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PRIMARY CARE: Martin Roland, Mark Dusheiko, Hugh Gravelle, and Stuart Parker Follow up of people aged 65 and over with a history of emergency admissions: analysis of routine admission data BMJ 2005; 330: 289-292 [Abstract] [Full text]

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Rapid Responses published:

Interim Report on Evercare Illustrates Dangers of Premature "good news" briefings.

David Oliver   (4 February 2005)

Improving case management of the vulnerable elderly

Richard Smith   (4 February 2005)

Re: Improving case management of the vulnerable elderly

David Oliver   (7 February 2005)

Evaluating Evercare nurses and data guided case management

Anthony P Roberts, Alison Roe   (8 February 2005)

Timeliness of delivery of the case management intervention may be critical –and currently lacking

Georgios Lyratzopoulos   (9 February 2005)

Experience in practice of case management

Joe McManners, Carl heneghan Clinical Fellow University of Oxford   (9 February 2005)

Re: Timeliness of delivery of the case management intervention may be critical –and currently lacking.

Roberto Vivancos   (18 February 2005)

The devil is in the detail

Moyez Jiwa   (21 February 2005)

Admission rates still a useful outcome measure

Peter T Donnan, Frank Sullivan, Tom Fahey, Andrew Morris   (26 February 2005)

Follow up of people aged 65 and over with a history of emergency admissions:analysis of routine admission data

Hannah E Patrick, Natasha Roberts, Jim Connelly, David Oliver   (23 March 2005)

Can rehabilitation at home prevent hospital readmission in frail older people?

Paolo Stofler, Simone Franzoni, and Marco Trabucchi   (18 April 2005)

