Structured disease management has been proposed as a means to improve the quality and reduce the cost of healthcare, and to improve health outcomes for people with chronic conditions. However, the evidence on the ability of such approaches to achieve this remains inconclusive, and what we know is mainly based on small studies of high-risk patients, often undertaken in academic settings.
There is a need to better understand and learn more about the effects of large, population-based programmes using widely accepted evaluation methods that are scientifically sound and are also practicable in routine settings. Such evaluation methods should form a precondition for the selection of efficient and effective interventions to address the growing burden of chronic disease.
DISMEVAL aimed to contribute to developing new research methods and to generating the evidence base to inform decision making in the field of chronic disease management evaluation. Specifically, its three-year programme of work sought to:
The DISMEVAL project has achieved these aims at three levels. First, we inform on the range of approaches to chronic care adopted in 13 European countries, and, by reflecting on facilitators and barriers to implementation, we provide policy makers and practitioners with a portfolio of options to advance care in a given policy context. We note how there remain considerable challenges towards the development of a policy framework for a strategic response to chronic disease, with considerable variation in the nature and scope of approaches to care across Europe. Challenges include a continued focus on complications management, with some movement towards more systematic disease management, and an overall lack of coordination between levels; failure to integrate risk minimisation and disease prevention with other components along the care spectrum; misalignment of financial incentives that tend to reward ‘cure’ over prevention; and a disjoint between intent, at national level, to enhance coordination and integration, and ability at regional or local level to translate these ambitions into practice. These observations emphasise the need for the development of a coherent response to chronic disease that takes account of the various tiers in the system and along the care continuum, with involvement of professionals forming a crucial component for achieving sustainable change.
Second, through testing and validating different evaluation methods using existing data we advance the research base in evaluation design and methodology, inform the design of future evaluations and enhance their value for decision-making. While acknowledging that a randomised controlled design should generally be considered as the most robust way of determining the effectiveness of a given intervention, the DISMEVAL project has identified and tested a wide range of methods for the evaluation of disease management that can be employed in situations where randomisation is not possible. We emphasise that rigorous evaluation is still possible even where baseline or predefined control groups are not available and how advanced designs can help better understand how different care components and processes might be effective for managing chronic disease in patients with different characteristics.
Future evaluation work drawing on such approaches can provide insight into what works for whom in disease management, a question that randomised trials have thus far been unable to answer. Project work further highlighted, through the introduction of statistical controls for selection or statistical matching, how findings were substantially different from simple comparisons of patients receiving a given disease management intervention and those who do not. Thus, the DISMEVAL project has shown how the use of randomisation or other methods of control is necessary to accurately assess the impact of such interventions. It also identified a range of methods that can be employed successfully to implement such controls.
Third, through the development of a report on recommendations for the evaluation of chronic disease management interventions DISMEVAL contributes to strengthening evidence-based policy and practice in Europe. The report is specifically targeted at policymakers, programme operators and researchers, explaining choices, options and trade-offs at methodological, practical and wider societal levels.