Disease Management : Dm最新文献

Compliance with hemoglobin A1c (A1c) testing is suboptimal despite the clear national recommendations and guidelines established for care of patients with diabetes. Recent studies have demonstrated a relationship between participation in a diabetes disease management (DM) program and improved adherence to A1c testing. A focused intervention study was initiated to investigate the ability of a DM program to drive improvement in A1c testing. A cohort of 36,327 members experienced a statistically significant increase (29%) in A1c testing while participating in the 6-month focused intervention. This finding demonstrated that a focused DM intervention is able to deliver improvement in a clinical process metric critical for managing patients with diabetes, thereby reducing their risk of disease exacerbation.

The aim of this study was to investigate whether, in a randomized controlled trial (RCT) of vulnerable elders with heart failure (HF), advanced practice nurses (APNs) who were coordinating care in the transition from hospital to home could improve outcomes, prevent rehospitalizations, and reduce costs when compared with usual care. The APN strategies focused on improving patient and family or caregiver effectiveness in managing their illnesses, strengthening the patient-provider relationship, and managing comorbid conditions while improving overall health. The results were positive. By capitalizing on the patient's desire to achieve their identified goals, APNs successfully educated patients about the meaning of their symptoms and appropriate self-management strategies; improved patient-provider communication patterns; and marshaled caregiver and community resources to maximize patient adherence to the treatment plan and overall quality of life. While HF was the primary reason for enrollment in the study, optimal health outcomes demanded a strong focus on integrating management of comorbid conditions and other long-standing health problems. Specific strategies used by the APN to achieve these positive outcomes are addressed in this report. These strategies are compared with nursing interventions used in other RCTs of HF home management. Directions for future research are explored.

We conducted and evaluated a 4-year, web-based wellness program involving 2498 global employees. The program was designed to encourage improvement in diet, exercise level, and weight control. Each month, after enrollment, participants were prompted to log on and enter personal data. Four years' worth of nonparametric data were analyzed. Seventy-seven percent of participants were men, 53% were overweight or obese, and mean beginning body mass index (BMI) was 25.9. Only 35% of starting participants ate five or more servings of fruit and vegetables daily, and fewer than 38% engaged in 30 min of activity or 10,000 steps. At the end of the intervention, there was a statistically significant (p < 0.05) improvement in the diet, exercise habits, and weight of participants. Results suggests that our web-based wellness intervention was successful in improving key health indicators for a mobile, global workforce.

This study assessed the feasibility of a telephonic nurse double-disease management program (DDMP) for patients with depression and congestive heart failure. Thirty-five patients with depression and congestive heart failure were entered into a novel DDMP modeled after Wagner's chronic illness care model and implemented as part of a 13-month Breakthrough Series Collaborative administered by the Institute of Healthcare Improvement. Twenty-four patients remained in the program long enough to complete at least one follow-up assessment (ie, 6 weeks or longer). Patients were entered into the program based on depression severity scores from either the interactive voice response (IVR) version of the Hospital Anxiety and Depression Scale (HADS) or the self-administered (or telephonic) Patient Health Questionnaire (PHQ). Because use of the IVR version of the HADS was eliminated after several weeks into the program (because of poor patient acceptance), 19 patients had both entry and follow-up scores on the same instrument (PHQ). Depression "response" was defined as a 50% improvement in PHQ score. Mixed models regression was used to test the statistical significance of change in PHQ scores over time. Patient and clinician reports were obtained to evaluate program acceptability and satisfaction. Eighty-two percent of patients (n = 11) with Major Depressive Disorder (MDD) responded, and 75% of patients (n = 8) with "other depression" (PHQ score < 10) responded. Mean change in PHQ scores for the sample as a whole improved significantly over the 24 weeks of the program (p < 0.0003), as well as for those with major depression and other depression considered separately (p < 0.01 for both). In some patients who refused medication, depression seemed to respond to self-management support interventions of the care manager. Based on patient acceptance and clinicians' reports, the program appeared feasible and possibly effective. DDMP appears feasible and possibly effective. Future clinical trials are warranted.

Diabetes is an increasing health problem, but efforts to handle this pandemic by disease management programs (DMP) have shown conflicting results. Our hypothesis is that, in addition to a program's content and setting, the choice of the right patients is crucial to a program's efficacy and effectiveness. We used individualized predictive disease modeling (IPDM) on a cohort of 918 patients with type 2 diabetes to identify those patients with the greatest potential to benefit from inclusion in a DMP. A portion of the patients (4.7%) did not have even a theoretical potential for an increase in life expectancy and would therefore be unlikely to benefit from a DMP. Approximately 16.1% had an increase in life expectancy of less than half a year. Stratification of the entire cohort by surrogate parameters like preventable 10-year costs or gain in life expectancy was much more effective than stratification by classical clinical parameters such as high HbA1c level. Preventable costs increased up to 50.6% (or 1,010 per patient (1 = US dollars 1.28), p < 0.01) and life expectancy increased up to 54.8% (or 2.3 years, p < 0.01). IPDM is a valuable strategy to identify those patients with the greatest potential to avoid diabetes-related complications and thus can improve the overall effectiveness and efficacy of DMPs for diabetes mellitus.

The objective of this study was to explore the relationship between health-related quality of life (HRQOL) and treatment compliance among a sample of patients with diabetes. A sample of 198 employees with diabetes of a large southeastern health plan, who were continuously enrolled in 2004, was surveyed using the Short Form Health Survey (SF-12)--a measure of HRQOL. Of the 198 identified members, 111 (56%) completed and returned the SF-12. Treatment compliance was measured using medical claims data. Compliance scores were then calculated as the number of American Diabetes Association (2005) recommended guidelines completed in 2004. These guidelines include two hemoglobin tests, a cholesterol test, a microalbuminuria test, and an eye exam. Compliance scores ranged from zero (no treatments) to five (all treatments). Both age and the Mental Composite Score (MCS) of the SF-12 were significant predictors of compliance. Age was positively related to compliance, which means that compliance with treatment guidelines increases as a person ages. MCS was negatively related to compliance, which means that those who score lower on the MCS are more likely to be compliant with diabetes care. Results of this pilot study indicate that disease management programs may need to focus special attention on those people with diabetes who are younger and have better mental health. Moreover, factors other than past utilization of care or predicted costs may be beneficial to consider in the inclusion criteria for disease management programs.

Anticoagulation therapy has been identified as an area in which new approaches to treatment and monitoring may allow for significant improvements in healthcare quality and costs. We evaluated the potential benefits of a new approach to anticoagulation therapy, utilizing decision support software, point-of-service testing, and workflow redesign. We performed an intervention study in the setting of a university-affiliated primary care clinic, involving 40 patients receiving chronic anticoagulation therapy. Study measurement included anticoagulation control, complications of therapy and related costs, as well as clinic revenue and overhead costs. After implementation of the new approach, the frequency of international normalized ratio (INR) results within therapeutic range increased from 34% to 67%. During a 1-year follow-up period, complications related to anticoagulation therapy were reduced by 91% (p < 0.01). Labor-related overhead costs decreased from approximately 12,600 to 3,100 US dollars. During the same period, the clinic generated approximately 35,000 US dollars in new revenue. For every dollar spent on clinic implementation and maintenance, over 25 US dollars was returned from cost containment and new revenue production. This approach allows a clinic to show improved anticoagulation control and complication rates while simultaneously improving financial performance.