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: 17.45). 09/2007; 335(7615):336. DOI: 10.1136/bmj.39251.599259.55
Source: PubMed


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.

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Available from: Tom Patrick Burns
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    • "Daarnaast vergeten we in onze ijver om 'modelgetrouw' te werken met de hiervoor genoemde instrumenten, dat we niet weten welke van de vele voorgeschreven elementen nu echt bijdragen aan het effect. Voor het model waarvan de effectiviteit in Noord-Amerika en Australië in ieder geval krachtig is aangetoond, ACT, is duidelijk geworden dat outreachende hulpverlening (het huisbezoek dus) en integratie van sociale en medische zorg cruciaal zijn.[16] Dit laatste wordt in FACT vertaald naar de multidisciplinaire samenstelling van het team. "
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    ABSTRACT: ACT en FACT zijn populair in de zorg voor mensen met ernstige psychische aandoeningen, maar niet erg goed onderzocht op effectiviteit. In plaats van op die grote modellen zou het onderzoek zich beter kunnen richten op welke onderdelen of ‘kernels’ ervan effectief zijn.
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    • "Assertive community treatment (ACT) was developed as an integrated model to meet the needs of difficult-to-engage patients with complex problems [5]. Critical components of ACT associated with reducing hospital admissions were shared caseload, community based services, 7x 24 hour services, a team leader who participated in patient care, full responsibility for treatment services, daily team meetings and time unlimited services [6]. Although there is no agreement on which critical components of ACT are associated with psychosocial outcomes, better outcomes have both been shown to be associated with having a better team structure and with having a consumer provider in the team [7-9]. "
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    ABSTRACT: Due to fragmented mental, somatic, and social healthcare services, it can be hard to engage into care older patients with severe mental illness (SMI). In adult mental health care, assertive community treatment (ACT) is an organizational model of care for treating patients with SMI who are difficult to engage. So far all outcome studies of assertive community treatment have been conducted in adults. In a randomized controlled trial design we compared the effectiveness of ACT for elderly patients with that of treatment as usual (TAU). Sixty-two outpatients (60 years and older) with SMI who were difficult to engage in psychiatric treatment were randomly assigned to the intervention or control group (32 to ACT for elderly patients and 30 to TAU). Primary outcomes included number of patients who had a first treatment contact within 3 months, the number of dropouts (i.e. those discharged from care due to refusing care or those who unintentionally lost contact with the service over a period of at least 3 months); and patients' psychosocial functioning (HoNOS65+ scores) during 18 months follow-up. Secondary outcomes included the number of unmet needs and mental health care use. Analyses were based on intention-to-treat. Of the 62 patients who were randomized, 26 were lost to follow-up (10 patients in ACT for elderly patients and 16 in TAU). Relative to patients with TAU, more patients allocated to ACT had a first contact within three months (96.9 versus 66.7%; X2 (df = 1) = 9.68, p = 0.002). ACT for elderly patients also had fewer dropouts from treatment (18.8% of assertive community treatment for elderly patients versus 50% of TAU patients; X2 (df = 1) = 6.75, p = 0.009). There were no differences in the other primary and secondary outcome variables. These findings suggest that ACT for elderly patients with SMI engaged patients in treatment more successfully.Trial registration: NTR1620.
    Full-text · Article · Feb 2014 · BMC Psychiatry
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    • "There is some international evidence available that home treatment of severely mentally ill persons provided by multidisciplinary psychosocial intervention teams has the potential to be effective. Home treatment was shown to reduce the need for inpatient treatment; it decreased suicidality, improved patients’ functional status and also increased satisfaction with treatment [1-3]. The efficiency of home treatment as part of integrated care models has also been shown under the care conditions of the German health care system [4]. "
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    ABSTRACT: While evidence is available that home treatment could be effective for treating severe mental illness, there is a lack of evidence on what exactly makes home treatment effective. The study presented here aims to develop recommendations for structures and processes in home treatment that are necessary for its effectiveness. 14 provider networks of home treatment for severe mental illness will be analyzed and compared according to their structures, processes and patient-related outcomes. Data will be drawn from health care claims data, routine assessments of psychosocial functioning, and from questionnaires on structures and processes. The primary outcome will be psychosocial functioning; secondary outcomes, quality of life and days spent in hospital. The relation between structures and processes on one hand side and outcomes on the other side will be identified by multilevel analysis. In addition, focus groups with patients, relatives and network staff will be held to add further insight into relevant processes. All networks will receive individual quality reports, providing them with feedback on the results of this research and benchmarking them against the average. Based on this research, recommendations for processes and structures of home treatment will be developed. The research will use longitudinal data on outcomes routinely assessed since 2009 and claims data. Routine data is also used for the assessment of structures and processes. By way of additional questionnaires developed in discussion with providers, further relevant factors can be included. The approach of this study becomes more comprehensive by conducting focus groups with patients, relatives and providers and by having the chance to evaluate the results with the networks by providing feedback of results. Several factors such as outcomes related to regional availability of hospital beds or size of networks might limit this study.
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