These patients have the highest health care costs and the worst outcomes, but a new study suggests that a team-based approach to managing care could improve outcomes and potentially save taxpayers billions.
Researchers at the University of Washington and the Seattle-based managed care organization Group Health Cooperative published their findings in the Dec. 30 issue of The New England Journal of Medicine.
The intervention involves specially trained nurses who work closely with patients to coordinate their health care needs, paying specific attention to optimizing the treatment of depression, blood pressure, blood sugar, and cholesterol.
One year after entering the trial, patients who worked with the nurse coaches had less depression and better control of their diabetes and heart disease risk factors than patients who got standard care.
Sixty-two-year-old Dennis Revoyr, of Lynnwood, Wash., who has depression and diabetes, was one of these patients.
“I don’t just feel better, I am better,” Revoyr tells WebMD. “The biggest difference was that I have one person who knows everything that is going on with me.”
Depression and Chronic Disease
Depression is common in older patients with chronic conditions like diabetes and heart disease, but its impact on these diseases is not well understood.
In earlier research, University of Washington psychiatry professor Wayne J. Katon, MD, and colleagues followed nearly 5,000 diabetes patients for about a decade, finding that one in four suffered from depression.
Katon and colleagues found that patients benefited from having a nurse case manager whose role was to integrate depression and diabetes treatment.
In their latest study, they examined an even more comprehensive treatment approach. “We hypothesized that treating depression is a necessary first step, but it alone is not sufficient to improve chronic disease outcomes,” Katon tells WebMD.
The new trial included 214 patients with poorly managed diabetes and/or heart disease, randomly assigned to either standard care or the collaborative care intervention, called TEAMcare. The average age of the patients was 60, and about half were eligible for Medicare.
The TEAMcare patients were assigned a doctor-supervised nurse coach who coordinated their medical care. The nurses screened the patients for depression and recommended adjustments in blood pressure, blood sugar, cholesterol, and depression medications as needed.
Nurse coaches also worked with patients to set and achieve attainable health goals.
During the yearlong study, patients with the nurse coaches had more frequent adjustments in insulin and in medications for depression, blood pressure, cholesterol, and blood sugar than patients who got standard care.
They also achieved better control of their depression, diabetes, and heart disease and reported better quality of life and more satisfaction with medical care.
Nurse coach Susan Ruedebusch, RN, who has been a diabetes educator with Group Health for 27 years, says she has rarely seen such dramatic improvements in patients.
She ended up coaching several of her previous patients who had never made much progress before entering the study.
“We entered into a totally different relationship, where the patients set the agenda for the goals they wanted to achieve,” she says. “The improvement I saw was amazing.”
Potential Reduction in Health Costs
The average cost of the collaborative care intervention was about $1,200 for two years of nurse coaching.
Katon and colleagues are currently conducting a cost-benefit analysis of the intervention, but the researcher says the savings to the health care system associated with better management of chronic disease could be huge.
The average cost of treating a patient with multiple chronic diseases is about $10,000 annually, Katon says.
“Clearly, this is a timely intervention,” he says. “Over the next decade, Medicare costs are going to skyrocket. We are going to have to do something or it will break the bank.”
Depression and diabetes researcher Briana Mezuk, PhD, of Virginia Commonwealth University says the collaborative care model is increasingly being used by managed care groups to treat chronic disease.
She adds that the importance of integrating depression screening and treatment into the management of chronic disease is also being realized.
“We know that if we help patients manage depression they will take better care of themselves,” she says. “They are more likely to take their medications and do the other things their doctors want them to do.”
Dennis Revoyr says getting his depression under control and becoming an active participant in the management of his diabetes has made all the difference.
“For me, being involved in the decision-making process helped me do my part and follow through with what I needed to do to improve my health,” he tells WebMD. “I don’t like to be told what to do.”