November 1998

Grant Results


From 1992 to 1995, staff at Stanford University School of Medicine adapted MULTIFIT — a computer-based case management system initially developed for patients suffering from acute myocardial infarction — to the care of patients with congestive heart failure, diabetes and hypertension.

The project team also tested the adapted system with patients in each disease category.

Key Findings

  • The project demonstrated that it was feasible to adapt the MULTIFIT system for all three chronic illnesses and that nurses could effectively implement the management algorithms.
  • The use of the system with patients in the three disease categories improved both regimen adherence and outcomes.

The Robert Wood Johnson Foundation (RWJF) supported this project through two grants and a contract totaling of $927,964:

  • The first grant to Stanford University School of Medicine covered the adaptation of MULTIFIT. The second grant, an extension of the first, was needed because of unanticipated patient-enrollment shortages.
  • A contract to the Kaiser Foundation Research Institute also addressed this shortage by allowing their liaison physicians to participate in patient enrollment for the development and testing of MULTIFIT.

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The American health care system is primarily focused on the treatment of acute medical conditions. As a result, patients with chronic conditions rarely receive the kind of care necessary to prevent relapse (repeated cardiac events, for example). Outpatient care for these patients historically has not included longitudinal follow-up and assessment.

MULTIFIT is a computer-based case management system developed by the Stanford Cardiac Rehabilitation Program to manage coronary risk factors in the year following acute myocardial infarction (heart attack). As a generic expert system, MULTIFIT addresses what actions need to be taken, when, and by whom. In early randomized clinical trials, MULTIFIT enabled outpatient nurses to provide effective, cost-saving, longitudinal care to these patients.

The clinical trials indicated that this system helped reduce risk factors. For example, after one year, compared to a group of patients receiving usual care, the smoking-cessation rate in the MULTIFIT population was 65 percent, versus 50 percent in the comparison group; the LDL cholesterol level was 110, versus 137 in the usual care group.

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The first grant, ID# 020297, supported an exploration of the feasibility of adapting the existing MULTIFIT system to the needs of patients with one of three chronic diseases: congestive heart failure, diabetes, or hypertension. Its objectives were to:

  1. analyze current treatment practices for the three diseases through a medical record review of the Kaiser Permanente Medical Groups in and around San Francisco;
  2. develop preliminary management algorithms for the three diseases;
  3. pilot test approximately 100 patients with each disease over a six-month period to identify problems in treatment and improve the computer-based algorithms;
  4. create a training course for nurses, which would then be developed into a multimedia home study course for national distribution;
  5. develop a computer system for dietary counseling, based on the weight-reduction program from the earlier MULTIFIT trial;
  6. generate sufficient pilot data on effectiveness to support further study via randomized controlled trials.

The work was conducted at various Kaiser Permanente Medical Centers and adapted to the circumstances at each center.

The extension grant, ID# 024202, was necessary because adapting the MULTIFIT software for the three diseases took longer than expected. The objectives associated with the extension grant were to:

  1. train nurses to implement the management algorithms for the three diseases;
  2. pilot test MULTIFIT for patients with these diseases;
  3. modify the Computer Assisted Learning System (CALS — a database providing extensive information about the dietary needs of patients with the three diseases) for patients needing to reduce their fat and/or salt intake.

The program contract ID# PC428, running concurrent with the extension grant, enabled liaison physicians at the Kaiser Foundation Research Institute to participate in the development and pilot testing of MULTIFIT. This associated program contract was necessary because of the shortfalls in patient enrollment for the pilot testing under grant ID# 024204. With the help of the liaison physicians, the researchers were able to complete the enrollment of approximately 70–80 patients in each of the three disease categories. This number of patients was essential to meet the statistical criteria for demonstration of MULTIFIT as a safe and feasible case management system.

