Disease Management

Disease management can be considered a major component of care management, which is “a comprehensive systems approach to medical care that combines the latest medical knowledge on the best clinical methods, population-based outcomes measurement and evaluation, and advanced practice tools” (Juhn, Solomon, & Pettay, 1998). Disease management is a specific application of the care management approach to a disease entity, and organizations that perform disease management must have the infrastructure to manage the disease from before the onset of symptoms in high-risk populations, through the end stages of the illness. The process involves the following elements:

• Stratifying populations at risk for the illness
• Creating interventions for each degree of the illness
• Implementing the interventions for the appropriate stratum
• Monitoring the effects of the interventions as well as clinical, economic, and social outcomes

The backbone of an effective disease management program is a comprehensive data management system, preferably automated. Collecting, managing, and trending large volumes of data require a degree of sophistication that cannot be achieved in a manual data processing system. Systems used for disease management are among the more sophisticated electronic patient records available.

The concept of disease management was developed in the 1980s by the Boston Consulting Group, and the term was coined in the early 1990s (Boston Consulting Group, HealthCare Practice, http://www.bcg.com/practice/health_care.asp). The approach has been applied in many different types of organizations since that time, including

• Health maintenance organizations (HMOs)
• Hospitals
• Medical groups
• Pharmacy benefit management organizations
• Disease management organizations
• Home health agencies
• Governmental health-related agencies
• Public health programs
• Health-related charitable organizations

Each of these organizations has a different purpose for applying disease management. For example, health maintenance organizations use disease management techniques to better manage the care of high-cost patients to avoid duplication of services and inappropriate, high-cost procedures (Agovino, 2001). Charitable organizations may use disease management for clinical conditions such as acquired immune deficiency syndrome (AIDS) to improve access to services for clients with the disease. Medical groups may offer disease management services to their patients to decrease the workload of the physician by appropriately tracking and monitoring patients using clinical practice guidelines that provide instructions for care by allied health professionals. Pharmacy benefit management organizations (PBMOs), in fact, evolved as an outgrowth of the concept of disease management. PBMOs provide a number of services to health care payers, from processing pharmacy claims to contracting with participating pharmacies for medication delivery and evaluation of patterns of drug use based on claims evaluations. Regardless of the reason for applying the principles of disease management, the approach is essentially the same.

[Page 140]The process of disease management is based on the premise that specific interventions are effective at various phases of an individual's progression along the continuum of a clinical condition. Most disease management programs stratify populations according to their level of severity of the disease state. For example, a population at risk for diabetes could be divided into five groups, as in Table 1.

The stratification process is conducted on administrative or clinical data, depending on the organization's focus. The clinical data may be obtained from a review of medical charts or from risk-screening surveys that may be administered by staff members of the organization via telephone, by mailed surveys, or over the Internet.

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