762135

review-article2018
WJNXXX10.1177/0193945918762135Western Journal of Nursing ResearchJoo and Huber

Review
Western Journal of Nursing Research
1­–23
Case Management © The Author(s) 2018
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DOI: 10.1177/0193945918762135
https://doi.org/10.1177/0193945918762135
Care Utilization journals.sagepub.com/home/wjn

Outcomes: A Systematic
Review of Reviews

Jee Young Joo1 and Diane L. Huber2

Abstract
Case management is a cost-effective strategy for coordinating chronic illness
care. However, research showing how case management affects health
care is mixed. This study systematically synthesizes and critically evaluates
evidence in systematic reviews of health care utilization outcomes from
case management interventions for the care of chronic illnesses. Results
are synthesized from seven English language systematic reviews published
between January 1990 and June 2017. Hospital readmissions, length of
hospital stay, institutionalization, emergency department visits, and hospitals/
primary care visits were all identified as health care utilization outcomes of
case management interventions. There was evidence that these interventions
positively reduced health care utilization; however, results were mixed.
These results and the implications of this review of reviews may be valuable
for clinical practitioners, health care researchers, and policymakers.

Keywords
case management, systematic review, health care utilization, chronic illnesses,
review of reviews

1Gachon University, Incheon, South Korea

2The University of Iowa, Iowa City, IA, USA

Corresponding Author:
Jee Young Joo, College of Nursing, Gachon University, 191 Hambakmoeiro, Yeonsu-gu,
Incheon, 21936, South Korea.
Email: drjoo@gachon.ac.kr
2 Western Journal of Nursing Research 00(0)

Worldwide, 38 million people die of chronic illnesses annually, enough that

these illnesses make up 7 of the 10 top causes of death in the world (World
Health Organization, 2017). Moreover, they are associated with high rates of
hospital utilization, such as unplanned hospital readmissions and recurrent
emergency department (ED) visits (Brainard, Ford, Steel, & Jones, 2016;
Joo, 2014). A high rate of health care utilization is directly associated with
increasing health care costs (Centers for Disease Control and Prevention
[CDC], 2017; Huntley, Johnson, King, Morris, & Purdy, 2016). Indeed, it is
estimated that chronic illnesses account for 87% of national health care
expenditures in the United States (CDC, 2017).
Recurrent hospital use by individuals with chronic illnesses is due to frag-
mented, episodic, and poorly transitioned care between health care settings
(Joo, 2014; Joo & Liu, 2017). Chronic illnesses are not cured at once; they
need continuous and prolonged care by health care professionals (Joo & Liu,
2017). To reduce health care costs associated with chronic illness care and to
increase the quality of that care, many practitioners rely on case management
(CM; Joo & Huber, 2017; You, Dunt, Doyle, & Hsueh, 2012).
CM is “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 communica-
tion and available resources to promote quality, cost-effective outcomes”
(Case Management Society of America, 2017). Systematic reviews and meta-
analyses have found CM to positively affect objective clinical data and psy-
chosocial outcomes, including in the care of several chronic illnesses (Joo &
Huber, 2017). Several systematic reviews have shown that CM improved
both medical and psychological conditions (Berthelsen & Kristensson, 2015;
Joo & Huber, 2015; You et al., 2012). For instance, in a review of randomized
controlled trials (RCTs) and comparative studies that targeted frail elderly
individuals with chronic illnesses, You et al. (2012) found CM to effectively
improve psychological health and patients’ unmet service needs. Likewise, in
a systematic review of RCTs, Joo and Huber (2015) found that community-
based CM interventions significantly improved substance abuse patients’ sat-
isfaction with care and reduced their social problems. In addition to improving
chronic illness care, CM has been shown to significantly and positively affect
the emotional health of caregivers (Berthelsen & Kristensson, 2015).
Several empirical studies have also analyzed CM’s impact on health care
utilization outcomes and total health care costs, but in these studies, results
have been mixed. For example, Joo (2014) reported in a secondary analysis
of chronic illness care among Medicare beneficiaries that CM reduced patient
hospitalizations. But a review by You, Dunt, and Doyle (2013) reported that
CM’s impact on medical care use with frail elderly individuals is unclear.
Joo and Huber 3

Although CM was developed to reduce health care costs and hospital use
while improving quality of care, how effective the intervention is in bringing
about these reductions is yet unclear.
Although a systematic review of systematic reviews is relatively new in
health care intervention research, the methodology was developed to resolve
unclear conclusions such as are found in the question of CM’s impact on
health care utilization outcomes (Kumar, Beaton, & Hughes, 2013; Smith,
Devane, Begley, & Clarke, 2011). The methodology’s aim is to synthesize the
available evidence to reach clear conclusions for health care intervention
research (Smith et al., 2011). However, this methodology has yet to be widely
adopted in nursing research. This review of reviews will demonstrate the
methodology’s value to nursing science by synthesizing the best evidence of
the effectiveness of CM on health care utilization outcomes.

