Wednesday, October 27, 2010

Peer Reviewed Versus Press Released: The Patient Centered Medical Home Needs to Learn from the Mistakes of the Disease Management Industry

In the Stephen King TV movie The Langoliers, passengers in a star-crossed jet airplane end up in a grey featureless world of "past time." There is no energy, people are strangely absent and there is little in the way of sensation like taste and odor. The rest of the movie, featuring big space-chomping bubbles is rather silly, but the Disease Management Care Blog found the notion of a parallel hollow universe strangely... compelling.

That's because the DMCB and the rest of the disease management industry crossed over from that faux reality years ago. It still has nightmares about that colorless place of vacuous press releases, empty branding campaigns, superficial white papers, marketing fluff and insipid trade publications. Once it re-entered present time, substantive and credible publications like this began reanimate the population health universe.

In this instance, Kaiser tapped their databases to conduct a retrospective cohort study, using a matched control group, to evaluate the impact of a "collaborative cardiovascular risk reduction service" on 628 patients. After statistical adjustment, the program was associated with an approximate $22,000 per patient savings. The published study has the modest title of "Reduced Health Care Expenditures After Enrollment in a Collaborative Cardiac Care Service," uses a rigorously contrived control group, got past the scrutiny of objective peer review, states the program was associated with savings (not caused it) and has enough information to allow readers to make an informed judgment. Sure, it's Kaiser, but they're competitors in an insurance industry competing for patients.

Compare that to an ethereal world of press releases like this from another member of the health insurance industry, South Carolina Blue Cross. The release says that 809 PCMH participants showed a 10.4% decrease in admissions and 12.4% fewer ER visits compared "to the same population's previous year." They also "had better control of cholesterol and glucose levels, improved their Body Mass Index and measures of potential kidney damage, as well as had higher rates of recommended eye exams." In addition to the pre-post evaluation, there was also a comparison to a population of "continuously enrolled diabetic patients treated by all other primary care providers" with similar age and gender mix and similar baseline costs. Compared to that group, there were 11% fewer admissions, 36% fewer inpatient days and 32% fewer ER visits.

The Disease Management Care Blog has some unsolicited advice for its colleagues in the PCMH movement: learn from disease management and resist the temptation to release outcomes results into the public domain with stand-alone press releases. The stakes are too high and that universe is too barren. Policymakers, regulators, government, physicians and patients need to understand the merits of comparison control groups, have the input of objective peer review and grasp the details that go into quantitating "improved" outcomes. Without that, the results - even if they the product of a rigorous analysis - may not only fail policy muster, but end up being chomped on by the Langoliers.

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