Cost-effectiveness of Case Management: A Systematic Review

ABSTRACT

Objectives: In this time of aging and increasingly multimorbid populations, effective and efficient case management approaches play a crucial role in supporting patients who are navigating complex health care systems. Until now, no rigorous systematic review has synthesized studies about the cost-effectiveness of case management.

Study Design: A systematic review was performed.

Methods: The bibliographic databases PubMed and CINAHL Plus were systematically searched using key blocks and synonyms of the terms case management, effectiveness, and costs. The methodological quality of the studies was assessed using the Consensus Health Economic Criteria list.

Results: A total of 29 studies were included. In 3 studies, the intervention was less effective and more costly than the control group and can therefore be considered not cost-effective. Two studies found that the intervention was less effective and less costly. A more effective and less costly intervention, and therefore a strong recommendation for case management, was found in 6 studies. In 17 studies, the intervention was more effective while being more costly. Nearly half of the studies met most of the quality criteria, with 16 or more points out of 19.

Conclusions: Existing studies often have adequate quality and, in many cases, show cost-effective or even cost-saving results. Case management appears to be a promising method to support patients facing complex care situations. However, variation among case management approaches is very high, and the topic needs further study to determine the most cost-effective way of providing such care coordination.

Am J Manag Care. 2022;28(7):e271-e279. https://doi.org/10.37765/ajmc.2022.89186

Takeaway Points

• Case management approaches play a crucial role in supporting patients who are navigating complex health care systems.
• Case management intervention studies often have adequate quality and, in many cases, show cost-effective or even cost-saving results.
• Variation among case management approaches is very high, and the topic needs further study to determine the most cost-effective way of providing such care coordination.

Health systems around the world are getting more complex. This increasing complexity may affect patients’ ability to access the right health services at the right time. This struggle to navigate the system has individual implications for the care seeker’s well-being and economic implications when it results in wasting the health system’s scarce resources and delaying the provision of the right treatment to the right patient or providing unnecessary care. Case management programs intend to guide individuals with complex medical needs through the health system to improve health service effectiveness and the efficiency of service provision. The concept of case management is not new; it has been practiced in the United States for more than a century, primarily in the disciplines of nursing and social services.¹ Case management programs are generally designed to tackle the challenges of episodic care, which are often fraught with inadequate transitions between care services and health care settings. The programs aim to coordinate fragmented services by providing guidance to individuals, attempting to improve health service effectiveness and reduce cost. Ideally, a case management program facilitates communication and the coordination of care, and its collaborative practice includes patients, caregivers, nurses, social workers, physicians, payers, support staff, other practitioners, and the community.²

The oldest and largest case management membership organization in the world, the Case Management Society of America, which facilitates the growth and development of case management, defines case management as “a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost-effective outcomes.”³ As defined by the UK-based Medical Research Council as well, case management is quite complex.⁴ The complexity of case management interventions arises from, among other factors, the number of groups or organizational levels targeted by the intervention, the number and variability of outcomes, the number and difficulty of behaviors required by those delivering or receiving the intervention, and the degree of flexibility or tailoring of the intervention. Furthermore, there is complexity in the intervention components, among them case finding and assessment, case planning, navigation and coordination, monitoring, and reviewing of the case plan. These components aim to improve continuity of care and to enhance patients’ self-management skills and hence are intended to increase efficiency within the health care system.

Especially in regard to the aging multimorbid population, case management may play an important role in the support of patients facing complex care situations. With better coordination, it is posited, the health system’s ability to provide high-quality care and maintain resource requirements can improve. One recent analysis of case management’s effectiveness is the RubiN project (funded by the Federal Joint Committee’s German Innovations Fund), which is evaluating the implementation of case management for geriatric patients. The goal of RubiN is to develop a form of care throughout Germany that enables older people to remain in their homes for as long as possible. It is hoped that by case managers informing and guiding patients and their (caretaking) relatives, the quality of treatment will rise—by closing gaps in care—and support will be provided to physicians—by conserving scarce personnel resources.

