Impact of a Diabetes Disease Management Program by Race and Ethnicity

Background

In the US, diabetes mellitus affects people in all racial and ethnic groups, but the prevalence and risk of complications are considerably higher among African Americans, Hispanics, American Indians, and Alaskan Natives. This study aimed to evaluate the impact of enrollment for at least 1 calendar year in a diabetes disease management program (DDMP) in a large, commercially insured, managed care population. We assessed changes in utilization of preventive services and adoption of diabetes self-management behaviors by race and ethnicity.

Methods

Participants were aged >17 years and had type 1 or 2 diabetes. They were enrolled in a targeted, high-risk level DDMP between January 2003 and September 2003 and were enrolled in the managed care organization (MCO) for a 2-year period beginning 1 year prior to their enrollment in the DDMP. At baseline, 19 483 MCO enrollees who were participating in the targeted high-risk level DDMP were mailed a 40-item, self-administered baseline survey, which took between 10 and 15 minutes to complete. Baseline results are reported elsewhere. One year later, in June 2004, 5174 of the baseline responders were mailed a slightly modified version of the 40-item survey. The survey measured use of eight preventive services (cholesterol test, dental examination, dilated eye examination, urinalysis, foot examination, influenza vaccination, pneumococcal vaccination, and glycated hemoglobin testing) and engagement in four self-management behaviors (blood glucose tests, diet monitoring, exercise, and smoking avoidance).

Results

Of the 5174 follow-up surveys mailed, 1961 (37.9%) were eligible for comparative analysis. Blacks and Hispanics reported more annual healthcare visits (average of 6.2 and 6.5, respectively) compared with Whites (average of 5.0, p < 0.0001). However, at follow-up, both Blacks and Hispanics had lower utilization rates than Whites for six of the eight preventive services that were measured. At follow-up, both Blacks and Whites were more likely than at baseline to report up-to-date status of influenza and pneumococcal vaccination (p ≤ 0.0001). At follow-up, the racial/ethnic gap in self-management behaviors that was observed at baseline had reduced and in fact had reversed direction for glucose tests, as Blacks were more likely than Whites to routinely test their blood glucose.

Conclusions

These data indicate that DDMP enrollment for at least 1 calendar year had a mixed impact on overall diabetes behaviors and on racial/ethnic disparities in preventive services utilization and self-management behaviors. Further studies are needed to give a clearer understanding of why some diabetic MCO enrollees are less likely to use preventive services, and why disparities remain even in settings where healthcare services are universally available.

     

Cost Analysis of a Maternity Disease Management Program

Background

With over 4 million births annually in the US, pregnancy is a high-volume and high-cost condition for both public and private payers. Although pregnancy is generally considered to be a time of Wellness, certain maternal habits and medical conditions place a pregnancy at risk of maternal and/or neonatal complications. Disease management (DM) provides a framework in which to identify and manage pregnancies at risk of expensive adverse outcomes.

Objective

To analyze the costs of a maternity DM program in a commercial health plan population.

Methods

We conducted an analysis of maternal and newborn data from a commercial health plan collected before utilization of a maternity DM program (baseline period: January–December 2003) and after initiation of the program (operations period: January–December 2004). The maternity DM program consisted of telephonic risk assessment, patient education, and case management of patients identified as being at high risk for adverse pregnancy outcomes. The average costs per high-risk case and high-risk condition were compared between the baseline and operational periods.

Results

A baseline population of 8704 pregnant women in a delivery window of 1 January 2003–31 December 2003 was compared with 7770 pregnant women enrolled for maternity DM in the operations window of 1 January 2004–31 December 2004. In the baseline period, 4756 high-risk conditions were found in 3626 of the 8704 women who experienced a pregnancy (41.7% of patients; a mean of 1.3 conditions per affected pregnancy), while in the operational period, 4377 high-risk conditions were found in 3352 of the 7770 women who experienced a pregnancy (43.1 % of patients; a mean of 1.3 conditions). The most common high-risk condition in both study windows was preterm labor (22.8% baseline vs 23.6% operational). The largest average cost per high-risk case in both periods was for multiple-gestation pregnancies ($US23 171 vs $US28 148; year 2004 values). The cost per mother-baby pair was $US9686 in the baseline period compared with $US9116 in the operations period ($US478 per net savings per mother-baby pair). The net return on investment for maternity DM services was 5.2:1 (DM costs to payer of $US713 220).

