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NeuroRehabilitation 35 (2014) 635–641 DOI:10.3233/NRE-141161 IOS Press
Review Article
Effects of case management after brain injury: A systematic review Natasha A. Lannina,b,c,∗ , Kate Lavera,d , Kareena Henrye , Michelle Turnbulle , Megan Eldere , Josephine Campisie , Julia Schmidtc,f and Emma Schneiderb a Department
of Occupational Therapy, La Trobe University, VIC, Australia Therapy Department, Alfred Health, VIC, Australia c Rehabilitation Studies Unit, Sydney Medical School, The University of Sydney, NSW, Australia d Faculty of Health Sciences, The University of Sydney, NSW, Australia e All About Rehabilitation Pty. Ltd, Sydney, NSW, Australia f Department of Occupational Therapy, Australian Catholic University, Sydney, NSW, Australia b Occupational
Abstract. BACKGROUND: Adults who survive traumatic brain injury (TBI) often receive case (care) management to overcome the difficulties commonly faced negotiating a number of different health and social care services and systems. Little is known about the effectiveness of a case management intervention. OBJECTIVE: To examine the effects of case management for patients with severe head injury on outcome, family function, and provision of rehabilitation services. METHODS: Systematic review methodology. Electronic databases (Medline, CINAHL, Psycbite and OTSeeker) were searched up to 7/1/2013. A total of 655 articles were screened of which six met the criteria for inclusion in the review. Study quality was evaluated using the PEDro scale or AMSTAR checklist dependent on study design. RESULTS: One systematic review, three controlled trials and two case series reports were appraised. There was significant clinical heterogeneity between studies and studies scored poorly on the appraisal checklists. Due to methodological limitations, there was no clear evidence of effectiveness or ineffectiveness of case management after brain injury. CONCLUSION: Principal findings are that there is a paucity of applicable research on case management, and a need to evaluate the impact of case management on life participation outcomes. Keywords: Case management, managed care programs, review, brain injuries, rehabilitation
1. Introduction An increasing number of adults now survive severe traumatic brain injury (TBI) with long hospitalisations and multiple impairments in function (Helps, Henley & ∗ Address for correspondence: Natasha Lannin, Alfred Clinical School, La Trobe University, Level 4, The Alfred Centre, 99 Commercial Road, Prahran, VIC 3181, Australia. Tel.: +61 3 9479 6745; E-mail: [email protected].
Harrison, 2008; Sanchez et al., 2012). Persons surviving moderate-severe TBI receive input from multiple health care professionals and services, including medical and surgical specialists, allied health professionals, as well as professionals from legal and insurance backgrounds (Ponsford, Harrington, Olver & Roper, 2006). With severe brain injury being a new and often foreign experience for both the patient and their family, the loss of roles after brain injury, ongoing care needs,
1053-8135/14/$27.50 © 2014 – IOS Press and the authors. All rights reserved
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and unknown future often results in significant distress for all. To overcome this distress and difficulty planning for the future, many TBI programmes provide case management, which is also known in the literature as care co-ordination or case planning (Smith & Newton, 2007). The concept of case management is intuitively appealing in order to; address the difficulties the client or their family face negotiating the complex health system, improve continuity of care by linking the client with required services, as well as to improve the client’s quality of life in the community. Case management varies in form and function according to the system within which it is developed. However, the central theme of case management is common, with the responsibility for meeting the needs of the client and linking the client with services required for a successful outcome (Lee, Mackenzie, Dudley-Brown & Chin, 1998). The ABIKUS Evidence Based Recommendations for Rehabilitation of Moderate to Severe Acquired Brain Injury (2007) recommend that “there should be a case management or equivalent system, which gives persons with brain injuries and their family/caregivers an identifiable guide and advocate (navigator) through the continuum of care” (ABIKUS, 2007). This recommendation was made based on expert opinion rather than published research. In practice, the provision of case management services is widely accepted and provided for clients with TBI (Transport Accident Commission, 2013). Yet there is currently a lack of evidence of the effectiveness of case management and cost when compared with usual care provided by community brain injury services. The purpose of this paper is to explore the effectiveness of case management for clients with TBI. Specific outcomes of interest include readmission to acute or rehabilitation services, utilisation of health and social care services, cost, vocational outcome and living situation and quality of life of the person with TBI.