Here, we set out to provide an overview of the evidence regarding cost-effectiveness of case management; until now, no systematic review has been conducted on this topic. Yet systematic reviews that have been done on case management’s overall effectiveness are promising: They have found that case management can effectively reduce hospital use and improve satisfaction with care when chronic illnesses are present.^5-7 Furthermore, a systematic review of reviews has found evidence that case management interventions reduce health care utilization in patients with chronic illnesses.⁸

However, the question of whether case management is cost-effective has so far not been adequately addressed. Further, it is unclear whether cost-effective case management interventions have certain characteristics in common. The aim of this systematic review is therefore to investigate the cost-effectiveness of case management.

METHODS

Objectives and Study Design

The objective of this systematic review was to synthesize the evidence for cost-effectiveness of case management.We conducted a systematic review of the literature following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.⁹ Also, this review reported according to the PICOS (Population, Intervention, Comparison, Outcomes, Setting) Framework.¹⁰ A protocol was developed before searching electronic databases.

Eligibility Criteria

Inclusion and exclusion criteria are outlined in Table 1. Briefly, the review included cost-effectiveness studies that compare case management interventions with usual care. Model-based studies were excluded. No limits were applied to language and publication date.

Electronic Bibliographic Database Searches

The bibliographic databases PubMed and CINAHL Plus were systematically searched using key blocks of the terms case management, effectiveness, and costs and their synonyms. A complete search strategy list is provided in the eAppendix (available at ajmc.com).

Study Selection

Two authors (A.K.K. and J.J.) independently screened titles and abstracts from unduplicated references. The full text was reviewed when a decision was not possible from reading the abstract. Any discrepancies were resolved by discussion.

Data Collection and Synthesis

Data were collected using an extraction form developed to retrieve relevant information. This included study characteristics (nation, setting, patient group and sample size, comparison group, study design, type of economic evaluation, study duration), case management characteristics (case management model [with description], intensity of intervention, team or single case manager, training received, supervision, 24-hour availability of case manager, caseload per manager/team), and outcome characteristics (outcome measures, costs included, cost perspective, time horizon, cost analysis method, findings, sensitivity analysis/uncertainty assessment). The studies were summarized and synthesized by the first author independently. The extraction table is provided in the eAppendix.

Quality Assessment

The methodological quality of the cost-effectiveness analyses was assessed by the Consensus Health Economic Criteria (CHEC) list.¹¹ If a study qualified in a criterion, it scored 1; otherwise, it scored 0. Thus, this tool’s range was 0 to 19. In cases in which criteria were not applicable (eg, the question about the appropriate discount rate in a year-long study), the overall achievable score was reduced. Quality appraisal was verified by a second reviewer.

RESULTS

Study Selection

A total of 2388 unduplicated studies were retrieved from the database searches. After reading titles and abstracts, 61 full texts were analyzed, and inclusion and exclusion criteria were applied. From these, 32 studies were excluded. The remaining 29 studies were included in the qualitative analysis of the review. A flow diagram of this process, according to PRISMA guidelines, is presented in Figure 1.⁹

Quality Assessment

The results of the CHEC list show that nearly half of the studies (n = 13) met most of the quality criteria (≥ 16 of 19).^12-24 The main limitations were the narrow perspective chosen, as only about a quarter (n = 7) of all studies chose a broad societal perspective,^{12,16,17,20,23,25,26} and the chosen short time horizon, which was only 1 year in about half the studies (n = 14).^{13,16,19,26-36}

Study Characteristics

Studies were from the United States (n = 12)^{13-16,18,28,29,34,35,37-39} more than from any other nation, followed by studies from Germany (n = 8),^{12,20,21,24,26,30,31,33} the Netherlands (n = 4),^17,19,22,23 the United Kingdom (n = 2),^32,40 Sweden (n = 1),²⁵ Denmark (n = 1),³⁶ and Canada (n = 1).²⁷ Except for one,³³ all studies were trial-based economic evaluations, assessing the cost-effectiveness of case management compared with usual care. Twenty-two of the economic evaluations were based on randomized controlled trials (RCTs)^{12-16,18,20-30,32,34,36,39,40}; the rest used non-RCT designs, such as nonrandomized controlled observational studies. Twenty of the studies adopted a health care system perspective in the analysis.^{13-15,19,21,24,27-40} A societal perspective was adopted by 7 studies.^{12,16,17,20,23,25,26} One study took the employers’ perspective.¹⁸ One study adopted a health care perspective, a social care perspective, and a societal perspective.²²

