REVIEW
Does disease management improve clinical and economic outcomes in patients with chronic diseases? A systematic review

https://doi.org/10.1016/j.amjmed.2004.03.018Get rights and content

Purpose

To assess the clinical and economic effects of disease management in patients with chronic diseases.

Methods

Electronic databases were searched for English-language articles from 1987 to 2001. Articles were included if they used a systematic approach to care and evaluated patients with chronic disease, reported objective measurements of the processes or outcomes of care, and employed acceptable experimental or quasi-experimental study designs as defined by the Cochrane Effective Practice and Organization of Care Group.

Results

Two reviewers evaluated 16,917 titles and identified 102 studies that met the inclusion criteria. Identified studies represented 11 chronic conditions: depression, diabetes, rheumatoid arthritis, chronic pain, coronary artery disease, asthma, heart failure, back pain, chronic obstructive pulmonary disease, hypertension, and hyperlipidemia. Disease management programs for patients with depression had the highest percentage of comparisons (48% [41/86]) showing substantial improvements in patient care, whereas programs for patients with chronic obstructive pulmonary disease (9% [2/22]) or chronic pain (8% [1/12]) appeared to be the least effective. Of the outcomes more frequently studied, disease management appeared to improve patient satisfaction (71% [12/17]), patient adherence (47% [17/36]), and disease control (45% [33/74]) most commonly and cost-related outcomes least frequently (11% to 16%).

Conclusion

Disease management programs were associated with marked improvements in many different processes and outcomes of care. Few studies demonstrated a notable reduction in costs. Further research is needed to understand how disease management can most effectively improve the quality and cost of care for patients with chronic diseases.

Section snippets

Literature review

We reviewed the literature to identify studies of the effectiveness of disease management programs in improving care or reducing costs for patients with a variety of common chronic diseases, defined as conditions affecting at least 1% of the U.S. adult population (7). In collaboration with an expert librarian, we searched the MEDLINE, HEALTHSTAR, and Cochrane databases for English-language articles published between January 1987 and June 2001 using the following Medical Subject Headings:

Results

The search identified 16,917 references published between January 1987 and June 2001. We accepted 2963 titles for further screening and 581 abstracts for the article review stage. Eighty-five percent (n = 493) of accepted abstracts did not meet the inclusion criteria, leaving a pool of 88 articles. Hand searches of bibliographies and expert consultation yielded 51 additional articles, of which 14 were accepted. Overall, 102 studies were accepted and addressed the following conditions: asthma (

Discussion

Our results suggest that many disease management programs are associated with improvements in the quality of patient care. Successful examples included programs focusing on patients with cardiovascular diseases, such as heart failure, coronary artery disease, hyperlipidemia, and hypertension. Overall, improvements in care were greatest for patient satisfaction, patient adherence to treatment recommendations, disease control, and provider adherence to guidelines. Often, there were greater

References (121)

  • S. Stewart et al.

    Effects of a multidisciplinary, home-based intervention on unplanned readmissions and survival among patients with chronic congestive heart failurea randomised controlled study

    Lancet

    (1999)
  • C. Thompson et al.

    Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary careHampshire Depression Project randomised controlled trial

    Lancet

    (2000)
  • K. Kulkarni et al.

    Nutrition Practice Guidelines for Type 1 Diabetes Mellitus positively affect dietitian practices and patient outcomes. The Diabetes Care and Education Dietetic Practice Group

    J Am Diet Assoc

    (1998)
  • F. Vinicor et al.

    DIABEDSa randomized trial of the effects of physician and/or patient education on diabetes patient outcomes

    J Chronic Dis

    (1987)
  • M.J. Franz et al.

    Effectiveness of medical nutrition therapy provided by dietitians in the management of non-insulin-dependent diabetes mellitusa randomized, controlled clinical trial

    J Am Diet Assoc

    (1995)
  • D.J. Hyman et al.

    Dietary intervention for cholesterol reduction in public clinic patients

    Am J Prev Med

    (1998)
  • J.E. Fielding et al.

    A randomized trial of the IMPACT worksite cholesterol reduction program

    Am J Prev Med

    (1995)
  • G. Ellrodt et al.

    Evidence-based disease management

    JAMA

    (1997)
  • P. Wehrwein

    What happens when politicians play doctor?

    Manag Care

    (1997)
  • NCQA: National Committee for Quality Assurance website. NCQA Releases Final Disease Management Accreditation and...
  • MeetingsNet website. JCAHO Publishes Draft Standards For Disease-Specific Care Certification. Available at:...
  • Statistical biases, small samples producing questionable DM outcome data–DM outcomes: industry's “seamy underside,”...
  • S.R. Weingarten et al.