Method
Aim
This study aimed to systemically synthesize and critically evaluate evidence
from systematic reviews that studied the health care utilization outcomes of
CM interventions for the care of chronic illnesses. The review question was
“How effectively do CM interventions improve health care utilization out-
comes for individuals with chronic illnesses?”

Study Design
This review of reviews was guided by a systematic review of systematic
reviews methodology devised by Smith et al. (2011)—a relatively new meth-
odology for evidence-based health care research. Smith et al. (2011) noted
that the methodology enables researchers to describe, summarize, compare,
and discuss the strength of reviews’ evidence. This systematic review of
reviews also adheres to the Participants, Interventions, Comparison,
Outcomes (PICO) Framework (Robinson, Saldanha, & McKoy, 2011) and
the Preferred Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) statement for the reporting of systematic reviews (Moher, Liberati,
Tetzlaff, Altman, & The PRISMA Group, 2009).

Search Strategy
Five electronic bibliographic databases—PubMed, CINAHL, Web of
Science, PsycINFO, and the Cochrane Database of Systematic
4 Western Journal of Nursing Research 00(0)

Reviews—were searched for relevant studies published from January 1990

to June 2017. The database searches were performed using Medical Subject
Headings (MeSH) and the following keywords: (systematic review odds
ratio [OR] meta-analysis) AND (chronic illnesses, chronic disease, OR
chronic conditions) AND (CM, nursing CM, OR nurse-led CM). The
search was limited to English language publications. The initial search was
performed by the principal author and a research scientist in June 2017; a
verification search was conducted in July 2017. The studies were selected
using the following scope of review and inclusion/exclusion criteria.

Scope of Review
The following PICO format was applied as the scope of this review (Robinson
et al., 2011):

Participants: Adults (≥ 18 years of age) who have been diagnosed with one or
more chronic illnesses.

Interventions: CM interventions targeted to the care of chronic illnesses.

Comparison: Treatment as usual. Individuals with comparison groups received

non-CM interventions or care as usual.

Outcomes: Any healthcare utilization outcomes.

Inclusion and Exclusion Criteria

A systematic review was selected for review according to the following
inclusion criteria: the review (a) was a systematic review and/or meta-analy-
sis that reviewed empirical studies with RCTs or quasi-experimental designs,
(b) evaluated CM intervention effectiveness and tested health care utiliza-
tions and/or health care costs as primary outcomes of the CM interventions,
and (c) focused on adults more than 18 years of age and populations with
chronic illnesses—namely diabetes, heart disease, hypertension, kidney fail-
ure, dementia, or chronic pulmonary disease (COPD), all of which are chronic
diseases identified by the CDC (2017). In this study, health care utilization
was defined as the quantified use of any health care services by patients with
chronic illnesses.
Reviews that included non-CM interventions were excluded. Also
excluded were results irrelevant to health care utilization or health care cost
analysis.
Joo and Huber 5

Figure 1. PRISMA flowchart of searching and screening strategy.

Search Outcome
The initial search yielded 98 publications. These were imported to EndNote
X8, and 51 duplicate articles were removed. Of the remaining 47 reviews
screened by title and abstract, 15 were identified for full text assessment. Eight
of these were rejected because their outcomes (Sinha, Bessman, Flomenbaum,
& Leff, 2011; Somme et al., 2012; Thomas, Wilson, Birch, & Woytowich,
2014; You et al., 2012), interventions (Burns et al., 2007; Eklund & Wilhelmson,
2009), or target populations (de Vet et al., 2013; Oeseburg, Wynia, Middel, &
Reijneveld, 2009) did not meet the inclusion criteria. The seven remaining sys-
tematic reviews were selected and assessed for methodological quality. Figure
1 shows a PRISMA flowchart of the search and screening process.

Quality Appraisal
Seven reviews were scored for quality by the principal author and a research
scientist using A Measurement Tool to Assess Systematic Reviews
(AMSTAR) (Shea et al., 2007). AMSTAR is a validated instrument devel-
oped for assessing risk of bias of systematic reviews (Smith et al., 2011). The
instrument consists of 11 criteria scored as yes, no, not applicable, or cannot
answer; higher scores indicate higher quality (a score of 8-11 = high quality;
4-7 = medium quality; 3 or lower = low quality). The first and second author
reached agreement on the AMSTAR scores.
6 Western Journal of Nursing Research 00(0)

Data Extraction
Data was extracted from the seven systematic reviews following the system-
atic review of systematic reviews methodology (Smith et al., 2011). The prin-
cipal author tabulated the data of interest: review aim, design and methodology
of study, search strategy, study participants, CM interventions, comparator,
and outcomes. The second author cross-checked between the reviews and the
extracted data table.

Data Synthesis
Due to the heterogeneity of outcomes of the selected reviews, it was not pos-
sible to statistically pool outcomes. Instead, this systematic review of reviews
used a narrative synthesis of the numerical data of primary outcomes of indi-
vidual studies. Following Smith et al. (2011), the authors used a summary
table to present clear, specific, and structured results from the selected
reviews. They then synthesized these results to identify broad conclusions. In
unreported results, the authors also checked duplicates of the original studies
and adjusted for the overlap in outcomes.