Interim Report on Evercare Illustrates Dangers of Premature "good news" briefings. 4 February 2005
David Oliver, Senior Lecturer, Elderly Care Medicine, University of Reading. Consultant Physician, Royal Berkshire ..Hospitals Trust. Send response to journal: Re: Interim Report on Evercare Illustrates Dangers of Premature "good news" briefings.	Sir The article by Roland et al (BMJ Feb 5)[1] illustrates the difficulties in evaluating complex interventions with complex endpoints in a group of patients who epitomise complexity. Few would dispute that the principles of chronic disease management are sound and that our current approach to the care of these patients is often disjointed, focused on crisis intervention rather than proactive case management. Nor that systems re-engineering and a change of focus is required. Nor that United Health have developed leading expertise in this area and that there are already very positive experiences emanating from a number of the PCTs currently piloting the intervention and from patients receiving it.[2] Nonetheless, the initial paper frequently cited by Evercare in their consultancy reports [3] applied to US care home residents rather than UK patients dwelling in their own homes - the validity of extrapolation therefore being far from cast-iron. A recent Kings Fund report on the for chronic disease management [4] showed a patchy evidence base. Meanwhile the Department of Health have gone full steam ahead in implementing 9 "pilot studies" at a cost of over £4million, with the bulk of the funding going straight into the "for profit" sector - much on travel, consultancy fees and training. [5] Nurses were seconded for advanced practitioner training in each site, and some money was provided to each PCT to help in covering backfill of posts. The independent evaluation of the Evercare scheme reported here is not due for completion until 2006 and the difficulties in not using RCT methodology and relying on inadequate existing datasystems will make the quantitative component of evaluation tricky. Moreover, it was commissioned after the decision to fund Evercare Pilots had been taken - as was the internal evaluation which Evercare are currently performing. The Department of Health have, in my view, behaved at best disingenuously in repeatedly briefing the press on the success of Evercare and reinforcing the message at a series of evangelising roadshows at which non peer reviewed data have been presented in the form of good news stories. Having failed to do what they should have done and commissioned properly planned RCTs in the first place, they have instead bolted on an evaluation to the pilot schemes, failed to wait until the results are published and peer reviewed and then announced that the intervention has worked so well it will be "rolled out" nationally building on the "success". This is intellectually dishonest. If there is a committment to evidence based commissioning then we should await the evidence or build rigorous evaluation into pilots before they are purchased. Alternatively, the politicians should have transparently stated their true view on the matter, which in my estimation would read "We are worried about access and capacity. We need more focus on prevention and primary care. This seems like a good idea, lets go with it". Instead of which, large sums of taxpayers money have been invested on a pilot which is to be mandated for all, whatever its results demonstrate. Yet in an example of doublespeak, the health minister has said "Evercare is just one of a range of different models we are learning from. We are confident our model is the right one for the NHS". [5] So there we have it. Confidence-based commissioning. The danger is that anyone who dares to utter these criticisms will be labelled in New Labour Speak as "off message" or offering "problems, not solutions" David Oliver 1. Roland M, Dusheiko M, Gravelle H, Parker S. BMJ 2005; 330: 289- 292. 2. Implementing the Evercare Programme. Interim report. February 2004. www.natpact.nhs.uk/cms/186.php 3. Kane E, Huck S. The implementation of the Evercare Demonstration Project. Am J Managed Care 2000; 6: 881-6. 4. The Kings Fund. Case-Managing Long Term Conditions. London; 2004: Kings Fund 5. Carvel J, Doubt cast on health scheme for the elderly. The Guardian. Feb 4 2005; p11. Competing interests: None declared
Improving case management of the vulnerable elderly 4 February 2005
Richard Smith, Chief executive UnitedHealth Europe, 15 Greycoat Place, London SW1 Send response to journal: Re: Improving case management of the vulnerable elderly	Martin Roland and others make an important point in showing that using unplanned hospital admissions is not the best method of entering vulnerable patients into case management programmes (5 February, p 289). (1) Something better is needed, and better methods are already available--including from UnitedHealth Europe, the company that introduced Evercare into the UK. Unplanned admissions were used as one of the entry points into the Evercare programme (together with nominations by GPs) because it was all that was possible at the time with the state of information systems in the NHS. Ideally, the programme would have selected patients using other sources of information, including on clinical condition, use of community services, medications, and social circumstances. The data would also be collected over time in order to see trends. Such tools can be much more sensitive in identifying those who are the most