Section 8: The Care Management Evidence Base (continued)

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

Review Synopsis: Chronic Obstructive Pulmonary Disease

To evaluate the effect of care management on chronic obstructive pulmonary disease (COPD), we reviewed six relevant articles; four that examined the impact of patient interventions, one that examined the impact of provider interventions, and one that examined the impact of a combination of patient and provider interventions. The interventions evaluated most commonly were:

  • In-person care management (4 articles).
  • Care management (1 article).
  • Decision support (1 article).
  • Provider education (1 article).

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

Clinical Outcome Measures

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

  • Quality of life.
  • Dyspnea.
  • Emotional function.
  • Fatigue.
  • "Feeling mastery over disease."

Of the four intervention categories, in-person care management appeared to exert the strongest impact on clinical outcomes. This intervention significantly improved quality of life, dyspnea, emotional function, fatigue, and the feeling of mastery over disease. Care management, decision support, and provider education appeared to have the weakest effects, demonstrating no significant impacts on clinical outcomes.

  • 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.
  • Care Management. One systematic review addressed the effect of care management on clinical outcomes. In this review, the authors concluded that no significant effects on health-related quality of life, lung function, functional capacity, symptom scores, mortality, anxiety, and depression occurred.3
  • Provider Education. One study showed that provider education resulted in no significant increases in generic and disease-specific quality-of-life scores.2

Clinical Process Measures

We identified two studies that showed how care management can improve clinical process measures. The clinical process measures examined in this review include exercise tolerance, recognition of severe disease exacerbation, self-action in the event of exacerbation, and initiation of steroids, antibiotics, or both. Of the four intervention categories, in-person care management and care management appeared to exert the most effect on clinical process measures.

  • In-Person Care Management. One study found that in-person care management was effective at significantly improving COPD patients' exercise tolerance.1 This intervention showed that improved clinical process measures are achievable with use of in-person care management.
  • Care Management. One systematic study using a care management intervention found that it significantly improved recognition of severe disease exacerbation, use of self-action in the event of exacerbation, and initiation and use of steroids, antibiotics, or both.3

Activation Measures

  • One systematic study examined the effect of care management on activation measures, including self-management knowledge.
  • Care management. The systematic study found that care management of COPD helped to significantly improve self-management knowledge.3

Utilization Measures

We identified five studies relevant to utilization and savings, a majority of which showed that resource use decreased and savings increased. In-person care management and decision support for providers were the main interventions used to decrease utilization and increase savings.

Impact on Utilization
  • In-Person Care Management. One study found that in-person care management significantly decreased hospital use, ER use, and skilled nursing facility resources.4 This same study also showed that in-person care management significantly increased use of home health care. Contrasting these results is one study that found no significant differences in hospital admissions rates when in-person care management was employed.5 This study also found no significant differences in number of ER visits.
  • Decision Support. One study evaluating use of decision support showed that average hospital stay decreased significantly from 7.8 days to 5.6 days.6 This study found that decision support was an effective tool used to decrease health care utilization.
  • Care Management. One systematic review found that care management was an ineffective intervention used to decrease health care utilization. The results of this study found no significant impact on health care utilization rates.3
  • Provider Education. Similarly, one study that evaluated use of provider education also found no significant differences in number of ER visits and hospital admissions when a provider education intervention was employed.2
Impact on Savings
  • In-Person Care Management. One study found that using in-person care management resulted in an average savings of more than $13,000 per patient.4
  • Decision Support. Like the in-person care management study, one study found that using decision support for COPD management helped to significantly reduce the cost of an average case, from $4,050 to $3,170.6

Conclusion

Using in-person care management, care management, decision support, and provider education to manage COPD can lead to positive outcomes. According to the evidence found, improved clinical outcomes such as quality of life, dyspnea, emotional function, fatigue, and feeling of mastery over the disease are best accomplished by in-person care management. In addition, in-person care management and care management are two interventions that can improve clinical process measures such as exercise tolerance, recognition of severe disease exacerbation, use of self-action in the event of exacerbation, and initiation and use of steroids, antibiotics, or both. This literature review also found that COPD management helped to significantly improve activation measures. Lastly, decreased health care utilization and increased savings were shown for in-person care management, decision support, and care management interventions. 

Reference List 

  1. Shafazand S, Canfield J, Kuschner WG. Improved quality of life among patients completing a pulmonary rehabilitation program: one center's early experience. Respir Care 2001;46(6):595-600.
  2. Coultas D, Frederick J, Barnett B, et al. A randomized trial of two types of nurse-assisted home care for patients with COPD. Chest 2005;128(4):2017-24.
  3. Turnock AC, Walters EH, Walters JAE, et al. Action plans for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2005 Oct 19(4):CD005074.
  4. Steinel JA , Madigan EA. Resource utilization in home health chronic obstructive pulmonary disease management. Outcomes Manag 2003;7(1):23-7.
  5. Pearson S, Inglis SC, McLennan SN, et al. Prolonged effects of a home-based intervention in patients with chronic illness. Arch Intern Med 2006;166(6):645-50.
  6. [No authors listed.] COPD pathway cuts costs per case by $900. Hosp Case Manag 1997;5(9):156-8.