    Interventions used in disease management programmes for patients with chronic illness—which ones work? Meta-analysis of published reports

    BMJ

    (2002)
  • NTIS–National Technical Information Service website. Available at: http://www.ntis.gov/index.html. Accessed July...
  • S.H. Woolf

    Practice guidelinesa new reality in medicine. I. Recent developments

    Arch Intern Med

    (1990)
  • Committee to Advise the Public Health Service on Clinical Practice Guidelines, Institute of Medicine. In: Field MJ,...
  • Effective Practice and Organisation of Care Group website. Available at: http://www.epoc.uottawa.ca/. Accessed July...
  • J.K. Sont et al.

    Clinical control and histopathologic outcome of asthma when using airway hyperresponsiveness as an additional guide to long-term treatment. The AMPUL Study Group

    Am J Respir Crit Care Med

    (1999)
  • E. Mulloy et al.

    A one-year prospective audit of an asthma education programme in an out-patient setting

    Ir Med J

    (1996)
  • J. Berg et al.

    An evaluation of a self-management program for adults with asthma

    Clin Nurs Res

    (1997)
  • J. Cote et al.

    Influence on asthma morbidity of asthma education programs based on self-management plans following treatment optimization

    Am J Respir Crit Care Med

    (1997)
  • J.M. Ignacio-Garcia et al.

    Asthma self-management education program by home monitoring of peak expiratory flow

    Am J Respir Crit Care Med

    (1995)
  • R.A. Windsor et al.

    Evaluation of the efficacy and cost effectiveness of health education methods to increase medication adherence among adults with asthma

    Am J Public Health

    (1990)
  • W.C. Bailey et al.

    A randomized trial to improve self-management practices of adults with asthma

    Arch Intern Med

    (1990)
  • A.R. Heard et al.

    Randomised controlled trial of general practice based asthma clinics

    Med J Aust

    (1999)
  • Integrated care for asthma: a clinical, social, and economic evaluation. Grampian Asthma Study of Integrated Care...
  • M. Rossignol et al.

    Coordination of primary health care for back pain. A randomized controlled trial

    Spine

    (2000)
  • H. Alaranta et al.

    Intensive physical and psychosocial training program for patients with chronic low back pain. A controlled clinical trial

    Spine

    (1994)
  • K. Harkapaa et al.

    A controlled study on the outcome of inpatient and outpatient treatment of low back pain. Part I. Pain, disability, compliance, and reported treatment benefits three months after treatment

    Scand J Rehabil Med

    (1989)
  • M. Von Korff et al.

    A randomized trial of a lay person-led self-management group intervention for back pain patients in primary care

    Spine

    (1998)
  • K.E. Bendstrup et al.

    Out-patient rehabilitation improves activities of daily living, quality of life and exercise tolerance in chronic obstructive pulmonary disease

    Eur Respir J

    (1997)
  • A.L. Ries et al.

    Effects of pulmonary rehabilitation on physiologic and psychosocial outcomes in patients with chronic obstructive pulmonary disease

    Ann Intern Med

    (1995)
  • I.B. Jensen et al.

    Cognitive-behavioural treatment for workers with chronic spinal paina matched and controlled cohort study in Sweden

    Occup Environ Med

    (1994)
  • E.Z. Oddone et al.

    Enhanced access to primary care for patients with congestive heart failure. Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmission

    Eff Clin Pract

    (1999)
  • C.M. Cline et al.

    Cost effective management programme for heart failure reduces hospitalisation

    Heart

    (1998)
  • W.A. Gattis et al.

    Reduction in heart failure events by the addition of a clinical pharmacist to the heart failure management teamresults of the Pharmacist in Heart Failure Assessment Recommendation and Monitoring (PHARM) Study

    Arch Intern Med

    (1999)
  • T. Jaarsma et al.

    Effects of education and support on self-care and resource utilization in patients with heart failure

    Eur Heart J

    (1999)
  • M.W. Rich et al.

    Prevention of readmission in elderly patients with congestive heart failureresults of a prospective, randomized pilot study

    J Gen Intern Med

    (1993)
  • I. Ekman et al.

    Feasibility of a nurse-monitored, outpatient-care programme for elderly patients with moderate-to-severe, chronic heart failure

    Eur Heart J

    (1998)
  • M.W. Rich et al.

    A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure

    N Engl J Med

    (1995)
  • Cited by (237)

    • Heart rate variability biofeedback in chronic disease management: A systematic review

      2021, Complementary Therapies in Medicine
      Citation Excerpt :

      Their global prevalence is increasing and this burden is leading to growing social and economic consequences.2 The quality and effectiveness of disease management is therefore a major concern for improving patient care and reducing health care costs.3 Chronic diseases are generally related to impairments of the autonomous nervous system (ANS) balance resulting in sympathetic overstimulation and a lack of vagal activity.4

    View all citing articles on Scopus

    This investigator-initiated work was partially supported by a research grant from TAP Pharmaceutical Products, Inc., Lake Forest, Illinois.

    View full text