Conclusion

This analysis demonstrates that maternity DM in a commercial population is cost saving.

     

Role of the Workplace in Migraine Disease Management

Migraine is a highly prevalent, nonfatal disorder typically characterized by recurrent episodes of headache associated with such symptoms as nausea, vomiting, photophobia, phonophobia and impaired functioning. The attacks may be infrequent and relatively mild; more often they are frequent, severe and disabling. They are 3 times more common in women than in men and occur most often between the ages of 25 and 45 years, the prime working years. As a result, the burden placed on employers and on society due to lost and impaired productivity is far greater than the not-inconsiderable costs of healthcare.A large variety of treatments are effective in aborting and in preventing or minimizing the attacks. Patients with migraine whose attacks are infrequent and mild do quite well on self-treatment with simple remedies. Those with attacks that are more frequent and severe require professional supervision and may need a long period of trial and error until a satisfactory regimen can be evolved. Unfortunately, a large proportion of patients with migraine, even some of those with severe attacks, have either not sought medical care or have been misdiagnosed and mismanaged. Particularly for these, disease management, an evolving strategy which features evidence-based treatment and continuing close collaboration between the patient with migraine and his/her physician, offers the best approach for control of this disease.Because of the high prevalence of migraine in the workforce and the burden of disruptions and/or impaired productivity that it places on the organization, the employer has a vested interest in using the workplace as an arena for activities (e.g. patient education and improving access to healthcare) that will contribute to the success of disease management in mitigating the impact of the disease.     

Evaluating Disease Management Program Effectiveness

Disease management (DM) program evaluations are somewhat limited in scope because of typically small sample sizes comprising important subsets of the treated population. Identifying subsets of the data that have differing results from the aggregate of the whole program can lend insight into where, when, and how the program achieves its results. Additionally, there is a very limited set of classical tools available for the smaller sample sizes typically encountered in DM. Without readily available standard error and confidence interval (CI) calculations, the analyst may be fooled by specious details.A method called the ‘bootstrap’ is introduced as a suitable technique for allowing DM program evaluators to use a broader array of quantities of interest and to extend inferences to the population based on results achieved in the program. The bootstrap uses the power of modern computers to generate many random samples from a given data set, allowing the use of repeated samples’ statistic (e.g. mean, proportion, and median). Using a congestive heart failure (CHF) program as an example, the bootstrap technique is used to extend a DM program evaluation beyond questions addressed using classical statistical inference: (i) how much of a median cost decrease can be expected as a result of the program?; (ii) did the program impact the highest and lowest costing members equally; and (iii) how much of a decrease in the proportion of patients experiencing a hospitalization can be expected as a result of the program?The potential advantages of the bootstrap technique in DM program evaluation were clearly illustrated using this small CHF program example. A more robust understanding of program impact is possible when more tools and methods are available to the evaluator. This is particularly the case in DM, which is inherently biased in case-mix (e.g. strive to enroll sickest first), often has skewed distributions or outliers, and may suffer from small sample sizes.The bootstrap technique creates distributions that allow for a more accurate method of drawing statistical inferences of a population. Moreover, since classical statistical inference techniques were designed specifically for parametric statistics (i.e. assuming a normal distribution), the bootstrap can be used for measures that have no convenient statistical formulae. Additionally, CIs can be defined around this statistic, making it a viable option for evaluating DM program effectiveness.     

