| This dissertation investigates the efficacy of a disease management (DM) program on patient outcomes. The DM program was designed to address administrative, clinician-specific, economic and community oriented barriers to the implementation of the Canadian Cardiovascular Society's Guidelines for myocardial infarction patients. It begins with a discussion of the systematic process that was used to develop the components of the DM program for patients with chronic heart disease. The four components were: a pathway, referral criteria for specialty care management, communication systems and patient education. Methods used to implement the DM program in the context of a prospective randomized controlled trial are then described. A process evaluation confirmed that the DM program was implemented as planned. Prospectively, we agreed that the primary outcome measure would be readmission days per follow-up days for angina, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) and that secondary measures would include all-cause readmission days per follow-up days, emergency room visits, and OHIP billings for physician visits, diagnostic and therapeutic services and laboratory services. Readmission days for angina, CHF and COPD per follow-up days were significantly lower for DM program patients than usual care patients (Incidence Density Ratio = 1.29; 95% confidence interval 1.02--1.64, z = 2.1, p = 0.04). The usual care patients were significantly more likely than the DM patients to have more than one readmission for angina, CHF or COPD (12.0% versus 1.3%, p = 0.05). All-cause readmission days per follow-up days were significantly higher for patients in the usual care group than for patients in the DM group (Incidence Density Ratio = 1.53, 95% confidence interval 1.37--1.71; z = 7.4; p = 0.0001). The difference in ER encounters per follow-up days was significant (Incidence Density Ratio = 2.08, z = 5.0, p = 0.0001). During the first 225 days after discharge, there were significantly fewer OHIP claims submitted for DM patients than usual care patients for diagnostic and therapeutic services (z = -2.5, p < 0.01); emergency room visits (z = -2.7, p < 0.007), and laboratory services (z = -2.7, p < 0.003). The results of this trial provide strong evidence that a DM program, appropriately developed and implemented, has a positive impact on patient outcomes. |
