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Disease Management

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Handbook Integrated Care

Abstract

Health professionals, policymakers and institutions in many countries have begun introducing some form of disease management programme and similar approaches to address the rising burden of chronic disease. The nature and scope of programmes and care models differ however, and so does the evidence about their effectiveness, about the value of different approaches, and about what works in what contexts and for what populations. This chapter explores the nature of disease management as a tool or strategy for integrated care. It shows that, overall, disease management holds promise to improve processes and outcomes of care but evidence that is available tends to be limited to a small set of conditions only. Disease management approaches that employ a multifaceted strategy and target those most likely to benefit are more likely to enhance outcomes of those with chronic disease. However, disease-specific approaches may be ill-suited to meet the needs of the typical patient in primary care who frequently has multiple health problems with complex needs.

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References

  • Adams, S., Smith, P., Allan, P., et al. (2007). Systematic review of the chronic care model in chronic obstructive pulmonary disease prevention and management. Archives of Internal Medicine, 167, 551–561.

    Article  Google Scholar 

  • Archer, J., Bower, P., Gilbody, S., et al. (2012). Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews, 10, CD006525.

    Google Scholar 

  • Aspin, C., Jowsey, T., Nolte, E., et al. (2010). Health policy responses to rising rates of multi-morbid chronic illness in Australia and New Zealand. Australian and New Zealand Journal of Public Health, 34, 386–393.

    Article  Google Scholar 

  • Bodenheimer, T. (1999). Disease management–promises and pitfalls. The New England Journal of Medicine, 340, 1202–1205.

    Article  Google Scholar 

  • Boland, M. R., Tsiachristas, A., Kruis, A. L., et al. (2013). The health economic impact of disease management programs for COPD: A systematic literature review and meta-analysis. BMC Pulmonary Medicine, 13, 40.

    Article  Google Scholar 

  • Care Continuum Alliance. (2010). Outcomes guidelines report (Vol. 5). Washington, DC: Care Continuum Alliance.

    Google Scholar 

  • Coelho, A., Leone, C., Ribeiro, V., et al. (2014). Integrated disease management: A critical review of foreign and Portuguese experience. Acta Médica Portuguesa, 27, 116–125.

    Article  Google Scholar 

  • Coleman, K., Mattke, S., Perrault, P., et al. (2009). Untangling practice redesign from disease management: How do we best care for the chronically ill? Annual Review of Public Health, 30, 385–408.

    Article  Google Scholar 

  • Craig, P., Dieppe, P., Macintyre, S., et al. (2008). Developing and evaluating complex interventions: New guidance. London: Medical Research Council.

    Google Scholar 

  • de Bakker, D., Struijs, J., Baan, C., et al. (2013). Early results from adoption of bundled payment for diabetes care in the Netherlands show improvement in care coordination. Health Affairs, 31, 426–433.

    Article  Google Scholar 

  • de Bruin, S., Heijink, R., Lemmens, L., et al. (2011). Impact of disease management programs on healthcare expenditures for patients with diabetes, depression, heart failure or chronic obstructive pulmonary disease: A systematic review of the literature. Health Policy, 101, 105–121.

    Article  Google Scholar 

  • Drewes, H., Steuten, L., Lemmens, L., et al. (2012). The effectiveness of chronic care management for heart failure: Meta-regression analyses to explain the heterogeneity in outcomes. Health Services Research, 47, 1926–1959.

    Article  Google Scholar 

  • Egginton, J., Ridgeway, J., Shah, N., et al. (2012). Care management for type 2 diabates in the United States: A systematic review and meta-analyis. BMC Health Services Research, 12, 72.

    Article  Google Scholar 

  • Ekers, D., Murphy, R., Archer, J., et al. (2013). Nurse-delivered collaborative care for depression and long-term physical conditions: A systematic review and meta-analysis. Journal of Affective Disorders, 149, 14–22.

    Article  Google Scholar 

  • Elissen, A., Duimel-Peeters, I., Spreeuwenberg, C., et al. (2012). Toward tailored disease management for type 2 diabetes. The American Journal of Managed Care, 18, 619–630.

    Google Scholar 

  • Elissen, A., Adams, J., Spreeuwenberg, M., et al. (2013a). Advancing current approaches to disease management evaluation: Capitalizing on heterogeneity to understand what works and for whom. BMC Medical Research Methodology, 13, 40.

    Article  Google Scholar 

  • Elissen, A. M., Steuten, L. M., Lemmens, L. C., et al. (2013b). Meta-analysis of the effectiveness of chronic care management for diabetes: Investigating heterogeneity in outcomes. Journal of Evaluation in Clinical Practice, 19, 753–762.

