Case Management for older people

The management and care of patients with long-term conditions has become a priority for the NHS. A Public Service Agreement target was announced earlier this year (2004) to reduce the number of emergency-bed days by 5 per cent from next year. 

This is set against a trend of rising emergency admissions, many of which are of elderly patients with multiple chronic diseases. The Government’s framework for long-term conditions aims to contribute to this target by promoting three broad approaches to improve care:

· Case management, or the provision of intensive, personally tailored care to the 3–5 per cent of people at greatest risk of hospital admissions

· Disease management to provide ongoing monitoring and review of patients with less severe clinical symptoms

· Support for self-management for the 70 per cent of people living with long-term conditions whose symptoms are largely stable.

These initiatives are in addition to ongoing work to improve long-term care, driven by various National Service Frameworks.

Case management has been defined as the process of planning, co-ordinating, managing and reviewing the care of an individual.

The broad aim is to develop cost-effective and efficient ways of co-ordinating services in order to improve quality of life.

Many forms of case management already exist in the NHS and new arrangements are emerging. The core elements of case management are case finding or screening, assessment, care planning, implementation, monitoring and review.

They may be undertaken as the specific job of a ‘case manager’ or as a series of tasks fulfilled by members of a team.

Recent evaluation of case-management pilots in England has shown that 3 per cent of patients over 65 years old account for 35 per cent of admissions.

By targeting this 3 per cent of patients with case management, Primary Care Trusts (PCTs) are expecting to see a reduction in emergency hospital admissions as a result of ‘upstream’ care to prevent deterioration and emergency admission.

There is currently only weak evidence for the effectiveness of case management in preventing admissions to acute care in elderly patients. Of the studies reviewed, five (only two of which were RCTs) demonstrated significant reductions in admissions, seven found no difference, and four found reductions in admissions that did not reach statistical significance. Two showed non-significant increases in admissions.

Source: King’s Fund

Back to top

NSAIDS in Osteoarthritis

A systematic review and meta-analysis of randomised placebo controlled trials was carried out to estimate the analgesic efficacy of non-steroidal anti-inflammatory drugs (NSAIDs), including selective cyclo-oxygenase-2 inhibitors (coxibs), in patients with osteoarthritis of the knee.

There were 23 trials including 10,845 patients, with a median age of 62.5 years. 7807 patients received adequate doses of NSAIDs and 3038 received placebo. The mean baseline pain score was 64.2 mm on 100 mm visual analogue scale (VAS), and average duration of symptoms was 8.2 years.

The main outcome measure was the change in overall intensity of pain.  The methodological quality of the trials was acceptable, but 13 trials excluded patients before randomisation if they did not respond to NSAIDs. One trial provided long term data for pain that showed no significant effect of NSAIDs compared with placebo at one to four years.

The pooled difference for pain on a visual analogue scale in all included trials was 10.1mm  or 15.6% better than placebo after 2-13 weeks. The results were very mixed, and the effect size for pain reduction was 0.32 in a random effects model.

In 10 trials that did not exclude non-responders to NSAID treatment the results were homogeneous, with an effect size for pain reduction of 0.23.

Overall NSAIDs can reduce short term pain in osteoarthritis of the knee slightly better than placebo, but this new analysis did not support long term use of NSAIDs for this condition.

As serious adverse effects are associated with oral NSAIDs, only limited use can be recommended.

Source: Web

Back to top

Parenteral metoclopramide for acute migraine

Migraine headache is a common problem in adult populations, with 6% of men and 15-17% of women experiencing around 36 episodes each a year. Migraine can be disabling; the average length of bed rest during an episode is 4.5 hours for men and 6.0 hours for women.

This impairs quality of life, limits daily activities, and strains personal and professional relationships. Migraine headaches have important economic effects due to lost productivity and increased utilisation of healthcare services.

A meta-analysis of randomised controlled trials was carried out to assess the evidence from controlled trials on the efficacy and tolerability of parenteral metoclopramide for acute migraine in adults.

They reviewed 596 potentially relevant abstracts and found 13 eligible trials totaling 655 adults. In studies comparing metoclopramide with placebo, metoclopramide was more likely to provide significant reduction in migraine pain (odds ratio 2.84, 95% confidence interval 1.05 to 7.68).

Used as the only agent, metoclopramide showed mixed effectiveness when compared with other single agents. Heterogeneity of studies for combination treatment prevented statistical pooling. Treatments that did include metoclopramide were as, or more, effective than comparison  treatments for pain, nausea, and relapse outcomes reported in all studies.

They conclude that metoclopramide is an effective treatment for migraine headache and may be effective when combined with other treatments. Given its non-narcotic and anti-emetic properties, metoclopramide should be considered a primary agent in the treatment of acute migraines in emergency departments.

Source: Web

Back to top