Results Summary
What was the research about?
When older adults have more than one long-term, or chronic, health problem, their health care may be hard to manage. Case managers—nurses or social workers who help manage a patient’s care—may be able to help. If their care is managed well, patients may be able to stay healthy and avoid going to the emergency room, or ER, or hospital.
In this study, the research team wanted to find out if having help from case managers kept patients with chronic health problems from going to the ER or hospital. The team compared patients with and without case managers.
What were the results?
A year after patients started getting help from case managers, patients with and without case managers didn’t differ in the number of ER visits or days they stayed in the hospital.
Who was in the study?
The study included electronic health record data from 5,768 patients receiving care at two Medicare accountable care organizations, or ACOs. ACOs are groups of healthcare providers, such as doctors and hospitals, who work together to provide patient care. Of these patients, 88 percent were White, and 12 percent were other races. The average age was 71, and 57 percent were women. More than 90 percent of patients had three or more chronic health problems, like diabetes.
What did the research team do?
The research team linked electronic health records from the ACOs with Medicare claims from January 2011 through September 2015. The team identified records for patients who were enrolled in a case management program. In the program, a nurse or social worker managed patients’ care. They also called patients twice a month to check on their needs.
Based on patient traits in the records, such as type of health problem, the research team matched patients who were enrolled in the case management program with patients who weren’t. Then they compared the patients who were in the program with those who weren’t. The team looked at the number of ER visits and days patients spent in the hospital one year after they started the program.
Patients, health system administrators, and doctors provided input on the study design and analysis.
What were the limits of the study?
The research team only looked at data from patients for one year after starting the program. Results may differ if the team looked at data for longer than one year.
Future research could look at other ways to support patients with chronic health problems.
How can people use the results?
ACOs can use these results when considering ways to help patients with chronic health problems manage their care.
| How this project fits under PCORI’s Research Priorities The PCORnet® Study reported in this results summary was conducted using PCORnet®, the National Patient-Centered Clinical Research Network. PCORnet® is intended to improve the nation’s capacity to conduct health research, particularly comparative effectiveness research (CER), efficiently by creating a large, highly representative network for conducting clinical outcomes research. PCORnet® has been developed with funding from the Patient-Centered Outcomes Research Institute® (PCORI®). |
Professional Abstract
Objective
To compare the effectiveness of case management programs versus usual care on reducing the number of days spent in the hospital and visits to the emergency department (ED) for patients with chronic conditions receiving care at Medicare accountable care organizations (ACOs)
Study Design
| Design Element | Description |
|---|---|
| Design | Observational: cohort study |
| Population | Electronic health record data from 5,768 patients ages 18 and older with chronic conditions who were receiving care at 2 Medicare ACOs |
| Interventions/ Comparators |
|
| Outcomes | Number of ED visits and days spent in hospital |
| Timeframe | 1-year follow-up for study outcome |
This retrospective cohort study compared the effectiveness of patient participation in case management programs versus usual care on reducing the number of days spent in the hospital and the number of visits to the ED among patients receiving care at two different Medicare ACOs.
Researchers linked data from electronic health records from the PCORnet® Common Data Model data to Medicare claims from January 2011 through September 2015. After stratifying the data into two groups, researchers compared patients enrolled in an existing case management program with patients who received usual care.
In the case management program, a nurse or social worker coordinated patients’ care. They contacted patients twice a month. Providers used a risk stratification scoring system to identify patients who might need case management.
Researchers used propensity score matching to match each case management patient to one or two usual care patients based on patient characteristics such as healthcare utilization and chronic condition type. After matching, researchers examined the number of days patients spent in the hospital and the number of visits to the ED one year after their enrollment in the case management program.
The study included 5,768 patients receiving care at two different Medicare ACOs from the Midwest and Northeast. Of these patients, 88% were White, and 12% were other races. The average age was 71, 57% were female, and more than 90% of patients had three or more chronic conditions.
Patients, health system administrators, and physicians provided input on the study design and analysis.
Results
After a year, the number of days spent in the hospital and the number of ED visits did not differ significantly between patients in the case management program and patients receiving usual care.
Limitations
Researchers only followed study outcomes for one year after patients enrolled in the case management program. Results may have differed if researchers had followed patients for longer than one year.
Conclusions and Relevance
In this study, the case management program did not further reduce days spent in the hospital or ED visits among patients with multiple chronic conditions compared with usual care.
