Current issues of ACP Journal Club are published in Annals of Internal Medicine


Quality Improvement

Review: Case management programs improve patient outcomes but do not reduce costs

ACP J Club. 1998 Sep-Oct;129:53. doi:10.7326/ACPJC-1998-129-2-053


Source Citation

Ferguson JA, Weinberger M. Case management programs in primary care. J Gen Intern Med. 1998 Feb;13: 123-6.


Abstract

Question

What are the effects of case management programs on patient-centered outcomes, health care resource use, and costs? (Case management was defined as “a program that uses physician or nonphysician providers to maintain continuous contact with patients via telephone or in-home visits in order to prevent disease exacerbation through intensive assessment and education techniques.”)

Data sources

English-language studies were identified by searching MEDLINE and Health STAR (1985 to 1997) using the terms case management, patient care planning, patient-centered care, disease management, care management, and management care programs. Bibliographies of relevant papers were also reviewed.

Study selection

Studies were selected if they were randomized controlled trials. Studies were excluded if they did not contain original data; did not include adult patients; or focused on discharge planning, inpatient interventions, treatment of AIDS, malignant conditions, end-stage renal disease, or psychiatric illnesses.

Data extraction

Data were extracted on the target population, intervention (focus of intervention, general or specialized caregiver, and single- or multiple-site study), sample size, length of follow-up, outcome measures, and results.

Main results

None of the articles identified from the database searches met the inclusion criteria. 9 studies identified from the review of bibliographies of seminal articles were included in the analysis. Meta-analysis was not done because of the heterogeneity of study designs. 4 studies involved patients with a specific condition (i.e., asthma, congestive heart failure, diabetes, and coronary heart disease), and 5 involved patients with various conditions (e.g., elderly patients and patients after hospital discharge); 3 were done by medical subspecialists, and 6 were done by generalists; and 7 studies were done in single sites, and 2 were done at multiple sites. Study sample size ranged from 104 to 1396 participants, and length of follow-up ranged from 3 months to 1 year.

7 studies that included health care utilization outcomes had conflicting results: 2 found reduced health care use with case management programs, 4 found no differences, and 1 found increased use. No cost savings were found in 3 studies. Case management improved clinical outcomes in 2 studies and patient satisfaction, quality of life, and functional status in 6 studies. None of the interventions that targeted heterogeneous populations or that were done by generalists reduced the use of health care resources.

Conclusions

Case management programs improve some clinical outcomes, patient satisfaction, quality of life, and functional status but do not reduce costs. The effect on health care utilization is unclear.

Source of funding: No external funding.

For correspondence: Dr. J.A. Ferguson, Richard L. Roudebush VAMC, HSR&D (11H), 1481 West 10th Street, Indianapolis, IN 46202, USA. FAX 317-554-0114.


Commentary

Managed care has shifted its original focus from utilization review to utilization management. Whereas early success in care management was accomplished by simply reviewing care and denying charges, health maintenance organizations could not succeed using such a rudimentary approach in mature and penetrated markets. An understanding that care denied today may increase the cost of care tomorrow is now reflected in case management calculations.

Case management evolved from a belief that morbidity and disability could be compressed in aging populations with successfully applied care programs (1-3). It was an attempt to avoid uncoordinated, ineffective, and costly care while reducing morbidity and disability. The study by Ferguson and Weinberger neither confirms nor refutes these beliefs.

The study definition of case management does not reflect the structure of most case management programs. First, physicians are not case managers. Second, continuous contact is a structural and fiscal impossibility in most case management programs. Finally, in addition to assessment and education functions, case managers may have concurrent clinical and financial roles that sometimes lead them to override coverage limitations when benefits to patient outcomes and long-term care costs are possible. The definition used by Ferguson and Weinberger more accurately fits a subgroup of case management: disease management.

The authors described various shortcomings of the primary studies, including the limited duration (3 to 12 mo), varied outcome measures, and difficulties of assessing the effects on costs. Solutions to these methodologic shortcomings are limited in general medicine populations. Three factors make it difficult to establish an adequate control group in studies of case management: the predominance of the case management model across all insurers, the growing number of provider groups that hire their own case managers, and the lack of comparability of the health care and economic environments for patients who fall outside of these 2 systems. Controlled trials of disease-specific populations in disease management programs are possible.

Charles Mills, MD
Fallon Community Health PlanWorcester, Massachusetts, USA

Charles Mills, MD
Fallon Community Health Plan
Worcester, Massachusetts, USA


References

1. Fries JF. Aging, natural death, and the compression of morbidity. N Engl J Med. 1980; 303:130-5.

2. Vita AJ, Terry RB, Hubert HB, Fries JF. Aging, health risks, and cumulative disability. N Engl J Med. 1998;338:1035-41.

3. Campion EW. Aging better. N Engl J Med. 1998;338:1064-6.