Sunday, March 2, 2008

Kaiser Permanente's Lesson for the Disease Management Community

The disease management care blog found this blog posting of an interesting letter from George Halvorson, CEO of Kaiser Permanente. In it, he celebrates Kaiser’s unique information systems that have “all of the data about the provision of care and about the cost of care.” He points out this capability was responsible for important research published in the American Journal of Obstetrics and Gynecology on the association between caffeine consumption and miscarriage. He takes not a small amount of pleasure in noting that the findings of that study were reported in many news outlets worldwide.

According to George (that’s how he signed the letter) just what is it about the Kaiser information systems that make them so special? He gushes that it is its comprehensiveness, thanks to patients getting all their care at Kaiser. This secret sauce contrasts with the “splintered” care in other settings, where patients are unnecessarily victimized by unconnected clinics and hospitals.

So, the ever curious disease management blog went to the published study (hats off to AJOG for making it fully available on-line) to give it a once-over. It turns out the study was not an exercise in culling and correlating extant caffeine and miscarriage data from the user-friendly KP information ether. The authors’ success was the result of hard work, done the old fashioned way, surveying volunteers (with a 43% refusal rate) about their caffeine intake one interview at a time. And yes, while the ready availability of a single clinical data repository aided the researchers, the statistically significant association between caffeine intake and miscarriage:

a) could have also been extracted from a splintered electronic health record and

b) depended not only on the databases and the medical records but on “contacting participants whose outcomes could not be determined by using the previous 2 methods.” Those would be the folks in the Kaiser System getting splintered care.

While it is the nature of health care CEOs to spin, the disease management blog thinks Dr. Halvorson (assuming the letter is completely reproduced) could have mentioned the lead author Xiaoping Weng and colleagues Roxana Odouli and De-Kun Li by name, congratulated them for their hard work and not implied that the information systems yielded up the association after the researchers keystroked Esc-F1.

That being said, George has a point. The study was significantly aided by the Kaiser registries. This has a huge lesson for the disease management community. I believe these companies’ multi-state multi-payor insurance claims and clinical data bases rival Kaiser’s. In fact, they probably exceed it. Toss in their IVR and telephonic-based access to millions of persons and the possibilities become astonishing. The Carl Saganesque access to billions and billions of 1s and 0s make it possible for them to discover hitherto unknown, important and possibly life-saving associations.

Want a small example? At a prior DMAA meeting, the disease management blog sat in on a presentation about the use of disease management data as well as other public information to better identify persons at risk for diabetes. A fascinating finding was the discovery of a strong association between diabetes and ownership of a minivan. Yup, a minivan. It makes sense when you think about it: exclude persons with an age and gender consistent being a soccer mom, and the remainder are older individuals with an abdominal girth that is best accommodated by the height and style of the “captain’s chair” typical of that style of automobile. Is this life saving? While it doesn’t rise to the level of miscarriages, asking patients about the presence of a minivan may be the next best thing if you can’t get BMI or waist circumference data, lead to a strong recommendation to see a doctor and….you get the picture.

The difference is that Weng, Odouli and Li did us a great service by getting their insight into the public domain. In contrast, the relative silence from the disease management companies is deafening. Either that or their work is not getting the attention it deserves.

More on the implications of this tomorrow.


Anonymous said...

This is the first I heard of this correlation -- it is fascinating to think that mini vans and diabetes are associated.

Jaan can be easily said...

It is interesting, isn't it? It's a shame that it hasn't been put into the public domain and put to good use.