Practical Considerations for the Design and Evaluation of Disease Education and Management Programs in the Workplace

This article describes the rationale for health promotion and disease management (DM) activities in the workplace. It also reviews the trends that are driving DM in the workplace, such as increased healthcare costs and reduced length of stay in the hospital setting. Specific discussion of DM in the workplace includes principles of effective program design and evaluation. Some key issues of effective design involve: (i) using a behavioral model for the design framework that addresses the maintenance phase of behavior; (ii) including educational topics beyond the disease-specific issues; (iii) providing materials in a variety of formats; (iv) stratifying the program by risk level; (v) using multiple distribution channels; (vi) having the information reinforce the clinical guidelines; (vii) ensuring repeated contacts with the participants; and (viii) making the program low-cost, easy to administrate and portable. The critical theme in the evaluation of DM programs is to include both process and impact assessments. The uses of experimental and quasi-experimental designs are discussed as tools to determine program impact. The design is also important in order to eliminate alternative explanations for program findings.     

How might diabetes organisations address diabetes‐related stigma? Findings from a deliberative democratic case study

IntroductionThis study sought to identify how diabetes organisations conceptualize the problem of diabetes‐related stigma and how this shapes the selection of stigma‐reduction interventions.MethodsA qualitative deliberative democratic methodology was used to access an informed dialogue about what should be done by diabetes organisations to address diabetes‐related stigma, drawing from the perspectives of board members, healthcare services staff, and communications and marketing staff from a single state‐wide diabetes organisation in Australia (n = 25).ResultsParticipants navigated the stigma concept along two axes: one that drew attention to either disease attributes or personal moral attributes as the object of stigmatisation, and one that positioned stigma as an individual or structural problem. This shaped the selection of stigma‐reduction interventions, which included interventions to: (i) reduce the prevalence of stigmatized attributes, (ii) correct misunderstandings about diabetes, (iii) modify representations of persons with diabetes, (iii) enhance coping amongst persons with diabetes and (iv) make healthcare more person‐centred and democratic.ConclusionThis study identified several grievances with ‘diabetes‐related stigma’, which are grievances that can be conceptualized and addressed at both individual and structural levels, and involve correcting misinformation about diabetes or challenging and communicating alternative representations of persons living with diabetes.Patient or Public ContributionThe organisation''s management and board were consulted throughout all stages of research development, analysis and reporting. The information and vignettes presented to participants drew from illness narratives obtained from earlier research involving adults with type 2 diabetes. Research participants included adults with various diabetes types.     

Disease Management of the Frail Elderly Population

Success stories of disease management programs have heightened the interest of healthcare payors and providers in the adoption of disease management principles for their aging members. However, caution is needed for rapid adoption, as several crucial characteristics within the aging population may clash with disease management principles.When developing disease management programs, the characteristics of the frail elderly must be considered, otherwise there may be a potential for misapplication of disease management principles. For example: (i) frailty is a state rather than a condition; (ii) the complex needs of frail elders are less straightforward and therefore make it more difficult to apply a formalized set of treatment guidelines; (iii) the mental health and cognitive issues may challenge the reliance on self-management; and (iv) the involvement of caregivers may broaden the scope well beyond clinical care.This article summarizes several successes of disease management programs and examines the critical components leading to their success, including patient self-management and education, better provider coordination, risk stratifying tools, and the use of evidence-based guidelines.In considering the possibility of using disease management principles to care for the frail elderly population, this article demonstrates that more research, discussions, and practical applications are needed prior to widespread program implementation. The frail condition experienced by many older adults is not just the sum of several disease conditions; therefore, merely combining several disease management programs to serve this population may prove to be less effective than is hoped. Hence the pursuit of more effective approaches to providing care for an aging population continues. Disease management for the frail is most effective when the treatment integrates both the social and medical needs of the patient and caregivers. It is also essential to manage the patient’s multiple diseases even though the patient selection and primary focus may be on the primary disease.     