2. Methods 2.1. Identification and selection of studies The systematic review is based on articles published until 7 January 2013 selected after a computerized search strategy in the following databases: Medline (OVID), CINAHL, OTSeeker and Psycbite. The following search terms were exploded in each database: head injury, craniocerebral trauma, case management, conti-
nuity of patient care, patient centered care and managed care (the full search strategy is available on request). There was no restriction on the date of publication. In addition, the reference lists of retrieved studies, reviews and grey literature were scanned for other relevant studies. Each title and abstract was independently screened by two review authors to determine eligibility. In case of disagreement, a third reviewer made the final decision. 2.2. Selection criteria Articles published in English meeting the following criteria were included in the review: a. Types of studies: Only randomised controlled trials and quasi-randomised controlled trials were considered eligible for inclusion in meta-analyses. However, all study designs (including systematic reviews, controlled trials and case series) were eligible for inclusion in the review. b. Types of participants: Adults with traumatic brain injury. c. Types of interventions: Case management elements were defined as entry screening, assessment, planning, coordination, monitoring, review and exit/case closure planning. Elements of direct service provision and post-service evaluation were considered to be non-essential (Case Management Society of Australia, 2013). d. Types of outcomes: outcomes measured at the level of activity and/or participation (World Health Organization, 2013). 2.3. Assessment of characteristics of studies The AMSTAR checklist (AMSTAR, 2013) was used to assess the quality of systematic reviews and the PEDro scale (Physiotherapy Evidence Database, 2013) was used to assess the quality of controlled trials. Data from the included studies were extracted by two authors, and included study author name/s and date of study, study design, setting, number of participants, diagnosis, interventions, outcomes, and a summary description of findings. 2.4. Quantitative analysis Since case management is a complex intervention, primary outcomes were defined under the areas of readmission to acute or rehabilitation services, utilisation of health and social care services, cost, vocational
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outcome, living situation and quality of life of the person with TBI. We planned to use Hedges’s g to calculate the effect size of the different studies should meta analysis be appropriate (permitting adjustment for small sample bias). We planned to contact authors of articles by email to provide data and/or study details as required.
3. Results The search identified 655 potentially relevant articles. After screening for eligibility (including full text review where required), it was determined that six articles met the inclusion criteria. Of these, one was a systematic review (Chesnut et al., 1999; Patterson et al., 1999), three were non-randomised controlled trials (Ashley, Lehr, Krych, Persel & Feldman, 1994; Greenwood et al., 1994; Heinemann, Corrigan & Moore, 2004) (one of these conducted retrospectively) and the remaining two studies used a case series design (Malec, Buffington, Moessner & Thompson, 1995; Malec, Buffington, Moessner & Degiorgio, 2000). All studies were published prior to 2005. Details of the included studies are presented (see Table 1). Due to the range of research designs and characteristics it was not possible to pool studies and thus a narrative synthesis of studies is presented. 3.1. Characteristics of studies The systematic review (Chesnut et al., 1999; Patterson et al., 1999) was published in 1999 and included three studies (Ashley et al., 1994; Greenwood et al., 1994; Malec et al., 1995) which are also included in this review; the systematic review provided a narrative summary of studies and results. The review was associated with several methodological limitations as can be seen by the appraisal using the AMSTAR checklist (see Table 2). Sample sizes involved in the five clinical studies were relatively large (ranging from 39–217). The participant groups involved in the studies varied. Greenwood et al. (1994) recruited patients with severe head injury (with mean scores of 18/30 (extremely severe) on the Disability Rating Scale (DRS) (Rappaport, Hall, Hopkins, Berleza & Cope 1980) in the case managed group) whereas the participants recruited by Ashley et al. (1994) had a mean score of 5/30 (moderate) on the DRS. Heinemann et al. (2004) specifically recruited participants that had a dual diagnosis of traumatic brain injury
637
and post-injury alcohol abuse or dependence. The participants recruited by Malec et al. (2000) ranged from mild severity (21% of the group) to severe (56% of the group). The content of the case management program provided was often poorly described. While the characteristics of case management varied between studies there were commonalities including a focus on early intervention and linking with readily available services in the community. A wide range of outcome measures were used and included measures at the level of impairment, activity and participation (WHO, 2013) Measurement of vocational outcome and living situation were common across studies although the measurement tools used to asses these domains varied. Appraisal of the five clinical studies using the PEDro scale demonstrated that the methodological quality of the included studies was low; studies were often poorly reported and none of the studies used a true randomisation process; thus there were differences between the control and intervention groups. None of the studies reported that outcome assessments were conducted by blinded assessors. 3.2. Effect of intervention We were unable to identify any randomised controlled trials meeting our inclusion criteria and unable to conduct quantitative analyses. One controlled trial examined use of health and social care services and found that patients receiving case management were more likely to be referred to a rehabilitation unit (Odds Ratio (OR) 3.2, 95% Confidence Interval (CI) 0.7 to 14.8; p < 0.05) or outpatient services (OR 2.3, 95% CI 0.9 to 5.9; p < 0.05) (Greenwood et al., 1994). Once admitted, patients receiving case management did not have a longer length of stay in the rehabilitation unit than those without case management. Four of the studies reported on the vocational outcome for persons receiving case management (Ashley et al., 1994; Greenwood et al., 1994; Malec et al., 1995, 2000). One controlled trial found there were no significant differences in vocational outcome between the case management and the control group. In another controlled study there was limited evidence that a model involving one case manager and insurance carrier was more effective than a model involving multiple case managers and insurance carriers in improving vocational status at the time of discharge. Ashley et al. (1994) reported that patients with one case manager improved from a mean of 14.95 (not working) to 3.19 (part-time
Design and aim Systematic Review The aim of the review was to identify evidence of case management effectiveness in TBI rehabilitation
Controlled trial The aim was to examine the effects of early case management for patients with severe head injury on outcome, family function and provision of rehabilitation services