Results
Characteristics of Included Reviews
Table 1 presents a descriptive summary of characteristics of the seven sys-
tematic reviews that met the aim of this systematic review of reviews (Huntley
et al., 2016; Joo & Liu, 2017; Kumar & Klein, 2013; Latour et al., 2007;
Pimouguet, Lavaud, Dartigues, & Helmer, 2010; Reilly et al., 2015; Tam-
Tham, Cepoiu-Martin, Ronksley, Maxwell, & Hemmelgarn, 2013). The
seven reviews aimed to identify evidence of the effectiveness of CM on
health care utilization outcomes. Three of the studies were a systematic
review with meta-analysis (Huntley et al., 2016; Reilly et al., 2015; Tam-
Tham et al., 2013). All reviews adhered to the PRISMA statement or fol-
lowed Cochrane processes for their systematic review methodology. Reviews
included RCTs as individual studies, but some reviews included studies that
were quasi-experimental designs. All reviews searched multiple electronic
databases using search terms.
In brief, the seven systematic reviews reported the effectiveness of CM
interventions on health care utilization outcomes for individuals with chronic
illnesses across 76 trials. (About 18 studies were duplicated across five of the
reviews. This study adjusts for the overlap.) Reviews were published between
 Table 1. Characteristics of the Included Reviews.

Review (Year)/ Study Designs in

Original Studies Reviews/Methods/Meta- CM Interventions (Duration of
Year Analysis Participants (Total No. of Participants) M Age Interventions)
Huntley et al. (2016) 22 studies: 17 RCTs, Adults with HF (N = 8,626) 73.2 years Nurse-led multicomponent care
1993–2012 five non-RCTs. Review of CM, both hospital-initiated
adhered to PRISMA. and community-initiated CM
Yes interventions(1-24 months)
Joo and Liu (2017) 10 RCTs. Chronic illnesses: asthma, COPD, CHF, Nurse-led and multidisciplinary
2007–2015 Review adhered to diabetes, end-stage kidney disease, and team-based CM interventions
PRISMA and Cochrane hypertension (N = 7,125) (6 months-5 years)
processes. 61.7 years
No
Kumar and Klein 12 studies: two RCTs, Frequent users of hospital ED services CM interventions:
(2013) 10 non-RCTs. Review with mental illness, substance abuse, multidisciplinary CM team
1996–2011 adhered to PRISMA. cardiovascular diseases, and diabetes or single case manager (5-24
No (N = 960) months)
43.7 years
Latour et al. (2007) 10 studies: eight RCTs, Patients with complex chronic conditions: Nurse-led CM interventions
1993–2004 two non-RCTs. Review CHF, HF, chronic illnesses with psychiatric (3-18 months)
adhered to Cochrane problems, solid cancer, diabetes, COPD,
processes. and so on.
No (N = 5,092)
Age ≥ 60

(continued)

7
8
Table 1. (continued)

Review (Year)/ Study Designs in

Original Studies Reviews/Methods/Meta- CM Interventions (Duration of
Year Analysis Participants (Total No. of Participants) M Age Interventions)
Reilly et al. (2015) 13 RCTs. People with dementia living in their Community-based CM
1999–2011 Review adhered to communities (N = 9,615) interventions (6 months-36
Cochrane processes. Age ≥ 43.6 months)
Yes
Pimouguet et al. 13 RCTs. People with dementia living in their CM interventions with health
(2010) Review adhered to communities (N = 9,897) care assessment, caregiver’s
1990–2009 Cochrane processes. Age ≥ 45 education, and referrals to
No community resources (6
months-8 years)
Tam-Tham et al. 17 RCTs. Older people with dementia residing in their Dementia CM interventions:
(2013) Review adhered to communities a single case manager
1990–2010 PRISMA. (N = 5,257) intervention, multidisciplinary
Yes Age range: 70-81 years team-based CM model
(6 months-15.9 years, including
follow-up duration)

Note. CHF = congestive heart failure; CM = case management; COPD = chronic obstructive pulmonary disease; ED = emergency department; HF =
heart failure; RCT = randomized controlled trial.
Joo and Huber 9

2007 and 2017; the individual studies in the reviews were published between
1990 and 2015. The ages of the review participants ranged from 43.7 to 81
years, which covers populations from adults to elders. The total number of
participants in reviews ranged from 960 to 9,897. Chronic illnesses included
asthma, COPD, congestive heart failure (CHF), diabetes, end-stage kidney
disease, dementia, mental disorder, cancer, or hypertension. Review partici-
pants were diagnosed with at least one chronic illness. Most of the individual
studies included in the seven reviews were conducted in the United States,
but studies were also conducted in Australia, China, Germany, the Netherlands,
the United Kingdom, Spain, and Sweden.

