Wednesday, July 9, 2008

The DMCB Does It Again: A Summary of the Latest Disease Management Journal

The Disease Management Care Blog blew tanks and surfaced this afternoon from the day's work by taking a stroll out to the mail box and finding the latest issue of one of its fav journals, Disease Management. Feeling guilty about either not subscribing to it or not having the time to crack the cover? Good thing you check in on the DMCB regularly, because it's time for it to once again to come to your rescue with a brief summary of each article. If a topic catches your eye, you can sample the original for yourself. Think of this post as a smörgåsbord for your reading pleasure.

Stone, R: Where we've gone wrong

This short editorial from the the Chief Strategy Officer of Healthways chastises the U.S. health care system for only devoting 3% of its $2 trillion budget to stop feeding the chronic disease generating machine. He says change is needed, including 1) devoting resources on maintaining health, 2) modifying bad lifestyle behaviors and 3) providing access to evidence-based care for those with chronic illness. Of course he implies the disease management industry stands ready to help the U.S. to devote a greater percentage of it's budget to pursuing this change. The DMCB is all for it, and modestly suggests it receive 1/10th of one percent.

Lawrence DB, Allison W, Chen JC, Demand M: Improving medication adherence with a targeted technology driven disease management intervention.

Finally! An acronym. BlueCross BlueShield of South Carolina and Pfizer Health Solutions report on the impact of the ‘opt in’ ‘Longitudinal Adherence Treatment Evaluation’ (LATE) Program on medication adherence in a commercial managed care population with a Caremark-run pharmacy benefit. Using a claims data base and Pfizer’s “LATE” software, high-risk patient lists were created for statins, ACE/ARBs, beta blockers, ‘other’ anti-hypertensives and ‘other’ oral hypoglycemic agents. Participants were already enrolled in disease management. A control was selected from persons from a health plan without disease management. Care Managers telephoned the targeted patients to increase medication compliance. 'Medication re-adherence' was 59.3% in the intervention group (N=94) and 42.1% in the control group (N=61); the difference was statistically significant. Thanks to this lead article, the DMCB learned that disease management coaches can also address medication compliance among patients already in program, but finds the 60% ceiling depressing - assuming the results are generalizable. It also wonders why the authors didn’t report the percent improvement over baseline as the principal outcome.

Horswell R, Butler JK, Kaiser M, Moody-Thomas S, McNabb S, Besse J, Abrams A: Disease management programs for the underserved.

Think all our friends in academia aren’t into disease management? Think again, because this is a descriptive report of what the Louisiana State University Health Care Services Division has been up to as the largest provider of care to Louisiana’s uninsured over the last ten years. They work in 8 centers across the state and have impressive outcomes for their populations in diabetes, chronic heart failure, asthma, HIV, cancer screening and tobacco abuse. The DMCB checked the DMAA membership list and can’t find Louisiana State. It wonders why. Maybe because it's one of the industry's better kept secrets.

Shen C, Sambamoorthi U, Rust G: Co-occurring mental illness and health care utilization and expenditures in adults with obesity and chronic physical illness.

Using a nationally representative survey of over 2000 noninstitutionalized persons in the U.S. with either obesity (BMI >30) or a chronic illness, the authors examined what happened if mental illness 1) was or 2) was not present. Among the 25% with mental illness, total yearly costs were higher ($9900 vs. $6600), the likelihood of being hospitalized was greater (20% vs. 14%) and emergency room use was higher (29% vs. 18%). So, what else is new? However, this study does speak to the need to have robust mental health resources – including screening, diagnosis, management at the nurse-coach level and referral options – in any good disease management program.

Fetterolf DE, Stanziano G, Istwan N: Application of disease management principles to pregnancy and the postpartum person.

Want to learn how Matria used to approach pregnancy disease management? The DMCB says “used” because they’ve been acquired by Inverness and are no more. Hopefully, if the folks in the C-suite want to stay in this particular business line, they’ll read this review paper on the approach to preconception, pregnancy identification/referral, risk stratification, education, case management, NICU case management, postpartum interventions and outcomes assessment. The DMCB finds it interesting that this manuscript doesn’t focus very much on the use of medical devices.

Wilhide C, Hayes JR, Farah JR et al: Impact of behavioral adherence on clinical improvement and function status in a diabetes disease management program

Nationwide Better Health’s program looked at the pre-post 6 month outcomes for persons with diabetes and “agreed to participate” in their disease management program. The study was limited, according to the authors in their discussion, by the lack of a control group. The DMCB agrees very much.

Bailey B, Jacobsen DJ, Donnelly JE: Weight loss and maintenance outcomes using moderate and severe caloric restriction in an outpatient setting.

This is a retrospective University of Massachusetts and Energy Balance Laboratory analysis from three weight loss clinics comparing 12 week outcomes in two non-randomly assigned groups of persons: those assigned a ‘very’ low liquid energy diet and those assigned a low energy liquid diet. After statistically controlling for baseline characteristics (heavier persons, for example, were assigned to the very low diet) both diets appeared to perform equally well in weight loss, amounting to approximately 15% of body weight or between 13 and 18 kg. Over the next 48 weeks, there was a 4 to 7 kg. weight gain, but once again, after controlling for baseline, there was no difference between the two groups. If the very low diets require medical monitoring, this study suggest just a low energy diet may bet good enough.

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