Abstract
Improving the health of chronically ill older adults is a major challenge facing modern health care systems. A community-based nursing intervention developed by Health Quality Partners (HQP) was one of 15 different models of care coordination tested in randomized controlled trials within the Medicare Coordinated Care Demonstration (MCCD), a national US study. Evaluation of the HQP program began in 2002. The study reported here was designed to evaluate the survival impact of the HQP program versus usual care up to five years post-enrollment. HQP enrolled 1,736 adults aged 65 and over, with one or more eligible chronic conditions (coronary artery disease, heart failure, diabetes, asthma, hypertension, or hyperlipidemia) during the first six years of the study. The intervention group (n = 873) was offered a comprehensive, integrated, and tightly managed system of care coordination, disease management, and preventive services provided by community-based nurse care managers working collaboratively with primary care providers. The control group (n = 863) received usual care. Overall, a 25% lower relative risk of death (hazard ratio [HR] 0.75 [95% CI 0.57-1.00], p = 0.047) was observed among intervention participants with 86 (9.9%) deaths in the intervention group and 111 (12.9%) deaths in the control group during a mean follow-up of 4.2 years. When covariates for sex, age group, primary diagnosis, perceived health, number of medications taken, hospital stays in the past 6 months, and tobacco use were included, the adjusted HR was 0.73 (95% CI 0.55-0.98, p = 0.033). Subgroup analyses did not demonstrate statistically significant interaction effects for any subgroup. No suspected program-related adverse events were identified. The HQP model of community-based nurse care management appeared to reduce all-cause mortality in chronically ill older adults. Limitations of the study are that few low-income and non-white individuals were enrolled and implementation was in a single geographic region of the US. Additional research to confirm these findings and determine the model's scalability and generalizability is warranted. ClinicalTrials.gov NCT01071967. Please see later in the article for the Editors' Summary.
Highlights
Ill older adults have complex patterns of health care, frequent hospital readmissions, often receive poor or inconsistent quality of care, and account for the majority of health care expenditures in the United States [1,2,3,4,5,6]
Several leading organizations and experts argue that care coordination emphasizing wellness, prevention, and chronic disease management is a promising means to increase the quality and perhaps reduce the costs of care for chronic illness in the elderly [9,10,11]
Broader testing and use of chronic disease management interventions in several countries have resulted in reports describing the challenges associated with such efforts, but very few have provided evidence of improved long-term health outcomes or reduced health care expenditures [12,13,14,15,16,17,18,19,20,21,22]
Summary
Ill older adults have complex patterns of health care, frequent hospital readmissions, often receive poor or inconsistent quality of care, and account for the majority of health care expenditures in the United States [1,2,3,4,5,6]. Broader testing and use of chronic disease management interventions in several countries have resulted in reports describing the challenges associated with such efforts, but very few have provided evidence of improved long-term health outcomes or reduced health care expenditures [12,13,14,15,16,17,18,19,20,21,22]. In almost every country in the world, the proportion of people aged over 60 years is growing faster than any other age group because of increased life expectancy This demographic change has several implications for public health, especially as older age is a risk factor for many chronic diseases—diseases of long duration and generally slow progression. The researchers used the gold standard of research, a randomized controlled trial, to examine the impact of a community-based nurse care management model for older adults with chronic illnesses in the United States as part of a series of studies supported by the Centers for Medicare and Medicaid Services
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