Patient Groups

The patient group represented more than any other (see Table 2^12-40) were those with psychiatric disorders (n = 9), such as depressive disorders, anxiety, and/or posttraumatic stress disorder^{12,15,16,18,22,30,31,35,39}; they were followed by older patients (n = 4),^19,25,29,38 patients with dementia (n = 3),^17,24,33 and patients with diabetes (n = 2).^13,37 Further, several studies included patients belonging to more than 1 patient group, such as patients with diabetes and depression,¹⁴ older patients with depression,^32,40 and older patients with myocardial infarction.^20,26 The rest of the studies included patients with HIV,²³ chronic obstructive pulmonary disease,^27,36 elevated blood pressure,²⁸ hypercholesterolemia,³⁴ and a long-term indication for oral anticoagulation therapy.²¹

Case Management Model

In most studies, the case management interventions were described in enough detail to identify the program components. These components are case finding and assessment, case planning, navigation and coordination, monitoring, and reviewing of the case plan (Table 2^12-40).

The component of monitoring could be found in most descriptions of the case management intervention: Symptom monitoring and regular visits or telephone calls were described in 24 studies. Furthermore, the case management models often included navigation and coordination (n = 19) and health education (n = 17) components, such as informing the patient about the disease, counseling on general health behavior, emphasizing lifestyle changes, and promoting treatment adherence, self-care, and autonomy.

A combination of the components of monitoring and health education was often described,^{13,15,21,23,27} as was the combination of monitoring and navigation/coordination.^{14,32,37,39,40}

A case management model with all components (assessment, case planning, navigation and coordination, monitoring, and health education) was described in 5 studies.^{22,25,28,29,36}

Case Managers

Case managers were nurses, health care assistants, social workers, physiotherapists, clinical therapists, pharmacists, and mental health workers. About half the studies (n = 14) stated that the case managers received training beforehand. The scope of the training received was heterogenous, with a duration of several hours, 2 days, or even 2 weeks. Case managers worked alone, although they frequently collaborated closely with the patient’s physician. Caseloads ranged between 10 and 76 patients, although 1 study analyzing a telecommunication-supported case management model stated a caseload of up to 120 less-active cases.³⁵

Outcomes and Costs

Highly heterogeneous among the studies were the outcomes. They included patient utility measures (eg, quality of life with EuroQol 5-dimension instrument, Short Form-36 questionnaire, World Health Organization Quality of Life), patient health effect measures (eg, mortality, symptoms, functioning in activities of daily living), other patient-relevant measures or system measures (eg, outpatient contacts, time in patients’ home environment, absenteeism), and situational program measures (eg, quality of parenting, abstinence).

Depending on the perspective chosen, intervention costs, direct medical costs (eg, inpatient and outpatient costs, emergency department costs, medication costs), direct nonmedical costs (costs for social support services [eg, community care such as nurse care and family support]), and indirect costs (eg, informal care costs and productivity losses) were included in the analyses of the studies. A table of perspectives chosen and costs included is provided in the eAppendix.

Economic Analyses

Findings regarding the economic analyses, the classification within the cost-effectiveness plane, and the results of the quality assessment using the CHEC list are listed in the results grid (Table 3 [part A and part B]^12-40).

All except 2 studies^20,25 included an incremental analysis of costs and outcomes; most calculated an incremental cost-effectiveness ratio (n = 24) and conducted a sensitivity analysis (n = 24).

In Figure 2, results are visualized in a cost-effectiveness plane, which is used to visually represent the differences in costs and health outcomes (effects) between treatment alternatives in 2 dimensions by plotting the costs against effects on a graph. Effects and costs are plotted on the x-axis and y-axis, respectively. The cost-effectiveness plane includes 4 quadrants: northwest (NW), southwest (SW), northeast (NE), and southeast (SE).

In 3 studies, the intervention was less effective and more costly than the control group (NW quadrant) and can therefore be considered not cost-effective.^19,30,35 The intervention is dominated by usual care.

