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Intensive case management: the targetted patient population matters as much as case-load size
- Phil Harrison-Read (9 March 2007)
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Response to Harrison-Read
- Tom Burns, Jenny Yiend, Peter Tyrer (28 March 2007)
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Phil Harrison-Read, Consultant Psychiatrist Department of Psychiatry, Royal Free Hospital, Pond Street, London NW3 2QG
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phil.harrison-read{at}royalfree.nhs.uk Phil Harrison-Read
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In their re-examination of data from the UK700 study of standard versus intensive case management (ICM), Burns et al (2007) conclude that although case-load size can affect the quantity and possibly the type and quality of community care delivered to people with severe psychotic disorders, there is no overall clinical advantage associated with any particular case-load size within the approximate range 1:10 to 1:20. The results of another RCT involving 193 'heavy users' of psychiatric inpatient services (Harrison-Read et al, 2002) can also help throw light on this issue. In this latter study, ICM was delivered in order to 'enhance' the care already being provided by the standard locality mental health service in a socially-deprived outer London borough. The case-load size of the standard service was 1:20 or more, and although the case-load size of the ICM team varied between only 1:8 and 1:15, and achieved an average 2.4 fold increase in community contacts compared to the standard service alone, overall the study intervention produced no statistically significant benefits e.g. on hospital bed use, direct costs of care or clinical outcomes. In about one fifth of the 'heavy user' subjects in the study group, patients' needs were already being adequately met by the standard service, and the study team did little more than serve a care-coordination role, with very low rates of community contact. These 'low-contact' subjects were mainly managed by the standard service, as of course were all the subjects in the control group. However after excluding the 'low contact' subjects in a post hoc analysis, there were still no measureable benefits from the study intervention. Since minimal intervention corresponds to greater 'virtual' case-load size (Burns et, 2007), the implication of this finding is that case-load size in the approximate range 1:10 to 1:20 does not have a major impact on health and cost outcomes of ICM in a sample of this type. By contrast, when the impact of the study intervention was re- examined in a subgroup of 'very heavy users' representing the upper quartile of the study sample (n=23), the health care costs were nearly halved in comparison to controls (n=25) (P<0.001). These 'very heavy users' tended to receive the most intensive care from the study team, with particular attention being paid to addressing vulnerability factors determining relapse and presentations which were likely to lead to hospital re-admission. This provisional finding implies that for this particular subgroup of subjects, targetted ICM which achieves improved costs and clinical outcomes might indeed benefit from or require small case-loads of around 1:10. This adds to the conclusion of Burns et al (2007) that as well as care structures such a case-load size, and the type and quality of care, it is also the targetted patient population that determines the impact of ICM. Declaration of interest: none. References. Burns, T., Yiend, J., Doll, H., et al (2007) Using activity data to explore the influence of case-load size on care patterns. British Journal of Psychiatry, 190, 217-222. Harrison-Read, P., Lucas, B., Tyrer, P., et al (2002) Heavy users of acute psychiatric beds: randomized controlled trial of enhanced community management in an outer London borough. Psychological Medicine, 32, 403- 416. |
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Tom Burns , Jenny Yiend, Peter Tyrer
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tom.burns{at}psych.ox.ac.uk Tom Burns, et al.
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Harrison-Read’s observation of the impact of ICM on hospitalisation in highly selected heavy service users confirms a clinical observation with which we would generally agree. The UK700 trial (Burns et al, 1999) generated considerable controversy and consequently we were reluctant to perform post-hoc analyses. Subsequent work has generally confirmed and, to some extent, explained the UK700 findings (Burns et al, 2002). It is quite possible that a low case-load size has particular advantages for some groups with severe mental illness and the UK700 study did find such benefit for those with comorbid borderline intelligence (Hassiotis et al, 2001); very heavy users of services may contain more of these comorbidities. We did not, however, conclude in our current paper (Burns et al 2007) that ‘..there is no overall clinical advantage associated with a particular case-load size within the approximate range 1:10 – 1:20.’ as Harrison-Read states. Our conclusions are more limited, namely that there is a change in practice across this range but we make no claims about its impact on outcome. Indeed we make clear that we cannot draw such conclusions because of the way in which our two proxy measures were constructed. If anything our findings confirm the likely importance of caseload size by demonstrating that different levels are associated with change in practice. The importance of our findings are that they challenge a strongly held belief that there is a predetermined caseload level at which ICM ‘switches’ to ACT. This view was frequently advanced to discount the UK700 trial’s results claiming the ICM caseload (1:15) was above this critical threshold. We agree wholeheartedly with Harrison-Read that clarity and precision about caseload size, content of care and effective targeting of the patient population are all necessary for both good clinical care and for meaningful research. We hope that researchers will move on from trying to explain away differences in outcome studies to exploring them to obtain a better understanding of which components are effective. Our original conclusion that 'how extra resource is used is more important than how it is organised' (Burns et al 1999) remains valid. Reference List Burns, T., Catty, J., Watt, H., et al (2002) International differences in home treatment for mental health problems. Results of a systematic review. British Journal of Psychiatry, 181, 375-382. Burns, T., Creed, F., Fahy, T., et al (1999) Intensive versus standard case management for severe psychotic illness: a randomised trial. The Lancet, 353, 2185-2189. Burns, T., Yiend, J., Doll, H., et al (2007) What is a small case- load in mental health? Using activity data to explore the influence of case-load size on care patterns. British Journal of Psychiatry 190, 217-222 Hassiotis, A., Ukoumunne, O.C., Byford, S., et al (2001). Intellectual functioning and outcome of patients with severe psychotic illness randomised to intensive case management: report from the UK700 case management trial. British Journal of Psychiatry, 178, 166-171. |
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