Untangling practice redesign from disease management: How do we best care for the chronically ill?

Annual Review of Public Health

Volumn 30, Issue , 2009, Pages 385-408

  Coleman, Katie ^a   Mattke, Soeren ^b   Perrault, Patrick J ^a   Wagner, Edward H ^a  

^a CENTER FOR HEALTH STUDIES   (United States)

^b Bain and Company   (United States)

Author keywords

Chronic care model; Chronic illness; Disease management; Primary care

Indexed keywords

CHRONIC PATIENT; HEALTH CARE COST; HEALTH CARE DELIVERY; HEALTH CARE QUALITY; HEALTH CARE UTILIZATION; HUMAN; MEDICAL PRACTICE; MEDICAL SOCIETY; PATIENT CARE; PATIENT EDUCATION; PRIMARY MEDICAL CARE; PRIORITY JOURNAL; REVIEW;

CHRONIC DISEASE; DELIVERY OF HEALTH CARE; EVIDENCE-BASED MEDICINE; HUMANS; OUTCOME ASSESSMENT (HEALTH CARE); PRIMARY HEALTH CARE; QUALITY OF HEALTH CARE;

EID: 67650725824     PISSN: 01637525     EISSN: None     Source Type: Book Series    
DOI: 10.1146/annurev.publhealth.031308.100249     Document Type: Review

References (91)

1. 1998. Disease management program improves diabetes outcomes, curbs hospital costs, utilization. Health Care Cost Reeng. Rep. 3:42-45
2. 1998. New study confirms benefit of disease management for less severe cases of diabetes. Healthc. Demand Dis. Manag. 4:120-22
3. Anderson G, Horvath J. 2004. The growing burden of chronic disease in America. Public Health Rep. 119:263-70
4. Anderson GF. 2003. Physician, public, and policymaker perspectives on chronic conditions. Arch. Intern. Med. 163:437-42
5. Ara S. 2004. A literature review of cardiovascular disease management programs in managed care populations. J. Manag. Care Pharm. 10:326-44
6. Aubert RE, Herman WH,Waters J, Moore W, Sutton D, et al. 1998. Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. A randomized, controlled trial. Ann. Intern. Med. 129:605-12
7. Badamgarav E,Weingarten SR, Henning JM, Knight K, Hasselblad V, et al. 2003. Effectiveness of disease management programs in depression: a systematic review. Am. J. Psychiatry 160:2080-90
8. Benjamin EM, Schneider MS, Hinchey KT. 1999. Implementing practice guidelines for diabetes care using problem-based learning. A prospective controlled trial using firm systems. Diabetes Care 22:1672-78
9. Berg GD, Wadhwa S. 2002. Diabetes disease management in a community-based setting. Manag. Care 11:42, 45-50
10. Berwick DM. 2008. The science of improvement. JAMA 299:1182-84
11. Bodenheimer T, Wagner EH, Grumbach K. 2002. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 288:1909-14
12. Bogden PE, Abbott RD, Williamson P, Onopa JK, Koontz LM. 1998. Comparing standard care with a physician and pharmacist team approach for uncontrolled hypertension. J. Gen. Intern. Med. 13:740-45
13. Bogden PE, Koontz LM, Williamson P, Abbott RD. 1997. The physician and pharmacist team. An effective approach to cholesterol reduction. J. Gen. Intern. Med. 12:158-64
14. Brown R, Peikes D, Chen A, Ng J, Schore J, Soh C. 2006. Second report to Congress on the evaluation of the Medicare coordinated care demonstration. Rep. 8756-420, Math. Policy Res., Princeton, NJ
15. Buchner DA, Butt LT, De Stefano A, Edgren B, Suarez A, Evans RM. 1998. Effects of an asthma management program on the asthmatic member: patient-centered results of a 2-year study in a managed care organization. Am. J. Manag. Care 4:1288-97
16. Campbell NC, Ritchie LD, Thain J, Deans HG, Rawles JM, Squair JL. 1998. Secondary prevention in coronary heart disease: a randomised trial of nurse led clinics in primary care. Heart 80:447-52
17. Campbell NC, Thain J, Deans HG, Ritchie LD, Rawles JM, Squair JL. 1998. Secondary prevention clinics for coronary heart disease: randomised trial of effect on health. BMJ 316:1434-37
18. Cannon-Wagner M, Soule DS, Walker DR, Vance RP. 2002. An independent practice associationsupported disease management program: impact on patients with coronary artery disease. Dis. Manag. Health Outcomes 10:571-77
19. Casalino LP. 2005. Disease management and the organization of physician practice. JAMA 293:485-88
20. Coleman EA, Grothaus LC, Sandhu N,Wagner EH. 1999. Chronic care clinics: a randomized controlled trial of a new model of primary care for frail older adults. J. Am. Geriatr. Soc. 47:775-83
21. Coultas D, Frederick J, Barnett B, Singh G, Wludyka P. 2005. A randomized trial of two types of nurseassisted home care for patients with COPD. Chest 128:2017-24
22. Crippen DL. 2002. Disease Management in Medicare: Data Analysis and Benefit Design Issues. Testimony before the Special Committee on Aging.Washington, DC: Congr. Budg. Off. http://www.cbo.gov/ftpdocs/ 37xx/doc3776/09-19-Medicare.pdf
23. Davidoff F. 2002. Shame: the elephant in the room. BMJ 324:623-24
24. Deichmann RE, Castello E, Horswell R, Friday KE. 1999. Improvements in diabetic care as measured by HbA1c after a physician education project. Diabetes Care 22:1612-16
25. de Sonnaville JJ, Bouma M, Colly LP, Deville W, Wijkel D, Heine RJ. 1997. Sustained good glycaemic control in NIDDM patients by implementation of structured care in general practice: 2-year follow-up study. Diabetologia 40:1334-40
26. DMAA. 2008. DMAA definition of disease management. http://www.dmaa.org/dm definition.asp
27. Erickson SR, Slaughter R, Halapy H. 1997. Pharmacists' ability to influence outcomes of hypertension therapy. Pharmacotherapy 17:140-47
28. Fireman B, Bartlett J, Selby J. 2004. Can disease management reduce health care costs by improving quality? Health Aff. (Millwood) 23:63-75
29. Fonarow GC. 2004. Heart failure disease management programs: not a class effect. Circulation 110:3506-8
30. Gagnon AJ, Schein C,McVey L, Bergman H. 1999. Randomized controlled trial of nurse case management of frail older people. J. Am. Geriatr. Soc. 47:1118-24
31. Glasgow RE, Funnell MM, Bonomi AE, Davis C, Beckham V, Wagner EH. 2002. Self-management aspects of the improving chronic illness care breakthrough series: implementation with diabetes and heart failure teams. Ann. Behav. Med. 24:80-87
32. Goetzel RZ, Ozminkowski RJ, Villagra VG, Duffy J. 2005. Return on investment in disease management: a review. Health Care Financ. Rev. 26:1-19
