Disease Management

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Table 1 Definitions of disease management. Disease management refers to the use of an explicit systematic population-based approach to identify persons at risk, intervene with specific programs of care, and measure clinical outcomes Epstein and Sherwood, [ 1 ]. Disease management has three parts: An approach to patient care that emphasizes coordinated, comprehensive care along the continuum of disease and across health care delivery systems Ellrodt et al.

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Disease management is generally defined as a comprehensive, integrated approach to care and reimbursement based on a disease's natural course. The goal of disease management is to address the illness or condition with maximum effectiveness and efficiency regardless of treatment setting s or typical reimbursement Zitter, [ 4 ]. Disease management is an intervention designed to manage or prevent a chronic condition using a systematic approach to care and potentially employing multiple treatment modalities Weingarten et al. Disease management typically refers to multidisciplinary efforts to improve the quality and cost-effectiveness of care for selected patients suffering from chronic conditions Faxon et al.

AHA, [ 6 ]. Disease management is a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant DMAA, [ 7 ]. Open in a separate window. Footnotes 1 For the conference archive visit: From outcomes research to disease management: Annals of Internal Medicine. Drastically improving health care with focus on managing the patient with a disease: Journal of the American Medical Association.

A new paradigm in health care delivery: Todd WE, Nash D, editors.

More recent experience

American Hospital Association; Interventions used in disease management programmes for patients with chronic illness — which ones work? Meta-analysis of published reports. Improving quality of care through disease management: The Care Continuum Alliance. Patient education, reminders, and financial incentives were all associated with improvements in patient disease control effect sizes 0. All studied interventions were associated with improvements in provider adherence to practice guidelines and disease control. The type and number of interventions varied greatly, and future studies should directly compare different types of intervention to find the most effective.

Disease management programmes have gained popularity in recent years as a means of improving the quality and efficiency of care of patients with chronic diseases. A limited number of trials have documented the effectiveness of disease management in specific situations, but uncertainty remains about its overall value and which interventions are most effective.

Programmes using education, feedback, or reminders for healthcare providers produced significant improvements in provider adherence to care guidelines. Programmes using the provider strategies or education, reminders, or financial incentives for patients improved disease control. Further study is needed to assess the relative effectiveness of the different strategies. Chronic diseases account for billions of dollars in annual medical expenditures. Unsurprisingly, therefore, there has been much interest in systematically improving the quality and reducing the cost of caring for patients with chronic illness.

Disease management programmes have proliferated recently as a means of improving the quality and efficiency of care for patients with chronic illness. Ellrodt et al defined disease management as a multidisciplinary approach to care for chronic diseases that coordinates comprehensive care along the disease continuum across healthcare delivery systems.

However, disease management programmes can be costly to develop, implement, and evaluate. A limited number of published trials have documented the effectiveness of disease management in specific situations, but uncertainty remains about its overall value. Understanding which interventions are most effective could guide the development of disease management programmes.

Several qualitative reviews have described the effects of interventions such as educational programmes, giving feedback to healthcare providers, and patient financial incentives to promote adherence to practice guidelines. Additionally, there have been only limited evaluations of the quantitative effects of specific types of interventions to complement qualitative and descriptive information. This study reviews the types of interventions used in published trials of disease management programmes and provides quantitative and qualitative evaluation of the evidence regarding the effectiveness of different types of intervention.

We performed a systematic review of the medical literature to identify studies evaluating the effectiveness of disease management programmes in improving care or reducing costs for patients with common chronic conditions. In collaboration with a librarian experienced in searching computerised bibliographic databases, we conducted a search of the Medline, HealthStar, and Cochrane databases for English language articles published between January and June The search used the following medical subject heading MeSH terms: Hand searches of bibliographies from relevant articles and reviews and consultations with experts in the subject yielded further references.

We excluded programmes aimed exclusively at evaluations of single treatment methods such as psychotherapy or specific drugs and drug compliance programmes. We rejected articles if they included only paediatric cases or if they were reviews, case reports, editorials, letters, or meeting abstracts. We also rejected articles if they did not use acceptable experimental or quasi-experimental study designs as defined by the Cochrane Effective Practice and Organisation of Care EPOC Group's criteria for acceptable study designs, 14 or if they did not report sufficient information to allow for estimation of at least one relevant measure of programme effect and its variance.

Failure to meet this criterion could be due to inadequate reporting of results or to lack of an appropriate comparison group. Based on these explicit inclusion and exclusion criteria for titles, abstracts, and articles, two reviewers trained in health services research and the principles of critical appraisal independently reviewed random samples of titles, abstracts, and reviews.

Results from accepted articles reporting results for disease management programmes were used to address study objectives. Provider education—Materials or instruction given to healthcare providers regarding appropriate care for patients with the condition targeted by the programme. Provider feedback—Information given to healthcare providers regarding the specific care or results of care received or experienced by their patients. Patient education—Materials and instructions issued to patients providing information on their condition and how it could be managed.

Patient reminders—Prompts given to patients to perform specific tasks related to care for their condition. Patient financial incentives—Payments direct monetary payments, discounts, or services made to patients for achieving specific treatment related goals. We also searched for programmes using provider financial incentives but found no such interventions. The proportions of interventions using each of the different interventions were described, as were the proportions with one, two, three, or four components no intervention included more than four components.

Our analyses focused on measures of provider adherence to guidelines as key processes of care and on measures of disease control as key outcomes of care. Using a standardised abstraction form, we collected data describing interventions, components used, study design, population characteristics, sample size, intervention strategies, and measures of programme effects on processes and outcomes of care from unmasked articles that met our inclusion criteria. For each disease and condition, we had a defined method for selecting each disease specific process or outcome indicator as a measure of disease control see appendix 2 on bmj.

We treated multiple reports of results from the same study as a single programme evaluation. Reports with multiple intervention arms contributed one observation for each. When separate results were reported for mutually exclusive subgroups, each subgroup contributed an observation, and the overall results were not included.

Disease management (health)

When appropriate, we used changes over baseline values rather than follow up values in our analyses. Variances for changes over baseline were often not reported, in which case we assumed that the variance for the change was equal to the average of the variances of the baseline and follow up distributions if both were given. If the baseline variance was not provided, we assumed that the variance for the change was equal to the variance of the follow up distribution.

We calculated effect sizes—defined as a difference between the means of the treatment and control arms divided by the pooled estimate of the standard deviation continuous variables or the log odds ratio multiplied by a constant variance term binary outcomes 15 —for each study outcome to allow pooling of similar outcomes. The method of interpreting the clinical importance of different effect sizes has been reported previously.

We used the more conservative random effects, empirical bayesian method of Hedges and Olkin to pool the estimated effects. We also pooled results for each of these measures for interventions containing one, two, three, and four intervention components. When more than one process or outcome result within a category was reported for the same group of subjects, we used the one associated with the smallest effect size. Our initial search strategy identified 16 references published between January and June figure.

We accepted titles for further screening, and abstracts met our explicit inclusion criteria. Bibliographic hand searches and expert consultation yielded an extra 51 articles for review, of which 14 were accepted. In total studies met our criteria for inclusion. Multiple reports of the same intervention reduced the count of studies by The accepted studies evaluated discrete intervention programmes and reported estimates of programme effect. Selected programmes were heterogeneous with regard to the types of intervention they used table 1.

Of the programmes, 92 used patient education, 47 used provider education, 32 used provider feedback, 28 used patient reminders, 19 used provider reminders, and only six used financial incentives for patients. The six programmes that used financial incentives for patients were for asthma, depression, hyperlipidaemia, and hypertension. The number of different interventions included in each disease management programme varied, with 48 programmes using a single intervention, 41 using two, 22 using three, and seven using four interventions table 2.

Number of different interventions used in disease management programmes for chronic diseases. We identified 32 programmes addressing six conditions that included provider education and evaluated disease control table 3. Overall, programmes that included provider education showed a modest but significant improvement in disease control effect size 0. Effects of disease management programmes with interventions directed at healthcare providers on disease control. Twenty three programmes addressing asthma, depression, diabetes, renal disease, hyperlipidaemia, and hypertension included provider feedback and evaluated disease control table 3.

Fourteen programmes incorporating provider reminders evaluated disease control table 3. Overall, the programmes made a small but significant improvement in disease control effect size 0. Overall, programmes with provider education components significantly improved provider adherence to guidelines effect size 0. Effects of disease management programmes with interventions directed at healthcare providers on provider adherence to guidelines. Sixteen programmes with provider feedback evaluated provider adherence to guidelines table 4. Overall, these programmes were effective in improving provider adherence effect size 0.

Ten programmes with provider reminders examined provider adherence table 4. Overall, these programmes were also effective in improving provider adherence effect size 0. Fifty five programmes included patient education and evaluated disease control table 5.

Overall, patient education produced a small but significant improvement in disease control effect size 0. Sixteen programmes including patient reminders evaluated disease control table 5. Overall, programmes with patient reminders produced a small but significant improvement in disease control effect size 0. Four programmes incorporating patient financial incentives evaluated disease control table 5. Overall, these programmes seemed effective in improving disease control effect size 0. Our study showed that many different interventions—including provider education, provider feedback, provider reminders, patient education, patient reminders, and patient financial incentives—were associated with improvements in provider adherence to guidelines and patient disease control.

However, since existing studies do not directly compare different interventions, less is known about which interventions produce the greatest relative improvements in care. There should be careful consideration of the most effective strategies for changing provider and patient behaviour, since it is difficult to postulate any improvements in patient care if both provider and patient behaviour remains unchanged. Our study showed that many different types of intervention are being used in disease management programmes, with patient education being the commonest.

The wide variety interventions used may reflect the paucity of available information to guide programme development and to define an optimal strategy. It is ironic that disease management programmes are designed to reduce unexplained variations in care, yet there are large and unexplained variations in the design, development, and implementation of disease management programmes. However, this investment in disease management should be guided by information on how to optimise the benefits of these programmes.

Unfortunately, disease management programme developers have had limited qualitative or quantitative information about which interventions achieve the greatest benefits, and programmes are therefore highly variable in design. To the best of our knowledge, our study is the first comprehensive attempt to evaluate the effectiveness of different disease management programmes for patients with chronic illness.

Our study brought together disparate information of disease management, to allow for qualitative and quantitative interpretation. We evaluated 16 different article titles and identified different disease management studies. We evaluated multiple potential implementation strategies for many different diseases and conditions, and we evaluated both the process of care provider adherence to guidelines and the outcome of care disease control. Disease control measures were carefully selected and related to the key clinical goals of the treatment of each disease. In addition, our study provided both qualitative and quantitative information to assess the effectiveness of different interventions; most other studies have evaluated only qualitative findings.

Our study has several limitations, most importantly the quality, quantity, and heterogeneity of the original studies.

The studies included great variation in interventions used, patient populations, provider populations, and measured processes and outcomes of care. Many provided insufficient detail in the methods section for us to understand the quality of the interventions and the intensity or duration of each intervention. For example, a study might report that provider education was used, but provide insufficient information for readers to understand how the educational process was performed and how to replicate the process. The clinical significance of effect sizes may be unclear and need to be interpreted with caution and related to the measured clinical effects reported in the trials.

The available published literature shows that most disease management programmes directed at providers and patients are associated with improvements in care. The need for effective DMPs has been clear for at least two decades. Population aging, poor dietary choices, physical inactivity, tobacco use, and other factors have increased the prevalence of chronic conditions significantly.

At the same time, the cost of care for patients with these conditions has risen markedly. Widespread use of DMPs began in the United States in the s as payors sought to rein in rising health care costs. By the end of that decade, DMPs for a wide range of different chronic conditions had been developed, and optimism ran high. Unfortunately, once the results of these early programs were published, it became clear that many had not proved their worth.

For example, an analysis of more than early DMPs found that the programs did tend to improve quality of care, but in most cases there was no conclusive evidence that the improvements resulted in better long-term outcomes or significant cost savings Exhibit 2. Soeren Mattke et al. Even worse, the asthma DMPs seemed to have had a negative impact on health outcomes and costs. There remained room for hope, however. The authors of these analyses acknowledged that most of the DMPs they had studied had significant limitations: Because of these limitations, the authors were not willing to conclude that DMPs could not work well.

Many health experts continued to believe that DMPs could be effective—a belief apparently vindicated by more recent results in a number of countries. Almost a decade ago, Germany decided to reform the way it was funding its public payors, which provide health insurance coverage for about 90 percent of the population. One of its concerns was that some payors had been trying to attract only young, healthy patients, which left the other payors at an economic disadvantage.

To discourage this type of cherry picking, Germany began giving its public payors extra funding for patients with chronic conditions. However, the size of the extra payments was capped to prevent health care costs from rising uncontrollably. Germany also coupled the increased funding with a requirement that the payors enroll patients with the most common chronic conditions in DMPs. Last year, Germany added congestive heart failure to this list. To overcome some of the problems that had hampered earlier DMPs, Germany set minimum standards for them. In addition, the programs had to be approved by a federal health agency and then run nationwide.

Although the program is only six years old, it has already enrolled more than three million patients Exhibit 3 and has demonstrated that it markedly improves health care delivery to those patients. For example, the patients are now significantly more likely to have their feet checked regularly by a specialist, as a result of which the incidence of certain types of foot ulcer has plummeted. Preliminary evidence also suggests that the program may be decreasing mortality. Antje Miksch et al. Furthermore, patient satisfaction with treatment has risen markedly, and the overall cost of care has decreased; the small increases the program has produced in outpatient and pharmaceutical costs have been more than offset by a drop of more than 25 percent in inpatient costs Exhibit 4.

Most of these costs result from additional fees paid to doctors. However, conversations we have had with several payors suggest that many of the programs, especially those for CAD and COPD, are also producing strong results. Although asthma and COPD are two separate diseases, they share many underlying pathophysiologic mechanisms and are often treated with similar medications. Lotte Steuten et al.

It has also reduced total per-patient health care costs. This DMP, which focuses on patients with impaired glucose tolerance who are at high risk of diabetes , has helped the patients lose weight and reduced by two-thirds the risk that they would develop diabetes. Kinori Kosaka et al. Donatella Del Sindaco et al.

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A Swedish heart-failure DMP has also shortened the duration of hospital stays although it has not lowered the hospitalization rate itself and improved survival rates among enrolled patients. Anna Stromberg et al. Sweden has also had success using DMPs for patients with hypertension and cancer. Many other successful programs from other countries are now being reported.

Nestlé Nutrition Institute

We analyzed a wide range of DMPs from countries around the world to determine the characteristics that differentiate successful and unsuccessful programs. Five traits seemed to be the most important in ensuring that DMPs meet their goals: Large DMPs are more likely to be successful than small programs because they benefit from economies of scale: As a result, it is often easier to achieve net savings. Large programs are also more likely to improve their processes regularly, because they are usually better able to mine the data they are collecting and to use those analyses to refine their processes.

Furthermore, large DMPs often find it easier to develop and to ensure compliance with the evidence-based care pathways used for treatment.

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