Monday, May 19, 2008

Read the Disease Management Blog and Keep Up with the Peer-Reviewed Literature on Diabetes and Chronic Heart Failure

Holmes AM, Ackermann RD, Zillich AJ, Katz BP, Downs SM, Inui TS: The net fiscal impact of a chronic disease management program: Indiana Medicaid. Health Affairs 2008;27(3):855-64

The Disease Management Care Blog would expect nothing less than a prospective randomized trial on disease management from one of the Gods of General Internal Medicine. Thomas S Inui is among the authors of such a study recently published in Health Affairs. His prodigious biosketch can be found here. Note that he is a former President of the very academic Society of General Internal Medicine (SGIM), which has been curiously mute on the exciting and controversial developments in real world population-based health care. More on this in a future blog.

But let’s turn our attention to the study at hand. It was about the economic impact on disease management (DM) in an Indiana Medicaid population. Indiana has been looking at the role of DM for quite awhile. As patients were randomly enrolled in the program, they were followed over time and compared to patients who had not yet been enrolled, otherwise known as a staggered implementation. Over 800 persons with either diabetes or chronic heart failure were studied with an average of 21 months’ worth of data. Cost of the program (excluding start up) ranged from about $20 per member per month (PMPM) for telephonic care up to about $57 PMPM for nurse care management. High risk persons were assigned to the nurse care management, while low risk patients were assigned to telephonic care.

AmeriChoice ran the call center. The Indiana Primary Health Care Association provided the nurse care management

For CHF:

High risk PMPM savings vs. controls: $150 – not statistically significant

Low risk PMPM savings: $247 – statistically significant

For Diabetes:

High risk PMPM savings: - $144 (more expensive in the intervention group) not statistically significant

Low risk PMPM savings: $3.80 – not statistically significant

The authors concluded that disease management was cost saving for the low risk heart failure group. They were unable to show savings in the high risk heart failure group or in either group with diabetes.

What does the DMCB think?

Once again, it’s possible to do credible research outside of research settings.

What’s true in Medicaid doesn’t necessarily apply to populations with other types of insurance. For example, a similar study in a commercial population showed diabetes disease management was associated with savings, while in an integrated delivery system, low risk heart failure disease management seemed to not result in savings. Go figure.

In their discussion, the authors expressed surprise that there were savings for low risk persons with CHF. For the DMCB, that’s still not that counterintuitive. Moderate amounts of disease may be more amenable to intervention. Persons with mild disease will do well no matter what you do, while those with advanced disease will have problems despite the best of care.

The authors also noted that the baseline characteristics of the control and intervention patients were imperfectly matched, which could have skewed the results. It’s also possible that higher numbers of participants may have achieved statistical significance. The DMCB also wonders if the protocols used to identify the 'high risk' versus 'low risk' patients could have been responsible or if the nurse protocols to manage the high risk heart failure patients or the diabetes patients weren’t up to snuff.

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