NEW ORLEANS — Participation in a disease management program for heart failure resulted in a moderate survival benefit but no objective improvement in functional capacity, no reduction in health care utilization, and no cost savings in the largest and most rigorous study to date of any disease management program.
The lack of demonstrable cost savings is a key finding. Disease management has become a trendy public policy issue now, with Medicare and many state Medicaid programs actively pushing disease management programs for depression, diabetes, and other chronic diseases as a means of saving money, Autumn Dawn Galbreath, M.D., observed at the annual scientific sessions of the American Heart Association.
“There's a great deal of money being spent on disease management at this time, in anticipation of promised cost savings. According to our study, those promises may be empty,” said Dr. Galbreath, vice chairman for clinical programs in the department of medicine at the University of Texas, San Antonio.
Prior studies which concluded that disease management programs are both clinically effective and cost-effective were small, nonrandomized, and/or based upon relatively homogeneous HMO populations. Recognition of these deficiencies provided the impetus for the South Texas Congestive Heart Failure Disease Management Project, in which 1,069 patients with systolic or diastolic heart failure were randomized 2:1 to a disease management program or usual care and followed for 18 months, she explained.
The subjects in the disease management group were assigned a nurse case manager who provided in-depth patient education and recommended medication changes in accord with national heart failure guidelines to the patient's primary care physician, although whether or not to follow the recommendations was left to the physician's discretion.
Patients randomized to disease management survived an average of 76 days longer than controls over the course of 18 months of follow-up. But their performance on a standard 6-minute walking test wasn't significantly better than that of controls, and neither was their mean left ventricular ejection fraction. The disease management program did not reduce hospitalizations, office or ER visits, procedures, or medications.
Subgroup analysis suggested the survival benefit was greatest in patients with New York Heart Association class III and IV systolic heart failure. But even in these patients with more severe heart failure, disease management didn't result in economic savings.
“If you factor in the cost of having to pay for the disease management services, disease management actually costs money over and above the cost of traditional care,” Dr. Galbreath said.
The investigators plan to analyze the data further to obtain cost-benefit ratios.