Monday, November 1, 2010

Osteoarthitis Disease Management: One of the "Big Six?"

The Disease Management Care Blog has always wondered why there aren't more disease management programs for osteoarthritis (OA). Sure, some population health vendors offer them (for example) but OA never achieved status as one of the "Big Five" (mentioned on page 5 here). That's curious, because the condition is quite prevalent, self-care has a role in limiting disability and big pricey surgery awaits at the end of the line. There is no shortage of rigorous peer-reviewed studies that show that patient education programs can reduce pain, increase mobility and reduce physician visits (for example, here and here).

By the way, osteoarthritis shouldn't be confused with other types of joint inflammation, such as "rheumatoid" arthritis. The former is primarily a disease of middle aged and older individuals involving the cartilage of the major joints (back, hip, knees and hands) typically accompanied by bony thickening. It is often a diagnosis of exclusion, made after other causes of joint inflammation are ruled out. Criteria on making the diagnosis can be found here.

Thanks to a randomized prospective study appearing in the latest Annals of Internal Medicine, it may be time to reconsider whether OA should become one of the "Big Six."Researchers at Durham VA scoured their electronic health record for patients with the diagnosis of OA, mailed them letters about the study and then telephoned them. Out of 3477 persons with an EHR diagnosis, 523 were successfully recruited for participation while 461 completed the study.

The patients were randomly allocated to one of three treatment arms:

1) the intervention OA self-management group (N=172) which received "grounded in social cognitive theory," education, goals setting, action plans with monthly phone calls from an educator,

2) the control health education group (N=172), which received generic education on a host of health issues plus phone monthly calls from an educator, and

3) usual care (N=171).

At the end of 12 months, measures using standardized self-assessment scales showed the intervention group was experiencing less pain and also had better mobility and flexibility. The intervention itself was estimated to cost a total of about $118 per participant versus $63 in the health education control group. 172 patients times $118 is just over $20,000. While avoided surgeries were not measured in this study, the figure of $20,000 contrasts with the cost of a single total knee replacement.

The DMCB was also struck by the similarity of the research protocol to standard disease management vendor approaches to covered populations. Instead of using an EHR to find patients, vendors use insurance claims. Just like the Durham Va researchers, they also send letters and then telephone patients with a less than 100% success rate. In addition, the economic game of cost "savings" or "ROI" success or failure can hinge on one or two patients. The only difference is that the authors never used the terms "disease management" or "population health management."

These study results, combined with more than a decade of other research, make the DMCB suspect that an $118 per member per year (PMPY) program like this would ultimately yield significant savings for a managed care health insurance or self insured sponsor. While it could benefit all patients with OA, the DMCB wonders if it couldn't be targeted at patients that have been referred by primary care physicians for specialty care, since those patients are probably at the greatest risk for having an elective total knee replacement.

Last but not least, note that evidence-based guidelines on the treatment of OA strongly emphasize the role of patient education. It may be time to update them so that they emphasize the role of cognitive psychology, goal setting, action plans and remote coaching. Of course, the guidelines could sum up all that and more with two simple words: "disease management."

Image from Wikipedia. Because the translucent cartilage that lines the joint is diseased, the bones that make up the knee are not separated and have begun to touch and rub on each other. There is also lipping and a knobby appearance, thought to occur as a result of the joint inflammation leading to attempts to heal.

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