Insulin Therapy in Patients with Type 2 Diabetes Mellitus

Objective: To support policy-making for patients with diabetes mellitus we compared the costs and effectiveness of initiation of insulin therapy in patients with type 2 diabetes mellitus in 2 settings in The Netherlands. Design: Retrospective cohort study. Setting: A shared-care setting and an outpatient care setting of a university hospital. Both settings are located in Amsterdam, The Netherlands. Patients: All patients with type 2 diabetes mellitus above 40 years of age who were transferred to insulin therapy in 1993 in both settings. Intervention: Initiation and monitoring of insulin therapy in patients with type 2 diabetes mellitus. Study perspective: Healthcare sector. Main outcome measures: Baseline and 12 months glycosylated hemoglobin (HbA_1c) values and fasting blood glucose levels, and direct healthcare costs of insulin therapy. Costs were expressed in 1996 Dutch guilders (NLG) [NLG1 = 0.5 US dollars ($US)]. Results: In the shared-care setting (n = 57) the per patient healthcare costs during 1 year of follow-up averaged NLG2467. In the secondary care setting (n = 45) healthcare costs averaged NLG2740. A sensitivity analysis demonstrated that healthcare costs per patient were in the same range in both settings, ranging from NLG2000 to about NLG3400 ($US1000 to $US1700). Mean HbA_1c values fell from 9.1 to 7.9% (shared-care setting; p < 0.05) and from 10.2 to 8.2% (secondary care setting; p < 0.05). The percentage of patients with poor glycemic control (HbA_1c >8.5%) decreased from 56 to 30% (shared-care setting) and from 76 to 36% (secondary care setting). The percentage of patients with good glycemic control (HbA_1c <7%) increased from 4 to 23% (shared-care setting) and from 2 to 18% (secondary care setting). Conclusions: The study shows that in the first year of insulin therapy in patients with type 2 diabetes mellitus, acceptable glycemic control (HbA_1c >8.5%) can be attained in the majority of patients in both a shared-care and a secondary care setting, at comparable low average costs per patient.     

Analysis of Asthma-Related Costs and Patterns of Resource Utilization in a Managed-Care Population

Objectives: To identify the asthma prevalence rate, the total healthcare and asthma-related treatment costs, and the medical and pharmacy costs associated with different asthma medication usage patterns in a managed-care organisation (MCO). Study design and participants: The medical and pharmacy claims databases from a 400 000 member MCO were used. The medical claims database was searched from 1994 to 1996 for patients having at least one asthma medical claim in either the first or second diagnosis field of the medical claims, and the total healthcare and asthma-related costs were determined. A subpopulation with a more restrictive asthma definition was identified and their costs were also determined. In addition, the patterns of drug treatment were identified. Study perspective: MCO perspective. Results: The mean total healthcare cost of caring for patients with asthma was significant and approximately twice the mean cost of all patients enrolled in the MCO. Using a broad definition of asthma, the mean (± standard deviation) annual total per patient healthcare cost was $US2511 ± 7314 and the annual asthma-related cost was $US679 ± 2247 (1996 values). Using a more restrictive definition of asthma, the mean annual total per patient healthcare cost was $US2653 ± 5268 and the asthma-related cost was $1026 ± 2447. There appeared to be a low overall use of asthma medications, especially anti-inflammatory formulations; <3% of patients with asthma were high users of anti-inflammatory inhalers. Conclusions: Patients with asthma are costly to managed-care organizations. Asthma-related costs constitute a minority (<30%) of the costs of caring for these patients, and under utilization of anti-inflammatory products by patients is widespread. Further research is needed to assess the cost impact of different asthma treatment patterns.     

