Disease Management : Dm最新文献

The objective of this study was to determine if a formula diet of 520 kilocalorie (kcal, 2177 kilojoules [kJ]) compared to 850 kcal (3558 kJ) produces significantly greater weight loss and improved weight maintenance in a clinical outpatient setting. The investigation was a retrospective analysis of data from 1887 participants who underwent weight loss between December 1994 and January 2003. Participants were between the ages of 18 and 70 and completed a minimum of 12 weeks of a very-low-energy diet (VLED; 520 kcal) or a low-energy diet (LED; 850 kcal). Participants attended weekly meetings, were weighed, and received instruction in behavioral skills. Following active weight loss, participants transitioned to weight maintenance and were prescribed an individual structured meal plan aimed at maintaining body weight. Both levels of energy intake produced significant weight loss over 12 weeks (P < 0.05). Weight loss was 15.2 +/- 4.1% and 14.3 +/- 3.7% of initial body weight for participants in the VLED (n = 1231) and LED (n = 656), respectively. After controlling for baseline body weight, there was no significant difference between diets. Similarly, there was no significant difference in weight regain between VLED and LED after 12, 24, 36, and 48 weeks of weight maintenance. VLED did not produce a greater weight loss than the LED. LED provides similar weight loss with a lower incidence of adverse events and diminished need for medical monitoring. We conclude LED is an efficacious, safe, and less burdensome diet compared to VLED.

Pregnancy and newborn care rank among the top health care expenditures for health plans and employers. Traditionally treated as episodic conditions, maternity and newborn clinical management is most often reactive in nature, event driven, and not perceived as a continuum. Existing models of pure disease management are not suited for addressing this continuum because the condition of pregnancy is not a disease, is not chronic, and is self-limited. Wellness approaches may be applicable for prenatal care, but they fail to fully engage the complexities and intervention needed for high-risk pregnancies. Case management alone is too comprehensive to focus on the high volume of pregnancies, which must be screened and accommodated at the health plan level. Alternatively, the management of a pregnant population through a continuum starting with early prenatal care and commencing with newborn and maternal postpartum care is optimal. We describe a total maternal-newborn solution (TMNS) that considers pregnancy as a unique, high-volume condition with infrequent, but costly, complications that can benefit from primary and secondary preventive efforts to avoid or reduce the impact of complications in a cost-effective manner. A TMNS helps to improve the quality of care delivered as participants and their health care providers are encouraged to follow standardized clinical guidelines and monitored for compliance. A TMNS is made possible with the use of an enterprise information technology platform that provides a common infrastructure to track participant encounters and interventions and measure and report on maternal and newborn care delivered. Preliminary outcomes for the TMNS program prove it to be a promising approach for addressing the clinical and cost management of the pregnancy continuum.

Treatment adherence is critical in managing chronic disease, but achieving it remains an elusive goal across many prevalent conditions. As part of its care management strategy, BlueCross BlueShield of South Carolina (BCBSSC) implemented the Longitudinal Adherence Treatment Evaluation program, a behavioral intervention to improve medication adherence among members with cardiovascular disease and/or diabetes. The objectives of this study were to 1) assess the effectiveness of telephonic intervention in influencing reinitiation of medication therapy, and 2) evaluate the rate and timing of medication reinitiation. BCBSSC applied algorithms against pharmacy claims data to identify patients prescribed targeted medications who were 60 or more days overdue for refills. This information was provided to care managers to address during their next patient contact. Care managers received focused training on techniques for medication behavior change, readiness to change, motivational interviewing, and active listening. Training also addressed common barriers to adherence and available resources, including side effect management, mail order benefits, drug assistance programs, medication organizers, and reminder systems. Overdue refills were tracked for 12 months, with medication reinitiation followed for an additional 3 months. In the intervention group, 94 patients were identified with 123 instances of late medication refills. In the age- and gender-matched comparison group, 61 patients were identified with 76 late refills. The intervention group had a significantly higher rate of medication reinitiation (59.3%) than the control group (42.1%; P < 0.05). Time to reinitiation was significantly shorter in the intervention group, 59.5 (+/- 69.0) days vs. 107.4 (+/- 109) days for the control group (P < 0.05). This initiative demonstrated that a targeted disease management intervention promoting patient behavior change increased the number of patients who reinitiated therapy after a period of nonadherence and decreased the time from nonadherence to adherence.

Disease management has become an important tool for improving population patient outcomes. The Louisiana State University Health Care Services Division (HCSD) has used this tool to provide care to a largely uninsured population for approximately 10 years. Eight programs currently exist within the HCSD focusing on diabetes, asthma, congestive heart failure, HIV, cancer screening, smoking cessation, chronic kidney disease, and diet, exercise, and weight control. These programs operate at hospital and clinic sites located in 8 population centers throughout southern Louisiana. The programs are structured to be managed at the system level with a clinical expert for each area guiding the scope of the program and defining new goals. Care largely adheres to evidence-based guidelines set forth by professional organizations. To monitor quality of care, indicators are defined within each area and benchmarked to achieve the most effective measures in our population. For example, hemoglobin A1c levels have shown improvements with nearly 54% of the population <7.0%. To support these management efforts, HCSD utilizes an electronic data repository that allows physicians to track patient labs and other tests as well as reminders. To ensure appropriate treatment, patients are able to enroll in the Medication Assistance program. This largely improves adherence to medications for those patients unable to afford them otherwise.

A prospective, observational study of 1289 members completing an evidence-based diabetes management program was evaluated for clinical effectiveness and cost impact. The program consisted of direct contacts by nurse educators who worked with members to complete modules in a specific order based on the individual's readiness to change and specific standards of diabetes care behaviors lacking adherence. A total of 668 members were at HbA1c target values (HbA1c 7%) at baseline. At follow-up 899 members had either reached the target level or improved their values by 1 percentage point. At baseline, 516 members recorded normal blood pressure; at follow-up 755 members either met the target level of less than 130/80 mmHg or reduced their blood pressure by at least 10/5 mmHg. Claims data indicated that 89% (n = 233) of those who had a hospitalization in the prior year did not have a hospitalization in the program year, compared to 3% (n = 32) who did not have a hospitalization in the previous year but needed a hospital visit in the program year. There were statistically significant improvements in other health behaviors and quality of life measures. Cost avoidance was estimated at $7,402,578 for the 1289 members who completed the program and reported their results. This figure includes those who were in compliance prior to the start of the intervention. The study supported the results from large multicenter trials on diabetes management when translated to an intervention.

The objectives of the study were to compare health care expenditures between adults with and without mental illness among individuals with obesity and chronic physical illness. We performed a cross-sectional analysis of 2440 adults (older than age 21) with obesity using a nationally representative survey of households, the Medical Expenditure Panel Survey. Chronic physical illness consisted of self-reported asthma, diabetes, heart disease, hypertension, or osteoarthritis. Mental illness included affective disorders; anxiety, somatoform, dissociative, personality disorders; and schizophrenia. Utilization and expenditures by type of service (total, inpatient, outpatient, emergency room, pharmacy, and other) were the dependent variables. Chi-square tests, logistic regression on likelihood of use, and ordinary least squares regression on logged expenditures among users were performed. All regressions controlled for gender, race/ethnicity, age, martial status, region, education, employment, poverty status, health insurance, smoking, and exercise. All analyses accounted for the complex design of the survey. We found that 25% of adults with obesity and physical illness had a mental illness. The average total expenditures for obese adults with physical illness and mental illness were $9897; average expenditures were $6584 for those with physical illness only. Mean pharmacy expenditures for obese adults with physical illness and mental illness and for those with physical illness only were $3343 and $1756, respectively. After controlling for all independent variables, among adults with obesity and physical illness, those with mental illness were more likely to use emergency services and had higher total, outpatient, and pharmaceutical expenditures than those without mental illness. Among individuals with obesity and chronic physical illness, expenditures increased when mental illness is added. Our study findings suggest cost-savings efforts should examine the reasons for high utilization and expenditures for those with obesity, chronic physical illness, and mental illness.

Our objective was to test for evidence of regression to the mean in chronic obstructive pulmonary disease (COPD)-related health care utilization in a Colorado Medicaid population that met the criteria for, but were not participating in, a COPD disease management (DM) program. National Jewish Medical and Research Center had enrolled individuals who (1) had a diagnosis of COPD for at least 1 year and (2) were active participants in Colorado Medicaid's 1-year DM program called breatheWise; the present study sought a comparator group for that population. In order to test for evidence of regression to the mean (ie, high utilization from the recruitment period reducing without active intervention) in this case management model, we conducted a case-controlled analysis of total spending for a comparator population that would have met the inclusion criteria for the DM program. The present study assessed health care utilization for fiscal years 2002 and 2003 in terms of total rates of emergency room (ER) visits and hospitalizations for all causes in the comparator group of COPD patients. In addition, total costs related to both ER visits and hospitalizations were compiled. In total, 354 individuals met the inclusion criteria and were identified as the comparator group. ER visits and hospitalizations were consistent for 2002 and 2003. ER visits totaled 314 and 315 in 2002 and 2003, respectively, indicating a 0.3% increase that was not significant. Hospitalizations decreased from 0.53 admissions per patient in 2002 to 0.48 in 2003-a 9.4% reduction that was not significant. With comparable rates of ER visits and hospitalizations, total costs for health care utilization remained virtually unchanged between 2002 and 2003. There is minimal evidence of regression to the mean over 2 consecutive years in the Colorado Medicaid patients with moderate to severe COPD.