Development and Evaluation of Disease Management Program and Service Framework for Patients with Chronic Disease

Abstract

We developed a disease management program and service framework to enhance the self-management skills of patients with chronic diseases for the first time in Japan. In this study, we analyzed the efficacy of this program. A single-group pre-test and post-test design was used. In the program, disease management nurses provided self-management education to patients that were specific for their disease and risk factors in cooperation with their primary physicians. The duration of the program was 6 or 12 months. A total of 1258 patients were enrolled. After excluding discontinued subjects, 987 patients in the diabetes program and 11 patients (except those with diabetic nephropathy) in the chronic kidney disease (CKD) program were analyzed. The diabetic patients showed improvement of HbA1c and blood pressure after intervention, as well as maintaining renal function. CKD patients showed no change of renal function after intervention, but there was improvement of non high density lipoprotein-cholesterol (HDL-c). The patients acquired the ability to detect at an early stage and respond to abnormal symptoms and data, which enabled them to avoid progression of their diseases and emergency hospitalization. The program was effective at preventing disease progression in patients with chronic illnesses and may contribute to the containment of medical costs.