Thursday, November 26, 2009

The Latest Population Health Management Journal Summary For Your Summarized Reading Pleasure

Better late than never says the Disease Management Care Blog.

Just like yours, the DMCB's latest copy of the Population Health Management Journal has gone guiltily unread. Unable to resist any longer, it broke out the caffeinated beverages, donned it's reading spectacles and jumped in. It took notes and took no prisoners.

Good thing. The holidays are fast approaching, time is tight and you need know which articles are worth a closer look so you can quote them to the amazement of your coworkers.

James Gill, Ying Xia Chen, Joseph Glutting, James Diamond, Michael Lieberman: Impact of Decision Support in Electronic Medical Records on Lipid Management in Primary Care. Clinics that were already using GE’s ‘Centricity’ electronic medical record (EMR) and were members of the ‘Medical Quality Improvement Consortium’ (MQIC) were randomly assigned to either: a) an interactive point-of-care EMR disease management tool (12 clinics with 26,696 patients), or b) usual use of the EMR (13 clinics with 37,454). The tool consisted of an on-screen ‘pop-up’ that included a warning, patient assessment and patient management prompts. One year later, high risk patients (as determined by ATP-III criteria) were statistically significantly more likely to be tested. However, there was no difference in the rates of blood cholesterol levels being at recommended levels or being on lipid-lowering medications. Moderate and low risk patients were no different in both testing and being at recommended levels. Maybe it was the Centricity EHR, maybe it’s because docs don’t like/respond to pop-ups, maybe there are no financial incentives or maybe the EMR just doesn’t have the healthcare mojo the HIT nudninks would have us believe. Heads up Mr. Blumenthal.

Kurt Angstman, Ramona DeJesus and Mark Williams: Initial Implementation of a Depression Care Manager Model: An Observational Study of Outpatient Utilization in Primary Care Clinics. This is a retrospective study looking at the impact of an ICSI ‘coordinated’ and creatively named ‘Depression Improvement Across Minnesota Offering a New Direction’ (DIAMOND) project that is housed within two Rochester area Mayo Family Clinics with about 19,000 patients. Two care manager nurses were hired to assist in the care of patients with depression (defined as not only having the diagnosis but a PHQ score of 10 or greater). 38 DIAMOND participants were compared to 49 depressed patients who went without the care managers. DIAMOND patients had a higher number of return visits (averaging 1.24 vs. .69 for any reason and averaging .95 vs. .55 for depression) within a month. However, in looking at the proportion with at least one visit, 66% of the DIAMOND patients had a return visit for any cause within a month vs. 37% of controls (a difference that was statistically significant) and 55% of the DIAMOND patients had a return visit for depression in one month vs. 32.7% of the controls (not statistically significant). While the authors pronounced DIAMOND a success, the inability to find a statistically significant increase in the proportion of patients with follow-up visits for depressionthe basis of a key HEDIS measure – makes the DMCB think otherwise about the 'success.'

Tine Hansen-Turton, Caroline Ridgway Sandra Festa Ryan and David Nash: Convenient Care Clinics: The Future of Accessible Health Care – The Formation Years 2006-2008. This is a thoroughly referenced history, description, review and editorial for Convenient Care Clinics (CCCs). If you can get past the marketing infomercial-like framing (the early ‘fledgling years,’ or ‘pleased’ consumers ‘ have ‘driven ….the increase in third party contracting, or ‘the core values’ are ‘quality, accessibility, price transparency and affordability,’ or CCCs ‘resonate with parents’ etc. etc.) you can learn about the Convenient Care Association, Harris polls, the growth of the industry, a RAND study that purports to show CCCs Are A Righteous And Good Thing, the underlying business model and the regulatory challenges.