vulnerable and most at risk of unplanned hospital admission and of use of other resources. Data from the US show that overall costs can be brought down by over 30% between year one and two and by about 10% thereafter, but the evidence also shows that the programmes take around 18 months to embed and produce maximum benefit. It's also important that the programmes are intensively managed. Case management is conceptually straightforward but hard to implement. As your recent editorial said, "Case management is a tough, difficult job to do well, whose complexity and difficulty is often underestimated." (2) Another important point that arises from Roland's study is that other measures need to accompany case management in order to reduce hospital admissions. In particular it will be important to increase intermediate care services so that, for example, intravenous treatments can be given in the home or community hospitals can provide for patients and their carers a less intense, risky, and costly alternative to an acute hospital. This emphasises the role of primary care trusts in commissioning. The BMJ paper was a small part of the interim evaluation of Evercare, and it's important for BMJ readers to understand that an independent survey conducted by the Picker Institute Europe showed that patients and carers showed very high levels of satisfaction with the programme. Angela Coulter, the head of the institute, says: "The survey results show that patients' and carers' experience of the Evercare programme was highly positive. Ratings of support received from nurses were considerably better than those normally achieved in the national patient survey programme for the NHS in England, which is coordinated by the Picker Institute. Patients and carers also gave very positive evaluations of the effects of the programme, with 95% reporting improvements in coping ability and high proportions saying they achieved a better understanding of their health problems." The Picker surveys also showed that the advanced practice nurses felt much more able to help their patients than they had in their old roles and that GPs generally thought that the care of patients was improved and their workload lightened. As Roland and others conclude, "Wider benefits than reduced admissions should be considered when introducing intensive case management of older people." Richard Smith Chief executive UnitedHealth Europe 1 Roland M, Dusheiko M, Gravelle H, Parker S. Follow up of people aged 65 and over with a history of emergency admissions: analysis of routine admission data BMJ 2005; 330: 289 - 92. 2 Murphy E. Case management and community matrons for long term conditions. BMJ 2004; 329: 1251 - 1252. Competing interests: I am the chief executive of UnitedHealth Europe, which introduced the Evercare programme into the NHS
Re: Improving case management of the vulnerable elderly 7 February 2005
David Oliver, Senior Lecturer, Elderly Care Meidicine, University of Reading School of Health and Social Care, University of Reading Send response to journal: Re: Re: Improving case management of the vulnerable elderly	Dr Smith's point [1] about the encouraging early feedback on the popularity of the Evercare intervention with professional staff and patients is well taken. Nonetheless, the point he articulates so well - namely that admission avoidance schemes such as these have tended to become effective only in their 2nd or 3rd operational year, further emphasises the folly of touting the pilot schemes as a roaring success and mandating widespread introduction of similar models by 2007. We simply do not know. And a transparent peer review process is crucial. Meanwhile the very team awarded the tender for independent evaluation have admitted the difficulties of measuring impact on hospital admissons (despite all the rhetoric from the DOH - the biggest driver for these initiatives), without a control group. This illustrates the folly of a precipate rush to implement first and then ask clinical academics to advise on evaluation of this quasi experiment when it was already out of the starting blocks. They might have suggested a planning phase so that controls might be selected in advance. The evidence which the Department of Health use to promote these schemes remains un peer reviewed. The first tranche of published evidence in this issue of the BMJ still leaves considerable room for doubt. Yet It would seem that the government more than are happy to defer to the rigours of the scientific method in some aspects of public policy - witness the marshalling of evidence over the triple vaccine. David Oliver 1. Smith R. BMJ Rapid Responses. Feb 5 Competing interests: None declared
Evaluating Evercare nurses and data guided case management 8 February 2005
