Disease management (health)
Encyclopedia
Disease management is defined as "a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant." For people who can access health care practitioners or peer support it is the process whereby persons with long-term conditions (and often family/friend/carer) share knowledge, responsibility and care plans with healthcare practitioners and/or peers. To be effective it requires 'whole system' implementation with community social support networks, a range of satisfying occupations and activities relevant to the context, clinical professionals willing to act as partners or coaches and on-line resources which are verified and relevant to the country and context. Knowledge sharing, knowledge building and a learning community are integral to the concept of disease management. It is a population health strategy as well as an approach to personal health. It may reduce healthcare costs and/or improve quality of life for individuals by preventing or minimizing the effects of [disease]], usually a chronic condition, through knowledge, skills, enabling a sense of control over life (despite symptoms of disease) and integrative care.
, specialty capitation, and health service demand management
, and refers to the processes and people concerned with improving or maintaining health in large populations. It is concerned with common chronic
illnesses, and the reduction of future complications associated with those diseases.
Illnesses that disease management would concern itself with would include: coronary heart disease
, chronic obstructive pulmonary disease
(COPD), kidney failure, hypertension
, heart failure, obesity
, diabetes mellitus
, asthma
, cancer
, arthritis
, clinical depression
, sleep apnea
, osteoporosis
, and other common ailments.
, Healthways
, LifeMasters (now part of StayWell), LifeSynch (formerly Corphealth), Magellan, McKesson Health Solutions, and MedAssurant.
Disease management is of particular importance to health plans, agencies, trusts, associations and employers that offer health insurance
. A 2002 survey found that 99.5% of enrollees of Health Maintenance Organization
/Point Of Service
(HMO/POS) plans are in plans that cover at least one disease management program. A Mercer Consulting study indicated that the percentage of employer-sponsored health plans offering disease management programs grew to 58% in 2003, up from 41% in 2002.
It was reported that $85 million was spent on disease management in the United States in 1997, and $600 million in 2002. Between 2000 and 2005, the compound annual growth rate of revenues for disease management organizations was 28%. In 2000, the Boston Consulting Group
estimated that the U.S. market for outsourced disease management could be $20 billion by 2010; however, in 2008 the Disease Management Purchasing Consortium estimated that disease management organization revenues would be $2.8 billion by 2010. As of 2010, a study using National Ambulatory Medical Care Survey data estimated that 21.3% of patients in the U.S. with at least one chronic condition use disease management programs.
(ROI) for their programs, although over the years there have been dozens of ways to measure ROI. Responding to this inconsistency, an industry trade association, the Care Continuum Alliance, convened industry leaders to develop consensus guidelines for measuring clinical and financial outcomes in disease management, wellness and other population-based programs. Contributing to the work were public and private health and quality organizations, including the federal Agency for Healthcare Research and Quality
, the National Committee for Quality Assurance
, URAC
, and the Joint Commission. The project produced the first volume of a now four-volume Outcomes Guidelines Report, which details industry-consensus approaches to measuring outcomes.
Tools include web-based assessment tools, clinical guidelines, health risk assessments, outbound and inbound call-center-based triage, best practices, formularies, and numerous other devices, systems and protocols.
Experts include actuaries
, physician
s, medical economists
, nurses, nutritionist
s, physical therapists, statistician
s, epidemiologists, and human resources professionals
. Equipment can include mailing systems, web-based applications (with or without interactive modes), monitoring devices, or telephonic systems.
; that is, a program may "attract enrollees who were [already] highly motivated to succeed". At least two studies have found that people who enroll in disease management programs differ significantly from those who do not on baseline clinical, demographic, cost, utilization and quality parameters. To minimize any bias in estimates of the effectiveness of disease management due to differences in baseline characteristics, randomized controlled trial
s are better than observational studies
.