Outcomes Associated with a Disease Management Program for End-Stage Renal Disease

Disease-state management is gaining in use for the management of chronically ill individuals including those with diabetes mellitus, congestive heart failure, asthma, and some forms of cancer. Recently, disease management (DM) has been applied to patients with chronic kidney disease (CKD), a growing population of patients with high annual costs. CKD is ideally suited to DM since the definition of the condition is unambiguous and current care is highly fragmented. There are currently over 240 000 patients receiving dialysis for end-stage renal disease (ESRD), with projected numbers of nearly 600 000 by 2010, and nearly 9 million individuals with CKD not yet on dialysis. The total cost of care for patients with ESRD alone exceeded $US17 billion in 2000. Over 40% of costs for patients with ESRD result from hospitalizations, many of which can be avoided. In addition, much of the clinical morbidity and cost relates to associated comorbidities rather than ESRD per se, with little management presently provided for these conditions in the dialysis facility setting.DM for CKD uses field-based nurse care managers who can risk-assess patients and provide coordination of care so that the renal issues as well as comorbidities are identified and appropriately managed. Although few results from such efforts have been published, those that have, from RMS Disease Mnagement Inc., show remarkable improvements in a variety of clinical outcomes including mortality and hospitalization.Challenges to expanding DM for CKD include up-front funding to provide the needed DM, the availability of robust information systems to manage and analyze clinical and financial data, and the interest and participation of nephrologists, primary care providers and dialysis facilities, as well as other key providers to ensure that the DM approach is effective. With continuing increases in the number of patients with CKD in managed health plans, DM for this population will be even more important in the future to optimize clinical outcomes while constraining the costs of care.     

Improved Diabetes Control Through a Provider-Based Disease Management Program

Objective: The primary aim of this study was to evaluate the effectiveness of a newly implemented hospital-based diabetes mellitus disease management program. A secondary aim was to determine if relationships existed among variables.Design and setting: Effectiveness was evaluated in terms of glycemic control, post-program acute care resource utilization, adherence with American Diabetes Association (ADA) standards of care, and health-related quality of life. Participants in the Diabetes LifeCare program (DLC) received all standards of care which included diabetes self-management education, medical management by a primary care provider (PCP) supported by an evaluation and recommendations by an Advanced Practice Registered Nurse (APRN), nutritional counseling and at minimum, quarterly follow-up appointments for 1 year.Patients: Patients who were aged ≥18 years and referred to the DLC program with new a diagnosis or history of type 1 or 2 diabetes mellitus.Main outcome measures and results: Results demonstrated that at 3 months after enrollment in the DLC, participants in the study with available data (n = 142) had a mean decrease in predominant glycosylated hemoglobin (HbA_1c) values from 9.31 to 7.21 (p < 0.001). The HbA_1c value for participants with data at the 6-month visit (n = 66) decreased from 9.23 to 7.22 at 3 months and to 6.80 at 6 months (p < 0.001). At baseline, 52 of the 142 participants (36.5%) had HbA1c values less than 8.0, compared with 107 patients (75.4%) at 3 months (p < 0.0001). A total of 185 of 227 patients (81.5%) received eye examinations as per ADA guidelines. A total of 225 of 227 patients (99.1%) were in compliance with the ADA guidelines for nutritional counseling as a result of participation in the program. On the Physical Component Summary, their mean scores were 42.75 [standard deviation (SD) = 11.17] at enrollment, compared with 45.12 (SD = 10.52) at 3 months (p < 0.001). The Mental Component Summary score increased from 47.52 (SD = 11.90) to 50.83 (SD = 10.47) [p < 0.001]. Regarding resource utilization, during the follow-up period only 3 of 227 patients had emergency room visits and there were no inpatient visits for acute problems related to diabetes.Conclusions: Our results show that, in the short term, significant improvement in glycemic control can be achieved through a comprehensive program of patient education and management, that includes collaborative efforts with the patient’s primary care provider. High rates of eye and foot examination can also be attained by reinforcing patient involvement and admissions for acute metabolic complications can be minimized.     

