Wednesday, March 24, 2010

Why Health Reform's Medicare Prevention Provisions For Diabetes Are As Inadequate As Octogenarian Moon Walking

The Disease Management Care Blog often invites feedback from the DMCB spouse. With her usual discerning eye, she critically appraised yesterday's Part 2 post and characterized it as "bleh bleh disease management blah prevention blah blah blah Medicare personalized prevention plan bleh Pam Anderson bleh blah prevention."

Guilty as charged, but the DMCB forges on with this Part 3 post on the topic of prevention and health reform, while drawing more inspiration from another Dancing With The Stars contestant, Buzz Aldrin. The octogenarian, former jet pilot and moon-walking astronaut did a remarkable job of competing against a much younger field, but his future appearances on that show are numbered. The DMCB agrees with judge Bruno Tonioli: he moved like he still had his moon boots on.

And so does Medicare when it comes to prevention. The DMCB explains.

In the (allegedly off-topic) prior post, it was pointed out that the published science takes a dim view of 1) physician-led and 2) non-selective exercise and obesity prevention programs. That doesn't mean that ALL programs are a waste of time, as amply demonstrated in employer based programs and by Silver Sneakers.

What makes them different than the plodding non-evidence-based approach now included in Federal health reform? They a) don't rely on the patient-physician dyad and b) target their interventions.

Consider the need for preventing diabetes mellitus, where is good news. This randomized prospective New England Journal of Medicine study published back in 2001 showed nutritionist-led "detailed" dietary advice with food record review, along with regular, supervised and tailored exercise sessions reduced the incidence of diabetes in persons at risk to 11%, versus a 23% in the control group, over 4 years.

And check out this Diabetes Prevention Program study that was published the following year, also in the New England Journal. Persons at risk for diabetes were randomly allocated to either a) "life style recommendations," b) receipt of the same recommendations plus taking a drug called metformin (which was thought to possess some preventive potential) or c) a far more rigorous "intensive program of lifestyle modification." The latter arm of the study was designed....

" achieve and maintain weight reduction of at least 7 percent of initial body weight through a healthy low-calorie, low-fat diet and to engage in physical activity of moderate intensity, such as brisk walking, for at least 150 minutes per week. A 16-lesson curriculum covering diet, exercise, and behavior modification was designed to help the participants achieve these goals. The curriculum, taught by case managers on a one-to-one basis during the first 24 weeks after enrollment, was flexible, culturally sensitive, and individualized. Subsequent individual sessions (usually monthly) and group sessions with the case managers were designed to reinforce the behavioral changes" (bolding from the DMCB).

After just less than 3 years, the incidence of diabetes was 4.8% in the intensive group versus 7.8% in the metformin group and 11% in the life style recommendations group. A follow-up study showed that the beneficial effect continued after ten years. That's pretty impressive with a number needed to treat of about 20 to prevent one case of diabetes.

So what can be concluded from the success of employer based wellness programs, Silver Sneakers and these New England Journal diabetes prevention studies?

1) Employer based programs succeed because they typically focus their interventions on segments of the population that stand to gain the greatest benefit. They use health risk assessment surveys to identify those persons at risk and to ascertain willingness to participate. The DMCB thinks it may be possible for physicians to also do this during a 1-on-1 personalized prevention plan encounter, but - based on physicians' lack of confidence and perceptions about their patients described in the prior post - that'll be the exception and not the rule.

2) Silver Sneakers succeeds without requiring a physician office visit as a condition of participation. Patients show up at the gym and there are fitness coordinators that tailor programs, much like the interventions described in the New England Journal.

3) The diabetes prevention studies described above, Silver Sneakers and employer-based wellness programs succeed by relying on non-physicians such as nutritionists, fitness trainers and case managers to do the "heavy lifting" of patient engagement and supervision.

And finally, it should be pointed out that fee-for-service Medicare still doesn't cover the actual preventive care by nuritionists, fitness experts or case managers. As of yesterday's health reform signing ceremony, the only that's covered is the physician-based "planning."

Which is why the admiring DMCB regretfully thinks dancing Buzz Aldrin is symbolic of an aging and plodding Medicare. In their prime, Buzz and Medicare were truly remarkable. As the years have gone on, both still deserve utmost respect but let's face it: neither are up to their assigned tasks. This latest bill's prevention provisions is much like Buzz's shuffling moon walk last night: decades late and unable to adapt to the rhythms of a modern age.

In the last installment of this series tomorrow, the DMCB will speculate about what could be done in health reform to take full advantage of what science tells us about prevention. As for Buzz, there is little the DMCB can do, but it wishes his coaching dance partner much luck.

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