CM Interventions
All seven reviews synthesized evidence of CM interventions’ effectiveness
on hospital utilization outcomes. CM intervention types included commu-
nity- and hospital-based interventions as well as and interventions that were
initiated in hospitals and carried over into communities. The duration of CM
interventions was 1 month to 15.9 years. Three studies reviewed trials of
nurse-led CM interventions (Huntley et al., 2016; Joo & Liu, 2017; Latour
et al., 2007). Other studies reviewed trials that included multidisciplinary
teams with case managers. All CM interventions were congruent with the
components of the Case Management Society of America’s definitions of
CM; they included assessment and planning, education, transitional services,
referrals to primary or other social or health services, and face-to-face or
telephone contacts for regular follow-up. Control groups (CGs) of all studies
reviewed in the reviews received usual treatment of care.

Quality of Included Reviews

Table 2 presents the quality assessment of the included systematic reviews.
Five of the reviews were given AMSTAR scores of 9 to 10 (of 11), which
means they are high-quality studies and are unlikely to be biased. Two
reviews received scores of 7, which means they are medium quality (Kumar
& Klein, 2013; Latour et al., 2007). Declarations of conflicts of interest were
reported in two reviews (Joo & Liu, 2017; Tam-Tham et al., 2013).

Quality of Included Studies

All seven reviews assessed the methodologies of their included individual
studies with acceptable quality assessment tools. However, only four reviews
(Huntley et al., 2016; Joo & Liu, 2017; Pimouguet et al., 2010; Reilly et al.,
10
Table 2. AMSTAR Quality Appraisal of Included Systematic Reviews.
5. Was 8. Was the
2. Was there 4. Was the a list of 7. Was the scientific quality 9. Were the 11. Was
duplicate 3. Was a status of studies 6. Were the scientific of the included methods used 10. Was the the
1. Was an study comprehensive publication (included characteristics quality of the studies used to combine likelihood of conflict
“a priori” selection literature used as an and of the included included studies appropriately the findings publication of Total score
design and data search inclusion excluded) studies assessed and in formulating of studies bias interest (quality
provided? extraction? performed? criterion? provided? provided? documented? conclusions? appropriate? assessed? stated? rating)

Huntley et al. (2016) Y Y Y Y Y Y Y Y Y Y N 10 (high)

Joo and Liu (2017) Y Y Y Y Y Y Y Y Y N Y 10 (high)
Kumar and Klein (2012) Y Y Y Y Y Y N N Y N N 7 (medium)
Latour et al. (2007) Y Y Y Y Y Y N N Y N N 7 (medium)
Pimouguet, Lavaud, Y Y Y Y Y Y Y Y Y N N 9 (high)
Dartigues, and Helmer
(2010)
Reilly et al. (2015) Y Y Y Y Y Y Y Y Y Y N 10 (high)
Tam-Tham, Cepoiu- Y Y Y Y Y Y N N Y Y Y 9 (high)
Martin, Ronksley,
Maxwell, and
Hemmelgarn (2013)

Note. Y = Yes; N = No.

Joo and Huber 11

2015) clearly reported both a summary/rating of criteria of each studies’ sci-

entific quality and a description of the methodological quality of their indi-
vidual studies. According to AMSTAR (Smith et al., 2011), the quality
appraisal should include both rating scores and a detailed explanation of
methodological quality.
In Huntley et al.’s (2016) review, the Cochrane risk-of-bias tool was used for
included RCTs, and the Effective Practice and Organization of Care risk-of-bias
tool was used for non-RCTs. To assess their included RCTs, Joo and Liu (2017)
used the Jadad scale, which assesses randomization method, double-blind, and
withdrawals on a 0 to 5 scale, with studies that score >3 considered as good
quality. Pimouguet et al. (2010) appraised study design and methodology in the
areas of quality control, group comparability, follow-up rate, dropouts, blinding,
and analyses. Reilly et al. (2015) assessed risk of bias using a tool described in
the Cochrane Handbook for Systematic Reviews of Interventions.

Health care Utilization Outcomes of Reviews

The main health care utilization outcomes from the seven systematic reviews
are presented and summarized in Table 3. All reviews reported these out-
comes as primary outcomes of CM interventions. Health care utilizations
were categorized into five outcomes: hospital readmissions, length of hospi-
tal stay (LOS), institutionalization, ED visits, and hospitals/primary care vis-
its. Findings about health care costs were also synthesized. A narrative
synthesis of these findings follows.

Hospital readmissions. All seven reviews reported on the outcome of hospital

readmissions. The reviews investigated “hospital readmission rates” or “the
number of admissions to hospitals” as outcomes when comparing interven-
tion groups (IGs) and CGs. Two reviews reported that CM interventions were
statistically significant in reducing hospital readmissions (Huntley et al.,
2016; Joo & Liu, 2017). Huntley et al. (2016), a high-quality review, sepa-
rated the results of hospital-initiated CM intervention studies and commu-
nity-initiated studies. The pooled results of unplanned hospital readmissions
were reduced in the hospital-initiated IGs compared with the CGs, (rate ratio
= 0.74, 95% confidence interval [CI] = [0.60-0.92], p = .008, 3,346 partici-
pants, 13 trials). With community-initiated CM interventions, the hospital
readmissions were statistically reduced in two RCTs (227 participants), but
no significant differences were found between groups in non-RCTs (1,405
participants, two studies). Joo and Liu (2017), also a high-quality review,
reported that three RCTs had significant reductions in hospital admissions in
the IGs over the CGs (p = .018, .005, and < .05; 4,764 participants).
12
Table 3. Summary of Health Care Utilization Outcomes of Included Reviews.
Tam-Tham, Cepoiu-Martin,
Kumar and Pimouguet et al. Ronksley, Maxwell, and
Outcome Huntley et al. (2016) Joo and Liu (2017) Klein (2013) Latour et al. (2007) (2010) Reilly et al. (2015) Hemmelgarn (2013)

