Thursday, January 7, 2010

A Summary of the Latest Population Health Management Journal

Now that the holidays are over, it's back to work. E-mail boxes are overflowing, meetings are in full swing, budgets are being reviewed, spending is still being restrained and business opportunities abound. If it's not a memo, RFP or business plan, you're probably not going to have the time to read it.

Of course, like thousands of others in the care management business, you do take the time to read the Disease Management Care Blog. While there are plenty of reasons to do so, one important feature is its quick-read summaries of the latest issue of the Population Health Management Journal. You get to keep up to date with the latest peer review literature, see what the competition may is looking at or writing about and quote science to the amazement of your colleagues and business associations.

So, without further ado......

Martin Chung, Peter Melnyk, Donald Blue, Donald Renaud, Marie-Claude Breton: Worksite Health Promotion: The Value of the Tune Up Your Heart Program.

A Canada-located Chrysler automotive plant and the auto workers’ union agreed to add a ‘Tune Up Your Heart’ cardiac risk-lowering program to its other worksite wellness programs. Employees took a Framingham-based 10 year risk survey and those with ‘above average’ risk were invited to participate in an intervention. This consisted of a package of programs, including seminars, access to an 800 number, newsletters, a body mass index calculator, newsletters, written materials, nurse visits for individualized goal setting and, depending on the degree of risk, follow-up monitoring and medication review. Of 1078 employees, 580 were ‘invited,’ and 343 participated. 18 months later, average Framingham risk went from 10.7 to 9.3, average systolic blood and diastolic pressure dropped by 7 mm. and 1 mm. of Hg, respectively, total to HDL cholesterol ratios dropped by .2 and the BMI dropped by 0.2. Knowledge and satisfaction were high and cost-modeled per person per year (PPPY) savings were 793 Canadian dollars. Unfortunately, there was no control group, so this article's conclusions may be undermined by regression to the mean. There also is no description of the non-participants, so the reader can’t rule out the possibility of self-selection bias. What’s more, the DMCB found the economic cost modeling difficult to understand and the nurse intervention was not well described. This double whammy was important because, according to the model, almost 75% of the savings was based on nurse-driven medication changes in this Pfizer-funded study. The DMCB also wonders how there were no drop outs. The authors, to their credit, warn the reader at the end of the article about the possible biases and the questionable generalizability of a study from a single payor system to the U.S. market. Despite the assertion that this program was unique, the DMCB is aware of other workforce programs that utilize the same principles.

Joseph Yaskin, Richard Toner and Neil Goldfarb: Obesity Management Interventions: A Review of the Literature.

Want to know everything, and the DMCB means everything, there is to know about the published good, bad and ugly about the treatment of obesity? Well, you’re in luck because this paper takes the existing literature (99 references) to task and it’s mostly ugly. Keep in mind that the National Institutes of Health (NIH) has established criteria for what constitutes for a successful weight loss intervention: sustained reducton of 5-10% of baseline weight over one year, period. According to the authors, there were too few non-surgical studies that were of the sufficient duration one year duration. The few good studies that exist showed NIH-defined success was achieved only when behavior change (diet, exercise or counseling) was combined with drug treatment. What’s more, NIH-defined success, depending on how the drugs or the surgery were priced, did not actually reduce total costs or ‘save’ money. Instead, the amount of money spent per year of life-saved seemed, compared to other things that are covered by health insurers, justifiable. The authors have much more to say on the debate over the merits of various types of bariatric surgery, the implications of some new bench research discoveries, the role of disease management and the need for better research. Note to disease management organizations that are selling weight loss programs: it’s time to rely on the NIH definition of weight loss success and if you think you have a better mousetrap, you need to prove it by subjecting your results to the scrutiny of peer review.

Scott Taylor and Jack Weiss: Review of Insomnia Pharmacotherapy Options for the Elderly: Implications for Managed Care.

OK, instead of obesity, maybe you’d rather know everything about insomnia in the elderly, including its prevalence (especially in persons with chronic conditions), what the treatment guidelines have to say, the option of non-pharmacologic treatment, the merits of the three classes of FDA-approved prescription drug treatments, safety issues, the potential for drug abuse and how little is known about comparative clinical and cost effectiveness of the many drugs used for insomnia. You’re in luck here. Some important take away messages that the DMCB found interesting: insomnia is a prevalent and hidden problem for probably up to 50% of all those persons enrolled in disease management programs, disease management may have something to offer in making time consuming and first-line non-pharmacologic counseling/treatments available and while direct to consumer advertising suggests otherwise, all sleeiping pill drugs – pending studies that show otherwise - probably have the same success rate: who can blame managed care formularies for restricting choice?

