Wednesday, October 29, 2008

The Partnership to Fight Chronic Disease, the Harlem DM CHF Study and When a Medical Home is not House

A Threefer from the Disease Management Care Blog:

Check out this ad from the Partnership to Fight Chronic Disease, featuring famous women using their considerable star power to remind the rest of us to pay close attention to the candidates’ positions on addressing chronic disease.

Well done, but the DMCB wonders if stars who are known to have actually battled some key chronic illnesses would have taken a good commercial and made if better: Mary Tyler Moore (diabetes mellitus), Elizabeth Taylor (chronic heart failure), Lindsay Lohan (asthma), Cloris Leachman (high blood pressure), Patty Duke (coronary artery disease) and Sally Field (osteoporosis), for example. Still, any excuse to include the still remarkable Ms. Bacall in a commercial is fine by the DMCB.


You may have heard that the Annals of Internal Medicine published an interesting DM study conducted in New York City’s Harlem. The authors were Paul Hebert, Jane Sisk, Jason Wang, Leah Tuzzio, Jodi Casabianca, Mark R. Chassin, Carol Horowitz, and Mary Ann McLaughlin. Just over 400 patients were randomly assigned to usual care versus ‘nurse management’ that consisted of one face-to-face visit plus ‘periodic’ follow-up phone calls, along with ‘working’ with the physician to optimize medications. The authors were unable to show that they saved money. However, SF-12 scores held more steady and quality of life declined less in the intervention group. Depending on how “quality of life years” were calculated, the nurse intervention was a relative bargain of between $15,000 to approximately $21,500 per 'QALY' gained. In others words, there was a measurable benefit to the patients receiving the intervention and the cost of that intervention compares favorably to other commonly used medical treatments, such as dialysis or the treatment of diabetes. The DMCB has written about this before: maybe disease management for chronic conditions isn’t free, but the cost is worth it.

Some things to think about when you read this paper and decide for yourself if the findings are useful:

The DMCB suspects the money saving potential of disease management is greatest when there is high baseline utilization and considerable variation. It wonders if Harlem is an area with relatively blunted access to health care, lessening the opportunity to reduce claims expense.

The cost of the nursing intervention was $158 per year, which is far less than charged in typical commercial disease management programs. The DMCB wonders if the authors (and the patients) got what they paid for.

There is little detail on just what the nurses ‘did’ in the course of their follow-up. The DMCB is not sure if the coaching was culturally appropriate, made use of state-of-art principles of patient engagement or if the phone call follow-up was intense enough.

Yes, this is the prestigious Annals but other studies on the topic of CHF have indicated that savings are possible.


During the course of today’s business planning with two smart colleagues, the topic of the ‘patient centered medical home’ came up. Both responded the same way, mistaking it as some sort of skilled nursing facility ‘where people… go away to, like, get… better?’ The DMCB responded by describing it as an enhanced primary care clinic, like ‘Marcus Welby, only better.’

‘Who is Marcus Welby?’ I was asked by both. Disappointed by this reminder of the DMCB’s age and that neither were regularly reading this blog, it reached into its bag of vulgar popular culture and asked if they were familiar with the TV character ‘House.’ Both immediately recognized the misanthropic doctor, so I explained the medical home as ‘anti-House on niceness steroids.’ I think they got it.

The DMCB believes the term 'medical home' is something that only its fellow 'internists' could have agreed to.

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