Hospital Reduced unplanned Statistically significant No significant Mixed results: No effect on No difference in the admissions No difference in the risk
readmissions readmission in hospital- reductions difference in statistically hospitalization to hospital at 6 months (439 of hospitalization for
initiated CM IG compared in hospital groups (463 significant reductions rates (363 participants, four studies), the IG compared with
with the CG (rate ratio = readmissions with participants, in hospital participants, two 12 months (585 participants, the CG (pooled risk
0.74, 95% CI = [0.60-0.92] IG compared four studies) readmissions in studies) five studies), 18 months (613 ratio = 1.00, 95% CI =
p = .008, 3,346 participants, 13 with CG (4,764 the IG compared participants, five studies) [0.76-1.33], p = .984,
studies) participants, three with the CG 509 participants, three
Reduced in the community- studies) (2,695 participants, studies)
initiated CM IG compared four studies);
with the CG (227 no effectiveness
participants, two studies); no between groups
difference between groups (1,947 participants,
(1,405 participants, two four studies);
studies) insufficient data (75
participants, one
study)
LOS Reduction in the hospital- Nonsignificant Mixed results: hospital No effect on LOS Reduction in the number of days No difference in mean
initiated CM IG compared reductions (316 days were reduced in hospitals (805 per month in a nursing home days to long-term care
with the CG (M difference = participants, two in the IG compared participants, three or hospital unit in the IG at 6 placement for the IG
−1.28 days, 95% CI = [−2.04- studies) with the CG studies) months (M difference = −5.80, compared with the CG
−0.52], p = .001, 1,765 Significant reduction (2,349 participants, Significant reduction 95% CI = [−7.93-−3.67], p < (weighted M difference
participants, nine studies) (29%) (p = .005, four studies); no in length of .0001, 88 participants, one = 77.79,
Reduction with the community- 405 participants, difference between institutionalization study) and at 12 months 95% CI = [−70.53-
initiated CM IG compared one study) groups (1,494 (88 participants, (MD = −7.70, 95% CI = 226.12], p = .304, 578
with the CG (p = .0014, participant, two one study) [−9.38-−6.02], p < .0001, 88 participants, five studies)
1043 participants, one study) studies) participants, one study)

(continued)
 Table 3. (continued)
Tam-Tham, Cepoiu-Martin,
Kumar and Pimouguet et al. Ronksley, Maxwell, and
Outcome Huntley et al. (2016) Joo and Liu (2017) Klein (2013) Latour et al. (2007) (2010) Reilly et al. (2015) Hemmelgarn (2013)

Institutionalization Nursing home CM IG was significantly less Statistically significant

(Nursing home admissions were likely to be institutionalized reduction in the risk
admissions) delayed with the (admitted to residential or of long-term care
IG compared nursing homes) at 6 months placement for the IG
with the CG (749 (odds ratio = 0.82, 95% CI = compared with the CG
participants, four [0.69-0.98], 5,741 participants, when follow-up duration
studies) I² = 0%, p = .02, six studies); at was less than 18 months
18 months (odds ratio = 0.25, (average follow-up of 1
95% CI = [0.10-0.61], year), (pooled risk ratio
363 participants, I² = 0%, p = = 0.61, 95% CI = [0.41-
.003, four studies) 0.91], p = .015, 10,166
The effects were uncertain at participants, 16 studies)
24 months (odds ratio = 1.03, After 18 months, the effect
95% CI = [0.52-2.03], 201 was no longer significant
participants, I² = 0%, p = .94, when the duration of
two studies) follow-up was at 18
months (pooled risk
ratio = 0.95, 95% CI =
[0.62-1.46], p = .827,
10,166 participants, 16
trials)
ED visits Statistically significant Significant No significant No difference No significant difference
reductions in reduction difference between between groups between groups in
ED visits (1,551 in ED groups in ED on ED visits (627 ED visit rates (296
participants, five visits (770 visit rates (2,154 participants, three participants, one study)
studies) participants, participants, four studies)
Nonsignificant eight studies)
Reductions in ED studies)
(945 participants, Failed to
one study) demonstrate
a reduction
(120
participants,
two studies)

13
(continued)
14
Table 3. (continued)
Tam-Tham, Cepoiu-Martin,
Kumar and Pimouguet et al. Ronksley, Maxwell, and
Outcome Huntley et al. (2016) Joo and Liu (2017) Klein (2013) Latour et al. (2007) (2010) Reilly et al. (2015) Hemmelgarn (2013)

