Monday, June 23, 2008

Big JAMA Article on Chronic Care Model, er, no Disease Management, er... no wait, it's the Chronic Care Model

Suppose the Disease Management Care Blog announced that a famous medical journal had recently published a noteworthy lead article on the management of a chronic condition? That hundreds of patients with the condition were randomly assigned to either:

a) usual care, or

b) usual care plus home monitoring and web-access to a library plus secure email with their physician, or

c) the same usual care, home monitoring, web-access and email PLUS a remote non-physician using an action plan that included lifestyle goals and a guideline-driven treatment protocol? That the non-physicians used telephone and web-messaging with copies to the patients’ physicians?

And suppose a blinded assessment at one year showed a) 31% of those in usual care, versus b) 36% of those in home monitoring plus web, versus c) 56% with the addition of the non-physician achieved control of the condition?

It seems to the DMCB that the average reader with a working familiarity of disease management a.k.a population health improvement would hail the study as further evidence that this approach to care is an answer to the challenge of chronic illness care.

After all, the 3rd and most successful arm of the study had all the necessary elements: population identification (patients meeting clinical criteria were recruited into the study), comprehensive needs assessment (the action plan was tailored), increased patient awareness (detailed education about the condition), patient centric goals (that included patient selected lifestyle goals), self-management with behaviorally-based interventions (home-based monitoring and mutual decision making) and feedback loops (every two weeks).

But don’t break out the champagne disease management fans. In the article (not on-line yet) on hypertension control by Green and colleagues at Group Health that was published in the June 25 JAMA, the study design using pharmacists was based on…

care to guess?

…. not disease management, but the Chronic Care Model (CCM), because of ‘self management support, clinical information systems, delivery system redesign, decision support, health care reorganization and community resources.’ In fact, the authors go on to state that this was 'the 1st randomized controlled trial that has applied the CCM to hypertension….' and 'adding pharmacist care allowed the CCM to be integrated…..'

The DMCB will agree that the approach, as described in the publication, may certainly be consistent with the CCM. However, based on the information presented, it is also quite reminiscent of the approach taken by disease management. In fact, the DMCB will speculate (and if any readers know different, please speak up) that the remotely located pharmacists in this study were not physically assigned to any particular clinic or were dedicated one team. Rather, they were virtual, supplying their services from afar and letting the physician know after the fact.

DM or CCM? You be the judge.

Oh wait, the DMCB thinks it knows how to tell the difference between DM and CCM in the literature. It's figured out what to do when overlapping principles from both are used in an integrated approach for the care of persons with a chronic condition. If it’s successful, call it “the chronic care model” or “medical home” and neglect any mention of disease management. If the same approach turns out to be unsuccessful, THEN call it “disease management.” Your mainstream journal editors, peer reviewers and academic readers will thank you for it.

The DMCB has already burned up too much rant, but it thanks Jones and Peterson in the accompanying editorial in the same issue. This is not only an excellent review of the article but they include this salient observation:

the “use of the internet by these investigators was certainly novel, yet their interventions share commonalities with many disease management strategies.”

The DMCB won’t cancel its JAMA subscription.

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