Future Research Needs
Future research could examine other ways to support patients with chronic conditions who are receiving Medicare benefits.
| How this project fits under PCORI’s Research Priorities The PCORnet® Study reported in this results summary was conducted using PCORnet®, the National Patient-Centered Clinical Research Network. PCORnet® is intended to improve the nation’s capacity to conduct health research, particularly comparative effectiveness research (CER), efficiently by creating a large, highly representative network for conducting clinical outcomes research. PCORnet® has been developed with funding from the Patient-Centered Outcomes Research Institute® (PCORI®). |
COVID-19-Related Study
Examining How Pandemic-Related Healthcare Changes Impact Older Adults with Multiple Chronic Conditions -- A PCORnet® Study
Results Summary
In response to the COVID-19 public health crisis in 2020, PCORI launched an initiative to enhance existing research projects so that they could offer findings related to COVID-19. The initiative funded this study and others.
What was this COVID-19 study about?
During the COVID-19 pandemic, health systems had to delay care and shift to telehealth. Telehealth is a way to provide care to patients remotely by phone or video. These healthcare changes may have made it hard for older adults to manage long-term health conditions.
In this study, the research team wanted to learn how the pandemic affected older patients’ healthcare use and health outcomes. The team compared primary care use before versus during the pandemic for patients with conditions that put them at high or low risk for hospital stays. They also looked at telehealth use during the pandemic for these patients.
The research team then looked at patients with diabetes or high blood pressure who had another long-term health condition. For these patients, the team looked at primary and specialty care use, health outcomes, and deaths unrelated to COVID-19. They also looked to see if having a case manager helped these patients. A case manager is a nurse or social worker who helps patients manage their care.
What were the results?
During the first six months of the pandemic, both patients at high and low risk received less primary care overall than they did the previous year. Telehealth use was 38 percent among patients at low risk and 65 percent for patients at high risk. Older patients were less likely to use telehealth.
During the first nine months of the pandemic, patients with diabetes or high blood pressure and another health condition had fewer in-person healthcare visits. They also had more deaths unrelated to COVID-19. Fewer patients had good control of their blood pressure.
Patients who had case managers had fewer unplanned hospital stays than patients who didn’t have case managers. Having a case manager didn’t change the:
- Number of primary care, specialty, or unplanned emergency room visits
- Amount of Medicare payments
- Number of deaths unrelated to COVID-19
What did the research team do?
The research team linked health records with Medicare claims from March 2018 through December 2020. The team used data from:
- 32,417 patients with high or low risk of hospital stays
- 27,006 patients with diabetes or high blood pressure and another long-term health condition
- 3,144 patients with more than one long-term health condition, half of whom had a case manager
All patients were age 65 or older and received care at a Midwest health system.
The research team divided each set of patients into two groups. For one group, the team looked at data during the pandemic and the year prior. For the other, they looked at data from the two years prior to the pandemic. The team compared changes in care and health outcomes between the two groups.
Health system leaders gave input on the study.
What were the limits of the study?
The study included data from one Midwest health system. Results may differ for other locations or health systems.
How can people use the results?
Health systems can use these results when planning for public health emergencies.
| How this project fits under PCORI’s Research Priorities The PCORnet® Study reported in this results summary was conducted using PCORnet®, the National Patient-Centered Clinical Research Network. PCORnet® is intended to improve the nation’s capacity to conduct health research, particularly comparative effectiveness research (CER), efficiently by creating a large, highly representative network for conducting clinical outcomes research. PCORnet® has been developed with funding from the Patient-Centered Outcomes Research Institute® (PCORI®). |
Professional Abstract
In response to the COVID-19 public health crisis in 2020, PCORI launched an initiative to enhance existing research projects so that they could offer findings related to COVID-19. The initiative funded this study and others.
Background
During the COVID-19 pandemic, health systems delayed elective care and shifted to telehealth, resulting in decreased healthcare utilization. These changes may adversely affect the health of patients with multiple chronic conditions (MCC), such as hypertension and diabetes. Case management may mitigate the effects of changes in healthcare delivery on health outcomes.
Objective
To examine the impact of COVID-19-related changes in primary care utilization for older patients (1) stratified by high versus low risk for hospitalizations and emergency department (ED) visits, (2) with hypertension or diabetes, and (3) with MCC and receiving case management
Study Design
| Design Element | Description |
|---|---|
| Design | Observational: cohort study |
| Population |
EHR data from patients age 65 or older with Medicare who were receiving care from an ACO:
|
| Outcomes |
High versus low risk: change in primary care visits (in person and telehealth), telehealth use Patients with hypertension or diabetes: number of unplanned hospitalizations and ED visits, number of days hospitalized, total Medicare payments, number of outpatient visits (primary care and specialty care), blood pressure control, non-COVID-19-related mortality; percentage of patients with two or more A1c tests (diabetes only), blood glucose control (diabetes only) Case management: number of unplanned hospitalizations and ED visits, number of days hospitalized, total Medicare payments, number of outpatient visits (primary care and specialty care), non-COVID-19-related mortality) |
| Data Collection Timeframe |
High versus low risk:
Patients with hypertension or diabetes, or case management:
|
This retrospective cohort study examined the pandemic’s impact on healthcare utilization in older adults with Medicare receiving care at an Accountable Care Organization (ACO). Researchers also examined health outcomes, payments, and mortality for patients with hypertension or diabetes and at least one other chronic condition and the effect of case management on these outcomes for patients with MCC.
