- Research
- Open access
- Published:
The economic impact of a local, collaborative, stepped, and personalized care management for older people with chronic diseases: results from the randomized comparative effectiveness LoChro-trial
BMC Health Services Research volume 23, Article number: 1422 (2023)
Abstract
Background
Within the ageing population of Western societies, an increasing number of older people have multiple chronic conditions. Because multiple health problems require the involvement of several health professionals, multimorbid older people often face a fragmented health care system. To address these challenges, in a two-group parallel randomized controlled trial, a newly developed care management approach (LoChro-Care) was compared with usual care.
Methods
LoChro-Care consists of individualized care provided by chronic care managers with 7 to 16 contacts over 12 months. Patients aged 65 + with chronic conditions were recruited from inpatient and outpatient departments. Healthcare utilization costs are calculated by using an adapted version of the generic, self-reporting FIMA©-questionnaire with the application of standardized unit costs. Questionnaires were given at 3 time points (T0 baseline, T1 after 12 months, T2 after 18 months). The primary outcome was overall 3-month costs of healthcare utilization at T1 and T2. The data were analyzed using generalized linear models with log-link and gamma distribution and adjustment for age, sex, level of care as well as the 3-month costs of care at T0.
Results
Three hundred thirty patients were analyzed. The results showed no significant difference in the costs of healthcare utilization between participants who received LoChro-Care and those who received usual care, regardless of whether the costs were evaluated 12 (adjusted mean difference € 130.99, 95%CI €-1477.73 to €1739.71, p = 0.873) or 18 (adjusted mean difference €192.99, 95%CI €-1894.66 to €2280.65, p = 0.856) months after the start of the intervention.
Conclusion
This study revealed no differences in costs between older people receiving LoChro-Care or usual care. Before implementing the intervention, further studies with larger sample sizes are needed to provide robust evidence on the cost effects of LoChro-Care.
Trial registration
German Clinical Trials Register (DRKS): DRKS00013904, https://drks.de/search/de/trial/DRKS00013904; date of first registration 02/02/2018.
Introduction
Against the background that older people often have chronic, mostly multiple illnesses and these are accompanied by physical, mental, and functional limitations, a new local, collaborative, stepped, and personalized form of care, the LoChro-Care intervention, was developed and evaluated [1,2,3,4,5,6]. LoChro-Care was designed to improve patients’ self-management in coordinating their individual care network [1, 7]. For this purpose, trained chronic care managers (CCM) provided assistance to establish contact to formal and informal support (e.g., general practitioner, family, regional geriatric outpatient services). In detail, LoChro-Care comprised (a) a comprehensive assessment of the patients’ health constitution and context, (b) the creation of a tailored healthcare plan that aligns with the patient’s prioritized healthcare issues and preferences, (c) the implementation, monitoring, and modification of the plan, and (d) a closing session [1, 7]. In the case of mild depression, diabetes, or the absence of a primary caregiver, extra interventional components were applied (problem solving therapy, skill training, trained volunteers). At least the first three contacts took place in the home environment, whereas the subsequent sessions could also be conducted by telephone. The intervention lasted 12 month, with 7–16 contacts with the CCM. As a result, patients’ health-related outcomes were expected to be improved or at least worsening progression delayed. Therefore, LoChro-Care was evaluated in terms of patients’ physical, psychological, and social health status (as indicated by functional health and depression), as well as their perceived heath care situation, health-related quality of life, life-satisfaction [7], and medication appropriateness.
The objective of the present study is to outline the effectiveness of LoChro-Care regarding the secondary endpoint of health resource utilization. Specifically, we hypothesized that LoChro-Care would lead to a more appropriate utilization of health and nursing care services in terms of decreased emergency hospitalizations, reduced non-elective hospital days and nursing home admissions, more adequate use of informal and formal community services, as well as enhanced disease self-management abilities that contribute to save health care costs [1].