Even if a particular study is a randomized trial, it may not provide strong evidence for the effectiveness of disease management. A 2009 review paper examined randomized trials and meta-analyses of disease management programs for heart failure and asserted that many failed the PICO process
and Consolidated Standards of Reporting Trials
: "interventions and comparisons are not sufficiently well described; that complex programs have been excessively oversimplified; and that potentially salient differences in programs, populations, and settings are not incorporated into analyses."
of 2003 authorized the Centers for Medicare and Medicaid Services
(CMS) to conduct what became the "Medicare Health Support" project to examine disease management. Phase I of the project involved disease management companies (such as Aetna
Health Management, CIGNA
Health Support, Health Dialog Services Corp., Healthways, and McKesson Health Solutions) chosen by a competitive process in eight states and the District of Columbia. The project focused on people with diabetes or heart failure who had relatively high Medicare payments; in each location, approximately 20,000 such people were randomly assigned to an intervention group and 10,000 were randomly assigned to a control group. CMS set goals in the areas of clinical quality and beneficiary satisfaction, and negotiated with the disease management programs for a target of 5% savings in Medicare costs. The programs started between August 2005 and January 2006. What is now the Care Continuum Alliance praised the project as "the first-ever national pilot integrating sophisticated care management techniques into the Medicare fee-for-service program".
An initial evaluation of Phase I of the project by RTI International
appeared in June 2007 which had "three key participation and financial findings":
DMAA focused on another finding of the initial evaluation, the "high levels of satisfaction with chronic disease management services among beneficiaries and physicians". One commentary noted that the project "can only be observational" since "equivalence was not achieved at baseline". Another commentary claimed that the project was "in big trouble". A paper on the six-month evaluation, published in fall 2008, concluded that "Results to date indicate limited success in achieving Medicare cost savings or reducing acute care utilization".
In December 2007, CMS changed the financial threshold from 5% savings to budget neutrality, a change that DMAA "hailed". In January 2008, however, CMS decided to end Phase I because it claimed that the statutory authority had run out. Four U.S. senators wrote a letter to CMS to reverse its decision. DMAA decried the termination of Phase I and called upon CMS to start Phase II as soon as possible. Among other criticisms of the project, the disease management companies claimed that Medicare "signed up patients who were much sicker than they had expected," failed to transmit information on patients' prescriptions and laboratory results to them in a timely fashion, and disallowed the companies from selecting patients most likely to benefit from disease management.
By April 2008, CMS had spent $360 million on the project. The individual programs ended between December 2006 and August 2008.
The results of the program were published in The New England Journal of Medicine in November 2011. Comparing the 163,107 patients randomized to the intervention group with the 79,310 patients randomized to the control group, the researchers found that "disease-management programs did not reduce hospital admissions or emergency room visits, as compared with usual care." Furthermore, there was "no demonstrable savings in Medicare expenditures," with the net
fees for disease management ranging from 3.8% to 10.9% per patient per month. The researchers suggested that the findings might be explained by the severity of chronic disease among the patients studied, delays in patients' receiving disease management after hospitalizations, and lack of integration between health coaches and the patients' primary care providers.
Recent studies not reviewed in the aforementioned papers include the following:
History
Disease management has evolved from managed careManaged care
...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on...
, specialty capitation, and health service demand management
Demand management
Demand management is a planning methodology used to manage forecasted demand.-Demand management in economics:In economics, demand management is the art or science of controlling economic demand to avoid a recession...
, and refers to the processes and people concerned with improving or maintaining health in large populations. It is concerned with common chronic
Chronic (medicine)
A chronic disease is a disease or other human health condition that is persistent or long-lasting in nature. The term chronic is usually applied when the course of the disease lasts for more than three months. Common chronic diseases include asthma, cancer, diabetes and HIV/AIDS.In medicine, the...
illnesses, and the reduction of future complications associated with those diseases.
Illnesses that disease management would concern itself with would include: coronary heart disease
Coronary heart disease
Coronary artery disease is the end result of the accumulation of atheromatous plaques within the walls of the coronary arteries that supply the myocardium with oxygen and nutrients. It is sometimes also called coronary heart disease...
, chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease , also known as chronic obstructive lung disease , chronic obstructive airway disease , chronic airflow limitation and chronic obstructive respiratory disease , is the co-occurrence of chronic bronchitis and emphysema, a pair of commonly co-existing diseases...
(COPD), kidney failure, hypertension
Hypertension
Hypertension or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. What that means is that the heart is having to work harder than it should to pump the blood around the body. Blood pressure involves two measurements, systolic and...
, heart failure, obesity
Obesity
Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...
, diabetes mellitus
Diabetes mellitus
Diabetes mellitus, often simply referred to as diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced...
, asthma
Asthma
Asthma is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Symptoms include wheezing, coughing, chest tightness, and shortness of breath...
, cancer
Cancer
Cancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...
, arthritis
Arthritis
Arthritis is a form of joint disorder that involves inflammation of one or more joints....
, clinical depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
, sleep apnea
Sleep apnea
Sleep apnea is a sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing, during sleep. Each pause in breathing, called an apnea, can last from a few seconds to minutes, and may occur 5 to 30 times or more an hour. Similarly, each abnormally low...
, osteoporosis
Osteoporosis
Osteoporosis is a disease of bones that leads to an increased risk of fracture. In osteoporosis the bone mineral density is reduced, bone microarchitecture is deteriorating, and the amount and variety of proteins in bone is altered...
, and other common ailments.
The disease management industry
In the United States, disease management is a large industry with many vendors. Major disease management organizations based on revenues and other criteria include Accordant (a subsidiary of Caremark), Alere (now including ParadigmHealth and Matria Healthcare), Caremark (excluding its Accordant subsidiary), Evercare, Health DialogHealth Dialog
Health Dialog is a care management, employee wellness, and decision support provider, and wholly owned subsidiary of Bupa. The company is based in the United States and headquartered in Boston, Massachusetts. The company was founded in 1997 to address the unwarranted variation research done by Dr....
, Healthways
Healthways
Healthways is a disease management company founded in 1981 and headquartered in Franklin, Tennessee.In 2003, the company topped a list of "America's fastest-growing small companies," based on earnings/share growth, revenue growth, and total return...
, LifeMasters (now part of StayWell), LifeSynch (formerly Corphealth), Magellan, McKesson Health Solutions, and MedAssurant.
Disease management is of particular importance to health plans, agencies, trusts, associations and employers that offer health insurance
Health insurance
Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care expenses among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is...
. A 2002 survey found that 99.5% of enrollees of Health Maintenance Organization
Health maintenance organization
A health maintenance organization is an organization that provides managed care for health insurance contracts in the United States as a liaison with health care providers...
/Point Of Service
Point of service plan
A point of service plan, or POS plan, is a type of managed care health insurance system. It combines characteristics of both the HMO and the PPO. Members of a POS plan do not make a choice about which system to use until the point at which the service is being used.The POS is based on the basic...
(HMO/POS) plans are in plans that cover at least one disease management program. A Mercer Consulting study indicated that the percentage of employer-sponsored health plans offering disease management programs grew to 58% in 2003, up from 41% in 2002.
It was reported that $85 million was spent on disease management in the United States in 1997, and $600 million in 2002. Between 2000 and 2005, the compound annual growth rate of revenues for disease management organizations was 28%. In 2000, the Boston Consulting Group
Boston Consulting Group
The Boston Consulting Group is a global management consulting firm with offices in 42 countries. It is recognized as one of the most prestigious management consulting firms in the world. It is one of only three companies to appear in the top 15 of Fortunes "Best Companies to Work For" report for...
estimated that the U.S. market for outsourced disease management could be $20 billion by 2010; however, in 2008 the Disease Management Purchasing Consortium estimated that disease management organization revenues would be $2.8 billion by 2010. As of 2010, a study using National Ambulatory Medical Care Survey data estimated that 21.3% of patients in the U.S. with at least one chronic condition use disease management programs.
