Sunday, January 11, 2009

Population Health Management Journal Summary For Your Perusing Pleasure

It's that time again! The December 2008 issue of Population Health Management, that journal formerly known as Disease Management is about to land on your desk. But you're busy. Those e-mails are overwelming your in-box. The December '08 let-it-wait-till-January-'09 management decisions are looming. Do you crack the cover of that journal and if so, which articles are of interest to you? More importantly, is there one you can quote or comment on at that staff meeting tomorrow to the amazement of your colleagues and boss?

The Disease Management Care Blog at your service! Plenty of stuff here across the employer, program, behavioral and actuarial settings........

Ron Loeppke, Sean Nicholson, Michael Taitel, Matthew Sweeney, Vince Haufle, Ronald Kessler: The impact of an integrated population health enhancement and disease management program on employee health risk, health conditions and productivity.

Is the company you work at self insured? You’re in luck because your employer can be like DIRECTV. They distributed an employee health risk assessment in April of 2003 with a $15 gift certificate incentive for completion followed by a $300 credit for their health insurance if a) low risk or b) moderate or high risk and willing to participate in up to 6 lifestyle-health improvement programs. The programs included in-person as well as remote coaching. $15 was enough to get a 60% baseline participation rate. There was a follow up survey in 2005. This report focuses on 543 persons that completed both surveys. As expected there was ‘risk’ shifting over time among the low, medium and high risk populations, but the downhill flow of persons from high to medium and from medium to low exceeded the uphill flow. A reduction in risk was associated with a reduction of 3.5 absences per year versus a comparison group. Unfortunately there is little information on the penetration of this program into the entire DIRECTV workforce: is 543 employees enough to make a difference for an entire company? What’s more frustrating, the authors state we need to wait for another publication to find out if health care insurance claims expense was reduced.

Roger Mazze, Margaret Powers, Harry Wetzler, Cori Ofstead: Partners in advancing care and education solutions study: Impact on processes and outcomes of diabetes care.

The International Diabetes Center at Park Nicollet has developed a ‘Partners in Advancing Care and Education Solutions’ (PACES) program based on their Staged Diabetes Management approach to diabetes care combined with an educational curriculum. 40 medical centers were invited to compete for inclusion in a pilot and 10 were eventually selected. Using the NCQA’s Diabetes Physician Recognition Program and the ADA Education Recognition Program criteria at baseline and at follow-up, there was a broad improvement in most of the diabetes quality measures pre-post. In addition, all participating centers ended up being certified by the NCQA and the ADA. The DMCB wonders if the authors chose the centers that were performing at a low level and/or had the highest interest in succeeding. If so, the generalizability of this study may be limited. On the other hand, if you want to turbocharge your institution’s likelihood of getting ADA or NCQA recognition, these guys may be the ones to call.

Ramsey Farah, Kyahn Kamali, Jeffrey Harner, Ian Duncan, Thomas Messer: Random fluctuations and validity in measuring disease management effectiveness for small populations.

Want to know if your disease management program saved money? Well, if the number of persons in the program is small, the ability to spot any meaningful savings is decreased and gets worse as the number of participants goes down. As a result, you may need to a) hire an actuary or b) read this paper or c) do both. If you read this paper, you’ll be better able to understand using 1 vs. 2 standard deviations, 1 or 2 sided testing, admission based savings calculations, truncation at a $100,000 stop loss limit and various external populations for non-chronic trending. After reading this paper, the DMCB thinks you'll need to hire an actuary anyway.

Cynthia Hartsfield, Eli Korner, Jennifer Ellis, Marsha Raebel, John Merenich and Nancy Brandenburg: Painful diabetic peripheral neuropathy in a managed care setting: patient identification, prevalence estimates and pharmacy utilization patterns.

Using claims submitted by physicians to insurance companies to indentify populations with a condition of interest is very much an art and a science. Claims can both “overcall” a diagnosis (be falsely positive) or miss a diagnosis (falsely negative). Thanks to a grant from a manufacturer of a drug meant to treat diabetic neuropathy, the folks at Kaiser used the gold standard of chart audits to fine-tune a claims-based algorithm that had a so-so false positive rate (of about 50%) and a low false negative rate (about 1%) for this condition. They estimate that among persons with diabetes, the prevalence of neuropathy, depending on the criteria used, is between 11-21%. Furthermore, treatment of diabetic neuropathy is very difficult: nothing works very well. As expected, medication claims in this population is highly variable in both the numbers of persons receiving treatment and the types of drugs being used. This is a good paper because the authors provided the ICD-9 codes and the reader gets to think about the good and the bad about using insurance claims instead of chart reviews; many of the lessons here apply to other conditions.

Karen Fitzner, Deborah Greenwood, Hildegarde Payne, John Thomson, Lana Vukovljak, Amber McCulloch and James Specker: An assessment of patient education and self management in diabetes disease management – two case studies.

The wonderful folks at the American Association of Diabetes Educators are pointing out in this review of the literature that there is some evidence that Certified Diabetes Educators (CDEs) can be a valuable asset in diabetes disease management. Yes, there are registered nurses and case managers, but the CDEs can provide an extra level of expertise to patients that need it. They even provide two case studies – one from an integrated delivery system and the other from a for-profit disease management organization – that spell it out in greater detail. The DMCB knows CDEs are an important option in disease management and is glad to finally see a paper that confirms its suspicions.

Thomas Blakely and Gregory Dziadosz: The chronic care model for behavioral health care.

This is a report from an outfit called ‘Touchstone innovare’ who implemented a behavioral version of the chronic care model in their Michigan mental health agency. Frankly, this is a difficult paper to read because there’s no description of the workings of the agency or the disease burden in the population. There was a control group but they were contaminated by being the same agency. That being said, a pre-post analysis showed an improvement in multiple measures of psychological well being and an astounding 39% reduction in inpatient days. This is a good start, but much work needs to be done before we really know how the chronic care model will work in outpatient behavioral medicine.

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