Disease management is a coordinated disease-specific approach to patient care that seeks the best measured outcome at the lowest possible cost (The Genesis Report)¹. 

Disease management of chronic medical conditions and the closely related concepts of collaborative or integrated care have been advocated and increasingly practised in the U.S. since the 1990s.  By then, the social and financial  burden of chronic conditions had overtaken infectious diseases and sanitary problems that had been the main focus of health care in the industrialised world until the middle of the 20th century. Today, people are living longer with chronic diseases, and expenditure on new and innovative treatments that can alleviate but will not cure such diseases has risen steeply and will continue to rise.

By the 1990s, the consequential pressure on health care budgets was becoming evident throughout the world’s leading economies and began to appear in the more prosperous urban communities of the emerging economies.  In response, Managed Care Organisations [MCOs] were set up in the U.S. (but not widely elsewhere) with the objective of applying a more organised approach to health care expenditure and outcomes.

The economics of Chronic Disease Management

Chronic Disease Management is not necessarily practised in depth by individual MCOs, the focus of whose  activities is best known for their formularies of prescription medicines that will determine the prices and conditions of reimbursed access for patients insured by MCO clients.  But if formal collaborative disease management is to be performed effectively and economically, it needs ‘structure’ in the form of MCOs or other types of allied group practices of doctors with access to a variety of medical and related skills.

In other words, chronic disease management is costly. To be affordable, it should ideally be both clinically effective (producing measurably better health outcomes) and cost-effective (meaning that, in society’s view, expenditure on disease management is balanced or outweighed by savings when compared with usual care). Examples of desirable outcomes for patients include fewer days of necessary treatment, prevention of mild/moderate phases advancing to severe or fatal levels of a disease, lower incidence of relapse, avoidance of institutional care, improved adherence to prescribed medication, and better quality of life.

Economic considerations have dictated 

• Firstly, that the initial focus of chronic disease management has been on some of the most prevalent diseases whose treatment involves a high proportion of total national health care expenditure in industrialised countries 

and 

• Secondly, that unnecessary, unjustified and damaging variations in usual care of such diseases should be avoidable or can be corrected by organised forms of collaborative disease management.

Both of these considerations were from the start seen as clearly applicable to diabetes, coronary artery disease, asthma, and chronic obstructive pulmonary disease [COPD].  For these, chronic disease management is being increasingly adopted in the U.S. It has begun to influence treatment in some European countries, though mostly without the formal organisational structure of MCOs.

Early results (1996-2002) for the four diseases recorded by U.S. pioneers like Kaiser Permanente concluded that “ most of the treatments recommended for the targeted conditions are cost-effective but not cost-saving. They increase the length and quality of life at a cost that is reasonable…but higher than the savings that accrue when exacerbations and complications are prevented”².  The distinction between cost-saving and cost-effectiveness is important, in that cost-saving is directly measurable, whereas cost-effectiveness is a combination of quantitative and qualitative judgments that will ultimately reflect society’s preferences and priorities.

A more wide-ranging analysis of the results of chronic disease management has found a variety of good and poor results and warns about forming generalised conclusions. The authors present a list of factors that characterise ‘successful interventions’ and point to “consistent patterns through which savings can be achieved on a predictable basis” under U.S. conditions. They conclude, however, that “Depression care management, as presently formulated, tends to increase costs, reflecting in part the substantial under-use of mental care services”³. However, a recent study that monitored elderly patients with depression for 4 years contradicts this view and provides evidence of significant cost-savings. It is described later in this review.

Disease management of depression

Under-use, failures of diagnosis as well as of treatment and follow-up, the inhibiting effect of social stigma, the masking of elderly depression by comorbidities, and the problems created for elderly depressed patients by polypharmacy have been described in previous articles in this series. 

It is therefore not surprising that managed intervention in depression generally - and in elderly depression more specifically - is still experimental in terms of clinical and cost-effectiveness. 

The contemporary approach to managed intervention in depression is essentially based on ‘Collaborative Care’ which usually, but not always, involves the technique of  ‘Stepped Care’. 

Stepped Care

The main features of stepped care are guidelines setting out separate pathways for the management of mild/moderate and severe depression (requiring accurate diagnosis of patients from the start) and the sequential application of different types of treatment, followed by monitoring progress in each group’s progress and outcomes.

For example, efforts to improve the management of depression in the Netherlands   have described the pathway for mild/moderate depression during the initial 6-12 weeks as mainly ‘watchful waiting’, education, self help and counselling, 8 psychotherapy sessions and physical exercise: note the avoidance of antidepressant medication during this period.

By contrast, the pathway for patients with severe depressive symptoms begins with a more elaborate diagnostic effort and (within one month) a selection of treatments involving antidepressants and/or various forms of psychotherapy.

In the UK, NICE Clinical Guideline 91⁵ involves four steps, advancing from Step 1 (All known and suspected presentations of depression for assessment and support) to Step 4 (Severe and complex depression; risk to life; severe self-neglect). Here, guidance includes the introduction of collaborative care in Step 3 (moderate/severe depression and inadequate response to treatment of mild/moderate cases), and of in-patient care in Step 4.