Process
The underlying premise of disease management is that when the right tools, ...experts, and equipment are applied to a population, then labor costs (specifically: absenteeism, presenteeism, and direct insurance expenses) can be minimized in the near term, or resources can be provided more efficiently. The general idea is to ease the disease path, rather than cure the disease. Improving quality and activities for daily living are first and foremost. Improving cost, in some programs, is a necessary component, as well. However, some disease management systems believe that reductions in longer term problems may not be measureable today, but may warrant continuation of disease management programs until better data is available in 10–20 years. Most disease management vendors offer return on investmentReturn on investment
Return on investment is one way of considering profits in relation to capital invested. Return on assets , return on net assets , return on capital and return on invested capital are similar measures with variations on how “investment” is defined.Marketing not only influences net profits but also...
(ROI) for their programs, although over the years there have been dozens of ways to measure ROI. Responding to this inconsistency, an industry trade association, the Care Continuum Alliance, convened industry leaders to develop consensus guidelines for measuring clinical and financial outcomes in disease management, wellness and other population-based programs. Contributing to the work were public and private health and quality organizations, including the federal Agency for Healthcare Research and Quality
Agency for Healthcare Research and Quality
The Agency for Healthcare Research and Quality is a part of the United States Department of Health and Human Services, which supports research designed to improve the outcomes and quality of health care, reduce its costs, address patient safety and medical errors, and broaden access to effective...
, the National Committee for Quality Assurance
National Committee for Quality Assurance
The National Committee for Quality Assurance is an independent 501 non-profit organization in the United States designed to improve health care quality. It was established in 1990 with support from the Robert Wood Johnson Foundation. NCQA manages voluntary accreditation programs for individual...
, URAC
Urac
URAC, formerly known as the Utilization Review Accreditation Commission, is a nonprofit organization promoting healthcare quality by accrediting healthcare organizations.- Mission :...
, and the Joint Commission. The project produced the first volume of a now four-volume Outcomes Guidelines Report, which details industry-consensus approaches to measuring outcomes.
Tools include web-based assessment tools, clinical guidelines, health risk assessments, outbound and inbound call-center-based triage, best practices, formularies, and numerous other devices, systems and protocols.
Experts include actuaries
Actuary
An actuary is a business professional who deals with the financial impact of risk and uncertainty. Actuaries provide expert assessments of financial security systems, with a focus on their complexity, their mathematics, and their mechanisms ....
, physician
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
s, medical economists
Economist
An economist is a professional in the social science discipline of economics. The individual may also study, develop, and apply theories and concepts from economics and write about economic policy...
, nurses, nutritionist
Nutritionist
A nutritionist is a person who advises on matters of food and nutrition impacts on health. Different professional terms are used in different countries, employment settings and contexts — some examples include: nutrition scientist, public health nutritionist, dietitian-nutritionist, clinical...
s, physical therapists, statistician
Statistician
A statistician is someone who works with theoretical or applied statistics. The profession exists in both the private and public sectors. The core of that work is to measure, interpret, and describe the world and human activity patterns within it...
s, epidemiologists, and human resources professionals
Human resources
Human resources is a term used to describe the individuals who make up the workforce of an organization, although it is also applied in labor economics to, for example, business sectors or even whole nations...
. Equipment can include mailing systems, web-based applications (with or without interactive modes), monitoring devices, or telephonic systems.
Possible biases and other problems in effectiveness studies
When disease management programs are voluntary, studies of their effectiveness may be affected by a self-selection biasSelection bias
Selection bias is a statistical bias in which there is an error in choosing the individuals or groups to take part in a scientific study. It is sometimes referred to as the selection effect. The term "selection bias" most often refers to the distortion of a statistical analysis, resulting from the...
