Section 8: The Care Management Evidence Base (continued)

Designing and Implementing Medicaid Disease and Care Management Programs: A User's Guide

Review Synopsis: Congestive Heart Failure

To evaluate the effect of care management on congestive heart failure (CHF), we reviewed 18 relevant articles. Of these studies, 13 articles examined the impact of patient interventions, 3 examined the impact of provider interventions, and 1 examined the impact of a combination of patient and provider interventions. The interventions evaluated most commonly were:

• In-person care management (2 articles).
• Telephonic care management (7 articles).
• Self-management and monitoring (5 articles).
• Patient education (1 article).
• Provider education (2 articles).
• Decision support (2 articles).

Findings are organized below by measurement category (i.e., clinical outcomes measures, clinical process measures, activation measures, and utilization measures).

Clinical Outcome Measures

Our search returned 11 studies that found care management interventions can lead to improved clinical outcomes. Clinical outcomes examined include:

• Quality of life.
• Mortality.
• Self-reported health and self-efficacy.
• Scores from the Minnesota Living with Heart Failure and Kansas City Cardiomyopathy questionnaires.

Of the six intervention categories, in-person care management, telephonic care management, self-management and monitoring, and decision support appeared to have equal impact on clinical outcomes. These interventions significantly improved quality of life, self-reported health, self-efficacy, and scores for the Minnesota Living with Hearth Failure and Kansas City Cardiomyopathy questionnaires. Patient and provider education appeared to exert the weakest effects, demonstrating no significant impacts on clinical outcomes.

Impact on Quality of Life

• In-Person Care Management. One study found significant improvement in quality of life for interventions using in-person care management.¹ This study showed that patients were more likely to have improved quality of life in three of the eight Short Form Health Survey 36 (SF-36) quality-of-life measurements.
• Decision Support. One study examining whether decision support interventions could improve quality of life found that patients whose nurses received an e-mail message addressing six heart failure recommendations were significantly more likely to see an improved quality-of-life score.²

Contrasting these results are two studies that examine the effect of telephonic care management on quality-of-life levels.^3,4 The results of these studies found no significant changes in quality of life when telephonic care management was employed. Another study focusing on self-management and monitoring found no significant changes in CHF-related quality of life when a telephonic care management intervention was employed.⁵

Impact on Mortality

• Telephonic Care Management. One study demonstrated significantly decreased mortality rates when telephonic care management was used. The investigators concluded that patient mortality rates decreased and, consequently, patients gained 76 days by using telephonic care management.⁶ In contrast to this study, two other studies found no significant changes in mortality when telephonic care management intervention was employed.^3,7
• Self-Management and Monitoring. One study found that fewer patients died when a self-management and monitoring intervention was used.⁵ Furthermore, another study showed that mortality was significantly reduced at year one with the help of self-management and monitoring interventions.⁸

Impact on Self-Reported Health and Self-Efficacy

• Telephonic Care Management. One study showed that self-reported health improved significantly when telephonic care management was employed.⁴ In particular, this study found self-reported health improved at 6 months and 12 months. However, this study failed to show improvement in health-related quality-of-life scores when using the SF-36.
• Self-Management and Monitoring. One study found that self-management and monitoring resulted in a significantly improved self-perceived health status.⁹ Similarly, the same study found that self-management and monitoring can significantly improve a patient's self-efficacy.

Impact on Minnesota Living with Heart Failure Questionnaire Scores and Kansas City Cardiomyopathy Questionnaire Scores

• Telephonic Care Management. One study showed that telephonic care management exerted a positive impact on scores for the Minnesota Living with Heart Failure questionnaire.¹⁰ Using telephonic care management helped improve scores by 9.9 points over 3 months. The results demonstrate that using this technique for low-literacy patients is highly effective.
• Decision Support. The results of one study showed that decision support constituted an effective tool to improve scores for the Kansas City Cardiomyopathy questionnaire.²

Other Impacts

Three other studies focusing on telephonic care management and self-management and monitoring found that these care management interventions failed to significantly change level of depression,³ functional status,⁷ and CHF severity.¹¹

Clinical Process Measures

We identified nine studies that showed how care management can improve clinical process measures. The clinical process measures examined in this review include use of medication and tests, weight monitoring, and self-care and management behavior. Of the six intervention categories, the intervention that appeared to exert the strongest impact on clinical process measures was self-management, which significantly affected medication and test use, as well as self-care and management behavior. Patient education, decision support, and provider education also were effective in improving clinical process measures.

