What can improve chronic disease care?

Journal of the American Geriatrics Society

Volumn 57, Issue 12, 2009, Pages 2338-2345

  Kane, Robert L ^a  

^a UNIVERSITY OF MINNESOTA   (United States)

Author keywords

Care coordination; Disease management; Geriatrics; Primary care; Self care

Indexed keywords

ASTHMA; CHRONIC DISEASE; CHRONIC OBSTRUCTIVE LUNG DISEASE; CLINICAL EFFECTIVENESS; CONGESTIVE HEART FAILURE; COOPERATION; COST EFFECTIVENESS ANALYSIS; DEPRESSION; DIABETES MELLITUS; DISEASE CONTROL; DISEASE COURSE; HEALTH CARE COST; HEALTH CARE UTILIZATION; HUMAN; PATIENT ASSESSMENT; PATIENT CARE; PATIENT MONITORING; PATIENT PARTICIPATION; REVIEW; SELF CARE;

AGED; CHRONIC DISEASE; GERIATRICS; HUMANS; SELF CARE;

EID: 71549136825     PISSN: 00028614     EISSN: 15325415     Source Type: Journal    
DOI: 10.1111/j.1532-5415.2009.02569.x     Document Type: Review

References (90)

1. Kane RL. The future history of geriatrics: Geriatrics at the crossroads. J Gerontol A Biol Sci Med Sci 2002 57A : M803 M805.
2. Kane RL, Priester R, Totten AM. Meeting the Challenge of Chronic Illness. Baltimore : Johns Hopkins University Press, 2005.
3. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996 74 : 511 543.
4. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC : National Academy Press, 2001.
5. Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ 2003 326 : 1419.
6. Kane RL, Keckhafer G, Flood S et al. The effect of Evercare on hospital use. J Am Geriatr Socy 2003 51 : 1427 1434.
7. Daaleman TP. The medical home: Locus of physician formation. J Am Board Fam Med 2008 21 : 451 457.
8. Rosenthal TC. The medical home: Growing evidence to support a new approach to primary care. J Am Board Fam Med 2008 21 : 427 440.
9. Philbin EF. Comprehensive multidisciplinary programs for the management of patients with congestive heart failure. J Gen Intern Med 1999 14 : 130 135.
10. McAlister FA, Lawson FM, Teo KK et al. A systematic review of randomized trials of disease management programs in heart failure. Am J Med 2001 110 : 378 384.
11. Vale MJ, Jelinek MV, Best JD et al. Coaching patients on Achieving Cardiovascular Health (COACH): A multicenter randomized trial in patients with coronary heart disease. Arch Intern Med 2003 163 : 2775 2783.
12. Leveille SG, Huang A, Tsai SB et al. Health coaching via an internet portal for primary care patients with chronic conditions: A randomized controlled trial. Med Care 2009 47 : 41 47.
13. Loveman E, Royle P, Waugh N. Specialist nurses in diabetes mellitus (review). Cochrane Database Syst Rev 2003 CD003286. Review.
14. Knight K, Badamgarav E, Henning JM et al. A systematic review of diabetes disease management programs. Am J Manage Care 2005 11 : 242 250.
15. Norris SL, Nichols PJ, Caspersen CJ et al. The effectiveness of disease and case management for people with diabetes. A systematic review. Am J Prev Med 2002 22 (4 Suppl) : 15 38.
16. Renders CM, Valk GD, Griffin S et al. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database Syst Rev 2001 CD001481. Review.
17. Shojania KG, Ranji SR, McDonald KM et al. Effects of quality improvement strategies for type 2 diabetes on glycemic control: A meta-regression analysis. JAMA 2006 296 : 427 440.
18. Taylor S, Bestall J, Cotter S et al. Clinical service organisation for heart failure (review). Cochrane Database Syst Rev 2005 CD002752.
19. Ofman JJ, Badamgarav E, Henning JM et al. Does disease management improve clinical and economic outcomes in patients with chronic diseases? A systematic review. Am J Med 2004 117 : 182 192. (Pubitemid 39055870)
20. McAlister FA, Lawson FM, Teo KK et al. Randomised trials of secondary prevention programmes in coronary heart disease: Systematic review. BMJ 2001 323 : 957 962.
