The effectiveness of disease management programmes: a review of the literature

Onderzoek toont aan dat disease-managementprogramma's een positief effect hebben op de behandeling van chronisch zieken. In deze programma's wordt de zorg door verschillende behandelaars en instellingen beter op elkaar afgestemd. De zorg rond chronisch zieken is gefragmenteerd waardoor het risico bestaat dat chronisch zieken geen optimale zorg krijgen. Om de zorg voor chronisch zieken te optimaliseren en de groeiende zorglast door de vergrijzing het hoofd te kunnen bieden, zijn maatregelen nodig om de kwaliteit van de zorg voor chronisch zieken te verbeteren. Disease-managementprogramma's kunnen hieraan bijdragen. Op basis van een inventarisatie van de internationale literatuur is onderzocht wat het effect is van disease-managementinitiatieven voor chronisch zieken in het algemeen en voor de specifieke ziekten COPD (Chronic Obstructive Pulmonary Disease), chronisch hartfalen, depressie en diabetes. Hierbij is onderzocht wat het effect is van deze programma's op de ernst van de ziekte, sterfte, kwaliteit van leven, de zorgverlening en de tevredenheid van patienten. Tussen de verschillende studies is veel variatie in de activiteiten die in het kader van disease- managementprogramma's worden uitgevoerd. Disease-managementinitiatieven met meerdere activiteiten lijken effectiever dan initiatieven met slechts een activiteit. Daarnaast blijken multidisciplinaire teams, preventie, en medicatievoorschriften door casemanagers regelmatig deel uit te maken van effectieve initiatieven. Hoewel de variatie in de onderzochte studies groot was, concluderen we dat disease-managementprogramma's in het algemeen een positief effect kunnen hebben voor chronisch zieken.Studies have shown that disease management programmes have a positive effect on the treatment of chronically ill patients. In these programmes, health care by different professionals and in different institutions is better tuned and coordinated. Health care for chronically ill patients is fragmented into different care episodes, which increases the risk of sub-optimal care. To optimize the health care for the chronically ill, disease management programmes have been used to improve the coordination of care delivery. In this study we included scientific publications on the effect of disease management in chronically ill patients in general, and in specific chronic conditions: COPD (Chronic Obstructive Pulmonary Disease), congestive heart failure, depression and diabetes. We studied the effectiveness of disease management on severity of the disease, mortality, quality of life, care processes and patient satisfaction. Activities within the disease management programmes varied considerably among the included studies. Disease management programmes with several activities tend to be more effective compared to programmes with a focus on a single activity. Effective programmes often comprised the use of multidisciplinary teams, activities on prevention, and medication prescription by case managers. Although the variety among the disease management programmes was substantial, we conclude that disease management programmes in general can contribute to better care for the chronically ill.VW