Retrospective case-controlled study The aim was to identify the impact of case management techniques and to clarify their relationship to patient recovery
Study
Patterson et al. (1999)
Greenwood et al. (1994)
Ashley et al. (1994)
Intervention Case management was described as including initial assessment, care-plan development, referral to other services, coordination of services and collaboration between care providers, informal caregivers and the client
Summary of main results
The authors provided a narrative review and comparison of the studies They reported that two studies demonstrated that case management improved vocational status. However, there was conflicting evidence regarding the impact of case management on function and other aspects of recovery N = 126 patients aged 16–60 with severe Patients were recruited within seven More of the patients receiving case head injury days of injury management were in contact with Patients were recruited from 11 hospitals in The intervention group received case rehabilitation or community services London management which involved Case management also increased the A coin toss was used to allocate patients assessment and development of a number of referrals to physiotherapy, (N = 56) from one of these groups of rehabilitation plan and facilitated occupational therapy, clinical hospitals to receive case management cooperation between the patient, psychology, social work and speech family and professionals. The case therapy manager provided general information There was no significant difference about head injury and informal between groups in regards to counselling and support but did not physical or cognitive impairment or provide formal treatment, retraining or social functioning education The control group received normal services N = 39 patients with TBI treated at a Group 1 participants (N = 21) were Both groups improved on the Disability post-acute rehabilitation facility covered by the same insurance carrier Rating Scale, Living Status Scale Patients were included if they had an initial and supervised by a single case and Occupational Status Scale Disability Rating Scale score of 10 or less manager between admission and discharge (Moderately Severe) and were involved Group 2 (N = 18) comprised patients Group 1 improved significantly more in a vocational rehabilitation program with different insurance carriers with on the DRS and OSS and the average Patients were then divided into two groups different case managers cost of rehabilitation was based on their different case management significantly less arrangements however, were matched based on criteria such as gender, time post injury, age and treatment
Participants This review included the three studies included in this review (Ashley, 1994; Greenwood, 1994; Malec, 1995)
Table 1 Summary of included studies
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Design and aim Case series The aim was to describe a medical and vocational case management system intended to decrease the time between injury and successful community integration Case series The aim was to evaluate the effects of a medical/vocational case coordination system
Controlled study The aim was to evaluate a community based approach to substance abuse using case management for persons with TBI
Study
Malec et al. (1995)
Malec et al. (2000)
Heinemann et al. (2004)
Participants
Adults with TBI and post-injury alcohol abuse or dependence The study involved patients treated at two facilities where case management was provided (N = 217). A control group was recruited from another facility which did not provide case management (N = 102)
Patients with traumatic or other acquired brain injury aged 18–65 years (N = 114). Patients were excluded if they had a primary psychiatric or substance abuse diagnosis or lived in residential care
People aged between 18 and 55 with a diagnosis of brain injury and no primary psychiatric or substance abuse diagnosis or reside in residential care. Data is presented for 147 patients including an in-depth case report for one patient
Table 1 (Continued) Intervention Early implementation of case management is provided by a nurse case coordinator and vocational case coordinator. Case management involves detailed assessment, linking with services and development of a reintegration plan The case management system is based on early intervention and the interface of a nurse case coordinator and vocational case coordinator. The coordinators ensure that patients access required medical services, rehabilitation, vocational rehabilitation and social services with assessment, linking and a reintegration plan Case management involved ensuring access to appropriate substance abuse treatment services, ensuring continuity between treatment phases and coordination of social services. Clients were also linked in to other relevant services such as vocational rehabilitation
Summary of main results
Participants in the case management group had higher levels of alcohol and drug use than the control group Both groups experienced increased community integration and health related quality of life. Patients in the case management group reported gains in life satisfaction whereas those in the control group did not
Vocational outcomes at 1 year follow up approached or exceeded initial benchmarks set
Data indicated a reduction in the amount of time between injury and initiation of vocational and other appropriate services since the commencement of the case management program
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N.A. Lannin et al. / Case Management Review Table 2 Quality of included studies Study
Study design
Patterson (1999) Greenwood (1994) Heinemann (2004) Ashley (1994) Malec (1995) Malec (2000)
Systematic Review Controlled Trial Controlled Study Retrospective Case-controlled Study Case Series Case Series
at former job or equal position) on an Occupational Status Scale whereas patients with multiple case managers made less improvement from 15.00 (not working) to 10.28 (volunteer). The difference between groups was statistically significant (P < 0.05). Two studies using a case series design reported positive vocational outcomes following a case management intervention; the majority of clients were placed in sheltered, supported, transitional or independent work and retention rates were high (Malec et al., 1995, 2000). Ashley (1994) found in their controlled study that patients receiving case management improved more on the Living Status Scale; on average improving from a status of ‘living in private quarters with professional help’ to ‘living in private quarters with no help’. Two studies reported on quality of life outcomes for the person with TBI (Greenwood et al., 1994; Heinemann et al., 2004). In their controlled trial, Greenwood et al. (1994) found no significant difference between groups at follow up on the General Health Questionnaire. There was limited evidence that case management for people with TBI and alcohol abuse or dependence is associated with increased life satisfaction in comparison to those that do not receive case management services. Another controlled trial (Heinemann et al., 2004) found that patients in both groups reported similar level of life satisfaction at commencement of the study however, patients receiving case management reported significant improvements (33.4 to 43.1 on the Satisfaction with Life Scale (Pavot & Diener, 1993)) whereas those not receiving case management did not (35.5 to 37.1). We found insufficient evidence to determine whether case management resulted in readmissions or reductions in the cost of care.
