Case management program for multimorbidity in old age: evaluation of cost-effectiveness

Individual lifestyles, living conditions, coping potential, adequate medical and social care, prevention and rehabilitation influence both the state of health, quality of life and well-being in old age as well as the costs incurred in the medical and nursing sectors. Geriatric patients have a higher risk of hospitalization and usually suffer not only from a chronic illness, but from other (co-)morbidities. Cross-indication, preventative geriatric case management is a promising approach to improving the quality of life and self-management skills of those affected and at the same time reducing hospital expenses.

>> Especially in the hospital sector, as the sector that causes the highest costs in the health system, people over 65 are mainly responsible for the serious increase in inpatient costs. This is caused specifically by diseases of the circulatory, digestive and musculoskeletal systems as well as psychological and behavioral disorders; more than half of the medical costs incurred can be attributed to them (Federal Statistical Office 2010). The adequate treatment of several diseases occurring at the same time often involves polypharmacotherapy. However, this and the lack of medication compliance in older people can in many cases lead to undesirable interactions and side effects, which in turn result in avoidable hospital stays (Howard et al. 2006: 136-147; Berthold/Steinhagen-Thiessen 2009: 1415 ff.).
Falls are also a serious health problem for older people. About a third of people over 65 and living at home fall at least once a year. Approximately one in five falls requires medical treatment, and one in ten results in a fracture. The most important factors for the high risk of falls in older groups of people are cognitive and mobility limitations. Fall events known from the past and their consequences increase the fear of falling and thus the risk of falling (Fillibeck et al. 2005: 44 ff.). So the following year, 60-70 % of those who fell fall again. It has been scientifically proven that preventive home visits by nursing staff can make a positive contribution to reducing avoidable hospital stays and improving quality of life. However, prevention in old age still does not receive much attention in the German healthcare system and is not a regular part of routine care (Zeitler/Gulich 2004: 9, 28; von dem Knesebeck et al: 168).
Frailty and a lack of knowledge about how to deal with multiple chronic illnesses occurring at the same time often lead to a lack of independence in the home and social environment in older people. In order to prevent unwanted escalations of crisis situations, outpatient stabilization should be carried out in a timely manner so that resulting unnecessary hospital admissions can be avoided. Preserving or strengthening everyday skills and delaying the need for care can be effectively supported through preventive measures and age-specific health promotion. Existing comprehensive supply systems
However, offers have so far mainly only been designed for one underlying illness, although the individual secondary and secondary illnesses have a negative influence on each other in their progression. Therefore, the focus of treatment should preferably be on a cross-indication basis (SVR 2009: 251 f., 373), because the increasing geriatricization and age-related multimorbidity of the population will only increase in the next few years.
Casaplus® - Systematic case management for geriatric multimorbid patients in their home environment
In order to meet the described demographic development and the increasing care needs of the numerous chronically ill, multimorbid patients, MedicalContact AG has developed the case management program Casaplus®. This aims to offer comprehensive, low-threshold and at the same time high-quality care for patients aged 55 and over, because this group represents more than half of the patients admitted to hospital (Robert Koch Institute 2006: 161). A prediction model developed specifically for this purpose prospectively and precisely identifies patients based on routine data who are most likely to be hospitalized in the next twelve months (Fleckenstein/Heinzen 2007: 36 f.).
The program is a telephone consultation with the aim of avoiding avoidable inpatient stays by promoting individual everyday skills and self-management. This contributes to greater safety in dealing with the disease on a daily basis. A preventive home visit by the case manager complements telephone contact and is intended, in particular, to reduce the high risk of falls among the participants by providing adequate recommendations for action and preventative measures. If critical drug combinations are identified, the participant will be offered additional drug advice from pharmaceutical specialists in order to prevent or counteract undesirable side effects and interactions.
Casaplus® takes a holistic approach. The patient is not given disease-focused advice, but advice independent of the indication. Accordingly, after a written declaration of consent has been received, the individual exposure to age-typical risks is first clarified with the help of a geriatric initial assessment. For example, if there are risks associated with gastrointestinal or cardiovascular diseases, the patient is enrolled in the Casaplus® program and receives risk training tailored to their needs. The subsequent consultation is carried out closely by specially trained and experienced case managers. Each participant is assigned a permanent advisor in order to promote the development of a sustainable relationship of trust. As part of the telephone consultation, the participant is regularly trained in dealing with symptoms and in the early detection of crises, his self-management potential is activated and health-promoting behavior is trained. The participant receives written information materials on the topics discussed in order to deepen their knowledge in the long term.
