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opinion matters 9/30/05 12:39 Page 47
OPINION MATTERS
improving overall health.
Disease management components include:
➜ Population identification processes;
➜ Evidence-based practice guidelines;
➜ Collaborative practice models to include physician and
support-service providers;
➜ Patient self-management education (may include
primary prevention, behavior modification programmes,
and compliance/surveillance);
➜ Process and outcomes measurement, evaluation, and
management;
➜ Routine reporting/feedback loop (may include
communication with patient, physician, health plan and
ancillary providers, and practice profiling).
Full service disease management programmes must
include all six components. Programmes consisting of fewer
components are Disease Management Support Services
Outcomes…
Reduced: Range of Results
ER Visits - 8-27%
Hospitalizations - 18-38%
Hospital Days - 15-17%
Total Cost - 9-15%
Increased EBM
Compliance + 49%
Table 1: Matria DM Programme outcomes
Unfortunately, many “disease management” initiatives do
not meet this definition. There is also considerable
confusion about DM because a number of partial programs
were implemented in order to fit them into existing systems
of reimbursement. The results were less than ideal… and
created confusion.
Forces driving expansion of disease management - The
forces fueling disease management remain largely financial
in most countries. In the United States total healthcare costs
are expected to expand from $1.7 trillion dollars in 2002 to
over $2.6 trillion in 2010. In addition, the World Health
Organization also projects that the global burden of chronic
disease will increase from 27% of GNP in 1990 to over 43%
in 2020.
Another disturbing statistic that will drive DM expansion
is the declining ratio of workers/employees to retirees: 25:1
in 1935 to less than 2:1 in 2025. Fewer working age people
funding an expanding chronically ill population will add
further pressure to our economic systems.
Finally, there is also increasing recognition that DM also
represents an opportunity to improve clinical outcomes.
Based on figures in the United States, people with chronic
illness receive only 56.1% of recommended care.
DM performance – DM expansion has been stimulated
by the success of DM in the United States. A study by the
DMAA of almost 200 peer-reviewed articles on DM showed
consistently positive outcomes including economic, clinical
and humanistic benefits.
In addition, a review of the outcomes from one of the
leading United States disease management organizations
confirms the potential power of DM to generate favorable
clinical, economic and humanistic outcomes. Table 1
highlights the range of outcomes covering seven asthma,
diabetes, CHF, COPD, CAD, depression, and cancer
produced by Matria.
Importantly, DM has been successful despite having to
operate in a healthcare infrastructure that has been
defined by the Institutes of Medicine as “…inadequate,
fragmented, and broken” in regards to the system’s ability to
foster the better management of chronic disease.
Global expansion of DM - The success of disease
management in the United States has resulted in its global
expansion. Countries on five continents are now
experimenting with the adaptation of US-style disease
management programmes to the unique characteristics of
their own systems.
The next generation of disease management – DM
program success in the private sector has also led to
adoption by the public sector Medicare and Medicaid where
private sectors models are now being adapted for new
populations, the elderly and the poor. These new challenges
will undoubtedly lead to the further enhancement to DM
programmes.
In the meantime, there are many challenges and
opportunities to increase both the efficiency and the
effectiveness of disease management. The expanded use of
new technologies and the aggressive adaptation of behaviour
change science will certainly be at the core of these
improvements.
Technology - Unfortunately first generation DM
programmes have not been very successful in
operationalizing the abundance of technology available to us
today. According to Dr Joseph Coughlin of AgeTel, the very
real threat of an aging population will serve to significantly
accelerate adoption of technology.
New technologies offer a huge potential to improve the
efficiency and effectiveness of healthcare systems
and DM programmes. New developments in patient
communications and remote patient monitoring have been
especially noteworthy. Predictive modeling represents
another area where we have made considerable progress in
identifying which low utilizers today will become high cost
utilizers tomorrow, and therefore expedite interventions.
Behaviour Change Science represents another major
opportunity for enhancing future disease management
programmes. Changing consumer expectation and
empowering patients to take accountability for their chronic
disease is not an easy process. As noted by the famous
behaviouralist, Dr James Prochaska, “…only 20% of people
in a population that need to make a change are prepared to
do so at any one time. However, 90% of behaviour change
programs are designed with only this 20% in mind.”
According to Dr Prochaska most behavior change
programmes today fail to deal with the fact that, at the
moment they are asked to change, most people cannot
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