TO THE EDITORS:
It’s axiomatic. If you ask the wrong question, you’ll probably get the wrong answer. That assumes, of course, that you’re not asking the wrong question because you want the wrong answer. And therein lies the essence of the entire debate, both inside our industry and out, about whether disease management works.
The question is usually put like this: “Does disease management work?” To answer that question requires that there be some common, agreed upon understanding of both “disease management” and “work.” Of course, as the readers of this journal know full well, there is no common, agreed upon understanding of either. And so, the answer to the question, “Does disease management work?” is most often a reflection of the prior bias of the person asking the question, or of those who are paying for that person to answer the question.
So, before we can answer the question of whether it works, we must first agree on what disease management is. The DMAA: The Care Continuum Alliance defines disease management as follows:
Disease management is a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant.
Disease management:• Supports the physician or practitioner/patient relationship and plan of care;
• Evaluates clinical, humanistic, and economic outcomes on an on-going basis with the goal of improving overall health.
Disease management components include:a
• Evidence-based practice guidelines;
• Patient self-management education (may include primary prevention, behavior modification programs, and compliance / surveillance);
• Routine reporting/feedback loop (may include communication with patient, physician, health plan and ancillary providers, and practice profiling).
It is interesting to note that, in most public presentations of the definition, the section relating to “disease management components” and the categorization of what constitutes comprehensive disease management programs is usually left out. And the first part of the definition is so general that it enables just about any entity that interacts with a patient to claim they are providing disease management services. Come to think of it, maybe that’s why the second part of the definition is so often omitted.
In any event, absent the application of a rigorous definition, disease management has become a meaningless, homogeneous phrase that means whatever the person—or entity - asking the question wants it to mean. But, even if there were a generally accepted definition of disease management, the entire process falls off the cliff when we get to the second key word in our original question—“work.” As we all know, even though there is general agreement about the elements of disease management’s value proposition— improved health, improved satisfaction with the care experience, and reduced cost of care—there is no agreement on how to measure the performance of a disease management program across those elements. And so, those asking and answering the question are free to apply whatever methodology they want to reach whatever conclusion advances their cause, or that of their clients.
As a result, the answer to the question, “Does disease management work?” is at best neutral1 and at worst “No.”2 And that doesn’t even count the “studies” that selectively review published outcomes papers to draw whatever conclusion their authors wanted to reach in the first place.
This whole situation is further complicated by two unpleasant realities. First, not all disease management programs—even those that would qualify as comprehensive under the DMAA definition—are created equal. Second, execution matters.
It might be argued that there is a certain common recipe for disease management programs which would include such ingredients as identification and stratification algorithms, assessment logic, intervention processes, data management systems and the like. But even if all of these ingredients were alike—which they’re not—how they’re applied will inevitably lead to differences in results. And, since financial performance is one of the dimensions against which the success of programs is evaluated, the cost related to how all of these are configured for delivery for large populations, makes a difference as well.
In this regard, disease management is a lot like cooking; millions of cookbooks are sold every year, but very few of the purchasers become fine chefs. At the risk of torturing this analogy even further, we also can’t forget those who want to buy the meal but insist that the chef change the ingredients or proportions and then are unhappy with its final taste.
We know that disease management works because there are countless studies validating the underlying standards of care on which the disease management translation effort is based. Accordingly, we are seeking the disease management solution that offers the most effective translation.
Given these realities, the only reasonable question for a purchaser, policy maker, or research institution to ask is, “Whose disease management program works?” While the simple truth is not all of them do, the literature is replete with third-party peer-review studies and meta-analyses that clearly prove that well-designed, well-implemented, and well-executed programs do, in fact, work. The fact that these studies come from only a very small number of organizations who purport to offer disease management services is unfortunate; it is, however, the case.
Of course, if that’s not the answer for which you’re looking, selective research can provide the answer you want.
components are disease management support services.
2. Mattke S, Seid M, Ma S. Evidence for the effect of disease management: is $1 billion a year a good investment? Am J Manag Care. 2007;13(12):670-676.