Use of intensive case management to reduce time in hospital in people with severe mental illness: systematic review and meta-regression

doi:10.1136/bmj.39251.599259.55

BMJ 2007;335:336 (18 August), doi:10.1136/bmj.39251.599259.55 (published 13 July 2007)

Research

Use of intensive case management to reduce time in hospital in people with severe mental illness: systematic review and meta-regression

Tom Burns, professor of social psychiatry¹, Jocelyn Catty, research fellow², Michael Dash, research assistant², Chris Roberts, statistician³, Austin Lockwood, research nurse⁴, Max Marshall, professor of community psychiatry⁴

¹ University of Oxford, Warneford Hospital, Oxford OX3 7JX, ² Division of Mental Health, St George's, University of London, London SW17 0RE, ³ School of Epidemiology and Health Sciences, University of Manchester, Manchester, ⁴ Division of Psychiatry and Behavioural Sciences, University of Manchester, Preston

Correspondence to: T Burns Tom.burns{at}psych.ox.ac.uk

Objectives To explain why clinical trials of intensive casemanagement for people with severe mental illness show such inconsistenteffects on the use of hospital care.

Design Systematic review with meta-regression techniques appliedto data from randomised controlled trials.

Data Sources Cochrane central register of controlled trials,CINAHL, Embase, Medline, and PsychINFO databases from inceptionto January 2007. Additional anonymised data on patients wereobtained for multicentre trials.

Review methods Included trials examined intensive case managementcompared with standard care or low intensity case managementfor people with severe mental illness living in the community.We used a fidelity scale to rate adherence to the model of assertivecommunity treatment. Multicentre trials were disaggregated intoindividual centres with fidelity data specific for each centre.A multivariate meta-regression used mean days per month in hospitalas the dependent variable.

Results 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 intensivecase 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 organisedaccording to the model of assertive community treatment weremore likely to reduce the use of hospital care (coefficient–0.31, –0.59 to –0.03), but this finding wasless robust in sensitivity analyses and was not found for staffinglevels recommended for assertive community treatment.

Conclusions Intensive case management works best when participantstend to use a lot of hospital care and less well when they donot. When hospital use is high, intensive case management canreduce it, but it is less successful when hospital use is alreadylow. The benefits of intensive case management might be marginalin settings that have already achieved low rates of bed use,and team organisation is more important than the details ofstaffing. It might not be necessary to apply the full modelof assertive community treatment to achieve reductions in inpatientcare.

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