4. Discussion This review of case management for patients with TBI included one systematic review, three controlled
Evaluation tool
Score
AMSTAR checklist PEDro PEDro PEDro PEDro PEDro
3/11 2/10 2/10 1/10 1/10 1/10
studies and two studies using a case series design. Results of these studies suggested that there was limited evidence that case management increased contact with community services, improved vocational outcome and was associated with improved life satisfaction when provided to patients that had alcohol dependency or abuse. There was insufficient information to determine the effect of case management on other outcomes either for the patient, the organisation or the community. There was considerable heterogeneity between the included studies in regards to the participants included, the case management intervention and timing and type of outcome measures which also limited our ability to synthesise study results. Studies included in the review were of low methodological quality and published in or prior to 2004. Given the increase in research output in more recent years it is surprising that more recent studies have not been conducted. Particularly with the rising costs of health care placing pressure on health care services and increased survival rates of people with TBI. It should be acknowledged that there are limitations associated with this review. Firstly, we were unable to achieve our aim of pooling studies due to the lack of high quality studies meeting our inclusion criteria. Our inclusion criteria were broad and included all research types therefore it is felt that no relevant studies were excluded on this basis. Secondly, our search involved multiple databases however, we did not search clinical trial registers so it is possible that the review was susceptible to publication bias in which studies reporting negative findings associated with case management were not reported. Findings of the review reveal that at present, there is neither evidence for nor against the provision of case management for persons with TBI therefore implications for current practice are limited. Given the high cost of care associated with TBI, high quality research to determine the effectiveness of case management is urgently required. Ideally, research would utilise a randomised controlled trial design. While it may not seem
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ethical to randomise patients to programs without case management, research is required to justify the cost of case management services for future people with TBI as at present there is a lack of evidence that this approach improves patient outcomes.
5. Conclusion There is limited applicable research regarding case management outcomes and effectiveness. This review highlights a need to evaluate the impact of case management on outcomes for both the person with TBI and the community.
Funding The authors received no funding to conduct this review.
Conflicts of interest None.
References ABIKUS (2007). Evidence Based Recommendations for Rehabilitation of Moderate to Severe Acquired Brain Injury. Retrieved August 22, 2013 from http://www.abiebr.com/abikusPublished 2007 AMSTAR. Retrieved August 22, 2013 from http://amstar.ca Ashley, M., Lehr, R., Krych, D., Persel, C., & Feldman, B. (1994). Post-acute rehabilitation outcome: Relationship to casemanagement technique. J Insur Med, 26, 348-354. Case. Management Society of Australia. Retrieved January 1, 2013 from http://www.cmsa.org.au Chesnut, R., Carney, N., Maynard, H., Mann, N. C., Patterson, P., & Helfand, M. (1999). Summary report: Evidence for the effectiveness of rehabilitation for persons with traumatic brain injury. J Head Trauma Rehabil, 14, 176-188.