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Review Synopsis: Coronary Artery Disease

To evaluate the effect of care management on coronary artery disease (CAD), we reviewed five relevant articles. Of these studies, three examined the impact of patient interventions, one examined the impact of provider interventions, and one examined the impact of a combination of patient and provider interventions. The interventions evaluated most commonly were:

  • In-person care management (2 articles).
  • Self-management education (3 articles).
  • Decision support (1 article).
  • Provider education (1 article).

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

Clinical Outcome Measures

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

  • Frequency of angina.
  • LDL levels.
  • CAD-related physical limitations.

Of the four intervention categories, in-person care management appeared to have the strongest impact on clinical outcomes. This intervention significantly reduced angina frequency and CAD-related physical limitations while significantly increasing angina stability and the percentage of people with LDL levels less than 130 mg/dl and LDL levels less than 100mg/dl. Self-management education and decision support also appeared to affect clinical outcomes.

  • In-Person Care Management. Two studies evaluating in-person care management found significant improvement in clinical outcomes when this intervention was used.1,2 In particular, the studies showed that frequency of angina and number of CAD-related physical limitations were reduced significantly.1 Moreover, this study found that in-person care management significantly improved angina stability, by 14.7 points on the Seattle Angina questionnaire. Another study found that of the patients who used an in-person care management intervention, 84 percent had LDL levels less than 130 mg/dl and 48 percent had LDL levels less than 100 mg/dl.2
  • Self-Management Education. One study showed that the percentage of patients with LDL levels less than or equal to 100 mg/dl increased significantly when using self-management education interventions.3
  • Decision Support. One study showed that using a decision support intervention helped to significantly reduce the percentage of patients with LDL levels greater than 130 mg/dl.4

Clinical Process Measures

We identified four studies that showed how care management can improve clinical process measures. The clinical process measures examined in this review include screening rates and medication use. Of the four intervention categories—in-person care management, self-management education, decision support, and provider education—all appeared to exert similar effects on improving clinical process measures.

  • In-Person Care Management. One study found that using in-person care management interventions helped increase LDL screening rates up to 97 percent. This same study also found that 89 percent of the patients with LDL levels greater than 120 mg/dl also were on lipid-lowering therapy. Similarly, patients used significantly more aspirin/antiplatelet and beta-blocker medication.2
  • Self-Management Education. Two studies found that self-management education, like in-person care management, helped to significantly increase use of aspirin, beta-blockers, ACE inhibitors, and statins.3,5
  • Decision Support. One study showed that decision support was successful at significantly improving the rate of prescription change at 1 month.4 However, this same study found no significant changes at 1 year.
  • Provider Education. One study showed that provider education significantly improved the use of statins, by 19 percent, and the use of ACE inhibitors, by 28 percent, compared to the control group. Although insignificant, trends from this study also indicate a greater use of aspirin and beta-blockers among the intervention group.

Activation Measures

Only one study examined the effect of care management on activation measures, including treatment satisfaction.

  • In-Person Care Management. This study found that in-person care management of CAD helped to significantly improve treatment satisfaction.1 Results from the Seattle Angina questionnaire found that patients using in-person care management improved their scores by 8.6 points.

Conclusion

Using in-person care management, self-management education, decision support, and provider education to manage CAD can lead to positive outcomes. According to the evidence found, improved clinical outcomes such as frequency of angina, stability of angina, CAD-related physical limitations, and LDL levels are best accomplished by in-person care management. Self-management education and decision support also improve clinical outcomes. In addition, in-person care management, self-management education, decision support, and provider education are interventions that can improve clinical process measures such as screening rates and medication usage. This literature review also found that in-person care management of CAD helped to significantly improve activation measures. 

Reference List 

  1. Spertus JA, Dewhurst TA, Dougherty CM, et al. Benefits of an "angina clinic" for patients with coronary artery disease: a demonstration of health status measures as markers of health care quality. Am Heart J 2002;143(1):145-50.
  2. Merenich JA, Lousberg TR, Brennan SH, et al. Optimizing treatment of dyslipidemia in patients with coronary artery disease in the managed-care environment (the Rocky Mountain Kaiser Permanente experience). Am J Cardiol 2000;85(3A):36A-42A.
  3. Fonarow GC, Gawlinski A, Moughrabi S, et al. Improved treatment of coronary heart disease by implementation of a Cardiac Hospitalization Atherosclerosis Management Program (CHAMP). Am J Cardiol 2001;87(7):819-22.
  4. Lester WT, Grant RW, Barnett GO, et al. Randomized controlled trial of an informatics-based intervention to increase statin prescription for secondary prevention of coronary disease. J Gen Intern Med 2006;21(1):22-9.
  5. Krantz MJ, Havranek EP, Mehler PS, et al. Impact of a cardiac risk reduction program in vulnerable patients hospitalized with coronary artery disease. Pharmacotherapy 2004;24(6):768-75.

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Current as of March 2008
Internet Citation: Section 8: The Care Management Evidence Base (continued): Designing and Implementing Medicaid Disease and Care Management Programs: A User's Guide. March 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/hcbs/medicaidmgmt/medicaidmgmt8c.html