Wednesday, March 3, 2010

A Summary of the Latest Population Health Management Journal

The Disease Management Care Blog is broadcasting live tonight from Ottawa, a beautiful city that reminds the DMCB of a private U.S. college campus, only with more traffic. When it passed through Canadian customs, it had three key items in its possession: 1) a U.S. passport, 2) a declaration form and 3) the latest issue of the Population Health Management Journal.

The DMCB knows many of its readers travel also, but they have to use the time trapped in planes, trains, automobiles and airports participating in conference calls while perusing spread sheets, business plans and policy changes. The DMCB feels your pain and comes to the rescue with this very efficient summary of the latest PHM contents. Check it out and decide which articles deserve a closer look when you have the time......

Burton WN, Chen C-Y, Schultz AB, Edington DW: The Association Between Achieving Low-Density Lipoprotein Cholesterol Goal and Statin Treatment in an Employee Population. This study tapped the database of 1607 employees of a large unnamed financial services company who underwent 'executive physical examinations' between 1995 through 2004 that included blood cholesterol testing. 150 of these individuals had filled at least one prescription for a cholesterol lowering drug in the year preceding their last executive examination. While the authors found an unsurprising association between the 'medication possession ratio' (or MPR) and the 150 subjects' cholesterol levels, the most interesting statistic was that only 68% of these individuals filled enough prescriptions to achieve a MPR of 80%. Once again, the science of population-based care management demonstrates that it takes more than a) a doctor telling you to take your pills and b) economic well-being to take full advantage of a medication class that saves lives.

Fayssoux R, Goldfarb, NI, Vaccaro AR, Harrop: Indirect Costs Associated with Surgery for Low Back Pain - A Secondary Analysis of Clinical Trial Data. 150 patients with unremitting back pain were randomly assigned to one of two surgical options: a standard anterior lumbar interbody fusion with a 'cage,' versus a "Charite" artificial lumbar disc. In this analysis, while the authors had a passing interest in comparing the clinical outcomes of the two groups, what caught the DMCB's attention was how long it took for the participants to return to employment. The bottom line is that 55% of individuals were working prior to surgery, this dropped in the weeks following the operation to about 24% and then slowly climbed over two years to about 63%. If you've paid any attention to what workman's compensation experts say, you won't be surprised that regression analysis showed that the greatest predictor of returning to work was being employed prior to surgery. By the way, the DMCB also points out that other studies have shown conservative non-surgical treatment generally results in the same outcomes over the long term. The DMCB thought this article was a good example of how collecting more than traditional "clinical" outcomes data in patients like this can yield rich insights about the expected time to recovery. To employers and patients, these are the outcomes that count.

Bolge SC, Joish VN, Balkrishnam R, Kannan H, Drake CL: Burden of Chronic Sleep Maintenance Insomnia Characterized by Nighttime Awakenings. The sleeping pill manufacturing pharmaceutical industry has been conducting and sponsoring research for years showing that there is an association between sleep disturbance and quality of life. This is such a study, based on a web based survey called the 2006 U.S. National Health and Wellness Survey (NHWS). Of 62,833 respondents, 2% had 'chronic insomnia characterized by awakenings' or CINA. These insomniacs, compared to persons reporting no sleep problems, had more emergency room visits, days in the hospital, visits to physicians, greater unemployment, higher levels of absenteeism and greater 'activity impairment.' None of this is surprising to the DMCB, but it still isn't sure of the directionality: does insomnia "cause" greater insurance claims expense, or does being ill with greater insurance claims expense cause insomnia? Based on this study and others like it, the DMCB still thinks that managed care organizations have reason to be skeptical that disease management sleep programs and/or liberal pharmacy benefit coverage of sleeping pills will help "bend the curve."

Diette GB, Orr P, McCormack MC, Gady W, Hamar B: Is Pharmacologic Care of Chronic Obstructive Pulmonary Disease Consistent with the Guidelines? The authors in this study looked at the claims data base of a "large managed care organization" with 2272 individuals with at least one claim for a provider visit for COPD. Physician prescribing of the various types of inhalers and pills used to treat this condition were all over the map, so the answer to the title of this article is quite consistent with what other studies have shown: "no." Of special interest is a potential benchmark statistic for those of us working in this field: of the persons with a history of one or more exacerbations of their disease that required a course of oral corticosteroids (the last line of defense before putting someone in the hospital), only about 63% had filled a prescription for an inhaled corticosteroid medication. This class of drugs, otherwise known as "ICS," has been showed to prevent the kinds of exacerbations that lead to oral corticosteroids in the first place. This may be the Holy Grail of COPD disease management: getting 100% of patients with "bad" COPD to regularly use their ICS so they don't have to be exposed to the risks of taking oral steroids.

Elliott JP, Desch C, Istwan NB, Rhea D, Collins AM, Stanziano GF: The Reliability of Patient-Reported Pregnancy Outcome Data. If you are running a disease management program and, like all good disease management programs, you want to follow outomes, should you go to the time and expense of requesting and going through copies of the medical records, or can you get away by simply calling the patient and asking what happened? Well, when it comes to pregancy outcomes, this study of 285 high risk moms showed having a nurse call and interview the patient yielded a high 'kappa statistic' when matched up against the patents charts. Yet, while it works in pregnancy outcomes, the DMCB isn't too sure the same is true for other conditions. In addition, the advent of electronic health records and functional registries may eventually lead to another question: does relying on remote electronic access of provider records perform as well as the relatively time-consuming patient interview?

Goldberg SW, Mulshine JL, Hagstrom D, Pyenson BS: An Actuarial Approach to Comparing Early Stage and Late Stage Lung Care Mortality and Survival. Count on those crazy actuaries to examine lung cancer death statistics in the Surveillance, Epidemiology and End Results (SEER) database to come up with a new point of view about early lung cancer detection and survival. When segmented by age, gender and race and compared to persons without lung cancer, it appears being lucky enough to have an early diagnosis of your cancer is associated with a significant survival advantage. The authors also accounted for 'lead time' bias in their analyses to stand by their conclusion that early detection of lung cancer could lead to saving 70,000 lives a year. The DMCB still isn't too sure because a) the article isn't easy to read and b) in addition to lead time bias, some tumors are slow growing, not necessarily detected earlier. When you sit down to read this one, be prepared to go over it several times. The DMCB is going to read this again on the flight back home. It's just not sure if the accompanying beverage will contain caffeine or ethanol.

Twells LK, Knight J, Alaghebandan R: The Relationship Among Body Mass Index, Subjective Report of Chronic Disease and the Use of Health Care Service in Newfoundland and Labrador, Canada. The DMCB suspects, thanks to Canada's health care system, that patients with chronic illness ar more likely to be 'funneled' to a primary care provider and experience queues when it comes to specialist and hospital services. That appears to be the case in this population-based Canadian Community Health Survey (with an impressive reponsive rate of 85%), which found our neighbors to the north have a 17% obesity rate, that those individuals had a greater burden of chronic disease, see primary care physicians more often but don't necessary access other parts of the system with greater frequency. This study would appear to confirm what we already know about obesity and health 'systemness.'

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