Review article
Nurse-led case management for ambulatory complex patients in general health care: A systematic review

https://doi.org/10.1016/j.jpsychores.2006.10.015Get rights and content

Abstract

Objective

The aim of this study was to summarize the available literature on the effectiveness of ambulatory nurse-led case management for complex patients in general health care.

Method

We searched MEDLINE, EMBASE, the Cochrane Controlled Trials Register, and Cinahl. We included randomized controlled trials, controlled clinical trials, controlled before/after study, and time series studies; identified references were screened by two reviewers. Two reviewers rated the quality of each article. Data extracted from the selected publications included design, characteristics of the participants, the intervention, type of outcome measures, and results.

Results

We identified 10 relevant publications. Nine studies used readmission rate as primary outcome. Fewer studies investigated duration of hospital readmissions, emergency department (ED) visits, functional status, quality of life, or patient satisfaction. In general, results with regard to the effectiveness of case management were conflicting.

Conclusion

There is moderate evidence that case management has a positive effect on patient satisfaction and no effect on ED visits. It was not possible to draw firm conclusions on the other outcomes.

Introduction

Case management has, in recent years, been described as a solution to improve outcomes in complex patients [1], [2], [3]. Case management is concerned with an optimisation of multidisciplinary treatment for complex patients and on the integral care needs of the individual patient without focusing on only one specific illness or population (as in disease management [4]). Case management has been applied in the field of psychiatry for a long time. A review of the literature [6] showed that psychiatric case management in psychiatric health care may be associated with improved compliance and reductions in hospitalization. Over the past decade, more attention has been directed toward the effects of case management in general health care [2], [7], [8], [9], [10].

With respect to the characteristics of complex patients in general health care, these patients have by definition multiple health problems in various health domains. In other words, case management is about flexible treatment plans in mixed populations. We defined complex patients as patients with acute or chronic multimorbid medical condition(s) or symptoms with psychiatric comorbidity [11] and/or social vulnerabilities, with more than one health care worker involved in the care process. These complex conditions have a deleterious effect on health care utilization, quality of life, morbidity, compliance, and mortality in primary care as well as in hospital care [5], [12], [13], [14], leading to an extended duration of hospital stay, more doctor visits and emergency department (ED) visits, and more readmissions [15], [16], [17]. Because of an increase in the number of patients with complex problems due to an ageing population, increasing comorbidity, and a more complex health care organisation [20], [21], it is expected that more patients will need case management in the years to come [3], [7], [18], [19]. We aimed to summarize evidence for the effectiveness of postdischarge nurse-led case management for complex patients by means of a systematic review.

Section snippets

Types of studies

Studies published from 1966 until June 15, 2005, were eligible for inclusion in the review; no language restrictions were applied. We included randomized controlled trials (RCTs), controlled clinical trials (CCTs), controlled before/after studies (CBAs), and time series studies addressing the effectiveness of postdischarge nurse-led case management for complex patients in general health care.

Types of participants

Studies considered for inclusion in this review focused on ambulatory patients over 18 years of age and

Literature search and study selection

We first performed our search in MEDLINE (928 titles of articles), then in EMBASE (195 additional hits), and subsequently in the Cochrane Library (79 additional hits) and Cinahl (416 additional hits). By reference checking, we identified an additional 20 hits, resulting in a total of 1638 hits. (Fig. 1) Based on titles and abstracts, 105 full-text articles were retrieved, 10 of which met the inclusion criteria [1], [2], [3], [7], [9], [18], [19], [24], [25], [26].

Of the 95 studies that were

Discussion

In this systematic review, we summarized the available literature on the effectiveness of a postdischarge nurse-led case management for complex patients in general health care. The review provides moderate evidence that case management has a positive effect on patient satisfaction. There is strong evidence that case management has no significant effect on the number of ED visits.

However, given the conflicting results on the other outcome variables it was not possible to draw firm conclusions

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