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Greenwood, R. J., McMillan, T. M., Brooks, D. N., Dunn, G., Brock, D., Dinsdale, S., Murphy, L. D., & Price, J. R. (1994). Effects of case management after severe head injury, BMJ, 308, 1199. Heinemann, A., Corrigan, J., & Moore, D. (2004). Case management for traumatic brain injury survivors with alcohol programs. Rehabil Psychol, 49, 156-166. Helps, Y., Henley, G., & Harrison, J. E. (2008). Hospital separations due to traumatic brain injury, Australia 2004–05. AIHW Injury research and statistics series number 45. 2008: Cat no. INJCAT 116. Lee, D. T., Mackenzie, A. E., Dudley-Brown, S., & Chin, T. M. (1998). Case management: A review of the definitions and practices. J Adv Nurs, 27, 933-939. Malec, J., Buffington, A., Moessner, A., & Thompson, J. (1995). Maximizing vocational outcome after brain injury: Integration of medical and vocational hospital-based services. Mayo Clin Proc, 70, 1165-1171. Malec, J., Buffington, A., Moessner, A., & Degiorgio, L. (2000). A medical/vocational case coordination system for persons with brain injury: An evaluation of employment outcomes. Arch Phys Med Rehabil, 81, 1007-1015. Patterson, P., Maynard, H., Chesnut, R. M., Carney, N., Mann, N. C., & Helfand, M. (1999). Evidence of case management effect on traumatic brain injured adults in rehabilitation. Case Management Journal, 1, 87-97. Pavot, W., & Diener, E. (1993). Review of the Satisfaction with Life Scale. Psychol Assess, 5, 164-172. Physiotherapy Evidence Database. Retrieved 11 January 2013 from http://www.pedro.org.au/english/downloads/pedro-scale Ponsford, J., Harrington, H., Olver, J., & Roper, M. (2006). Evaluation of a community-based model of rehabilitation following traumatic brain injury. Neuropsychol Rehabil, 16, 315-328. Rappaport, M., Hall, K., Hopkins, K., Berleza, T., & Cope, D. (1980). Disability rating scale for severe head trauma patients: Coma to community. Arch Phys Med Rehabil, 63, 118-123. Sanchez, A., Krafty, R. T., Weiss, H. B., Rubiano, A. M., Peitzman, A. B., & Puyana, J. C. (2012). Trends in survival and early functional outcomes from hospitalized severe adult traumatic brain injuries, Pennsylvania, 1998 to 2007. J Head Trauma Rehabil, 2, 159-169. Smith, L., & Newton, R. (2007). Systematic review of case management. Aust N Z J Psychiatry, 41, 29. Transport Accident Commission. Case Management Model. Retrieved January 12, 2013 from http://www.tac.vic.gov.au/ policies/supporting/tac-case-management-model World Health Organization (2010). International Classification of Functioning, Disability and Health Retrieved January 11, 2013 from http://www.who.int/classifications/icf/en/
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NeuroRehabilitation 35 (2014) 635–641 DOI:10.3233/NRE-141161 IOS Press
Review Article
Effects of case management after brain injury: A systematic review Natasha A. Lannina,b,c,∗ , Kate Lavera,d , Kareena Henrye , Michelle Turnbulle , Megan Eldere , Josephine Campisie , Julia Schmidtc,f and Emma Schneiderb a Department
of Occupational Therapy, La Trobe University, VIC, Australia Therapy Department, Alfred Health, VIC, Australia c Rehabilitation Studies Unit, Sydney Medical School, The University of Sydney, NSW, Australia d Faculty of Health Sciences, The University of Sydney, NSW, Australia e All About Rehabilitation Pty. Ltd, Sydney, NSW, Australia f Department of Occupational Therapy, Australian Catholic University, Sydney, NSW, Australia b Occupational
Abstract. BACKGROUND: Adults who survive traumatic brain injury (TBI) often receive case (care) management to overcome the difficulties commonly faced negotiating a number of different health and social care services and systems. Little is known about the effectiveness of a case management intervention. OBJECTIVE: To examine the effects of case management for patients with severe head injury on outcome, family function, and provision of rehabilitation services. METHODS: Systematic review methodology. Electronic databases (Medline, CINAHL, Psycbite and OTSeeker) were searched up to 7/1/2013. A total of 655 articles were screened of which six met the criteria for inclusion in the review. Study quality was evaluated using the PEDro scale or AMSTAR checklist dependent on study design. RESULTS: One systematic review, three controlled trials and two case series reports were appraised. There was significant clinical heterogeneity between studies and studies scored poorly on the appraisal checklists. Due to methodological limitations, there was no clear evidence of effectiveness or ineffectiveness of case management after brain injury. CONCLUSION: Principal findings are that there is a paucity of applicable research on case management, and a need to evaluate the impact of case management on life participation outcomes. Keywords: Case management, managed care programs, review, brain injuries, rehabilitation
1. Introduction An increasing number of adults now survive severe traumatic brain injury (TBI) with long hospitalisations and multiple impairments in function (Helps, Henley & ∗ Address for correspondence: Natasha Lannin, Alfred Clinical School, La Trobe University, Level 4, The Alfred Centre, 99 Commercial Road, Prahran, VIC 3181, Australia. Tel.: +61 3 9479 6745; E-mail: [email protected].
