Chronic case management: Clinical governance with cost reductions / Gerenciamento de casos crônicos: governança clínica com redução de custos

SUMMARY Introduction: With increasing global impact of chronic degenerative non-communicable diseases (CDNCD), multidisciplinary chronic disease management care programs (CDMCP) come as a solution to improve the quality of patients care. Method: We conducted a cross-sectional epidemiologic prospective cohort study with data comparing a group of patients monitored by a CDMCP with subjects without CDMCP care, from 2010 to 2012. The patients monitored in this program were selected because they presented CDNCD with frequent hospitalization and/or emergency care in the year prior to study selection. Also, the patients could be referred to the program by their physicians and/or other programs such as HomeCare or family medicine. All costs related to the program were included and compared with the costs of users with the same epidemiological profile who opted for not participating in the CDMCP. Results: We analyzed data from 1,256 cases, including 639 (51%) men and 617 (49%) women. The mean age was 56.99 years and 73% were older than 50 years. There was a prevalence of 34% (428) cases with ischemic heart disease (myocardial infarction and stroke) and 17% (210) with neoplasms. The cases studied showed a reduction of 79% in the number of days of hospitalization compared with the cases without CDMCP monitoring. The average reduction of total costs (hospitalizations, emergency room visits and/or disease complications) was 31.94%, with average reduction of 8.36% in monthly costs. Conclusion: Multidisciplinary monitoring carried out by CDNCD patient management programs can reduce hospitalizations, emergency room visits and complications, positively impacting the costs with health care.

RESUMO Introdução: com o crescente impacto mundial das doenças crônico-degenerativas não transmissíveis (DCDNT), os programas multidisciplinares de gerenciamento de pacientes com doenças crônicas (PGDC) apresentam-se como uma solução para melhorar a qualidade do atendimento prestado. Método: foi realizado um estudo epidemiológico, tipo coorte, prospectivo, com dados comparando um grupo em acompanhamento em um PGDC com um grupo sem esse acompanhamento, no período de 2010 a 2012. Usuários acompanhados pelo programa eram selecionados por serem portadores de DCDNT, com internamentos e/ou consultas em serviços de emergência frequentes no ano anterior à seleção; por indicação do médico assistente e/ou outros programas como HomeCare ou medicina da família. Foram contabilizados todos os custos relacionados com assistência em saúde do programa e comparados com os custos de usuários com mesmo perfil epidemiológico que optaram pelo não acompanhamento no programa. Resultados: foram selecionados dados de 1.256 casos, sendo 639 (51%) do sexo masculino e 617 (49%) mulheres. A média etária foi de 56,99 e 73% dos casos acima dos 50 anos. Predomínio de 34% (428) de casos de doenças cardiovasculares isquêmicas (infarto do miocárdio e acidente vascular cerebral) e 17% (210) de neoplasias. Os casos acompanhados apresentaram redução de 79% dos dias de internamento em comparação com casos não acompanhados. A redução média de custos totais (internamentos, consultas de emergência e/ou complicações) foi de 31,94%, com redução média mensal de custos de 8,36%. Conclusão: acompanhamento multidisciplinar em programa de gerenciamento de pacientes portadores de DCDNT pode reduzir internamentos, consultas de emergência e complicações, impactando positivamente nos custos da assistência à saúde.

Case management hospitalario (manejo de casos): una forma alternativade manejar pacientes de alto riesgode estadías hospitalarias prolongadas,de reingreso, o con múltiplesrequerimientos al momento del alta / Hospital case management

Due to demographic changes, rising health expenditures, and the reimbursement mechanisms of insurers in the past 30 years, physicians and nurses have had to changethe way services are delivered. Concepts such as cost effectiveness and patient safetyhave also led to the emergence of case management. Case management, usually ledby nurses, is responsible for early recognition of patients at high risk for prolongedhospitalization, readmission, a high level of consumption of healthcare resources,and mobilizing strategies to discharge patients as soon as possible in a safe mannerwith appropriate medical follow-up. Additionally, the case management teams areresponsible for patient education in a systematic way, for proper codification ofdiagnoses, and for ensuring proper documentation at the moment of discharge. Casemanagement has proven to reduce the length of hospital stays and readmissions. Italso facilitates the care of patients who are overwhelmed by the increasingly complexhospital procedures that they must endure. This is an exhaustive review of the literature about hospital-based case management, its origins, characteristics, types, andhow it has produced a positive impact on patient safety and metrics within hospitals.