First, researchers analyzed electronic health record (EHR) data from 32,417 patients, creating a baseline and follow-up data set for pandemic and comparison cohorts. Using Hierarchical Condition Category scores, researchers categorized patients in both cohorts as high or low risk. Researchers compared changes in primary care and telehealth use between the pandemic and comparison cohorts.
Next, researchers analyzed EHR data from 27,006 patients with hypertension or diabetes and at least one other chronic condition, and EHR data from 3,144 patients with MCC, half of whom received case management during the study period. Researchers compared non-COVID-19-related mortality and changes in healthcare outcomes and utilization between the pandemic and comparison cohorts.
Health system administrators provided input on the study.
Results
High versus low risk: During the six-month follow-up period, compared with the comparison cohort, patients at low risk in the pandemic cohort experienced a 27% decrease in overall primary care visits, and patients at high risk experienced a 23% decrease. In the pandemic cohort, telehealth use was 38% among patients at low risk and 65% among patients at high risk across the follow-up period. Older patients were less likely to use telehealth compared with younger patients.
Patients with hypertension or diabetes: During the nine-month follow-up period, compared with patients in the comparison cohort, patients in the pandemic cohort experienced:
- A decrease in healthcare utilization (p<0.05)
- An increase in non-COVID-19-related mortality (p<0.05)
Also, fewer patients in the pandemic cohort had good blood pressure control (p<0.05).
Case management: During the pandemic, unplanned hospitalizations declined for patients receiving case management (p=0.02) but not for patients not receiving case management. Primary care, specialty, and ED visits declined for all patients in the pandemic cohort compared with the comparison cohort, with no significant differences by receipt of case management.
Non-COVID-19-related mortality did not differ between patients receiving and not receiving case management.
Limitations
The study took place in a single large Midwest health system. Results may differ in other systems or areas.
Conclusions and Relevance
Older patients with MCC may benefit from case management during disruptions to health care.
| How this project fits under PCORI’s Research Priorities The PCORnet® Study reported in this results summary was conducted using PCORnet®, the National Patient-Centered Clinical Research Network. PCORnet® is intended to improve the nation’s capacity to conduct health research, particularly comparative effectiveness research (CER), efficiently by creating a large, highly representative network for conducting clinical outcomes research. PCORnet® has been developed with funding from the Patient-Centered Outcomes Research Institute® (PCORI®). |
Peer Review Summary
The Peer-Review Summary for this COVID-19 study will be posted here soon.
Final Enhancement Report
This COVID-19 study's final enhancement report is expected to be available by June 2023.
Final Research Report
View this project's final research report.
Journal Citations
Related Journal Citations
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- The reviewers asked for clarification on what patient sample the researchers used in developing their predictive model, since the researchers stated that the predictive model was developed in a separate methodology project. The researchers clarified that while they developed the predictive model in another PCORI-funded project, the data came from the same patient sample as the current project.
- The reviewers suggested that the researchers expand their discussion of the interaction between affordable care organizations and case management, asking whether there were aspects of the affordable care organizations that affected the quality of the care management services. The researchers responded that this study could not answer this question. In truth, they said that patients mostly wanted to find a key point person to help them navigate health services and did not really consider the relevance of the affordable care organization structure or of being part of a large health system.
- The reviewers suggested that the report’s conclusions overstated the importance of the social work case management intervention given the results of the project, which did not demonstrate significant differences between groups based on availability of the intervention. The researchers revised the conclusions to instead suggest that patients viewed social work as important for patient engagement in their health care. The researchers also noted in their response to reviewers that a finding of no difference was not the same as no value, since patients and providers viewed the case management intervention as being of high value.
- One reviewer questioned the threshold the researchers applied to patient characteristics they used to match case management participants to controls. In this study, the researchers allowed matching covariates to vary up to 25 percent between the case and the control, but the reviewer noted that a more common threshold was 10 percent variation between case and control. The researchers pointed out their sample size was not large enough for a 10 percent threshold to be possible. In addition, the researchers noted that even in randomized samples there are likely to be a few covariates that vary 25 percent or more. The researchers also noted that in their analyses, they accounted for potential confounding from covariates that varied to this level.