Harrison, 2008; Sanchez et al., 2012). Persons surviving moderate-severe TBI receive input from multiple health care professionals and services, including medical and surgical specialists, allied health professionals, as well as professionals from legal and insurance backgrounds (Ponsford, Harrington, Olver & Roper, 2006). With severe brain injury being a new and often foreign experience for both the patient and their family, the loss of roles after brain injury, ongoing care needs,
1053-8135/14/$27.50 © 2014 – IOS Press and the authors. All rights reserved
636
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and unknown future often results in significant distress for all. To overcome this distress and difficulty planning for the future, many TBI programmes provide case management, which is also known in the literature as care co-ordination or case planning (Smith & Newton, 2007). The concept of case management is intuitively appealing in order to; address the difficulties the client or their family face negotiating the complex health system, improve continuity of care by linking the client with required services, as well as to improve the client’s quality of life in the community. Case management varies in form and function according to the system within which it is developed. However, the central theme of case management is common, with the responsibility for meeting the needs of the client and linking the client with services required for a successful outcome (Lee, Mackenzie, Dudley-Brown & Chin, 1998). The ABIKUS Evidence Based Recommendations for Rehabilitation of Moderate to Severe Acquired Brain Injury (2007) recommend that “there should be a case management or equivalent system, which gives persons with brain injuries and their family/caregivers an identifiable guide and advocate (navigator) through the continuum of care” (ABIKUS, 2007). This recommendation was made based on expert opinion rather than published research. In practice, the provision of case management services is widely accepted and provided for clients with TBI (Transport Accident Commission, 2013). Yet there is currently a lack of evidence of the effectiveness of case management and cost when compared with usual care provided by community brain injury services. The purpose of this paper is to explore the effectiveness of case management for clients with TBI. Specific outcomes of interest include readmission to acute or rehabilitation services, utilisation of health and social care services, cost, vocational outcome and living situation and quality of life of the person with TBI.
2. Methods 2.1. Identification and selection of studies The systematic review is based on articles published until 7 January 2013 selected after a computerized search strategy in the following databases: Medline (OVID), CINAHL, OTSeeker and Psycbite. The following search terms were exploded in each database: head injury, craniocerebral trauma, case management, conti-
nuity of patient care, patient centered care and managed care (the full search strategy is available on request). There was no restriction on the date of publication. In addition, the reference lists of retrieved studies, reviews and grey literature were scanned for other relevant studies. Each title and abstract was independently screened by two review authors to determine eligibility. In case of disagreement, a third reviewer made the final decision. 2.2. Selection criteria Articles published in English meeting the following criteria were included in the review: a. Types of studies: Only randomised controlled trials and quasi-randomised controlled trials were considered eligible for inclusion in meta-analyses. However, all study designs (including systematic reviews, controlled trials and case series) were eligible for inclusion in the review. b. Types of participants: Adults with traumatic brain injury. c. Types of interventions: Case management elements were defined as entry screening, assessment, planning, coordination, monitoring, review and exit/case closure planning. Elements of direct service provision and post-service evaluation were considered to be non-essential (Case Management Society of Australia, 2013). d. Types of outcomes: outcomes measured at the level of activity and/or participation (World Health Organization, 2013). 2.3. Assessment of characteristics of studies The AMSTAR checklist (AMSTAR, 2013) was used to assess the quality of systematic reviews and the PEDro scale (Physiotherapy Evidence Database, 2013) was used to assess the quality of controlled trials. Data from the included studies were extracted by two authors, and included study author name/s and date of study, study design, setting, number of participants, diagnosis, interventions, outcomes, and a summary description of findings. 2.4. Quantitative analysis Since case management is a complex intervention, primary outcomes were defined under the areas of readmission to acute or rehabilitation services, utilisation of health and social care services, cost, vocational
N.A. Lannin et al. / Case Management Review
outcome, living situation and quality of life of the person with TBI. We planned to use Hedges’s g to calculate the effect size of the different studies should meta analysis be appropriate (permitting adjustment for small sample bias). We planned to contact authors of articles by email to provide data and/or study details as required.
3. Results The search identified 655 potentially relevant articles. After screening for eligibility (including full text review where required), it was determined that six articles met the inclusion criteria. Of these, one was a systematic review (Chesnut et al., 1999; Patterson et al., 1999), three were non-randomised controlled trials (Ashley, Lehr, Krych, Persel & Feldman, 1994; Greenwood et al., 1994; Heinemann, Corrigan & Moore, 2004) (one of these conducted retrospectively) and the remaining two studies used a case series design (Malec, Buffington, Moessner & Thompson, 1995; Malec, Buffington, Moessner & Degiorgio, 2000). All studies were published prior to 2005. Details of the included studies are presented (see Table 1). Due to the range of research designs and characteristics it was not possible to pool studies and thus a narrative synthesis of studies is presented. 3.1. Characteristics of studies The systematic review (Chesnut et al., 1999; Patterson et al., 1999) was published in 1999 and included three studies (Ashley et al., 1994; Greenwood et al., 1994; Malec et al., 1995) which are also included in this review; the systematic review provided a narrative summary of studies and results. The review was associated with several methodological limitations as can be seen by the appraisal using the AMSTAR checklist (see Table 2). Sample sizes involved in the five clinical studies were relatively large (ranging from 39–217). The participant groups involved in the studies varied. Greenwood et al. (1994) recruited patients with severe head injury (with mean scores of 18/30 (extremely severe) on the Disability Rating Scale (DRS) (Rappaport, Hall, Hopkins, Berleza & Cope 1980) in the case managed group) whereas the participants recruited by Ashley et al. (1994) had a mean score of 5/30 (moderate) on the DRS. Heinemann et al. (2004) specifically recruited participants that had a dual diagnosis of traumatic brain injury