A central component of Casaplus® is the preventive home visit, which is offered in the initial assessment to participants at risk of falling and potentially malnourished. A home visit by qualified nursing staff is intended to support older people in their home environment. The case managers get an idea of the living situation and social environment of the participants, carry out risk awareness training and give tips suitable for everyday use. Identifying characteristics and risks associated with falls, such as tripping hazards and how to eliminate them, is part of the three-quarter-hour home visit. The advisors also point out simple age-appropriate preventive measures. In particular, fall prevention measures such as installing handrails in the bathroom, adjusting the lighting at night, wearing sturdy shoes, etc. (Bergert et al. 2008: 30; Steinhagen-Thiessen et al. 2003: 366 ff.) offer great potential. to avoid unnecessary hospitalizations and thus counteract the increase in health insurance costs.
Results of the satisfaction survey
More than 8,000 insured people are now enrolled in the Casaplus® geriatric case management program. The average age of the participants is 75 years, the proportion of men is 54 %. As part of program-related quality assurance and further development, the second anonymous, standardized survey of participant satisfaction with this care offer was carried out in July 2010. 2,000 questionnaires were sent to randomly selected participants, of which 880 questionnaires (44 %) were returned and evaluated. Overall satisfaction with the Casaplus® program was 95.7 %. More than 90 % respondents felt that Casaplus® confirmed their choice of health insurance provider or that they were well looked after by their health insurance company. For the majority of those surveyed, there have been positive changes since participating: almost two thirds said that they felt safer at home since enrolling in the program. According to their information, 56.2 % have taken medication more regularly since participating in the program. The ability to communicate problems more specifically to the doctor, as well as the use of aids and the recognition of age-typical dangers have also improved for many of those surveyed (Fig. 1).
The willingness to remain in the program can also be viewed as an indicator of satisfaction with an offer. While only 0.5 % could not imagine this under any circumstances, 95.1 % of all respondents wanted to continue taking advantage of the consultations in the future (65.9 % definitely, 29.2 % rather yes).
Evaluation methodology: intention-to-treat approach
To determine the economic effects, a comparison is made between the hospital costs of the Casaplus® participants and the expected hospital costs that would have arisen if no case management had been carried out. The expected hospital costs for Casaplus® participants are determined based on the actual costs of a control group drawn at random. The acquisition of program participants and the control group takes place in the following steps: The overall group of insured persons who were identified by the forecast model as having a high risk of hospitalization is adjusted for insured persons who meet one of the following exclusion criteria:
• Died in the meantime
• In the meantime no longer insured by the health insurance company
• Insured persons who receive nursing care insurance benefits in accordance with care level 3 or who live in a nursing home
• Insured persons who live in a region where the Casaplus® program cannot be implemented (usually because there is no regional nursing service contractually linked to MedicalContact AG)
The remaining people are the “eligible insured persons” for the Casaplus® program, from whom a control group of approx. 10 % is drawn using a random drawing (random number generator), which does not receive any further intervention from the program. A telephone screening is carried out with the remaining insured persons (“intervention group”) to determine whether the insured persons are suitable for the program and willing to participate. The actual “Casaplus® participants” are recruited from the population of the intervention group after the following insured persons (“non-participants”) have left:
• a. Insured persons who cannot be reached by telephone after multiple attempts (no screening possible)
• b. Insured persons who refuse to provide information about their health/risk status during the telephone screening, so that an assessment of suitability for the program is not possible
• c. Insured persons who do not give their consent to participate in case management
• d. Insured persons whose screening results do not confirm the statistically predicted risk of hospitalization.

The program effects are evaluated using the “intention-to-treat approach” (Altman 1991: 464), meaning a comparison of the control and intervention groups is carried out. The “intervention group” includes not only the actual program participants, but also all insured persons who, for the reasons mentioned (a. to d.), did not become actual participants or who terminated the program prematurely. Only insured persons in the control or intervention group who died during the analysis period are excluded from the analysis. This is done to avoid distortions caused by the often extreme costs of inpatient care immediately before death. This study design can ensure that the control group is so similar to the intervention group in terms of morbidity, utilization, treatment costs, regional distribution and other possible confounding variables that the observed program effects can be causally traced back to the Casaplus® interventions.
The analysis includes all insured persons who were assigned to eligible insured persons between May 1, 2008 and April 30, 2009 and randomized in the manner described. For these insured persons, the subsequent benefit period from May 1, 2009 to April 30, 2010 (12 months) was evaluated. A total of N=7,466 insured people are available for the investigations, consisting of N=6,696 people in the intervention group and N=770 insured people in the control group. The composition of the two groups is shown in Table 1.
