I applaud the King's Fund for reviewing the evidence on case management (news, pages 16-17, 2 December 2004), and its recommendations to primary care trusts are sensible.
As the authors concede, their study was not systematic, and it was disappointing that the review gave little information on length of interventions. The minimum was set at three months, but experience with Evercare suggests that it takes 18 months to achieve full benefits.
The reviewers had the common problem of comparing apples, oranges, and mangoes. Very different forms of case management were lumped together, making it risky to draw overall conclusions. It is a shame that the review did not look at patient and carer satisfaction and clinical benefit. Four studies in their review provided evidence on functional health status, and all four showed improvement or prevention of deterioration. The review failed to mention a full systematic review and meta-analysis published in the BMJ in 2001 that showed home visiting programmes for frail elderly people reduced mortality and admissions to institutions.
The review's conclusion is correct, but there is probably more evidence than for many non-drug interventions, and most of that evidence is positive rather than negative on utilisation of care and costs. There is a crucial difference between absence of evidence and evidence of ineffectiveness.
Richard Smith, chief executive, UnitedHealth Europe