Table 4.

Resource usage

Outcome	Type	Author, year	Findings	Evidence
Primary care	M_A	Stokes et al. (2015)	No effect on usage of primary and nonspecialist care (short-term: −0.08, 95% CI −0.22 to 0.05, I2 = 79.2%, P < 0.001, 16 studies; long-term: −0.10, 95% CI −0.29 to 0.09, I2 = 78.6%, P < 0.001, 7 studies)	Low consistency of evidence
	SR_A	Althaus et al. (2011)	2/6 studies confirmed a benefit of the intervention on the use of ambulatory care. One study reported an increase in primary care (19%; P = 0.003) and community care engagement (52%; P = 0.001) Another study described a significant increase in the median number of medical outpatient visits (1; P = 0.01) and a significant reduction in the number of patients lacking a primary care practitioner (−74%; P = 0.01).
	SR_A	Hickam et al. (2013)	CM does not reduce nursing home admissions for frail elderly (strength of evidence: low).
	SR_A	Low et al. (2011)	2/2 studies found an increased use of community services. 4/5 studies found a reduction in the risk of nursing home admission among CM patients, while 1/5 study found no difference.
	SR_A	You et al. (2013)	Moderate evidence of CMCAC interventions significantly improving clients’ use of some community care services (greater likelihood, higher intensity, higher frequency, and earlier use), delaying nursing home placement, reducing nursing home admissions, and shortening length of nursing home stays.
	SR_B	Eklund and Wilhelmson (2009)	The use of home services showed favorable results both in the intervention group (1/5 studies) and in controls (2/5 studies). Another 2 studies found no difference in primary care usage.
	SR_B	Oeseburg et al. (2009)	3/3 studies reported no difference in the number of nursing home admissions.
	SR_C	Lupari et al. (2011)	One study showed a reduction in General Practitioner (GP) contacts.
ED visits	SR_A	Althaus et al. (2011)	5/8 studies reported a decreased ED use. 2/8 studies reported no significant change. 1/8 studies reported an increased ED use. The magnitude of the decrease or increase was documented in 5 studies; the effect of the intervention on ED use was large in all these studies, with a decrease or increase in the mean or median number of ED visits ranging from 28% to 75%.	Low consistency of evidence
	SR_A	Low et al. (2011)	1/4 studies found a reduction in the risk of ED admission among CM patients. 2/4 studies found no difference. 1/4 studies found an increase in the risk of ED admission.
	SR_A	Soril et al. (2015)	RCTs: 1/2 studies reported no change in the mean number of ED visits following CM; 1/2 studies reported a slight decrease in median ED visits among patients in the intervention group. Comparative cohort studies: 8/9 studies observed a decrease in the mean (between −0.66 and −37 ED visits) or median (between −2.28 and −20 ED visits) number of ED visits compared to controls or before CM; 1/9 studies reported a 2.79 median increase in ED visits post-intervention.
	SR_B	Joo and Liu (2017)	5/6 studies reported a statistically significant reduction in the number of ED visits post-CM intervention. 1/6 studies found reductions in 30- or 90-day ED visit rates for the CM group compared with the control group, but the results were not significant.
	SR_B	Latour et al. (2007)	None of the 4 studies (2 low-quality, 2 high-quality) reported a positive effect on the number of ED visits.
	SR_B	Oeseburg et al. (2009)	One study reported a small but clinically relevant reduction in ED visits, while another one reported an increase in the number of ED visits.
	SR_C	Chiu and Newcomer (2007)	3/11 studies found significant reductions in presentations to an ED.
	SR_C	Hallberg and Kristensson (2004)	2/5 studies found fewer ED visits in the study group. 1/5 studies reported no effect on ED visits. 2/5 studies recorded more ED visits in the study group.
	SR_C	Hutt et al. (2004)	3/8 studies showed significant reductions in ED attendance following CM. 5/8 studies showed increases (2 significant and 3 nonsignificant) in ED attendance.
	SR_C	Kumar and Klein (2013)	8/11 studies reported a reduction in ED use. 2/11 studies reported no significant reduction. 1/11 studies reported an increase in ED use.
	SR_C	Lupari et al., 2011	2/3 studies found a reduction in ED admissions, while 1/3 studies reported no significant difference.