Dissonance-based Interventions for the Prevention of Eating Disorders: Using Persuasion Principles to Promote Health

The limited efficacy of prior eating disorder (ED) prevention programs led to the development of dissonance-based interventions (DBIs) that utilize dissonance-based persuasion principles from social psychology. Although DBIs have been used to change other attitudes and behaviors, only recently have they been applied to ED prevention. This article reviews the theoretical rationale and empirical support for this type of prevention program. Relative to assessment-only controls, DBIs have produced greater reductions in ED risk factors, ED symptoms, future risk for onset of threshold or subthreshold EDs, future risk for obesity onset, and mental health utilization, with some effects persisting through 3-year follow-up. DBIs have also produced significantly stronger effects than alternative interventions for many of these outcomes, though these effects typically fade more quickly. A meta-analysis indicated that the average effects for DBIs were significantly stronger than those for non-DBI ED prevention programs that have been evaluated. DBIs have produced effects when delivered to high-risk samples and unselected samples, as well as in efficacy and effectiveness trials conducted by six independent labs, suggesting that the effects are robust and that DBIs should be considered for the prevention of other problems, such as smoking, substance abuse, HIV, and diabetes care.     

Modelling the Economics of Type 2 Diabetes Mellitus Prevention: A Literature Review of Methods

Our objective was to review modelling methods for type 2 diabetes mellitus prevention cost-effectiveness studies. The review was conducted to inform the design of a policy analysis model capable of assisting resource allocation decisions across a spectrum of prevention strategies. We identified recent systematic reviews of economic evaluations in diabetes prevention and management of obesity. We extracted studies from two existing systematic reviews of economic evaluations for the prevention of diabetes. We extracted studies evaluating interventions in a non-diabetic population with type 2 diabetes as a modelled outcome, from two systematic reviews of obesity intervention economic evaluations. Databases were searched for studies published between 2008 and 2013. For each study, we reviewed details of the model type, structure, and methods for predicting diabetes and cardiovascular disease. Our review identified 46 articles and found variation in modelling approaches for cost-effectiveness evaluations for the prevention of type 2 diabetes. Investigation of the variables used to estimate the risk of type 2 diabetes suggested that impaired glucose regulation, and body mass index were used as the primary risk factors for type 2 diabetes. A minority of cost-effectiveness models for diabetes prevention accounted for the multivariate impacts of interventions on risk factors for type 2 diabetes. Twenty-eight cost-effectiveness models included cardiovascular events in addition to type 2 diabetes. Few cost-effectiveness models have flexibility to evaluate different intervention types. We conclude that to compare a range of prevention interventions it is necessary to incorporate multiple risk factors for diabetes, diabetes-related complications and obesity-related co-morbidity outcomes.     

Economic evaluation of lifestyle interventions for preventing diabetes and cardiovascular diseases

Lifestyle interventions (i.e., diet and/or physical activity) are effective in delaying or preventing the onset of diabetes and cardiovascular disease. However, policymakers must know the cost-effectiveness of such interventions before implementing them at the large-scale population level. This review discusses various issues (e.g., characteristics, modeling, and long-term effectiveness) in the economic evaluation of lifestyle interventions for the primary and secondary prevention of diabetes and cardiovascular disease. The diverse nature of lifestyle interventions, i.e., type of intervention, means of provision, target groups, setting, and methodology, are the main obstacles to comparing evaluation results. However, most lifestyle interventions are among the intervention options usually regarded as cost-effective. Diabetes prevention programs, such as interventions starting with targeted or universal screening, childhood obesity prevention, and community-based interventions, have reported favorable cost-effectiveness ratios.     

