Disease management in Europe

Likely to grow as pressure to deliver cost effective care mounts

Can healthcare providers improve the cost effectiveness of patient care by contracting out chunks to pharmaceutical companies? The evidence is equivocal, but the experiment is under way as drug companies move into chronic disease management.

The theory is as follows. Systematic, integrated, evidence based, long term care of populations of patients with chronic, high cost diseases such as asthma, back pain, rheumatoid arthritis, dementia, and diabetes is more effective than episodic fragmented care of individuals. The incidence of acute episodes and complications associated with disease is reduced and quality of life improves.1 Better health outcomes reduce costs. Setting up “disease management” programmes that operate across the boundaries of primary, secondary, and community care requires high capital investment and state of the art information technology. Few health care providers can readily supply these. Pharmaceutical industries can. Hence the logic of contracting out services or setting up joint ventures.

The difference between shared care (as, for example, in diabetes and asthma in Britain), and disease management is essentially one of quality—and control. Commercial programmes are built on rigorous economic as well as medical knowledge of the entire course of disease. There is huge emphasis on efficient delivery systems, tight monitoring, continuing audit and quality assurance, prevention, patient education, and the use of continually refined protocols and guidelines. The staff employed to run the programmes are given intensive and continuing training and support.2

In the past 10 years pharmaceutical companies in the United States and to a lesser extent in Europe have established various programmes. Many are for diabetic care but others include prenatal care, palliative care, management of end stage renal disease, and the care of patients with stroke. Programmes vary in size and scale, but several operate internationally and provide full services and products for each phase of care in a given disease.

The extent to which Europe will follow the United States down this commercial route was recently debated by the European Health Policy Forum. Much depends on individual countries' healthcare systems. The scope for improving standards and reducing costs through disease management programmes is largest in countries such as Germany and Belgium where primary care is comparatively weak and the healthcare market is competitive, unregulated, and costly.

One approach advocated is for providers to adopt the principles and practice of commercial disease management while remaining independent. The problem here is persuading health ministers that the investment in information technology and infrastructure is cost effective.3 This is not easy given that few data exist on the effect of disease management on overall health- care costs. Nevertheless, experience does suggest that, as well as improving disease control, these programmes are liked by patients and staff. One reason, according to Professor Cor Spreeuwenberg, director of primary health care studies, Maastricht University, may be that nurses assume the major role in provision of care. “Patients like seeing them and they tend to follow protocols better than doctors.”

The fact that a third of European drug companies have, or are developing, disease management programmes suggests that industry at least sees a future in them. Start up costs are high but judged worthwhile in return for credibility and market advantage. Where collaborative ventures are set up with reputable provider units the prestige for the company is considerable. There is also a guaranteed market for products and the opportunity to collect valuable long term outcome data on unselected patient populations.

“In the next few years we will see many more partnerships,” said Dr Johan Matthijs of Hoechst Marion Rousell, “not only between doctors and industry but between industry and governments too. One key factor that will determine the growth of disease management is how budgets are allocated. If they are set on a per capita basis the incentive is low, but when they are allocated per disease group the incentive rises rapidly. Another factor is the quality of information technology. These programmes require a common electronic record and fully computerised decision support and quality control systems.”

As experience of disease management grows, more attention is being focused on the possible disadvantages. Medical “carve outs” that entail patients being directed to specialist units for one disease risk fragmentation of care, especially for patients with multiple unrelated pathology.4 Concern has been expressed that disease management is more of a marketing tool for the drug industry than an efficient way of delivering care.5 The jury is still out over whether reduced costs are sustained long term. Real concern also exists over whether professional independence can be guaranteed in commercially driven enterprises.

Nevertheless, the pressure on governments to contain costs and foster evidence based, effective medical care is likely to encourage entrepreneurial collaboration between the health care sector and industry. Adoption and adaptation of its skills and technology may offer much.6 Providing that collaboration is fully transparent, patients seem unlikely to lose.