; that is, a program may "attract enrollees who were [already] highly motivated to succeed". At least two studies have found that people who enroll in disease management programs differ significantly from those who do not on baseline clinical, demographic, cost, utilization and quality parameters. To minimize any bias in estimates of the effectiveness of disease management due to differences in baseline characteristics, randomized controlled trial
Randomized controlled trial
A randomized controlled trial is a type of scientific experiment - a form of clinical trial - most commonly used in testing the safety and efficacy or effectiveness of healthcare services or health technologies A randomized controlled trial (RCT) is a type of scientific experiment - a form of...
s are better than observational studies
Observational study
In epidemiology and statistics, an observational study draws inferences about the possible effect of a treatment on subjects, where the assignment of subjects into a treated group versus a control group is outside the control of the investigator...
.
Even if a particular study is a randomized trial, it may not provide strong evidence for the effectiveness of disease management. A 2009 review paper examined randomized trials and meta-analyses of disease management programs for heart failure and asserted that many failed the PICO process
PICO process
The PICO process is a technique used in evidence based medicine to frame and answer a clinical question.The term is an acronym for patient problem or population , intervention , comparison and outcome ....
and Consolidated Standards of Reporting Trials
Consolidated Standards of Reporting Trials
CONSORT encompasses various initiatives developed by the CONSORT Group to alleviate the problems arising from inadequate reporting of randomized controlled trials.-The CONSORT Statement:...
: "interventions and comparisons are not sufficiently well described; that complex programs have been excessively oversimplified; and that potentially salient differences in programs, populations, and settings are not incorporated into analyses."
Medicare Health Support project, 2005–2011
Section 721 of the Medicare Prescription Drug, Improvement, and Modernization ActMedicare Prescription Drug, Improvement, and Modernization Act
The Medicare Prescription Drug, Improvement, and Modernization Act is a federal law of the United States, enacted in 2003. It produced the largest overhaul of Medicare in the public health program's 38-year history.The MMA was signed by President George W...
of 2003 authorized the Centers for Medicare and Medicaid Services
Centers for Medicare and Medicaid Services
The Centers for Medicare & Medicaid Services , previously known as the Health Care Financing Administration , is a federal agency within the United States Department of Health and Human Services that administers the Medicare program and works in partnership with state governments to administer...
(CMS) to conduct what became the "Medicare Health Support" project to examine disease management. Phase I of the project involved disease management companies (such as Aetna
Aetna
Aetna, Inc. is an American health insurance company, providing a range of traditional and consumer directed health care insurance products and related services, including medical, pharmaceutical, dental, behavioral health, group life, long-term care, and disability plans, and medical management...
Health Management, CIGNA
CIGNA
Cigna , headquartered in Bloomfield, Connecticut, is a global health services company, owing to its expanding international footprint and the fact that it provides administrative services only to approximately 80 percent of its clients...
Health Support, Health Dialog Services Corp., Healthways, and McKesson Health Solutions) chosen by a competitive process in eight states and the District of Columbia. The project focused on people with diabetes or heart failure who had relatively high Medicare payments; in each location, approximately 20,000 such people were randomly assigned to an intervention group and 10,000 were randomly assigned to a control group. CMS set goals in the areas of clinical quality and beneficiary satisfaction, and negotiated with the disease management programs for a target of 5% savings in Medicare costs. The programs started between August 2005 and January 2006. What is now the Care Continuum Alliance praised the project as "the first-ever national pilot integrating sophisticated care management techniques into the Medicare fee-for-service program".
An initial evaluation of Phase I of the project by RTI International
RTI International
RTI International is the trade name of the Research Triangle Institute, an independent research institute established in 1958. The founding tenant of North Carolina’s Research Triangle Park, RTI was created as part of a larger effort to harness the intellectual capital of the area’s three major...
appeared in June 2007 which had "three key participation and financial findings":
- Medicare expenditures for the intervention group were higher than those of the comparison group by the time the pilots started.
- Within the intervention group, participants had lower Medicare payments (i.e., tended to be healthier) than non-participants.
- The "fees paid to date far exceed any savings produced."