Since the Casaplus® program primarily aims to prevent avoidable hospital admissions, the “hospital utilization” parameter is the actually relevant effect size. The Casaplus® program does not directly influence the level of expenditure for those who use hospital care. In addition, differences in the number of hospital cases and the amount of expenditure between the intervention and control groups and the respective subgroups of insured persons with hospital use are analyzed.
The results on hospital costs can be strongly influenced by very few or even individual extreme cost cases and the comparison between the study and control groups can therefore be distorted. The comparative analyzes are therefore carried out after a one-sided winsorization of the hospital expenditure data was carried out (Shete et al. 2004: 153 ff.). After an exploratory analysis of the data, those values that exceed the 95 % quantile were replaced by these (intervention insured persons: 13,584 euros in expenditure per annum; control group 14,722 euros in expenditure per annum). This method eliminated extreme cost outliers in both the control and intervention groups while maintaining the sample size.
Evaluation results: avoidable hospital stays and hospital expenditure decrease
In the evaluation period from May 1, 2009 to April 30, 2010, a total of 3,826 insured people in the intervention group had no hospital stay and therefore no inpatient service expenditure, which corresponds to a proportion of 57.1 %. In the control group, this proportion was 3.6 percentage points lower than this at 53.5 %. All partial results are compared in Table 2. (Tab 2)
The higher proportion of non-use of inpatient services among those with intervention insurance is an indication of a positive program effect and can be interpreted as avoiding hospital cases through participation in the Casaplus® program. Using the statistical software SPSS 12.0, the odds ratio, ie the factor by which the “chance” of a hospital stay differs between the intervention group and the control group, was calculated using logistic regression and tested for significance. The determined value is 0.863. With this effect size, the conventional significance level of a maximum error probability of 5 % is only just missed with a 5.4 % error probability. When evaluating this finding and also the other results shown in Table 3, the following must be taken into account: Due to the study design described, the intervention group also includes insured people who do not actually take part in the program. Specifically, the proportion of actual participants in the intervention group was only 19 %. However, the effect is measured and tested at the level of the entire intervention group. Against this background, it is noteworthy that the 5% significance level is almost reached.
In Figure 2, the focus is on the insured persons who used inpatient services in the reporting year. The insured shares are shown according to expenditure classes. It can be seen here that in the control group the proportion of insured people in the lower spending classes predominates. It is clear that the program prevents hospital cases, particularly in this area. The hospital cases that result in higher costs are probably more likely due to serious illnesses for which hospitalizations could not be avoided through care in the program.
On average, the insured people in the intervention group had hospital expenses of 2,333 euros over the one-year study period; in the control group, these expenses were higher and amounted to an average of 2,580 euros. The hospital expenditure of all insured people who had a hospital stay at all was also higher in the control group than in the intervention group. The average number of hospital cases within the period examined was lower in the intervention group than in the control group. Table 3 shows the average hospital expenditures with the associated 95 % confidence ranges in brackets (Table 3)
Lower expenses through
positive program effect
The contract design between MedicalContact AG and the participating health insurance companies regarding the Casaplus® case management provides, among other things, a profit share in the annual average hospital savings. Therefore, in addition to the results presented here, it is of interest to MedicalContact AG how large the effect of the Casaplus® case management is in relation to the actual program participants. Of all the insured people in the intervention group, a total of 19 % actually took part in Casaplus® case management. In order to carry out this comparison, the obvious study design would be a randomization of the insured based on all insured persons willing to participate in Casaplus® case management. However, this would mean that insured people who have already indicated their willingness to participate would be excluded from the program. Such an approach would be difficult to implement in practice.
In order to be able to model the size of the program effect in relation to the actual program participants in the study design used here and presented above and not have to resort to methodologically problematic before-and-after comparisons (Lange 2006: 272), it is assumed that the control group similar to the group of those with intervention insurance in terms of theoretical willingness to participate in the program. On the one hand, it is assumed that if the control group had been contacted in the same way as the intervention group, 19 % of all insured persons would have taken part in the program and, further, that the remaining 81 % would have had the same use of inpatient services as the non-participants in the intervention group . From the results on hospital expenditure in the intervention and control groups and the observed results on the subpopulation of program participants, it is possible to draw conclusions about the expected hospital expenditure of the subpopulation of “expected” program participants in the control group (Table 4).
As a result, this comparison shows that hospital costs for the insured persons cared for in the Casaplus® program are 108 euros lower per month than expected. <<