Hospital admissions	M_A	Huntley et al. (2013)	9/11 RCTs showed no significant benefit in terms of CM reducing unplanned hospital admissions compared with usual care. One study, which recruited >50% of electively admitted patients, showed a significant reduction in hospital readmissions. CM initiated in hospital (or on discharge) versus usual care in the older population: relative rate of readmissions = 0.71(95% CI 0.49 to 1.03) Heterogeneity: I2 = 0.08; χ2 = 7.13; df = 2 (P = 0.03); I2 = 72%. n studies = 3; Case management initiated in the community versus usual care in the older population: mean difference in admissions 0.05 (−0.04 to +0.15) Heterogeneity: χ2 = 1.44; df = 2 (P = 0.49); I2 = 0%. n studies = 3.	High consistency of evidence of CM having no effect
	M_A	Kim and Soeken (2005)	Overall OR for readmission in 10 studies: 0.87 with a 95% CI of 0.69 to 1.04. The effect size can be interpreted as a 6% decrease in readmissions for patients involved in a CM program. No evidence of heterogeneity was found among the studies (QT [total heterogeneity]= 13.24, df = 8, P > 0.10). The effect of CM interventions in reducing readmissions did not differ by diagnosis: heart failure: OR = 0.749 with 95% CI of 0.446 to 1.052 (4 studies); frail elders: OR = 0.971 with 95% CI of 0.754 to 1.188 (3 studies).
	M_A	Smith et al. (2016)	1/5 studies reported improvements for intervention group participants across a variety of measures relating to hospital admissions. 4/5 studies found no difference in admission-related outcomes.
	M_A	Stokes et al. (2015)	No effect on secondary care: short-term: 0.04, 95% CI −0.02 to 0.10, I2 = 39.6%, P = 0.027, 23 studies; long-term: −0.02, 95% CI −0.08 to 0.04, I2 = 22.8%, P = 0.194, 16 studies.
	SR_A	Althaus et al. (2011)	None of the 4 studies assessing hospitalization identified significant differences.
	SR_A	Hickam et al. (2013)	CM programs that serve patients with one or more chronic diseases do not reduce overall rates of hospitalization (strength of evidence: moderate). CM is more effective in reducing hospitalization rates among patients with a greater burden of disease (strength of evidence: low). CM is more effective in preventing hospitalizations when case managers have more personal contact with patients and physicians (strength of evidence: low). CM does not reduce acute hospitalizations for the frail elderly (strength of evidence: low).
	SR_A	Low et al. (2011)	2/3 studies found a reduction in the risk of hospital admission among CM patients, while 1/3 studies found no difference.
	SR_A	Purdy et al. (2012)	Case management initiated in hospital or on discharge versus usual care in the older population: relative rate of readmissions 0.71 (95% CI 0.49;1.03). CM initiated in hospital: 2 RCTs, one demonstrated a reduction of readmission and another no reduction. CM initiated on discharge from hospital: 3/4 RCTs showed no significant difference in unplanned hospital admissions between CM and usual care, while 1/4 showed a reduction in admissions. Case management initiated in the community versus usual care in the older population: mean difference in admissions 0.05 (95% CI −0.04;0.15). 4/5 RCTs showed no advantage of CM over usual care; one RCT showed a small, insignificant reduction in the relative rate of unplanned hospital admissions at 12 months with GP-led CM compared with usual care.
	SR_A	You et al. (2013)	No evidence that CMCAC interventions can significantly influence clients’ use of hospital care.
	SR_B	Joo and Liu (2017)	Readmission rate: 3/10 studies reported statistically significant reductions in hospital readmissions; 3/10 studies reported fewer readmissions but results were not statistically significant; 4/10 studies reported no effect on readmission rates. Total number of hospital visits for each participant: 2/2 studies found statistically significant reductions in the number of hospital visits.
	SR_B	Latour et al. (2007)	4/8 studies (3 high-quality and 1 low-quality) reported a positive result in the intervention group regarding readmission rates. 4/8 studies (2 high-quality and 2 low-quality) found no significantly better outcomes associated with CM.