Methods
A two-group, parallel randomized controlled trial was conducted. Patients aged 65 + with one or multiple chronic conditions or geriatric symptoms (e.g., diabetes, hypertension, ischemic heart disease, atrial fibrillation) were recruited by research associates at inpatient and outpatient departments of the Medical Centre, University of Freiburg, Germany, between January 2018 and March 2020 [7]. Eligible patients were asked to participate in a short screening (“Identification of Seniors at Risk” questionnaire [8] to assess their risk of unplanned readmission and need for nursing care. Inclusion criteria required at least 2 positive responses out of 6 risk domains. Patients with terminal medical conditions and insufficient German language skills were excluded. Healthcare utilization costs are calculated by using an adapted version of the generic, self-reporting FIMA©- questionnaire [9,10,11,12] in combination with the application of standardized unit costs [13, 14]. Questionnaires were given at 3 time points (T0 baseline, T1 after 12 months, T2 after 18 months). Overall, utilization of 10 cost indicators (General practitioner, Specialist, Day hospital, Hospitalization days [normal ward and intensive care days], Inpatient rehabilitation, Ambulatory nursing, Inpatient nursing, Remendies, Auxiliary means) were measured and total healthcare utilization costs were calculated for a 3-month period prior to T0, T1 and T2. All costs are expressed in 2021 values and represent the perspective of the healthcare system.
Utilization of the different cost indicators at T1 and T2 was analyzed using negative binomial regression models with adjustment for age, sex and level of care (at baseline) as well as the utilization of the respective indicator at T0 [15]. In Germany, there are different levels of care, which also depends on the amount of financial support a patient receives from the statutory long term care insurance. To determine the level of care, an assessment is carried out, which evaluates the individual’s ability to perform everyday activities and the level of support required. As a higher level of care translates into more financial support from the compulsory long-term care insurance, the level of care may change frequently over time when the degree of care dependency increases.
In addition, joint analysis of T1 and T2 utilizations are applied using confounder adjusted negative binomial regression models with the patients ID as a random intercept to account for multiple records on the patient level. The results are shown as adjusted incidence rate ratios.
The overall 3-month costs of care at T1 and T2 are analyzed using generalized linear models with log-link and gamma distribution [16, 17]. Again, adjustment for age, sex, the level of care at 3-month costs prior to T0 took place. Joint analysis of 3-month costs at T1 and T2 were conducted using a population –averaged panel data model (with log-link and gamma distribution) to account for multiple records on the patient level. In a last step, the impact of baseline characteristics on overall 3-month costs of care were analyzed across all three periods (T0, T1 and T2). Furthermore, a population–averaged panel data model (with log-link and gamma distribution) was used to account for multiple records on the patient level. Included confounders were group, age sex and level of care. All analyses were performed using Stata 17 (Stata Corp., Texas, USA).
Results
Three hundred thirty patients were eligible for the final investigation, which were well balanced between the groups (163 patients from the intervention group and 167 patients from the control group). Out of the 167 control group patients, 40.12% were males while in the intervention group, 46.01% were males. The mean age of the participants was 77.36 ± 6.60 and 76.19 ± 6.12 in the control group and intervention group, respectively. As shown in Table 1, most of the patients (78.44% and 76.07% in the control group and intervention group, respectively) were not eligible for long-term care benefits from the statutory long-term care insurance (level of care 0). With respect to the other levels of care, percentages are balanced between the groups.
When comparing the various cost indicators, no significant difference was found between the two groups. The total costs of health care utilization were at comparable levels in T1 (intervention group: M = 6656.79€, SD = 10709.03€; control group: M = 6178.09€, SD = 10595.24€) and T2 (intervention group: M = 6809.13€, SD = 9907.18€; control group: M = 6221.26€, SD = 9616.46€). The same is true for the 10 cost indicators that were collected for 3-month periods prior to T0, T1 and T2 (see Table 2).
Accordingly, no significant effect of group membership at T1 (adjusted mean difference € 130.99, 95%CI €-1477.73 to €1739.71, p = 0.873), T2 (adjusted mean difference €192.99, 95%CI €-1894.66 to €2280.65, p = 0.856) or over both measurement points together (adjusted mean difference €91.87, 95%CI €-1458.03 to €1641.77, p = 0.908) could be shown by regression analysis.
When analyzing different cost indicators at T1 and T2, negative binomial regression models were performed. Figure 1 shows the corresponding incidence rate ratios when analyzing over both measurement points (T1 and T2). All cost indicators were statistically insignificant (p-values > 0.05). Similar results occur when analyzing T1 and T2 separately (see supplemental material, Figure S1 and S2). In summary, no statistically significant difference between the intervention group and the control group could be found in any of the endpoints.