One-Year Outcomes from a Disease Management Program for Chronic Obstructive Pulmonary Disease

Objective: to present the results of our 1-year, telephonic disease management interventions for 349 patients with mild to severe chronic obstructive pulmonary disease (COPD). Methods: parameters measuring utilization of medical services, days lost from work, and quality-of-life measurements (utilizing the St. George’s Questionnaire) were determined for the 12-month period prior to enrollment of patients and compared with those observed during the 12-month participation in the program. Results: there was a statistically significant reduction in all utilization measurements and a statistically significant improvement in quality of life. Emergency room (ER) visits decreased by 57% (p < 0.001), hospitalizations by 53% (p < 0.001), intensive care unit admissions by 66% (p = 0.001), unscheduled office visits by 67% (p < 0.001), and oral antibacterial bursts by 48% (p < 0.001). Of the 114 employed patients, days missed from work were reduced by 77% (p < 0.001). The total saving from reduction in hospitalizations and ER visits was $US672 000. This was against an approximate cost of the program of $US223 500 (average of $US635 per enrollee). Costs associated with medications and physician visits were not obtained. Conclusions: these outcomes suggest that, with ongoing patient support, the provision of physical rehabilitation, and improved communication between those engaged in the healing process, it is possible to reduce utilization and overall healthcare expenditures and improve the quality of life for a population of patients with moderate to severe COPD. This intervention was both cost effective and medically effective. Our experience suggests that further trials of COPD disease management are warranted.     

Standardized Telephonic Case Management in a Hispanic Heart Failure Population

Background: Heart failure (HF) is as common in Hispanic as it is in non-Hispanic populations. However, there do not appear to be any published reports of HF disease management programs which include Hispanic populations. Objective:To test the effectiveness of a standardized telephonic disease management intervention, Pfizer Inc.’s At Home With Heart Failure?, in decreasing acute care resource use and cost in Hispanic patients with HF. Participants and methods: A factorial design was used to analyze data obtained in a randomized controlled clinical trial. Patients with HF were enrolled in the trial when admitted to hospital, randomized to the intervention or usual care control groups, and followed for 6 months. Of the 358 participants, 93 (26%) were Hispanic (35 in the intervention group, 58 in the usual care group). Data were analyzed to determine if comparable decreases in acute care resource use were evident in Hispanic and non-Hispanic intervention group patients. Intervention: Registered nurses telephoned patients after hospital discharge to provide advice, solve problems, encourage adherence, and facilitate access to needed services. Results: Acute care resource use was lowered as effectively in the Hispanic patients as in the non-Hispanic patients, despite significant between-group differences in education, income, and living situations. When a fully crossed (language by group) analysis was conducted, no significant differences were found between the Hispanic and non-Hispanic intervention groups. However, in most categories there was a trend towards lower resource use in the Hispanic intervention group. The cost of inpatient care was more than $US1000 (2000 values) less in the Hispanic than the non-Hispanic intervention group. Conclusion: The results of this study suggest that Hispanic patients with HF are receptive of, and responsive to, a case management intervention provided in a culturally competent manner, despite differences in cultural views on chronic illness and self-care as discussed in the literature.     

Excess Healthcare Costs Associated with Excess Health Risks in Diseased and Non-Diseased Health Risk Appraisal Participants

Background: Concerns regarding the effectiveness and impact of disease management are largely based on disease compliance measures. Although disease management programs have measured improvements in compliance and quality of life and cost savings from reductions in hospitalizations and emergency room visits, few programs have focused on changing behavioral health risks not directly related to the specific disease. The basic relationship between behavioral health risks and healthcare costs shows that those individuals with more high-risk behaviors are associated with higher healthcare costs compared with those with low-risk behaviors. The concept of excess costs associated with excess risks is a calculation of theoretical maximum percent savings for an entire group assuming everyone reduces to low risk, and changes in healthcare costs follow the changes in risks. Objective: To establish the magnitude of excess healthcare costs associated with excess health risks, given a diagnosed chronic disease. Methods: 135 251 current and retired employees of General Motors Corporation who had completed a Health Risk Appraisal (HRA) were evaluated. Participants were continuously enrolled in traditional or Preferred Provider Organization (PPO) medical plans from 1996 to 1999 and had completed at least one HRA between 1996 and 1998. Results: Those with and without self-reported disease averaged 19.2 and 9.1% excess healthcare costs associated with excess health risks, respectively. However, the magnitude of the impact differed across age groups and diseases. Individuals less than 45 years of age with self-reported disease were most affected by the presence of additional health risks (44% excess costs) while those aged ≥65 years without disease were least affected (8.2% excess costs). Among those with diseases, those with diabetes mellitus and bronchitis/emphysema were most affected (19.2 and 21.0%, respectively). Conclusions: Disease management programs should ideally provide a systematic approach to assist patients with interventions that improve overall health, as well as focusing on disease compliance measures. The implications for disease management programs are that, even given the presence of disease, promoting and/or maintaining low-risk status can result in potential cost savings.     