Costo-efectividad de un tratamiento antituberculoso alternativo: seguimiento a convivientes residenciales de los pacientes / Cost-effectiveness of an alternative tuberculosis treatment: home-based guardian monitoring of patients

Objetivo. Estimar la relación de costo-efectividad del tratamiento de corta duración bajoobservación directa (DOTS), comparándolo con una variación de dicho tratamiento, que incluyeun mayor seguimiento a los convivientes residenciales de los pacientes (DOTS-R) parael tratamiento de tuberculosis (TB).Métodos. Tomando una perspectiva social que incluye los costos para las institucionesde salud, para los pacientes y sus familiares, y para otras entidades que contribuyen a hacerefectiva la operación del programa, se evaluaron los costos incurridos con cada una de las dosestrategias y se estimaron razones costo-efectividad adoptando las medidas de efecto usadas porlos programas de control. La estimación de los costos de cada una de las dos estrategias incluyelos correspondientes a las instituciones de salud que administran el tratamiento, los pacientesy sus familiares, y los de la secretaría de salud que gestiona los programas de salud pública anivel municipal. Con base en estos costos y el número de casos curados y tratamientos terminadoscomo medidas de resultado de cada una de las estrategias evaluadas, se calcularon lasrazones costo-efectividad y costo incremental.Resultados. El DOTS-R se halló más costo-efectivo para lograr tratamientos exitosos queel DOTS. El DOTS-R registró costos de entre US$ 1 122,4 y US$ 1 152,7 por caso curado,comparados con valores de entre US$ 1 137,0 y US$ 1 494,3 correspondientes al DOTS. Laproporción de casos tratados con éxito fue mayor con DOTS-R que con DOTS.Conclusiones. El DOTS-R es una alternativa costo-efectiva promisoria para mejorar elcontrol de la TB en sitios endémicos. Se recomienda a las autoridades del sector salud incorporaren su gestión institucional del programa contra la TB, acciones de seguimiento de losconvivientes de pacientes, con la participación del personal de salud y los recursos físicos yfinancieros que apoyan actualmente dicho programa.

Objective. Estimate the cost-effectiveness ratio of the directly observed treatmentshort course (DOTS) for treatment of tuberculosis (TB), comparing it to a variation ofthis treatment that includes increased home-based guardian monitoring of patients(DOTS-R).Methods. Taking a social perspective that includes the costs for the healthinstitutions, the patients, and their family members, and for other entities thatcontribute to making operation of the program effective, the costs incurred with eachof the two strategies were evaluated and the cost-effectiveness ratios were estimatedadopting the measures of effect used by the control programs. The estimate of the costof each of the two strategies includes the cost to the health institutions that administertreatment, the patients and their family members, and the cost to the Ministry ofHealth that manages public health programs on the municipal level. Based on thesecosts and the number of cases cured and treatments completed as outcome measuresof each of the strategies evaluated, the cost-effectiveness ratio and incremental costwere calculated.Results. The DOTS-R was found to be more cost-effective for achievement ofsuccessful treatments than the DOTS. The DOTS-R recorded costs of US$ 1 122.40 toUS$ 1 152.70 for each case cured compared to values of US$ 1 137.00 to US$ 1 494.30for the DOTS. The percentage of cases treated successfully was higher with DOTS-Rthan with DOTS.Conclusions. The DOTS-R is a promising cost-effective alternative for improvedcontrol of TB in endemic areas. It is recommended that the health authorities includehome-based guardian monitoring of patients in their institutional management of theTB program, with the participation of health workers and the physical and financialresources that currently support this program.

Care mapping: a common sense approach.

Because of trends in the health care environment, hospitals are searching for ways to continuously improve the quality of care and to decrease the costs of care. One approach that is gaining widespread recognition throughout the United States is the use of case management and practice guidelines such as critical paths, CareMaps, and in the neonatal field, NeoMaps. The NeoMap is a clinical tool which delineates practice guidelines for each discipline that provide care to a specific infant population. It reduces variation in clinical process and thereby has been shown to improve the quality of infant care. When practice guidelines are linked to both health and economic outcomes, they have significant impact on health care costs. In this paper, case management and the development of the NeoMap will be described in relation to the Intensive Care Nursery (ICN) at Pennsylvania Hospital.