The analysis of potential confounders showed that group (Intervention vs. control group, p = 0.600), age (p = 0.499) and sex (p = 0.506) did not impact 3-month costs of care. The level of care, however, had a major impact on the 3-month costs of care. As shown in Fig. 2, a patient at care level 0 (N = 255) was associated €5509.64 costs of care (95%CI €4906.66 to €6112.61) while a patient at care level 2 (N = 37) was associated €11147.50 costs of care (95%CI €9098.35 to €13196.64).
Discussion
The economic evaluation of our new local, collaborative, stepped, and personalized LoChro care management program showed no significant difference in health care costs between participants who received the LoChro-Care and those who received usual care, regardless of whether health care costs were measured 12 or 18 months after the start of the intervention. Thus, we did not find evidence to support our hypothesis that LoChro-Care would be associated with savings in health care costs. This result suggests that the overall extent of health care utilization progressed similarly between the two groups, regardless of the type of intervention they received.
In addition, our hypothesis - that LoChro-Care leads to more appropriate use of health and care services - was not supported. For the ten different cost indicators measured 12 and 18 months after the start of the intervention, we found no group differences. This means that participants who received LoChro-Care were not associated with the expected reduction in emergency hospital admissions, reduction in non-elective hospital days and nursing home admissions, more appropriate use of informal and formal community services, and improved ability to self-manage their condition, compared to participants who received usual care.
Our analysis however showed that 3-month health care costs of LoChro-Care are highly correlated with the patients’ formal level of care. In Germany, a structured assessment of care needs, e.g. for activities of daily living, mobility or personal hygiene, is used to determine the level of care and thus the amount of financial support a patient receives from the statutory long term care insurance. This financial support was not included in the healthcare utilization costs assessed in this study because it is provided by the German long term care insurance rather than the health care insurance, on which our analysis focused. In addition, because reducing the need for nursing care is a lengthy process, we hypothesized that LoChro-Care would offer potential for short-term health care cost savings rather than impacting long-term costs.
Direct comparison of the results with other studies offers a number of challenges. First, inclusion in the study occurred during a hospital contact. Secondly, inclusion in the study was based on a pre-assessment regarding the participants’ risk of unplanned readmission and need for nursing care. Nevertheless, the result of the LoChro study is in line with previous studies analyzing the costs of care among older patients in the outpatient sector [14, 18,19,20,21,22,23]. From the point of view of the intervention, Kari’s study appears to be the most suitable for direct comparison with the present results. Unfortunately, the site of inclusion differs substantially between the studies: in Kari’s study, patients were invited to participate by letter and irrespective of a hospital contact, whereas in the present study, patients were approached during a hospital contact combined with a pre-assessment of the severity of underlying conditions. Without going into detail about the intervention, Kari’s people-centered care model is quite comparable to the LoChro intervention. The same applies to the results regarding the impact of the intervention on the cost of care. Neither in the first year of the study (p = 0.31) nor in the second year (p = 0.76), nor over both years together (p = 0.42) a difference between intervention and control group could be shown in the study by Kari et al. [18]. A look at the individual components of the costs analysed by Kari and colleagues also showed no trend towards a more appropriate use of health and care services (less emergency admissions, hospital stays) between intervention and control group [18]. In contrast, intervention programs for multimorbid older people, which were found to be cost effective, were characterized by an earlier start in the development of chronic multimorbidity (e.g. with preventive home visits) [24], or comprised not only support for self-management but also active therapeutic measures such as home safety modifications [25, 26], or mobility training [27]. LoChro care adaptions in this direction might be reasonable, followed by a re-evaluation of the adapted program.
Limitations
Taking into account that LoChro-Care was a novel intervention being implemented for the first time, some limitations should be mentioned. First, the self-reporting nature of the questionnaires may have resulted in recall biases, especially in face of our target sample of older people.
A substantial limitation regarding the external validity could be the regional specificity of the study. The conduct of the study was limited to the area of Freiburg and the surrounding area. The implementation of the intervention and the study results may have been influenced by specific characteristics of this area, such as relatively high socioeconomic performance. Moreover, we excluded patients with terminal illnesses and insufficient knowledge of German.
