Reilly Siobhan, Miranda-Castillo Claudia, Malouf Reem, Hoe Juanita, Toot Sandeep, Challis David, Orrell Martin
Division of Health Research, Faculty of Health and Medicine, Lancaster University, C07 Furness Building, Lancaster, UK, LA1 4YG.
Cochrane Database Syst Rev. 2015 Jan 5;1(1):CD008345. doi: 10.1002/14651858.CD008345.pub2.
Over 35 million people are estimated to be living with dementia in the world and the societal costs are very high. Case management is a widely used and strongly promoted complex intervention for organising and co-ordinating care at the level of the individual, with the aim of providing long-term care for people with dementia in the community as an alternative to early admission to a care home or hospital.
To evaluate the effectiveness of case management approaches to home support for people with dementia, from the perspective of the different people involved (patients, carers, and staff) compared with other forms of treatment, including 'treatment as usual', standard community treatment and other non-case management interventions.
We searched the following databases up to 31 December 2013: ALOIS, the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group,The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS, Web of Science (including Science Citation Index Expanded (SCI-EXPANDED) and Social Science Citation Index), Campbell Collaboration/SORO database and the Specialised Register of the Cochrane Effective Practice and Organisation of Care Group. We updated this search in March 2014 but results have not yet been incorporated.
We include randomised controlled trials (RCTs) of case management interventions for people with dementia living in the community and their carers. We screened interventions to ensure that they focused on planning and co-ordination of care.
We used standard methodological procedures as required by The Cochrane Collaboration. Two review authors independently extracted data and made 'Risk of bias' assessments using Cochrane criteria. For continuous outcomes, we used the mean difference (MD) or standardised mean difference (SMD) between groups along with its confidence interval (95% CI). We applied a fixed- or random-effects model as appropriate. For binary or dichotomous data, we generated the corresponding odds ratio (OR) with 95% CI. We assessed heterogeneity by the I² statistic.
We include 13 RCTs involving 9615 participants with dementia in the review. Case management interventions in studies varied. We found low to moderate overall risk of bias; 69% of studies were at high risk for performance bias.The case management group were significantly less likely to be institutionalised (admissions to residential or nursing homes) at six months (OR 0.82, 95% CI 0.69 to 0.98, n = 5741, 6 RCTs, I² = 0%, P = 0.02) and at 18 months (OR 0.25, 95% CI 0.10 to 0.61, n = 363, 4 RCTs, I² = 0%, P = 0.003). However, the effects at 10 - 12 months (OR 0.95, 95% CI 0.83 to 1.08, n = 5990, 9 RCTs, I² = 48%, P = 0.39) and 24 months (OR 1.03, 95% CI 0.52 to 2.03, n = 201, 2 RCTs, I² = 0%, P = 0.94) were uncertain. There was evidence from one trial of a reduction in the number of days per month in a residential home or hospital unit in the case management group at six months (MD -5.80, 95% CI -7.93 to -3.67, n = 88, 1 RCT, P < 0.0001) and at 12 months (MD -7.70, 95% CI -9.38 to -6.02, n = 88, 1 RCT, P < 0.0001). One trial reported the length of time until participants were institutionalised at 12 months and the effects were uncertain (hazard ratio (HR): 0.66, 95% CI 0.38 to 1.14, P = 0.14). There was no difference in the number of people admitted to hospital at six (4 RCTs, 439 participants), 12 (5 RCTs, 585 participants) and 18 months (5 RCTs, 613 participants). For mortality at 4 - 6, 12, 18 - 24 and 36 months, and for participants' or carers' quality of life at 4, 6, 12 and 18 months, there were no significant effects. There was some evidence of benefits in carer burden at six months (SMD -0.07, 95% CI -0.12 to -0.01, n = 4601, 4 RCTs, I² = 26%, P = 0.03) but the effects at 12 or 18 months were uncertain. Additionally, some evidence indicated case management was more effective at reducing behaviour disturbance at 18 months (SMD -0.35, 95% CI -0.63 to -0.07, n = 206, 2 RCTs I² = 0%, P = 0.01) but effects were uncertain at four (2 RCTs), six (4 RCTs) or 12 months (5 RCTs).The case management group showed a small significant improvement in carer depression at 18 months (SMD -0.08, 95% CI -0.16 to -0.01, n = 2888, 3 RCTs, I² = 0%, P = 0.03). Conversely, the case management group showed greater improvement in carer well-being in a single study at six months (MD -2.20 CI CI -4.14 to -0.26, n = 65, 1 RCT, P = 0.03) but the effects were uncertain at 12 or 18 months. There was some evidence that case management reduced the total cost of services at 12 months (SMD -0.07, 95% CI -0.12 to -0.02, n = 5276, 2 RCTs, P = 0.01) and incurred lower dollar expenditure for the total three years (MD= -705.00, 95% CI -1170.31 to -239.69, n = 5170, 1 RCT, P = 0.003). Data on a number of outcomes consistently indicated that the intervention group received significantly more community services.
AUTHORS' CONCLUSIONS: There is some evidence that case management is beneficial at improving some outcomes at certain time points, both in the person with dementia and in their carer. However, there was considerable heterogeneity between the interventions, outcomes measured and time points across the 13 included RCTs. There was some evidence from good-quality studies to suggest that admissions to care homes and overall healthcare costs are reduced in the medium term; however, the results at longer points of follow-up were uncertain. There was not enough evidence to clearly assess whether case management could delay institutionalisation in care homes. There were uncertain results in patient depression, functional abilities and cognition. Further work should be undertaken to investigate what components of case management are associated with improvement in outcomes. Increased consistency in measures of outcome would support future meta-analysis.