Impact on Medication Use and Tests Performed

• Self-Management and Monitoring. One study found that self-management and monitoring significantly improved the use of alpha-beta blockers, lipid panels, and the number of electrocardiograms performed.¹² However, self-management and monitoring intervention failed to significantly change the use of beta-blockers.
• Patient and Provider Education. One study showed that using patient and provider education significantly improved prescription patterns for ACE inhibitors and beta-blockers.¹³
• Decision Support. Similar to the results from the provider and patient intervention study, the results of another study showed that decision support was useful at significantly improving the administration of ACE inhibitors.¹⁴

Impact on Daily Weight Monitoring

• Decision Support. Two studies found that weight monitoring and diet use improved significantly when decision support was employed.^2,5
• Telephonic Care Management. Contrasting the decision support results was one study that found the percentage of patients weighing themselves daily failed to increase significantly when telephonic care management was used.¹⁰

Other Impacts

• Self-Management and Monitoring. Using self-management and monitoring was found to significantly increase the rate of pneumococcal vaccination and significantly decrease the number of cardiac catheterizations.¹² Two other studies also found that this intervention significantly improved self-care and management behaviors.^9,11
• Provider Education. Using provider education appeared to significantly increase use of evidence-based care.¹⁵

Activation Measures

Four studies examined the effect of care management on activation measures. The activation measures identified in this literature review include patient satisfaction and patient knowledge. Telephonic care management, self-management and monitoring, and decision support appeared to influence these activation measures more strongly.

Impact on Knowledge

• Self-Management and Monitoring. One study showed that CHF knowledge improved significantly when self-management and monitoring interventions were used.¹¹
• Decision Support. In particular, patient knowledge of medication improved significantly when decision support interventions were used.²
• Telephonic Care Management. One study found no significant changes in patient knowledge when telephonic care management was used.¹⁰

Impact on Patient Satisfaction

• Telephonic Care Management. One study found that patient satisfaction increased with use of telephonic care management.¹⁶

Utilization Measures

We identified 13 studies relevant to utilization, savings, or both. Of these studies, we found that utilization decreased and savings increased. In-person care management, telephonic care management, self-management and monitoring, patient education, decision support, and provider education all help to decrease utilization and increase savings.

Impact on Utilization

• In-Person Care Management. One study found that the 6-month readmissions rate was significantly reduced, by 74 percent, when in-person care management was used.¹⁷
• Telephonic Care Management. Three studies found that telephonic care management significantly reduced utilization.^7,12,16 All three studies showed that telephonic care management significantly reduced the number of hospital readmissions. In particular, two of the three studies found that telephonic care management helped significantly reduce the number of CHF-related hospitalizations, between 44 percent and 47.8 percent.^12,16 The results of one study showed that the number of CHF-related hospital days was significantly fewer with telephonic care management.¹⁶ Results of another study also found that the number of inpatient bed days was reduced by 26 percent, whereas the number of skilled nursing facilities days was decreased by 45 percent.¹² This same study also found that the number of ER visits decreased significantly with telephonic care management. Lastly, the third study showed that telephonic care management helped significantly reduce time to "hospital encounter."⁷
• Self-Management and Monitoring. Four studies evaluated the effect of self-management and monitoring on utilization. The first study found that self-management and monitoring significantly reduced the hospitalization of low-literacy patients.⁵ In addition, another study showed that this intervention could significantly reduce the number of inpatient admissions and the number of inpatient bed days.¹² Furthermore, a third study showed that the number of readmissions decreased significantly when self-management and monitoring was employed. Lastly, one study found that hospital utilization decreased, with specific attention to a decrease in ER use, when self-management and monitoring interventions were used.⁹
• Patient and Provider Education. One study found that patient and provider education was effective at significantly reducing length of hospital stay as well as number of readmissions.¹³
• Decision Support. One study showed that number of patients released from the hospital in 4 days or fewer increased significantly with use of decision support interventions.¹⁴

Impact on Savings

• In-Person Care Management. One study showed that the average cost savings associated with in-person care management was $1,541.¹⁷
• Telephonic Care Management. One study found that in-person care management increased savings. This study showed that the cost of inpatient heart failure was reduced significantly by using in-person care management.¹⁶ In contrast, three studies found no significant changes in number of CHF-related hospitalizations,⁷ CHF-related days in the hospital,³ CHF-related cost of care,³ and health care utilization when using in-person care managment.⁶ A fourth study showed that even when in-person care management was used, no significant changes occurred in cost shifting to the outpatient environment.¹⁶
• Self-Management and Monitoring. One study found that self-management and monitoring significantly reduced per-month cost for each member.⁹ Moreover, this same study found that ROI ranged between $1.08 and $1.15 per dollar spent.
• Decision Support. Two studies found that savings increased significantly with use of decision support. One study showed that median hospital charges were reduced significantly, by 45 percent, or, in other words, by $2,500.¹⁴ Similarly, another study found that basic decision support was more cost effective than a more complicated decision support intervention.²

