Diabetes Disease Management Results in Hispanic Medicaid Patients Esteban R. López, MD, MBA, FAAP...
-
Upload
sherilyn-mckenzie -
Category
Documents
-
view
213 -
download
0
Transcript of Diabetes Disease Management Results in Hispanic Medicaid Patients Esteban R. López, MD, MBA, FAAP...
Diabetes Disease Management Results in Hispanic Medicaid Patients
Esteban R. López, MD, MBA, FAAPProgram Director and Medical Director, McKesson Health SolutionsNational Hispanic Medical AssociationMarch 20, 2011Washington, DC
Objective of Presentation
• To present medical service utilization from a telephonic nursing disease-management program for Medicaid patients with diabetes residing in Puerto Rico
• Published in Journal of Health Care for the Poor and Underservedo May 2009
Disease Management
• Care Continuum Alliance (CCA) disease management definition:o Supports the physician/practitioner patient relationship
and plan of careo Emphasizes prevention of exacerbation and
complications utilizing evidence-based practice guidelines and patient empowerment strategies; and
o Evaluates clinical, humanistic, and economic outcomes on an on-going basis with the goal of improving overall health
Components of Disease Management
• Disease management components include:o Population identification processo Evidence-based practice guidelineso Collaborative practice models (physicians and others)o Patient self management educationo Process and outcomes measurement, evaluation, and
managemento Routine reporting/feedback loop
Diabetes Disease Management
Previous research shows that an increased number of patients can be managed in an ambulatory care setting through• Increased understanding of pathophysiology of
diabetes• Pharmacological interventions• Non-pharmacological intervention
Goals are:• Increased quality of life and less expensive health care
Diabetes Disease Management
Centers for Medicare and Medicaid Services (CMS)• Recognize burden of chronic diseases• Will pilot differing disease management strategies• Previous research finds a multidisciplinary approach
has increased QOL and reduce overall medical costs through
• Disease management nurses• Frequent physician office visits• Telephone contact systems
Diabetes Disease Management
Limitations of Previous Research• Pre/Post Evaluations
o Least rigorous study methodology• Clinic-based interventions
o Not representative of community of diabetes patients• Costs are not clearly delineated
This Research• Uses a more rigorous study methodology• More representative of community of diabetes patients
Methods: Study Population
Diagnosed with Diabetes through administrative claims
Medicaid plan in Puerto Rico
Age 1-64
Methods: Study Population
Excluded people:• Those engaged in a local formal diabetes program.• Members age 65 or over• Members with less then three months eligibility prior to their study
start date or less than three months eligibility after their study start date.
• ESRD, Dialysis, Transplants, HIV/AIDS• Hospice • SNF• Intervention group members with less than three months
participation in the disease management program.
Methods: Study Population
Sample of 490 diabetes participants and 490 matched non-participants
• Matched non-participants drawn from sample of 7,966
Methods: Intervention
Created a customized self-management intervention plan o Risk stratificationo Formal scheduled nurse education sessionso 24 hour access to nurse counseling and symptom adviceo Printed action planso Workbookso Individualized assessment letterso Medication compliance reminders and vaccine reminderso Physician alerts
Methods: Intervention
Changes in medical service utilization is expected to result from improvements in patients’
Knowledge Behavior Health status
Methods: Study Design
Alternatives include• Randomized control trial• Matched two-group cohort• Population based pre/post• Participant only pre/post• Others
We used a 12 month, matched-cohort study.
Results
Medical service utilization (annualized rate per 1000)
Study group
Control group P-value
Change (%)
Inpatient admits 174 268.4 0.112 -35.2
Inpatient bed days 920.3 1,770.00 0.021 -48
Emergency Department visits 773.6 758.3 0.778 2Physician evaluation & management visit 5,153 4,651.80 0.649 10.8
Pharmacy scripts 39,530.40 40,932.90 0.704 -3.4
Diabetes inpatient admits 39.8 14.90 0.437 167.2
Diabetes inpatient bed days 148.8 108.60 0.699 37Diabetes Emergency Department visits 81.8 95.80 0.603 -14.7
Cardiac inpatient admits 25.2 98.00 0.001 -74.3
Cardiac inpatient bed days 134.2 528.20 0.002 -74.6
Cardiac Emergency Department visits 16.8 12.80 0.591 31.2
Inpatient 30 day readmits 29.4 42.60 0.635 -31.1
Results
Prescription drugs (% of people who have)
Study group
Control group P-value
Change (%)
ACE inhibitor (%) 31.6 25.7 0.041 23
Beta blocker (%) 27.6 25.7 0.516 7.1
Antihypertensives (%) 54.9 49.8 0.11 10.2
Diuretics (%) 45.3 36.1 0.004 25.4
Cardiac glycosides (%) 5.1 6.3 0.409 -19.4
Blood glucose regulators (%) 90.4 90.4 1,000 0
Results
Procedures performed (% of people who have)
Study group
Control group P-value
Change (%)
Hemoglobin A1c 21.2 16.5 0.061 28.4
Lipid panel 28 23.7 0.126 18.1
Eye examination 16.3 13.9 0.285 17.6
Maculopathy 3.9 3.5 0.734 11.8
Microalbumin 1.4 1.2 0.78 16.7
Echocardiography 4.9 7.6 0.086 -35.1
Cardiac catheterization 1.2 5.7 0 -78.6
Myocardial imaging/ perfusion 1.8 2 0.817 -7.1
Influenza immunization 7.1 2.4 0.001 191.7
Pneumococcal immunization 2.9 1 0.037 180
Results
Average costsStudy group
Control group
P-value
Change (%)
Monthly medical costs ($) 74.5 154.66 0.001 -51.8
Monthly pharmacy costs ($) 79.25 80.11 0.848 -1.1
Monthly total costs ($) 153.75 234.78 0.002 34.5
Discussion
Drugs and device manufactures often subject their products to clinical research to determine• Safety• Efficacy
Healthcare services are rarely subject to similar levels of clinical research • Some exceptions• CMS randomized pilot• HealthDialog has a randomized trial published in NEJM
Discussion
75% of managed care plans report having comprehensive disease management programs as defined by CCAIndustry growth likely due to:• Frustration with pace of guideline adoptions• Guaranteed financial savings by DM companies• High patient satisfaction• Other reasons
Discussion
Although Propensity Scores balance observable variables, unobservable variables may not be balanced• Motivation • Psycho-social factors• No drug information for this study
Selection Bias?• Is selection determined by observable or unobservable
variables?• If by unobservable, then bias may exist