DMAA focused on another finding of the initial evaluation, the "high levels of satisfaction with chronic disease management services among beneficiaries and physicians". One commentary noted that the project "can only be observational" since "equivalence was not achieved at baseline". Another commentary claimed that the project was "in big trouble". A paper on the six-month evaluation, published in fall 2008, concluded that "Results to date indicate limited success in achieving Medicare cost savings or reducing acute care utilization".
In December 2007, CMS changed the financial threshold from 5% savings to budget neutrality, a change that DMAA "hailed". In January 2008, however, CMS decided to end Phase I because it claimed that the statutory authority had run out. Four U.S. senators wrote a letter to CMS to reverse its decision. DMAA decried the termination of Phase I and called upon CMS to start Phase II as soon as possible. Among other criticisms of the project, the disease management companies claimed that Medicare "signed up patients who were much sicker than they had expected," failed to transmit information on patients' prescriptions and laboratory results to them in a timely fashion, and disallowed the companies from selecting patients most likely to benefit from disease management.
By April 2008, CMS had spent $360 million on the project. The individual programs ended between December 2006 and August 2008.
The results of the program were published in The New England Journal of Medicine in November 2011. Comparing the 163,107 patients randomized to the intervention group with the 79,310 patients randomized to the control group, the researchers found that "disease-management programs did not reduce hospital admissions or emergency room visits, as compared with usual care." Furthermore, there was "no demonstrable savings in Medicare expenditures," with the net
Net (economics)
In economics, net means after deductions. A related concept is gross, meaning before deductions.Nett is an alternative spelling used in British English.-Usage:...
fees for disease management ranging from 3.8% to 10.9% per patient per month. The researchers suggested that the findings might be explained by the severity of chronic disease among the patients studied, delays in patients' receiving disease management after hospitalizations, and lack of integration between health coaches and the patients' primary care providers.
Other studies
Studies that have reviewed other studies on the effectiveness of disease management include the following:- A 2004 Congressional Budget OfficeCongressional Budget OfficeThe Congressional Budget Office is a federal agency within the legislative branch of the United States government that provides economic data to Congress....
analysis concluded that published studies "do not provide a firm basis for concluding that disease management programs generally reduce total costs". The report caused the disease management industry to "scrambl[e] to build a better business case for their services". - A 2005 review of 44 studies on disease management found a positive return on investmentRate of returnIn finance, rate of return , also known as return on investment , rate of profit or sometimes just return, is the ratio of money gained or lost on an investment relative to the amount of money invested. The amount of money gained or lost may be referred to as interest, profit/loss, gain/loss, or...
(ROI) for congestive heart failure and multiple disease conditions, but inconclusive, mixed, or negative ROI for diabetes, asthma, and depression management programs. The lead author, of Cornell UniversityCornell UniversityCornell University is an Ivy League university located in Ithaca, New York, United States. It is a private land-grant university, receiving annual funding from the State of New York for certain educational missions...
and ThomsonThomson HealthcareThomson Healthcare was one of the five operating divisions of the Thomson Corporation unitl 2008. Following the merger of Thomson with Reuters to form Thomson Reuters in 2008, it became the healthcare business unit of the new company....
Medstat, was quoted as saying that the paucity of research conducted on the ROI of disease management was "a concern because so many companies and government agencies have adopted disease management to manage the cost of care for people with chronic conditions." - A 2007 RANDRANDRAND Corporation is a nonprofit global policy think tank first formed to offer research and analysis to the United States armed forces by Douglas Aircraft Company. It is currently financed by the U.S. government and private endowment, corporations including the healthcare industry, universities...
summary of 26 reviews and meta-analyses of small-scale disease management programs, and 3 evaluations of population-based disease management programs, concluded that "Payers and policy makers should remain skeptical about vendor claims [concerning disease management] and should demand supporting evidence based on transparent and scientifically sound methods." In specific:- Disease management improved "clinical processes of care" (e.g., adherence to evidence-based guidelines) for congestive heart failure, coronary artery disease, diabetes, and depression.