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  • This pilot project indicated the potential effectiveness of the existing MULTIFIT intervention for the three additional diseases: congestive heart failure, diabetes, and hypertension.
  • With each disease, patients' symptoms and hospital stays were considerably reduced by using the MULTIFIT case management system. In the case of patients with heart failure, the number of hospital days in the year after initial hospitalization decreased from eight to less than one. In all three populations, no serious drug side effects were reported. Pilot-based findings were sufficiently encouraging to warrant the preparation of proposals for randomized clinical trials to the National Institutes of Health and the Veterans Administration, two potential funders.
  • Nurses effectively implemented the management algorithms; physicians were extremely supportive of the system. Decisions on diet, drug therapy, and other post-hospitalization procedures that physicians would normally provide during follow-up office visits were handled by the nurse case manager during weekly phone conversations with patients. Nurses also gauged when physician intervention was necessary.
  • Customizing the decision-support process to match the needs of the medical staffs of individual hospitals was important. This feature of the system was well received by physicians and simplified the implementation process in different hospitals.
  • When MULTIFIT was used for the management of heart failure patients, researchers observed a low mortality rate, a significant decline in morbidity and emergency room hospitalizations, and a high degree of adherence to nurse-recommended diet and medical regimens. Nurse case managers educated patients in: adherence to diet and drug regimens, self-monitoring of weight, symptoms, and medications. They also provided procedures for initiating contact with case managers in the event of an unexpected problem.
  • Participation in MULTIFIT improved hypertensive patients' adherence to drug therapy. Through their contact with nurse case managers, hypertensive patients saw the results of their drug therapies promptly; case managers were able to gauge the effectiveness of different drug treatments and make week-to-week adjustments in patients' regimens.
  • In the diabetes study, a reduction in medical resource utilization occurred using MULTIFIT. Investigators found that a single health care provider, supported by a computerized database and occasional phone contact with a physician, provided the expertise of a multidisciplinary team of health professionals. This indicates that chronic conditions can be monitored effectively in outpatients without significantly draining health care resources.


The results of the original MULTIFIT study were published in the Annals of Internal Medicine (May 1, 1994). The researchers have prepared manuscripts about the heart-failure, diabetes, and hypertension trials. An article on the MULTIFIT heart-failure study was published in the American Journal of Cardiology. The principal investigator authored a summary of MULTIFIT's relevance to the practice of internal medicine and cardiology, which was published in Cardiology Clinics. In addition, the software and other technology developed during this project were made available for implementation within Kaiser Permanente Medical Centers. See the Bibliography for details.

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  1. The success of MULTIFIT depends in part on the chronic condition targeted. The heart failure study was relatively easy to market to physicians because, under ordinary conditions, treatment of patients with heart failure is complex and time-consuming. With these patients, physicians saw the benefits of MULTIFIT almost immediately. Some physicians in the other two studies, however, expressed concerns that the system would increase their workloads.

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After the completion of this grant, the investigators received a $1.8 million grant from the National Institutes of Health to conduct randomized clinical trials of the use of MULTIFIT in patients with heart failure. In addition, they received two RALIN Medical Awards of $528,000 each for a hypertension trial and a diabetes trial.

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Development of a Case Management System for Serious Disorders


Stanford University School of Medicine (Stanford,  CA)

  • Development of a Case Management System for Serious Disorders
    Amount: $ 772,964
    Dates: August 1992 to July 1994
    ID#:  020297

  • Amount: $ 135,000
    Dates: September 1994 to July 1995
    ID#:  024204


Robert F. DeBusk, M.D.
(415) 725-5007


Kaiser Foundation Research Institute (Oakland,  CA)

  • Develop a Case Management System for Serious Disorders
    Amount: $ 20,000
    Dates: September 1994 to January 1995
    ID#:  PC428


Nancy R. King
(510) 987-3236

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(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)


DeBusk RF. "MULTIFIT. A New Approach to Risk-Factor Modification." Cardiology Clinics, 14(1): 143–157, 1996. Abstract available online.

West JA, Miller NH, Parker KM, Senneca D, Ghandour G, Clark M, Greenwald G, Heller RS, Fowler MB and DeBusk RF. "A Comprehensive Management System for Heart Failure Improves Clinical Outcomes and Reduces Medical Resource Utilization." American Journal of Cardiology, 79(1): 58–63, 1997. Abstract available online.

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Report prepared by: Patricia Patrizi
Reviewed by: Marie Lyons
Reviewed by: Marian Bass
Program Officer: Lewis G. Sandy

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