637
and post-injury alcohol abuse or dependence. The participants recruited by Malec et al. (2000) ranged from mild severity (21% of the group) to severe (56% of the group). The content of the case management program provided was often poorly described. While the characteristics of case management varied between studies there were commonalities including a focus on early intervention and linking with readily available services in the community. A wide range of outcome measures were used and included measures at the level of impairment, activity and participation (WHO, 2013) Measurement of vocational outcome and living situation were common across studies although the measurement tools used to asses these domains varied. Appraisal of the five clinical studies using the PEDro scale demonstrated that the methodological quality of the included studies was low; studies were often poorly reported and none of the studies used a true randomisation process; thus there were differences between the control and intervention groups. None of the studies reported that outcome assessments were conducted by blinded assessors. 3.2. Effect of intervention We were unable to identify any randomised controlled trials meeting our inclusion criteria and unable to conduct quantitative analyses. One controlled trial examined use of health and social care services and found that patients receiving case management were more likely to be referred to a rehabilitation unit (Odds Ratio (OR) 3.2, 95% Confidence Interval (CI) 0.7 to 14.8; p < 0.05) or outpatient services (OR 2.3, 95% CI 0.9 to 5.9; p < 0.05) (Greenwood et al., 1994). Once admitted, patients receiving case management did not have a longer length of stay in the rehabilitation unit than those without case management. Four of the studies reported on the vocational outcome for persons receiving case management (Ashley et al., 1994; Greenwood et al., 1994; Malec et al., 1995, 2000). One controlled trial found there were no significant differences in vocational outcome between the case management and the control group. In another controlled study there was limited evidence that a model involving one case manager and insurance carrier was more effective than a model involving multiple case managers and insurance carriers in improving vocational status at the time of discharge. Ashley et al. (1994) reported that patients with one case manager improved from a mean of 14.95 (not working) to 3.19 (part-time
Design and aim Systematic Review The aim of the review was to identify evidence of case management effectiveness in TBI rehabilitation
Controlled trial The aim was to examine the effects of early case management for patients with severe head injury on outcome, family function and provision of rehabilitation services
Retrospective case-controlled study The aim was to identify the impact of case management techniques and to clarify their relationship to patient recovery
Study
Patterson et al. (1999)
Greenwood et al. (1994)
Ashley et al. (1994)
Intervention Case management was described as including initial assessment, care-plan development, referral to other services, coordination of services and collaboration between care providers, informal caregivers and the client
Summary of main results
The authors provided a narrative review and comparison of the studies They reported that two studies demonstrated that case management improved vocational status. However, there was conflicting evidence regarding the impact of case management on function and other aspects of recovery N = 126 patients aged 16–60 with severe Patients were recruited within seven More of the patients receiving case head injury days of injury management were in contact with Patients were recruited from 11 hospitals in The intervention group received case rehabilitation or community services London management which involved Case management also increased the A coin toss was used to allocate patients assessment and development of a number of referrals to physiotherapy, (N = 56) from one of these groups of rehabilitation plan and facilitated occupational therapy, clinical hospitals to receive case management cooperation between the patient, psychology, social work and speech family and professionals. The case therapy manager provided general information There was no significant difference about head injury and informal between groups in regards to counselling and support but did not physical or cognitive impairment or provide formal treatment, retraining or social functioning education The control group received normal services N = 39 patients with TBI treated at a Group 1 participants (N = 21) were Both groups improved on the Disability post-acute rehabilitation facility covered by the same insurance carrier Rating Scale, Living Status Scale Patients were included if they had an initial and supervised by a single case and Occupational Status Scale Disability Rating Scale score of 10 or less manager between admission and discharge (Moderately Severe) and were involved Group 2 (N = 18) comprised patients Group 1 improved significantly more in a vocational rehabilitation program with different insurance carriers with on the DRS and OSS and the average Patients were then divided into two groups different case managers cost of rehabilitation was based on their different case management significantly less arrangements however, were matched based on criteria such as gender, time post injury, age and treatment
Participants This review included the three studies included in this review (Ashley, 1994; Greenwood, 1994; Malec, 1995)
Table 1 Summary of included studies
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Design and aim Case series The aim was to describe a medical and vocational case management system intended to decrease the time between injury and successful community integration Case series The aim was to evaluate the effects of a medical/vocational case coordination system
Controlled study The aim was to evaluate a community based approach to substance abuse using case management for persons with TBI
Study
Malec et al. (1995)
Malec et al. (2000)
Heinemann et al. (2004)
Participants
Adults with TBI and post-injury alcohol abuse or dependence The study involved patients treated at two facilities where case management was provided (N = 217). A control group was recruited from another facility which did not provide case management (N = 102)