据估计，全球有超过3500万人患有痴呆症，社会成本非常高。病例管理是一种广泛应用且大力推广的复杂干预措施，用于在个体层面组织和协调护理，目的是为社区中的痴呆症患者提供长期护理，作为早期入住养老院或医院的替代方案。
从不同参与人群（患者、护理人员和工作人员）的角度，评估病例管理方法对痴呆症患者家庭支持的有效性，并与其他形式的治疗进行比较，包括“常规治疗”、标准社区治疗和其他非病例管理干预措施。
我们检索了截至2013年12月31日的以下数据库：ALOIS、Cochrane痴呆与认知改善小组专业注册库、Cochrane图书馆、MEDLINE、EMBASE、PsycINFO、CINAHL、LILACS、科学网（包括科学引文索引扩展版（SCI-EXPANDED）和社会科学引文索引）、Campbell协作网/SORO数据库以及Cochrane有效实践与护理组织小组专业注册库。我们在2014年3月更新了此检索，但结果尚未纳入。
我们纳入了针对社区中痴呆症患者及其护理人员的病例管理干预措施的随机对照试验（RCT）。我们筛选了干预措施，以确保它们侧重于护理的规划和协调。
我们按照Cochrane协作网的要求使用标准方法程序。两位综述作者独立提取数据，并使用Cochrane标准进行“偏倚风险”评估。对于连续性结局，我们使用组间均值差（MD）或标准化均值差（SMD）及其置信区间（95%CI）。我们根据情况应用固定效应或随机效应模型。对于二元或二分数据，我们生成相应的比值比（OR）及其95%CI。我们通过I²统计量评估异质性。
我们在综述中纳入了13项RCT，涉及9615名痴呆症患者。研究中的病例管理干预措施各不相同。我们发现总体偏倚风险为低到中度；69%的研究存在执行偏倚的高风险。病例管理组在6个月时入住机构（养老院或疗养院）的可能性显著降低（OR 0.82，95%CI 0.69至0.98，n = 5741，6项RCT，I² = 0%，P = 0.02），在18个月时也是如此（OR 0.25，95%CI 0.10至0.61，n = 363，4项RCT，I² = 0%，P = 0.003）。然而，在10 - 12个月时的效果（OR 0.95，95%CI 0.83至1.08，n = 5990，9项RCT，I² = 48%，P = 0.39）和24个月时的效果（OR 1.03，95%CI 0.52至2.03，n = 201，2项RCT，I² = 0%，P = 0.94）不确定。一项试验有证据表明，病例管理组在6个月时每月在养老院或医院病房的天数减少（MD -5.80，95%CI -7.93至-3.67，n = 88，1项RCT，P < 0.0001），在12个月时也是如此（MD -7.70，95%CI -9.38至-6.02，n = 88，1项RCT，P < 0.0001）。一项试验报告了参与者在12个月时入住机构的时间长度，效果不确定（风险比（HR）：0.66，95%CI 0.38至1.14，P = 0.14）。在6个月（4项RCT，439名参与者）、12个月（5项RCT，585名参与者）和18个月（5项RCT，613名参与者）时，住院人数没有差异。对于4 - 6个月、12个月、18 - 24个月和36个月时的死亡率，以及4个月、6个月、12个月和18个月时参与者或护理人员的生活质量，没有显著影响。有一些证据表明在6个月时护理负担有改善（SMD -0.07，95%CI -0.12至-0.01，n = 4601，4项RCT，I² = 26%，P = 0.03），但在12个月或18个月时效果不确定。此外，一些证据表明病例管理在18个月时更有效地减少行为障碍（SMD -0.35，95%CI -0.63至-0.07，n = 206，2项RCT，I² = 0%，P = 0.01），但在4个月（2项RCT）、6个月（4项RCT）或12个月（5项RCT）时效果不确定。病例管理组在18个月时护理人员的抑郁有小幅显著改善（SMD -0.08，95%CI -0.16至-0.01，n = 2888，3项RCT，I² = 0%，P = 0.03）。相反，在一项研究中，病例管理组在6个月时护理人员的幸福感有更大改善（MD -2.20，CI CI -4.14至-0.26，n = 65，1项RCT，P = 0.03），但在12个月或18个月时效果不确定。有一些证据表明病例管理在12个月时降低了服务总成本（SMD -0.07，95%CI -0.12至-0.02，n = 5,276，2项RCT，P = 0.01），并且在三年总支出方面花费更低（MD = -705.00，95%CI -1,170.31至-239.69，n = 5,170，1项RCT，P = 0.003）。关于一些结局的数据一致表明干预组接受了显著更多的社区服务。
有一些证据表明病例管理在改善痴呆症患者及其护理人员在某些时间点的一些结局方面是有益的。然而，在纳入的13项RCT中，干预措施、测量的结局和时间点之间存在相当大的异质性。高质量研究有一些证据表明，中期养老院入住率和总体医疗保健成本有所降低；然而，更长随访期的结果不确定。没有足够的证据来明确评估病例管理是否可以延迟养老院入住。在患者抑郁、功能能力和认知方面结果不确定。应该进一步开展工作，以研究病例管理的哪些组成部分与结局改善相关。结局测量的一致性提高将有助于未来的荟萃分析。