Age of onset of obesity and risk of type 2 diabetes

Objective : To compare a simple measure ‐ age of onset of obesity ‐ to an obese‐years construct (a product of duration and magnitude of obesity) as risk factors for type 2 diabetes. Method : Participants from the Framingham Heart Study who were not obese and did not have diabetes at baseline were included (n=4,320). The Akaike Information Criterion (AIC) was computed to compare four Cox proportional hazards models with incident diabetes as the outcome and: (i) obese‐years; (ii) age of onset of obesity; (iii) body mass index (BMI); and (iv) age of onset of obesity plus magnitude of BMI combined, as exposures. Results : AIC indicated that the model with obese‐years provided a more effective explanation of incidence of type 2 diabetes compared to the remaining three models. Models including age of onset of obesity plus BMI were not appreciably different from the model with BMI alone, except in those aged ≥60. Conclusions : While obese‐years was the optimal obesity construct to explain risk of type 2 diabetes, age of onset may be a useful, practical addition to current BMI in the elderly. Implications : Where computation of obese‐years is not possible or impractical, age of onset of obesity combined with BMI may provide a useful alternative.     

Population-Based Disease Management in the German Statutory Health Insurance

Social healthcare systems in Europe must cope with aging populations and rising costs. For the German social healthcare system, which dates back to the 19th century, this problem is especially apparent, as soaring structural unemployment and the demographic transition of the population threaten the financial basis of the Statutory Health Insurance (SHI) [Gesetzliche Krankenversicherung]. In order to preserve free access to high-quality care and mandatory insurance for most of the population with affordable contributions, the traditional methods of healthcare delivery are challenged. As a result of its historic development, the system is tailored to acute care. Infectious diseases and accidents, however, have lost their relevance as main sources of mortality and morbidity of the population.Chronic diseases that can be influenced in their course by patient self-management and preventive measures dominate as causes of morbidity, mortality, and rising costs of healthcare. Since cost-containment measures can no longer stabilize cost development, structural reforms are strongly advocated. The implementation of a legal framework for disease management programs is the first of several structural reform measures implemented in the SHI.Diseases for which a legal framework has been approved include type 1 and type 2 diabetes mellitus, coronary artery disease, breast cancer, and asthma/chronic obstructive pulmonary disease. Quality requirements for the programs are high and include a central-accreditation process, evaluation in 3-year intervals by independent investigators, and specific quality management measures outlined for each disease. Major features of the programs include a population-based, patient-centric, and physician-based design. Since 2002, >1.6 million patients were enrolled in diabetes programs nationwide.Preliminary results point to positive effects of the programs on outcomes and process parameters, such as blood glucose and blood pressure readings or performed yearly eye examinations for patients with diabetes. Differences in the German and the US approach to disease management not only include a top-down versus a bottom-up approach; the German approach aims at secondary prevention regardless of risk state, co-morbidities, and possible cost savings, whereas in the US high-risk approaches are common. For the US, the German physician-based approach to disease management could be of interest in the evolving Medicare programs whereas German programs could become more effective drawing on US pay-for-quality experiences.Disease management, whether vendor or physician based, may not be the ultimate solution to all problems in the care of chronically ill patients, but it may facilitate change from a system traditionally focused on acute care to one focused on chronic care.     

Prevention of HIV Among Adolescents

Adolescents are at risk for HIV primarily through their sexual behavior. A comprehensive prevention strategy includes a national HIV campaign based on social marketing principles; targeted social marketing, intensive skill building, and sexually transmitted disease control programs for youth at high risk; programs targeting institutions (e.g., school health clinics), providers, and parents; and interventions to identify and reduce risk acts among seropositive youth. The U.S. focus for HIV prevention has been single-session educational classes (an ineffective strategy) or intensive multi-session, small-group interventions for youth at high risk (demonstrated to increase condom use by about 30%). There is a need to expand the range, modalities, and dissemination of HIV prevention programs nationally, to recognize (especially by policymakers) limitations of abstinence programs, and to increase early detection of HIV among youth.     