	SR_B	Oeseburg et al. (2009)	One methodologically sound study reported a small but clinically relevant decrease in hospital admissions in the intervention group, whereas another study of lower methodological quality showed a negligible increase in hospital admissions in the experimental group.
	SR_B	Thomas et al. (2014)	1/2 studies found that seniors who received EOL CM for four weeks following hospital discharge were less likely to be hospitalized in the subsequent six months, compared to a control group. 1/2 studies found that case-managed elderly persons were more likely to be hospitalized and to use other health services during the last month of life than those who did not receive EOL CM.
	SR_C	Chiu and Newcomer (2007)	8/15 studies found statistically significant differences between treatment and comparison groups in unplanned readmissions: the intervention cases had differences of at least one-third fewer readmissions than the control cases. 7/15 studies found no significant differences.
	SR_C	Hallberg and Kristensson (2004)	In 5/9 studies the intervention group reportedly had fewer hospital (re)admissions. 4/9 studies found no effect on hospital (re)admissions.
	SR_C	Hutt et al. (2004)	5/16 studies (only two of which were RCTs) demonstrated significant reductions in admissions. 4/16 studies found reductions in admissions that did not reach statistical significance. 7/16 studies found no difference. 2/16 studies reported an insignificant increase in admissions.
	SR_C	Joo and Huber (2013)	3/4 studies found significant reductions in hospital admissions. 1/4 found no difference between the study and control groups.
	SR_C	Kumar and Klein (2013)	In one large RCT, CM intervention yielded only a small, insignificant reduction in hospital admission rates. 3 pre- and post-intervention studies identified no significant differences in hospital admission rates.
	SR_C	Lupari et al. (2011)	3/3 studies reported a reduction in hospital admissions.
Costs	M_A	Huntley et al. (2013)	5/5 RCTs reported favorable cost-outcome descriptions for CM compared with usual care.	Low consistency of evidence
	M_A	Stokes et al. (2015)	No significant effect was found on total costs of services (short-term: −0.00, 95% CI −0.07 to 0.06, I2 = 0.0%, P = 0.784, 8 studies; long-term: −0.03, 95% CI −0.16 to 0.10, I2 = 46.0%, P = 0.116, 5 studies)
	SR_A	Althaus et al. (2011)	In one RCT, total hospital costs were similar in the CM and the usual care groups when the costs of the intervention were factored in. Compared with usual care, CM was more cost-effective because it brought an improvement in clinical and social outcomes without adding to the overall costs. In 2 before-and-after studies, the intervention produced a cost saving: the reduction in hospital costs was larger than the cost of the CM team.
	SR_A	Hickam et al. (2013)	• CM programs that serve patients with one or more chronic diseases do not reduce Medicare expenditures (strength of evidence: high).
	SR_A	Purdy et al. (2012)	5/5 RCTs reported favorable cost outcomes for CM compared with usual care.
	SR_A	Soril et al. (2015)	2 RCTs: one reported a significantly smaller increase in the cost of care among patients exposed to the CM intervention compared to those in the control group (CM: $3116 added costs per patient versus control: $6659 added costs per patient; P < 0.01). The specific cost of the CM intervention was reportedly $3633 per patient. The other RCT estimated a 45% decrease in costs (statistically significant, P = 0.004). 4/4 comparative cohort studies reported lower hospital costs (i.e., ED and in-patient charges) per patient in the 12 months following a CM intervention.
	SR_A	You et al. (2013)	No evidence indicated that CMCAC interventions could significantly influence costs.
	SR_B	Eklund and Wilhelmson (2009)	1/4 studies showed a reduction in costs among CM clients. 3/4 studies reported no difference in costs between the study and control groups.
	SR_B	Joo and Liu (2017)	One study reported significant reductions in the total healthcare costs for the intervention group (45% less per person, P = 0.004). In another study, the cost of ED services decreased for the CM intervention group vis-à-vis the control group (P < 0.01), but the total hospital costs showed no difference between the two groups.
	SR_B	Oeseburg et al. (2009)	1/3 studies found extensive savings for the intervention group. 1/3 studies found statistically significant but practically negligible savings for the intervention group. 1/3 found a statistically insignificant increase in the costs for the intervention group.
