patients randomized to the intervention group with the 79,310 patients randomized to the control group, the researchers found that "disease-management programs did not reduce hospital admissions or emergency room visits, as compared with usual care." Furthermore, there was "no demonstrable savings in Medicare expenditures," with the net fees for disease management ranging from 3.8% to 10.9% per patient per month. The researchers suggested that the findings might be explained by the severity of chronic disease among the patients studied, delays in patients' receiving disease management after hospitalizations, and lack of integration between health coaches and the patients' primary care providers. Other studies Studies that have reviewed other studies on the effectiveness of disease management include the following: A 2004 Congressional Budget Office analysis concluded that published studies "do not provide a firm basis for concluding that disease management programs generally reduce total costs". The report caused the disease management industry to "scrambl[e] to build a better business case for their services". A 2005 review of 44 studies on disease management found a positive return on investment (ROI) for congestive heart failure and multiple disease conditions, but inconclusive, mixed, or negative ROI for diabetes, asthma, and depression management programs. The lead author, of Cornell University and Thomson Medstat, was quoted as saying that the paucity of research conducted on the ROI of disease management was "a concern because so many companies and government agencies have adopted disease management to manage the cost of care for people with chronic conditions." A 2007 RAND summary of 26 reviews and meta-analyses of small-scale disease management programs, and 3 evaluations of population-based disease management programs, concluded that "Payers and policy makers should remain skeptical about vendor claims [concerning disease management] and should demand supporting evidence based on transparent and scientifically sound methods." In specific: Disease management improved "clinical processes of care" (e.g., adherence to evidence-based guidelines) for congestive heart failure, coronary artery disease, diabetes, and depression. There was inconclusive evidence, insufficient evidence, or evidence for no effect of disease management on health-related behaviors. Disease management led to better disease control for congestive heart failure, coronary artery disease, diabetes, and depression. There was inconclusive evidence, insufficient evidence, or evidence for no effect of disease management on clinical outcomes (e.g., "mortality and functional status"). Disease management reduced hospital admission rates for congestive heart failure, but increased health care utilization for depression, with inconclusive or insufficient evidence for