Conclusion

Several care management interventions can be used effectively to treat CHF. According to the literature review, quality of life, mortality, self-reported health and self-efficacy, and scores from the Minnesota Living with Heart Failure and Kansas City Cardiomyopathy questionnaires were cited most frequently as types of clinical outcome evaluated using in-person care management, telephonic care management, and decision support interventions. In addition, a host of care management interventions that involve self-management and monitoring, patient and provider education, and decision support showed how clinical process measures can be improved. Similarly, self-management and monitoring and in-person care management also were found to improve activation measures, such as knowledge and patient satisfaction. Lastly, the evidence demonstrates that these care management interventions can significantly decrease health care utilization and increase savings. 

Reference List 

1. Sidorov J, Shull RD, Girolami S, et al. Use of the short form 36 in a primary care based disease management program for patients with congestive heart failure. Dis Manag 2003;6(2):111-7.
2. Feldman PH, Murtaugh CM, Pezzin LE, et al. Just-in-time evidence-based e-mail "reminders" in home health care: impact on patient outcomes. Health Serv Res 2005;40(3):865-85.
3. Riegel B, Carlson B, Glaser D, et al. Randomized controlled trial of telephone case management in Hispanics of Mexican origin with heart failure. J Card Fail 2006;12(3):211-9.
4. Smith B, Forkner E, Zaslow B, et al. Disease management produces limited quality-of-life improvements in patients with congestive heart failure: evidence from a randomized trial in community-dwelling patients. Am J Manag Care 2005;11(11):701-3.
5. DeWalt DA, Malone RM, Bryant ME, et al. A heart failure self-management program for patients of all literacy levels: a randomized, controlled trial [ISRCTN11535170]. BMC Health Serv Res 2006;6:30
6. Galbreath AD, Krasuski RA, Smith B, et al. Long-term healthcare and cost outcomes of disease management in a large, randomized, community-based population with heart failure. Circulation 2004;110(23):3518-26.
7. Dunagan WC, Littenberg B, Ewald GA, et al. Randomized trial of a nurse-administered, telephone-based disease management program for patients with heart failure. J Card Fail 2005;11(5):358-65.
8. Krumholz HM, Amatruda J, Smith GL, et al. Randomized trial of an education and support intervention to prevent readmission of patients with heart failure. J Am Coll Cardiol 2002;39(1):83-9.
9. Hudson LR, Hamar GB, Orr P, et al. Remote physiological monitoring: clinical, financial, and behavioral outcomes in a heart failure population. Dis Manag 2005;8(6):372-81.
10. DeWalt DA, Pignone M, Malone R, et al. Development and pilot testing of a disease management program for low literacy patients with heart failure. Patient Educ Couns 2004;55(1):78-86.
11. Caldwell MA, Peters KJ, Dracup KA. A simplified education program improves knowledge, self-care behavior, and disease severity in heart failure patients in rural settings. Am Heart J 2005;150(5):983
12. Berg GD, Wadhwa S, Johnson AE. A matched-cohort study of health services utilization and financial outcomes for a heart failure disease-management program in elderly patients. J Am Geriatr Soc 2004;52(10):1655-61.
13. Miranda MB, Gorski LA, LeFevre JG, et al. An evidence-based approach to improving care of patients with heart failure across the continuum. J Nurs Care Qual 2002;17(1):1-14.
14. Ranjan A, Tarigopula L, Srivastava RK, et al. Effectiveness of the clinical pathway in the management of congestive heart failure. South Med J 2003;96(7):661-3.
15. Murtaugh CM, Pezzin LE, McDonald MV, et al. Just-in-time evidence-based e-mail "reminders" in home health care: impact on nurse practices. Health Serv Res 2005;40(3):849-64.
16. Riegel B, Carlson B, Kopp Z, et al. Effect of a standardized nurse case-management telephone intervention on resource use in patients with chronic heart failure. Arch Intern Med 2002;162(6):705-12.
17. Anderson C, Deepak BV, Moateng-Adjepong Y, Zarich S. Benefits of comprehensive inpatient education and discharge planning combined with outpatient support in elderly patients with congestive heart failure. Congest Heart Fail 2005;11(6):315-21.

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