Evidence of case management effect on traumatic-brain-injured adults in rehabilitation.

The purpose of this study was to evaluate the evidence for effectiveness of case management during recovery front traumatic brain injury (TBI) in adults. After an overview of TBI incidence, prevalence, and problems, and a brief explanation of case management, the study methods are described, the findings are discussed and recommendations are made for future research. Medline, HealthSTAR, CINAHL, PsychlNFO, and the Cochrane Library databases were searched and 83 articles met the criteria for review. The strongest studies (n a 3) were critically appraised and their design features and data were placed in two evidence tables. Due to methodological limitations, there was neither clear evidence of effectiveness nor of ineffectiveness. For future research, we recommend controlled research designs, standardization of measures, adequate statistical analysis and specification of health outcomes of importance to persons with TBI and their families. Case management in health care attempts to control the balance of quality and cost for populations at risk of under- or overutilizing therapeutic services. One particularly vulnerable population consists of the persons who have sustained traumatic brain injury (TBI). This condition can cause extensive long-term functional setbacks and generate disturbing psychosocial sequelae that may not become apparent for several years. Some consequences are preventable, but timing is critical because treatment must be initiated when patients are ready for new learning and before secondary effects ensue. One response to these issues of how and when to access TBI rehabilitation has been case-management programs designed to monitor patients and match them with appropriate services. Based on a systematic review of available literature, this study sought evidence to determine whether such programs improve the well-being of braininjured persons and their families. After an overview of TBI incidence, prevalence and problems, and a brief explanation of case management, the study methods are described, the findings are discussed and recommendations are made for future research. Incidence and Prevalence of TBI The incidence of TBI in the United States is estimated at 200 cases per 100,000 population per year (Johnson & Hall, 1994). In 1989, the National Institutes of Health estimated the incidence at about 2 million cases per year, with 500,000 requiring hospitalization (Lloyd & Cuvo, 1994). In the U.S. and other western industrialized countries about 14 brain injuries occur per 100,000 population each year that are classed as severe; 2 of the 14 remain severely disabled after 6 months. Many of these cases are young people with long life expectancies which add up over the years to make a prevalence of about 150 cases disabled from TBI per 100,000 population (Annoni, Beer, & Kesselring, 1992). Some estimate that from 50,000 to 90,000 survivors of TBI each year begin a life of permanent disability (Ostby, Sakata, & Leung, 1991; Resnick, 1993). Although TBI is the third most common cause of death in the U.S., and the main cause of death in persons aged 38 years or younger (Ewing, Thomas, Sances, & Larson, 1983), most survive and many begin a life of partial recovery and permanent disability. Problems Addressed by TBI Rehabilitation Case Management The long-term consequences of TBI are well documented in longitudinal studies up to 5 years (Annoni et al.f 1992; Fearnside, Cook, McDougall, & Lewis, 1993; Kaitaro, Koskinen, & Kaipio, 1995; Masson et al., 1996; Olver, Ponsford, & Curran, 1996); at 6 to 10 years (Jacobs, Blatnick, & Sandborst, 1988; Rappaport, Herrero-Backe, Rappaport, & Winterfield, 1989; Schalen, Hansson, Nordstrom, G., & Nordstrom C.-H., 1994; Spatt, Zebenholzer, & Oder, 1997; Tate, Lulham, Broe, Strettles, & Pfaff, 1989; Tennant, Macdermott, & Neary, 1995); and at 20 to 23 years (Klonoff, Campbell, & Klonoff, 1993; Thomsen, 1992). …