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Case management can cut medical risks and cost

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Randall Stafford found case management can help patients handle chronic conditions such as heart disease on a long-term basis.

BY SUSAN IPAKTCHIAN

As U.S. policy experts continue to search for ways to re-engineer the country's health-care system, a new study from the School of Medicine shows that a case-management approach helped a diverse group of patients reduce their overall risk of heart disease by roughly 10 percent, and did so in a cost-effective way.

Case management makes use of specially trained health-care personnel, such as nurses and dietitians, who help patients manage chronic conditions on a long-term basis. Case managers handle many of the counseling and tracking roles currently performed by physicians. By divvying up the duties, physicians can devote their attention to patients requiring their specific expertise, while patients get the ongoing counseling and support they need to maintain their health.

"This really is a feasible alternative to the way that we currently organize health care," said lead author Randall Stafford, MD, PhD, associate professor of medicine at the Stanford Prevention Research Center. "Case management makes a lot of sense when it comes to chronic disease because you need to have constant contact with patients to pick up on any problems before they get worse."

The effectiveness of case management in providing preventive medical care and counseling has been explored in previous studies involving middle-class patients, but Stafford said this study is the first to test the approach in a diverse, low-income patient population. The study is published in the fall issue of the journal Disease Management.

According to the Centers for Disease Control and Prevention, chronic diseases—such as heart disease, cancer and diabetes—account for nearly 70 percent of the deaths in the United States, and affect the quality of life of more than 90 million Americans. Many of these diseases can be prevented or controlled through healthy behaviors, such as eating nutritious foods, getting regular exercise and avoiding tobacco.

The study grew out of an ongoing, federally funded project involving Stanford and nearby San Mateo County aimed at exploring a broad range of services to lower heart disease risks among a culturally diverse, low-income population.

For the case-management study, researchers followed 341 patients who were randomly assigned to receive either primary care alone or primary care augmented by case-management visits over a 17-month period.

The case-management visits took place at four clinics operated by San Mateo Medical Center, which is the county's public hospital and clinic system, and were supplemented with phone calls. Case managers emphasized behavior changes, such as better eating and more exercise, and helped ensure that patients used prescribed medications properly. Patients were involved in their own care through self-monitoring and reporting.

The patients had an average of 14 hours of contact with the case managers during the study period, usually in the form of face-to-face visits that lasted 40 to 60 minutes. At each visit, the patient and case manager reviewed the patient's progress on lifestyle and medication goals, and developed a plan for the coming weeks. Dictated notes about each visit were made available to the patient's primary-care physician.

At the study's outset, Stafford said, the patient population had a 10-15 percent risk of suffering a heart attack or severe heart disease within the next 10 years. After the study, the patients who participated in case-management visits lowered their risks by 1.6 percent—roughly a 10 percent reduction.

The study estimated the overall cost of the case-management visits at about $1,250 per patient, or about the price of six regular office visits to a primary-care physician. Stafford said that's a relatively small outlay to reduce the risk of a heart attack, which often entails hospital costs of more than $40,000.

With health-care costs burgeoning and resources becoming more strained, Stafford said case management offers many benefits, especially for health systems operated by state and local governments. "County health systems are under a particular burden because of chronic disease, and case management provides a cost-effective way of delivering improved care for those conditions," Stafford said.

San Mateo Medical Center's leaders were encouraged by the study results, and are now looking at ways of incorporating case management into their plans for revamping the county's health-care system. "These results are extremely important and timely for us as we develop ways to most effectively serve our patients with chronic diseases," said Susan Ehrlich, MD, the medical center's vice president and medical director of ambulatory services. "Our patients and staff have truly benefited from the collaboration with Stanford."

Stafford praised medical center officials for being open to exploring new health-care delivery models. "San Mateo is being very forward-thinking and willing to take some risks, and I think that reflects positively on them," Stafford said.

Stafford's co-author is Kathy Berra, RN, MS, senior research nurse at Stanford's Program on Prevention Outcomes and Practices. The study was funded by the National Institutes of Health.

The San Mateo Medical Center clinics that participated in the case-management study are in Daly City, South San Francisco, Redwood City and Menlo Park.