Diabetes Disease Management Program Research Articles

Pharmacist Led, Primary Care-Based Disease Management Improves Hemoglobin Aic in High-Risk Patients With Diabetes

We developed and evaluated a comprehensive pharmacist-led, primary care-based diabetes disease management program for patients with Type 2 diabetes and poor glucose control at our academic general internal medicine practice. The primary goal of this program was to improve glucose control, as measured by hemoglobin A1c (HbA1c). Clinic-based pharmacists offered support to patients with diabetes through direct teaching about diabetes, frequent phone follow-up, medication algorithms, and use of a database that tracked patient outcomes and actively identified opportunities to improve care. From September 1999, to May 2000, 159 subjects were enrolled, and complete follow-up data were available for 138 (87%) patients. Baseline HbA1c averaged 10.8%, and after an average of 6 months of intervention, the mean reduction in HbA1c was 1.9 percentage points (95% confidence interval, 1.5-2.3). In predictive regression modeling, baseline HbA1c and new onset diabetes were associated with significant improvements in HbA1c. Age, race, gender, educational level, and provider status were not significant predictors of improvement. In conclusion, a pharmacist-based diabetes care program integrated into primary care practice significantly reduced HbA1c among patients with diabetes and poor glucose control.

Diabetes disease management programme beneficial in the US

Diabetes disease management programme beneficial in the US

What is the Return on Investment Associated with Diabetes Disease Management?

In this article, we review the reduction in healthcare costs associated with a health maintenance organization (HMO)-sponsored diabetes disease management program in Pennsylvania, USA. The program emphasizes primary care-based nurse education and case management of patients with diabetes mellitus. We found participants in the program experienced a slight increase in health insurance claims related to diabetes care but a notable decrease in total healthcare claims, with a return on investment that exceeded $US3 saved for every dollar expended. The changes we observed appeared within a year of program entry, and were sustained on a month-to-month basis.

Diabetes disease management program for an indigent population empowered by telemedicine technology.

Mercy Health Center in Laredo, Texas implemented a Telemedicine Diabetes Disease Management Program to determine the impact of a web-based patient interface technology as part of a diabetes disease management program. The program featured the use of the Health Hero iCare Desktop and the Health Buddy appliance. The Mercy Health Center outcomes study aimed to assess the effect of telemedicine technology on the health of indigent border residents with diabetes. The study was conducted in calendar year 2000-2001 using comparative cohort data from calendar year 1999. Using the technology, patients were monitored daily at home, and to ensure early intervention, nurses were alerted if patients reported abnormalities. The goals of the program were to decrease hospital-based resource utilization, improve patient compliance with treatment plans, improve the level of patient satisfaction with healthcare services, and improve patients' perceived quality of life. Objective outcomes, including inpatient admissions, emergency room visits, postdischarge care visits, and outpatient visits, as well as charges for healthcare services, were all measured on a per patient per year basis. Subjective outcomes, including quality of life and patient satisfaction, were estimated from surveys conducted before, quarterly for two quarters within the program, and at the end of the study period. For each measure except for quality of life, comparisons were made between the year just prior to and the year of Health Buddy utilization. Quality of life was compared for the year just prior to Health Buddy utilization and at the end of the second quarter. After 1 year, reductions in overall utilization and charges, as well as improvements in quality of life, were demonstrated. Patients in the program showed reduced overall charges of 747 dollars per patient per year. Inpatient admissions were reduced 32% (p < 0.07), emergency room encounters were reduced 34% (p < 0.06), postdischarge care visits were reduced 44% (p < 0.28), and outpatient visits were reduced 49% (p < 0.001). Quality of life was assessed using the Medical Outcomes Study 12-item Short Form health survey. The mean improvement in the mental component after 6 months in the program was 2.8, from 45.1 preprogram to 47.9 within the program (p < 0.0264). The mean improvement in the physical component after 6 months in the program was 2.1, from 41.7 preprogram to 43.8 within the program (p < 0.0518). The reductions in utilization and improvement in quality of life can likely be attributed to the patient's enhanced self-management behaviors and the nurse's ability to intervene in a timely manner when warranted. Without technology and daily remote monitoring, standard patient care is based on episodic encounters between patients and their care providers, which does not allow for prevention, education, or early intervention. This program bridged the gap between office visits for the patients. The early intervention ultimately reduced the cost of care.

