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C HAPTER 42 / Disease Management Models for Cardiovascular Care 927
much easier to administer in clinical practice settings but do not completed through time-analysis records, enable one to determine
provide measurements of changes that are offered through longer the need for program restructuring. This type of process evalua-
instruments. tion is helpful in determining whether nonclinical tasks could be
Although general quality-of-life questionnaires can be useful, allocated to other personnel so nurses are performing the most
disease-specific tools are more valuable in defining patient out- important clinical tasks. Process measures also enable one to de-
comes. For example, the Minnesota Living with Heart Failure termine the actual implementation of intervention activities, im-
tool, which measures multiple domains of quality of life in heart portant to outcomes.
failure patients and contains 21 items, correlates well with as-
sessments of dyspnea and fatigue, is important in this popula- Outcomes Management
tion. 115 Finally, others suggest that using both a general and a
disease-specific measure of quality of life may enhance results. Outcomes management includes using evaluation data to make
6
Smith et al. reported on the quality of life in 1,069 community- necessary changes in program implementation for continued
dwelling patients in south Texas who were randomly assigned to quality improvement. Although the goal of a disease management
disease management versus a control group. Health-related quality model may not be to lower the cost of care, specific outcomes such
of life was based on the MOS 36-item Short Form Health Survey as reducing the frequency of physician visits for those in a disease
(SF-36) 112,113 measured at 6-month intervals. Although there was management program may be an important outcome of a busy
a positive effect of the intervention on self-reported improvement health maintenance organization. Moreover, increased patient sat-
in quality of health at 6 and 12 months, this was not sustained. isfaction as a result of the program may enable payers to retain pa-
This is the largest study conducted to date that evaluated quality of tients in their delivery system, thus increasing competition among
life in heart failure patients; the authors concluded that lack of a health industry providers. Finally, looking for more efficient ways
disease-specific measure to serve as a comparison was regrettable to deliver the program to a larger number of patients is often a
not available. 6 goal for those actively involved in disease management efforts. Be-
Measuring functional status of patients, which may be signifi- cause groups like Kaiser Permanente of Northern California have
cantly impacted as a result of disease management programs, succeeded in offering disease management to large numbers of pa-
should also be considered in developing outcome measures for tients for more than a decade, they offer insights about achievable
disease management. The Duke Activity Status Instrument outcomes that are useful to those planning new programs and
(DASI) 116 is an example of a simple self-administered question- large system changes. 122
naire that correlates well with functional activities in heart failure
subjects. Other tools that measure symptoms and function in-
clude the Canadian Cardiovascular Society (CCS) Functional Program Marketing
Classification used for functional disability and angina 117 and the Whereas the clinical aspects of disease management are critical to
Seattle Angina Questionnaire. 118 success, continual marketing of the program to hospital adminis-
Measures of patient satisfaction can be an important market- trators, payers, physicians, and other health care professionals is
ing tool for disease management program. Most large organiza- important to sustaining a program. Important marketing activi-
tions are committed to measuring patient satisfaction as part of ties include (1) a plan for recruiting program participants using
quality assurance. 119 However, there are no prevalent, systematic, brochures, flyers, letters, and other announcements, which are
or validated approaches for measuring patient satisfaction within continually maintained; (2) updating administrators and decision
the disease management industry. One exception is a tool meas- makers about program implementation through quarterly, bian-
uring satisfaction in individuals participating in diabetes disease nual, or annual reports and presentations; and (3) ensuring that
management programs. Thus, a clear need to develop a stan- physicians and other health care professionals outside the disease
dardized approach to the assessment of patient satisfaction is management program are continually informed of program deliv-
needed. ery changes, successes, and program volume. Satisfied patients
Measuring overall program satisfaction and satisfaction with and family members are often willing to write letters to key deci-
individual key components of the program may be helpful not sion makers about the value of the program to their overall care.
only to administrators but also to enhancing program delivery. As
noted earlier, assessment of patient satisfaction has also been ini-
tiated as part of quality-assurance assessments. 111 Likewise, brief TRAINING AND JOB
physician satisfaction surveys may help program administrators in
monitoring and can lead to restructuring of aspects of a disease QUALIFICATIONS FOR
management program. Because these programs are designed to DISEASE MANAGEMENT
support the physician’s care, physician satisfaction surveys should
measure items such as help in improving self-management, a re- Managing a caseload of patients as part of disease management re-
duction in physician’s time for various aspects of care, and support quires sound clinical expertise and a number of other important
in achieving national guidelines for quality care such as those es- qualifications. Qualifications for those involved in these programs
tablished by the Joint Committee on the Accreditation of Health include strong physical assessment skills, interpersonal skills
Care Organizations (www.jcaho.org) or the National Committee (warmth, empathy, good listening and problem solving, and an
for Quality Assurance (NCQA). 120,121 ability to work with families and a multidisciplinary team), the
Finally, many process measures enable disease management ability to work independently, leadership capability (advocate for
personnel to better understand the important aspects of program patients and families, the disease manager’s role, and the pro-
delivery. Observing the frequency of face-to-face or telephone gram), and good organizational skills (ability to use information
contacts, length of contacts, and the type of daily tasks performed, systems and time-management skills). Knowledge of and skills in