Targeting High Utilisers

Objective: To examine the utility of a self-reported health perception assessment as a screening tool to predict high near-term utilisation of healthcare services. Design and setiing: Prospective cohort study in a Midwest US commercial managed-care population. Participants completed a 70-question/126-response item paper-based health perception assessment (including demographic items) in late August 1997. Healthcare claims data were subsequently obtained from the health plan for the next 6 months and converted to total number of encounters and total dollars for each respondent. The dependent variable was the total number of encounters re-coded to a dichotomous variable with the cut-off set at 6 or more encounters as a subsequent high care user. All health perception assessment variables were dichotomised as well and then evaluated as independent variables for their ability to predict the probability that a member would become a high care user over the next 6 months.A split-half technique was used to identify the predictive model from the first half of the sample using logistic regression analysis. A formula was subsequently developed from that defined logistic model and then tested on the first split-half for levels of sensitivity and specificity. The chosen predictive formula was then tested using data from the other half of the sample. Study participants: A sample of 4210 non-institutionalised enrollees of the health plan, ranging in age from 18 to 65 years, who responded to an initial health perception assessment and were continuously enrolled in the health plan for the next 6 months. Main outcome measures and results: Using logistic regression for the first split-half of the sample, the resulting predictive model included 39 health perception assessment variables, correctly predicting 68.1% of the high care users and 61.9% of the low care users. The final logistic model was converted to a formula resulting in a probability score for each member, which indicates the likelihood the person will become a high utiliser in the near term. This formula was tested on both split-halves of the population yielding 66.7% sensitivity and 63.4% specificity on the first split-half and 59.4% sensitivity and 53.3% specificity on the second split-half. The predictive model permitted the number of health perception assessment survey questions to be lowered to 48 with 74 responses. Conclusions: Easily ascertained self-reported factors predict an adult’s probability of becoming a near term high care user. Utilising a powerful self-report survey overcomes many of the limitations of using less predictive traditional health risk/status models or cumbersome claims stratification methods.     

Economic Evaluations of Influenza Vaccination in the Elderly

Objective: To determine (i) whether influenza vaccination in the elderly is cost effective or cost saving compared with a non-intervention strategy and (ii) whether it is worth framing a vaccination policy for this population. Background: Influenza causes substantial morbidity and mortality in elderly people. Despite the availability of effective vaccines against this disease, vaccine coverage in the elderly is low in many countries. Evaluations of the economic impact of influenza vaccination can support public health policy decisions concerning vaccination and also may help influence changes in practice behaviour. Methods: We performed a literature review of cost-benefit and cost-effectiveness evaluations of influenza vaccination in the elderly. We provide a summary of the principal findings from 11 economic evaluations of influenza immunisation and discuss their effect on policy decisions for vaccination in the elderly population. Results: The cost-benefit and cost-effectiveness results in elderly individuals, derived from 7 model-based simulations, 3 observational analyses and a casecontrol study, all support the recommendations for vaccination of all persons of 65 years and over that are currently endorsed in the US, Australia, New Zealand and many European countries. All evaluations showed that influenza immunisation was cost effective or would result in cost savings compared with a novaccination strategy. Conclusions: Although clinical and economic data indicate the benefit of influenza vaccination in the elderly, the vaccine coverage rate in many countries is disappointing, even when vaccine is provided free of charge. It is clear that strategies aimed at the patient or healthcare provider are needed to increase implementation of a vaccination policy to ensure that any recommended vaccine programme is clinically and economically effective.     