Developing a Specialist Patient Program for Migraine

This review outlines a migraine-specific specialist patient program developed by the UK Migraine Action Association (MAA) for delivery to groups of patients with migraine throughout England and Wales. The program, which began in 2004, will deliver courses to 36 groups of 20 patients over 3 years. This paper reports the development of the program and the evaluation of the first six courses. The program enables participants to manage their migraine more effectively and educates them to provide information and support to other patients with migraine. Each course is open to 20 migraine patients aged between 18 and 70 years who fulfill the International Headache Society definition of migraine with or without aura. To develop the specialist migraine program, MAA staff researched the literature regarding the term ‘expert/specialist patients,’ which patients are invited to become after completing the program. MAA staff also consulted with experts in the field and organizations involved in delivering expert patient programs. Each course is delivered by a health professional, usually a general practitioner who is a local member of Migraine in Primary Care Advisors, and two lay trainers from the MAA.Results to date have shown that the majority of participants in the program now feel that they understand their condition better and are able to control it more effectively. Thirty-four percent of participants have agreed to become specialist patients within their own community. The program has succeeded in raising awareness of migraine in the areas visited, educating patients, and creating local networks of support for patients with migraine in these areas, which will complement and be supported by the services already provided by the MAA.     

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.     

Disease Management of Migraine and the Importance of Stratified Care

Migraine is a common neurological disorder that remains under-recognized, under-diagnosed and under-treated. The disorder imposes a large burden on individuals and the wider community in terms of migraine-related disability and high healthcare and societal costs. Moreover, there is a discrepancy between the availability of effective pharmacologic intervention and the level of treatment that patients with migraine actually receive. A disease management program can benefit individuals with migraine and society in general, by delivering improved care within a cost-effective framework.Disease management programs aim to reduce the burden of illness by identifying key factors that influence disease outcome. Herein, we consider a clinic-based migraine disease management program. Currently, step care remains the most common approach to migraine management. However, this approach frequently delays effective therapy and leads to patient dissatisfaction and lapse from medical care. Stratified care is an alternative approach to migraine management and tailors the choice of therapy to the individual treatment needs of patients.The Migraine Disability Assessment (MIDAS) Questionnaire offers a simple and reliable measure of migraine—related disability. It assesses the overall impact of disease and reflects illness severity and thereby helps guide the physician to the appropriate treatment.Implementation of stratified care, based on illness severity assessed by a disability measure, increases the likelihood that patients with migraine will receive the appropriate treatment plan from the initial consultation. In a randomized trial, step-care and stratified-care approaches were compared using aspirin (acetylsalicylic acid) plus metoclopramide or zolmitriptan 2.5mg oral tablet for the treatment of migraine attacks. The study demonstrated that stratified care produced significantly better clinical outcomes and improved the cost effectiveness of healthcare delivery for migraine compared with step care strategies.     

The Indiana Chronic Disease Management Program

The Indiana Chronic Disease Management Program (ICDMP) is intended to improve the quality and cost-effectiveness of care for Medicaid members with congestive heart failure (chronic heart failure), diabetes, asthma, and other conditions. The ICDMP is being assembled by Indiana Medicaid primarily from state and local resources and has seven components: (1) identification of eligible participants to create regional registries, (2) risk stratification of eligible participants, (3) nurse care management for high-risk participants, (4) telephonic intervention for all participants, (5) an Internet-based information system, (6) quality improvement collaboratives for primary care practices, and (7) program evaluation. The evaluation involves a randomized controlled trial in two inner-city group practices, as well as a statewide observational design. This article describes the ICDMP, highlights challenges, and discusses approaches to its evaluation.     