Jane Stacy, Seven Schwartz, Daniel Ershoff, Marilyn Standifer Shreve: Incorporating Tailored Interactive Patient Solutions Using Interactive Voice Response Technology to Improve Statin Adherence: Results of a Randomized Clinical Trial in a Managed Care Setting. Humana randomized enrollees on statins to either 1) three behaviorally-based highly personalized interactive voice response (IVR) phone calls coupled with personalized mailed materials (N=253) or 2) one IVR call and generic mailed materials (N=244). At six months, the group with the high intensity IVR was more likely to have submitted a pharmacy claim for their statin (implying they were taking their pills) than the lower intensity group: 70% vs. 61%. Other measures of medication compliance were also statistically significantly different. The authors state their intervention consisting of ‘an amalgam of discrete elements borrowed from various evidence-base adherence-enhancing strategies ….based on multiple behavioral theories,’ works, but its vagueness makes it difficult for the reader to assess whether the intervention is truly generalizable. Readers may also wonder why the control group didn’t get three low intensity phone calls: it’s possible it was the calls alone, not the content, that led to the 10% absolute improvement seen in the study population. (As an aside, IVR was used to recruit potential candidates for participation in the research project and ‘73% could not be contacted by the IVR system after three months’ of multiple attempts. Is IVR the blanket communication tool that many believe it is?)

Yujing Shen, Usha Sambamoorthi, Mangala Rajan, Donald Miller, Ranjana Banerjea, Leonard Pogach: Obesity and Expenditures Among Elderly Veterans Health Administration Users with Diabetes. This study used the 1999 Large Health Survey of Veteran Enrollees (LHSVE) and the 1999 Diabetes Epidemiology Cohort (DEpiC) to assess the interplay between diabetes, accompanying obesity and the costs among VA patients who were also enrolled in Medicare. Only 21% had a normal body mass index (BMI); the remainder were overweight (48%), obese (23%) or morbidly obese (9%). While you would think that excess weight would be associated with higher costs, that’s not what was found: a normal BMI had more than $10,000 in yearly expenditures, followed by overweight ($7500), obese ($6600) and morbidly obese ($6700). The authors looked into the categories of claims expenses and could find no simple explanation, summing things up by saying a normal BMI may be associated with ‘poorer health.’ While the findings are counterintuitive, the authors point out there are other studies that show a reverse relationship between weight and costs among elderly persons with chronic illness. Maybe the widespread assumption that there is a ROI from weight loss and that this a reason to include it in care management for an elderly population should be revisited.

Brian Leas, Bettina Berman, Kathryn Kash, Albert Crawford, Richard Toner, Neil Goldfarb and David Nash: Quality Measurement in Diabetes Care. Did you know there are multiple organizations promulgating their own methodologies for assessing quality in diabetes care? Of course you did, but the extent of the problem may be greater than you think. It’s tough enough that different groups (like the NCQA or the National Quality Forum and others) recommend different measures. For measures where there is agreement (for example hemoglobin A1c), there are differing standards over the determination of the numerator and denominator, the target goal or the time frame. After surveying the various quality standards organizations, the authors then asked an expert group of ‘key informants’ if they found the complexity problematic. Short answer: yes. In addition to better ‘harmonization,’ the authors recommend that some missing measures be developed, such as assessments of interventions for ‘pre’-diabetes, ‘population-based’ metrics (not just the patients with a claim or a provider visit with an index condition), better attention to measures in the unemployed or uninsured populations, patient-centric measures and assessments of access to care. Good idea says the DMCB.

Roxana Maffei, Daniel Burciago and Kim Dunn: Determining Business Models for Financial Sustainability in Regional Health Information Organizations (RHIOs): A Review. If you’re interested in boning up on Regional Health Information Organizations (RHIOs), this is the article for you. Reports of their death have been greatly exaggerated but their economics remain murky. Among the few RHIOs that have survived, success seems to be associated with being a free standing organization with a business model predicated on membership fees (local health organizations involved in exchanging data pay a fee to belong, i.e., pay to play) and transaction fees (billing the participating organizations based on the number or type of transactions occurring). This article points out that this is still very much a work in progress. Stay turned.

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