Case management for patients with poorly controlled diabetes: a randomized trial☆
Received 1 May 2003; received in revised form 20 November 2003; accepted 20 November 2003.
Abstract
Purpose
To evaluate the effects of a collaborative case management intervention for patients with poorly controlled type 2 diabetes on glycemic control, intermediate cardiovascular outcomes, satisfaction with care, and resource utilization.
Methods
We conducted a randomized controlled trial at two Department of Veterans Affairs Medical Centers involving 246 veterans with diabetes and baseline hemoglobin A1C (HbA1C) levels ≥7.5%. Two nurse practitioner case managers worked with patients and their primary care providers, monitoring and coordinating care for the intervention group for 18 months through the use of telephone contacts, collaborative goal setting, and treatment algorithms. Control patients received educational materials and usual care from their primary care providers.
Results
At the conclusion of the study, both case management and control patients remained under poor glycemic control and there was little difference between groups in mean exit HbA1C level (9.3% vs. 9.2%; difference = 0.1%; 95% confidence interval: −0.4% to 0.7%; P = 0.65). There was also no evidence that the intervention resulted in improvements in low-density lipoprotein cholesterol level or blood pressure control or greater intensification in medication therapy. However, intervention patients were substantially more satisfied with their diabetes care, with 82% rating their providers as better than average compared with 64% of patients in the control group (P = 0.04).
Conclusion
An intervention of collaborative case management did not improve key physiologic outcomes for high-risk patients with type 2 diabetes. The type of patients targeted for intervention, organizational factors, and program structure are likely critical determinants of the effectiveness of case management. Health systems must understand the potential limitations before expending substantial resources on case management, as the expected improvements in outcomes and downstream cost savings may not always be realized.
aVA Health Services Research and Development Center for Practice Management and Outcomes Research (SLK, MLK, SV, RAH), Ann Arbor, Michigan, USA
bVA GRECC (JTF), VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
cVA Veterans In Partnership (PR), VISN 11 Healthcare Network, Ann Arbor, Michigan, USA
dDepartments of Internal Medicine (SLK, SV, PR, RAH), Ann Arbor, USA
eMedical Education (JTF), University of Michigan School of Medicine, Ann Arbor, USA
fThe Michigan Diabetes Research and Training Center (SLK, SV, RAH), Ann Arbor, USA
gUniversity of Tennessee College of Nursing (JLL), Knoxville, USA
hJohn D. Dingell VA Medical Center and Department of Internal Medicine (AP), Wayne State University, Detroit, Michigan, USA
Requests for reprints should be addressed to Sarah L. Krein, PhD, RN, VA HSR&D, P.O. Box 130170, Ann Arbor, Michigan, USA 48113–0170
☆ This research was supported by the Office of Research and Development, Health Services Research and Development Service, Department of Veterans Affairs (IIR 970771). This work was also supported in part by the Michigan Diabetes Research and Training Center Grant P60DK-20572 from the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health, Bethesda, Maryland. Dr. Vijan is a Department of Veterans Affairs Career Development Awardee. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
ABSTRACT