    Google Scholar 

  • Ellrodt, G., Cook, D., Lee, J., et al. (1997). Evidence-based disease management. JAMA, 278, 1687–1692.

    Article  Google Scholar 

  • Epstein, R., & Sherwood, L. (1996). From outcomes research to disease management: A guide for the perplexed. Annals of Internal Medicine, 124, 832–837.

    Article  Google Scholar 

  • Fuchs, S., Henschke, C., Blumel, M., et al. (2014). Disease management programs for type 2 diabetes in Germany: A systematic literature review evaluating effectiveness. Deutsches Ärzteblatt International, 111, 453–463.

    Google Scholar 

  • Fullerton, B., Nolte, E., & Erler, A. (2011). Qualität der Versorgung chronisch Kranker in Deutschland. Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen, 105, 554–562.

    Article  Google Scholar 

  • Glasgow, N., Zwar, B., Harris, M., et al. (2008). Australia. In E. Nolte, C. Knai, & M. McKee (Eds.), Managing chronic conditions. Experience in eight countries. Copenhagen: World Health Organization on behalf of the European Observatory on Health Systems and Policies.

    Google Scholar 

  • Göhler, A., Januzzi, J., Worrell, S., et al. (2006). A systematic meta-analysis of the efficacy and heterogeneity of disease management programs in congestive heart failure. Journal of Cardiac Failure, 12, 554–567.

    Article  Google Scholar 

  • Goldfracht, M., Levin, D., Peled, O., et al. (2011). Twelve-year follow-up of a population-based primary care diabetes program in Israel. International Journal for Quality in Health Care, 23, 674–681.

    Article  Google Scholar 

  • Gonseth, J., Guallar-Castillon, P., Banegas, J. R., et al. (2004). The effectiveness of disease management programmes in reducing hospital re-admission in older patients with heart failure: A systematic review and meta-analysis of published reports. European Heart Journal, 25, 1570–1595.

    Article  Google Scholar 

  • Hamar, G., Rula, E., Coberley, C., et al. (2015). Long-term impact of a chronic disease management program on hospital utilization and cost in an Australian population with heart disease or diabetes. BMC Health Services Research, 15, 174.

    Article  Google Scholar 

  • Jacob, L., Hadji, P., Albert, U., et al. (2015). Impact of disease management programs on women with breast cancer in Germany. Breast Cancer Research and Treatment, 153, 391–395.

    Article  Google Scholar 

  • Knight, K., Badamgarav, E., Henning, J., et al. (2005). A systematic review of diabetes disease management programmes. The American Journal of Managed Care, 11, 241–250.

    Google Scholar 

  • Kruis, A. L., Smidt, N., Assendelft, W. J., et al. (2013). Integrated disease management interventions for patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews, 10, CD009437.

    Google Scholar 

  • Krumholz, H., Currie, P., Riegel, B., et al. (2006). A taxonomy for disease management: A scientific statement from the American Heart Association Disease Management Taxonomy writing group. Circulation, 114, 1432–1445.

    Article  Google Scholar 

  • Lemmens, K., Nieboer, A., & Huijsman, R. (2009). A systematic review of integrated use of disease-management interventions in asthma and COPD. Respiratory Medicine, 103, 670–691.

    Article  Google Scholar 

  • Lemmens, K., Lemmens, L., Boom, J., et al. (2011). Chronic care management for patients with COPD: A critical review of available evidence. Journal of Evaluation in Clinical Practice, 19, 734–752.

    Google Scholar 

  • Martinez-Gonzalez, N. A., Berchtold, P., Ullman, K., et al. (2014). Integrated care programmes for adults with chronic conditions: A meta-review. International Journal for Quality in Health Care, 26, 561–570.

    Article  Google Scholar 

  • Mattke, S., Seid, M., & Ma, S. (2007). Evidence for the effect of disease management: Is $1 billion a year a good investment? The American Journal of Managed Care, 13, 670–676.

    Google Scholar 

  • Mehring, M., Donnachie, E., Fexer, J., et al. (2014). Disease management programs for patients with COPD in Germany: A longitudinal evaluation of routinely collected patient records. Respiratory Care, 59, 1123–1132.

    Article  Google Scholar 

  • NCBI. (2016). Pubmed. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed

  • Neumeyer-Gromen, A., Lampert, T., Stark, K., et al. (2004). Disease management programs for depression: A systematic review and meta-analysis of randomized controlled trials. Medical Care, 42, 1211–1221.

    Article  Google Scholar 

  • Niesink, A., Trappenburg, J., de Weert-van Oene, G., et al. (2007). Systematic review of the effects of chronic disease management on quality-of-life in people with chronic obstructive pulmonary disease. Respiratory Medicine, 101, 2233–2239.

