Community-based case management effectiveness in populations that abuse substances J.Y. Joo1 PhD, RN & D.L. Huber2 PhD, RN, FAAN, NEA-BC 1 Assistant Professor, College of Nursing, University of Missouri–St. Louis, St. Louis, MO, 2 Professor, College of Nursing, University of Iowa, Iowa City, IA, USA
JOO, J. Y. & HUBER D. L. (2015) Community-based case management effectiveness in populations that abuse substances. International Nursing Review 62, 536–546 Background: The number of persons who are substance abusing has been increasing globally. A majority of them remain in their communities, untreated. Empirical studies have shown some positive impacts of case management on substance abuse. However, studies that systematically synthesize the effectiveness of community-based case management with populations that abuse substances are limited. Aim: To review evidence of the impact of case management in improving treatment of substance abuse among adults in community settings. Methods: The Cochrane processes guided this systematic review. PubMed, CINAHL, PsycINFO, Ovid and the Web of Science were searched to retrieve primary studies published from 2000 to 2013. All randomized controlled trials were considered for review. The methodological quality of the studies was assessed. Results: The initial unfiltered search identified 506 references. A total of seven randomized controlled trials were selected for review. Findings show that, compared with clinical case management and usual care, community-based case management services significantly improved clients’ ability to abstain from drug use, reduced social problems, supported unmet service needs and improved satisfaction. Studies also showed reduced use of healthcare services, but results were mixed. Conclusions: There is an evidence base for practicing case management among adults who are substance abusing. In general, studies concluded that case management is an active and assertive method of care coordination for formal substance abuse treatment. Further research is needed to assess case management’s cost-effectiveness and the impact of dosage on client outcomes. Implications for Nursing Policy: Because of the complexity of population health management across settings and over long time frames, evidence-based strategies are required to achieve health improvements. Because it
Correspondence address: Dr. Jee Young Joo, 304 Seton Hall, University of Missouri–St. Louis, One University Blvd, St. Louis, MO 63121, USA; Tel: +1-314-516-7075; Fax: +1-314-516-7082; E-mail: [email protected].
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors, or support in the form of equipment or other assistance. Conflicts of interest No conflict of interest. Ethical approval Because no human subjects’ research was engaged in this study, no Institutional Review Board approval was required.
© 2015 International Council of Nurses
536
bs_bs_banner
Literature Review
Effectiveness of community-based case management
537
provides continuous and timely care, healthcare leaders and policymakers should consider community-based case management as an important strategy for coordinating the care in populations that are substance abusing. Keywords: Community-based Case Management, Community Case Management, Community, Randomized Controlled Trials, Effectiveness, Substance Abuse, Systematic Review
Introduction Substance abuse is the taking of drugs, either regularly or occasionally, in ways that run counter to established medicine (World Health Organization 2014a) and it is a major risk factor for population health. The number of persons who are substance abusing (including drug abuse, problematic drug use, drug misuse or substance misuse) has been increasing globally (World Health Organization 2014b). Two hundred thirty million people – 5% of the world’s population – are estimated to have used drugs illicitly at least once in 2010 (United Nations 2012). Treatment of substance abuse needs a complex range of care because substance abuse presents individual, interpersonal and social problems (National Institute on Drug Abuse 2014). In the United States, the total healthcare-related costs of substance abuse in 2011 were estimated to be $11 billion, $30 billion and $96 billion for illicit drugs, alcohol and tobacco, respectively (National Institute on Drug Abuse 2014). Despite the increase in the number of persons who are substance abusing and the escalating cost to treat them, appropriate and effective interventions are as yet limited. The primary concern of substance dependency is the repeated use of drugs and/or alcohol (Lindahl et al. 2013). Persons who are substance abusing typically have personal and social dysfunctions and create family and legal problems (Tanner-Smith et al. 2013). Unfortunately, a majority of these individuals remain untreated in their communities. Studies suggest that current community-based substance abuse treatment methods support the needs of health services poorly (Lindahl et al. 2013; Slesnick & Erdem 2013). Persons who are substance abusing need continuous, repeated, long-term and community-based care (Substance Abuse and Mental Health Services Administration 2010). Fortunately, in the Patient Protection and Affordable Care Act, the United States government announced it would support evidence- and community-based programmes and practices to treat mental health and substance abuse (Substance Abuse and Mental Health Services Administration 2010). This support is capable of increasing long-term and continuous substance abuse care and of making
