Disease management is an approach
to the care of patients with chronic
illnesses that has been shown to
improve outcomes and constrain the costs
of care. It has been widely applied in the
care of patients with diabetes mellitus,
congestive heart failure, asthma, and
hypertension. Recently, several organizations
have developed and are applying the
principles of disease management to
patients with renal disease. This approach
to care places the patient, physician, and a
care manager at the center of the care
focus, with the care manager involved in
coordinating care across the continuum of
the disease and the many sites of care. This
is quite different from the usual approach
to end-stage renal disease (ESRD) care,
where most care is delivered in and
focused on activities in the dialysis center.
With disease management, problems and
complications are anticipated and avoided;
care is provided proactively. This improves
clinical outcomes and quality of life for
patients, while minimizing costly and
oftentimes unnecessary medications,
emergency room visits, and hospitalizations.
Early results of such programs suggest
that mortality, morbidity, and
intermediate outcomes for dialysis
patients are significantly improved using
this management approach.
Because there is a substantial up-front
investment involved in setting up and running
a disease management program, the
disease management approach usually
involves the organization taking financial
risk for patient care. In this way, cost savings,
particularly on the hospital side, are
used to offset the cost of providing the care
management and infrastructure (primarily
an information system and analytical
capabilities) needed to improve outcomes.
The recent introduction of more frequent
hemodialysis, at home or in-center, with
substantially improved patient outcomes,
offers a promising approach that fits well
with the concepts of disease management
and improved patient outcomes, leading to
overall lower costs of care.
Robert Lockridge Jr., MD, Lynchburg
Nephrology, Lynchburg, Virginia, presented
data on his nightly home hemodialysis
program (NHHD). He currently has 14
patients dialyzing using this approach. Dr.
Lockridge emphasized that NHHD offers a
win-win situation for all involved in ESRD
care. For patients there is an improved
quality of life; many patients may return to
work; there is a reduction in the need for
and, therefore, cost of medications; and
there is a new hope for improved health.
For providers, it is gratifying to have
patients with improved outcomes, to see
patients more responsible for their care, to
need fewer personnel to care for patients
since they are at home, and less need for
dialysis facility infrastructure. For
Medicare, there is a lowering of total
costs for the care of ESRD patients, since
fewer medications are generally needed
[e.g., erythropoietin (EPO), vitamin D],
and hospitalizations are reduced.
Patients who are unable to perform
home hemodialysis can also realize the
advantages of more frequent dialysis.
George Ting, El Camino Hospital,
Mountain View, California, described his
experience with in-center, short, daily
hemodialysis in Mountain View. He report-ed
on 30 patients who were placed on this
form of therapy. The clinical benefits mir-rored
those reported by others, including a
decrease in blood pressure medication and
EPO requirements, improved quality of life,
and decreased hospitalizations. There was
a reduction in global costs, as described by
Dr. Lockridge.
Currently, there are significant barriers
to the growth of more frequent dialysis,
including the need for patient acceptance
and adequate reimbursement. The latter
issue is less difficult to resolve when dis-ease
management organizations, particu-larly
those holding full financial risk for
patient expenses, are involved in patient
care. In this situation, the improved outcomes
of disease management per se,
combined with those of more frequent
dialysis, will lead to a healthier patient
with a higher quality of life. Providing such
treatment will be possible because the
disease management organization will
have sufficient funds available, from the
improved quality of care and the decreased
medications and hospitalizations, to support
the necessary proactive management
integral to this approach. Until Medicare
provides increased funding to dialysis programs
to increase the frequency of dialysis
in the fee-for-service environment, the
growth of such programs will likely be constricted
to capitated delivery systems,
largely run by managed care.