Landelijke monitor populatiemanagement : Deel 1: beschrijving proeftuinen

In Nederland zijn verschillende initiatieven gestart om zorg en ondersteuning op regionaal niveau anders vorm te geven. Deze regionale populatiegerichte aanpak wordt ook wel populatiemanagement genoemd. Doel van de initiatieven is de gezondheid van de populatie en de kwaliteit van de zorg te verbeteren en de kosten van de zorg te beheersen. Het ministerie van VWS heeft op voordracht van de zorgverzekeraars negen van deze regionale initiatieven geselecteerd als 'proeftuinen'. Het RIVM volgt deze proeftuinen om beter zicht te krijgen op het implementatieproces, op de succes- en faalfactoren en op het effect van de initiatieven op de gezondheid van de populatie en de kwaliteit en kosten van de zorg. Op dit moment zijn de proeftuinen sterk in ontwikkeling. Begin 2014 vormen de proeftuinen netwerken, vastgelegd in convenanten of samenwerkingsovereenkomsten. In de proeftuinen nemen veelal eerstelijnszorgorganisaties, ziekenhuizen en zorgverzekeraars deel, in variërende mate aangevuld met andere actoren zoals de gemeente. De populaties van de proeftuinen zijn op verschillende manieren afgebakend: geografisch (alle inwoners van een of meerdere gemeenten), op basis van het verzorgingsgebied van de betrokken huisartsen of zorggroepen, en ten slotte wordt nog onderscheid gemaakt tussen wel of niet verzekerd zijn bij de betrokken zorgverzekeraar. Iedere proeftuin heeft verschillende programma's (thema's) en een bijbehorende set interventies opgesteld. De scope van de programma's is breed en varieert tussen de proeftuinen. De interventies richten zich vaak op thema's als substitutie van zorg (verschuiving van zorg van tweede lijn naar eerste lijn), integratie van zorg (eventueel met welzijn) en preventie. In eerste instantie worden de interventies vooral toegepast op chronische zorg, medicatiegebruik en zorg rondom ontslag. De proeftuinen richten zich grotendeels nog op de eerste- en tweedelijnszorg. Wel is er de ambitie om dit gaandeweg uit te breiden met interventies in andere domeinen, zoals GGZ en jeugdzorg. De projectplannen van de proeftuinen zijn de afgelopen maanden verder uitgewerkt en de eerste interventies worden vanaf 2014 getest en/of geïmplementeerd. Nog niet voor alle geplande interventies is (structurele) financiering verworven. Vooralsnog zijn er tussen de deelnemende zorgaanbieder(s) en zorgverzekeraars in de proeftuinen geen definitieve afspraken gemaakt over uitkomstbekostiging en shared savings. Er zijn op dit gebied wel (voorzichtige) ontwikkelingen gaande, maar het is nog onduidelijk welke vorm dit gaat krijgen.In the Netherlands, several initiatives have emerged that aim to rearrange health services and promote intersectoral collaboration at regional level. These initiatives focus on the health needs of a specified population, resembling the ideas of population (health) management. The main goal is to improve population health and quality of care and to control health care costs. The Dutch Ministry of Health, Welfare and Sport designated nine of these initiatives as 'pioneer sites'. In the coming years, the National Institute for Public Health and the Environment (RIVM) will monitor these sites in order to get insight into the implementation process, the determinants of successful population management in the Dutch context, and the impact of the initiatives in terms of population health, quality of care and health spending. Currently, the nine pioneer sites are under development. Early 2014, they represent organizational networks including different types of organizations. Agreements were signed to confirm the intended cooperation within the network. All pioneer sites contain primary care organizations, hospitals and a health insurer. Other stakeholders or care providers in the health system, such as local governments, participate to varying degrees. Each pioneer site identified its target population in one of the following ways: geographically (including all citizens living in one or more municipalities); based on the catchment area of specific care providers; or enrollment in a health insurance program. Each pioneer site defined a set of programs or themes with accompanying interventions to achieve its goals. The scope of these programs is rather broad and varies between the sites. Often, interventions focus on intermediate goals such as substitution of care (from secondary to primary care), integration of services (possibly including welfare) and improved preventive care. At the start, most interventions concern chronic care, the use of medicines and the organization of care around hospital discharge. The pioneer sites aim to include other domains in the future, such as mental health care and youth care. In the past months, the pioneer sites have elaborated their project plans. Most interventions will be tested and/or implemented from 2014 onwards. More detailed financing arrangements will be made at the intervention level and at the level of the entire site. As yet, there are no definitive contracts between the health insurers and providers of care that are involved in the sites. Forthcoming contracts may include arrangements with respect to pay for performance or shared savings, but this will become clearer in the near future.Ministerie van VW

The impact of diabetes on multiple avoidable admissions: a cross-sectional study

Background Multiple admissions for ambulatory care sensitive conditions (ACSC) are responsible for an important proportion of health care expenditures. Diabetes is one of the conditions consensually classified as an ACSC being considered a major public health concern. The aim of this study was to analyse the impact of diabetes on the occurrence of multiple admissions for ACSC. Methods We analysed inpatient data of all public Portuguese NHS hospitals from 2013 to 2015 on multiple admissions for ACSC among adults aged 18 or older. Multiple ACSC users were identified if they had two or more admissions for any ACSC during the period of analysis. Two logistic regression models were computed. A baseline model where a logistic regression was performed to assess the association between multiple admissions and the presence of diabetes, adjusting for age and sex. A full model to test if diabetes had no constant association with multiple admissions by any ACSC across age groups. Results Among 301,334 ACSC admissions, 144,209 (47.9%) were classified as multiple admissions and from those, 59,436 had diabetes diagnosis, which corresponded to 23,692 patients. Patients with diabetes were 1.49 times (p < 0,001) more likely to be admitted multiple times for any ACSC than patients without diabetes. Younger adults with diabetes (18–39 years old) were more likely to become multiple users. Conclusion Diabetes increases the risk of multiple admissions for ACSC, especially in younger adults. Diabetes presence is associated with a higher resource utilization, which highlights the need for the implementation of adequate management of chronic diseases policies.NOVASaudeinfo:eu-repo/semantics/publishedVersio

Trends in HbA1c thresholds for initiation of hypoglycemic agents:Impact of changed recommendations for older and frail patients

