Case management for integrated care of older people with frailty in community settings

**Background:** Ageing populations globally have led to an increase in the number of people living with frailty, a health state characterized by reduced physiological reserves and increased susceptibility to adverse outcomes such as functional decline, hospitalisation, and mortality. Case management, a model of integrated care involving a designated care coordinator and a multidisciplinary team, has been proposed as a strategy to improve outcomes for this complex population. However, evidence for its effectiveness has been conflicting. This Cochrane review aimed to assess the effects of case management for integrated care of older people with frailty in community settings compared to usual care.

**Methods:** The review followed standard Cochrane and Effective Practice and Organisation of Care (EPOC) Group methods. The authors searched multiple electronic databases (CENTRAL, MEDLINE, Embase, CINAHL, Health Systems Evidence, PDQ Evidence) from inception to 23 September 2022, as well as clinical trial registries and grey literature. They included randomized controlled trials (RCTs) that compared case management with standard care in community-dwelling people aged 65 years and older living with frailty. Two review authors independently screened studies, extracted data, and assessed risk of bias using EPOC criteria. The GRADE approach was used to assess the certainty of the evidence. The primary outcomes were mortality, change in place of residence to a nursing home, quality of life, and serious adverse effects. Secondary outcomes included change in physical function, healthcare utilisation, costs, and patient satisfaction.

**Key Results:** The review included 20 trials with a total of 11,860 participants, all conducted in high-income countries. The interventions varied in their organisation, delivery, and providers. Follow-up ranged from 3 to 36 months. Most trials were judged at unclear risk of selection and performance bias.

For the primary outcomes, case management compared to standard care may result in little or no difference in: - Mortality at 12 months: 7.0% in the intervention group versus 7.5% in the control group (risk ratio [RR] 0.98, 95% confidence interval [CI] 0.84 to 1.15; I² = 11%; 14 trials, 9924 participants; low-certainty evidence). - Change in place of residence to a nursing home at 12 months: 9.9% in the intervention group versus 13.4% in the control group (RR 0.73, 95% CI 0.53 to 1.01; I² = 0%; 4 trials, 1108 participants; low-certainty evidence). - Quality of life at 3 to 24 months: results were not pooled; mean differences (MDs) ranged from -6.32 points (95% CI -11.04 to -1.59) to 6.1 points (95% CI -3.92 to 16.12) (11 trials, 9284 participants; low-certainty evidence). - Serious adverse effects at 12 to 24 months: results were not pooled; two trials (592 participants) found little or no difference (low-certainty evidence). - Change in physical function at 3 to 24 months: results were not pooled; MDs ranged from -0.12 points (95% CI -0.93 to 0.68) to 3.4 points (95% CI -2.35 to 9.15) (16 trials, 10,652 participants; low-certainty evidence).

For the secondary outcomes, case management compared to standard care probably results in little or no difference in: - Healthcare utilisation (hospital admissions) at 12 months: 32.7% in the intervention group versus 36.0% in the control group (RR 0.91, 95% CI 0.79 to 1.05; I² = 43%; 5 trials, 2424 participants; moderate-certainty evidence). - Change in costs at 6 to 36 months: results were not pooled; most of the 14 trials (8486 participants) reported little or no difference (moderate-certainty evidence).

**Clinical Implications:** The findings of this review provide low to moderate certainty evidence that case management for integrated care of older people with frailty in community settings does not lead to clinically meaningful improvements in mortality, nursing home admission, quality of life, physical function, hospital admissions, or costs compared to usual care. The authors note that the interventions were heterogeneous and that there was insufficient information to identify which components of case management might be effective or which patient subgroups might benefit. They conclude that there is a need for further research to develop a clear taxonomy of intervention components and to determine the active ingredients of case management. The current evidence does not support the widespread implementation of case management for this population to improve the outcomes measured in this review.