Guidelines are an essential component of stepped care, but their main problem is effective implementation, especially in primary care. The more elaborate the guidelines, the more uncertain will be the degree of  adherence achievable in ‘real life’ clinical practice. Moreover, NICE notes that “It has not been possible to determine costs or savings”(Ref.5) and is silent on whether these are going to be determined.

The Netherlands experiment with a stepped care model reported promising results with the mild/moderate patient group but observed that  as many as 43% of “severely depressed patients did not receive antidepressant treatment or psychotherapy within 1 month or were offered treatment options of a too low intensity”. Difficulties in implementation were in part ascribed to cultural problems, in that primary care professionals “were not used to discussing care processes and reflecting on results”(Ref.4). Initial difficulties do not imply prospective failure, but indicate that it is bound  to take time to bring new processes and techniques to fruition in dealing with the complexities of depression.

Even in the U.S. where ‘practice system tools’ are more widely accepted and adopted than in Europe, their use for depression lags behind that for diabetes, cardiovascular disease and asthma. The widest divergence has been recorded between depression and diabetes: among 41 American medical groups in the state of Minnesota, the routine provision of care management components for diabetes vs. depression was recorded as 56% vs. 15% for pre-visit planning; 27% vs. 2% for after visit follow-up; 71% vs. 24% for setting individual treatment goals; 66% vs. 22% for assessing patient progress towards goals; 78% vs. 24% for individual patient education and support; and 46% vs. 12% for following up missed appointments⁶.

Evidently, guidelines alone are not enough. What is needed is effective and persistent case management.

Collaborative Care of depression

Collaborative care involves team work in support of doctors, especially in primary care. Such teams can include nurses, psychological and behavioural therapists, psychiatrists, pharmacists, social workers and (for older patients) geriatricians. A  cardinal feature of collaborative care is the appointment of a Care Manager who will be responsible for coordinating the work of the professional team. Stepped care is often a component of collaborative teamwork. 

There is widespread evidence and agreement that collaborative care of depression produces better clinical results than ‘usual care’ (also in older patients), provided the process is well managed and integrates the contribution of appropriate professional disciplines. Where that is not the case, the benefits are questionable. 

For example, a review of depression in primary care by authors from the British universities of York, Manchester and Newcastle “clearly demonstrated that clinician education packages, when delivered alone, are a cost-ineffective strategy – bestowing no improved outcome at an increased cost”⁷. That is an important finding because of the mistaken but widespread belief that education alone may be enough to produce more effective results in the treatment of depression.

Integrated case management is also dependent on the availability of essential professional resources. Thus, the Spanish authors of the INDI project [Intervention for Depression Improvement] 2007-2010, observe that one of its limitation is that it “does not consider psychotherapy as a front-line therapeutic option in primary care because in ‘real’ caring practice in the Spanish health system it is a resource that is not often available"⁸.

In the U.S., where collaborative care for depression is more advanced than elsewhere, it is still in what might be called a ‘Late Experimental’ phase. By the middle of the last decade, its clinical effectiveness under strong management had been established, but (as noted above) evidence then available indicated that collaborative care was not cost-saving and that even the wider concept of ‘cost-effectiveness’ was unproven.

As a result, efforts to demonstrate cost savings and cost-effectiveness were intensified and  publication of evidence from longer term follow-up studies made it possible to distinguish between initial and lasting results. 

The IMPACT trial [Improving Mood: Promoting Access to Collaborative Treatment] in the U.S. has consistently followed up depressed patients aged 60+  in primary care. 1,801 patients were originally enrolled in the trial between 1999 and 2001 and randomly assigned to collaborative or ‘usual’ care.  The actual period in collaborative care was one year, but the results are reported for a total period of 4 years (including Years 2-3-4 with a relapse prevention plan for the collaborative care group who reverted to ‘usual’ care in Year 2).

The overall 4-year health care cost for patients under collaborative care in Year 1 averaged $29,422 (including $ 522 for the additional cost of collaborative intervention) compared with usual care $ 32,785, representing savings of $ 3,363 or a little over 10%. Savings occurred in every reported expenditure category of outpatient and inpatient care. The authors concluded that “for older adults with depression, collaborative care not only produces substantial clinical improvements but also carries the likelihood of long-term cost savings compared with care as usual”⁹.

That is impressive evidence of cost-effectiveness. It must, however, be borne in mind that the cost structure of U.S. health care is very different from that in Europe and other countries whose systems are predominantly financed by the public sector with different policies for health insurance, pricing, reimbursement, budgetary control and cost containment. Moreover,  American management experience of collaborative care of depression  has been developed and steadily improved over at least a decade; European efforts are more recent, less well resourced for effective management and (to judge from published reports) designed to demonstrate clinical results without seeking evidence of cost savings or cost-effectiveness. 

Subject to the development of sound management experience, the achievement of  clinical effectiveness of collaborative care for elderly depression may be regarded as a realistic goal. By contrast, cost-effectiveness and cost savings under European conditions have yet to be demonstrated. It would be highly desirable to attempt to do so in the interests of patients as well as of national health and social care systems.

Footnotes:
1. The Genesis Report/MCx, “Disease Management without illusion: Positive Outcomes, Competitive Price”, 7[1], November-December 2000