Lifestyle intervention for prevention of diabetes: determinants of success for future implementation

Lifestyle interventions are reported to reduce the risk of type 2 diabetes in high-risk individuals after mid- and long-term follow-up. Information on determinants of intervention outcome and adherence and the mechanisms underlying diabetes progression are valuable for a more targeted implementation. Weight loss seems a major determinant of diabetes risk reduction, whereas physical activity and dietary composition may contribute independently. Body composition and genetic variation may also affect the response to intervention. Lifestyle interventions are cost-effective and should be optimized to increase adherence and compliance, especially for individuals in the high-risk group with a low socioeconomic status, so that public health policy can introduce targeted implementation programs nationwide. The aims of this review are to summarize the mid- and long-term effects of lifestyle interventions on impaired glucose tolerance and type 2 diabetes mellitus and to provide determinants of intervention outcome and adherence, which can be used for future implementation of lifestyle interventions.     

A framework for the concurrent consideration of occupational hazards and obesity

Occupational hazards and obesity can lead to extensive morbidity and mortality and put great financial burden on society. Historically, occupational hazards and obesity have been addressed as separate unrelated issues, but both are public health problems and there may be public health benefits from considering them together. This paper provides a framework for the concurrent consideration of occupational hazards and obesity. The framework consists of the following elements: (i) investigate the relationship between occupational hazards and obesity, (ii) explore the impact of occupational morbidity and mortality and obesity on workplace absence, disability, productivity and healthcare costs, (iii) assess the utility of the workplace as a venue for obesity prevention programs, (iv) promote a comprehensive approach to worker health and (v) identify and address the ethical, legal and social issues. Utilizing this framework may advance the efforts to address the major societal health problems of occupational hazards and obesity.     

Relationship between Ultra-Processed Food Consumption and Risk of Diabetes Mellitus: A Mini-Review

Studying the factors that cause diabetes and conducting clinical trials has become a priority, particularly raising awareness of the dangers of the disease and how to overcome it. Diet habits are one of the most important risks that must be understood and carefully applied to reduce the risk of diabetes. Nowadays, consuming enough home-cooked food has become a challenge, particularly with modern life performance, pushing people to use processed foods. Ultra-processed food (UPF) consumption has grown dramatically over the last few decades worldwide. This growth is accompanied by the increasing prevalence of non-communicable diseases (NCDs) such as cardiovascular diseases, hypertension, and type 2 diabetes. UPFs represent three main health concerns: (i) they are generally high in non-nutritive compounds such as sugars, sodium, and trans fat and low in nutritional compounds such as proteins and fibers, (ii) they contain different types of additives that may cause severe health issues, and (iii) they are presented in packages made of synthetic materials that may also cause undesirable health side-effects. The association between the consumption of UPF and the risk of developing diabetes was discussed in this review. The high consumption of UPF, almost more than 10% of the diet proportion, could increase the risk of developing type 2 diabetes in adult individuals. In addition, UPF may slightly increase the risk of developing gestational diabetes. Further efforts are needed to confirm this association; studies such as randomized clinical trials and prospective cohorts in different populations and settings are highly recommended. Moreover, massive improvement in foods’ dietary guidelines to increase the awareness of UPF and their health concerns is highly recommended.     

Self-Management Services

For people with chronic illness, day-to-day responsibilities for care fall most heavily on patients and their families. Organising healthcare to strengthen and support self-management in chronic illness while assuring that effective medical, preventative and health maintenance interventions take place is key to effective disease management.This paper discusses the behavioural principles and empirical evidence about healthcare designed to maximise positive patient participation in chronic disease care. Four main essential elements are key: (i) collaborative definition of problems, in which patient-defined problems are identified along with medical problems diagnosed by physicians; (ii) targeting, goal-setting and planning, where patients and providers together agree on realistic objectives and set an action plan for attaining them; (iii) availability of a continuum of self-management training and support options that teach patients the skills needed to carry out medical regimens, guide health behaviour change and provide emotional support; (iv) active and sustained follow-up during which patients are contacted at specified intervals to monitor health status and reinforce progress in meeting care plan objectives. These elements constitute a common core of services and approaches that do not need to be replicated for each chronic condition.     