Hospital / primary IG showed significantly less Less likely to visit

care visits use of optional primary hospital in the IG
care visits compared with compared with the
the CG (1 year, p < .001, CG (relative risk
1,043 participants; 2 years, = 0.80, 95% CI =
p < .001, 1,043 participants, [0.75-0.84], 163
one study) participants, one
study)
Significant reduction
in hospital visits in
the IG compared
with the CG
(p = .047, 153
participants, one
study)
Health care costs No difference between Reduced health care Significant No significant
hospital-initiated CM IG and costs (45% less per reduction difference in
CG (1,166 participants, six person) in the IG in ED cost evaluations
studies) (163 participants, costs (560 between groups
No data reported between one study) participants, (8,767 participants,
community-initiated CM IG Reduction in ED four studies) three studies)
and CG costs (p < .01) Reduced ED
but no significant costs but no
difference in the difference
total health care in the total
costs in groups health care
(252 participants, costs in
one study) between
groups (252
participants,
one study)

Note. CG = control group; CI = confidence interval; CM = case management; ED = emergency department; IG = intervention group; LOS = length of hospital stay;
MD = mean difference.
Joo and Huber 15

Four reviews identified no associations between hospital admission reduc-

tions and CM interventions. Tam-Tham et al. (2013), pooling results from
three studies, identified no significant difference between IGs and CGs for
the risk of hospitalizations (pooled risk ratio = 1.00, 95% CI = [0.76-1.33],
p = .984, 509 participants). Reilly et al. (2015) reported the number of hospi-
tal admissions at 6, 12, and 18 months with RCTs. Synthesized results found
no difference in the number of admissions to hospitals for any of the follow-
up durations. In Kumar and Klein (2013), four studies that evaluated CM
interventions’ effectiveness demonstrated no significant differences between
the groups on hospital admission rates (463 participants). Similarly,
Pimouguet et al. (2010) found CM interventions did not affect hospital admis-
sion rates (363 participants, two studies). Latour et al. (2007) reported mixed
findings with CM effectiveness on hospital readmissions. Four of the studies
reported that CM interventions statistically reduced hospital readmissions in
the IGs compared with the CGs (2,695 participants), four studies reported no
effect (1,947 participants), and one study had insufficient data and gave no
conclusion (75 participants).

LOS. Six reviews used LOS as a health care utilization outcome of CM inter-
ventions in chronic illness care (Huntley et al., 2016; Joo & Liu, 2017; Latour
et al., 2007; Pimouguet et al., 2010; Reilly et al., 2015; Tam-Tham et al.,
2013). In the reviews, LOS was defined as the number of days in hospitals or
the number of days in long-term care facilities such as nursing homes. There
were mixed results of LOS with CM between the six reviews.
Huntley et al. (2016), pooling data from nine studies—eight of which
were RCTs—demonstrated that LOS was significantly reduced for chronic
illness care in hospital-initiated CM intervention studies (M difference =
−1.28 days, p = .001; I2 = 63%; 1,765 participants). Joo and Liu (2017) found
that LOS was reduced in two RCTs (316 participants); however, the results
were not significant: one RCT reported that overall LOS was reduced by 29%
in the IG over the CG (p = .005, 405 participants). Reilly et al. (2015) reported
that LOS was significantly reduced after 6 months (M difference = −5.80,
95% CI = [−7.93-−3.67], p < .0001, 88 participants, one study) and 12 months
of CM interventions (M difference = −7.70, 95% CI = [−9.38-−6.02], p <
.0001, 88 participants, one study).
Tam-Tham et al. (2013) conducted a meta-analysis for five studies report-
ing LOS with chronic illnesses. Results of pooled data showed no statistical
differences in the mean number of days in long-term care facility placement
between IGs and CGs (weighted M difference = 77.79, 95% CI = [−70.53,
226.12], p = .304, 578 participants). Pimouguet et al. (2010) found no differ-
ence in LOS in hospitals between IGs and CGs (805 participants, three
16 Western Journal of Nursing Research 00(0)

studies) but did report a significant reduction in LOS in nursing homes in the
IG (p < .001, 88 participants, one study). Likewise, Latour et al. (2007)
reported mixed results in LOS. LOS was reduced in the IGs (2,439 partici-
pants, four studies); however, no difference was found between groups with
high-quality scored studies (1,494 participants, two studies).

Institutionalization. In the reviews, institutionalization means admission to a

nursing home or long-term care facility. Three reviews identified CM inter-
ventions’ effectiveness on institutionalization (Pimouguet et al., 2010; Reilly
et al., 2015; Tam-Tham et al., 2013). All three reviews reported that CM
interventions were associated with reduced nursing home admissions. Pimou-
guet et al. (2010) reported that nursing home admissions were delayed in the
IGs compared with the CGs (749 participants, four studies) and that nursing
home admission rates were reduced (p = .02,.025, < .01, and < .05 across four
studies; 749 participants). Tam-Tham et al. (2013) pooled results from 16
studies and found significant reductions in the risk of long-term care place-
ment in CM interventions less than 18 months in duration (pooled risk ratio
= 0.61, 95% CI = [0.41-0.91]; p = .015; 10,166 participants). Likewise, Reilly
et al. (2015) reported significant reductions in institutionalization at six
months (OR = 0.82, 95% CI = [0.69-0.98]; 5,741 participants; I² = 0%; p =
.02; six studies) and 18 months (OR = 0.25, 95% CI = [0.10-0.61]; 363 par-
ticipants; I² = 0%; p = .003; four studies) for the IGs.