Although the sample size could be considered considerable in the context of geriatric research, it was relatively small in terms of a cost-effectiveness analysis. Given the enormous standard deviation in total costs (see Table 2 for details), a multiple of the current sample size would have been necessary to show even a moderately large difference in cost values. Moreover, we have limited ourselves to a simple cost-cost comparison from the perspective of the health care system. The background to this is the ineffectiveness of the LoChro trial regarding the endpoints of physical, psychological, and social health status as well as health-related quality of life and life satisfaction [7], as well as the lack of difference in service utilization between the groups. For the same reasons, the costs of the intervention were not calculated. However, even though this study has shown negative findings, the “Absence of evidence is not evidence of absence” [28].
Conclusion
This study revealed no differences in costs between older people receiving our new local, collaborative, stepped, and personalized LoChro-Care management program or usual care. Keeping in mind the relatively small sample size per economic standards, there is currently no economic incentive for a wider implementation of the intervention. Further studies with larger sample sizes are needed to provide robust evidence of cost savings or cost neutrality of LoChro-Care.
Data Availability
The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.
References
Frank F, Bjerregaard F, Bengel J, et al. Local, collaborative, stepped and personalised care management for older people with chronic diseases (LoChro): study protocol of a randomised comparative effectiveness trial. BMC Geriatr. 2019;19:1–11.
Shepperd S, Lannin NA, Clemson LM et al. Discharge planning from hospital to home. Cochrane Database Syst Rev. 2013.
O’Sullivan R, Inouye SK, Meagher D. Delirium and depression: inter-relationship and clinical overlap in elderly people. Lancet Psychiatry. 2014;1:303–11.
Gale CR, Cooper C, Aihie Sayer A. Prevalence of frailty and disability: findings from the english longitudinal study of Ageing. Age Ageing. 2014;44:162–5.
Petrak F, Baumeister H, Skinner TC, et al. Depression and Diabetes: treatment and health-care delivery. Lancet Diabetes Endocrinol. 2015;3:472–85.
Ward BW, Schiller JS, Goodman RA. Peer reviewed: multiple chronic conditions among us adults: a 2012 update. Prev Chronic Dis. 2014;11.
Metzner G, Horstmeier LM, Bengel J, et al. Local, collaborative, stepped, and personalized care management for older people with chronic Diseases–results from the randomized controlled LoChro-trial. BMC Geriatr. 2023;23:1–13.
Singler K, Heppner HJ, Skutetzky A, et al. Predictive validity of the identification of seniors at risk screening tool in a German emergency department setting. Gerontology. 2014;60:413–9.
Seidl H, Bowles D, Bock JO, et al. FIMA–questionnaire for health-related resource use in an elderly population: development and pilot study. Gesundheitswesen Bundesverb Arzte Offentlichen Gesundheitsdienstes Ger. 2014;77:46–52.
Zülke A, Luck T, Pabst A, et al. AgeWell. De–study protocol of a pragmatic multi-center cluster-randomized controlled prevention trial against cognitive decline in older primary care patients. BMC Geriatr. 2019;19:1–14.
Steinbeisser K, Schwarzkopf L, Graessel E, et al. Cost-effectiveness of a non-pharmacological treatment vs.care as usual in day care centers for community-dwelling older people with cognitive impairment: results from the German randomized controlled DeTaMAKS-trial. Eur J Health Econ. 2020;21:825–44.
Kienle GS, Werthmann PG, Grotejohann B, et al. A multi-centre, parallel-group, randomised controlled trial to assess the efficacy and safety of eurythmy therapy and tai chi in comparison with standard care in chronically ill elderly patients with increased risk of falling (ENTAiER): a trial protocol. BMC Geriatr. 2020;20:1–12.
Bock J-O, Brettschneider C, Seidl H, et al. Ermittlung Standardisierter Bewertungssätze aus gesellschaftlicher perspektive für die gesundheitsökonomische evaluation. Gesundheitswesen. 2015;77:53–61.
Kaier K, von Kampen F, Baumbach H, et al. Two-year post-discharge costs of care among patients treated with transcatheter or surgical aortic valve replacement in Germany. BMC Health Serv Res. 2017;17. https://doi.org/10.1186/s12913-017-2432-8.
Stroupe KT, Smith B, Weaver FM, et al. Healthcare utilization and costs for patients with Parkinson’s Disease after deep brain stimulation. Mov Disord Clin Pract. 2019;6:369–78.
