摘要:

After the establishment of an industry trade association and accreditation, standardizing performance measurement is the third critical milestone in the maturation of the disease management (DM) industry. The publication ofStandard Outcome Metrics and Evaluation Methodology for Disease Management Programsby American Healthways, a leading DM vendor, in 2003 is the first credible effort at achieving this milestone. This report is the product of collaboration between American Healthways and Johns Hopkins Outcomes Verification Program, along with a conference of almost 150 physicians and other healthcare professionals. It proposes 64 measures across five disease states, seven financial and utilization measures and survey standards for member and provider satisfaction.This paper presents a framework for developing and evaluating performance measurement standards based on four components or aspects: purpose, perspective, process and products (‘four Ps’). Purpose refers to the reasons and uses for the measurement. Perspective refers to who will use the measures and what the unit of analysis is. Process is how the standards are developed and chosen and includes the use of explicit criteria for selecting measures and standards, representative participation by all constituencies, the use of subject matter experts as consultants, and transparency. Products are the measures and their descriptions and specifications.With respect to the ‘four Ps’ framework, the American Healthways and Johns Hopkins paper includes a stated purpose, but is unclear with respect to who the intended users would be. Its perspective is primarily of physicians with lesser consideration given to public, DM purchaser and DM program manager stakeholders. The process by which the measures were selected and defined is not described, nor are the roles of the conference participants. No criteria for selecting measures are provided. The product is a reasonably comprehensive set of process and outcome indicators for the five disease states. No rationales for selecting these measures are provided, however, and the methodologies are not always well defined.There are many models of performance measurement standards and measures available. The performance measurement standards established by the National Committee for Quality Assurance and the Joint Commission on Accreditation of Healthcare Organizations are used as reference programs. These programs have done better at fulfilling the attributes offered in the framework, recognizing that they have developed through well-funded efforts over many years.The American Healthways and Johns Hopkins paper is a significant accomplishment and an important step in the establishment of measurement standards for DM. Further work needs to be done to achieve standards that will be useful and acceptable across the industry and among all constituents. A broader-based and broader-funded effort with more formalized or well-documented measure selection is needed, as well as testing, validation and dissemination of measures not commonly used in DM settings.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Cardiovascular disease is the leading cause of death in developed countries. It is estimated that about 15 million people worldwide die every year from heart disease, with a substantial proportion of these deaths occurring in developing nations. Congestive heart failure (CHF) is a condition that develops as a late complication from a variety of heart disease states. CHF remains a devastating disease. It exacts a high toll in terms of mortality and morbidity and carries a high price burden. As the population ages and treatments for conditions such as acute coronary syndrome and hypertension improve, the prevalence of heart failure can be expected to increase, because survivors of hypertension and myocardial infarction live long enough to develop complications such as congestive heart failure.Recent advances have clearly shown that treatment strategies including ACE inhibitors, β-adrenoceptor antagonists, and aldosterone inhibitors improve morbidity and survival. However, even among patients treated with recommended therapy at recommended doses, mortality remains high. Opportunities exist for further improvement of prognosis beyond current guidelines for heart failure. As new evidence emerges, it is evident that survival can be further improved by using other strategies such as angiotensin receptor antagonists as alternative or add-on therapy and ventricular resynchronization for qualifying candidates.The management of heart failure patients in the community presents unique challenges. Patients who are managed in community hospitals are often elderly and/or very ill, with several comorbidities and clinical characteristics that may be different from patients who qualify for clinical trials. Furthermore, there appears to be a delay in incorporating scientific evidence into practice and studies continue to show that many heart failure patients do not receive recommended medications at adequate doses.Disease management programs have evolved as a way of improving heart failure care. Different models have been established and some institutions have published the results of their specific programs. The consistent findings include reductions in hospitalization rates, improvements in quality of life, and reductions in cost. However, to date, such studies have not compared different models and until large prospective trials are available, the true benefits of these programs will continue to be debated.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

