BACKGROUND: Data on the long-term benefits of nonspecific disease management programs are limited. We performed a long-term follow-up of a previously published randomized trial. METHODS: We compared all-cause mortality and recurrent hospitalization during median follow-up of 7.5 years in a heterogeneous cohort of patients with chronic illness initially exposed to a multidisciplinary, home-based intervention (HBI) (n = 260) or to usual postdischarge care (n = 268). RESULTS: During follow-up, HBI had no impact on all-cause mortality (relative risk 1.04; 95% confidence interval 0.80 to 1.35) or event-free survival from death or unplanned hospitalization (relative risk 1.03; 95% confidence interval 0.86 to 1.24). Initial analysis suggested that HBI had only a marginal impact in reducing unplanned hospitalization, with 677 readmissions versus 824 for the usual care group (mean +/- SD rate, 0.72 +/- 0.96 versus 0.84 +/- 1.20 readmissions/patient per year; p = 0.08). When accounting for increased hospital activity in HBI patients with chronic obstructive pulmonary disease during follow-up for 2 years, post hoc analyses showed that HBI reduced readmissions by 14% within 2 years in patients without this condition (mean +/- SD rate 0.54 +/- 0.72 versus 0.63 +/- 0.88 readmission/patient per year; p = 0.04) and by 21% in all surviving patients within 3 to 8 years (mean +/- SD rate 0.64 +/- 1.26 versus 0.81 +/- 1.61 readmissions/patient per year; p = 0.03). Overall, recurrent hospital costs were significantly lower (14%) in the HBI group (mean +/- SD $823 +/- $1,642 versus $960 +/- $1,376 per patient per year; p = 0.045). CONCLUSION: This unique study suggests that a nonspecific HBI provides long-term cost benefits in a range of chronic illnesses, except for chronic obstructive pulmonary disease.

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