© 2015 International Council of Nurses
health care more accessible within local communities (Substance Abuse and Mental Health Services Administration 2010). Case management (CM) – especially community-based case management (CBCM) – is one suitable intervention for treating populations that are substance abusing. CM coordinates a variety of health and human services in order to connect patients with the services they need (Kirk et al. 2013). It has been shown to be an effective intervention for psychiatric illnesses (Agency for Healthcare Research and Quality 2013; Kirk et al. 2013). The impact of CM in clinical quality outcomes and cost effectiveness has also been shown in review studies with chronic illnesses such as diabetes and heart failure (Joo & Huber 2014). CM is also able to provide individualized, holistic, highquality care for treating populations that are substance abusing (Agency for Healthcare Research and Quality 2013). However, studies that have examined CM and its outcomes among populations that are substance abusing have had mixed results (Morgenstern et al. 2006; Rapp et al. 2014). For example, the effectiveness of CM in treatment outcomes varies by intervention compliance and duration. In addition, there has been little evidence of CM having a positive effect on reducing hospital admissions and hospital length of stay, although this may be confounded by the shortage of access to and reimbursement for mental health services. CBCM also plays a role in patient advocacy, seeking to find appropriate care and referral services within the healthcare system, but it does so from within an individual’s community rather than a hospital. CBCM has been shown to provide continuous, cost-effective and long-term care and it has reduced fragmentation of care within chronic illness patients’ communities (Joo & Huber 2014). For populations that are substance abusing, CBCM is a strategy for chronic disease management across discrete episodes of care through the coordination of health and social services and the monitoring of relapses over the long term (Lindahl et al. 2013; Slesnick & Erdem 2013). As a method of care coordination, CBCM has increased individuals’ quality of care and provided them with appropriate health service access (Joo & Huber 2014).
538
J. Y. Joo & D. L. Huber
For evidence-based CBCM to be put into practice effectively, intervention details need to be fully described. In particular, clear descriptions of intervention dosage, or ‘the amount of a therapeutic agent or action prescribed and administered or delivered’ (Huber et al. 2003, p. 276) are necessary because dosage is directly connected to outcomes (Manojlovich & Sidani 2008; Sidani et al. 2010). Huber & Craig (2007, p. 134) defined dosage in CM with the following characteristics: • Amount – the quantity of the target activity in one episode • Frequency – the rate of occurrence or repetition • Duration – how long the activity is available over time • Breadth – the number and type of possible intervention components or activities Measuring intervention dosage in CBCM, however, has been limited due to the complexity of intervention delivery (Joo & Huber 2014). To be used widely as a means of coordinating care for persons who are substance abusing, CBCM should be clearly demonstrated as effective in reducing problems associated with the disease. A preliminary assessment shows that a number of studies with randomized controlled trials (RCTs) have reported the impact and outcomes of CBCM with populations that are substance abusing. This systematic review looks closely at those studies.
Methods Aim
The aim of this review was to evaluate the impact of CBCM in substance abuse treatment. The specific research question was ‘Have CBCM interventions been effective in improving the outcomes experienced by populations that are substance abusing?’ Design
This review followed the guidelines set by the Cochrane Handbook for Systematic Reviews of Interventions (version 5.1.0; Higgins & Green 2011) regarding search protocol, inclusion criteria, quality appraisal, data abstraction and synthesis. This process will be described in detail in the following sections. Search strategy
The electronic databases PubMed, CINAHL, PsycINFO, Ovid and the Web of Science were searched to retrieve empirical studies published between 2000 and 2013. Figure 1 presents details of the search. The search terms combined case management or community case management or community-based case management; nurse case management; substance abuse; drug
Electronic databases search n = 506 445 studies rejected not meeting inclusion criteria by title
Papers selected for review of abstract n = 61 50 studies rejected because review of abstracts indicated the studies were not pertinent to purpose of review Papers selected for review n = 15 8 studies excluded because (1) not pertinent to substance abuse; (2) study intervention was mixed with other interventions; (3) outcomes of interest were not relevant Papers selected for final review n=7 Fig. 1 Flow diagram of systematic review process.
© 2015 International Council of Nurses
Effectiveness of community-based case management
abuse or problematic drug use or opioid dependence or drug misuse or substance misuse; effect or impact; and outcomes. The initial search was restricted only to RCTs. The Cochrane Library Search Manual was used to find additional studies.