Evaluation of a Comprehensive Diabetes Disease Management Program: Progress in the Struggle for Sustained Behavior Change

The successful management of diabetes with a goal of achieving near-normoglycemia requires patients to make multiple lifestyle changes as part of an intensive, complex, and coordinated therapeutic regimen aimed at reducing the risk of complications associated with the disease. The difficulty in creating and sustaining these lifestyle behavior changes is a major stumbling block in achieving the desired therapeutic goal. An underlying assumption of comprehensive disease management is that regular, personal contact with nurses and ancillary health professionals will facilitate these lifestyle behavior changes for program participants. The results of a survey of self-reported data from 750 participants in a comprehensive diabetes management program, reported on here, show strong perceptions of positive behavior change over the broad range of medical and lifestyle treatment areas associated with effective management of diabetes. These results suggest that diabetes disease management programs are an effective a...

Measuring Outcomes of Type 2 Diabetes Disease Management Program in an HMO Setting

There is a need to evaluate empirical disease management programs used in managing chronic diseases such as diabetes mellitus in managed care settings.We analyzed data from 252 patients with type 2 diabetes before and 1 year after enrollment in a disease management program. We examined clinical indicators such as HbA1C, HDL, LDL, total cholesterol, diastolic blood pressure, and BMI in addition to self-reported health status measured by SF-36 instrument.All clinical indicators showed statistically and clinically significant improvements. Only vitality and mental health showed statistically significant improvements in health status. Weak to moderate significant correlation between clinical indicators and health status was observed.Disease management can be effective at making significant clinical improvements for participants in a mixed-model HMO setting. No strong relationship between clinical indicators and health status was found. Future research is needed using a more specific health status measuring instrument and a randomized clinical trial design.

Measuring Outcomes of Type 2 Diabetes Disease Management Program in an HMO Setting

There is a need to evaluate empirical disease management programs used in managing chronic diseases such as diabetes mellitus in managed care settings. We analyzed data from 252 patients with type 2 diabetes before and 1 year after enrollment in a disease management program. We examined clinical indicators such as HbA1C, HDL, LDL, total cholesterol, diastolic blood pressure, and BMI in addition to self-reported health status measured by SF-36 instrument. All clinical indicators showed statistically and clinically significant improvements. Only vitality and mental health showed statistically significant improvements in health status. Weak to moderate significant correlation between clinical indicators and health status was observed. Disease management can be effective at making significant clinical improvements for participants in a mixed-model HMO setting. No strong relationship between clinical indicators and health status was found. Future research is needed using a more specific health status measuring instrument and a randomized clinical trial design.

The impact of initiatives in education, self-management training, and computer-assisted self-care on outcomes in diabetes disease management.

The purpose of this work is to elucidate the advantages and disadvantages arising from three distinct diabetes disease management initiatives in a managed care setting. The initiatives included (1) education alone, (2) education with self-management training, and (3) education with computer-assisted self-care. Outcomes of interest were changes in glycated hemoglobin (HbA1c), body weight, and costs of care in each cohort of care recipients. A total of 978 health plan members with diabetes within a mixed model HMO were included in the initiatives for improving blood glucose control. HbA1c was measured at baseline and at 3 and 12 months, body weight at baseline and 12 months, and costs of care over 1 year. Costs were derived from suppliers and the health plan. The design is a longitudinal observation study. With the edu-cation-alone initiative, costs, HbA1c, and body weight were unchanged. When education is supplemented with ongoing self-management training, HbA1c fell 1.1% (p < 0.01), body weight rose by 11 kg (p < 0.01), and costs for care increased by $18 per member per month. When education is supplemented with ongoing computer-assisted self-care, HbA1c also dropped by 1.1% (p < 0.01), body weight was unchanged (p > 0.4), and costs for care were $1.31 per member per month. All initiatives improved glycated hemoglobin. Other outcomes must therefore be considered. Among the initiatives, this study elucidated significant differences in body weight and costs. Therefore, in choosing a diabetes disease management program, it would appear that costs should be the primary consideration and methodologies that control body weight should be a priority.

