Disease Management : Dm最新文献

Case management (CM) is an important strategy for chronic disease care. By utilizing non-physician providers for conditions requiring ongoing care and follow-up, CM can facilitate guideline-concordant care, patient empowerment, and improvement in quality of life. We identify a series of critical factors required for successful CM implementation. Heart to Heart is a clinical trial evaluating CM for coronary heart disease (CHD) risk reduction in a multiethnic, low-income population. Patients at elevated cardiac risk were randomized to CM plus primary care (212 patients) or to primary care alone (207). Over a mean follow-up of 17 months, patients received face-to-face nurse and dietitian visits. Mean contact time was 14 hours provided at an estimated cost of $1250 per patient for the 341 (81%) patients completing follow-up. Visits emphasized behavior change, risk-factor monitoring, self-management skills, and guideline-based pharmacotherapy. A statistically significant reduction in mean Framingham risk probability occurred in CM plus primary care relative to primary care alone (1.6% decrease in 10-year CHD risk, p = 0.007). Favorable changes were noted across individual risk factors. Our findings suggest that successful CM implementation relies on choosing appropriate case managers and investing in training, integrating CM into existing care systems, delineating the scope and appropriate levels of clinical decision making, using information systems, and monitoring outcomes and costs. While our population, setting, and intervention model are unique, these insights are broadly relevant. If implemented with attention to critical factors, CM has great potential to improve the process and outcomes of chronic disease care.

Rational decision-making regarding health care spending for weight management requires an understanding of the cost of care provided to obese patients and the potential cost-effectiveness or cost savings of interventions. The purpose of this review is to assist health plans and disease management leaders in making informed decisions for weight management services. Among the review's findings, obesity and severe obesity are strongly and consistently associated with increased health care costs. The cost-effectiveness of obesity-related interventions is highly dependent on the risk status of the treated population, as well as the length, cost, and effectiveness of the intervention. Bariatric surgery offers high initial costs and uncertain long-term cost savings. From the perspective of a payor, obesity management services are as cost-effective as other commonly offered health services, though not likely to offer cost savings. Behavioral health promotion interventions in the worksite setting provide cost savings from the employer's perspective, if decreased rates of absenteeism are included in the analysis.

Migraine headache is a highly prevalent, chronic, episodic disorder that is associated with high direct and indirect costs. Migraine headache impacts not only patients, but also their employers due to substantial decreases in workplace productivity. Despite the prevalence and clinical and economic burdens of migraine, no national efforts to develop and implement standardized measures of quality of care have been made. The objective of this study was to collect and report on existing quality of care measures for migraine that could be suitable for quality measurement at the health-plan level. Published literature, the Agency for Healthcare Research and Quality's National Quality Measure Clearinghouse, and resources available from quality organizations (eg, the National Committee for Quality Assurance) were examined to identify existing quality indicators that can be used to assess the quality of care delivered to migraine sufferers at the health-plan level. Among the results of the study were the following: Quality of care measures for migraine include patient-reported measures and non-patient reported, diagnosis-related, prevention-related, and treatment-related indicators. Most existing measures have been developed by the Institute for Clinical Systems Improvement or summarized and reported by the RAND Corporation. Few of these measures can be used to assess migraine quality of care at the health-plan level. In conclusion, many measures exist, but they are not intended for use at the health-plan level. Incorporation of valid and reliable quality of care measures may increase the ability of migraine disease management programs to conform to clinical care guidelines. Significant effort is needed to determine what and how to measure quality among health plans to improve the quality of care delivered to individuals with migraine.

In addition to race and ethnicity, specific geographic regions are associated with poorer outcomes of care. Individuals with diabetes experiencing health disparities typically have worse long-term outcomes, such as increased diabetes complications and mortality. Zip code mapping, or geocoding, was utilized in this study to identify regions of the United States with high diabetes prevalence rates and to identify areas with high densities of minority populations. Use of this methodology to examine the effect of disease management on a large, diverse diabetes population revealed greater improvement in clinical testing rates in health disparity zones compared with members living outside of these areas. In particular, significant improvement was achieved by members living in minority zip codes and by members aged 65 years or older. These findings demonstrate that members living in areas of health disparity obtain even greater benefit from diabetes disease management program participation, helping to reduce gaps in care.

Nearly two thirds of the US population is overweight or obese and those numbers are climbing. Many organizations are beginning to recognize overweight and obesity as severe health threats and to acknowledge that treatment can serve as an important first step in addressing this epidemic. Through its Obesity with Co-morbidities Initiative, the Disease Management Association of America (DMAA) seeks to raise awareness and improve understanding of the role disease management (DM) can play in the treatment and management of obesity with comorbidities. Among the objectives of the Obesity with Co-morbidities Initiative was to develop standard definitions of obesity and obesity with comorbidities and to conduct qualitative research among key DM stakeholders. The first project undertaken and completed by the Obesity with Associated Co-morbidities Steering Committee and work group was to define the term "obesity" for consistent usage within the DM community for the purposes of population-based interventions. As part of this initiative, DMAA partnered with Synovate, a global market research firm, to conduct focus groups and in-depth interviews in order to collect qualitative data on attitudes and practices related to obesity treatment and coverage among key industry stakeholders, including health plans, disease management organizations, employers, and the business community. The findings indicated that obesity was widely recognized as a serious issue, but there remained varying opinions regarding responsibility, health and productivity costs, coverage, and best treatment methods among the participants. DMAA will continue this initiative through 2007 and will continue to develop a knowledge base of obesity guidelines and management practices, create valuable tools and resources including an online resource center, and facilitate partnerships with other organizations involved in the management and prevention of obesity.

