Sunday, March 30, 2014

Is depression a link between diabetes and kidney disease?

A team of epidemiologists and nephrologists led by Margaret K. Yu from the University of Washington and the VA recently published strong evidence that among diabetics, depression raises the risk of End-Stage Renal Disease (ESRD or renal failure) by 85%. This is a very big deal. There are lots of diabetics and lots of them have major depression.

Although it is not yet clear if treatment for depression can avert or delay ESRD for these folks, there are plenty of other reasons to identify and treat them. Even if treating depression doesn't prevent ESRD, it probably saves money, improves productivity, averts suicides, reduces morbidity and makes life better for the patient, the family, the neighbors and the rest of us. Given that the most effective treatment for depression is non-pharmacologic (Cognitive Behavioral Therapy) and doesn't impair glucose metabolism or renal function, the main issue is how so we get these patients into therapy?

Endocrinologists have a role, but they only see a small fraction of diabetic patients, and they often aren't equipped to diagnose and manage depression. This is one of those things that Primary Care does - and is getting better at all the time. More and more PCPs are routinely screening their patients for depression (often with the PHQ-9 - the same instrument used in Yu's study) and are developing systems to provide therapy either in the practice or by referral.

However, PCPs are prone to the same tunnel vision as every other doctor. If the patient isn't in the office, often nothing happens - no diagnosis, no treatment, no prevention. So, here is one more reason to use systematic patient engagement strategies to make sure that the PCP and the patient are interacting. Because that's when the good stuff happens!

Yu MK, Weiss NSDing XKaton WJZhou XHYoung BAAssociations between Depressive Symptoms and Incident ESRD in a Diabetic Cohort.  2014 Mar 27. [Epub ahead of print]

Sunday, March 23, 2014

Stories from the Experts by Experience

Pat Salber at The Doctor Weighs In blog reviewed a publication called Experts by Experience which reports a number of fascinating first-person stories of care gone horribly wrong (or brilliantly right) because of the ways that physicians and patients communicated. Patient Engagement is a new(ish) way of thinking about how patients interact with their problems, their health care and, especially, their providers. This lovely collection of a dozen short stories is an excellent reminder that listening is the most fundamental engagement tool of them all.  Enjoy!

(Hat tip to Bob Beltran at the Latino Medical Journal for pointing this out to me!)

Wednesday, March 12, 2014

Why is it so hard to communicate with cancer patients?

Carolyn D. Prouty and a team of researchers from Seattle, WA, Worcester, MA and Atlanta, GA just published an analysis of provider-patient communication in cancer care. Using focus group methods, they sorted out the causes of communication breakdown as seen by 59 providers. Some of the issues seem fundamental to the setting - patients are overwhelmed and scared - but some seem amenable to systematic interventions. For instance, these include inadequate time to meet with patients, failure of all the providers to agree on what the message to patients ought to be, and payment systems that undervalue communication. The next steps after this good work, of course, are to design and test some systematic interventions. 

Prouty CD, Mazor KM, Greene SM, Roblin DW, Firneno CL, Lemay CA, Robinson BE, Gallagher TH. Providers' Perceptions of Communication Breakdowns in Cancer Care. J Gen Intern Med. 2014 Mar 6. [Epub ahead of print]

Monday, March 3, 2014

The cost of diabetes care goes...down!

In a very surprising report in the American Journal of Managed Care, Peter Cunningham and  Emily Carter presented an analysis of the out-of-pocket costs for patient with diabetes. Over the years between 2001 and 2009, per-patient spending on prescriptions fell from $1,095 to $763, accounting for the bulk of the savings. This is due, in large part, to the shift from brand-name to generic drugs. As life-saving products to control blood sugar, but also cholesterol, blood pressure, depression and other common co-occurring conditions go off patent, they become available to many more patients without destroying their families. During the period of the study, the percentage of patients with "high financial burdens" (spending more than 10% of the family income on health care) fell from 23.9 to 18.6. What a relief - for patients, families and payers!

P. Cunningham and E. Carrier, “Trends in the Financial Burden of Medical Care for Nonelderly Adults with Diabetes, 2001 to 2009,”American Journal of Managed Care, Feb. 2014 20(2):135–42.

Sunday, March 2, 2014

DPS Health's Virtual Lifestyle Management Program

DPS Health has some very impressive results out for their Virtual Lifestyle Management Program (VLM). This is the web-based lifestyle coaching program that a number of health plans, provider and employers have been using to engage their employees in personal healthcare and risk reduction. The program includes multi-channel outreach, recruiting, and support for eligible members, a year-long comprehensive digital intervention with online education and dynamic behavior goal-setting, planning and tracking, and digital coaching via secure messaging and moderated chat. They also use accelerometers, journaling and other engagement tools.

The Government Employees Health Association has used it for a few years in about 5,000 members. After a year, 65% had lost weight and user satisfaction was good. They did a comparison to a matched population that did not have access to VLM and found that expenditures were lower in the VLM group. The saving came to $2,637 per member per year. This is a huge accomplishment and demonstrates the power of active engagement of patients to improve health and lower costs. More details are available here.

We are so impressed by DPS that my company, Patient Engagement Systems, recently announced that it has added VLM to its suite of patient engagement and clinical decision support tools for patients with diabetes and chronic kidney disease (CKD). This partnership means that the two services with the strongest data proving efficacy and cost savings can be integrated into one package, making them even better.