Wednesday, June 18, 2008

A Compressed Summary of the Debate over the Value of Disease Management

Check out this timeline summary of a series of publications in the American Journal of Managed Care (AJMC) focusing on the topic of disease management. This is a good encapsulation of much of the current debate on what we know and don't know about its value.

December 2007: The AJMC publishes a review article by Mattke, Seid and Ma of RAND that provocatively asks if there is "Evidence for the Effect of Disease Management: Is $1 Billion a Year a Good Investment?" After reviewing the available medical literature, they conclude that there is ample evidence of improvement in processes of care across multiple chronic disease states, but "no conclusive evidence that disease management leads to a net reduction of direct medical costs."

January 2008: AJMC publishes a response letter from Gordon Norman of Alere and Chair-Elect of the DMAA. He argues disease management has considerable face validity, sponsors have been unwilling to subject patients to serving as 'controls,' the industry is not in the business of conducting research, positive internal and non-published evaluations by industry are just as rigorous but not as publicly available as peer review studies, a critical mass of randomized prospective trials may be lacking but other methodologies have shown positive results, other accepted medical interventions have unfairly not been subjected to similar scrutiny and, finally, evidence is slowly accumulating. The DMAA issues a news release about Dr. Norman's letter.

May 2008: AJMC publishes another response letter from Robert Stone of Healthways, noting that there is considerable variation in what comprises disease management in the literature. As a result, a pooled analysis may include spurious results from faux-disease management programs. He argues a pooled analysis using more restrictive inclusion criteria, especially using programs that execute well, would show reductions in costs.

May 2008: The Disease Management Care Blog posts a discussion in reference to the above, arguing that if the disease management industry is going to gain advantage from publishing positive results in the peer review medical literature, it will also have to get used to the downside of critical scientific scrutiny. It also notes there are other approaches to better understanding the value of disease management.

June 2008: Dr. Mattke writes an editorial in AJMC, provocatively titled "Is There a Disease Management Backlash?" While the jumping off point is a discussion of negative outcomes associated with a disease management program aimed at pharmacologic treatment following myocardial infarction, he goes on to discuss the generally small limited studies that make up much of the disease management literature in general. He argues more studies are needed, that the industry should submit more of its results for peer review and that, in the meantime, purchasers would be well advised to heed the principle of caveat emptor. Dr. Mattke also makes another excellent point: instead of claiming disease management 'saves' money, perhaps the industry should examine the comparative benefit it delivers per unit of additional cost.

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