Chronic disease management: Does it improve health and save money?
A study published in the May/June issue of Health Affairs reports on the first randomized trial providing a scientifically valid look at what one might expect from chronic disease management programs that serve low-income individuals.
The study by IU researchers provides good news for state Medicaid leaders struggling to meet the needs of individuals with chronic conditions and also suggests that some disease management efforts, even among relatively low-risk patients, may be an effective strategy.
While chronic disease management programs, also known as chronic care management, have become widespread across the United States, gaining favor with employer groups, health-care organizations and health payers, these programs are being increasingly questioned because very little scientific evidence exists regarding their effectiveness and fiscal impact.
Researchers from the Indiana University School of Medicine, the Regenstrief Institute, and the School of Public and Environmental Affairs at Indiana University-Purdue University Indianapolis designed a study to determine whether chronic disease management of individuals with diabetes and/or congestive heart failure (CHF) improves health outcomes and lowers health care costs.
In contrast to earlier studies, the researchers randomly assigned individuals with the two chronic conditions to either chronic disease management or a control group based on their primary care provider's location. The researchers used a predictive model to identify individuals at risk for high levels of future health care utilization. Individuals judged to be at highest risk were given intensive health care management conducted by a nurse care manager. Those with lower risk were provided with education and care support over the phone.
The findings were much more complex than researchers had anticipated.
"The telephonic support, when given to the lower risk group for either disease, resulted in a significant reduction in subsequent health care claims paid," said study senior author Thomas S. Inui, IU School of Medicine associate dean for health care research and Sam Regenstrief Professor of Health Services Research. Dr. Inui also is president and CEO of the Regenstrief Institute.
Results for high-risk patients were more ambiguous. The researchers found that nurse care management resulted in lower average claims for high-risk CHF patients, but slightly higher average claims for high-risk diabetes patients, although neither effect was found to be statistically significant.
One of the strengths of this evaluation is that the fiscal impact analysis included the costs of delivering the chronic disease management intervention, not just the impact on claims for subsequent utilization. "Once we considered these additional costs, we discovered the net fiscal impact of chronic disease management was positive only for low-risk CHF patients," said lead author Ann M. Holmes, associate professor, IUPUI School of Public and Environmental Affairs.
The 23-month study was too short to determine clinical outcomes for either disease. Future work is needed to determine whether long run chronic care management improves control and outcomes in diabetes or improves heart function in those with CHF.
"This is a study with real health policy impact. Our findings were so encouraging that Indiana Medicaid, which funded our work, enrolled its Aging, Blind and Disabled program eligible patients in care management plans," said Dr. Inui.
In addition to Holmes and Inui, co-authors of the study are Ronald Ackermann, Barry P. Katz and Stephen M. Downs, all of the IU School of Medicine and the Regenstrief Institute, and Alan J. Zillich of the Purdue School of Pharmacy and the Richard Roudebush VA Medical Center.