	SR_B	Thomas et al. (2014)	4/6 studies found an economic benefit. 2/6 studies did not.
	SR_C	Boult et al. (2009)	1/3 studies found that CM was less expensive than usual care. 2/3 studies reported no difference in cost between CM and usual care.
	SR_C	Chiu and Newcomer (2007)	6/6 studies (3 of which addressed heart failure) showed lower expenditures in the intervention group. In most studies, comparisons were for hospital expenditures, but a few included community service expenditures and the cost of the intervention too.
	SR_C	Joo and Huber (2013)	According to these studies, community-based CM improved cost-effectiveness.
	SR_C	Kumar and Klein (2013)	3/4 studies (3 before-and-after studies) noted a significant reduction in ED costs among patients enrolled in CM interventions. 1/4 studies cited an insignificant reduction in ED-related costs.
Length of stay (LOS) in hospital	M_A	Kim and Soeken (2005)	CM intervention was not effective in reducing LOS: the overall average-weighted effect size (AWES) for 10 studies was 0.094 (Z = 1.46, P =.07) based on n = 2666 with a 95% CI of –0.032 to 0.220. CM was: effective for heart failure: AWES = 0.241 (Z = 2.059, P = .02) with a 95% CI of 0.012 to 0.470; not effective for stroke: AWES = –0.226 (Z = –1.404, P = .08) with a 95% CI of –0.542 to 0.089; not effective for frail elderly: AWES = 0.126 (Z = 1.242, P = 0.11) with a 95% CI of –0.073 to 0.324.	Low consistency of evidence
	SR_A	Low et al. (2011)	2/3 studies found no difference in LOS, while 1/3 studies found a reduction.
	SR_A	Purdy et al. (2012)	3/6 RCTs identified a significantly reduced LOS with CM compared to usual care. 3/6 RCTs did not provide this information (although one study showed a significant increase in the number of days elapsing before the first readmission).
	SR_A	You et al. (2013)	No evidence of CMCAC interventions being able to significantly influence clients’ use of hospital care.
	SR_B	Eklund and Wilhelmson (2009)	4/7 studies showed a reduction in the days spent in hospitals/institutions between CM patients and non-CM patients. 3/7 studies reported no difference in the days spent in hospitals/institutions between the two groups.
	SR_B	Joo and Liu (2017)	1/3 studies reported a significant (P = 0.005) difference one year after intervention (with 29% fewer days spent in hospital). 2/3 studies found reductions in LOS, but they were not statistically significant.
	SR_B	Latour et al. (2007)	4/6 studies (2 high-quality and 2 low-quality) showed a positive result in the intervention group. 2/6 studies (both of high quality) reported no significant differences compared to the control group.
	SR_B	Oeseburg et al. (2009)	Only 1/5 studies reported a negligible reduction in the number of days spent in a hospital per year in the intervention group.
	SR_C	Chiu and Newcomer (2007)	7/9 studies showed statistically significant reductions in the number of hospital readmission days or LOS. The differences in mean LOS were of the order of at least two days (and up to four days) and reflected a reduction of at least one-third in the number of days.
	SR_C	Hallberg and Kristensson (2004)	In 5/7 studies, the intervention group was reported to have a shorter LOS. 2/7 studies found no effect on number of days in hospital.
	SR_C	Hutt et al. (2004)	2/10 RCTs found a reduction in LOS. 8/10 RCTs found no statistically significant effects on overall LOS associated with CM. 2/6 non-RCTs demonstrated a significant difference in mean LOS. 4/6 non-RCTs did not find any significant differences associated with CM.
	SR_C	Joo and Huber (2013)	3/3 studies showed positive results for LOS.
	SR_C	Kumar and Klein (2013)	No significant reduction in medical inpatient days or psychiatric inpatient days associated with CM intervention.
	SR_C	Lupari et al. (2011)	1/3 studies found a reduction in LOS, while 2/3 reported no statistically significant difference.

M_A = high-quality meta-analyses; SR_A = high-quality systematic reviews; CMCAC = case management in community-aged care; SR_B = intermediate-quality systematic reviews; SR_C = low-quality systematic reviews; ED = emergency department; RCTs = randomized controlled trials; EOL CM = end-of-life care management.