Anthony P Roberts, Head of Clinical Effectiveness North Tees PCT, Thornaby, Stockton on Tees TS17 6SF, Alison Roe Send response to journal: Re: Evaluating Evercare nurses and data guided case management	Although not part of the Roland evaluation report (1), North Tees PCT worked with United Healthcare to develop sustainable planning and commissioning systems. As the tenth PCT involved in the pilot programme, we have been working with UHC in the development of HealthNumerics, tailoring US approaches to data management and analysis to meet PCT commissioning needs. So far, use of these systems has not been tested in conjuction with nurse-led case management. The HealthNumerics tool allows managers to utilise healthcare data to make commissioning decisions based on activity patterns and trends. Combining healthcare and population data, the analyses that can be performed go a considerable way towards supporting evidence based commissioning within a PCT. Having a thorough understanding of patterns of use across the PCT area, across electoral wards and neighbourhoods as well as within the traditional health boundaries, gives greater knowledge of local issues. By having a greater understanding of equity and need rather than simply basing case mangement on the number of unplanned admissions, our PCT has increased confidence to develop relevant and effective case management. We acknowledge that NHS information systems did not allow this in the Evercare nursing pilots (2). Integrating the HealthNumerics information with data from the disease registers kept in primary care and hospital benchmarking data, may allow the targeting of case management approaches towards areas where both the cost and quality of care might be improved. In order to understand the complex utilisation patterns we use funnel plots to help us visualise the variation (3). Perhaps the next step ought to be to test the combination of case management of patients who intensively use hospital services with the use of sophisticated data systems. These systems can guide allocation of patients to case management in primary care and assist with monitoring the impact on hospital utilisation. 1. Roland M, Dusheiko M, Gravelle H, Parker S. BMJ 2005; 330: 289- 292 2. Smith R. BMJ Rapid Responses. Feb 5 3. Spiegelhalter D. Funnel plots for institutional comparison. Quality and Safety in Health Care 2002;11:390-1 Competing interests: Both authors are employees of North Tees Primary Care Trust and have worked on the DH funded project with United Healthcare
Timeliness of delivery of the case management intervention may be critical –and currently lacking 9 February 2005
Georgios Lyratzopoulos, Consultant in Public Health Medicine Norfolk, Suffolk and Cambridgeshire Stategic Health Authority, Victoria House, Fulbourn, CB1 5XB Send response to journal: Re: Timeliness of delivery of the case management intervention may be critical –and currently lacking	Another UK-based cohort study examining the epidemiology of emergency medical readmissions was recently reported(1). As in the Roland et al. study(2), it was found that readmission risk is greatest in the period after discharge and “plateaus” over time. In particular, one third of all emergency medical readmissions that will occur during a year of follow-up would have occurred within 28 days from discharge, and over half within 3 months. The similarity of findings between these two cohort studies, particularly if several methodological differences are also taken into account, adds validity to the observation by Roland et al. that readmission risk “naturally” reduces over time. Where do the above leave policy makers? A controlled study to evaluate the effectiveness of case management (or any other intervention aiming to reduce readmission risk) is a pre-requisite. However such a study would have to be designed in a way that ensures the timely delivery of the intervention when it really matters most, e.g. immediately post discharge of the “high risk” individual. Anecdotally, most current initiatives construct “risk registers” in primary care, and retrospectively. In practice this means that most "high risk" patients are identified with considerable delay and outside the crucial “window of opportunity” immediately post-discharge. A robust system for the prospective identification of “high risk” patients should be developed. Such a system should in the first instance be embedded in hospitals (with subsequent “real time” information flows to primary care). Most importantly, the pursuit of potentially effective case management strategies should not distract from the employment of sound, evidence-based, condition-specific, hospital-based specialist interventions which are both highly effective in preventing readmissions and under-utilised. Chest pain observation units(3) and pulmonary rehabilitation(4) are but two examples…. Georgios Lyratzopoulos Consultant in Public Health Medicine Norfolk Suffolk and Cambridgeshire Strategic Health Authority 1. Lyratzopoulos G, Havely D, Gemmell I, Good GA. Factors influencing emergency medical readmission risk in a UK district general hospital: A prospective study. BMC Emerg Med. 2005 ; 5(1) : 1. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15663793 (accessed 08.02.2005) 2. Roland M, Dusheiko M, Gravell H, Parker S. Follow up of people aged 65 and over with a history of emergency admissions: analysis of routine admission data. BMJ 2005 ; 330 : 289-92. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15695276 accessed 08.02.2005) 3. Goodacre S, Nicholl J, Dixon S, Cross E, Angelini K, Arnold J, Revill S, Locker T, Capewell SJ, Quinney D, Campbell S, Morris F. Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care. BMJ 2004 ; 328 : 254. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14724129 (accessed 08.02.2005) 4. Chronic obstructive pulmonary disease - Management of chronic obstructive pulmonary disease in adults in primary and secondary care. NICE and National Collaborating Centre for Chronic Conditions. April 2004 http://www.nice.org.uk/page.aspx?o=104441 (accessed 08.02.2005) Competing interests: None
Experience in practice of case management 9 February 2005