- There was inconclusive evidence, insufficient evidence, or evidence for no effect of disease management on health-related behaviors.
- Disease management led to better disease control for congestive heart failure, coronary artery disease, diabetes, and depression.
- There was inconclusive evidence, insufficient evidence, or evidence for no effect of disease management on clinical outcomes (e.g., "mortality and functional status").
- Disease management reduced hospital admission rates for congestive heart failure, but increased health care utilization for depression, with inconclusive or insufficient evidence for the other diseases studied.
- In the area of financial outcomes, there was inconclusive evidence, insufficient evidence, evidence for no effect, or evidence for increased costs.
- Disease management increased patient satisfaction and health-related quality of life in congestive heart failure and depression, but the evidence was insufficient for the other diseases studied.
- A subsequent letter to the editor claimed that disease management might nevertheless "satisfy buyers today, even if academics remain unconvinced".
- A 2008 systematic review and meta-analysis concluded that disease management for COPD "modestly improved exercise capacity, health-related quality of life, and hospital admissions, but not all-cause mortality".
- A 2009 review of 27 studies "could not draw definitive conclusions about the effectiveness or cost-effectiveness of... asthma disease-management programs" for adults.
- A Canadian systematic review published in 2009 found that home telehealthTelehealthTelehealth is the delivery of health-related services and information via telecommunications technologies. Telehealth could be as simple as two health professionals discussing a case over the telephone or as sophisticated as doing robotic surgery between facilities at different ends of the...
in chronic disease management may be cost-saving but that "the quality of the studies was generally low." - Researchers from The Netherlands systematically reviewed 31 papers published 2007–2009 and determined that the evidence that disease management programs for four diseases reduce healthcare expenditures is "inconclusive."
- A meta-analysis of randomized trials published through 2009 estimated that disease management for diabetes has "a clinically moderate but significant impact on hemoglobin A1C levels," with an absolute mean difference of 0.51% between experimental and control groups.
- A 2011 "meta-review" (systematic review of meta-analyses) of heart failure disease management programs found them to be of "mixed quality" in that they did not report important characteristics of the studies reviewed.
Recent studies not reviewed in the aforementioned papers include the following:
- A U.K. study published in 2007 found certain improvements in the care of patients with coronary artery disease and heart failure (e.g., better management of blood pressure and cholesterol) if they received nurse-led disease management instead of usual care.
- In a 2007 Canadian study, people were randomized to receive or not receive disease management for heart failure for a period of six months. Emergency room visits, hospital readmissions, and all-cause deaths were no different in the two groups after 2.8 years of follow-up.
- A 2008 U.S. study found that nurse-led disease management for patients with heart failure was "reasonably cost-effective" per quality-adjusted life year compared with a "usual care group".
- A 2008 study from the Netherlands compared no disease management with "basic" nurse-led disease management with "intensive" nurse-led disease management for patients discharged from the hospital with heart failure; it detected no significant differences in hospitalization and death for the three groups of patients.
- A retrospective cohort study from 2008 found that disease management did not increase the use of drugs recommended for patients after a heart attack.
- Of 15 care coordination (disease management) programs followed for two years in a 2008 study, "few programs improved patient behaviors, health, or quality of care" and "no program reduced gross or net expenditures".
- After 18 months, a 2008 Florida study found "virtually no overall impacts on hospital or emergency room (ER) use, Medicare expenditures, quality of care, or prescription drug use" for a disease management program.
- With minor exceptions, a paper published in 2008 did not find significant differences in outcomes among people with asthma randomly assigned to telephonic disease management, augmented disease management (including in-home respiratory therapist visits), or traditional care.
- A 2009 review by the Centers for Medicare and Medicaid Services of 35 disease management programs that were part of demonstration projects between 1999 and 2008 found that relatively few improved quality in a budget-neutral manner.