539
studies that did not use CM services as the main intervention and studies that described the process of developing CM interventions were all excluded. Search outcome
Inclusion criteria
Table 1 shows the inclusion criteria used for screening this systematic review. Included studies were RCTs published in English between 2000 and 2013 with the following characteristics: Participants
Persons who were substance abusing and 18 years old and older. Intervention
CM interventions administered within communities, such as at community substance abuse treatment agencies or in their homes by nurse case managers or other healthcare professionals with a CM background. Outcomes
Objective outcomes intended to improve individuals’ outcomes, such as by decreasing substance abuse, causing fewer social problems, using fewer health services and increasing satisfaction with treatment. Exclusion criteria
Studies that included children as participants, studies conducted in hospitals or prisons, studies with persons who are substance abusing and who also had other diseases such as HIV/AIDS,
After removing duplicates, 506 study titles were retrieved and their titles were reviewed; 61 articles were identified for closer scrutiny. The abstracts of these 61 studies were reviewed to determine which studies met the purpose of this review and the inclusion criteria. Seven studies met these criteria and were fully reviewed. Two articles (Huber et al. 2003; Saleh et al. 2003) used the same data from the Iowa Case Management Project, but they had different perspectives of data analysis; therefore, they were included. All seven studies were then appraised for methodological quality. Quality appraisal
The Amsterdam–Maastricht Consensus List for Quality Assessment tool for reporting RCTs was used to review the methodological quality of the retrieved studies (Furlan et al. 2009; see Table 2). This tool, which is used to check the risk of bias, provides strict guidelines for systematic review. It consists of 12 criteria; each criterion is given a score of 1 if it is reported in the research, so the range of the tool is 0 to 12. All seven retrieved studies were critically appraised by two investigators. The first investigator performed quality assessment process independently and then a research assistant conducted a second independent appraisal. Investigators’ scores were compared and a final bias risk was assessed for each study based on the investigators’ judgments. Table 2 presents the rating of quality assessment of the seven retrieved studies. Data abstraction and synthesis
Table 1 Inclusion criteria used in the systematic review Criteria Databases searched CINAHL PubMed PsychINFO OVID Cochrane Library
Study type Population Intervention Outcome
© 2015 International Council of Nurses
Randomized controlled trial Substance abuse Adults (age ≥ 18) Case management in community-based setting Substance use (abstinence rate, substance use rate) Health services utilization (hospitalizations, emergency room visits, physician visit, other health services uses) Satisfaction
Data were extracted by the first investigator and the research assistant. Because one of the extracted studies was authored by the second author, the second author waived this process for increasing validity but concurred with the data extraction and results. After extracting the studies, the first investigator showed the process and results of the data extraction to the second author. Then the authors created a concordance. The investigators looked for the following information: (1) that study participants were dwelling in their communities and had been diagnosed with substance abuse, (2) that interventions were described with the amount, frequency, duration and breadth of dosage, (3) that treatment was compared with usual care or alternative forms of community intervention and (4) that main outcomes measured the effects of CM intervention in terms of substance and health service use. Tables 3 and 4 organize the data retrieved from this process. Table 3 summarizes the
540
J. Y. Joo & D. L. Huber
Table 2 Summary of study quality assessment using the Amsterdam–Maastricht Consensus List for Quality Assessment Items
1. 2. 3. 4.
Was the method of randomization adequate? Was the treatment allocation concealed? Was the patient blinded to the intervention? Was the care provider blinded to the intervention? 5. Was the outcome assessor blinded to the intervention? 6. Was the drop-out rate described and acceptable? 7. Were all randomized participants analysed in the group to which they were allocated? 8. Are reports of the study free of suggestion of selective outcome reporting? 9. Were the groups similar at baseline regarding the most important prognostic indicators? 10. Were co-interventions avoided or similar? 11. Was the compliance acceptable in all groups? 12. Was the timing of the outcome assessment similar in all groups? Total
Essock et al. 2006
Huber et al. 2003
Lindahl et al. 2013
Morgenstern et al. 2006
Saleh et al. 2003
Scott et al. 2002
Slesnick & Erdem 2013
+ + – –
+ + – –
+ + – –
+ + + +
+ + – –
+ + – –
+ + – +
–
–
–
+
–
–
–
+
+
+
–
–
–
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ + –
+ + +
+ + +
+ + +
+ + +
+ + +
+ + +
8
9
9
11
8
8
10
Note. Range = 0–12 points; +, yes; −, No, criterion was not met or not clearly stated.