21. Marshall M, Gray A, Green R. Case management for people with severe mental disorders (review). Cochrane Database Syst Rev 2000 CD000050.
22. Beswick AD, Rees K, Dieppe P et al. Complex interventions to improve physical function and maintain independent living in elderly people: A systematic review and meta-analysis. Lancet 2008 371 : 725 735.
23. Congressional Budget Office USC, Washington, DC. An analysis of the literature on disease management programs. 2004 October 13, 2004:28.
24. Goetzel R, Ozminkowski R, Villagra V et al. Return on investment in disease management: A review. Health Care Financ Rev 2005 23 : 1 19.
25. Berwick DM. The science of improvement. JAMA 2008 299 : 1182 1184.
26. Stuck AE, Siu AL, Wieland GD et al. Comprehensive geriatric assessment: A meta-analysis of controlled trials. Lancet 1993 342 : 1032 1036.
27. Cohen HJ, Feussner JR, Weinberger M et al. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med 2002 346 : 905 912. (Pubitemid 34984640)
28. Boult C, Boult LB, Morishita L et al. A randomized clinical trial of outpatient geriatric evaluation and management. J Am Geriatr Soc 2001 49 : 351 359.
29. Phibbs CS, Holty JE, Goldstein MK et al. The effect of geriatrics evaluation and management on nursing home use and health care costs: Results from a randomized trial. Med Care 2006 44 : 91 95.
30. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009 360 : 1418 1428.
31. Coleman EA, Parry C, Chalmers S et al. The care transitions intervention: Results of a randomized controlled trial. Arch Intern Med 2006 166 : 1822 1828.
32. Coleman EA, Berenson RA. Lost in transition: Challenges and opportunities for improving the quality of transitional care. Ann Intern Med 2004 141 : 533 536.
33. Coleman EA, Min SJ, Chomiak A et al. Posthospital care transitions: Patterns, complications, and risk identification. Health Serv Res 2004 39 : 1449 1465.
34. Coleman EA, Smith JD, Frank JC et al. Preparing patients and caregivers to participate in care delivered across settings: The care transitions intervention. J Am Geriatr Soc 2004 52 : 1817 1825.
35. Naylor M. Comprehensive discharge planning for hospitalized elderly: A pilot study. Nurs Res 1990 39 : 156 161.
36. Naylor M, Brooten D, Jones R et al. Comprehensive discharge planning for the hospitalized elderly: A randomized clinical trial. Ann Intern Med 1994 120 : 999 1006.
37. Naylor MD, Brooten D, Campbell R et al. Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA 1999 281 : 613 620.
38. Naylor M, Keating SA. Transitional care. Am J Nurs 2008 108 (9 Suppl) : 58 quiz.
39. Naylor MD, Brooten DA, Campbell RL et al. Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. J Am Geriatr Soc 2004 52 : 675 684.
40. Brand CA, Jones CT, Lowe AJ et al. A transitional care service for elderly chronic disease patients at risk of readmission. Aust Health Rev 2004 28 : 275 284.
41. Stuck A, Kane RL. Whom do preventive home visits help? J Am Geriatr Soc 2008 56 : 561 563.
42. Stuck AE, Egger M, Hammer A et al. Home visits to prevent nursing home admission and functional decline in elderly people: Systematic review and meta-regression analysis. JAMA 2002 287 : 1022 1028.
43. Smith SM, Allwright S, O'Dowd T. Effectiveness of shared care across the interface between primary and specialty care in chronic disease management. Cochrane Database Syst Rev, 2007: CD004910
44. Counsell SR, Callahan CM, Clark DO et al. Geriatric care management for low-income seniors: A randomized controlled trial. JAMA 2007 298 : 2623 2633.
45. Coleman EA, Grothaus LC, Sandhu N et al. Chronic care clinics: A randomized controlled trial of a new model of primary care for frail older adults. J Am Geriatr Soc 1999 47 : 775 783.
46. Peikes D, Chen A, Schore J et al. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA 2009 301 : 603 618.