ED visits. Five reviews reported ED visits as results of CM interventions in

the care of chronic illnesses. Two reviews associated CM interventions with
reducing ED visits. In Joo and Liu (2017), five studies reported that ED visits
were significantly reduced in IGs compared with CGs (1,551 participants),
and one study reported a nonsignificant reduction in the same (945 partici-
pants). Kumar and Klein (2013) reported significant reduction in ED visits in
eight studies (770 participants) and nonstatistically significant reductions in
two (120 participants).
Three reviews reported no reductions in ED visits with CM interventions.
Tam-Tham et al. (2013) reported no difference between groups in ED visit rates
(IG: 56.5%, CG: 52.4%; 296 participants, one study). Similarly, Latour et al.
(2007) demonstrated no difference between groups with IGs and CGs for ED
visit rates (2,154 participants, four studies). Finally, Pimouguet et al. (2010)
found CM ineffective in reducing ED visits (627 participants, three studies).

Hospital/primary care visits. As can be seen from Table 3, two reviews reported
that CM interventions were positively associated with outcomes of hospital
visits or primary care visits. These outcomes mean fewer visits were made to
Joo and Huber 17

primary care clinics or hospitals for any health care issues or optional visits.
Huntley et al. (2016) demonstrated that optional primary care visits were
significantly greater in the CG than the IG at both the first and second year of
CM intervention (p < .001, 1,043 participants, one study). In one study in Joo
and Liu (2017), the IG was 20% less likely to visit hospitals than the CG
(relative risk = 0.80, 95% CI = [0.75-0.84]; 163 participants), and another
study reported significant reduction in the number of hospital visits (p = .047,
153 participants). Therefore, one benefit of CM intervention may be a reduc-
tion in hospital/primary care visits.

Health care costs. CM’s effect on health care costs was treated as secondary
outcomes in this review of reviews. Four reviews assessed costs as a result of
CM interventions (Huntley et al., 2016; Joo & Liu, 2017; Kumar & Klein,
2013; Pimouguet et al., 2010).
Two reviews reported that CM interventions were not associated with total
health care costs. Huntley et al. (2016) found no differences between IGs and
CGs in total health care costs with hospital-initiated CM for individuals with
heart failure (intervention duration: 3-6 months; 1,166 participants; six stud-
ies). Pimouguet et al. (2010) also found no significant difference in costs
between groups (8,767 participants, three studies).
Meanwhile, Joo and Liu (2017), reported results from a single RCT (163
participants), found total health care costs were 45% less per person with CM
intervention. A second RCT (252 participants) in Joo and Liu found that ED
costs decreased in the IG compared with the CG (p < .01); however, no dif-
ferences were found in total health care costs. Similarly, Kumar and Klein
(2013) demonstrated significant ED cost effectiveness with CM interventions
(560 participants, four studies). These results suggest that CM interventions
may have positive benefits in terms of ED costs.

Discussion
This is the first systematic review of systematic reviews to synthesize evi-
dence of the effectiveness of CM interventions on health care utilization out-
comes for the care of chronic illnesses. From seven systematic reviews
encompassing 76 studies, five common primary health care utilization out-
comes were identified as effects of CM interventions: hospital readmissions,
LOS, institutionalization, ED visits, and hospitals/primary care visits. This
review also analyzed health care costs as a secondary outcome of CM inter-
ventions in chronic illness care. These findings represent a high level of evi-
dence of the impact CM interventions have on health care utilization for
individuals with chronic illnesses.
18 Western Journal of Nursing Research 00(0)

