Impact of case management (Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data

Abstract

Objectives: To determine the impact on outcomes in patients of the Evercare approach to case management of elderly people.

Design: Practice level before and after analysis of hospital admissions data with control group.

Setting: Nine primary care trusts in England that, in 2003-5, piloted case management of elderly people selected as being at high risk of emergency admission.

Main outcome measures: Rates of emergency admission, emergency bed days, and mortality from April 2001 to March 2005 in 62 Evercare practices and 6960-7695 control practices in England (depending on the analysis being carried out).

Results: The intervention had no significant effect on rates of emergency admission (increase 16.5%, (95% confidence interval -5.7% to 38.7%), emergency bed days (increase 19.0%, -5.3% to 43.2%), and mortality (increase 34.4%, -1.7% to 70.3%) for a high risk population aged >65 with a history of two or more emergency admissions in the preceding 13 months. For the general population aged > or =65 effects on the rates of emergency admission (increase 2.5%, -2.1% to 7.0%), emergency bed days (decrease -4.9%, -10.8% to 1.0%), and mortality (increase 5.5%, -3.5% to 14.5%) were also non-significant.

Conclusions: Case management of frail elderly people introduced an additional range of services into primary care without an associated reduction in hospital admissions. This may have been because of identification of additional cases. Employment of community matrons is now a key feature of case management policy in the NHS in England. Without more radical system redesign this policy is unlikely to reduce hospital admissions.

Fig 1 Emergency admission rates in two high risk cohorts in Evercare and control practices. Period 3 (last before intervention): 1 October 2002 to 31 March 2003; period 6 (last intervention period): 1 October 2004 to 31 March 2005. Emergency admission rate in period is number of admissions in period divided by initial size of cohort at 1 July 2001 (for before intervention) or 1 July 2003 (for during intervention) all multiplied by 2. Bars on vertical lines denote 95% confidence intervals

Fig 2 Emergency admission rates for general population aged ≥65 in Evercare and control practices. Before intervention: period 1: 1 July 2001 to 31 March 2002; period 2: 1 April 2002 to 30 September 2002; period 3: 1 October 2002 to 31 March 2003). During intervention: period 4: 1 July 2003 to 31 March 2004; period 5: 1 April 2004 to 30 September 2004; period 6: 1 October 2004 to 31 March 2005