Sunday, November 29, 2009

Two New Studies Show Telephonic Disease Management Works

When skeptics think about 'disease management' (DM), they think about distant and nurse-filled cubicle farms that put unsuspecting patients through a speed dial version of education-lite. Plumbing the depths of these telephonic knockoffs, critics have made it abundantly clear that don't like what they see: a pseudoscience that confounds patients and antagonizes physicians. They're fed up with the lack of financial provider incentives, lagging technology and ineffective leadership support. It's so bad, 'how to' articles like this have become necessary to help address the physicians' loss of prestige, influence over patient care and income. Policy makers, academics and organized medicine groups have all agreed that the outrageous vendor fees could be better used for other stuff. Like vaccinating upper-class suburban tots. Or paying for motorized wheelchair scooters for affluent octagenarians. Or increasing primary care physicians' fees.

A pox on disease management you say? Stone them?

Think again. Two important publications in the mainstream peer-reviewed medical literature suggest that traditional telephonic disease management is quite effective.

The first is this article, in which researchers from the University of Pittsburgh report the results from a randomized control trial that compares telephonic "collaborative care' (CC) (N=150) versus usual care (N=152) for fresh heart surgery patients that were discharged from one of seven Pittsburgh area hospitals with a surprisingly common side effect of their treatment: active depression (1).

The CC nurses provided 'psychoeducation' in the intervention group that increased awareness of depression treatment options. Backed-up by a psychiatrist/internist team, the nurses also facilitated the patients' treatment decisions. The article includes a description of the CC nurses' roles could have been written as a job description by any of the current for-profit disease management vendors:

'Adheres to evidence-based treatment protocols, supports patients with timely education about their illness, considers patients' prior treatment experiences and current preferences, teaches self-management techniques, actively involves primary care physicians in their patients' care through regular exchanges of real-time information, proactively monitors treatment responses and suggests adjustments when indicated, and facilitates co-management or transfer of care to local mental health specialists when patients do not respond to treatment, have clinically complicated cases, or upon request by the patient or primary care physician.'

Using an approach that is quite similar to any typical disease management vendor program, patients were telephoned every other week for two to four months with calls lasting 15-45 minutes. This was followed by a 'continuation phase' with a call every one to two months. Eight months later, various mood tests showed that the CC group had a greater and statistically significant improvement in psychological well being compared to the usual care group. In looking at the graphs from the study, the Disease Management Care Blog was unable to discern any meaningful difference in the overall rehospitalization rate, though it looks (no 'p' value was reported) like rehospitalizations for cardiovascular disease were considerably lower in the CC patients. CC women were also more likely to being taking antidepressants.

The second is this article, where the Duke University primary care clinics randomly assigned 636 patients to one of four treatments: 1) a telephonic bimonthly 'behavioral intervention' that used the patients' perceived risks, memory ability, literacy, educational level and the quality of the doctor-patient relationship to tailor engagement in the DASH diet (N=160) 2) just a home blood pressure (BP) monitoring device (N=158), 3) both education and a BP device (N=159) or 4) neither (N=159). Two years later, there was an absolute 11% increase in the proportion of patients that had blood pressure under control vs. 7.6% in the blood pressure cuff group vs. 4.3% in the phone call only group. There was no impact on health care costs (2).

First of all, the Disease Management Care Blog thinks both studies are an affirmation of what the mainstream DM vendors have been doing for years. While post-heart surgery depression hasn't been a topic of research, telephonic-based DM for depression in other settings has been shown to have considerable merit. As for hypertension, managed care insurers have known for years that BP control in primary care settings is not what it should be. In response, many DM vendors are selling patient engagement programs that promote the DASH diet with or without blood pressure monitors. Based on the Duke study, it would appear that the managed care organizations can expect and have achieved better blood pressure control with hypertension DM.

Secondly, aha, you ask, but are we getting our money's worth? Neither study 'saved money.' If the cost of the nurses was included, both interventions described above would probably be rated as money losing. While that may be technically 'true,' a) neither study followed patients for a sufficient period of time - it can take longer for a pay-off to accrue, b) commercial DM vendors are much better at identifying, targeting and successfully managing the high risk patients with a higher likelihood of excess costs, c) the interventions above were just for depression or hypertension; modern DM vendors are able to fold in additional care management interventions for other co-morbid conditions that can lead to hospitalization or increase costs and d) maybe, just maybe, the ultimate purpose of DM is not to save money but to increase quality of care at a price point that yields the greatest bang for the dollar. In other words, if depression or hypertension is better treated, maybe it's worth it to pay for it. Stick with usual primary care and you get what you pay for.

Thirdly, critics may point out that both studies above originated in physician-owned, operated and led settings. Fair enough, says the DMCB, but it also knows that primary care physicians in large health care systems are not necessarily more loyal to the 'home office' than any external vendor . In fact, close reading of both studies fails to show that the UPMC or Duke nurses were really all that different from any other external care management initiative. The DMCB doesn't believe the location/ownership of the nurses is what's important. Rather, it's what they do and which patients they do it to.

The DMCB has pointed out for years that telephonic disease management is an important option in the suite of services for caring for populations with chronic illness. It's nice to see that there are now two studies that confirm that perspective.

1. Rollman, B, Herbeck Belnap B, LeMenager MS, Mazumdar S, Houck PR, Counihan PF et al: Telephone-Delivered Collaborative Care for Treating Post-CABG Depression: A Randomized Controlled Trial. JAMA 2009;302(19):2095-2103

2. Bosworth HB, Olsen MK, Grubber JM, Neary AM, Orr MM, Pwers BJ et al: Two Self-management Interventions to Improve Hypertension Control. A Randomized Trial. Ann Intern Med 2009 151(10):687-695


Bruce Pyenson said...

Nicely done, Jaan -- as usual.

Unknown said...

Do you know we published our cost-effectiveness paper:
Bruce L. Rollman, MD,MPH
University of Pittsburgh

Jaan Sidorov said...

I do now! Thanks!!