Evaluation of an Asthma Disease Management Program in a Medicaid Population

In 2002, an asthma disease management program was initiated in Washington State in the US. The program was designed for clients of the state’s Medicaid program, which provides health coverage for qualified low-income state residents. In response to the escalating cost of healthcare and because of concerns about the quality of care, the Washington State Legislature mandated implementation of this disease management program as a pilot project to assist individuals to improve their health. Medicaid administrators used a carefully designed process to identify client needs and to obtain proposals for disease management programs.The asthma program seeks to narrow the gap between the standards of care and its practice. In particular, the program aims to provide patients with a richer understanding of asthma and how to control it. This is accomplished through disease education, symptom awareness and management, trigger avoidance, self-monitoring, and education on recommended medication strategies. The program is based on the US National Institutes of Health’s published guidelines on the optimal treatment of asthma.Enrollment of Medicaid clients into the asthma program began in April 2002. This article describes three approaches to evaluation of the first 3 years of the program: (i) 3 years of self-reported client data; (ii) an independent evaluation of the first year’s changes in utilization and quality of care; and (iii) an actuarial analysis of cost effectiveness. The first study used vendor-reported data collected during initial and follow-up assessments. The authors of this first study also reported the results of a satisfaction survey conducted on behalf of the vendor. The independent evaluation conducted by the University of Washington relied on medical record review and claims analysis, and reported statistical analysis of pre/post comparisons. The actuarial study also reported pre/post comparisons using an analysis of claims per member per month in periods before the program started and at 1 and 2 years of program operations.Clients were assessed according to several dimensions of health including self-management, symptoms, functional status, medication management, and trigger management. Numerous interventions were provided to study participants including access to round-the-clock telephone consultation with a registered nurse, self-care education, alerts sent to the primary provider, and symptom issue follow-up. The asthma disease management program outcomes provide evidence of initial success for those clients who completed the reassessment process. The results of the first 3 years of participation in the program indicate trends toward improved health status and client satisfaction with the program. Long-term evaluation will be necessary to determine if the program reduces costs and closes the quality chasm. If successful, this program could serve as a model for programs with similar clients and similar challenges.     

An Independent Practice Association-Supported Disease Management Program

Background: Disease management has been shown to improve outcomes in patients with chronic diseases such as coronary artery disease (CAD). Yet Independent Practice Associations (IPA) have expressed concern with the promise of disease management (DM) to improve patient outcomes. Managed care initiatives promote the use of case management, DM, and the use of practice guidelines. However, some physicians think that this may impinge on their autonomy. Objective: To demonstrate that integration of an independent DM company in conjunction with an IPA enhances compliance with guideline-recommended medications, reduces morbidity and improves quality of life in patients with CAD. Design: IPA physicians and an independent DM company were contracted with a health plan to provide care to patients with current or recent CAD. The DM company facilitated physician-ordered guideline implementations, provided member education, facilitated medication compliance, and collected all data, using a decision support software system. Collected data included: hospital utilization, quality of life, and reported medications and associated compliance rates. Setting: A large IPA group in the Midwest region of the US. Study Participants: Sixty-five high-risk patients with CAD who were active in the DM program as of April 2, 2002 and in the program for at least 180 days were included in the analysis. Results: The average age of the patients was 73.4 years and 54% were male. The mean duration in the DM program was 10 months (median = 7 months). For those patients (n = 54) with baseline and follow-up mental and physical quality-of-life (QOL) scores, mental QOL scores increased by 2.6% (not significant) and physical QOL scores increased by 11% (p < 0.05). In the 19 patients in the program for 12 months, a trend of reduced hospital admissions was observed. Medication compliance at baseline versus the most recent status for eligible patients was as follows: antihyperlipidemic therapy 59.7% versus 67.7%; β-adrenoceptor antagonist therapy post-myocardial infarction 60.0% versus 66.7%; and antiplatelet therapy was maintained at 98.4%. Conclusions: In spite of the small sample size and relatively short study duration, these results indicate that an integrated DM program may enhance clinical outcomes for patients and reduce hospital admissions.     

