EFFECTS OF CASE-MANAGEMENT AFTER SEVERE HEAD-INJURY

Objectives-To examine the effects of early case management for patients with severe head injury on outcome, family function, and provision of rehabilitation services. Design-Prospective controlled unmatched non-randomised study for up to two years after injury. Setting-Four district general hospitals and two university teaching hospitals, each with neurosurgical units, in east central, north, and north east London and its environs. Subjects-126 patients aged 16-60 recruited acutely and sequentially after severe head injury. All received standard rehabilitation services in each of the six hospitals and districts: case management was also provided for the 56 patients admitted to three of the hospitals. Main outcome measures-Standard measures of patients' physical and cognitive impairment; disability and handicap; and affective, behavioural, and social functioning and of relatives' affective and social functioning. Relatives' perception of burden; changes in patients' and relatives' housing, financial, vocational, recreational, and medical needs; and ongoing requirements for care and support; and the amount and type of paramedical input provided were assessed with structured questionnaires. Results-For a given severity of injury, case management increased the chance and range of contact with inpatient and outpatient rehabilitation services. However, duration of contact was not increased by case management, and there was no demonstrable improvement in outcome in the case managed group. Any trends were in favour of the control group and could be accounted for by group differences in initial severity of injury. Conclusions-Widespread introduction of early case management of patients after severe head injury is not supported, and early case management is not a substitute for improvement in provision of skilled and specialist rehabilitation for patients.