    Article  Google Scholar 

  • Nolte, E. (2017). Disease management. In R. Busse, N. Klazinga, J.-A. Røttingen, et al. (Eds.), Quality strategies in European health systems: A systematic assessment of their nature, use and effectiveness. Maidenhead: Open University Press.

    Google Scholar 

  • Nolte, E., & Knai, C. (2015). Assessing chronic disease management in European health systems. Country reports. Copenhagen: World Health Organization (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies).

    Google Scholar 

  • Nolte, E., & McKee, M. (2008a). Caring for people with chronic conditions: A health system perspective. Maidenhead: Open University Press.

    Google Scholar 

  • Nolte, E., & McKee, M. (2008b). Integration and chronic care: A review. In E. Nolte & M. McKee (Eds.), Caring for people with chronic conditions. A health system perspective (pp. 64–91). Maidenhead: Open University Press.

    Google Scholar 

  • Nolte, E., & Pitchforth, E. (2014). What we know: A brief review of the evidence of approaches to chronic care. In E. Nolte, C. Knai, & R. Saltman (Eds.), Assessing chronic disease management in European health systems. Concepts and approaches (pp. 9–22). Copenhagen: World Health Organization (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies).

    Google Scholar 

  • Nolte, E., McKee, M., & Knai, C. (2008). Managing chronic conditions: An introduction to the experience in eight countries. In E. Nolte, C. Knai, & M. McKee (Eds.), Managing chronic conditions: Experience in eight countries (pp. 1–14). World Health Organization on behalf of the European Observatory on Health Systems and Policies: Copenhagen.

    Google Scholar 

  • Nolte, E., Conklin, A., Adams, J., et al. (2012a). Evaluating chronic disease management. Recommendations for funders and users. Santa Monica: RAND Corporation.

    Google Scholar 

  • Nolte E, Knai C, Hofmarcher MC, A, et al. (2012b) Overcoming fragmentation in healthcare: Chronic care in Austria, Germany and the Netherlands. Health Economics, Policy, and Law 7: 125-146.

    Google Scholar 

  • Nolte, E., Knai, C., & Saltman, R. (2014). Assessing chronic disease management in European health systems. Country reports. Copenhagen: World Health Organization (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies).

    Google Scholar 

  • Norris, S., Glasgow, R., Engelgau, M., et al. (2003). Chronic disease management. A definition and systematic approach to component interventions. Disease Management and Health Outcomes, 11, 477–488.

    Article  Google Scholar 

  • Ofman, J., Badamgarav, E., Henning, J., et al. (2004). Does disease management improve clinical and economic outcomes in patients with chronic diseases? A systematic review. The American Journal of Medicine, 117, 182–192.

    Article  Google Scholar 

  • Ouwens, M., Wollersheim, H., Hermens, R., et al. (2005). Integrated care programmes for chronically ill patients: A review of systematic reviews. International Journal for Quality in Health Care, 17, 141–146.

    Article  Google Scholar 

  • Peytremann-Bridevaux, I., Staeger, P., Bridevaux, P., Ghali, W., et al. (2008). Effectiveness of chronic obstructive pulmonary disease-management programs: Systematic review and meta-analysis. The American Journal of Medicine, 121, 433–443.

    Article  Google Scholar 

  • Peytremann-Bridevaux, I., Arditi, C., Gex, G., et al. (2015). Chronic disease management programmes for adults with asthma. Cochrane Database of Systematic Reviews, 5, CD007988.

    Google Scholar 

  • Pimouguet, C., Le Goff, M., Thiébaut, R., et al. (2011). Effectiveness of disease-management programs for improving diabetes care: A meta-analysis. CMAJ, 183, E115–E127.

    Article  Google Scholar 

  • Rijken, M., Bekkema, N., Boeckxstaens, P., et al. (2012). Chronic Disease Management Programmes: An adequate response to patients’ needs? Health Expectations, 17, 608–621.

    Article  Google Scholar 

  • Roccaforte, R., Demers, C., Baldassarre, F., et al. (2005). Effectiveness of comprehensive disease management programmes in improving clinical outcomes in heart failure patients. A meta-analysis. European Journal of Heart Failure, 7, 1133–1144.

    Article  Google Scholar 

  • Roccaforte, R., Demers, C., Baldassarre, F., et al. (2006). Corrigendum to “Effectiveness of comprehensive disease management programmes in improving clinical outcomes in heart failure patients. A meta-analysis” [Eur J Hear Fail 7 (2005) 1133–1144]. European Heart Journal, 8, 223–224.

    Article  Google Scholar 

  • Rothman, A., & Wagner, E. (2003). Chronic illness management: What is the role of primary care? Annals of Internal Medicine, 138, 256–261.

