Outcomes Associated with a Disease Management Program for End-Stage Renal Disease
Allen R. Nissenson
Disease-state management is gaining in use for the management of chronically ill individuals including those with diabetes mellitus, congestive heart failure, asthma, and some forms of cancer. Recently, disease management (DM) has been applied to patients with chronic kidney disease (CKD), a growing population of patients with high annual costs. CKD is ideally suited to DM since the definition of the condition is unambiguous and current care is highly fragmented. There are currently over 240 000 patients receiving dialysis for end-stage renal disease (ESRD), with projected numbers of nearly 600 000 by 2010, and nearly 9 million individuals with CKD not yet on dialysis. The total cost of care for patients with ESRD alone exceeded $US17 billion in 2000. Over 40% of costs for patients with ESRD result from hospitalizations, many of which can be avoided. In addition, much of the clinical morbidity and cost relates to associated comorbidities rather than ESRD per se, with little management presently provided for these conditions in the dialysis facility setting. DM for CKD uses field-based nurse care managers who can risk-assess patients and provide coordination of care so that the renal issues as well as comorbidities are identified and appropriately managed. Although few results from such efforts have been published, those that have, from RMS Disease Mnagement Inc., show remarkable improvements in a variety of clinical outcomes including mortality and hospitalization. Challenges to expanding DM for CKD include up-front funding to provide the needed DM, the availability of robust information systems to manage and analyze clinical and financial data, and the interest and participation of nephrologists, primary care providers and dialysis facilities, as well as other key providers to ensure that the DM approach is effective. With continuing increases in the number of patients with CKD in managed health plans, DM for this population will be even more important in the future to optimize clinical outcomes while constraining the costs of care.
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