Treatment of Pneumonias in a Managed-Care Organisation

Objective: To evaluate a pneumonia disease management programme in a naturalistic setting. Design and Setting: A 300 000 member managed-care organisation introduced an antibacterial treatment guideline designed to change antibacterial prescribing by physicians. A relational database was created to measure changes in healthcare resources, use of antibacterials and health event profiles. One year of data before and after promoting the treatment guideline was compared. Intervention: The primary disease management intervention was the promotion of the guideline through mailings and face-to-face interventions by 2 disease management specialists. Participants: All patients with pneumonia diagnoses on the medical claims database were included in the analysis. Results: The study demonstrated that medical costs increased by 5 to 10% after the treatment guideline was implemented. Health event analysis demonstrated changes in antibacterial prescribing and average cost per antibacterial selected. In both years, the highest success rate was with the amoxicillin group. Although there were fewer patients, doxycycline also had success rates of at least 70%. The econometric model demonstrated that holding other variables constant, including patient age and the presence of any comorbidities, treatment with amoxicillin was associated with a statistically significant reduction in health event costs. Conclusions: The study identified the need for validating treatment guidelines with results from actual practice. The data also demonstrate the use and importance of measuring clinical and economic outcomes from disease management interventions by using databases readily available within most managed-care organisations. In addition, the econometric model was useful in comparing different drug groups with these retrospective data.     

Impact of a Migraine Disease Management Program

Objective: To assess the impact of a comprehensive migraine disease management program, as measured by humanistic outcomes measures, conducted in a managed care setting. Design: A prospective comparative study comprised of an intervention and a control group to evaluate the impact of the disease management initiative. Setting: Independent Practice Association (IPA)-type managed care organization. Study participants and main outcomes measures: Study participants resided in adjacent regions (intervention region included Minneapolis, MN, USA and the usual care region included St Paul, MN, USA and adjacent areas in MN, USA) separated by natural geographic barriers. Eligible patients were identified through a review of the Medica plan’s administrative claims database and were asked to complete the Migraine Therapy Assessment Questionnaire (MTAQ), a tool to assess the presence of migraine management issues. Responders (patients completing the MTAQ) who reported ≥2 migraine care risk indicators in the intervention region received the disease management intervention, while all responders in the control region received usual care. Responders in both regions with ≥2 migraine care risk indicators were also asked to complete the Migraine Disability Assessment (MIDAS) questionnaire and the 12-item Short Form Health Survey (SF-12) at baseline. All participants were asked to complete the same instruments at the end of the program as they did at baseline. Interventions: Disease management intervention activities included patient and physician education, as well as a patient feedback report containing migraine care risk indicators, which was sent to the treating physicians. All patients were encouraged to contact their physicians if they reported two or more migraine management issues. Results: A total of 2232 patients with migraine were enrolled in the study (1373 from the intervention region and 859 in the control region). Compared with patients in the control region, patients in the intervention region reported, as measured by MTAQ, significant improvement in migraine symptom relief, more knowledge about potential migraine triggers, a decrease in economic burden, and more satisfaction with migraine treatment. In addition, the change in MIDAS scores from baseline showed a greater shift towards decreasing disability in the intervention group compared with the control group. However, no statistically significant improvement was detected in terms of health status as measured by SF-12. Of the participants in the intervention region who completed the program evaluation survey, 40% indicated that they called or visited their physicians regarding their migraine survey results if it was recommended. For those contacting their physicians, 76% had their medications changed and 75% noted an improvement in relief due to a change in medication. Conclusions: Considering the significant toll of migraine on patients, employers, and the healthcare system, healthcare plans should consider implementing migraine disease management programs to improve migraine care.     

Behavioural Medicine Group Intervention for High-Utilising Somatising Patients

Objective: To determine the clinical effectiveness of a standardised behavioural medicine group intervention when implemented by different group leaders in 7 geographically diverse healthcare organisations (HCOs). Design: This study used longitudinal data collected for quality assurance purposes. Patients were asked to complete questionnaires measuring presenting problems (Initial Health Status questionnaire), health and functional status [Short Form-36 Health Survey (SF-36)], and physical [Medical Symptom Check List (MSCL)] and psychological distress [Brief Symptom Inventory (BSI)]. Intervention: The Personal Health Improvement Program? (PHIP) designed to treat somatising high utilisers of general medical services. Participants: Patients enrolled in PHIP courses at 7 different HCOs. Complete data were collected from 1194 patients before the course, 787 immediately after the course and 467 at a 6-month follow-up. 39% of patients who finished the course completed questionnaires at all 3 time-points (times 1, 2 and 3, respectively). Of the 467 patients who provided data at all points, complete information was obtained for 356 patients (the study sample). Main outcome measures and results: Patients’ symptoms of anxiety, depression, hostility and somatisation, as well as overall psychological distress improved (p ≤ 0.001) after the course and at follow-up as determined by repeated measures by group analysis of variance (ANOVA). Results were similar for health status (SF-36), with significant improvements in all of the functional health measures between time 1 and time 3. The majority of participants completing the PHIP reported long term reductions in patterns of distress commonly associated with high levels of medical utilisation. Participants also reported improvements in functional status. In addition, the value of the programme was highly rated by participants. Conclusions: Despite the lack of a control group, the consistency of these findings across the sites are likely to be due to the clinical effectiveness of the course content. The PHIP is an effective and standardised programme, which can be taught to leaders in a short period of time and implemented across very different sites to different populations.     

