Sunday, November 28, 2010

Population Health Management Journal Summarized Again!

It took a while and it needed some much needed breathing space, but the Disease Management Care Blog finally stopped looking guiltily at its unread October issue of the Population Health Management Journal and finally cracked the cover. It knows it's not the only one battling a very busy time of year and that there are holidays to contend with. So, here comes the DMCB to our mutual rescue with this handy narrative summary of each of the PHM articles. Now you can efficiently catch up, find some pearls to quote or decide to take a closer look at an article (your own copy can be found here) that captures your interest.

Dan Kent, Linda Haas, David Randal, Elizabeth Lin, Carolyn Thorpe, Suzanne Boren, Jan Fisher, Joan Heins, Patrick Lustman, Joe Nelson, Laurie Ruggiero, Tim Wysocki, Karen Fitzner, Dawn Sherr and Annette Lenzi Martin: Healthy coping: Issues and implications in diabetes education and care.

What happens when you put some CDEs, PhDs, RDs and one MD in a room and ask them about “coping skills” among persons with diabetes? This article is what happens, which has everything you’d want to know about the topic and more. The DMCB learned that “coping” is among the seven diabetes self-care skills (in addition to healthy eating, being active, monitoring, medications, problem solving and reducing risks) that has been identified by the American Association of Diabetes Educators (AADE). It can be defined as “responding to a psychological and physical challenge by recruiting available resources to increase the probability of favorable outcomes.” It’s difficult to measure, highly dependent on psychosocial factors, vulnerable to depression and should be routinely assessed in the course of patient counseling. The DMCB thinks this is a good article that give readers a different way to think about the coaching that they already know about.

Kavita Nair, Kerri Miller, Jinhee Park, Richard R. Allen, Joseph J. Saseen and Vinita Biddle: Prescription co-pay reduction program for diabetic employees.

The DMCB always thought that small swings in pharmacy insurance co-pays for medications would translate into big differences in medication compliance. So, when an unidentified “state employer” moved all its diabetic medications to the lowest tier ($10 to $20) co-pay it would have thought that the 589 continuously enrolled persons in this study would have had more than just a 3% increase in medication adherence (defined as filling 80% of chronic prescriptions) in the following year. There were decreases in emergency room and hospitalizations among the 589 persons who were continuously enrolled during the study period. Unfortunately, this was a "pre-post" study and authors are correct when they note that it's difficult to ascribe any of the measured changes to the decreases in the co-pay. The DMCB notes that it really can’t conclude anything after reading this article.

Safiya Abouzaid, Eric Jutkowitz, Kathy Foley, Laura Pizzi, Edward Kim and Jay Bates: Economic impact of prior authorization policies for atypical antipsychotics in the treatment of schizophrenia.

What happens when a research grant from a pharmaceutical company pays for a study that uses a “decision analytic model” to assess the impact of something disliked by pharma: insurer-based medication prior authorization (PA)? The DMCB figures chances are that it’ll show it doesn’t work. While this study showed “only modest savings approximately half the time,” the DMCB lives in the real world and doesn't trust this brew of model inputs, software, assumptions and sensitivity analyses.

James Springrose, Felix Friedman, Stephen Gumnit and Eric Schmidt: Engaging physician in risk factor reduction.

In this study, the authors got three primary care practices with 17 providers to agree to participate in a pay for performance (P4P) and referral program involving 546 patients who, on the basis of a claims analysis, appeared to have coronary artery disease, diabetes or high blood pressure. These were patients with two years of established care who were re-evaluated over the 6 months after the program started. Each "biomarker" improvement in weight, lipid levels, diabetic control or blood pressure control resulted in a $65 payment. Providers were also encouraged to refer patients to a disease management program. Compared to the baseline period, when there were 9 spontaneous biomarker improvements, the 6 month period had 96 pay-outs. Of 187 patients who appeared to be candidates for referral into disease management, 80 were actually referred by the providers and 43 agreed to participate. The DMCB thinks this is an interesting pilot study and the notion that P4P could promote buy-in for referring to disease management to be interesting. More research using a concurrent comparator would be a good next step.

Alex Harris, Katharine Bradley, Thomas Bowe, Patricia Henderson, Rudolf Moos: Associations between AUDIT-C and mortality vary by age and sex.

Screening for alcoholism identifies persons who are alcoholic and alcoholics have a higher rate of death, so do persons with a positive screening test have a higher rate of death? In this instance, from 2004-2005, approximately 225,000 Veterans Administration patients were given the AUDIT-C screening tool. When the 1-12 range (the higher the score, the greater the likelihood of alcoholism) AUDIT-C score was divided into quartiles, women in the highest quartile had an increased death rate, as did men in the higher two quartiles. Male non-drinkers also appeared to have a higher death rate. The DMCB finds none of this surprising and thinks this confirms the need to aggressively screen for alcoholism in the course any care programming.

Urvashi B. Patel, Quanhong Ni, Carol Clayton, Peter Lam, Joseph Parks An attempt to improve antipsychotic medication adherence by feedback of medication possession ratio scores to prescribers.

Missouri instituted a “Treatment Adherence Program (TAP) in four community mental health centers for patients that had been prescribed antipsychotic medications. When these patients failed to filled their prescriptions at 7, 30 and 45 days, an alert email was sent to a responsible provider in the clinic. 78 patients with a record of lapsed prescriptions were compared to a convenience group of 269 patients. Compared to the control group, patients in the intervention group has a small but statistically significant increase in filling their prescriptions over the 6 months surrounding the intervention. This decayed after the alerts were stopped. The DMCB thinks this was a nice try, but more will be needed to help these patients continue to take their life-saving medications than simply alerting their overworked providers.

Ronald Loeppke, Dee Edington, Sami Bég: Impact of the prevention plan on employee health risk reduction.

Three disparate employer groups used a wellness program (including a health risk assessment, blood screening tests, results review with recommendation, an action plan, live and web-based support services and ongoing feedback). 2606 employees completed the entire suite of services. 15 health risk measure categories were assessed over the course of the following year, and they were compared to the "Edington Natural Flow Model" that measures health risks in a population without access to health improvement. If you believe the model, the reduction in 10 of the risk categories achieved statistical significance that favored the intervention group. Close to half of individuals in the overall high and moderate risk categories moved to the next lower level of risk.

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