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John F. Fitzgerald, MD; David M. Smith, MD; Douglas K. Martin, MD; Jay A. Freedman, PhD; Barry P. Katz, PhD

Arch Intern Med. 1994;154(15):1721-1729.

Abstract
Background
Acute hospitalizations represent substantial financial liability to closed health care systems. Among hospitalized patients, those with repeated admissions are high-cost users. Most managed care plans employ case management to control hospital use. This technique attempts to detect and fulfill unmet medical and social needs, intensify postdischarge care, identify and mobilize effective community services, and enhance primary care access. Despite the popularity of case management to control hospital use, few trials have examined its efficacy.

Methods
We conducted a randomized controlled trial of an intervention of case managers at a university-affiliated Veterans Affairs medical center. Six hundred sixty-eight patients aged 45 years or older who were discharged from the general medicine inpatient service, who had access to a telephone, and who received primary care at the hospital's clinics were randomized to the intervention (N=333) and control (N=335) groups. Within 24 hours of discharge, case managers mailed educational materials and access information to intervention patients, and within 5 days they called to review and resolve unmet needs, early warning signs, barriers to keeping appointments, and any readmissions. Case managers contacted intervention patients if they made no visits for 30 days. This resulted in a total of 6260 patient—case manager contacts. Control and intervention patients were followed up for 12 months.

Results
Intervention patients had more frequent visits per patient per month to the general medicine clinic (0.30±0.23 vs 0.26±0.22, P=.008), but we detected no significant differences between groups in nonelective readmissions, readmission days, or total readmissions.

Conclusions
Frequent contacts for education, care, and accessibility by case managers using protocols were ineffective in reducing nonelective readmissions.

(Arch Intern Med. 1994;154:1721-1729)

Author Affiliations
From the Divisions of General Internal Medicine (Drs Fitzgerald, Smith, Martin, and Freedman) and Biostatistics (Dr Katz), Department of Medicine, Indiana University School of Medicine, the Richard L. Roudebush Veterans Affairs Medical Center (Drs Fitzgerald, Smith, Martin, and Freedman), and the Regenstrief Institute for Health Care (Drs Fitzgerald, Smith, and Katz), Indianapolis, Ind.

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