Joe McManners, General Practioner Oxford, Carl heneghan Clinical Fellow University of Oxford Send response to journal: Re: Experience in practice of case management	We agree with Martin Roland(1) in his analysis of repeat admissions being a crude way of predicting future admissions. As part of a senior registrar scheme in General Practice in the Oxford Deanery, we looked at a cohort of repeat admissions in Oxford City PCT and in a single large GP practice. We looked at the over 65s with 2 or more admissions. This group could be easily stratified into sub-groups who were at further risk of re- admission, and sub-groups who were clinically stable with minimal need for input. Of the latter group, patients often had repeated admissions for unrelated reasons, resolved problems or lack of ongoing risk factors. Further analysis of the cases showed that risk factors involved in multiple admissions included high number of chronic diseases (specifically cardiovascular disease), recent falls, number of medications and living alone. Of the over 65s who had three or more admissions in our analysis, a number went on to die (which is in concordance with the Roland discussion)and a proportion were also admitted to nursing homes. These factors help explain the findings that the vast majority of bed day usage was by this group. We agree with David Oliver,(2) that the instigation of case management seems to have jumped the gun. The framework set out in the MRC guidance on complex interventions suggests that the initial phase of any intervention should be based on sound evidence.(3) It seems the Kings Fund analysis(4) has come after the pilot schemes have been initiated. More work based on the analysis by Roland et al needs to be done. Further research should analyse the factors which would predict future admissions. These could then be applied to a large cohort of patients and adjustments could be made to the factors to improve the sensitivity of case finding. Our conclusion from this project suggests that it should be feasible to select the most at risk group of patients from practice data. As regarding which interventions to use, stratified randomised trials should be piloted. Any such strategy should be based around existing primary care teams to avoid fragmentation. 1. Roland M, Dusheiko M, Gravelle H, Parker S. BMJ 2005; 330: 289- 292. 2. Oliver D. BMJ Rapid Responses. Feb 4th. 3. Medical Research Council.A framework for development and evaluation of RCTs for complex interventions to improve health. London: Medical Research Council, 2000 4. The Kings Fund. Case-Managing Long Term Conditions. London; 2004: Kings Fund Competing interests: None declared
Re: Timeliness of delivery of the case management intervention may be critical –and currently lacking. 18 February 2005
Roberto Vivancos, Specialist Registrar in Public Health East Suffolk PCTs, Main Building, Bixley Ward, St Clements Hospital, Foxhall Road, Ipswich, IP3 8LS Send response to journal: Re: Re: Timeliness of delivery of the case management intervention may be critical –and currently lacking.	Sir, In their article, Roland et al showed that readmission to hospitals reduces overtime without the any intervention.[1] Following on the point made by Dr Lyratzopoulos, regarding the timing of interventions to deliver case management, as the risk of re-admission to hospital following discharge from a previous emergency admission decreases over time and is greater on the 3 months after it, it would be reasonable to suppose that when cases identified prospectively from the time of discharge could benefit from case management during the period when the risk is greater.[2] Unfortunately, the literature review conducted by Hutt et all precisely excludes interventions that lasted less than 3 months.[3] Hence it would be interesting to evaluate the effectiveness of case management provided in the after mouth of an emergency admission in patients with other risk factors for re-admissions. As the review by Hutt et al exclude short interventions, their findings can only be used with caution with regard to the effect of case management on admissions to hospital. Experience from UK pilot schemes appears to be based on short interventions with case management being provided for 8 to 10 weeks (information from these pilots can be accessed through the NaTPaCT website)[4]; hence, as voiced by Dr Oliver there is imperative need to get these pilots through a peer review process.[5] 1. Martin Roland, Mark Dusheiko, Hugh Gravelle, and Stuart Parker Follow up of people aged 65 and over with a history of emergency admissions: analysis of routine admission data BMJ 2005; 330: 289-292 2. Georgios Lyratzopoulos. Timeliness of delivery of the case management intervention may be critical –and currently lacking. BMJ Rapid Responses (9 February 2005) 3. Hutt R, Rosen R, McCauley J. Case managing long term conditions. London: King's Fund, 2004. 4. Supporting people with Long Term conditions: NHS examples. http://www.natpact.nhs.uk/cms/328.php (Accessed on 17 Feb 2005) 5. David Oliver. Interim Report on Evercare Illustrates Dangers of Premature "good news" briefings. BMJ Rapid Responses (4 February 2005) Competing interests: None declared
The devil is in the detail 21 February 2005
Moyez Jiwa, GP, Clincial lecturer, Director of Research Community Sciences block, Northern General Hospital, Sheffield S5 7AU Send response to journal: Re: The devil is in the detail	Dear Sir, We welcome the paper by Roland et al .1 We concur that the value of care provided to the ‘at risk’ older patients cannot be judged by a review of statistics and databases. The worm’s eye view of the so-called ‘at risk’ patient recognises an eclectic mix of the terminal and chronically ill and includes those whose carers are similarly affected.2 Therefore we were not surprised that in the same edition of the BMJ Holland et al report that medication reviews alone are not going to keep older patients out of hospital.3 The issues are probably more complicated and will require research in the complex and messy world of primary care. In reality when these patients are admitted to hospital God, society and the machinery of health and social services all move at varying speeds to remove, reduce or obviate future admissions to hospital. In a society where families are likely to be widely scattered with the passing of decades it is still true that many families retain a strong sense of responsibility for their older members. They can be persuaded to remove the risk of hospital admission. Furthermore there is a place for residential care in those circumstances where other options are impractical. It was not surprising that the patients admitted at one point in time seem less likely to be admitted with the passage of the years. The fact remains that these patients are surrounded by professionals and carers who do not turn a blind eye to their growing need for hospital attention. Their plight presents variously including requests for home visits, telephone calls from worried neighbours and so on. What may account for the high numbers who seem to enter the sanctuary of hospital year in year out is that we only act after the event because many of those from a stubbornly independent generation often equate ‘support’ to ‘charity’ or professionals or families are not alerted in time to be proactive in averting the looming crisis. Dr. Moyez Jiwa GP , Director of Research, Doncaster and Bassetlaw hospitals NHS Foundation Trust. Clinical Lecturer, ScHARR Email: m.jiwa@sheffield.ac.uk Competing interests: None declared
Admission rates still a useful outcome measure 26 February 2005
Peter T Donnan, Senior Lecturer in Medical Statistics Tayside Centre for General Practice, Mackenzie Building, University of Dundee DD2 4BF, Frank Sullivan, Tom Fahey, Andrew Morris Send response to journal: Re: Admission rates still a useful outcome measure	Sir, We enjoyed reading the important article by Roland et al(1) and the accompanying editorial(2). We would like to comment on two aspects of the analysis provided. Firstly, Roland et al(1) took no account of mortality, nor the natural replenishment of the over 65s by younger members of the population over time and hence did not measure the change in emergency admissions over time for all over 65s. The conclusion that studies using admission rates need a control group is sound, but stating that admission rates alone are not a good measure in intervention studies is more of an opinion. In an intervention study both intervention and control arms would have a fall in admission rates, any difference could still be attributed to the intervention. Alternatively, an outcome based on time series would not show a cohort effect as seen here. The results of Roland et al(1) also suggest that any intervention is perhaps better targeted at prevention of emergency admissions rather than a reduction in individuals once they have occurred. Secondly, there are two further potential explanations for the observed reduction in emergency admissions with implications for NHS resources: • Elderly patients may be involved in further planned admissions after the initial emergency admissions; • Following an emergency admission there may be planned admission to long stay accommodation where the elderly may have increased personal and nursing care. These other potential explanations mean it would be misleading to conclude that there is a reduction in NHS use over time when other NHS use has not been accounted for. We are currently engaged in a study of this topic in Tayside, Scotland which has more detail of all hospitalisations, prescribing and demography for the whole population than that available to our colleagues from the North of England and hope to ascertain predictors of emergency hospital admissions. Peter T. Donnan, senior lecturer in medical statistics Frank Sullivan, professor of r&d in primary care Tom Fahey, professor of primary care medicine Tayside Centre for General Practice, Community Health Sciences University of Dundee Andrew Morris, professor of diabetic medicine University of Dundee Competing Interests: No competing interests other than as researchers we see the value of admission rates as an outcome in health services research. References 1. Roland M, Dusheiko M, Gravelle H, Parker S. Follow-up of people aged 65 and over with a history of emergency admissions: analysis of routine admission data. BMJ 2005; 330: 289-92. 2. Morrison J. Identifying people at high risk of emergency hospital admission. BMJ 2005; 330: 266. Competing interests: None declared
Follow up of people aged 65 and over with a history of emergency admissions:analysis of routine admission data 23 March 2005
Hannah E Patrick, Consultant in PUblic Health Medicine Bexley Care Trust, Natasha Roberts, Jim Connelly, David Oliver Send response to journal: Re: Follow up of people aged 65 and over with a history of emergency admissions:analysis of routine admission data	Sir We welcome the article by Roland et al [1] which illustrates the dangers of assessing outcomes in “before and after” studies of interventions – re-emphasising that, in some circumstances, such studies tend to overestimate effect size when compared to controlled trials [2]. With adequate foresight and planning, a randomised controlled trial of the Evercare intervention could have been designed resulting in higher internal and external validity. When Bexley Care Trust agreed to be a “pilot site” for Evercare, it was clear to the local team that a control group would be required to make meaningful inferences. Yet the way in which the project had been set up did not allow a formal RCT to be designed or approved. In the meantime, guidance on external evaluation from United Healthcare and the DOH went through a series of iterations. Bexley seconded its first two Advanced Practitioner Nurses (APNs) (The forerunner of “community matrons” now envisaged for all PCTs) in February 2003 from existing community nursing teams, with project management from United HealthCare. The nurses were given a total of eight days training to become skilled in diagnosis and clinical assessment, before establishing caseloads in March 03. There was limited central funding to cover “backfill of posts”. No new treatment or prescribing responsibilities were assigned to the nurses. A total of 5 APNS had been enrolled by March 04. Doctors in the practices and local hospital were asked to mentor the nurses in order to support them in their new role. Patients were identified for the “Evercare” caseload from the Hospital Information System and by nomination according to criteria set by United Health Care. Criteria for inclusion in the project for patients who were registered with practices on the Evercare Caseloads were at least one of the following: · 2 or more emergency admissions within the 13th month period 1st Jan 2002 – 31st Jan 2003 · Recent exacerbation or decompensation of chronic illness (within the last 90 days) · Recent falls (2 falls in 2 months) · Recently bereaved and at risk for medical decline (death of spouse or family member in past 6 months) · Cognitively impaired, living alone, medically unstable, or in receipt of a high intensity social service package. · Registration with one of the practices involved in the Evercare project. Five general practices were selected on the basis of readiness to adopt the approach, provide support to the nurses and also having sufficient patients meeting the criteria above. Tools developed and recommended by the Evercare programme were implemented with mixed success: The “Red Man” (used to encourage patients to recognise signs of illness early in order to prevent the development of serious illness) was used by the APNs from autumn 03. “Risk Stratification Tool” (used to manage the caseload of the APNs and assist in evaluation of the impact of the work) was introduced in January 04. “Hospital admissions tool” (used to analyse admissions within 24 hours in order to promote professional development and patient/carer education) was introduced in Jan 04 but not implementable because of lack of senior clinical support. “Change of condition” monitor was not implemented in Bexley because it was considered too American for English use Contact sheets (used to monitor the caseload of staff) was used from the beginning Patients from the ad hoc “control” group were selected on the same criteria, but from non-participating GP Practices. 192 patients were taken on to the APN caseloads from March 03 to the end of September 04 (11 subsequently died and 5 moved out of the area). Local analysis of hospital utilization (presented below and based on patients for whom at least 6 months of follow up information was available) showed that admissions decreased over time in case and comparison groups – mirroring Roland’s findings [1] . The rate difference, after intervention, between the Evercare Group and the Control group was 0.022 admissions per month (95% CI –0.009 to 0.053 , p >0.05),even though the rate difference before the intervention between the groups was highly significant with the control group showing the higher rate(P,0.001)However, there was (in line with experience in other sites)encouraging anecdotal evidence from the APNs of cases where their intervention had prevented a pattern of repeated admissions. Many positive experiences were reported from staff, patients and carers delivering or receiving case management Table 1: Local analysis of admissions data pre and post Evercare Number patients included 103 cases 66 “controls” Total no. months analysed prior to start of project 1236 792 Total no. admissions prior to start 177 195 Admissions per month 0.14 0.25 Total no. months followup after start of project adjusted for censoring 852 792 Total no. admissions after start of Evercare project 102 77 Admissions/month 0.119 0.097 Moving to possible confounders, the data were accessed “blind” from routine information systems. Against positive confounding there was a significant difference between the groups in mean length of hospital stay in the 12 months prior to the intervention with the longer LOS in the control group (mean difference in los based on 66 cases and 66 controls was 9.24 days per person ;P=0.03). Nor have differences in mortality between the groups been demonstrated. However, the numbers of patients are relatively small. The control group was not randomly selected, though casemix is unlikely to show systematic bias as the criteria for selection employed several markers of frailty and co-morbidity Different approaches to medical care in the non-participating practices could also conceivably have confounded the results. . Finally, these data are interim, non-peer reviewed and report an intervention in its first operational year, when such schemes [3] often fail to deliver benefit until they are embedded in practice. These data effectively have the same status as other sources of non-peer reviewed and unpublished interim data on case management initiatives. Despite all these caveats – openly admitted, these findings at least build on attempts to select a control group which seemed an obvious pre-requisite at the start of the project. Therefore it is our belief that the “Castlefields Data” – reported as showing large effect size in admissions reduction - are repeatedly cited in literature and events promoting case management and the early reports of the success of the Evercare Pilots – alluding to admissions reductions, should be subjected to full peer review and scrutiny before they can be used as conclusive evidence for the level of effectiveness of case management. We may well find that by the second or third year of this intervention that it is delivering benefits in terms of admission avoidance and a range of qualitative outcome measures. However, these interim data add further weight to the view that success in UK case management should not be reported prematurely. Also that the precise model used for intervention and case finding is open to debate and local modification. Dr Hannah Patrick. Consultant in Public Health Medicine, Bexley Care Trust Natasha Roberts Information manager, Bexley Care Trust Jim Connelly, Professor of Public Health, University of Reading Dr David Oliver, Senior Lecturer in Geriatric Medicine, University of Reading 1. M Roland, M Dusheiko, H Gravelle, and S Parker Follow up of people aged 65 and over with a history of emergency admissions: analysis of routine admission data BMJ 2005; 330: 289-292 2. Kunz R, Oxman AD. The unpredictability Paradox. A review of empirical comparisons of randomized and non-randomised trials. BMJ 1998; 317: 1185-91. 3. Smith R. Improving Case Management of Vulnerable Elderly. Rapid Responses. BMJ 2005; 330. 4. Report of Castlefields Project. In. Implementing the Evercare Programme. Interim report. February 2004. Availablewww.natpact.nhs.uk/cms/186.php Competing interests: None declared
Can rehabilitation at home prevent hospital readmission in frail older people? 18 April 2005
Paolo Stofler, medical doctor Richiedei Hospital Palazzolo s/O, Italy, Simone Franzoni, and Marco Trabucchi Send response to journal: Re: Can rehabilitation at home prevent hospital readmission in frail older people?	EDITOR- In their recent paper, Roland et al provide interesting considerations regarding interventions designed to avoid emergency readmission of frail older people. The care of specially trained nurses at home is associated with reduced risk of readmission to hospital(1). We propose another model of informal monitoring of frail older subjects, obtaining important results. We observed 448 patients (age 77+7.1, F 73.2%), consecutively discharged from a Geriatric Rehabilitation Unit (GRU) after 35.8+14.9 days of therapy for acute disabling disease (mostly stroke, hip fracture, peripheral obliterating arteriopaty). N. 185 (41.3%) patients prosecuted with low intensity rehabilitation programme at home (ReH; number of treatments 32.6+12.5 / patient / year), because of a low level of functional recovery (number of Basic Activity of Daily Living – BADL lost 2.1+2.0 vs 1.2+1.6, p.001) and high level of comorbidity (Burden of Disease – BoD 10.4+3.7 vs 9.1+3.7, p.001) on discharge from GRU. After 1 year follow up, the prevalence of hospital admission for every causes was significantly lower in ReH group than in controls (28.6 % vs 36.5 %, p.05), while functional decline was similar in two groups (number of BADL lost 0.8+1.7 vs 0.8+1.6). To assess factors related to hospital readmission after discharge from GRU, a multivariate analysis was performed after stratification for sex, age, functional and mental status, and depressive symptoms. Comorbidity (BoD 1.1 [95%CI: 1.05-1.17]) appeared to increase, while ReH (0.6 [0.39-0.96]) decreased the use of hospitalisation. The protective role of specialized ReH on rehospitalization is demonstrate only for specific diseases(2,3). In our heterogeneous patients, rehabilitation therapists monitor both functional decline and clinical status, thus perceiving early abnormal clinical symptoms and signs and starting timely clinical interventions. We suggest that specifically trained rehabilitation therapists may act as controllers of the frail elderly people, obtaining important results both from clinical and economical point of view. P.M.Stofler,S.Franzoni: GERU, Richiedei Hospital, Palazzolo s/O – Brescia, Italy M. Trabucchi: GRG, Geriatric Research Group, Brescia, Italy. 1 Roland M, Dusheico M, Gravelle H, Parker S. Follow up of people aged 65 and over with a history of emergency admission: analysis of routine admission data. BMJ 2005;330:289-92. 2 American Thoracic Society. Pulmonary rehabilitation-1999. Am J Respir Crit Care Med 1999; 159:1666-82. 3 Ileana L.Pina, Carl S. Apstein, Gary J.Balady, Romualdo Belardinelli, Bernard R. Chaitman, Brian D.Duscha, Barbara J.Fletcher, Jerome L. Fleg, Jonathan N. Myers, Martin J.Sullivan. Exercise and heart failure. A statement from the heart association committee on exercise, rehabilitation, and prevention. Circulation 2003;107:1210-55. Competing interests: None declared