Table 3 Characteristics of retrieved studies Characteristics
Study design Nation of publication Mean age of participants Total sample size
Year of publication Case management intervention duration
Description
Randomized controlled trial United States Sweden 18≥,
JOO, J. Y. & HUBER D. L. (2015) Community-based case management effectiveness in populations that abuse substances. International Nursing Review 62, 536–546 Background: The number of persons who are substance abusing has been increasing globally. A majority of them remain in their communities, untreated. Empirical studies have shown some positive impacts of case management on substance abuse. However, studies that systematically synthesize the effectiveness of community-based case management with populations that abuse substances are limited. Aim: To review evidence of the impact of case management in improving treatment of substance abuse among adults in community settings. Methods: The Cochrane processes guided this systematic review. PubMed, CINAHL, PsycINFO, Ovid and the Web of Science were searched to retrieve primary studies published from 2000 to 2013. All randomized controlled trials were considered for review. The methodological quality of the studies was assessed. Results: The initial unfiltered search identified 506 references. A total of seven randomized controlled trials were selected for review. Findings show that, compared with clinical case management and usual care, community-based case management services significantly improved clients’ ability to abstain from drug use, reduced social problems, supported unmet service needs and improved satisfaction. Studies also showed reduced use of healthcare services, but results were mixed. Conclusions: There is an evidence base for practicing case management among adults who are substance abusing. In general, studies concluded that case management is an active and assertive method of care coordination for formal substance abuse treatment. Further research is needed to assess case management’s cost-effectiveness and the impact of dosage on client outcomes. Implications for Nursing Policy: Because of the complexity of population health management across settings and over long time frames, evidence-based strategies are required to achieve health improvements. Because it
Correspondence address: Dr. Jee Young Joo, 304 Seton Hall, University of Missouri–St. Louis, One University Blvd, St. Louis, MO 63121, USA; Tel: +1-314-516-7075; Fax: +1-314-516-7082; E-mail: [email protected].
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors, or support in the form of equipment or other assistance. Conflicts of interest No conflict of interest. Ethical approval Because no human subjects’ research was engaged in this study, no Institutional Review Board approval was required.
© 2015 International Council of Nurses
536
bs_bs_banner
Literature Review
Effectiveness of community-based case management
537
provides continuous and timely care, healthcare leaders and policymakers should consider community-based case management as an important strategy for coordinating the care in populations that are substance abusing. Keywords: Community-based Case Management, Community Case Management, Community, Randomized Controlled Trials, Effectiveness, Substance Abuse, Systematic Review
Introduction Substance abuse is the taking of drugs, either regularly or occasionally, in ways that run counter to established medicine (World Health Organization 2014a) and it is a major risk factor for population health. The number of persons who are substance abusing (including drug abuse, problematic drug use, drug misuse or substance misuse) has been increasing globally (World Health Organization 2014b). Two hundred thirty million people – 5% of the world’s population – are estimated to have used drugs illicitly at least once in 2010 (United Nations 2012). Treatment of substance abuse needs a complex range of care because substance abuse presents individual, interpersonal and social problems (National Institute on Drug Abuse 2014). In the United States, the total healthcare-related costs of substance abuse in 2011 were estimated to be $11 billion, $30 billion and $96 billion for illicit drugs, alcohol and tobacco, respectively (National Institute on Drug Abuse 2014). Despite the increase in the number of persons who are substance abusing and the escalating cost to treat them, appropriate and effective interventions are as yet limited. The primary concern of substance dependency is the repeated use of drugs and/or alcohol (Lindahl et al. 2013). Persons who are substance abusing typically have personal and social dysfunctions and create family and legal problems (Tanner-Smith et al. 2013). Unfortunately, a majority of these individuals remain untreated in their communities. Studies suggest that current community-based substance abuse treatment methods support the needs of health services poorly (Lindahl et al. 2013; Slesnick & Erdem 2013). Persons who are substance abusing need continuous, repeated, long-term and community-based care (Substance Abuse and Mental Health Services Administration 2010). Fortunately, in the Patient Protection and Affordable Care Act, the United States government announced it would support evidence- and community-based programmes and practices to treat mental health and substance abuse (Substance Abuse and Mental Health Services Administration 2010). This support is capable of increasing long-term and continuous substance abuse care and of making