33. Goldberg HI, Neighbor WE, Hirsch IB, Cheadle AD, Ramsey SD, Gore E. 2002. Evidence-based management: using serial firm trials to improve diabetes care quality. Jt. Comm. J. Qual. Improv. 28:155-66
34. Greineder DK, Loane KC, Parks P. 1999. A randomized controlled trial of a pediatric asthma outreach program. J. Allergy Clin. Immunol. 103:436-40
35. Hackbarth GM, Reischauer RD, Miller ME. 2003. Statement of the Medicare Payment Advisory Commission: disease management in traditional Medicare. Presented at Comm. Aging U.S. Senate,Washington, DC
36. Heard AR, Richards IJ, Alpers JH, Pilotto LS, Smith BJ, Black JA. 1999. Randomised controlled trial of general practice based asthma clinics. Med. J. Aust. 171:68-71
37. Heidenreich PA, Ruggerio CM,Massie BM. 1999. Effect of a home monitoring system on hospitalization and resource use for patients with heart failure. Am. Heart J. 138:633-40
38. Hughes SL, Weaver FM, Giobbie-Hurder A, Manheim L, Henderson W, et al. 2000. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA 284:2877-85
39. Hunkeler EM, Meresman JF, Hargreaves WA, Fireman B, Berman WH, et al. 2000. Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. Arch. Fam. Med. 9:700-8
40. Inst. Med. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: Natl. Acad. Press
41. Jaber LA, Halapy H, Fernet M, Tummalapalli S, Diwakaran H. 1996. Evaluation of a pharmaceutical care model on diabetes management. Ann. Pharmacother. 30:238-43
42. Jowers JR, Schwartz AL, Tinkelman DG, Reed KE, Corsello PR, et al. 2000. Disease management program improves asthma outcomes. Am. J. Manag. Care 6:585-92
43. Kaiser Perm. 2000. Asthma disease management program. Perm. J. 4:48-56
44. Katon W, Robinson P, Von Korff M, Lin E, Bush T, et al. 1996. A multifaceted intervention to improve treatment of depression in primary care. Arch. Gen. Psychiatry 53:924-32
45. Katon W, Von Korff M, Lin E, Simon G, Walker E, et al. 1999. Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch. Gen. Psychiatry 56:1109-15
46. Katon W, Von Korff M, Lin E,Walker E, Simon GE, et al. 1995. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA 273:1026-31
47. Katzelnick DJ, Simon GE, Pearson SD, Manning WG, Helstad CP, et al. 2000. Randomized trial of a depression management program in high utilizers of medical care. Arch. Fam. Med. 9:345-51
48. Knight K, Badamgarav E, Henning JM, Hasselblad V, Gano ADJ, et al. 2005. A systematic review of diabetes disease management programs. Am. J. Manag. Care 11:242-50
49. Krause DS. 2005. Economic effectiveness of disease management programs: a meta-analysis. Dis. Manag. 8:114-34
50. Legorreta AP, Leung KM, Berkbigler D, Evans R, Liu X. 2000. Outcomes of a population-based asthma management program: quality of life, absenteeism, and utilization. Ann. Allergy Asthma Immunol. 85:28-34
51. Leveille SG,Wagner EH, Davis C, Grothaus L,Wallace J, et al. 1998. Preventing disability and managing chronic illness in frail older adults: a randomized trial of a community-based partnership with primary care. J. Am. Geriatr. Soc. 46:1191-98
52. Litaker D, Mion L, Planavsky L, Kippes C, Mehta N, Frolkis J. 2003. Physician-nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients' perception of care. J. Interprof. Care 17:223-37
53. Lukacs SL, France EK, Baron AE, Crane LA. 2002. Effectiveness of an asthma management program for pediatric members of a large health maintenance organization. Arch. Pediatr. Adolesc. Med. 156:872-76
54. Mattke S, Seid M, Ma S. 2007. Evidence for the effect of disease management: Is $1 billion a year a good investment? Am. J. Manag. Care 13:670-76
55. McAlister F, Lawson FM, Teo KK, Armstrong PW. 2001. Randomised trials of secondary prevention programmes in coronary heart disease: systematic review. BMJ 323:957-62
56. McAlister FA, Lawson FM, Teo KK, Armstrong PW. 2001. A systematic review of randomized trials of disease management programs in heart failure. Am. J. Med. 110:378-84
57. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, et al. 2003. The quality of health care delivered to adults in the United States. N. Engl. J. Med. 348:2635-45
58. Munroe WP, Kunz K, Dalmady-Israel C, Potter L, Schonfeld WH. 1997. Economic evaluation of pharmacist involvement in disease management in a community pharmacy setting. Clin. Ther. 19:113-23
59. Norris SL, Nichols PJ, Caspersen CJ, Glasgow RE, Engelgau MM, et al. 2002. The effectiveness of disease and case management for people with diabetes. A systematic review. Am. J. Prev. Med. 22:15-38
60. O'Connor PJ, RushWA, Peterson J, Morben P, Cherney L, et al. 1996. Continuous quality improvement can improve glycemic control for HMO patients with diabetes. Arch. Fam. Med. 5:502-6
61. Ofman JJ, Badamgarav E, Henning JM, Knight K, Gano ADJ, et al. 2004. Does disease management improve clinical and economic outcomes in patients with chronic diseases? A systematic review. Am. J. Med. 117:182-92
62. Olivarius NF, Beck-Nielsen H, Andreasen AH, Horder M, Pedersen PA. 2001. Randomised controlled trial of structured personal care of type 2 diabetes mellitus. BMJ 323:970-75
