Clinical study
Case management for patients with poorly controlled diabetes: a randomized trial

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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.

Section snippets

Methods

This study was conducted as a prospective, randomized controlled trial at two academically affiliated Department of Veterans Affairs (VA) Medical Centers: a suburban facility that cares for approximately 3000 veterans with diabetes and an inner-city facility that cares for over 4000 veterans with diabetes. Approval was obtained from Institutional Review Boards at the Ann Arbor VA Healthcare System and Wayne State University.

Using automated clinical data from each facility, we identified

Results

The baseline attributes of the intervention and control groups were similar (Table 1). Except for having a higher percentage of nonwhite participants, study enrollees were demographically representative of VA ambulatory patients. Patients who refused to participate tended to be older than the study participants (mean age, 66 years) and had higher mean HbA1C values (10.1%). Clinically, study participants had poor glycemic control, low physical and mental health scores, and high comorbidity.

Mean

Discussion

Innovative approaches to improve outcomes and decrease costs for persons with chronic health conditions are an increasingly important part of health care. Accordingly, care models such as case management are being actively promoted 26, 27, 32, 45. However, evidence to support the effectiveness of such strategies has been limited, especially for more ill and socially disadvantaged patients (22). This study examined the implementation and effectiveness of an outpatient-based, collaborative case

Acknowledgements

The authors would like to thank Barb Fredrick and Christine Weglarz for their invaluable assistance throughout the course of this study, and Bill Herman and Morris Weinberger for their contributions and encouragement especially during the early stages of the study. We would like to acknowledge Jennifer Davis for her help with obtaining data and Judy Fox for conducting the semistructured interviews and assisting with the qualitative analysis.

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    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.

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