Glucose control guidelines: current concepts

The Diabetes Control and Complications Trial (DCCT) ended decades of controversy regarding the necessity of tight glycemic control for type 1 diabetes by demonstrating that glucose control using intensive insulin therapy significantly reduced long-term microvascular complications. The American Diabetes Association (ADA) guidelines empirically support the same goal of attempting to obtain normoglycemia in patients with type 2 disease; however, unlike in type 1 disease, insulin is a tertiary option, following diet, exercise, and oral agents. Emerging long-term intervention data in type 2 diabetes suggest that insulin may pose increased cardiovascular risk in this already 'at-risk' population. However, many type 2 diabetics will eventually require insulin. Clearly, more studies are warranted to assess the risks, benefits, and feasibility of improved glycemic control in type 2 diabetes. Nonetheless, two principles are clear. First, promoting blood glucose levels approaching normoglycemia is an important factor in preventing long-term microvascular complications. Second, type 2 diabetes comprises numerous metabolic conditions; therefore an integrated effort by the patient and healthcare team is required to optimize blood glucose and serum lipid levels and minimize cardiovascular risk factors.     

Key principles for the improved conduct of health technology assessments for resource allocation decisions

Health technology assessment (HTA) is a dynamic, rapidly evolving process, embracing different types of assessments that inform real-world decisions about the value (i.e., benefits, risks, and costs) of new and existing technologies. Historically, most HTA agencies have focused on producing high quality assessment reports that can be used by a range of decision makers. However, increasingly organizations are undertaking or commissioning HTAs to inform a particular resource allocation decision, such as listing a drug on a national or local formulary, defining the range of coverage under insurance plans, or issuing mandatory guidance on the use of health technologies in a particular healthcare system. A set of fifteen principles that can be used in assessing existing or establishing new HTA activities is proposed, providing examples from existing HTA programs. The principal focus is on those HTA activities that are linked to, or include, a particular resource allocation decision. In these HTAs, the consideration of both costs and benefits, in an economic evaluation, is critical. It is also important to consider the link between the HTA and the decision that will follow. The principles are organized into four sections: (i) "Structure" of HTA programs; (ii) "Methods" of HTA; (iii) "Processes for Conduct" of HTA; and (iv) "Use of HTAs in Decision Making."     

Behavior matters

Behavior has a broad and central role in health. Behavioral interventions can be effectively used to prevent disease, improve management of existing disease, increase quality of life, and reduce healthcare costs. A summary is presented of evidence for these conclusions in cardiovascular disease/diabetes, cancer, and HIV/AIDS as well as with key risk factors: tobacco use, poor diet, physical inactivity, and excessive alcohol consumption. For each, documentation is made of (1) moderation of genetic and other fundamental biological influences by behaviors and social-environmental factors; (2) impacts of behaviors on health; (3) success of behavioral interventions in prevention; (4) disease management; (5) quality of life, and (6) improvements in the health of populations through behavioral health promotion programs. Evidence indicates the cost effectiveness and value of behavioral interventions, especially relative to other common health services as well as the value they add in terms of quality of life. Pertinent to clinicians and their patients as well as to health policy and population health, the benefits of behavioral interventions extend beyond impacts on a particular disease or risk factor. Rather, they include broad effects and benefits on prevention, disease management, and well-being across the life span. Among priorities for dissemination research, the application of behavioral approaches is challenged by diverse barriers, including socioeconomic barriers linked to health disparities. However, behavioral approaches including those emphasizing community and social influences appear to be useful in addressing such challenges. In sum, behavioral approaches should have a central place in prevention and health care of the 21st century.     

Prediction and prevention of type 2 diabetes

Type 2 diabetes mellitus is one of the most costly and burdensome chronic diseases of our time and a condition that is increasing in epidemic proportions worldwide. Its complications are a significant cause of morbidity and mortality and a tremendous economic burden to the society. Effective prevention programs are therefore urgently needed. Some of the risk factors for the development of type 2 diabetes, such as obesity, physical inactivity and high-fat diet, can potentially be modified. Compelling evidence now exists from well designed randomized studies that the disease can be prevented or delayed in subjects at high risk for its development, i.e. subjects with impaired glucose tolerance (IGT) or impaired fasting glucose (IFG). The interventions studied include lifestyle modifications (with diet and exercise) and drug treatment. Weight loss with lifestyle modification seems to be the most effective way so far, given the fact that it addresses other cardiovascular disease risk factors as well. The big challenge we are facing now is to try to implement these findings in our society or among our high-risk patients, taking into consideration the great difficulties involved in changing lifestyle and in maintaining lifestyle modifications.     

Using computer technology for HIV prevention among African-Americans: development of a tailored information program for safer sex (TIPSS)

New prevention options are urgently needed for African-Americans in the United States given the disproportionate impact of HIV/AIDS on this group. This combined with recent evidence supporting the efficacy of computer technology-based interventions in HIV prevention led our research group to pursue the development of a computer-delivered individually tailored intervention for heterosexually active African-Americans--the tailored information program for safer sex (TIPSS). In the current article, we discuss the development of the TIPSS program, including (i) the targeted population and behavior, (ii) theoretical basis for the intervention, (iii) design of the intervention, (iv) formative research, (v) technical development and testing and (vi) intervention delivery and ongoing randomized controlled trial. Given the many advantages of computer-based interventions, including low-cost delivery once developed, they offer much promise for the future of HIV prevention among African-Americans and other at-risk groups.     

Interactive Voice Response in Disease Management

The effective management of chronic illness has historically been plagued by patient non-adherence to treatment regimens. While disease management initiatives have recently proliferated in an attempt to more effectively manage these chronic illnesses, many of these new programmes have lacked effective behaviour change interventions. It is expected that this void will hopefully be corrected as more sophisticated second generation disease management programmes are developed.This article explores the major issues and forces driving patient non-adherence and recommends a number of strategies to be used to enhance patient adherence and to improve patient self-management. Specifically, the authors propose 6 guiding principles for improving patient adherence and self-management. These principles include: (i) taking a comprehensive, holistic, patient-centred approach to disease management; (ii) being aware of the many different forms of nonadherence; (iii) facilitation of patient motivation and readiness to change; (iv) collaboratively supporting self-management behaviour; (v) focusing less on problems and more on solutions; and (vi) establishing and maintaining good communications with the patient.The success of disease management will require, in many cases, a major reengineering of how we deliver and coordinate healthcare. Importantly, the development of systematic behaviour change interventions and adoption of a true patient-centred approach to disease management will be essential if meaningful, long term clinical and economic outcomes are to be achieved. Case managers and specialty disease management organisations that focus on the development of new, implementable behaviour change interventions will play a major role in insuring that our second generation of disease management programmes incorporate these new patient empowerment interventions.     

Comparing Smoking Cessation Interventions for Work-Site Disease Management

Smoking cessation continues to be one of the most cost-effective preventive measures for work-site disease management. The US Public Health Service Clinical Practice Guideline, entitled ‘Treating Tobacco Use and Dependence,’ provides guidance for evaluating and choosing smoking cessation programs for work sites.Smoking cessation interventions can be characterized by the resource intensity of the effort, the format and methods of interacting with patients and the focus and objectives of the content. These features are compared with typical group, phone and Internet-based program options. Pharmacotherapy treatment recommendations are reviewed as well as characteristics of first-line nicotine replacement therapy (NRT) medications (e.g. nicotine patch, gum, spray and inhaler) and bupropion.It is suggested that work-site recruitment and participation campaigns may fail for a variety of reasons including: (i) too narrowly cast recruitment messages; (ii) inadequate exposure to campaign messages; (iii) lack of immediate and accessible enrollment mechanisms; and (iv) passive rather than active outreach. Four broad issues to consider when comparing outcomes data from potential smoking cessation programs are: (i) at what follow-up point(s) is the quit rate measured?; (ii) is there a comparison group?; (iii) how was quit status determined?; and (iv) how is the status of participants who are lost to follow-up calculated in the outcomes data?