Abstract
Background: As registry use for disease- and care-management (DCM) has become more common, subsets of patients with multiple chronic illnesses may be listed in multiple registries and subject to outreach by multiple DCM clinicians. While much outreach is beneficial, too many different types of DCM contacts per patient may be inefficient and/or create competing demands for patients.
Methods: We assessed number and type of DCM encounters in a two year cohort of 23,385 HMO members listed in 2 or more of the following disease registries: diabetes, coronary artery disease, hypertension, congestive heart failure, and chronic kidney disease. Outcomes were 0, 1, or 2+ encounters; and 3+ types vs. 1 or 2 types of encounter. We assessed all types of DCM not just those specific to the five registries. Descriptors included: age group, gender, overall morbidity, specific diagnoses for each registry, utilization, and depression diagnosis. We assessed frequencies of descriptors, and used multivariate techniques to identify those significantly associated with outcomes.
Results: Ages ranged from 17 to 98, and 55% were male. 5,626 had no DCM encounters, 3,090 had one, and 14,669 had two or more. Of the 17,759 persons with DCM encounters, 45% received one type of DCM (e.g. diabetes care management), 31% received two types, 15% received 3 types, and 9% (or 1,668 persons) received 4 or more types of DCM. The most common types of care management received were lipid management, chronic care coordination (a global care management service that includes hospital follow-up), diabetes care management, and nutritional counseling. In multivariate analyses, female gender, higher morbidity level, emergency department or inpatient admission, diagnosis of depression, and each of the individual registry diagnoses were significantly associated with receipt of 2 or more DCM encounters. All of these characteristics except gender were also associated with receiving 3+ types of care management encounters relative to 1 or 2 types.
Conclusions: Within a clinical environment that is able to make near-optimal use of DCM technology and processes, we explored the potential limitations of outreach-based care management for a subset of multimorbid patients. Certain patients characterized by higher morbidity, a diagnosis of depression, and high utilization receive more numbers and types of DCM and may benefit from careful assessment of their care needs.
