Monday, August 31, 2009

Want to Improve Diabetes Outcomes? Start a Hypertension Disease Management Program

An enduring criticism of disease management (DM) is that it is 'siloed." Contrasting it with the comprehensive care offered by primary care physicians, critics have charged that insurance sponsored DM balkanizes chronic care for patients into separate, inefficient and overlapping programs. As a result, patients with hypertension and diabetes and high cholesterol could spend all day on the phone dealing with separate hypertension, diabetes and cholesterol disease management nurses. The Disease Management Care Blog believed that was a canard, but its opinion fell short of its own evidence-based standard. Up until now, there were no peer-reviewed studies that specifically examined the silo allegation.

Until now. Check out this study from the Durham VA Medical Center and Duke University that was published in the July issue of the American Journal of Medicine, authored by Benjamin Powers, Maren Olsen, Eugen Oddone and Hayden Bosworth. The V-STICH Trial lasted 24 months and compared hypertension disease management consisting of telephonic-based nurse support versus usual care. While there was a modest effect of disease management on blood pressure control, the authors noticed that many of the participants had other chronic conditions, like diabetes and high cholesterol. This was a unique opportunity to assess the impact of the hypertension disease management program on the other conditions.

Of the 588 hypertensive volunteers that participated in the trial, 219 had diabetes and, of these, 216 had had a hemoglobin A1c checked during the course of follow-up. Baseline patient characteristics were not statistically significant among the diabetics in the two arms of the study. However, over the two years, the mean A1c went from 7.54% to 7.26% in the disease management group, while the A1c increased from a baseline of 7.20% to 7.38% in the usual care group. Comparison of the relative changes in the average A1c between the two groups reached statistical significance.

The authors were also curious about the impact on 528 persons who had had a cholesterol checked. The LDL declined in both the intervention and the usual care groups but did not achieve statistical significance.

The authors concluded that their hypertension disease management program had had an 'unintended effect' on blood sugar control among persons with diabetes. The DMCB is unsurprised. Disease management organizations (DMOs) typically instruct their nurses to trigger other engagement modules whenever another chronic condition is detected. At a contractual level that makes sense, because the DMOs often bear some risk for insurance claims expense and it's in their financial interest to help their assigned patients reduce their global risk. However, the DMCB suspect there is something more signficiant afoot: good nurses can't avoid helping patients manage other conditions.

They can't help themselves.

The DMCB witnessed this first hand when it witnessed how disease management nurses do their thing. It sat in on a patient-nurse telephone call for a client-patient and listened how the interchange quickly veered off-course. The nurse helped the patient deal with a new medical problem, offered some emotional support, served up some common sense advice and then closed wth some 'hang-in-there' cheer leading. The DMCB was very impressed but not surprised.

Critics of DM shouldn't be surprised either.

No comments: