Tuesday, May 25, 2010

A Summary of the Latest Population Health Management Journal

It's that time again. The Population Health Management Journal (PHMJ) has arrived and it's full of your competitors' published findings on wellness, prevention and care and case management. Good thing you read the Disease Management Care Blog. It's saving you time with this handy PHMJ summary so that you can quickly and efficiently scan the contents over your low fat, weight controlling lunchtime yogurt and fruit snack. You'll know which articles deserve closer attention. The result will be better market awareness, enhancement of your professional development, heightened competitiveness for your company, advancement of the science of population care management, fewer Americans with chronic illness and reduction of the national debt. And that's just for starters.

Without further ado:

Impact of Online Primary Care Visits on Standard Costs: A Pilot Study by James Rohrer, Kurt Angstman, Steven Adamson, Matthew Bernard, John Bachman and Mark Morgan

Do “on-line” visits save money? It depends on your definition of saving money. These researchers from the Mayo Clinic pulled the records of 391 patients who were “served online via a secure patient portal” and compared them to 376 consecutive patients who were seen at a “same day clinic at a downtown location,” all of whom were served/seen during a six month period in 2008. The online visit used branching logic to solicit the patients’ history and then forwarded it to a physician for his/her review and reply. In order to use the online option, patients had to have a Minnesota primary care provider and be willing to pay the $35 if their insurer didn’t cover it. “Outlier status,” defined as being outside the 75% national percentile of total costs ($219) over the next 6 months, was used to assess cost savings. 28% of the "same-day clinic" patients met outlier status versus 21% of the "on-line" patients; median costs for both groups were $131 and $87, respectively. Both differences in median costs and outlier status held up as statistically significant even after controlling for baseline utilization. The DMCB thinks that much of this depends on the portal software (“Medfusion”), so we don’t know how generalizable this is. That being said, the DMCB is intrigued by the novel definition of cost savings that is based on an "outlier status." The DMCB also wonders if the next and even more cost-saving step is to have non-physicians handle much of the on line review and reply, oh wait, that is already being done in many population-based care management programs....

Disease Management to Promote Blood Pressure Control Among African Americans by Troyen Brennan, Claire Spettell, Victor Villagra, Elizabth Ofili, Cheryl McMahil-Walraven, Elizabeth Lowy, Pamela Daniels, Alexander Quarshie and Robert Mayberry

In this study, primary care physicians and their patients with an Aetna insurance claims history were randomly assigned to either 1) a high intensity, multi-modal and culturally competent nurse-support program with blood pressure monitors and instructions on how to use the monitors or 2) a “light support” program that included just the instructions and the monitors. 5932 persons were approached for participation and 320 were eventually assigned to the high intensity group while 318 were assigned to the light group. Patients were telephoned to self-assess and report their baseline and 6 month follow-up blood pressures. Mean baseline pressures were not different between the two groups at the start of the study, but at 6 months the high intensity group’s mean systolic pressure was 124, while the light group was 127. While an approximate 3 point difference may seem small, this is what is typically seen in the science of successful blood pressure control. What’s more, the difference was statistically significant. The DMCB likes this study because it’s directed at a population that suffers from disparities in access to care and it shows that additional patient support trumps skinnied-down home blood pressure monitoring. Kudos to Aetna for supporting this study.

Do Case Management Programs Save Money? by Donald Fetterolf, Albert Holt, Travis Tucker and Nazmul Khan.

After reading this article that describes how Alere thinks about it, you may still not know the answer. The good news is that you’ll have a better appreciation for the highly variable nature of patients that are typically entered into case management and how their care is prone to overuse, underuse, misuse and abuse. You’ll also learn that the cost and utilization patterns in this group speak to the problem of health system variation. While this is consistent with the policy message of the Dartmouth Atlas, the broad baseline confidence intervals also can get in the way of statistically proving that case management “works”; the authors used a standard power calculation for a typical cohort of case management patients’ cost patterns and found that more than 30,000 patients would be needed to conduct a research study on return on investment (ROI). Their common sense suggestions to assess the impact of case management include 1) assess and infer from other process, operational and clinical outcomes, 2) look at other pertinent markers of utilization, such as nursing home days per thousand, 3) apply known savings that have been demonstrated in clinical trials to the smaller population of interest and 4) measure quality of life, patient and physician satisfaction and use self-reported anecdotes. Unfortunately, grumpy purchasers may not appreciate how difficult this is and insist on other measures such as 1) estimates from the case managers on individual client savings that are, in turn rolled up (but fail to capture other costs), 2) propensity matching (but also prone to no achieving statistical significance) 3) a “book of business” approach that’s described in the DMAA Guidelines III Document. After all that, the best business approach to case management is to 1) document methodology, case mix, the impact of variation on “ROI,” 2) educate clients about the limitations, 3) agree on directional estimates in lieu of point values, 4) use “performance corridors,” 5) limit only small amount of any performance guarantee on “ROI” and 6) plan for the likelihood that any calculation of program savings may show a loss. The DMCB says this is "must" reading if you're in the case management business.