© 2015 International Council of Nurses
health care more accessible within local communities (Substance Abuse and Mental Health Services Administration 2010). Case management (CM) – especially community-based case management (CBCM) – is one suitable intervention for treating populations that are substance abusing. CM coordinates a variety of health and human services in order to connect patients with the services they need (Kirk et al. 2013). It has been shown to be an effective intervention for psychiatric illnesses (Agency for Healthcare Research and Quality 2013; Kirk et al. 2013). The impact of CM in clinical quality outcomes and cost effectiveness has also been shown in review studies with chronic illnesses such as diabetes and heart failure (Joo & Huber 2014). CM is also able to provide individualized, holistic, highquality care for treating populations that are substance abusing (Agency for Healthcare Research and Quality 2013). However, studies that have examined CM and its outcomes among populations that are substance abusing have had mixed results (Morgenstern et al. 2006; Rapp et al. 2014). For example, the effectiveness of CM in treatment outcomes varies by intervention compliance and duration. In addition, there has been little evidence of CM having a positive effect on reducing hospital admissions and hospital length of stay, although this may be confounded by the shortage of access to and reimbursement for mental health services. CBCM also plays a role in patient advocacy, seeking to find appropriate care and referral services within the healthcare system, but it does so from within an individual’s community rather than a hospital. CBCM has been shown to provide continuous, cost-effective and long-term care and it has reduced fragmentation of care within chronic illness patients’ communities (Joo & Huber 2014). For populations that are substance abusing, CBCM is a strategy for chronic disease management across discrete episodes of care through the coordination of health and social services and the monitoring of relapses over the long term (Lindahl et al. 2013; Slesnick & Erdem 2013). As a method of care coordination, CBCM has increased individuals’ quality of care and provided them with appropriate health service access (Joo & Huber 2014).
538
J. Y. Joo & D. L. Huber
For evidence-based CBCM to be put into practice effectively, intervention details need to be fully described. In particular, clear descriptions of intervention dosage, or ‘the amount of a therapeutic agent or action prescribed and administered or delivered’ (Huber et al. 2003, p. 276) are necessary because dosage is directly connected to outcomes (Manojlovich & Sidani 2008; Sidani et al. 2010). Huber & Craig (2007, p. 134) defined dosage in CM with the following characteristics: • Amount – the quantity of the target activity in one episode • Frequency – the rate of occurrence or repetition • Duration – how long the activity is available over time • Breadth – the number and type of possible intervention components or activities Measuring intervention dosage in CBCM, however, has been limited due to the complexity of intervention delivery (Joo & Huber 2014). To be used widely as a means of coordinating care for persons who are substance abusing, CBCM should be clearly demonstrated as effective in reducing problems associated with the disease. A preliminary assessment shows that a number of studies with randomized controlled trials (RCTs) have reported the impact and outcomes of CBCM with populations that are substance abusing. This systematic review looks closely at those studies.
Methods Aim
The aim of this review was to evaluate the impact of CBCM in substance abuse treatment. The specific research question was ‘Have CBCM interventions been effective in improving the outcomes experienced by populations that are substance abusing?’ Design
This review followed the guidelines set by the Cochrane Handbook for Systematic Reviews of Interventions (version 5.1.0; Higgins & Green 2011) regarding search protocol, inclusion criteria, quality appraisal, data abstraction and synthesis. This process will be described in detail in the following sections. Search strategy
The electronic databases PubMed, CINAHL, PsycINFO, Ovid and the Web of Science were searched to retrieve empirical studies published between 2000 and 2013. Figure 1 presents details of the search. The search terms combined case management or community case management or community-based case management; nurse case management; substance abuse; drug
Electronic databases search n = 506 445 studies rejected not meeting inclusion criteria by title
Papers selected for review of abstract n = 61 50 studies rejected because review of abstracts indicated the studies were not pertinent to purpose of review Papers selected for review n = 15 8 studies excluded because (1) not pertinent to substance abuse; (2) study intervention was mixed with other interventions; (3) outcomes of interest were not relevant Papers selected for final review n=7 Fig. 1 Flow diagram of systematic review process.
© 2015 International Council of Nurses
Effectiveness of community-based case management
abuse or problematic drug use or opioid dependence or drug misuse or substance misuse; effect or impact; and outcomes. The initial search was restricted only to RCTs. The Cochrane Library Search Manual was used to find additional studies.
539
studies that did not use CM services as the main intervention and studies that described the process of developing CM interventions were all excluded. Search outcome
Inclusion criteria
Table 1 shows the inclusion criteria used for screening this systematic review. Included studies were RCTs published in English between 2000 and 2013 with the following characteristics: Participants
Persons who were substance abusing and 18 years old and older. Intervention
CM interventions administered within communities, such as at community substance abuse treatment agencies or in their homes by nurse case managers or other healthcare professionals with a CM background. Outcomes
Objective outcomes intended to improve individuals’ outcomes, such as by decreasing substance abuse, causing fewer social problems, using fewer health services and increasing satisfaction with treatment. Exclusion criteria
Studies that included children as participants, studies conducted in hospitals or prisons, studies with persons who are substance abusing and who also had other diseases such as HIV/AIDS,
After removing duplicates, 506 study titles were retrieved and their titles were reviewed; 61 articles were identified for closer scrutiny. The abstracts of these 61 studies were reviewed to determine which studies met the purpose of this review and the inclusion criteria. Seven studies met these criteria and were fully reviewed. Two articles (Huber et al. 2003; Saleh et al. 2003) used the same data from the Iowa Case Management Project, but they had different perspectives of data analysis; therefore, they were included. All seven studies were then appraised for methodological quality. Quality appraisal
The Amsterdam–Maastricht Consensus List for Quality Assessment tool for reporting RCTs was used to review the methodological quality of the retrieved studies (Furlan et al. 2009; see Table 2). This tool, which is used to check the risk of bias, provides strict guidelines for systematic review. It consists of 12 criteria; each criterion is given a score of 1 if it is reported in the research, so the range of the tool is 0 to 12. All seven retrieved studies were critically appraised by two investigators. The first investigator performed quality assessment process independently and then a research assistant conducted a second independent appraisal. Investigators’ scores were compared and a final bias risk was assessed for each study based on the investigators’ judgments. Table 2 presents the rating of quality assessment of the seven retrieved studies. Data abstraction and synthesis
Table 1 Inclusion criteria used in the systematic review Criteria Databases searched CINAHL PubMed PsychINFO OVID Cochrane Library
Study type Population Intervention Outcome
© 2015 International Council of Nurses
Randomized controlled trial Substance abuse Adults (age ≥ 18) Case management in community-based setting Substance use (abstinence rate, substance use rate) Health services utilization (hospitalizations, emergency room visits, physician visit, other health services uses) Satisfaction
Data were extracted by the first investigator and the research assistant. Because one of the extracted studies was authored by the second author, the second author waived this process for increasing validity but concurred with the data extraction and results. After extracting the studies, the first investigator showed the process and results of the data extraction to the second author. Then the authors created a concordance. The investigators looked for the following information: (1) that study participants were dwelling in their communities and had been diagnosed with substance abuse, (2) that interventions were described with the amount, frequency, duration and breadth of dosage, (3) that treatment was compared with usual care or alternative forms of community intervention and (4) that main outcomes measured the effects of CM intervention in terms of substance and health service use. Tables 3 and 4 organize the data retrieved from this process. Table 3 summarizes the
540
J. Y. Joo & D. L. Huber
Table 2 Summary of study quality assessment using the Amsterdam–Maastricht Consensus List for Quality Assessment Items
1. 2. 3. 4.
Was the method of randomization adequate? Was the treatment allocation concealed? Was the patient blinded to the intervention? Was the care provider blinded to the intervention? 5. Was the outcome assessor blinded to the intervention? 6. Was the drop-out rate described and acceptable? 7. Were all randomized participants analysed in the group to which they were allocated? 8. Are reports of the study free of suggestion of selective outcome reporting? 9. Were the groups similar at baseline regarding the most important prognostic indicators? 10. Were co-interventions avoided or similar? 11. Was the compliance acceptable in all groups? 12. Was the timing of the outcome assessment similar in all groups? Total
Essock et al. 2006
Huber et al. 2003
Lindahl et al. 2013
Morgenstern et al. 2006
Saleh et al. 2003
Scott et al. 2002
Slesnick & Erdem 2013
+ + – –
+ + – –
+ + – –
+ + + +
+ + – –
+ + – –
+ + – +
–
–
–
+
–
–
–
+
+
+
–
–
–
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ + –
+ + +
+ + +
+ + +
+ + +
+ + +
+ + +
8
9
9
11
8
8
10
Note. Range = 0–12 points; +, yes; −, No, criterion was not met or not clearly stated.
Table 3 Characteristics of retrieved studies Characteristics
Study design Nation of publication Mean age of participants Total sample size
Year of publication Case management intervention duration
Description
Randomized controlled trial United States Sweden 18≥,
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