Monday, January 10, 2011

Another Study Proves Disease Managment Works - Even Though the Researchers Didn't Call It "Disease Management" but "Collaborative Care"

Two tiresome canards about "disease management" are that 1) it fails to address the full spectrum of patient care needs by being limited to one condition at a time, and 2) it leaves the patients' physicians out of the loop. While that may have characterized some of the earliest disease management programs back in the 1990s, both issues were quickly addressed by the industry for all the obvious reasons and then some: well-meaning nurse-coaches are simply unable to stray into their patients other health needs and consumers are more likely to "opt-out" unless they know their doc approves of what they're doing. All modern (and newly renamed) population health management (PHM) programs routinely help patients with "co-morbidities" and routinely drive docs to distraction with their faxes, phone calls, emails and growing access to the electronic health record.

Assuming, however, that a disease management programs addressed multiple conditions at once - like cholesterol, blood pressure and depression - and simultaneously developed a good working relationship with the physicians, could that offer greater insight on the merits of PHM?

Researchers Wayne Katon, Elizabeth Lin, Michael Von Korff, Paul Ciechanowski, Evette Ludman, Bessie Young, Do Peterson, Carolyn Rutter, Mary McGregor and David McCulloch probably didn't think of their study design in those terms, but that's precisely how the Disease Management Care Blog thought about it when it read Collaborative Care for Patients with Depression and Chronic Illnesses in the December 30, 2010 New England Journal

9838 patients being cared for in 14 primary care clinics for diabetes and coronary heart disease in Washington State's Group Health Cooperative were recruited for disease management that was relabeled "collaborative care." Persons who agreed to participate were screened for concurrent depression. Persons who met study criteria and screened positive had to fill out additional surveys and get past an interview. This ultimately left 106 persons randomly assigned to a "modern" disease management intervention (telephonic and in-person collaborative self-care support with motivational coaching by nurses who championed treatment protocols) versus 108 who were assigned to "usual care." The authors estimated that the the cost of the disease management was $1,224 per patient over the course of the 12 month study and that the intervention group each received about 11 telephone contacts and 10 in-person contacts.

83% of the participants completed one year of follow-up. The persons assigned to disease management had better control of depression (using an assessment tool called the SCL-20), lower average A1cs (7.33 vs. 7.81, despite the intervention group starting out with a higher level) and lower average LDL ("bad") cholesterol levels (92 vs. 101). Blood pressures were not significantly different. The intervention group had higher levels of medication adjustments.

The conclusion of the authors?

As compared with usual care, an intervention involving nurses who provided guideline-based, patient-centered management of depression and chronic disease significantly improved control of medical disease and depression.

"No kidding!" says the DMCB. The greater than 90% of managed care organizations and employers that have been investing in nurse-based programs like this have been achieving these kind of results for over a decade. While they haven't published their data, their commitment to modern versions of disease management/population health management is also testimony to proof of concept.

While the authors may call it "collaborative care," this is really PHM. The paper deserves to quoted by the marketing folks of every vendor and managed care organization that is trying to convince any lingering skeptics that its long-standing nurse-coaching programs are for real. It's nice, isn't it? Researchers, using a rigorously conducted prospective randomized one year clinical trial, have actually taken the time to prove what you're selling actually works .

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