing number of controlled trials of imported and culturally adapted ESIs. This article is informed by outcome research on family-based interventions including programs listed in the American Blueprints Model and Promising Programs. Evidence from these controlled trials is mixed and, because it is comprised of both successful and unsuccessful replications of ESIs, it provides clues for the translation of promising programs in the future. At least four explanations appear plausible for the mixed results in replication trials. One has to do with methodological differences across trials. A second deals with ambiguities in the cultural adaptation process. A third explanation is that ESIs in failed replications have not been adequately implemented. A fourth source of variation derives from unanticipated contextual influences that might affect the effects of ESIs when transported to other cultures and countries. This article describes a model that allows for the differential examination of adaptations of interventions in new cultural contexts.
    Evaluation &amp the Health Professions 01/2013; 37(2). DOI:10.1177/0163278712469813 · 1.67 Impact Factor
  • Source
    • "w to engage and manage clients ( Killaspy et al . 2009 ) , perhaps related to the rating of better engagement with clients according to Melbourne staff , as well as mitigating the adverse impact of changes of key workers ( Davidson & Campbell , 2007 ) . Further , this appears to be the most important factor associated with reducing admis - sions ( Burns et al . 2007 ) . The other important feature of home treatment services identified by Catty et al . ( 2002 ) is the proportion of in vivo client contact . We"
    [Show abstract] [Hide abstract]
    ABSTRACT: The efficacy of Assertive Community Treatment (ACT) is well established in the USA, and to a lesser extent in Australia, whereas UK studies suggest little advantage for ACT over usual care. Implementation of ACT varies and these differences may explain variability in reported efficacy. We aimed to investigate differences in ACT implementation between Melbourne, Australia and London, UK. In a cross-sectional survey, we investigated team organisation, staff and client characteristics from four Melbourne ACT teams using almost identical methods to the Pan London Assertive Outreach studies of 24 ACT teams. Client characteristics, staff satisfaction and burnout were very similar. Three of four Melbourne teams made over 70% of client contacts 'in vivo' compared to only one-third of comparable London teams, although all teams were rated as 'ACT-like'. Melbourne teams scored more highly on team approach. Three quarters of clients were admitted in the preceding 2 years but Melbourne clients had shorter stays. Differences in the implementation of 'active components' of home treatment models that have been associated with better client outcomes (home visiting, team approach) may explain international differences in ACT efficacy. Existing fidelity measures may not adequately weight these important elements of the model.
    Epidemiology and Psychiatric Sciences 06/2011; 20(2):151-61. DOI:10.1017/S2045796011000230 · 3.36 Impact Factor
  • Source
    • "In this study, the programs showing efficacy in reducing hospital use follow the Clinical CM model rather than the ACT model. This agrees with findings of other studies such as UK700, PRISM, and REACT (Thornicroft et al. 1998; Burns et al. 1999; Killaspy et al. 2006), in which less intensive interventions (standard CM interventions) of their CMHS proved to be as effective as ACT. It should be taken into account that in those studies, the standard, less intensive groups of intervention had already implemented the Care Program Approach, which comprises CM in all CMHS. "
    [Show abstract] [Hide abstract]
    ABSTRACT: To assess the impact of the Continuity-of-Care Program (CCP; a clinical case management model) on hospital use of persons with schizophrenia in three Community Mental Health Services in Madrid (Spain). Using data provided by the Psychiatric Case Register, we analyzed the use of hospitalization in 250 individuals before and after the date of inclusion in this program. During the first year after launching the program, there was a 40-69% reduction in the number of admissions, length of each hospital stay, proportion of admitted patients, total number of days in-hospital, proportion of patients visiting the emergency room, and emergency room visits. This drop was maintained over the subsequent 3 years of program functioning. These results encourage the development and implementation of such programs, even though more studies evaluating the effectiveness of these programs for other endpoints are needed.
    Epidemiology and Psychiatric Sciences 03/2011; 20(1):65-72. DOI:10.1017/S2045796011000138 · 3.36 Impact Factor
Show more