Safeer, R: The role of incentives in the improvement of health.
Dr. Safeer is the Preventive Medicine Medical Director at Maryland’s CareFirst BlueCross Blue Shield and provides a very brief ‘Point Of View’ summary on the field. Like most of my colleagues in who specialize in Preventive Medicine, he notes most studies on the topic show incentives work and he believes them too. This article’s 14 references are a good starting point if you need to find literature supporting the case for preventive care.
Callan CM: Health information technology for the disease management.
Dr. Callan also provides a brief ‘Point Of View’ that extols the virtues of health information technology in decreasing costs, increasing quality, expanding medical modernism, meeting consumer expectations and shifting toward patient centered care. Physician uptake is ‘disappointing,’ but that’s OK because we can educate, address workflow management, pursue registries and embrace medication management. References? None.
Holland N, Segraves D, Nnadi VO, Belletti DA, Wogen J, Arcona S: Identifying barriers to hypertension care: Implications for quality improvement Initiatives.
A non-randomly selected (‘convenience’) sample of 18 physicians and their support staff at 10 clinics in the North Carolina Forsyth Medical Group were surveyed about the Seventh Report of the Joint National Committee of Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC VII). The DMCB thought it was interesting that ‘44%’ of physicians are equivocal about letting patients remain hypertensive. A greater majority cite support staff factors such as inaccurate BP measurement and lack of time as barriers to successful treatment. Staff echoed these sentiments. In their discussion, the authors point to clinical inertia as a factor that may account for much of the physicians’ attitudes.
Lairson Dr, Yoon S-J, Carter PM, Greisinger AJ, Talluri KC, Aggarwal M, Wehmanen O: Economic evaluation of an intensified disease management system for patients with type 2 diabetes.
What happens when a disease management company imposes its program on top of a clinic’s already existing state of the art diabetes program? While McKesson’s program included remote telephony and active case management, the clinic already had CDE classes and individual visits, physician feedback and patient reminder letters. Testing compliance increased but little other benefit was observed including claims expense. Having two overlapping DM programs may be no better than one alone. None of the authors appeared to be from McKesson.
Linden A: Sample size in disease management program evaluation: the challenge of demonstrating a statistically significant reduction in admissions.
Even if you know about statistical significance, power, effect size and standard deviation, this is a still good tutorial from a Jedi Knight of disease management.
Tinkelman D, Wilson S: Regression to the mean: A limited issue in disease management programs for chronic obstructive pulmonary disease.
The authors used criteria for inclusion in a COPD disease management program to extract a sample of Colorado Medicaid patients. They could NOT find that the claims expense in this population decreased over the next year. They argue these patients will not regress to the mean because they are sick and stay sick. Maybe they have a point, because that is what most docs who take care of these patients will tell you. Plus, these guys ARE from National Jewish in CO.
Coberley C, Morrow G, McGinnis M, Wells A, Coberley S, Orr P, Shurney D: Increased adherence to cardiac standards of care during participation in cardiac disease management programs.
The folks at Healthways pooled the pre-post data from more than 20,000 patients on measures such as LDL measure/control, use of ACE/ARBs/Beta-blockers and statin use. Care to guess which way the numbers went? Worth a look if you want benchmark industry averages.
Bray K, Turpin RS, Jungkind K, Heuser G: Defining success in diabetes disease management: digging deeper into the data.
Quite the title, especially when it applies to only 23 physicians 5 Virginia practice sites that participated in a diabetes disease management program. Of the tens of thousands of persons with diabetes in these sites, 1117 were the topic of this study. 772 had two or more face-to-face visits with a health coach, while the remainder did not. While the patients with the coaching did better with A1c control versus the ones without the face-to-face visits, the DCMB found this manuscript interesting because it describes the travails of putting external nurses into doc’s offices. Despite considerable effort at creating buy-in, some docs cooperate, others don’t and when they don’t, the outcomes show it.
Brazil K, Cloutier MM, Tennen H, Bailit H, Higgins PS: A qualitative study of the relationship between clinician attributes, organization and patient characteristics on implementation of a disease management program.
The authors used open ended interviews involving 36 physicians, 24 nurses and 33 others about implementing an asthma disease management program. Physicians don’t feel confident, suffer from therapeutic nihilism, don’t think about it, distrust cookbook medicine and don’t perceive there is much help. Staffing realities as well as the limits of trying to pull this off for socioeconomically deprived populations are also issues.