63. Oxman AD, Thomson MA, Davis DA, Haynes RB. 1995. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ 153:1423-31
64. Peters AL, Davidson MB, Ossorio RC. 1995. Management of patients with diabetes by nurses with support of subspecialists. HMO Pract. 9:8-13
65. Piette JD,Weinberger M, Kraemer FB, McPhee SJ. 2001. Impact of automated calls with nurse follow-up on diabetes treatment outcomes in a Department of Veterans Affairs Health Care System: a randomized controlled trial. Diabetes Care 24:202-8
66. Piette JD,Weinberger M, McPhee SJ. 2000. The effect of automated calls with telephone nurse follow-up on patient-centered outcomes of diabetes care: a randomized, controlled trial. Med. Care 38:218-30
67. Quevedo SF, Blenkiron P, Lynch K. 1998. Diabetes case management: experience in the staff and IPA model HMO. HMO Pract. 12:44-46
68. Rea H, McAuley S, Stewart A, Lamont C, Roseman P, Didsbury P. 2004. A chronic disease management programme can reduce days in hospital for patients with chronic obstructive pulmonary disease. Intern. Med. J. 34:608-14
69. Renders CM,Valk GD, Griffin S,Wagner EH, Eijk JT, Assendelft WJ. 2002. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database Syst. Rev.: CD001481
70. Rich MW. 1999. Heart failure disease management: a critical review. J. Card. Fail. 5:64-75
71. Rost K, Nutting P, Smith J, Werner J, Duan N. 2001. Improving depression outcomes in community primary care practice: a randomized trial of the quEST intervention. Quality Enhancement by Strategic Teaming. J. Gen. Intern. Med. 16:143-49
72. Rubin RJ, Dietrich KA, Hawk AD. 1998. Clinical and economic impact of implementing a comprehensive diabetes management program in managed care. J. Clin. Endocrinol. Metab. 83:2635-42
73. Sadur CN,Moline N, Costa M, Michalik D, Mendlowitz D, et al. 1999. Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits. Diabetes Care 22:2011-17
74. Shojania KG, Ranji SR, McDonald KM, Grimshaw JM, Sundaram V, et al. 2006. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. JAMA 296:427-40
75. Short A, Mays G, Mittler J. 2003. Disease management: a leap of faith to lower-cost, higher-quality health care. Issue Brief Cent Stud. Health Syst. Change. 69:1-4
76. Sidorov J, Gabbay R, Harris R, Shull RD, Girolami S, et al. 2000. Disease management for diabetes mellitus: impact on hemoglobin A1c. Am. J. Manag. Care 6:1217-26
77. Sidorov J, Shull R,Tomcavage J, Girolami S, Lawton N, Harris R. 2002. Does diabetes disease management save money and improve outcomes? A report of simultaneous short-term savings and quality improvement associated with a health maintenance organization-sponsored disease management program among patients fulfilling health employer data and information set criteria. Diabetes Care 25:684-89
78. Simon GE, Manning WG, Katzelnick DJ, Pearson SD, Henk HJ,Helstad CS. 2001. Cost-effectiveness of systematic depression treatment for high utilizers of general medical care. Arch. Gen. Psychiatry 58:181-87
79. Simon GE, Von Korff M, Rutter C, Wagner E. 2000. Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care. BMJ 320:550-54
80. Stone EG, Morton SC, Hulscher ME, Maglione MA, Roth EA, et al. 2002. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann. Intern. Med. 136:641-51
81. Vaccaro J, Cherry J, Harper A, O'Connell M. 2001. Utilization reduction, cost savings, and return on investment for the PacifiCare Chronic Heart Failure Program, "Taking Charge of Your Heart Health." Dis. Manag. 4:131-38
82. Villagra VG, Ahmed T. 2004. Effectiveness of a disease management program for patients with diabetes. Health Aff. (Millwood) 23:255-66
83. Von Korff M, Gruman J, Schaefer J, Curry SJ,Wagner EH. 1997. Collaborative management of chronic illness. Ann. Intern. Med. 127:1097-102
84. Wagner EH. 1998. Chronic disease management: What will it take to improve care for chronic illness? Eff. Clin. Pract. 1:2-4
85. Wagner EH. 1998. More than a case manager. Ann. Intern. Med. 129:654-56
86. Wagner EH, Austin BT, Von Korff M. 1996. Organizing care for patients with chronic illness. Milbank Q. 74:511-44
87. Walker EA, Katon WJ, Russo J, Von Korff M, Lin E, et al. 2000. Predictors of outcome in a primary care depression trial. J. Gen. Intern. Med. 15:859-67
88. Weinberger M, Kirkman MS, Samsa GP, Shortliffe EA, Landsman PB, et al. 1995. A nurse-coordinated intervention for primary care patients with non-insulin-dependent diabetes mellitus: impact on glycemic control and health-related quality of life. J. Gen. Intern. Med. 10:59-66
89. Weingarten SR, Henning JM, Badamgarav E, Knight K, Hasselblad V, et al. 2002. Interventions used in disease management programmes for patients with chronic illness-which ones work? Meta-analysis of published reports. BMJ 325:925
90. Wells KB, Sherbourne C, Schoenbaum M, Duan N, Meredith L, et al. 2000. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA 283:212-20
91. West JA, Miller NH, Parker KM, Senneca D, Ghandour G, et al. 1997. A comprehensive management system for heart failure improves clinical outcomes and reduces medical resource utilization. Am. J. Cardiol. 79:58-63