Disease Management : Dm最新文献

Nurse case management has been shown to improve the quality of diabetes care in closed model health maintenance organizations and Veterans Affairs medical clinics. A randomized controlled trial of a similar intervention within HealthTexas Provider Network, a fee-for-service primary care network in North Texas, demonstrated no benefit in processes of care or clinical outcomes for Medicare diabetes patients. To investigate whether the case management model impacted the cost of diabetes care from the Medicare perspective, we compared the average payments and charges incurred between intervention arms: claims-based audit and feedback; claims- and medical-record-based audit and feedback; and claims- and medical-record-based audit and feedback plus a practice-based diabetes resource nurse. Following adjustment for baseline differences between groups, no significant differences were observed. Thus, within this setting, it appears the nurse case management model produced no improvement in either clinical quality or in costs associated with diabetes from a Medicare perspective.

This study was conducted in order to test the proposition that medical claim records, when searched electronically, can be reliably used to locate individual, disease-specific hospital admissions. For the study, admissions for coronary artery disease (CAD), self-reported by employer-sponsored recipients of chronic disease management (DM) services, were verified against physician-compiled medical records. Confirmed events were then subjected to electronic searching of the corresponding medical claim records using a variety of conditional requirements for included types of evidence. At maximum sensitivity (92.6%), the search algorithm positively identified 126 of 136 verified admissions while falsely identifying 1,025 others. At maximum specificity (98.7%), the algorithm positively identified 55 of 136 while falsely identifying 13. The maximum value of the true positive to false positive ratio was 4.47. The maximum Youden index value was obtained by requiring that the diagnostic intensity (proportion of event-related claims having a CAD-related diagnosis code) have a minimum value of 0.20. The study concluded that an admission search algorithm applied to typical commercial medical claims generated results that are unsatisfactory for the determination of admission incidence in the CAD population. While the methods may be sound, they fail to overcome the weaknesses of the searched data.

Survivors of ischemic stroke are at significant risk for recurrent stroke. Appropriate therapy for stroke prevention is needed given the significant morbidity and mortality associated with stroke, the high financial costs, and the neurologic disability associated with treatment failure. A treatment strategy based on assessed risk represents an appropriate use of medical resources and results in improved outcomes. This approach requires evaluation of major risk factors, the most serious of which is a history of ischemic stroke or transient ischemic attack. The annual risk for recurrent stroke is 6% during the first 5 years after an initial stroke. Non-modifiable risk factors include age, race, ethnicity, gender, family history, and geography. The most important modifiable risk factor is hypertension. Diabetes mellitus, hyperlipidemia, left ventricular hypertrophy, atrial fibrillation, and lifestyle factors such as smoking, alcohol abuse, and obesity contribute to stroke risk. Antihypertensive, lipid-lowering, and antiplatelet therapies have been successful in reducing the incidence of secondary stroke. Clinical trials validate the benefits of statin therapy in reducing the risk for secondary stroke. Studies of antiplatelet agents, including aspirin, clopidogrel, and aspirin combined with extended-release dipyridamole, have evaluated the risk reduction in recurrent stroke and have been concerned particularly with the risk for hemorrhage. Therapy for stroke prevention based on risk stratification can identify patients who are appropriate targets for aggressive intervention.

To better understand obesity, its related conditions and risk factors, and the best assessment and management approaches for the adult population, the Disease Management Association of America and the National Committee for Quality Assurance partnered to conduct a literature review that could inform future initiatives of both organizations as well as others. The goals of the literature review were to: (1) describe the prevalence of obesity and related conditions and their health and financial impacts; (2) illustrate the clinical importance and interrelatedness of the conditions; and, the focus of this article, (3) describe the evidence supporting the different assessment and management options for obesity and comorbid conditions.

This study evaluates 1-year outcomes of an asthma disease management program implemented in an Oregon Medicaid population. A non-randomized pre-post study, a matched case-control study, and a "programmatic effects" analysis were conducted. Compared to matched controls, the treatment cohort had significantly fewer emergency room visits per thousand (7 vs. 28, P < 0.001) and higher office visits per thousand (57 vs. 7, P < 0.0001) but no significant difference in hospital admission rates. The programmatic effects model identified the participants' initial severity levels and the number of various communications they received as the most important variables in explaining the change in asthma severity from baseline to 12 months. These findings are supportive of the DM design, which is to reduce acute services by improving coordination of care between patients and their providers. Additionally, it appears that there is a close association between the number of patient contacts and their subsequent change in health status.

The challenge for care coordination is to identify members at a moment in time when they are receptive to intervention and provide the appropriate care management services. This manuscript describes a pilot program using inbound nurse advice calls from members to engage them in a care management program including disease management (DM). Annual medical claims diagnoses were used to identify members and their associated disease conditions. For each condition group for each year, nurse advice call data were used to calculate inbound nurse advice service call rates for each group. A pilot program was set up to engage inbound nurse advice callers in a broader discussion of their health concerns and refer them to a care management program. Among the program results, both the call rate by condition group and the correlation between average costs and call rates show that higher cost groups of members call the nurse advice service disproportionately more than lower cost members. Members who entered the DM programs through the nurse advice service were more likely to stay in the program than those who participated in the standard opt-in program. The results of this pilot program suggest that members who voluntarily call in to the nurse advice service for triage are at a "teachable moment" and highly motivated to participate in appropriate care management programs. The implication is that the nurse advice service may well be an innovative and effective way to enhance participation in a variety of care management programs including DM.