Monday, August 12, 2013

Should Patients in Population Health Management Programs Have Access to Lay Care Coaches?

Based on prior posts like this, the Disease Management Care Blog thinks the answer is yes

That being said, this hot-off-the-presses research paper shows just much we need to learn about this emerging approach to the care of persons with chronic conditions like diabetes, high blood pressure and chronic heart failure.

Lay Persons Educating Persons With Chronic Conditions in Primary Care Clinics

The paper was just published in the Annals of Internal Medicine. It was a one year randomized study involving the patients at six Allina Health primary care clinics. 

Twelve lay "care guides" had at least 2 years of college education and "strong interpersonal skills." They received two weeks of education that included setting goals, identifying and overcoming care barriers, behavior change techniques, the limits of scope of practice and how to use the electronic records to message physicians.  It was up to the care guides and the patients to decide on how often they needed to meet in face or by telephone. The guides were supervised by two RNs.

Active (i.e. seen in the clinics within 6 months) patients who agreed to be in the study with high blood pressure, diabetes or heart failure were allocated in a 2:1 ratio to either a "care guide" or usual care. Goals were proscribed and were the usual HEDIS-style outcomes, such as achieving blood pressure control, reaching an A1c level, getting an echocardiogram, being on beta-blocker medications or getting a pneumovax immunization.
The study was not "blinded," in that they and their providers were aware of the assignment. Recruitment began in July of 2010 and the study was completed in April of 2012. 6168 patients were screened, 2135 patients agreed to participate and 1423 and 702 completed the study from the care guide and usual care study arms.


One year later, 82.6% of the care guide patients achieved their selected care goals vs. 79.1% of the usual care patients. That 3.5% increase was statistically significant.

Most of that improvement was accounted by a higher rates of tobacco cessation, pneumovax immunization, getting persons with diabetes to get an eye exam as well as urine protein testing, and getting persons with heart failure to go through an echocardiogram.  There were no statistically significant impacts on blood pressure control, diabetes control, cholesterol control or medication prescribing.

The care guides interacted with their patients on average 7 times (2 face-to-face and 5 by telephone).  They messaged physicians an average of 4 times.  There was no difference between the two groups in primary care office visits. Estimated cost was $286 per patient per year.

The Disease Management Care Blog's take:

There is increasing interest in incorporating lay-persons in the outpatient care of persons with chronic conditions.  That makes sense, because much of the educational "payload" may be deliverable using far cheaper and more engaging "peer" members of the community who - literally - speak the patients' language.  This is a nicely done randomized clinical trial done in a real world setting that adds to our understanding of this care option. The bottom line is that this study showed that the care guides had a real impact.

When the DMCB looks at the actual numbers, it is also clear that the study had an uphill climb.  Many of the baseline measures of blood pressure, diabetes and heart failure quality relatively high to begin with. The impact of the care guides may have been much greater in a population with a lower baseline (such as in this study) with more "room" to move.

Problems to think about for the next study.....

Not all outcomes are created equally: Unfortunately, this study was something of a disappointment because the improvements were spotty, relatively small and limited to lightweight "testing" outcomes vs. more -hard-to-achieve disease control outcomes.  It may one thing for a peer patient to talk a patient into a urine test or a heart scan, it's another getting a patient to take more pills.  That may take a professional educator, a pharmacist or nurse.

What do the patients want: In addition, the goals were based on a one-size-fits-all HEDIS approach.  They were not adaptable, negotiable or subject to shared decision-making.  If that had been in the mix, patient engagement may have been an additional ingredient that could have pushed other outcome measures toward statistical significance.

What do the docs think: The DMCB notes that provider office visits did not go down among the care guide patients compared to the usual care patients. This makes the DMCB wonder if there wasn't enough physician buy-in: if there had been higher trust in the care guides' ability to manage these patients, it would have been reflected in less need to see the patients for a separate appointment.

Predictive modeling to the rescue: Finally, there is the problem of treating all chronic illness patients the same. Not all patients with high blood pressure, diabetes or heart failure are as susceptible to behavior change, and not all patients who engage in behavior change achieve better outcomes.  The trick is to use risk stratification to find the patients with the greatest chance at benefit.  This study may have benefited from a more focused approach.

1 comment:

Anonymous said...

Having, a few years ago run the chronic condition clinical care division of a large national disease management company, I can see this as a useful tool... similar to AA for alcoholics and lay people working with weight loss programs.

My concern is the scalability, training, cost and quality control of these programs.

Another alternative is to use Artificial Intelligence base natural language "Avatars". They can be totally programmed by the agency or MCO deploying them with instant scalability and total control on the content and education. The cost is a fraction of the cost of humans and there is a growing literature base of their efficacy.