47. Sylvia ML, Griswold M, Dunbar L et al. Guided care: Cost and utilization outcomes in a pilot study. Dis Manage 2008 11 : 29 36.
48. Kimura J, DaSilva K, Marshall R. Population management, systems-based practice, and planned chronic illness care: Integrating disease management competencies into primary care to improve composite diabetes quality measures. Dis Manage 2008 11 : 13 22.
49. Butler M, Kane RL, McAlpine D et al. Integration of Mental Health/Substance Abuse and Primary Care. Rockville, MD: Prepared by the Minnesota Evidence-based Practice Center for the Agency for Healthcare Research and Quality under Contract No. 290-02-0009; Evidence Report/Technology Assessment No. 173, AHRQ Publication No. 09-E003. October 2008.
50. Marks R, Allegrante JP, Lorig K. A review and synthesis of research evidence for self-efficacy-enhancing interventions for reducing chronic disability: Implications for health education practice (part II). Health Promot Pract 2005 6 : 148 156.
51. Marks R, Allegrante JP, Lorig K. A review and synthesis of research evidence for self-efficacy-enhancing interventions for reducing chronic disability: Implications for health education practice (part I). Health Promot Pract 2005 6 : 37 43.
52. Bodenheimer T, Lorig K, Holman H et al. Patient self-management of chronic disease in primary care. JAMA 2002 288 : 2469 2475.
53. Jerant A, Moore M, Lorig K et al. Perceived control moderated the self-efficacy-enhancing effects of a chronic illness self-management intervention. Chronic Illness 2008 4 : 173 182.
54. Lorig KR, Holman H. Self-management education: History, definition, outcomes, and mechanisms. Ann Behav Med 2003 26 : 1 7.
55. Monninkhof E, van der Valk P, van der Palen J et al. Self-management education for patients with chronic obstructive pulmonary disease: A systematic review. Thorax 2003 58 : 394 398. (Pubitemid 36560941)
56. Lorig KR, Sobel DS, Stewart AL et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: A randomized trial. Med Care 1999 3 : 5 14.
57. Lorig K, Ritter PL, Plant K. A disease-specific self-help program compared with a generalized chronic disease self-help program for arthritis patients. Arthritis Rheum 2005 53 : 950 957.
58. Lorig KR, Ritter PL, Jacquez A. Outcomes of border health Spanish/English chronic disease self-management programs. Diabetes Educ 2005 31 : 401 409.
59. Lorig K, Gonzalez VM, Ritter P. Community-based Spanish language arthritis education program: A randomized trial. Med Care 1999 37 : 957 963.
60. Lorig KR, Ritter PL, Laurent DD et al. The internet-based arthritis self-management program: A one-year randomized trial for patients with arthritis or fibromyalgia. Arthritis Rheum 2008 59 : 1009 1017.
61. Lorig KR, Ritter PL, Laurent DD et al. Internet-based chronic disease self-management: A randomized trial. Med Care 2006 44 : 964 971.
62. Lorig KR, Ritter PL, Laurent DD et al. Long-term randomized controlled trials of tailored-print and small-group arthritis self-management interventions. Med Care 2004 42 : 346 354.
63. Jimison H, Gorman P, Woods S et al. Barriers and Drivers of Health Information Technology Use for the Elderly, Chronically Ill, and Underserved. Rockville, MD: Prepared by the Oregon Evidence-based Practice Center for the Agency for Healthcare Research and Quality under Contract No. 290-02-0024; Evidence Report/Technology Assessment No. 175, AHRQ Publication No. 09-E004. November 2008.
64. Lorig KR, Ritter P, Stewart AL et al. Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care 2001 39 : 1217 1223.
65. Osborne RH, Wilson T, Lorig KR et al. Does self-management lead to sustainable health benefits in people with arthritis? A 2-year transition study of 452 Australians. J Rheumatol 2007 34 : 1112 1117.
66. Bruce B, Lorig K, Laurent D. Participation in patient self-management programs. Arthritis Rheum 2007 57 : 851 854.