Barber J, Thompson S. Multiple regression of cost data: use of generalised linear models. J Health Serv Res Policy. 2004;9:197–204.
Moran JL, Peisach AR, Solomon PJ, et al. Cost calculation and prediction in adult intensive care: a ground-up utilization study. Anaesth Intensive Care. 2004;32:787–97.
Kari H, Äijö-Jensen N, Kortejärvi H, et al. Effectiveness and cost-effectiveness of a people-centred care model for community-living older people versus usual care a randomised controlled trial. Res Soc Adm Pharm. 2022;18:3004–12.
Kast K, Wachter C-P, Schöffski O, et al. Economic evidence with respect to cost-effectiveness of the transitional care model among geriatric patients discharged from hospital to home: a systematic review. Eur J Health Econ. 2021;22:961–75.
König H-H, Lehnert T, Brenner H, et al. Health service use and costs associated with excess weight in older adults in Germany. Age Ageing. 2015;44:616–23.
McBride D, Mattenklotz AM, Willich SN, et al. The costs of care in atrial fibrillation and the effect of treatment modalities in Germany. Value Health. 2009;12:293–301.
Heider D, Matschinger H, Müller H, et al. Health care costs in the elderly in Germany: an analysis applying Andersen’s behavioral model of health care utilization. BMC Health Serv Res. 2014;14:1–12.
Reese JP, Heßmann P, Seeberg G, et al. Cost and care of patients with Alzheimer’s Disease: clinical predictors in German health care settings. J Alzheimers Dis. 2011;27:723–36.
Liimatta H, Lampela P, Laitinen-Parkkonen P, et al. Effects of preventive home visits on older people’s use and costs of health care services: a systematic review. Eur Geriatr Med. 2016;7:571–80.
Szanton SL, Leff B, Li Q, et al. CAPABLE program improves disability in multiple randomized trials. J Am Geriatr Soc. 2021;69:3631–40.
Jutkowitz E, Gitlin LN, Pizzi LT et al. Cost effectiveness of a home-based intervention that helps functionally vulnerable older adults age in place at home. J Aging Res. 2012;2012.
Fairhall N, Kurrle SE, Sherrington C, et al. Effectiveness of a multifactorial intervention on preventing development of frailty in pre-frail older people: study protocol for a randomised controlled trial. BMJ Open. 2015;5:e007091.
Altman DG, Bland JM. Absence of evidence is not evidence of absence. BMJ. 1995;311:485.
Acknowledgements
The article processing charge in BMC Heath Services Research was funded by the German Research Foundation (DFG) and the Albert Ludwig University of Freiburg in the funding program Open Access Publishing.
Funding
This study is supported by the German Federal Ministry of Education and Research (BMBF) (grant number 01GL1703). The funding body has had no role in the design of the study or collection, analysis, or interpretation of data or in writing the manuscript.
Open Access funding enabled and organized by Projekt DEAL.
Author information
Authors and Affiliations
Contributions
Study concept and design: KK, SVR, EFG. KK, GM and JK were responsible for the conception of the assessment instruments. JK conducted the data collection, GM was responsible for the data management. Statistical analysis: KK. Drafting of the manuscript: KK and GM. Revision of the manuscript: JK, BH, LH, SVR, EFG, EMB. All authors contributed to interpretation of the data, read and approved the final version of the manuscript.
Corresponding author
Ethics declarations
Ethics approval and consent to participate
Approval for the study was received from the institutional review board at the Medical Faculty of the University of Freiburg, Germany (no. 495 − 17, date: 19th of December 2017). Written informed consent was obtained from the patients or their legal representatives before enrolment. All experiments were performed in accordance with relevant guidelines and regulations (such as the Declaration of Helsinki).
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Supplementary Material 1: Figure 1:
Analysis of cost indicators at T1. Figure 2: Analysis of cost indicators at T2
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
About this article
Cite this article
Kaier, K., Metzner, G., Horstmeier, L. et al. The economic impact of a local, collaborative, stepped, and personalized care management for older people with chronic diseases: results from the randomized comparative effectiveness LoChro-trial. BMC Health Serv Res 23, 1422 (2023). https://doi.org/10.1186/s12913-023-10401-1
Received:
Accepted:
Published:
DOI: https://doi.org/10.1186/s12913-023-10401-1