ArticleThe effectiveness of disease and case management for people with diabetes: A systematic review
Introduction
Diabetes mellitus (diabetes) is a prevalent, costly condition that causes significant morbidity and mortality. In the United States, 15.7 million people (5.9% of the total population) have diabetes, of whom 5.4 million are undiagnosed.1 In 1997 alone, 789,000 new cases were diagnosed.1 Moreover, according to death certificate data, diabetes is the seventh leading cause of death in the United States.1 Mortality is primarily related to heart disease: adults with diabetes have death rates from heart disease about 2 to 4 times higher than those without diabetes.1 In addition, the risk of stroke is 2 to 4 times higher in people with diabetes. Diabetes is the leading cause of new cases of blindness in adults aged 20 to 74 years, and it is also the leading cause of end-stage renal disease, accounting for about 40% of new cases. Neuropathy is also a major problem, as 60% to 70% of people with diabetes have this condition, and more than half of lower limb amputations occur among people with diabetes. Finally, the rate of pregnancies resulting in death of the newborn is twice as high among women with diabetes than among those without this disorder.1
Consistent with its extraordinary effect on the health of Americans, the costs of diabetes to the U.S. healthcare system are enormous: total (direct and indirect) costs were estimated at $98 billion in 1997.2 Selby et al.3 calculated that per-person expenditures for members of a managed care organization with diabetes were 2.4 times higher than for those without diabetes. Thirty-eight percent of the total excess costs was spent on treating long-term complications, particularly coronary heart disease.
Traditionally, healthcare delivery involves individual providers reacting to patient-initiated complaints and visits. Care is frequently fragmented, disorganized, duplicative, and focused on managing established disease and complications. Providers practice what they have been taught and what their anecdotal experiences have led them to believe is effective. The goals are generally short term, such as pain control or avoidance of hospital admission. Management is provider-directed and focuses on pharmacologic and technologic interventions, with little attention to patient self-management behaviors or provider-patient interactions.4
Traditional methods of healthcare delivery do not adequately address the needs of individual people or populations with diabetes. For example, in a survey of the care received by patients of primary care providers, people with diabetes were receiving only 64% to 74% of the services recommended by the American Diabetes Association (ADA) Provider Recognition Program.5 And in a chart audit covering 1 year in a health maintenance organization (HMO) setting, glycated hemoglobin (GHb)a values were documented for only 44% of people with diabetes (ADA recommends two to four measurements per year), and annual urine protein measurements were performed on only 48% of patients.6
Available evidence shows that improving care for people with diabetes results in cost savings for healthcare organizations. In a review of economic analyses of interventions for diabetes, eye care and preconception care were found to be cost saving, and preventing neuropathy in type 1b diabetes and improving glycemic control with either type 1 or type 2 diabetes were found to be clearly cost-effective.7 Gilmer et al.8 modeled cost savings at an HMO and found that every percentage point increase in hemoglobin A1c (HbA1c) above normal was associated with a significant increase in costs over the next 3 years. Testa et al.9 noted that improved glycemic control was associated with short-term decreases in healthcare utilization, increased productivity, and enhanced quality of life. Wagner et al.10 found that a sustained reduction in HbA1c was associated with cost savings among adults with diabetes within 1 to 2 years of improved glycemic control.
In the last decade, innovative interventions for healthcare delivery have emerged that show promise for improving care, outcomes, and costs for individuals and populations with diabetes. Disease and case management are two such new interventions. This review examines the extent and quality of the evidence of their effectiveness when applied to people with diabetes.
Section snippets
The guide to community preventive services
The systematic reviews in this report represent the work of the independent, nonfederal Task Force on Community Preventive Services (the Task Force). The Task Force is developing the Guide to Community Preventive Services (the Community Guide) with the support of the U.S. Department of Health and Human Services (DHHS) and in collaboration with public and private partners. The Centers for Disease Control and Prevention (CDC) provides staff support to the Task Force to develop the Community Guide
Methods
The Community Guide’s methods for conducting systematic reviews and linking evidence to effectiveness are described elsewhere.22, 23 In brief, for each Community Guide topic, a systematic review development team representing diverse disciplines, backgrounds, and work settings conducts a review by
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developing an approach to identifying, organizing, grouping, and selecting interventions for review;
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developing an analytic framework depicting interrelationships between interventions, populations, and
Disease management
Disease management has played a prominent role in innovative systems of clinical care over the past two decades. The earliest application of a disease-focused intervention involved prescription drugs,52 and the first use of the term disease management appears to have been in the late 1980s at the Mayo Clinic.53 In the mid-1990s the term emerged in the general medical literature, and by 1999 approximately 200 companies offered disease management services.54 The initial focus of disease
Research issues for disease and case management interventions in diabetes
Even though disease and case management were found effective in the managed care setting for improving glycemic control and provider monitoring of certain important outcomes, several important research gaps were identified in this review. One of the most pressing needs is to better define effective interventions. Disease management has multiple component interventions. To make optimal use of resources, however, only the interventions that contribute most to positive outcomes should be
Conclusions
According to Community Guide rules of evidence,22 strong evidence exists that disease management interventions are effective in improving glycemic control in people with diabetes and in improving provider monitoring of GHb and screening for diabetic retinopathy. There is sufficient evidence that disease management is effective in improving provider screening for foot lesions and peripheral neuropathy, screening of urine for protein, and monitoring of lipid concentrations. For case management,
Acknowledgements
The authors thank Stephanie Zaza, MD, MPH, for support, technical assistance, and editorial review; Kristi Riccio, BSc, for technical assistance; and Kate W. Harris, BA, for editorial and technical assistance. The authors acknowledge the following consultants for their contribution to this manuscript: Tanya Agurs-Collins, PhD, Howard University Cancer Center, Washington, DC; Ann Albright, PhD, RD, California Department of Health Services, Sacramento; Pam Allweiss, MD, Lexington, KY; Elizabeth
References (155)
- et al.