The incidence of diabetes mellitus (both type 1 and type 2) is growing to epidemic proportions, with an expected combined worldwide prevalence of 220 million by the year 2010. A subsequent increase in the incidence of diabetes complications is likely to follow if present trends continue, placing an increased burden on already troubled healthcare systems. While there are many identified biologic mechanisms for the development of diabetes complications, there has been little exploration of healthcare provider issues and their contribution to these outcomes. One area of research with few data is the influence of diabetes specialty care on outcomes in type 1 diabetic patients. Evidence demonstrates that both process delivery and outcomes are better in individuals with type1 diabetes who are cared for by diabetes specialists compared with generalists. For example, those receiving care from diabetes specialists were more likely to receive diabetes education, to be treated with intensive insulin therapy (>2 injections/day), and to receive an eye examination compared with those receiving generalist care. Additionally, lower rates of proliferative retinopathy were observed in those receiving specialist care. Recent evidence also demonstrates that there are lower incidences of neuropathy, overt nephropathy, and coronary artery disease in those patients who spend a higher proportion of the duration of their diabetes in specialist care. Based on these observations, it is recommended that attempts be made to replicate the favorable characteristics of specialty care in the primary care setting. Healthcare systems should ensure the availability of access to diabetes specialists, as well as ancillary healthcare professionals including diabetes educators, with increased emphasis placed on coordinated care.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

There is increasing evidence that pharmacists practicing in a myriad of clinical settings, including outpatient clinics and community pharmacies, can play a key role in efforts to manage many chronic diseases. This is especially true for conditions that are prevalent, costly, and where patients frequently self-medicate using over-the-counter drugs. The acid-peptic disorders (e.g. peptic ulcer disease, gastroesophageal reflux, and reflux esophagitis) meet these criteria and present pharmacists with an ideal opportunity to improve patient outcomes, acting independently or as part of a more comprehensive disease management initiative. The opportunity exists for pharmacists to enhance the care of patients with acid-peptic disorders by identifying patients who have one of these conditions, assessing their risk for serious diagnoses (e.g. cancer) or complications (e.g. bleeding), educating patients on self management, and optimizing medical regimens through collaboration with physicians. The major barrier for integrating pharmacists into disease management programs is reimbursement; however, some patients may be willing to pay for these services, and innovative payors may begin to provide compensation to pharmacists, Pharmacists should play a key role in new disease management models designed for conditions, such as acid-peptic disorders, that meet the criteria discussed in this article.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

