Session number: 1133
Abstract title: Proactive Diabetes Case Management: Expectation Versus Reality
Author(s):
SL Krein - VA Center for Practice Management and Outcomes Research, VA Ann Arbor Healthcare System, Ann Arbor, MI and Department of Internal Medicine, University of Michigan, Ann Arbor, MI
ML Klamerus - VA Center for Practice Management and Outcomes Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
S Vijan - VA Center for Practice Management and Outcomes Research, VA Ann Arbor Healthcare System, Ann Arbor, MI and Department of Internal Medicine, University of Michigan, Ann Arbor, MI
A Pawlow - John D. Dingell VA Medical Center, Detroit, MI
P Reeves - VISN 11, Ann Arbor, MI
RA Hayward - VA Center for Practice Management and Outcomes Research, VA Ann Arbor Healthcare System, Ann Arbor, MI and Department of Internal Medicine, University of Michigan, Ann Arbor, MI
Objectives: Case management is proposed as a method for improving the care of patients with chronic disease. However, there is a lack of rigorous studies demonstrating significant benefits or cost-savings with these programs. The objective of this study was to evaluate the effectiveness of a targeted, proactive case management intervention for high-risk veterans with type 2 diabetes on: glycemic control (A1c), blood pressure, lipid control, and satisfaction.
Methods: 246 high-risk individuals with diabetes at two VAMCs were recruited and randomly assigned to intervention and control groups. Two nurse practitioners monitored and coordinated care for the intervention patients for approximately 18 months. Baseline and follow-up data were obtained through lab tests, surveys and the VA medical information system. Data analysis included bivariate methods (t-test, Wilcoxon rank-sum, chi-square) and multivariable regression.
Results: Follow-up data were obtained for 94% of the study participants. Mean A1c values in both groups at both baseline and follow-up were over 9% (p = .69). The mean change in LDL cholesterol was -17.8 for the intervention group and -12.5 for the controls (p = .19). For both groups, mean diastolic blood pressure decreased slightly (-2.5 versus -3.3, p = .74), while systolic blood pressure increased slightly (2.5 versus .6, p = .74). 82% of intervention patients were satisfied with their diabetes care and 78% rated their health care providers as better than average compared with 74% and 67% of those in the control group respectively (p = .16, .08).
Conclusions: Prevailing wisdom suggests that added support for patients with chronic conditions and their primary care providers is likely to improve outcomes. This study found little evidence to support this idea for high-risk patients with type 2 diabetes. How these results were influenced by patient selection, the case management model, or other factors warrants further study.
Impact statement: Case management may not be a sufficient strategy for achieving long-term improvements in outcomes for many high-risk patients or in certain practice settings. Health systems must recognize the potential limitations of this approach before expending substantial resources, time and effort on case management programs; as the expected improvements in outcomes and down-stream cost-savings may not be realized.