“全项目管理”在疾病控制事业管理中的应用

作者通过试行机构层"全项目管理"机制的实践,阐述了通过全部业务的项目化管理以全面落实疾病控制绩效考核,提高工作效益的理念。国家通过公共卫生服务内容项目化确保公共卫生均等化目标最终实现的方略,要求疾病控制事业项目化管理的体制机制设计必然从项目责任上形成疾病控制项目筹资方、管理方和执行方立体格局。同时,在确保各项业务项目得到规范实施、科学评价的同时,也能确保各项管理活动得到规范实施和科学评价。也就是说,将项目管理理念运用到疾控机构日常管理的各重要环节中,通过管理的项目化,来推进和实现业务的项目化管理既是现实需要,也是大势所趋。     

上海慢性病自我管理项目对自我效能的影响评价

目的　评价上海慢性病自我管理健康教育项目实施 6个月之后在改变患者自我效能方面的效果。方法　按照社区随机对照试验研究设计 ,将 954名患有高血压病、心脏病、关节炎、中风、哮喘、糖尿病、慢性阻塞性肺病 (COPD)等疾病自愿参加该项目的慢性病人 ,随机分为干预组和对照组。采用协方差的秩检验 ,比较了有基线和 6个月之后两次问卷调查数据的 4 30名干预组患者和 34 9名对照组患者在项目实施 6个月之后在自我效能评分方面的变化。结果　干预组患者的症状管理自我效能和疾病共性管理自我效能评分 6个月的增加值 ,分别比对照组高出 0 6 9分和 0 6 3分 (P值均 <0 0 1)。结论　上海慢性病自我管理项目可提高参加者对疾病管理的自我效能     

Why it Pays for Hospitals to Initiate a Heart Failure Disease Management Program

Heart failure is a clinical syndrome usually caused by structural changes in the heart. These changes result in varying degrees of symptomatic functional limitation, typically shortness of breath and fatigue. Heart failure is common, with a lifetime risk for its occurrence in a healthy 40-year-old of 20%. In the US, the cost of heart failure care is now estimated at over $US30 billion annually (year 2007 values).Several forms of treatment have been devised for heart failure: medical, device based, and surgical. These are best individualized to each patient and used in stepped progression to goals that are based on current expert guidelines. When goal-directed treatment is accomplished, three major outcomes are expected: (i) symptom relief and improved quality of life; (ii) a slowing or partial reversal of cardiac structural abnormalities; and (iii) a reduction in mortality.Attempts to deliver care for this complex syndrome have led to the development of heart failure-specific disease management programs. These programs can take different forms. Some involve multi-disciplinary teams that comprise a wide array of specialized physicians, cardiac surgeons, nurses, and other allied health workers, all with specific tasks. Others have a more narrow focus and are nurse-led programs. These programs, when fully implemented, help the patient manage his/her disease more effectively through education about heart failure, the purpose and correct use of medication, and the full utilization of nutritional interventions. These programs are also ideally suited to deliver care for patients with end-stage disease, particularly those needing implantation of left ventricular assist devices or transplantation.When effectively implemented, these programs have been shown to improve quality of life, decrease rate of heart failure hospitalizations, and improve survival compared with usual care. Cost analyses of these programs are challenging, and in the most favorable circumstances the greater up-front cost of more intense care is paid back by a lower rate of utilization of inpatient resources. The details of the University of Wisconsin Program are discussed as an example of a comprehensive management program.     

Impact of Disease and Health Management Strategies on Formulary Design and Management

Although Medicare risk plans have been withdrawn in a number of US geographical areas, the size and dollar value associated with the senior demographic group is too large for health plans to ignore.Unlike other developed nations, the US government offers to Medicare-eligible citizens a choice between payment methods for health services. The fee-for-service reimbursement system (Medicare Parts A and B) has been in effect for 30 years; capitated prepaid Medicare risk plans (Medicare+Choice), the subject of this article, are a more recent addition. Active discussion has emerged on how best to pursue disease management in the Medicare risk environment.Disease management must constructively address comorbidities and realise bottom-line medical management savings. With limited medical management resources and a requirement for near-term results, successful programmes will anticipate and concentrate on the tiny fraction of members who generate a large portion of costs.In the future, health plans will make use of the Internet to share essential information across fragmented delivery systems and individually engage seniors, who are increasingly on-line, in their care.