67. 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.
68. Wright SP, Walsh H, Ingley KM et al. Uptake of self-management strategies in a heart failure management programme. Eur J Heart Fail 2003 5 : 371 380.
69. Rogers A, Kennedy A, Bower P et al. The United Kingdom expert patients programme: Results and implications from a national evaluation. Med J Aust 2008 189 (10 Suppl) : S21 S24.
70. Gallefoss F. The effects of patient education in COPD in a 1-year follow-up randomised, controlled trial. Patient Educ Couns 2004 52 : 259 266.
71. Gallefoss F, Bakke PS. Impact of patient education and self-management on morbidity in asthmatics and patients with chronic obstructive pulmonary disease. Respir Med 2000 94 : 279 287.
72. Monninkhof E, van der Valk P, van der Palen J et al. Effects of a comprehensive self-management programme in patients with chronic obstructive pulmonary disease. Eur Respir J 2003 22 : 815 820. (Pubitemid 37369572)
73. Monninkhof E, van der Valk P, Schermer T et al. Economic evaluation of a comprehensive self-management programme in patients with moderate to severe chronic obstructive pulmonary disease. Chronic Respir Dis 2004 1 : 7 16.
74. Bourbeau J, Collet JP, Schwartzman K et al. Economic benefits of self-management education in COPD. Chest 2006 130 : 1704 1711.
75. Gadoury MA, Schwartzman K, Rouleau M et al. Self-management reduces both short- and long-term hospitalisation in COPD. Eur Respir J 2005 26 : 853 857.
76. Bourbeau J, Julien M, Maltais F et al. Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: A disease-specific self-management intervention. Arch Intern Med 2003 163 : 585 591. (Pubitemid 36314346)
77. 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 : 2017 2024.
78. Davis AH, Carrieri-Kohlman V, Janson SL et al. Effects of treatment on two types of self-efficacy in people with chronic obstructive pulmonary disease. J Pain Symptom Manage 2006 32 : 60 70.
79. Carrieri-Kohlman V, Nguyen HQ, Donesky-Cuenco D et al. Impact of brief or extended exercise training on the benefit of a dyspnea self-management program in COPD. J Cardiopulm Rehabil 2005 25 : 275 284.
80. McGeoch GR, Willsman KJ, Dowson CA et al. Self-management plans in the primary care of patients with chronic obstructive pulmonary disease. Respirology 2006 11 : 611 618.
81. Janson SL, Fahy JV, Covington JK et al. Effects of individual self-management education on clinical, biological, and adherence outcomes in asthma. Am J Med 2003 115 : 620 626.
82. Thoonen BP, Schermer TR, Van Den Boom G et al. Self-management of asthma in general practice, asthma control and quality of life: A randomised controlled trial. Thorax 2003 58 : 30 36.
83. Fisher ES, McClellan MB, Bertko J et al. Fostering accountable health care: Moving forward in medicare. Health Aff (Millwood) 2009 28 : w219 w231.
84. Fisher ES. Building a medical neighborhood for the medical home. N Engl J Med 2008 359 : 1202 1205.
85. Barr MS. The need to test the patient-centered medical home. JAMA 2008 300 : 834 835.
86. Joyce GF, Keeler EB, Shang B et al. The lifetime burden of chronic disease among the elderly. Health Aff (Millwood) 2005 24 Suppl 2 : W5R18 W5R29.
87. Prochaska JO. Systems of Psychotherapy: A Transtheoretical Analysis. Homewood, IL : Dorsey Press, 1979.
88. Prochaska JO, DiClemente CC. Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory Res Pract 1982 19 : 276 288.
89. Hibbard JH, Stockard J, Mahoney ER et al. Development of the Patient Activation Measure (PAM): Conceptualizing and measuring activation in patients and consumers. Health Serv Res 2004 39 (4 Pt 1) : 1005 1026.
90. Goroll AH, Berenson RA, Schoenbaum SC et al. Fundamental reform of payment for adult primary care: Comprehensive payment for comprehensive care. J Gen Intern Med 2007 22 : 410 415.