Case management for frail older people. Effects on healthcare utilisation, cost in relation to utility, and experiences of the intervention
The overall aim of this thesis was to investigate healthcare utilisation patterns and to explore the effects of a case management intervention for frail older people on healthcare utilisation and costs in relation to utility. A further aim was to explore the older people’s and case managers’ experiences of the intervention. Study I was a quantitative study comprising ten age cohorts aged between 60 and 96 years (n=1402). Baseline data and data on number and length of hospital stays for the six subsequent years were collected. Two pairs of groups; those who were dependent/independent in activities of daily living (ADL), and those at risk/not at risk of depression. In Studies II and III 153 people were randomly allocated to either a control group (n=73) or a group that received a case management intervention (n=80). Inpatient and outpatient healthcare utilisation data (Study II) and costs (Study III) for one year before baseline and for the study year were collected from registers. Data concerning health-related quality of life (HRQoL) used for calculations of Quality-adjusted life-years (QALY), informal care, municipal home care and municipal home services (Study III) were collected through structured interviews at baseline and 3, 6, 9 and 12 months after baseline. Study IV had a qualitative design and interviews were made with 14 participants who had received the case management in Studies II and III. Also six case managers were interviewed about 15 different participants, whom they had met in the intervention. Study I revealed similar utilisation patterns among those dependent/independent in ADL and those at risk/not at risk of depression with more hospital stays among ADL-dependent persons and those at risk of depression. Age was the only universal predictor for healthcare utilisation in all regression models. Other predictors found were previous healthcare utilisation and various symptoms, various diagnostic groups and various physical variables. Studies II revealed that the intervention group had a significantly lower mean number and proportion of emergency department visits not leading to hospitalisation, and lower mean number of visits to physicians in outpatient care. For the whole study year the intervention group had significantly less help with self-reported informal care in terms of provided hours and costs for help with Instrumental ADL (IADL). No significant differences were found for total cost or QALY of the one-year study. In Study IV the experience of the case management intervention was interpreted in two content areas: providing/receiving case management as a model and working as, or interacting with, a case manager as a professional. The findings in Study IV constituted four categories: case management as entering a new professional role and the case manager as a coaching guard, as seen from the provider’s perspective; and case management as a possible additional resource and the case manager as a helping hand, as seen from the receiver’s perspective. Case management appears to have some impact on healthcare utilisation, informal care, and is cost neutral. This may be explained by the intervention providing interpersonal continuity, coordination of care, someone that discovers problems, support in a long term strong relationship and the case managers’ ability to work in close collaboration with primary care. The overall aim of this thesis was to investigate healthcare utilisation patterns and to explore the effects of a case management intervention for frail older people on healthcare utilisation and costs in relation to utility. A further aim was to explore the older people’s and the case managers’ experiences of the intervention. Study I was a quantitative study comprising ten age cohorts aged between 60 and 96 years (n=1402) drawn from the Swedish National Study on Aging and Care (SNAC). Baseline data were collected between 2001 and 2003 and data on number and length of hospital stays were collected for the six years after the baseline year. The sample was divided into two pairs of groups; those who were dependent/independent in activities of daily living (ADL), and those at risk/not at risk of depression. The six years period of healthcare utilisation was also divided into utilisation 1-2, 3-4, and 5-6 years after baseline. Studies II and III had an experimental design where 153 people were consecutively and randomly allocated to either a control group (n=73) or a group that received a case management intervention (n=80). Included were those aged 65+ years who lived in their ordinary homes, were dependent in two or more ADL, and had had at least two hospital stays, or four physician visits, in the previous year. Data concerning inpatient (hospital stays and length of stay) and outpatient healthcare utilisation (contacts with physician or other healthcare professionals, and emergency department visits) (Study II) and costs (Study III) for the year before baseline and for the one year study were collected from registers. Data concerning health-related quality of life (HRQoL) used for calculations of Quality-adjusted life-years (QALY), informal care, municipal home care and municipal home services (Study III) were collected through structured interviews at baseline and 3, 6, 9 and 12 months after baseline. Study IV had a qualitative design and interviews were made with 14 participants who had received the case management intervention in Studies II and III, and six case managers who had performed the intervention. The case managers were interviewed about a total of 15 different participants, whom they had met in the intervention. The interviews were analysed with content analysis. Study I revealed a significant increase in hospital stays in all groups over time. ADL-dependent persons and those at risk of depression had significantly more hospital stays, except for those at/not at risk of depression in years 2, 4 and 5. Main predictors for healthcare utilisation 5-6 years after baseline were age, previous healthcare utilisation and various symptoms; and at 1-2 and 3-4 years after baseline, age, various diagnostic groups and various physical variables. Thus healthcare utilisation patterns seem to be similar for the different groups over the six years, but it is difficult to find universal predictors. In Studies II and III there were no differences between the interventions and control groups were found at baseline (in demographics, baseline characteristics, in or outpatient healthcare utilisation, utilisation in informal care, municipal home care, municipal home services or costs). The results showed that, compared to the control group, the intervention group had significantly lower mean number and proportion of emergency department visits not leading to hospitalisation 6-12 months after baseline (0.08 vs. 0.37, p=0.041 and 16.7 vs. 46.9%, p=0.012, respectively). The intervention group also had a significantly lower mean number of visits to physicians in outpatient care 6-12 months after baseline (4.09 vs. 5.29, p=0.047). The intervention group had significantly less help with self-reported informal care in terms of provided hours and cost for help with Instrumental ADL (IADL) during the one-year study (200 vs. 333 hours per year, p=0.037; €3927 vs. €6550, p=0.037). There were no significant differences between the intervention group and control group in terms of total cost of the one-year study, or QALY. Study IV showed that the experience of the case management intervention could be interpreted according to two content areas: providing/receiving case management as a model and working as, or interacting with, a case manager as a professional. The findings in Study IV constituted four categories: case management as entering a new professional role and the case manager as a coaching guard, as seen from the provider’s perspective; and case management as a possible additional resource and the case manager as a helping hand, as seen from the receiver’s perspective. Each category constituted different subcategories, all reflecting aspects of the respective category. The results indicate that the population of older people are heterogeneous which may be one reason for the difficulties to find universal predictors for healthcare utilisation. This may also be the reason for the lack of effects on hospital stays, length of stay, and HRQoL in the case management studies. However, the case management intervention appears to have effects in emergency department visits not leading to hospitalisation, visits to physician in outpatient care, in informal care, and is cost neutral. This indicates that the case management intervention seems to have impact on the situation; not only for the older person, but also their informal caregivers. Possible features of the case management intervention that may explain these effects may be interpersonal continuity, coordination of care, someone that discovers problems and potential problems, support in a long term strong relationship and the case managers’ ability to work in close collaboration with primary care. Further investigations about the process and delivery of the intervention are needed in the future to determine the efficacy of the intervention. Also long-term follow-ups are needed since 12 months may be too short to see effects on for HRQoL.
Health Sciences, Nursing, Intervention Studies, Hospitalisation, Informal Caregiver, Case Management, Content Analysis, Registries, Healthcare Utilisation, Frail Elderly, Complex intervention, Healthcare Costs
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