As a result of the high cost of diabetes, an array of interventions for managing this disease has been developed. Estimating the cost of various approaches to diabetes disease management is critical to inform purchasing decisions. This review focuses on 5 provider- and payer-sponsored diabetes management approaches that use information technology (IT) and provides cost estimates for each approach based on a literature review and interviews with 38 provider practices, hospitals, payers, and vendors. Cost estimates are reported for "typical" small, medium, and large provider practices and payers. Provider-sponsored diabetes registries are estimated to be the least expensive approach for small and medium sized practices. For large practices with electronic health record systems, modifying such systems with diabetes-specific clinical decision support capabilities is projected to be the most economical approach. While limited data prevented the inclusion of all implementation costs, these projections serve as a starting point to inform the purchasing decisions of organizations planning to introduce IT-enabled diabetes management.

The objective of the study was to examine the burden of coronary artery disease (CAD) and heart failure (HF) on health-related quality of life (HRQOL) and the HRQOL trajectory among participants in a disease management (DM) program characterized by personalized models of education, counseling, and supportive contact. In all, 2,590 CAD and 3,182 HF patients were assessed at baseline and at 3, 6, 9, and 12 months post-enrollment. HRQOL was measured via a computerized dynamic test, whose core consisted of SF-8 items. HRQOL burden was assessed by comparing physical component summary (PCS) and mental component summary (MCS) scores to demographically adjusted US norms and to historical controls. Disease trajectories were assessed with change score analyses and by a categorization of participants as improving, stable, or deteriorating. Among the results, both groups showed between 1.7 to 2.6 times the likelihood of improving over worsening after a full year of DM participation in all measures. In contrast, historical controls experienced no significant HRQOL improvement or decline after 2 years of standard treatment. After 1 or 2 years they were more likely to decline than to improve in their PCS scores and were about as likely to improve as to worsen in their MCS scores. In conclusion, HF places a substantial burden on HRQOL, and the burden of CAD is also noticeable. While the study design does not allow causal interpretations, HRQOL significantly improved for both CAD and HF patients during DM program participation. This trend is in contrast to historic controls, where no significant HRQOL improvement occurred over time.

This study sought to determine the impact of different levels of weight loss on blood pressure in overweight/obese women. One hundred fifty-nine overweight/obese women (age 48.7 +/- 9.7, weight 101.3 +/- 18.7 kg, BMI 37.3 +/- 6.6 kg/m(2)) completed a six-month clinical weight loss program that included weekly nutrition, behavior, and exercise instruction. Participants consumed a very-low-energy diet (VLED) for 12 weeks. VLED was followed by four weeks of gradual reintroduction to solid foods. At week 16, participants received a diet to maintain weight or slightly reduce weight (<0.5 lb/week) which they followed for the duration of the study. All lab and blood pressure assessments were performed at baseline and six months. Three groups were formed according to the proportion of weight loss after six months; Group 1 had < 10% (n = 19), Group 2 had 10%-20% (n = 64), and Group 3 had >20% (n = 76) weight loss. Differences in systolic blood pressure (mm Hg) were found in dose response fashion for weight loss at six months with 125 +/- 17 (<10%), 119 +/- 13 (10%-20%), and 117 +/- 15 (>20%; p = 0.005). Differences in diastolic blood pressure (mm Hg) were also found in dose response fashion with 81 +/- 9 (<10%), 77 +/- 9 (10%-20%), and 75 +/- 9 (20%; p = 0.003). These data indicate that increasing weight loss beyond 10% of initial body weight may provide added improvements in blood pressure compared to less than 10% weight loss in overweight or obese women.

With a focus on those patients who are candidates for treatment with biologic agents, we review the impact that current pharmacy benefit trends have on patients with chronic complex diseases and how they affect opportunities for disease management in this unique patient population. Dramatic increases in health care costs have led to a variety of strategies to manage cost. Many of these strategies either limit access to care or increase the patient's responsibility for choosing and paying for care, especially for medications. These strategies have a disproportionate impact on patients with chronic complex diseases, particularly those who require the use of biologic medications. A fundamental prerequisite of disease management has been coverage of disease-modifying therapies. If current pharmacy benefit trends continue, unintended consequences will likely occur including lost opportunities for disease management. Current pharmacy benefit trends could adversely impact disease management, particularly for patients requiring the use of biologic agents. Health plans should consider innovative benefit designs that reflect an appropriate level of cost sharing across all key stake-holders, ensuring appropriate access to needed therapies. Additional research is needed to clarify the value of newer approaches to therapies or benefit design changes.