Aims: Less strict glycated hemoglobin (HbA1c) thresholds have been recommended in older and/or frail type 2 diabetes (T2D) patients than in younger and less frail patients for initiating hypoglycemic agents since 2011. We aimed to assess trends in HbA1c thresholds at initiation of a first hypoglycemic agent(s) in T2D patients and the influence of age and frailty on these trends. Materials and methods: The groningen initiative to analyze type 2 diabetes treatment (GIANTT) database was used, which includes primary care T2D patients from the north of the Netherlands. Patients initiating a first non-insulin hypoglycemic agent(s) between 2008 and 2014 with an HbA1c measurement within 120 days before initiation were included. The influence of calendar year, age, or frailty and the interaction between calendar year and age or frailty were assessed using multilevel regression analyses adjusted for confounders. Results: We included 4588 patients. The mean HbA1c threshold at treatment initiation was 7.4% up to 2010, decreasing to 7.1% in 2011 and increasing to 7.4% in 2014. This quadratic change over the years was significant (P 0.05). Conclusions: HbA1c thresholds at initiation of a first hypoglycemic agent(s) changed significantly over time, showing a decrease after 2010 and an increase after 2012. The HbA1c threshold at initiation was not influenced by age or frailty, which is in contrast with recommendations for more personalized treatment

Comorbidity in patients with diabetes mellitus: impact on medical health care utilization

BACKGROUND: Comorbidity has been shown to intensify health care utilization and to increase medical care costs for patients with diabetes. However, most studies have been focused on one health care service, mainly hospital care, or limited their analyses to one additional comorbid disease, or the data were based on self-reported questionnaires instead of health care registration data. The purpose of this study is to estimate the effects a broad spectrum of of comorbidities on the type and volume of medical health care utilization of patients with diabetes. METHODS: By linking general practice and hospital based registrations in the Netherlands, data on comorbidity and health care utilization of patients with diabetes (n = 7,499) were obtained. Comorbidity was defined as diabetes-related comorbiiabetes-related comorbidity. Multilevel regression analyses were applied to estimate the effects of comorbidity on health care utilization. RESULTS: Our results show that both diabetes-related and non diabetes-related comorbidity increase the use of medical care substantially in patients with diabetes. Having both diabeterelated and non diabetes-related comorbidity incrases the demand for health care even more. Differences in health care utilization patterns were observed between the comorbidities. CONCLUSION: Non diabetes-related comorbidity increases the health care demand as much as diabetes-related comorbidity. Current single-disease approach of integrated diabetes care should be extended with additional care modules, which must be generic and include multiple diseases in order to meet the complex health care demands of patients with diabetes in the future

Chronic disease risk factors associated with health service use in the elderly

<p>Abstract</p> <p>Background</p> <p>To examine the association between number and combination of chronic disease risk factors on health service use.</p> <p>Methods</p> <p>Data from the 1995 Nova Scotia Health Survey (n = 2,653) was linked to provincial health services administrative databases. Multivariate regression models were developed that included important interactions between risk factors and were stratified by sex and at age 50. Negative-binomial regression models were estimated using generalized estimating equations assuming an autoregressive covariance structure.</p> <p>Results</p> <p>As the number of chronic disease risk factors increased so did the number of annual general practitioner visits, specialist visits and days spent in hospital in people aged 50 and older. This was not seen among individuals under age 50. Comparison of smokers, people with high blood pressure and people with high cholesterol showed no significantly different impact on health service use.</p> <p>Conclusion</p> <p>As the number of chronic disease risk factors increased so did health service use among individuals over age 50 but risk factor combination had no impact.</p

Why do GPs hesitate to refer diabetes patients to a self-management education program: a qualitative study

<p>Abstract</p> <p>Background</p> <p>Self-management support is seen as a cornerstone of good diabetes care and many countries are currently engaged in initiatives to integrate self-management support in primary care. Concerning the organisation of these programs, evidence is growing that engagement of health care professionals, in particular of GPs, is critical for successful application. This paper reports on a study exploring why a substantial number of GPs was (initially) reluctant to refer patients to a self-management education program in Belgium.</p> <p>Methods</p> <p>Qualitative analysis of semi-structured face-to-face interviews with a purposive sample of 20 GPs who were not regular users of the service. The Greenhalgh diffusion of innovation framework was used as background and organising framework.</p> <p>Results</p> <p>Several barriers, linked to different components of the Greenhalgh model, emerged from the interview data. One of the most striking ones was the limited readiness for innovation among GPs. Feelings of fear of further fragmentation of diabetes care and frustration and insecurity regarding their own role in diabetes care prevented them from engaging in the innovation process. GPs needed time to be reassured that the program respects their role and has an added value to usual care. Once GPs considered referring patients, it was not clear enough which of their patients would benefit from the program. Some GPs expressed the need for training in motivational skills, so that they could better motivate their patients to participate. A practical but often mentioned barrier was the distance to the centre where the program was delivered. Further, uncertainty about continuity interfered with the uptake of the offer.</p> <p>Conclusions</p> <p>The study results contribute to a better understanding of the reasons why GPs hesitate to refer patients to a self-management education program. First of all, the role of GPs and other health care providers in diabetes care needs to be clarified before introducing new functions. Feelings of security and a basic trust of providers in the health system are a prerequisite for participation in care innovation. Moreover, some important lessons regarding the implementation of an education program in primary care have been learned from the study.</p