PDB14: IMPACT OF A DIABETES DISEASE MANAGEMENT PROGRAM: A RETROSPECTIVE CLAIMS-BASED EVALUATION

OBJECTIVE: Evaluate the impact of a comprehensive diabetes disease management (DM) program on health care costs, quality of life and patient satisfaction. METHODS: Diabetes patients targeted by pharmacy claims were invited to enroll in a voluntary payor-sponsored DM program (n = 2,178). Eligible non-enrollees were used for the control group (n = 6,396). Medical and pharmacy claims were combined to determine health care costs. Quality of life and patient satisfaction were also assessed, via patient interview. The analysis timeframe encompassed two years prior and one year following program initiation. RESULTS: Enrollees had higher direct health care costs than non-enrollees. We were able to predict accurately the medical spend in our control group in absence of intervention with standard time series analysis within 4%. Following DM intervention, enrollees' health care spend was lower than their baseline spend and lower than their projected spend (−$116, −$1,056). Conversely, health care spend increased in the non-enrollee group from baseline (+$714) (Table 1). Additionally, enrollee quality of life measures improved from baseline and patient satisfaction with the DM program was high. CONCLUSIONS: A comprehensive diabetes DM program can lower health care cost and improve patient reported quality of life while demonstrating consistently high patient satisfaction.

Economic Impact of a Diabetes Disease Management Program in a Self-Insured Health Plan: Early Results

Disease management has grown to a $350 million industry with over 100 providers. Delivery models vary among providers, but short-term economic outcomes are the standard by which a program's success is generally measured. This report focuses on a large self-insured organization that offered the CarePatterns® Disease Management Program for diabetes. Individuals with diabetes were identified by pharmacy claims and invited to participate. Enrollment was voluntary (n = 2745). Medical claims history of eligible individuals who chose not to participate (control group) was used to understand the progress of these chronic diseases in the absence of intervention (n = 8978). Standard forecasting methods using medical claims data from 1997 and 1998 were used for spending projections. The study period ran from 1/1/1997 through 12/31/1999. Evaluation of 24 months of medical claims data showed that participants in the program had higher direct healthcare costs than nonparticipants. Actual medical expenditures for participants decreased by $747 (9.4%) from the baseline period (1998). When participants' 1999 actual spending is compared to 1999 projected medical spending, savings are $1474 (17%) per participant. Conversely, nonparticipant control medical spending increased by $230 (3.3%) per individual. Pharmacy spending for participants increased 23.5% from Baseline to 1999. For nonparticipant controls, pharmacy spending increased by 19.7%. Although further analysis is required to determine which component of interventions significantly contributed, an effective patient-focused disease management program is an important factor in promoting the appropriate use of pharmaceuticals and medical resource utilization.

Development and validation of a questionnaire to evaluate patient satisfaction with diabetes disease management.

To develop a reliable and valid questionnaire to measure patient satisfaction with diabetes disease management programs. Questions related to structure, process, and outcomes were categorized into 14 domains defining the essential elements of diabetes disease management. Health professionals confirmed the content validity. Face validity was established by a patient focus group. The questionnaire was mailed to 711 patients with diabetes who participated in a disease management program. To reduce the number of questionnaire items, a principal components analysis was performed using a varimax rotation. The Scree test was used to select significant components. To further assess reliability and validity; Cronbach's alpha and product-moment correlations were calculated for components having > or =3 items with loadings >0.50. The validated 73-item mailed satisfaction survey had a 34.1% response rate. Principal components analysis yielded 13 components with eigenvalues > 1.0. The Scree test proposed a 6-component solution (39 items), which explained 59% of the total variation. Internal consistency reliabilities computed for the first 6 components (alpha = 0.79-0.95) were acceptable. The final questionnaire, the Diabetes Management Evaluation Tool (DMET), was designed to assess patient satisfaction with diabetes disease management programs. Although more extensive testing of the questionnaire is appropriate, preliminary reliability and validity of the DMET has been demonstrated.

Diabetes in the managed care setting: a prospective plan.

As managed care organizations (MCOs) continue to expand into the care of the chronically ill, the concept of providing cost-effective care with a preventive approach is vital for primary care providers (PCPs) to embrace. Diabetes is an ideal disease to incorporate this concept. We reviewed the literature using MEDLINE. We used the American Diabetes Association (ADA) Provider Recognition Program guidelines as the foundation for MCOs to establish a diabetes disease management program. The implementation of disease management protocols, the use of computerized management systems, and the team approach can provide cost-effective diabetic care. To compete in the managed care market, it is vital for providers to link with their Independent Practice Associations (IPA), the ADA, and MCOs to implement standard protocols and negotiate for adequate reimbursement.