Technology-Based Disease Management

Background: Although information technology applications are part of all disease management programs, most programs involve extensive nurse interventions. Objective: To present clinical and financial outcomes data from One Health Plan’s technology-based program(s), which provide asthma, diabetes mellitus, and cardiovascular care to over 90 000 participants. Methods: The programs are designed to support the health plan’s patient population with asthma, diabetes, congestive heart failure, and coronary artery disease. Data from the health plan’s medical and pharmaceutical claims were used to identify the total patient population. The program(s) use extensively mail, Internet, and Interactive Voice Response (IVR) services with only limited nurse interventions to engage the patients and intervene in their care.Patient engagement consisted of an introductory mailing supported by follow-up mailing. The objective was for the targeted patient to respond by completing a survey on paper, over the Internet, or via IVR. The CareResults ^SM program, uses participant-reported information to risk stratify the population and to track patients progress as part of the measurements of the program’s results. The risk stratification algorithm scores the participant’s clinical status and ability to self-manage their care. Both dimensions impact the participant’s risk score, which in turn determines the follow-up activities. CareResults ^SM mails a personalized feedback booklet as part of a care kit to educate the participant on the current treatment protocols. The goal is to help the participant recognize good healthcare and teach them to work with their physicians to achieve this. Results: The programs demonstrate that improved outcomes can be rapidly achieved for a large number of participants without costly nurse interventions. One Health Plan offered the program to over 250 000 members in the year 2000 and had over 93 000 elect to participate. Improved clinical outcomes were demonstrated for asthma, diabetes, and the cardiovascular diseases. Highlights include a 55.2% increase in candidates with diabetes receiving glycosylated hemoglobin A_1c test, and a 27% self-reported increase in the use of low-dose aspirin for participants with a cardiovascular condition. Financially, current analysis comparing 1999 costs to 2000 costs indicates that the program’s per member per year net savings ranged from $US300 to $US1000 depending on the specific disease state. In all cases, the programs demonstrated a significant positive gross saving. Conclusion: One Health Plan’s experience demonstrates that the technology-based CareResults ^SM program produces positive financial and clinical results without significant nurse interventions.     

Methods Aimed at Improving Asthma Care and Outcomes Management

Objectives: To compare the experience of one managed care organization (MCO) [Anthem Blue Cross and Blue Shield Midwest Region] to the experience of a reference group of 15 other MCOs participating in a study designed to test the usefulness of outcomes management information in developing and implementing interventions to improve the quality of care in asthma. Study design: Prospective study. Patients and methods: Adult patients with moderate or severe asthma enrolled in sixteen participating MCOs who completed an initial baseline survey in 1993 and follow-up surveys in 1994 and 1995. Data analyses focused on differences between Anthem and the reference group at each round of data collection as well as longitudinal analyses of changes over time. Results: Baseline data suggested some deficiencies in care at all MCO sites. Cross-sectional comparisons between Anthem and the reference group revealed statistically significant differences in outcomes measures (hospitalization and emergency room visits, canceled activities per month because of asthma, asthma attacks per month, and work days lost in the past month). Improvements in these outcomes were reported over the subsequent two years. Patients at Anthem reported a significantly greater increase in peak flow meter (PFM) possession than did those in the reference group (p = 0.01) which may have resulted from an administrative change that made PFMs a funded item. However, other interventions (e.g. educational programs) may have also contributed to the improvements. Conclusions: This study illustrates the ability of MCOs to collect and use patient-reported outcomes data to monitor and improve patient care. Such information allowed this national group of participating MCOs to identify deficiencies in quality of care provided, design tailored interventions and measure the potential impact of these interventions on patient care.     