Thomas Sandberg, Amy Wilson, Holly Rodin, Nancy Garrett, Eric Bargman, David Dobmeyer and David Plocher: Improving the Imputation of Race: Evaluating the Benefits of Stratifying by Age.

It can be difficult or awkward for health insurers to collect information about race. Enrollees may wonder if that information will be used to discriminate against them and many refuse to answer the question even if they fill out a survey. On the other hand, insurers have a role to play in reducing health care disparities and that will be difficult to do if its severity cannot be assessed. This paper adds to the science of inferring race from ‘geocoding.’ This is the use of location (county, zip code or street) to estimate the racial make-up of population segments. In addition to location, surname has been used to identify persons of Asian and Hispanic heritage. In this study, the authors took advantage of the observation that African-American households may have younger persons present. Lo and behold, when age was statistically combined in the geomapping mathematical modeling, the positive predictive value increased by 1-2%. It’s not a lot, but every little bit helps. The DMCB, wonders, if this would work outside of Minnesota, so additional studies are necessary.

James Rohrer, Kurt Angstman and Gregory Bartel: Impact of Retail Medicine on Standard Costs in Primary Care: A Semiparametric Analysis.

Don't let the term 'parametric' bother you, the DMCB isn't sure what that means either. 141 persons used a Mayo Clinic sponsored walk-in retail clinic and 137 used regular office care in the same period of time for one of five conditions: pink-eye, sore throat, viral illness, cough or bronchitis. Over the ensuing 6 months, average total costs for persons who used the retail clinic patients were $138 vs. $180 for the regular clinic users. After adjusting for the number of previous visits, age and gender, the difference turned about to be statistically significant. If doubters about retail clinics believe conditions are being ‘missed’ by that style of care, the economics in this study (assuming Mayo runs these clinics like the rest of the industry) would seem to suggest otherwise. The authors do an outstanding job of reviewing the possible sources of bias in this study and appropriately call for more studies. This report should have been this particular Population Health Management issue’s lead study. Read this if you want to see how a well executed study can be combined with economy of wording and scientific transparency.

Kathryn Kash, Smiriti Sharma and Neil Goldfarb. Is Disease Management Right for Oncology?

The DMCB always wondered just what disease management had to offer oncology. After all, these patients have very different types and stages of cancer, varied co-morbidities, complex treatment regimens and heavy physician involvement. Well according to this review of the literature, there seem to be three reasons why disease management may be right: 1) organizations such as the American Cancer Society and the National Cancer Institute have endorsed the involvement of ‘patient navigators,’ 2) patients are living longer and longer beyond the acute stages of their care and 3) there are some commonalities across many types of cancer that are quite amenable to the kind of support available in classic disease management. Those commonalities include the physical side effects of fatigue, nosocomial infections, dehydration/pain and anemia as well as the psychosocial issues of depression, symptom relief in palliative care, facilitating appropriate decision-making about end-of-life-care, coordinating multiple physicians, and managing lifestyle. As readers may surmise, there are not many studies on the cost effectiveness of oncology disease management, but there are two good studies from commercial settings and both appeared to be associated with declines in claims expense.

Don MacDonald, Michael Murry, Kayla Collins, Alvin Simms, Ken Fowler, Larry Felt, Alison Edwards and Reza Alaghehbandan: Challenges and Opportunities for Using Administrative Data to Explore Changes in Health Status: A Study of the Closure of the Newfoundland Cod Fishery.
What happens from a population based perspective when a major industry is closed and a lot of people are thrown out of work? While the moratorium on cod fishing in the Canadian provinces of Newfoundland and Labrador may not have direct lessons for those of us in the United States, the description of the methodologies that were used is instructive. The authors tell an interesting story of how they accessed and reconciled numerous and seemingly unrelated data bases to piece together an insightful snapshot of what happened to the population. The absolute numbers of declined as people moved away but grew older because it was predominantly younger people that were moving. Yet, average health status increased and death rates decreased thanks to the very old also moving out. Educational levels increased and new businesses appeared.

There’s also and editorial by Alan Lyles titled “Improving Long Term Weight Management: Social Capital and Missed Opportunities. In it, he describes how the social “capital” of mutual interpersonal support among like minded persons can act as a power catalyst in behavior change. He notes that social capital has been in decline in the United States over the last few decades. One bright spot, however, has been in the classic 12 Step programs, which includes Overeaters Anonymous. He notes their conspicuous absence in the science of battling obesity and suggests we'd do a lot in the fight against obesity if we learned how to harness this important social force.

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