- In a 2009 randomized trial, high- and moderate-intensity disease management did not improve smoking cessation rates after 24 months compared with drug therapy alone.
- A randomized trial published in 2010 determined that disease management reduced a composite score of emergency room visits and hospitalizations among patients discharged from Veterans AdministrationVeterans Health AdministrationThe Veterans Health Administration is the component of the United States Department of Veterans Affairs led by the Under Secretary of Veterans Affairs for Health that implements the medical assistance program of the VA through the administration and operation of numerous VA outpatient clinics,...
hospitals for chronic obstructive pulmonary disease. A 2011 post-hoc analysisPost-hoc analysisPost-hoc analysis , in the context of design and analysis of experiments, refers to looking at the data—after the experiment has concluded—for patterns that were not specified a priori. It is sometimes called by critics data dredging to evoke the sense that the more one looks the more likely...
of the study's data estimated that the intervention produced a netNet (economics)In economics, net means after deductions. A related concept is gross, meaning before deductions.Nett is an alternative spelling used in British English.-Usage:...
cost savings of $593 per patient. - A Spanish study published in 2011 randomized 52 people hospitalized for heart failure to follow-up with usual care, 52 to home visits, 52 to telephone follow-up, and 52 to an in-hospital heart failure unit. After a median of 10.8 months of follow-up, there were no significant differences in hospitalization or mortality among the four groups.
- Among 18–64 year old people with chronic diseases receiving MedicaidMedicaidMedicaid is the United States health program for certain people and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states. People served by Medicaid are U.S. citizens or legal permanent...
, telephone-based disease management in one group of members did not reduce ambulatory care visits, hospitalizations, or expenditures relative to a control group. Furthermore, in this 2011 study, the group receiving disease management had a lower decrease in emergency department visits than the group not receiving disease management.
Further reading
- Todd, Warren E., and David B. Nash. Disease management: a systems approach to improving patient outcomes. Chicago: American Hospital Pub., 1997. ISBN 1556481683
- Couch, James B. The health care professional's guide to disease management: patient-centered care for the 21st century. Gaithersburg, MD: Aspen Publishers, 1998. ISBN 0834211661
- Patterson, Richard. Changing patient behavior: improving outcomes in health and disease management. San Francisco: Jossey-Bass, 2001. ISBN 0787952796
- Disease management for nurse practitioners. Springhouse, PA: Springhouse, 2002. ISBN 1582550697
- Howe, Rufus S. The disease manager's handbook. Sudbury, MA: Jones and Bartlett, 2005. ISBN 0763747831
- Huber, Diane. Disease management: a guide for case managers. St. Louis: Elsevier Saunders, 2005. ISBN 0721639119
- Nuovo, Jim, editor. Chronic disease management. New York, NY: Springer, 2007. ISBN 9780387329277
- Evidence-based nursing guide to disease management. Philadelphia: Lippincott Williams & Wilkins, 2009. ISBN 9780781788267
External links
- Australian Disease Management Association
- Care Continuum Alliance. Advancing the Population Health Improvement Model.
- Center for Managing Chronic Disease. University of Michigan
- Disease Management: A collection of articles from MANAGED CARE magazine
- Disease Management Association of India
- Disease Management: Findings from Leading State Programs by Ben Wheatley (AcademyHealth State Coverage Initiatives Issue Brief, Vol. III, No. 3, December 2002)
- Disease Management in Medicare: Data Analysis and Benefit Design Issues by Dan L. Crippen (Testimony before the Special Committee on Aging, United States Senate, September 19, 2002)
- Disease Management Purchasing Consortium International, Inc.
- Disease Management Resources by National Conference of State Legislatures (Updated August 2007)
- Evaluating ROI in State Disease Management Programs by Thomas W. Wilson (AcademyHealth State Coverage Initiatives Issue Brief, Vol. IV, No. 5, November 2003)
- Square peg in a round hole? Disease management in traditional Medicare. Special Committee on Aging, U.S. Senate, November 4, 2003.