Successful Implementation of a Comprehensive Diabetes Disease Management Program in an Integrated Academic Health System

Diabetes mellitus is a costly, chronic, metabolic disorder that is commonly undiagnosed and frequently inadequately treated. The Diabetes Control and Complications Trail (DCCT) in 1993 and the U.K. Prospective Diabetes Study (UKPDS) in 1998 demonstrated clearly that intensive control of blood glucose has a dramatic effect on reducing the incidence of complications, improving the quality and length of life and reducing costs of care for these patients. Despite that, numerous studies have shown a large gap between current practice and bestpractice care for patients with diabetes. Recently, disease management has been suggested as an innovative strategy to improve the quality of care delivered to patients with chronic diseases. A diabetes disease management program was implemented in the University of Pennsylvania Health System (UPHS), an academic-based, integrated healthcare delivery system, in the spring of 1997. Prior to implementation of the program, a snapshot assessment of current practice was obtained by random retrospective review of approximately 40 charts from patients with diabetes. We now report data from 1779 patients enrolled in the program. Just over half the patients are female and the mean age is 60.2 years. A highly significant improvement has been noted in hemoglobin A1c (HbA1c) levels. Before enrollment, from the snapshot review, average HbA1c values were 9.03%±2.11% and this has fallen in study patients to 8.30%±2.06% (p = 0.03). If only study patients are evaluated, the mean preprogram HbA1c value was 8.31%±2.10% and, in those cases where repeat values are available, it has fallen to 8.07%±1.62% (p =.07). Overall, by the time of this report, 60% of the patients enrolled in the disease management program have a HbA1c level of less than 8%, considerably higher than the 40% documented before the program was started. Impressive improvements also were noted in several key process measures, including foot examinations, blood sugar measurement, and blood pressure documentation. While these are encouraging early outcomes, we consider it a work-in-progress as we continually modify and enhance program components and processes of care delivery to constantly improve the outcomes. It is also important to emphasize that our results demonstrate clearly that this approach is entirely appropriate and can be sucessfully implemented in a large, complex academic health system such as the UPHS. Medical students and residents are now intensely involved at all stages of the program and have revealed a high level of enthusiasm and excitement as they find themselves being part of this dramatic new healthcare re-engineering process.

Phased Competency

New roles for nurses are emerging as managed-care organisations continue to evolve. Many of these roles are new for nurses; others expand or redefine traditional roles in the diabetes disease management environment in integrated healthcare systems. It is important now to redefine these roles for nurses in a way which supports the organisation’s quality outcomes. Patient education, one of the cornerstones in diabetes disease management programmes, has been an important nursing role for decades. In the diabetes disease management environment, the challenge for nurses is to provide appropriate education to the diabetes population in a way which acknowledges the continuum of care, the course of the disease and the progression of patient learning needs. Much of the outcomes research studying the effectiveness of patient educationprogrammes isrelatedtotraditional,hospital-basedprogrammes.Simply adapting traditional diabetes education programmes may not be sufficient to address patient education needs for the entire diabetes population within the integrated healthcare system. Phased diabetes competency for nurses is built on the premise that both paPRACTICAL DISEASE MANAGMENT

Design, Development and Implementation of a Multidisciplinary Diabetes Disease Management Programme

Disease management initiatives are becoming increasingly popular in the US as a way for managed-care plans to care for their members with chronic conditions. Diabetes is one of the most expensive chronic conditions, both in terms of human lives and actual healthcare costs. Managed-care plans are adopting different approaches to caring for their members with diabetes. The experience of one organisation shows that a population management approach to caring for people with diabetes is the best way to improve clinical outcomes and reduce healthcare costs for managed-care organisations in the short term.

Diabetes Mellitus

Because of the extensive burden that diabetes mellitus imposes on individuals and healthcare systems, this disease state is frequently on the priority lists of managed-care organisations for improving quality of care while controlling costs. This article explains diabetes disease management concepts and interventions aimed at improving clinical outcomes illustrated with details of the Lovelace Health Systems Diabetes Episodes of Care (R) programme. The effectiveness of diabetes disease management programmes can best be evaluated by the clinical outcome of haemoglobin A1c measures. Process measurements include diabetes education access, annual eye examinations and documentation of annual clinical evaluations of feet. Short term cost reductions are frequently unrealistic expectations of diabetes disease management programmes because of the complex, chronic nature of the disease. Coordination of previously fragmented services, eventual reduction of long term complications and meeting regulatory standards are potential achievements of these programmes.