Tuesday, January 10, 2012

What's The Right Diabetes Disease Management Program For Your Patients?

The answer is "it depends."

For a good example of why that's true, check out this hot-off-the-presses Health Affairs article that describes two parallel approaches to disease management.  Both were offered side by side to a largely Hispanic and socioeconomically disadvantaged population in Los Angeles (LA). 

One program was provided in the LA Department of Health Services primary care health centers. Patients with poor diabetes control were referred to a separate turn-key "one stop" care program with non-physician educators under the direction of an endocrinologist. Using a combination of in-person and telephonic management, patients were put through a six to nine month protocol designed to optimize their medication treatment plan, foster better living habits and improve self-care.  Nurse case loads averaged 125 patients.

In LA's independently-run community clinics (many of which are federally qualified health centers), case managers and clinical pharmacists were available on-site for lifestyle counseling, education on self-care and medication management that included initiating insulin and adjusting other drugs. Nurse case loads numbered 400 patients, while the pharmacists had about 200 patients.

Based on pre-post measurements involving hundreds of patients, both the LA health centers' and community clinics' patients experienced impressive improvements in blood glucose control and cholesterol levels.  That's typical in disease management programs. 

However, there were some differences.  In the LA health clinics, the program was separate, overseen by a specialist, limited to patients with poor glucose control and involved a more intense program of patient education.  In the community health clinics, the nurses and pharmacists were "part" of the clinic and, based on the caseloads, were less labor-intensive.

Despite the differences, the DMCB couldn't really tell if one approach to diabetes care management was "better" than another.  There was little information on the content of the care plans and no information  on costs.  Yet, all things being equal, the DMCB suspects that architects of similar programs nationwide are ultimately selecting from a menu of care and staffing options based not only on patient need but highly subjective (or yet-to-be-investigated) preferences based on local physician culture (sometimes specialist leadership is important), access to special resources (like pharmacists) and local budgetary realities.

The key lesson in this article is how two parallel clinic systems in the same population serving a similar population decided to deploy different disease management programs.  Both resulted in patient betterment.  Both had relative strengths and weaknesses.  Deciding which approach is "better" remains a matter of local judgement based on a complex number of factors.

In other words, it depends.

Image from the Kentucky Diabetes Resource Directory

No comments: