Disease Management : Dm最新文献

Previous studies have shown that the primary factor underlying increased spending on pharmaceuticals has been the rising utilization of medications, rather than increases in unit drug price. This study examined the evolution of clinical practice guidelines to assess possible reasons for the rising drug volume. Clinical practice guidelines from 1970 to the present were reviewed for the six most prevalent treatable medical conditions/risk factors listed as priority areas by the Institute of Medicine. We searched the National Guidelines Clearinghouse, PubMed and Medline databases, and Web sites of relevant national organizations for US clinical practice guidelines published through January 2005. Information pertaining to the therapeutic regimen (eg, the frequency and duration of recommended treatment, when treatment should be initiated, the patient population for whom the guideline was intended) was abstracted and entered into evidence tables. Changes in guidelines were distributed across three themes that recommended evidence-based increases in medication use, including: (1) changes in the size of the treatable population; (2) changes in the number and type of recommended pharmaceutical therapeutic options, including movement from monotherapy to combination therapy, treatment of comorbidities, and use of newer types of medicines; and (3) changes in the therapeutic regimen, including a shift from episodic care to preventive and chronic care. Many of these changes point to an important, but not often noticed, addition of secondary prevention of disease effects to the objectives of medical care. These trends are likely to continue with important economic, clinical, and policy ramifications.

We evaluated the use of an additive Index of Coexisting Diseases (ICED)-based stratification schema to determine subsequent hospitalization and mortality in a hemodialysis population. Patients from five commercial health plans were stratified into low-, medium-, and high-risk groups and followed for up to 1 year. Patients were reassessed and restratified at 90-day intervals and censored when disease management ceased. Outcome measures collected through selfreports and health plan records were captured in an active database. Survival to first hospitalization/ mortality was compared by Kaplan Meier curves, survivor function differences by the Wilcoxon test, and group comparisons by ANOVA and chi square. Population characteristics included mean age of 63.0, 57.7% male, and 58.8% diabetic. Mortality was 13.0% per patient year (standardized mortality ratio 0.43) and the hospitalization rate was 0.59 per patient year (standardized hospitalization ratio 0.24). Survival curves demonstrated differences in mortality and hospitalization between the patients in different initial risk categories (p < 0.01). Mean hospitalizations were 0.81 +/- 1.53 per patient year (high risk), 0.45 +/- 0.99 (medium risk), and 0.15 +/- 0.51 for the low-risk group (p < 0.001). Stratification was dynamic; 47.3% decreased and 4.7% increased risk level between the first and second assessment. These changes were associated with survival differences for initial low (p = 0.06) or medium patients (p < 0.01), and hospital-free survival for initial medium (p = 0.08) or high patients (p < 0.05). In conclusion, this ICED-based stratification schema predicted mortality and hospitalization for hemodialysis patients participating in our disease management program.

The aim of this study was to evaluate the cost savings of outpatient management services for women with pregnancy-related hypertensive conditions. The outpatient management program included verbal and written patient education related to the hypertensive disease process during pregnancy as well as self-care procedures. Biometric data (ie, automated blood pressure measurement, qualitative urine protein) were collected at least daily by the patient and transmitted telephonically to a nursing call center. Data were evaluated and subjective symptoms assessed daily. Electronic records were maintained and reports provided to the prescribing physician and case manager. Included for analysis were: patients with pregnancy-related hypertensive conditions receiving outpatient services between January 1999 and November 2003, singleton gestation, no history of chronic hypertension, and gestational age of 20.0-36.9 weeks at start of outpatient program (n = 1,140). Maternal characteristics, antenatal hospitalization and length of stay, progression of disease, and neonatal outcome were analyzed. To evaluate cost-effectiveness, a model was developed to compare the cost of the program plus adjunctive antenatal hospitalization, to control data. The mean gestational age at program start was 32.6 weeks. Antenatal hospital admission was required for 24.8% of patients, with a mean length of stay of 2.3 days per admission. Progression to severe preeclampsia occurred in 14.3% of patients. Mean gestational age at delivery was 37.0 weeks. Antepartum charges averaged 10,327 US dollars per control patient and 4,888 US dollars per program patient, a difference of 5,439 US dollars. For each dollar spent on outpatient management, an average of 2.50 US dollars was saved. Utilizing outpatient management services for women with pregnancy-related hypertension reduces the need for inpatient care and is cost-effective.

The objective of this study was to evaluate the outcomes of a diabetes disease management initiative among TennCare's Medicaid Population. A quasi-experimental group design was conducted using a control group and a diabetes disease management intervention group. Primary outcomes measures were rates for three key recommended tests (ie, microalbuminuria, lipids, and hemoglobin A1c). Secondary performance measures --patient satisfaction and program evaluation issues -- also were assessed. The study was performed among TennCare beneficiaries with diabetes mellitus. It utilized a quasi-experimental nonequivalent control group design, with 993 intervention participants in Knoxville and 1167 control group members in Chattanooga. Variables analyzed included testing rates for hemoglobin A1c, lipids, microalbuminuria, and demographics. A logistic regression model using baseline covariates was constructed to analyze the differences between the intervention and the control groups. Intracluster correlations were accounted for by generalized estimating equations. Statistical process control detected process changes in testing rates over time. There were meaningful changes in the rate of ordering recommended tests. The odds of an individual in the intervention group having at least one microalbuminuria test were 196% more (confidence interval [CI] = 1.50, 5.82; p = 0.002); the odds of having at least one lipid profile were 43% more (CI = 1.01, 2.02; p = 0.042); and the odds of having two or more hemoglobin A1c tests were 39% more (CI = 0.87, 2.23; p = 0.165) than the odds of an individual in the control group. The analysis also showed a high rate of satisfaction among patients in the intervention group. The program was successful in meeting its stated goals of providing effective disease management for TennCare patients with diabetes.

We assessed the degree that managed care organization (MCO) enrollees used preventive services and engaged in diabetes self-management behaviors by race/ethnicity. A 40-item selfadministered survey was mailed to 19,483 diabetic MCO enrollees. The survey measured use of eight preventive services and engagement in four self-management behaviors among enrollees who self-identified as black, white, or Hispanic. Of the 6,035 surveys analyzed, 4,623 respondents (76.6%) were white, 984 (16.3%) were black, and 428 (7.0%) were Hispanic. Black and Hispanic respondents reported more healthcare visits (mean of 7.0 and 6.5, respectively) in the past year compared to whites (mean, 5.7; p < 0.0001). However, compared to whites, blacks had significantly lower utilization of five of the eight preventive services measured, and Hispanics had significantly lower utilization of seven of the eight preventive services (p < 0.005). With regard to self-management behaviors, blacks were significantly less likely than whites to monitor their diet (65.9% vs. 73.7%, p < 0.0001), exercise (46.4% vs. 52.8%; p = 0.0004) and not smoke (85.1% vs. 89.3%; p = 0.0002); while Hispanics were less likely to monitor their diet (67.3% vs. 73.7%, p = 0.0051). All racial/ethnic groups had low levels of selfmanagement behaviors. Further research is warranted to identify why disparities remain in settings where services are universally available, and to find practical ways to eliminate disparities in a group with routine healthcare encounters.

This study at a major financial services corporation sought to investigate the association of arthritis with on-the-job productivity, also termed "presenteeism." Using a modified version of the Work Limitations Questionnaire (WLQ) incorporated into a Health Risk Appraisal (HRA), 17,685 employees responded to the survey in 2002. Of the 16,651 respondents meeting inclusion criteria, 2,469 (14.8%) reported having arthritis, and 986 (39.9% of those with arthritis) also reported that they were under medical care and/or taking medication for arthritis. Employees with arthritis were older, predominantly female, and reported a higher number of comorbidities. Although all four domains of the WLQ (physical, time, mental, and output) were impacted by arthritis, the greatest productivity effect, as expected, was on physical work tasks. Health risks also play a role in the relationship between arthritis and presenteeism, with high-risk individuals reporting 7%-10% additional loss of productivity compared to lowrisk individuals. In addition, those who reported receiving medication and/or treatment for arthritis had a 2.5% excess productivity loss independently attributed to their arthritis, which equals approximately 1,250 US dollars per employee per year, or 5.4 million US dollars to the corporation. This arthritis effect was discernible in those with low and moderate levels of health risk, but was not as evident in those with high health risks; in that group, health-associated decrements in productivity were much larger. Arthritis is associated with work productivity loss. Disease management programs should focus on pain management and arthritis-associated health risks and comorbidities in order to significantly decrease arthritis-related losses in on-the-job productivity.

Care management program evaluations bring together constituents from finance, medicine, and social sciences. The differing assumptions and scientific philosophies that these constituents bring to the task often lead to frustrations and even contentions. Given the forms and variations of care management programs, the difficulty associated with program outcomes measurement should not be surprising. It is no wonder then that methods for clinical and economic evaluations of program efficacy continue to be debated and have yet to be standardized. We describe these somewhat hidden processes, examine where the industry stands, and provide recommendations for steps to standardize evaluation methodology.

Obesity is a health issue of epidemic proportions in the United States, creating a health and financial burden for Medicare, Medicaid, and commercial populations alike. While obesity has been linked to an increased risk for any number of health conditions, including heart disease, diabetes, and certain cancers, even a moderate weight loss can mitigate some of the negative medical consequences of unhealthy weight. Obese individuals are often unsuccessful at meeting their weight loss goals for a variety of reasons. Many are increasingly looking to gastric bypass surgery as an easy-fix weight loss solution without fully addressing underlying issues for the original weight gain and failures with previous attempts to lose weight. Because of this, over the past five years an increase in gastric bypass surgeries has resulted in cases with poor outcomes and a subsequent reaction by health plans and employers across the country to eliminate coverage. Others have determined that, while exclusion is not the answer, neither is coverage as standard policies allow. Instead, these groups are opting to implement best practice programs that merge individualized counseling, nutritional education/ planning, and physical activity goals with specific policy changes. Evidence has shown that they are achieving success in managing obesity and its impact on healthcare costs and outcomes.

The objective of this study was to assess whether educational attainment moderates outcomes in the intervention group in a trial of disease management in heart failure (HF). Data were collected from a sample of 654 patients enrolled in the disease management arm of a community- based study of HF patients. The full sample was used to analyze two primary outcomes- all-cause mortality and cardiac event-free survival. Two other primary outcomes- rates of HF-related emergency department (ED) visits and inpatient admissions-and secondary outcomes (patient self-confidence in managing HF symptoms and daily dietary sodium intake in milligrams) were analyzed in a smaller sample of 602 patients who completed at least 6 months of disease management. One-way analysis of variance and chi (2) tests were used to assess differences in baseline demographic and clinical characteristics. Survival analyses were conducted with proportional hazards regression, while negative binomial regression was used to assess educational differences in ED usage and inpatient admissions. Repeated measures analysis of variance models were used to assess whether secondary outcomes differed across educational strata and/or over time. All outcome analyses were adjusted for confounders. Patients with the least education fared the poorest for all-cause mortality, but education- related differences failed to achieve statistical significance. No education-related differences were observed for cardiac event-free survival, or for the rates of inpatient admission and ED usage. For secondary outcomes, sodium intake differed significantly by education (p = 0.04), with the largest drop (-838 mg/day) observed in the least well-educated group. Confidence increased an approximately equal amount (2.1-3.0 points on a 100-point scale) across all educational strata (p = ns). Low educational attainment may not be a barrier to effective disease management.

Screening for the long-term complications of diabetes is a critical component of diabetes management; however, evidence demonstrates that screening rates in diabetes populations are suboptimal. Our objective was to determine the use and predictors of optimal screening behavior, defined as receiving a fasting lipid test, dilated eye exam, spot urine test, foot examination, blood pressure reading, and hemoglobin A1c (HbA1c) in the previous year in a representative cohort of subjects with type 1 diabetes. Data are from the Pittsburgh Epidemiology of Diabetes Complications Study, a prospective cohort study of subjects with childhood onset type 1 diabetes. Data from 325 participants who responded to a survey during 1999-2001 were included in analyses. Reported screening rates were as follows: 87.9% had at least one HbA1c measurement in the past year, 63% had a foot exam, 73.3% had a spot urine test, 81.9% had a dilated eye exam, 93.5% had a blood pressure reading and 68.7% received a fasting lipid profile. Within this group, 37.7% of subjects reported undergoing all five tests (optimal screening). Independent correlates of optimal screening were receiving care from a specialist provider (odds ratio [OR] = 2.4; 95% confidence interval [CI]: 1.4-4.1) and blood glucose monitoring at least weekly (OR = 2.6; 95% CI: 1.1-6.2). These findings indicate that a large proportion of persons with type 1 diabetes are not being screened at the optimal level. Our data indicate that efforts to rectify this should focus on men and those who do not monitor blood glucose, and should involve primary care practitioners.