Case management doesn’t reduce emergency admissions

Following the failure of two high profile case management schemes to reduce emergency admissions in England (Evercare and the DH Integrated Care Pilots), Sarah Purdy and colleagues in Bristol have published a systematic review and meta-analysis of the impact of case management interventions on hospital admissions (Huntley A et al Family Practice 2013 doi:10.1093/fampra/cms081). None of the five community based trials they reviewed showed a reduction in emergency admissions.

People find these results odd, as anecdotes abound describing admissions which have clearly been avoided. If some admissions are genuinely avoided, how come the schemes don’t show overall reductions in admission (or in the case of the Integrated Care Pilots, how can they show an increase in emergency admissions)?

My answer to this is ‘supply induced demand’ – a concept well known to health economists but to which policy makers are curiously blind. If you put in more services, employ more healthcare staff, they find things to do. In the case of frail elderly people they almost certainly find unmet need – some of which will result in hospital admission. So, some admissions may be avoided, but others occur as a result of the intervention. Net effect = zero.

Unfortunately it’s much easier to improve care than to save money.

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