An Empirical Model for the Development of Disease Management Programs in General Practice

Objective: The aim of this research was to develop an empirically derived methodological model for the development of disease management programs in general practice. The model was developed applying the example of hypertension. Methods: Using a rapid appraisal framework, empirical investigations, which included structured panel discussions, face-to-face structured interviews and formal presentations, were conducted to design, test and confirm the disease management model. A broad range of stakeholders were consulted from general practice, other health providers, industry, federal government and consumers. Results: The outcome of the research was a testable definition of disease management for hypertension, and the Australian Disease Management Approach to Hypertension in General Practice (ADAGE) for patients at low to high risk of major cardiovascular events. The central platform of this program is an information, communication technology package for risk assessment and management, plus access to a dietician commissioned by the program and a tailored suite of audiovisual and written material. Conclusion: This study used hypertension to demonstrate a model for the development of theoretically sound disease management models for application in general practice. The ADAGE program is currently under evaluation in a cluster randomized trial of 76 general practices in South Australia and Victoria in both metropolitan and rural settings. It is anticipated that this model will contribute to the development of other disease management programs for addressing chronic disease.     

Comparative Studies of Metal Air Pollution by Atomic Spectrometry Techniques and Biomonitoring with Moss and Lichens

Our study was dedicated to the analysis of air pollution level with metals in Dambovita County, Romania; maps of the concentration distributions for air pollutants were drawn; statistical analysis includes calculation of the background concentrations and the contamination factors. The highest values of the contamination factor CF is 63.1 ± 6.63 for mosses samples and 33.12 ± 3.96 for lichens and it indicates extreme contaminations in the surroundings of steel works and an electric plant. The comparison of the distribution maps for Cr, Cu, Fe, Ni, Pb and Zn concentrations enables the identification of the pollution sources, the limits of areas with very high levels of pollution, the comparison of the concentration gradients in some areas and the influence of woodlands on the spread of pollutants through the air.     

Hepatitis C Screening and Treatment versus Liver Transplantation

Objectives: To: (i) calculate the number needed to screen (NNS) and community effectiveness of combination treatment (interferon-α plus ribavirin) compared with its efficacy of 28 to 45%; (ii) compare the cost of opportunistic hepatitis C virus (HCV) screening and combined treatment to prevent 1 high risk patient developing cirrhosis with the cost of liver transplantation; and (iii) put a cash value on how much purchasing authorities should bid in a commissioning round for new HCV treatments. Design: (i) A financial option appraisal of liver transplantation versus opportunistic HCV screening and treatment; (ii) a financial/commissioning model from a purchasers’s perspective using the latest national and international standards/guidelines and audit reports. Setting and participants: West Kent Health Authority (963 000 residents and 9 primary care groups). All patients at high risk of HCV presenting to health services in 1998/1999 who had an anti-HCV test. Results: Using current National Institute of Clinical Excellence (NICE) guidance (combined treatment for moderate to severe liver changes), about 113 479 high risk persons need to be screened and medically treated, costing about 50 947 pounds sterling (£) to prevent 1 patient developing cirrhosis in 10 to 20 years. The community effectiveness therefore is 0.00088%.Thenetpresent value (NPV) of HCV screening and combined treatment is ?£32 471 to ?£25 407 to prevent 1 patient developing cirrhosis compared with liver transplantation; and the marginal cost to fund current volumes is £54 000. In contrast, if current international standards were used (which advocates combined treatment for mild, moderate and severe liver changes), the NNS is 118 to prevent 1 high risk patient developing cirrhosis; the community effectiveness is 0.847%; the NPV is ?£6479 to £584; and the variable cost to fund current volumes is £796 850. Conclusion: The community effectiveness of combined treatment, at best (i.e. using the international model), is 33 to 53 times less than its efficacy; HCV screening and drug treatment is more expensive than liver transplantation. Furthermore, the international model is a far more technically efficient pathway for delivering HCV care than that recommended by NICE guidance.