Two studies found that the intervention was less effective and less costly (SW quadrant). One of these studies found that both costs (–€17.61) and effects (–0.0163 quality-adjusted life-years [QALYs]) were lower in the intervention group; therefore, the incremental cost-effectiveness ratio (€1080/QALY) represents the savings per additional QALY lost.²⁶ A study from the Netherlands,¹⁷ which analyzed the cost-effectiveness of case management for patients with diagnosed dementia and their informal caregivers, found that the intervention saves costs and there is an approximately 45% chance that the intervention also has positive effects.

A more effective and less costly intervention (SE quadrant), and therefore evidence for cost-effectiveness, was provided in 6 studies.^{12,20,24,27-29}

The majority of studies (n = 18) found that the intervention was more effective while being more costly (NE quadrant). Of these, 7 studies reported incremental cost-effectiveness ratios below a willingness-to-pay threshold of US$50,000 for the gain of 1 QALY.^{14,16,21,23,32,36,40} Only 1 study used QALYs and found that case management is not cost effective at US$50,000.¹³ The remaining studies either used different outcome measures or did not provide a recommendation.

Case management interventions across all studies varied considerably. In cost-effective case management interventions, no patterns of common characteristics, such as case management model, type of case manager, or patient group, could be identified. No correlation of cost-effectiveness with a certain kind of health care system, study design, or time horizon could be observed either. Therefore, it remains unclear what makes some case management interventions cost-effective.

DISCUSSION

To our knowledge, this is the first systematic review that systematically synthesized studies to identify the cost-effectiveness of case management interventions. We identified 29 studies, which were published between 2000 and 2019. All studies compared case management to usual care without case management.

The results of the quality assessment of economic evaluations show that the quality of the included studies is good, although most studies chose a payer’s perspective and therefore did not include indirect costs such as productivity losses. In addition, in about half of all studies, the chosen time horizon was only 1 year. This is a short observation period, not appropriate to capture all relevant outcomes, because case management effects might be visible only after longer periods of time. In addition, considering that at the beginning of an intervention, costs of case management can be considerably higher because of up-front training costs, a relatively short study period of only 1 year might distort results. Results of the KORINNA studies illustrate this: After 1 year the case management for elderly patients with myocardial infarction was deemed less effective and less costly than usual care,²⁶ but a follow-up after 3 years²⁰ showed higher QALYs, significantly better quality of life, and lower costs (although not significantly lower). Hence, longer study durations are strongly recommended.

To provide successful case management, case managers require specialized training. However, only half of the studies stated that the case managers received training. A detailed description of the scope and content of training was scarce. The same applies for data on caseloads and descriptions of the intensity of case management—in other words, the patient contacts. We therefore recommend that studies provide detailed intervention protocols.

Limitations

The studies included conducted their interventions in 7 nations in which transferability of the data and conclusions to the German context was possible. Evidence from low- and middle-income countries was not included in this systematic review, and therefore its results may not be broadly applicable.

CONCLUSIONS

This systematic review found that because of a large variation in case management programs, the evidence for cost-effectiveness is not yet fully conclusive for case management in general. More definitive studies with a defined protocol of case management are needed to determine cost-effectiveness. However, the existing studies often have adequate quality and, in most cases, produce recommendable conclusions. The confluence of highly developed health systems, fragmented health care services, and aging populations with multimorbidity is a situation that calls out for individualized coordination and support. Case management appears to be a promising method to support patients facing complex care situations. We therefore advise policy makers to establish case management programs as core components of effective, patient-oriented health care systems, and to support rigorous evaluation of each program. 

Author Affiliations: inav – Institute for Applied Health Services Research (AKK, JJ, FF, MA), Berlin, Germany.

Source of Funding: This study was conducted in the context of the research project RubiN, funded by the Federal Joint Committee’s German Innovations Fund.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (AKK, JJ, FF, MA); acquisition of data (AKK, JJ); analysis and interpretation of data (AKK, MA); drafting of the manuscript (AKK); critical revision of the manuscript for important intellectual content (JJ, FF, MA); administrative, technical, or logistic support (AKK, FF); and supervision (MA).

Address Correspondence to: Ann-Kathrin Klaehn, MSc, inav – Institute for Applied Health Services Research, Schiffbauerdamm 12, 10117 Berlin, Germany. Email: klaehn@inav-berlin.de.

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