The evidence base derived from the research literature has clearly established that type 2 diabetes mellitus may be prevented or delayed through pharmacological interventions and, most efficaciously, through lifestyle interventions. Unfortunately, efforts to translate the research results into programs that may be applied to the clinical or healthcare system setting are lacking. The purpose of this article is 3-fold:to briefly review the results of the major trials conducted in the area of type 2 diabetes;to outline an approach that may guide the design and development of type 2 diabetes prevention programs for clinical care; andto present a protocol that may support the process of implementation in the practice setting.The literature review clearly delineates critical type 2 diabetes prevention program outcomes, i.e. modest weight loss, dietary changes, an increase in physical activity level and, in the case of pharmacological interventions, good adherence to medication regimens. Guided by evidence-informed approaches to translation, this article outlines a set of critical program design principles that guide the development of type 2 diabetes prevention programs, and are systematically included and recognized in the programs; these principles are termed the ‘4Ss’:effect size;program scope;scalability; andlong-term sustainability in the real-world setting.Based on additional literature that addresses operational feasibility and principles of design and evaluation, this paper describes a protocol that may help healthcare systems and care delivery settings design such prevention programs and successfully document desired impacts that are meaningful to their customers. The protocol is designed to include the total membership of a healthcare system and it systematically allows for the identification and stratification of the risk of developing type 2 diabetes. Individuals are assigned to one of three risk strata:low risk of developing type 2 diabetes;high risk of developing type 2 diabetes; oractive disease (already diagnosed with type 2 diabetes).The high-risk group is subsequently invited to participate in risk-reduction strategies that are designed to reduce the incidence of type 2 diabetes.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Asthma in the US is widespread, with incidence rates and morbidity increasing dramatically over the last 2 decades. The cost of asthma-related morbidity and mortality is large. There is substantial and convincing evidence that environmental factors are associated with asthma exacerbation, and more limited evidence that environmental factors play a role in the development of asthma. Educational interventions, which include an avoidance of ‘triggers’ or focus on reducing exposure to cigarette smoke, have been shown to be moderately effective. While various interventions have been shown to reduce environmental exposures, fewer studies have collected sufficient information on their effectiveness in reducing morbidity.Cost-effectiveness analyses on educational interventions suggest that reductions in direct costs are most prominently seen for severe asthma, with the interpretation of study findings impaired by a lack of methodological consistency. One analysis from a study that included physical interventions found that the incremental cost-effectiveness ratio was $US9.20 per symptom-free day (95% CI −$US12.56, $US55.29), with potential cost savings for more severe asthma.We point out that current practice in managed care organizations (MCOs), as well as in other settings, rarely conforms to the current clinical practice guidelines for asthma. Two reviews of the policies and actions of MCOs found that while some were integrating environmental controls into their asthma disease management plans, their commitment to these strategies was limited by lack of a strong evidence base.We recommend the following:continuation of educational programs;continuation and expansion of case management, including home visits;full integration of smoking cessation programs into asthma disease management;development of policies around reimbursement for durable goods;participation in the setting of a policy agenda for population-based approaches to controlling key environmental factors;development of exploratory programs to address occupational asthma;integration, analysis and dissemination of environmental data collected by MCOs; andwidespread MCO participation in research on environmental prevention of asthma.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

ObjectiveTo assess the impact of a comprehensive migraine disease management program, as measured by humanistic outcomes measures, conducted in a managed care setting.DesignA prospective comparative study comprised of an intervention and a control group to evaluate the impact of the disease management initiative.SettingIndependent Practice Association (IPA)-type managed care organization.Study participants and main outcomes measuresStudy participants resided in adjacent regions (intervention region included Minneapolis, MN, USA and the usual care region included St Paul, MN, USA and adjacent areas in MN, USA) separated by natural geographic barriers. Eligible patients were identified through a review of the Medica plan’s administrative claims database and were asked to complete the Migraine Therapy Assessment Questionnaire (MTAQ), a tool to assess the presence of migraine management issues. Responders (patients completing the MTAQ) who reported ≥2 migraine care risk indicators in the intervention region received the disease management intervention, while all responders in the control region received usual care. Responders in both regions with ≥2 migraine care risk indicators were also asked to complete the Migraine Disability Assessment (MIDAS) questionnaire and the 12-item Short Form Health Survey (SF-12) at baseline. All participants were asked to complete the same instruments at the end of the program as they did at baseline.InterventionsDisease management intervention activities included patient and physician education, as well as a patient feedback report containing migraine care risk indicators, which was sent to the treating physicians. All patients were encouraged to contact their physicians if they reported two or more migraine management issues.ResultsA total of 2232 patients with migraine were enrolled in the study (1373 from the intervention region and 859 in the control region). Compared with patients in the control region, patients in the intervention region reported, as measured by MTAQ, significant improvement in migraine symptom relief, more knowledge about potential migraine triggers, a decrease in economic burden, and more satisfaction with migraine treatment. In addition, the change in MIDAS scores from baseline showed a greater shift towards decreasing disability in the intervention group compared with the control group. However, no statistically significant improvement was detected in terms of health status as measured by SF-12. Of the participants in the intervention region who completed the program evaluation survey, 40% indicated that they called or visited their physicians regarding their migraine survey results if it was recommended. For those contacting their physicians, 76% had their medications changed and 75% noted an improvement in relief due to a change in medication.ConclusionsConsidering the significant toll of migraine on patients, employers, and the healthcare system, healthcare plans should consider implementing migraine disease management programs to improve migraine care.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS