Project objectives

To conduct a mixed method review by:

1. Systematically reviewing the quantitative evidence for the effectiveness of case management of patients with CHF for unscheduled secondary and primary care resources (synthesis one: quantitative);
2. Systematically reviewing the qualitative evidence relevant to patients with CHF, regarding case management for their condition (synthesis two: qualitative);
3. Combining the above quantitative and qualitative evidence in order to make recommendations for successful care of patients with CHF (synthesis three: mixed methods).

Changes to project objectives

Rob Anderson and Helen England were unable to contribute significantly to the project a few months in due to workload.

The plan was to combine all the data from the review in one paper but once the studies to be included were identified it was decided by the group that it would be more appropriate to produce a quantitative and a mixed method paper from the available data.

We conducted additional analysis in the quantitative review. We planned to present the components of case management narratively but have also performed meta-regression. We invited Professor Richard Morris (Centre of Primary Health Care (CAPC), University of Bristol) to advise on this.

We did not have any PPI representation in our advisory group (details in PPI section). 

Brief summary

Mixed method systematic review methodology was used. We searched for both quantitative and qualitative papers in one combined search strategy, adapted for each of the databases searched.

The following objectives were addressed:

1. We systematically reviewed the quantitative evidence from clinical studies for the effect of case management of patients with CHF on unscheduled secondary care and primary care resources;
2. We identified the core components and setting of the case management interventions from the same studies;
3. We systematically reviewed the qualitative evidence from patients with CHF, their families/carers or relevant health care professionals regarding case management for CHF;
4. We combined the quantitative and qualitative evidence in one review in order to give a complete picture of case management for CHF.

Findings

We have completed objectives 1 & 2 (quantitative review) and these data are written up and ready to be submitted to BMJ open

This systematic review aimed to extend our knowledge of the effectiveness and cost- effectiveness of case management (CM) for patients with heart failure (HF) in reducing unplanned admissions. Searches were conducted in four databases plus relevant websites. Using pre-defined inclusion/exclusion criteria, references were dual screened first by title/abstract and then full text. Data from included trials were dual extracted in pre-defined tables and risk of bias was determined. Meta-analysis was performed as appropriate. Components of CM were identified and sub-group analysis performed as appropriate.

Twenty-two studies were included; 17 RCTs and five controlled trials. Data from hospital -initiated CM showed a reduced risk of admission (rate-ratio 0.77 [0.65, 0.92] p=0.004) and hospital length of stay (mean difference -1.04 days [--1.84,-0.24] p=0.01) in favour of CM. Subgroup analyses shows that the effect is only there are 3 months. Nine trials described cost data of which six reported no difference between CM and usual care. Data from three of five trials of community-initiated CM showed no differences in risk of admission (rate-ratio 1.08 [0.62, 1.87] p=0.8). Data from individual included studies suggests that family involvement and education/self-management are likely to be important in CM but this was not demonstrated in sub-group analysis. CM can be successful in reducing unplanned hospital admissions for HF and length of hospital stay in the short term for people with HF. Limited cost data suggest no difference between usual care and CM.

We have completed objective 3 (Qualitative review)

Once the qualitative papers were identified we followed the following methodology:

Identification of first and second order constructs

Four members of the research team firstly met and organised the first order constructs (patient and health professional quotes) according to each of the 19 authors’ themes (second order constructs) which had been identified by two members of the research team during data extraction. These were the themes exactly as they appeared in each of the six review papers. These were grouped in terms of patient quotes and health professional quotes.

Translation of authors’ themes in to ‘third order constructs’

The research team met for a second time to translate the second order construct themes in to reviewers’ themes derived from the data. In order to translate these themes, the team read and reread patient and health professional quotes to compare and contrast their content in order to develop these ‘third order constructs’. These were themes and the main concepts that had been derived from the second order constructs, which were then agreed amongst the group. The above themes relate to patients’ views. The following three themes (third order constructs) were also developed by the research team which relate to the views of health professionals.

The qualitative review yielded six papers which described five qualitative studies. Of these five qualitative studies, three were conducted as part of a mixed method study and associated with three of the included intervention studies. All five of the qualitative studies described community-initiated case management. These were papers published between 2005 and 2013 and included papers from Germany, Sweden, UK and Canada. Two papers focused on patient views of the case management of chronic heart failure, two examined health professional views and the other two described patients’ and health professionals’ perspectives. All included papers were critically appraised by two reviewers. None were excluded on the basis of poor quality overall.

Six final themes were derived from patient data in the qualitative papers. The nine themes (third order constructs) that the research team developed by translating the review authors’ second order constructs were: self-management and self-care; information provision; changes in behaviour; enhanced access to care; checking on and being cared for and finally, what is important to patients. The following themes relate to the views of health professionals: Feasibility of implementation of case management, Impact of case management (including benefits for patients), and Suggestions for improvements for case management.

Objective 4

These data are currently being written up as a mixed method review in combination with the quantitative data from the community-initiated studies. This review will comprise a parallel synthesis of the qualitative and quantitative data. The aim is submit this review in January 2016.

Plain English summary

Background

Case management (CM) of a patient means their care needs are assessed, care plans made and a co-ordinator (usually a nurse) ensure the care is provided and reviewed regularly. Research to date suggests that CM for reducing emergency hospital admissions of patients with heart failure (HF) is promising.

Aim

To determine how CM of patients with HF affects emergency care and primary health care use.

Methods

We reviewed the following: 1) studies which measure the effectiveness of CM in reducing unscheduled care for HF 2) to record the context and content of CM in these studies 3) studies of patients with HF, their families/carers and relevant health care professionals in which they were asked about CM 4) to combine the evidence from 1-3 to give an overall picture.

Results

Twenty-two studies investigated the effectiveness of CM, and five studies asked patients, carers and health professionals about CM.

Data from studies of effectiveness of CM initiated whilst the patient was in hospital showed a reduced risk of admission to hospital, and reduced length of stay (if they were admitted) but only with short-term (less than 3 month) CM. Nine trials described cost data of which six reported no difference in costs between CM and usual care. Data from three of five studies of community-initiated CM showed no differences in risk of admission to hospital. Examining the individual studies suggests that family involvement, education and self-management are likely to be important in CM but statistical analysis does not back this up.

The five studies that asked questions of patients, carers and health professionals were all based on community-initiated CM. Six themes were identified concerning patients opinions on CM: self-management and self-care; information provision; changes in behaviour; enhanced access to care; checking on and being cared for, and what is most important to patients. The following themes relate to health professionals: Feasibility of implementation, impact and suggestions for improvements for CM.

Conclusions

CM can be successful in reducing unplanned hospital admissions for HF and length of hospital stay in the short term for people with HF. Limited cost data suggest no difference between usual care and CM. Patients value CM not only for the clinical care but for the personal contact. Health professionals value CM but have concerns about resources to provide it. 

Dissemination

Planned articles

1. Huntley AL, Johnson R, King A, Morris RW, Purdy S. Does case management for heart failure reduce unplanned hospital admissions? A systematic review and meta-analysis. To be submitted to BMJ open in November 2015.
2. King AJL, Cramer H, Johnson R, Feder G, Purdy S. Mixed method systematic review of community case management for patients with chronic heart failure. To be submitted January 2016.

Oral presentations

This work was presented as part of workshop at Health Services Research Network Nottingham July 2015. The implications of recent research for managing and avoiding emergency admissions. Oral presentation.

Conference abstracts

Abstracts of both the prepared papers will be submitted to either SAPC-SW in Cardiff (March 2016) or the SAPC annual conference in Dublin (July 2016).

Public involvement

We said in our application that we would contact patient groups via Bristol Community Health who has previously helped us to contact patients for our projects or use a small database of patients who have been involved in previous projects, including one project on heart failure. Our plan was to invite at least two patients to join the project’s advisory group which will comprise of the co-applicants and patients.

However, in practice our contact in Bristol Community health had moved on and the patients we did identify via previous projects were actually in quite poor health and not in a situation to participate. On reflection the co-applicants decided not to pursue PPI involvement due to the relatively short time scale of the project and the difficulty in identifying further suitable candidates. The co-applicants still felt it would have been optimum to have PPI representation in an advisory capacity.

Impact

From the systematic review publications cited above we will work with commissioners to translate the main findings into commissioner friendly summary. This is will be on the University of Bristol website and distributed locally to commissioners.

This project was funded by the National Institute for Health Research School for Primary Care Research (project number 238)

Department of Health Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Primary Care Research, NIHR, NHS or the Department of Health.