The evidence presented in this review suggests that CM interventions

favorably affect health care utilization outcomes in chronic illness care. The
reviews of CM demonstrated fewer hospital readmissions (Huntley et al.,
2016; Joo & Liu, 2017; Latour et al., 2007), reduced LOS (Huntley et al.,
2016; Joo & Liu, 2017; Latour et al., 2007; Reilly et al., 2015), fewer institu-
tionalizations (Pimouguet et al., 2010; Reilly et al., 2015; Tam-Tham et al.,
2013), fewer ED visits (Joo & Liu, 2017; Kumar & Klein, 2013), fewer hos-
pital/primary care visits (Huntley et al., 2016; Joo & Liu, 2017), and reduced
costs with at least some types of care (Joo & Liu, 2017; Kumar & Klein,
2013). Although there are some discordant results across individual studies,
pooled results found one benefit of CM to be a reduction in health care
utilization.
The reviews surveyed gave limited information about intervention dos-
age, reported little on the intensity of CM interventions, and rarely analyzed
the impact of duration of CM intervention on health care utilization out-
comes. Huntley et al. (2016) compared the significance of outcomes over
certain periods of CM intervention. Similarly, Reilly et al. (2015) compared
outcomes for certain short- and long-term durations of CM services.
Meanwhile, only Huntley et al. (2016) studied which type of intervention
best reduces health care utilization by comparing hospital- and community-
initiated CM interventions. Overall, however, Huntley et al. (2016) had insuf-
ficient data to assess costs in community-initiated CM. The evidence from
reviews that dosage, intensity, or duration of CM services was considered in
the research was limited. Such dosage information must be connected to
patient outcomes for evidence-based CM practice and research (Joo & Huber,
2017). Future intervention studies and systematic reviews should consider
intervention type, intensity, duration, and frequency of services with supports
of outcomes.
The systematic reviews reported a wide range of sample sizes from indi-
vidual studies, and many of the studies had insufficient power. For example,
the sample size of studies in Huntley et al. (2016) was between 28 and 1,049
participants. Synthesizing the results of a wide range of sample sizes can cre-
ate reporting bias, or errors that occur when there is an effect present but
undetected (Burns & Grove, 2012). Power analysis is also important (Burns
& Grove, 2012). In the retrieved reviews, there was insufficient information
regarding power of sample sizes from individual studies. In Joo and Liu
(2017), for example, only 4 of 10 studies reported power analysis. Future
studies and reviews should report sample sizes and power analysis of indi-
vidual studies.
The heterogeneity of measured outcomes in the systematic reviews means
the ability to pool health care utilization outcomes was limited. Indeed, only
Joo and Huber 19

three reviews conducted a meta-analysis to pool data from individual stud-

ies. The heterogeneity stems from the wide variety of ways to measure
health care utilization outcomes. For example, some individual studies
investigated hospital readmission rates and others analyzed the mean num-
ber of hospital readmissions. Similar results were reported in ED visits and
costs of care. To limit the differences in measurements, patient outcomes
must be obtained using valid and standardized instruments (Joo, 2014) and
standard measures of health care utilization outcomes. Future research into
CM interventions is needed to develop reliable, valid, and congruent health
care utilization composite(s).
Stronger descriptions of outcomes would have strengthened the research.
For example, few of the systematic reviews described the reasons for hospital
utilizations. To demonstrate CM effectiveness clearly, it is important to report
unplanned hospital or primary care visits. Huntley et al. (2016) identified as
an outcome optional or unplanned visits and hospital readmissions during
CM interventions. If other studies follow suit, clearly demonstrating the rea-
son for health care utilizations in their studies, then it could be assuring evi-
dence of CM effectiveness. In addition, all seven reviews lacked descriptions
of usual care. Individual studies reported usual care as minimal care or regu-
lar checkups from hospital or health care professionals (Joo & Liu, 2017;
Pimouguet et al., 2010). Thus, it is essential to fully describe what usual care
was provided to the CGs in future intervention studies and systematic reviews
(Egan & Mainous, 2012).
Finally, hospital readmission rates and ED visits dominated the health care
utilization outcomes reported in the systematic reviews. Other outcomes,
such as nursing home admissions and home care visits by case managers with
CM interventions, were largely unreported. Patients with chronic illnesses
need continuous care in community-based settings after discharge from hos-
pitals (Joo & Huber, 2015). Such associations should be studied in depth.
This systematic review of reviews has limitations. First, the study could
not differentiate community-based or hospital-based CM interventions.
Second, it included only articles published in English. Third, most of the
reviews and the individual original studies were conducted in the United
States or Europe. Countries’ health care systems, culture, or health care
policy could result in unanticipated variation of results. Fourth, although
this study found five common health care utilization outcomes in the
reviews, there was a wide range of similar outcomes. Last, this review was
conducted by only two reviewers, which may significantly affect the sys-
tematic results. Future studies should be conducted with more than three
reviewers to ensure scientific advancement (Pieper, Jacobs, Weikert, Fishta,
& Wegewitz, 2017).
20 Western Journal of Nursing Research 00(0)

The results of this systematic review of reviews need to be publicized to

nursing researchers, health care professionals, and health policymakers
because of the benefits identified of CM’s effectiveness in managing chronic
illnesses. Nonetheless, more rigorous research into CM effectiveness with
health care utilization outcomes is needed. First, this research should prove
the associations between dosage of CM interventions on health care utiliza-
tion outcomes. Second, more individual RCTs need to be conducted, with
substantiated and adequate power of sample size. Third, future research
should identify chronic disease-specific outcome indicators and use reliable
and valid appropriate tools or composites to effectively assess the complexity
of health care utilization outcomes. This study provides some evidence that
health care professions such as nurse managers or multidisciplinary teams
can use CM as a core intervention for reducing unnecessary chronic illness
care utilization and attendant costs. Health policymakers may also consider it
as a strategy to reduce total costs for chronic illness care and should support
funding that seeks evidence of consistent CM practice and research. Finally,
it is recommended that full economic appraisals for further refinements of
CM effectiveness be made.

Acknowledgments
The authors thank Gachon University for supporting this research.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publi-
cation of this article.

ORCID iD
Jee Young Joo https://orcid.org/0000-0003-0450-6781

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