Preventive care practices for diabetes management in two primary care samples
Am J Prev Med
(2000) - et al.
Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. The Task Force on Community Preventive Services
Am J Prev Med
(2000) - et al.
Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke
Am J Prev Med
(2001) - et al.
Reviews of evidence regarding interventions to increase use of child safety seats
Am J Prev Med
(2001) - et al.
Developing an evidence-based Guide to Community Preventive Services—methods. The Task Force on Community Preventive Services
Am J Prev Med
(2000) - et al.
Methods for systematic review of economic evaluations for the Guide to Community Preventive Services. The Task Force on Community Preventive Services
Am J Prev Med
(2000) - et al.
Increasing diabetes self-management education in community settingsa systematic review
Am J Prev Med
(2002) - et al.
Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitusa randomized prospective 6-year study
Diabetes Res Clin Pract
(1995) - et al.
Cost-effectiveness of intensive insulin therapy for type 2 diabetesa 10-year follow-up of the Kumamoto study
Diabetes Res Clin Pract
(2000) - et al.
Preserving renal function in adults with hypertension and diabetesa consensus approach. National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group
Am J Kidney Dis
(2000)
Data collection instrument and procedure for systematic reviews in the Guide to Community Preventive Services
Am J Prev Med
Northwest Herts diabetic management system
Comput Methods Programs Biomed
Improving diabetes care in a large health care systeman enhanced primary care approach
Jt Comm J Qual Improv
Clinical performance improvement series. Classic CQI integrated with comprehensive disease management as a model for performance improvement
Jt Comm J Qual Improv
Shared care for diabetessupporting communication between primary and secondary care
Int J Med Inf
National diabetes fact sheet
Economic consequences of diabetes mellitus in the U.S. in 1997
Diabetes Care
Excess costs of medical care for patients with diabetes in a managed care population
Diabetes Care
Report of the Health Care Delivery Work Groupbehavioral research related to the establishment of a chronic disease model for diabetes care
Diabetes Care
Quality of outpatient care provided to diabetic patients. A health maintenance organization experience
Diabetes Care
An economic analysis of interventions for diabetes
Diabetes Care
The cost to health plans of poor glycemic control
Diabetes Care
Health economic benefits and quality of life during improved glycemic control in patients with type 2 diabetes mellitus
JAMA
Effect of improved glycemic control on health care costs and utilization
JAMA
Introducing the Guide to Community Preventive Servicesmethods, first recommendations and expert commentary
Am J Prev Med
Recommendations regarding interventions to improve vaccination coverage in children, adolescents, and adults
Am J Prev Med
Vaccine-preventable diseasesimproving vaccination coverage in children, adolescents, and adults. A report on recommendations of the Task Force on Community Preventive Services
MMWR Morb Mortal Wkly Rep
Strategies for reducing exposure to environmental tobacco smoke, increasing tobacco-use cessation, and reducing initiation in communities and health-care systems. A report on recommendations of the Task Force on Community Preventive Services
MMWR Morb Mortal Wkly Rep
Recommendations regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke
Am J Prev Med
Motor vehicle occupant injurystrategies for increasing use of child safety seats, increasing use of safety belts, and reducing alcohol-impaired driving
MMWR Morb Mortal Wkly Rep
Healthy people 2010
Recommendations for healthcare system and self-management education interventions to reduce morbidity and mortality from diabetes
Am J Prev Med
The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus
N Engl J Med
Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33)
Lancet
Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes (UKPDS 38)
Br Med J
Hypertriglyceridaemia as a risk factor of coronary heart disease mortality in subjects with impaired glucose tolerance or diabetes. Results from the 11-year follow-up of the Paris Prospective Study
Diabetologia
Standards of medical care for patients with diabetes mellitus
Diabetes Care
Preventive foot care in people with diabetes
Diabetes Care
Management of dyslipidemia in adults with diabetes
Diabetes Care
Tests of glycemia in diabetes
Diabetes Care
Long-term renoprotective effect of angiotensin-converting enzyme inhibition in non-insulin-dependent diabetes mellitus. A 7-year follow-up study
Arch Intern Med
Diabetic retinopathy
Diabetes Care
Lower extremity amputation in people with diabetes. Epidemiology and prevention
Diabetes Care
Identifying diabetic patients at high risk for lower-extremity amputation in a primary health care setting. A prospective evaluation of simple screening criteria
Diabetes Care
Early photocoagulation for diabetic retinopathy
Ophthalmology
Knowledge profile and control in diabetic patients
Diabet Med
Self-efficacy and health behavior among older adults
J Health Soc Behav
Psychosocial predictors of self-care behaviors (compliance) and glycemic control in non-insulin-dependent diabetes mellitus
Diabetes Care
Behavior change in diabetes education
Diabetes Educ
Beneficial effect of moderate weight loss in older patients with non-insulin-dependent diabetes mellitus poorly controlled with insulin
J Am Geriatr Soc
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