Primary Care Research

Case management of patients with chronic renal insufficiency did not improve outcomes over usual care

Case management of certain costly, chronic diseases has come into vogue in recent years. The approach focuses several types of experts and medical resources on the patient in order to cost-effectively manage the patient's condition and improve outcomes. However, a recent study shows that although case management represents state-of-the-art care, it did not improve the outcomes of patients with chronic renal insufficiency compared with usual care. Based on this finding, the researchers recommend that the case management approach, which is expensive, be tested prospectively before being widely introduced into practice. The study was supported in part by the Agency for Health Care Policy and Research (HS07632, HS07719, HS07763, and HS09083).

The researchers enrolled 437 primary care patients with chronic renal insufficiency who were being cared for in an urban academic general internal medicine practice. For 2 years, 231 patients received usual care, and 206 patients received intensive case management at an annual direct cost of $484 per patient. The goal of the program was to stabilize renal function and control costs. It included repeated consultations in a nephrology case management clinic staffed by two nephrologists, a renal nurse (who monitored medication compliance and taught self-help behaviors), a renal dietitian (who prescribed a low protein, low potassium diet), and a social worker (who identified and helped overcome barriers to receiving care). The clinic sent letters to the patients' primary care physicians (PCPs) about these interventions.

Although the patients had similar mild-to-moderate renal insufficiency originally, there were no differences in renal functioning, health services use, or deaths 5 years after study enrollment. Lack of improvement in the case management group may have been due in part to its reliance on action by the patient's PCP who had to review letters during typically short patient visits. On the other hand, the targeted level of renal insufficiency may have been too mild to expect a measurable difference in 5 years.

For more details, see "Effects of multidisciplinary case management in patients with chronic renal insufficiency," by Lisa E. Harris, M.D., Friedrich C. Luft, M.D., David W. Rudy, M.D., and others, in the December 1998 American Journal of Medicine 105, pp. 464-471.

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