Wellness, Hard to Define, Reduces Trend up to 4 Percent by Cyndy Nayer, Jan Berger and Jack Mahoney.

This is a title that says it all. The authors conducted a series of open ended and multiple choice surveys of a group of companies that had been selected by the “Center for Health Value Innovation” as particularly innovative and dedicated to wellness among their employees. Innovative respondents 1) seemed to have broader and more inclusive definitions of just what comprised "wellness" and 2) reported that they believe their cost trend was only 4%, compared to national trend of 8 to 10%. The DMCB agrees there is an association between wellness and trend but it still struggling to ascertain whether this is causal and if so how much. If it is, does being blessed with a low trend enable companies to be squishy over wellness?

Comparring Diverse Health Promotion Programs Using Overall Self-Rated Health as a Common Metric by James Rohrer, James Naessens, Juliette Liesinger and William Litchy.

In this study, employees who completed a health risk assessment (HRA) and had four or more “risks” identified were assigned to one of four telephonic coaching programs aimed at weight, exercise, stress or nutrition. Over six months, participants were asked about eating patterns, weight, levels of exercise and degrees of stress, as well as an additional single question: in general would you say your overall health is excellent, very good, good, fair or poor. Of the approximate 48,000 who took the HRA, about 16,000 agreed to participate in coaching, 10,500 were eligible and 2855 enrolled. Drop outs were significant, with 1.5% to 26.7% completing the six months. Improvement in the single question about overall health appeared to correlate with weight loss (an average of 4 lbs.) and exercise levels (increased by an average of 43 minutes a week). The single question did not correlate with stress management practices or healthy eating. The authors suggest that weight loss and exercise programs may have an beneficial impact on the perception of overall health compared to stress management and nutritional interventions. If this holds up, the DMCB wonders if weight loss and exercise programs can reduce overhead by limiting their data collection to a single question. Alternatively, the single question approach may not be adequate enough to detect well-being among stress and nutrition program participants.

Improved Blood Pressure Control Among School Bus Drivers with Hypertension by Joseph Dozy, Tina Severance-Fonte, Elizabeth Morandi-Matricara, Jenifer Wogen, Feride Frech-Tamas.

There is no reason to believe that commercial driver’s license (CDL) holders should be any less prone to hypertension. The pharma-company developers of the “BP Downshift” program don’t think so either, so they created a tailored program made up of multiple educational mailings and a website, BP kiosks that were available in employee areas, free dietitian advice and free gym memberships. The developers showed up at an unnamed school district’s annual orientation for their CDL-holding school bus drivers. 208 entered the study by undergoing a blood pressure screening. 120 had a follow-up blood pressure screening at the close of the school year. At follow-up, systolic and diastolic pressures decreased by 9 and 4 points respectively. Among those that completed surveys, there also appeared to be an increase in health behaviors, and personal health perception. Bravo to the authors for recognizing in the discussion that their study was limited by a lack of a satisfactory control group, lack of generalizability, possible selection bias, the possibility of regression to the mean and temporal factors leading to bias. The DMCB doesn’t think the authors – or the school district – were out to win a Nobel Prize here; rather may be better suited to being thought of as a feasibility study. The next step is to perform a more vigorous study to see if the school district and its taxpayers are getting their money’s worth.

There is also an editorial by Chris Behling named "The Ghosts of Disease Management Past." He laments the persistent haunting of population-based care management by the threefold perception 1) that disease management is all about five chronic diseases, 2) is really all about telephonic coaching and 3) that it's disconnected from primary care. He dispatches each specter with some compelling arguments and recommends the industry leverage it's corporate infrastructure, measure measure measure and "extend and enhance the reach of physicians while filling the gaps that exist in the current delivery of care. Hear hear, says the DMCB.

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