As a developing country with one fourth of the total world population, China is facing the problem of a large and rapidly increasing elderly population. The sixth population census in 2010 showed that the population aged 60 and over was 177,648,705 (13.26%), and that aged 65 and over, 118,831,709 (8.87%) . It is predicted that the elderly population over the age of 60 will increase from 144 million (11% in the total population) in 2005 up to over 437 million (30%) in 2051, with the number and accelerating speed of aging of the population in China ranking first on the globe. The average increase in the elderly population is 2-fold higher than in some Western developed countries . The Nanjing region, the location of this trial, is one of the most developed regions in China (total population of 8,004,680 and 60+ population of 1,248,730 or 15.6%, which is higher than the national average ). The rapid increase in the elderly population not only greatly influences the development of the social economy, but also poses significant challenges to health care in China. Health management has been looked upon as a way to deal with these challenges [4–6].
There have been a number of studies of health management. Since 1987, the US Union Pacific Railroad Company has provided health management services for their employees. Apart from a great improvement of health indices in the population, the economic benefit has been obvious, with a benefit-cost ratio of 3.24:1, i.e., there is a benefit of $3.24 for each dollar spent on health management. Health management helped the company save about 40 million dollars per year . Christian et al. indicated that the future development of health management programs has the potential to reduce the overall financial burden of global health care. The implementation of health promotion and education as key elements in health management may improve quality of life and patient satisfaction . Therefore, implementation of health management for the elderly has the potential for significant impacts on the application of health resources, including decreases in medical costs and improvements in the health of the elderly. Recently, Hunter et al. reviewed the research literature on health management in Europe from July 1995 to June 2005 in terms of quality, range and shortcomings of the research, and indicated that studies on health management in Europe were rare, those specially designed for the elderly were even less common, and their results were not consistent . However, with a randomized controlled intervention trial, Benabei et al. did demonstrate that integrated social and medical care with a case management program may provide a cost-effective approach to reduce admissions to institutions and to halt functional decline in the elderly living in the community . With the same type of trial, Harari investigated the effect of health risk factors evaluation, one of the steps in elderly health management. He has concluded that this step only slightly improved health behavior and prevention service acceptance in the elderly, and that more trials will be required to arrive at a definite conclusion .
In China, research on health management has been carried out [12, 13]. Adopting a random sampling method to select 120 elderly over the age of 60, Wang et al. compared health service demand and health knowledge before and after implementation of health management and showed that health management could improve the health and life quality of the elderly by raising health service utilization and health knowledge . Because of the small sample size of this study as well as a lack of randomized controlled trials for the health management of the elderly in China, the effectiveness of health management has been inconclusive so far.
The aim of this study was to evaluate the effects of community-based health management on the health of the elderly by using an RCT design. We focused on the following questions: 1) To what extent is health management effective in improving health-related indices? 2) What are the main factors affecting improvement of the health of elderly Chinese? We expected that health management might improve health-related indices in the subjective grading items, the objective measured indices, and health service utilization. We also hypothesized that community-based health management might reduce outpatient care visits and hospital admissions.