    Article  Google Scholar 

  • Royal College of Physicians. (2004). Clinicians, services and commissioning in chronic disease management in the NHS. The need for coordinated management programmes. London: Royal College of Physicians of London, Royal College of General Practitioners, NHS Alliance.

    Google Scholar 

  • Savard, L., Thompson, D., & Clark, A. (2011). A meta-review of evidence on heart failure disease management programs: The challenges of describing and synthesizing evidence on complex interventions. Trials, 12, 194.

    Article  Google Scholar 

  • Schrijvers, G. (2009). Disease management: A proposal for a new definition. International Journal of Integrated Care, 9, e06.

    Google Scholar 

  • Smidth, M., Christensen, M., Fenger-Grøn, M., et al. (2013). The effect of an active implementation of a disease management programme for chronic obstructive pulmonary disease on healthcare utilization–a cluster-randomised controlled trial. BMC Health Services Research, 13, 385.

    Article  Google Scholar 

  • Takeda, A., Taylor, S. J., Taylor, R. S., et al. (2012). Clinical service organisation for heart failure. Cochrane Database of Systematic Reviews, 9, CD002752.

    Google Scholar 

  • Tan, W., Ding, Y., Xia, W., et al. (2014). Effects of a population-based diabetes management program in Singapore. The American Journal of Managed Care, 20, e388–e398.

    Google Scholar 

  • The Boston Consulting Group. (2006). Realizing the promise of disease management. Boston: The Boston Consulting Group.

    Google Scholar 

  • Thota, A., Sipe, T., Byard, G., et al. (2012). Collaborative care to improve the management of depressive disorders: A community guide systematic review and meta-analysis. American Journal of Preventive Medicine, 42, 525–538.

    Article  Google Scholar 

  • Tsai, A., Morton, S., Mangione, C., et al. (2005). A meta-analysis of interventions to improve care for chronic illness. The American Journal of Managed Care, 11, 478–488.

    Google Scholar 

  • Tsiachristas, A., Burgers, L., & Rutten-van, M. M. (2015). Cost-effectiveness of disease management programs for cardiovascular risk and COPD in The Netherlands. Value in Health, 18, 977–986.

    Article  Google Scholar 

  • Wagner, E. (1998). Chronic disease management: What will it take to improve care for chronic illness. Effective Clinical Practice, 1, 2–4.

    Google Scholar 

  • Wagner, E., Davis, C., Schaefer, J., et al. (1999). A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly, 7, 56–66.

    Google Scholar 

  • Wagner, E., Glasgow, R., Davis, C., et al. (2001). Quality improvement in chronic illness care: A collaborative approach. Joint Commission Journal on Quality Improvement, 27, 63–80.

    Article  Google Scholar 

  • Weingarten, S., Henning, J., Badamgarav, E., et al. (2002). Interventions used in disease management programmes for patients with chronic illness – which ones work? Meta-analysis of published reports. BMJ, 325, 925–932.

    Article  Google Scholar 

  • Whellan, D. J., Hasselblad, V., Peterson, E., et al. (2005). Metaanalysis and review of heart failure disease management randomized controlled clinical trials. American Heart Journal, 149, 722–729.

    Article  Google Scholar 

  • Yu, D. S., Thompson, D. R., & Lee, D. T. (2006). Disease management programmes for older people with heart failure: Crucial characteristics which improve post-discharge outcomes. European Heart Journal, 27, 596–612.

    Article  Google Scholar 

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Authors and Affiliations

  1. European Observatory on Health Systems and Policies, London School of Economics and Political Science, London School of Hygiene & Tropical Medicine, London, UK

    Ellen Nolte

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  1. Ellen Nolte
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Correspondence to Ellen Nolte .

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Editors and Affiliations

  1. Institute for Epidemiology, Social Medicine and Health System Research, Medical School Hannover, Hannover, Germany

    Volker Amelung

  2. International Foundation for Integrated Care, Oxford, United Kingdom

    Viktoria Stein

  3. International Foundation for Integrated Care, Oxford, United Kingdom

    Nicholas Goodwin

  4. Health Policy Research and Planning, Clalit Health Services, Tel-Aviv, Israel

    Ran Balicer

  5. European Observatory on Health Systems and Policies, London School of Economics and Political Science, London School of Hygiene & Tropical Medicine, London, United Kingdom

    Ellen Nolte

  6. Workforce Research & Evaluation, Alberta Health Services Calgary, Calgary, Alberta, Canada

    Esther Suter

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Nolte, E. (2017). Disease Management. In: Amelung, V., Stein, V., Goodwin, N., Balicer, R., Nolte, E., Suter, E. (eds) Handbook Integrated Care. Springer, Cham. https://doi.org/10.1007/978-3-319-56103-5_5

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