Patients with traumatic or other acquired brain injury aged 18–65 years (N = 114). Patients were excluded if they had a primary psychiatric or substance abuse diagnosis or lived in residential care
People aged between 18 and 55 with a diagnosis of brain injury and no primary psychiatric or substance abuse diagnosis or reside in residential care. Data is presented for 147 patients including an in-depth case report for one patient
Table 1 (Continued) Intervention Early implementation of case management is provided by a nurse case coordinator and vocational case coordinator. Case management involves detailed assessment, linking with services and development of a reintegration plan The case management system is based on early intervention and the interface of a nurse case coordinator and vocational case coordinator. The coordinators ensure that patients access required medical services, rehabilitation, vocational rehabilitation and social services with assessment, linking and a reintegration plan Case management involved ensuring access to appropriate substance abuse treatment services, ensuring continuity between treatment phases and coordination of social services. Clients were also linked in to other relevant services such as vocational rehabilitation
Summary of main results
Participants in the case management group had higher levels of alcohol and drug use than the control group Both groups experienced increased community integration and health related quality of life. Patients in the case management group reported gains in life satisfaction whereas those in the control group did not
Vocational outcomes at 1 year follow up approached or exceeded initial benchmarks set
Data indicated a reduction in the amount of time between injury and initiation of vocational and other appropriate services since the commencement of the case management program
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N.A. Lannin et al. / Case Management Review Table 2 Quality of included studies Study
Study design
Patterson (1999) Greenwood (1994) Heinemann (2004) Ashley (1994) Malec (1995) Malec (2000)
Systematic Review Controlled Trial Controlled Study Retrospective Case-controlled Study Case Series Case Series
at former job or equal position) on an Occupational Status Scale whereas patients with multiple case managers made less improvement from 15.00 (not working) to 10.28 (volunteer). The difference between groups was statistically significant (P < 0.05). Two studies using a case series design reported positive vocational outcomes following a case management intervention; the majority of clients were placed in sheltered, supported, transitional or independent work and retention rates were high (Malec et al., 1995, 2000). Ashley (1994) found in their controlled study that patients receiving case management improved more on the Living Status Scale; on average improving from a status of ‘living in private quarters with professional help’ to ‘living in private quarters with no help’. Two studies reported on quality of life outcomes for the person with TBI (Greenwood et al., 1994; Heinemann et al., 2004). In their controlled trial, Greenwood et al. (1994) found no significant difference between groups at follow up on the General Health Questionnaire. There was limited evidence that case management for people with TBI and alcohol abuse or dependence is associated with increased life satisfaction in comparison to those that do not receive case management services. Another controlled trial (Heinemann et al., 2004) found that patients in both groups reported similar level of life satisfaction at commencement of the study however, patients receiving case management reported significant improvements (33.4 to 43.1 on the Satisfaction with Life Scale (Pavot & Diener, 1993)) whereas those not receiving case management did not (35.5 to 37.1). We found insufficient evidence to determine whether case management resulted in readmissions or reductions in the cost of care.
4. Discussion This review of case management for patients with TBI included one systematic review, three controlled
Evaluation tool
Score
AMSTAR checklist PEDro PEDro PEDro PEDro PEDro
3/11 2/10 2/10 1/10 1/10 1/10
studies and two studies using a case series design. Results of these studies suggested that there was limited evidence that case management increased contact with community services, improved vocational outcome and was associated with improved life satisfaction when provided to patients that had alcohol dependency or abuse. There was insufficient information to determine the effect of case management on other outcomes either for the patient, the organisation or the community. There was considerable heterogeneity between the included studies in regards to the participants included, the case management intervention and timing and type of outcome measures which also limited our ability to synthesise study results. Studies included in the review were of low methodological quality and published in or prior to 2004. Given the increase in research output in more recent years it is surprising that more recent studies have not been conducted. Particularly with the rising costs of health care placing pressure on health care services and increased survival rates of people with TBI. It should be acknowledged that there are limitations associated with this review. Firstly, we were unable to achieve our aim of pooling studies due to the lack of high quality studies meeting our inclusion criteria. Our inclusion criteria were broad and included all research types therefore it is felt that no relevant studies were excluded on this basis. Secondly, our search involved multiple databases however, we did not search clinical trial registers so it is possible that the review was susceptible to publication bias in which studies reporting negative findings associated with case management were not reported. Findings of the review reveal that at present, there is neither evidence for nor against the provision of case management for persons with TBI therefore implications for current practice are limited. Given the high cost of care associated with TBI, high quality research to determine the effectiveness of case management is urgently required. Ideally, research would utilise a randomised controlled trial design. While it may not seem
N.A. Lannin et al. / Case Management Review
ethical to randomise patients to programs without case management, research is required to justify the cost of case management services for future people with TBI as at present there is a lack of evidence that this approach improves patient outcomes.
5. Conclusion There is limited applicable research regarding case management outcomes and effectiveness. This review highlights a need to evaluate the impact of case management on outcomes for both the person with TBI and the community.
Funding The authors received no funding to conduct this review.
Conflicts of interest None.
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