tag:blogger.com,1999:blog-59262919573876965772024-03-12T19:17:58.050-07:00Patient EngagementIntermittent observations about health care, especially how to involve patients more actively in their own care, and how to work with patients to achieve better outcomes.Ben Littenberghttp://www.blogger.com/profile/06057049894764818725noreply@blogger.comBlogger20125tag:blogger.com,1999:blog-5926291957387696577.post-76923366409932177202015-04-09T04:47:00.000-07:002015-04-09T04:47:07.246-07:00The Affordable Care Act and Diabetes<b>Harvey W. Kaufman</b> and colleagues just published an excellent analysis of the impact of the Affordable Care Act in <i><a href="http://care.diabetesjournals.org/content/early/2015/03/19/dc14-2334.abstract" target="_blank">Diabetes Care</a></i>. Using laboratory testing orders sent to Quest Diagnostics (a large national clinical laboratory provider), they found how many patients were newly diagnosed with diabetes since the Act went into effect. The 26 states and District of Columbia that took advantage of Medicaid expansion under the Act saw a substantial 13% increase in the number of diabetics identified. The 24 states that limited Medicaid expansion saw only 0.4% more diabetics.<br />
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An <a href="http://care.diabetesjournals.org/content/early/2015/03/19/dc15-0348.full.pdf+html" target="_blank">accompanying editorial</a> by <b>William H. Herman </b>and <b>William T. Cefalu </b>reminds us that this lost opportunity to improve health in half the states is due to a Supreme Court decision allowing states to opt out of Medicaid expansion. Thanks, Supreme Court!<br />
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<br />Ben Littenberghttp://www.blogger.com/profile/06057049894764818725noreply@blogger.com0tag:blogger.com,1999:blog-5926291957387696577.post-71134683387425349002014-11-20T17:47:00.002-08:002014-11-20T17:47:28.795-08:00Using phone and fax to improve diabetes careThe <i>Journal of Diabetes and Its Complications</i> just published a study on "Diabetes self-management support using mHealth and enhanced informal caregiving" by a team of VA researchers from Michigan and Stanford. The team set up an IVR phone system for veterans with diabetes. The vets received phone calls every week to assess their status and generate automatic tailored messages about how to deal with their disease. The system was designed to also engage family members and other informal caregivers as well as the clinician. This was a fairly sophisticated system with multiple tree-structured algorithms that took 5 to 10 minutes per call to complete and covered a wide range of issues including hypoglycemia, hyperglycemia, medication adherence, foot self-care, self-monitoring of blood sugar and blood pressure, and so forth. Clinicians received a fax if the system detected a concern.<br />
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The paper reports very positive short-term outcomes. 72% of patients agreed to try it and 84% of the scheduled calls were completed. On average, the system detected about one problem for every 5 weeks of patient participation. Patients who had informal caregivers tended to have fewer problems. Of course, the <a href="http://en.wikipedia.org/wiki/Pareto_principle" target="_blank">Pareto Principle</a> applies here as everywhere and almost half of the problems were concentrated in 15% of patients. The best news is that the number of problems seemed to decrease over time, suggesting that the patients were achieving better stability.<br />
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At this time, there are no data on whether the patients actually got better in terms of physiologic control, complications, utilization or satisfaction with care. However, it looks like the relatively old fashioned technologies of phone and fax still have great potential to enhance care by engaging patients, caregivers and clinicians.<br />
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<a href="http://www.ncbi.nlm.nih.gov/pubmed/24374137" target="_blank">Aikens JE, Zivin K, Trivedi R, Piette JD. Diabetes self-management support using mHealth and enhanced informal caregiving. J Diabetes Complications. 2014;28: 171-6.</a><br />
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Ben Littenberghttp://www.blogger.com/profile/06057049894764818725noreply@blogger.com0tag:blogger.com,1999:blog-5926291957387696577.post-13288028741117529332014-09-08T11:10:00.001-07:002014-09-08T11:10:33.019-07:00Individualizing content for patient engagement efforts<span style="font-family: inherit;">I'm struck by the wise comments presented in <a href="http://www.mhealthnews.com/news/how-can-patient-engagement-really-work?single-page=true" target="_blank">this recent piece from mHealthNews</a>. Editor Eric Wicklund wrote about the efforts of Kyra Bobinet, MD, MPH to increase the "emotional intelligence" of communications between provider and patient. "<span style="background-color: white; color: #333333; line-height: 20.000499725341797px;">If it's personal and relevant," says Bobinet, "that should work." </span></span><br />
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<span style="background-color: white; color: #333333; line-height: 20.000499725341797px;"><span style="font-family: inherit;">I couldn't agree more. Generic messaging of the "everybody ought to get a flu shot" variety has little resonance with the patient and is unlikely to impact behavior in a big way. Specific, tailored messages along the lines of "Because your last A1C diabetes test was high, you need to recheck again now" are more motivating. Of course, they are much harder to produce if you don't have an automated system to scan the information you have about the patient, identify the most important opportunities to improve care, and reach out to the patient in language they will understand via media they will accept.</span></span><br />
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<span style="background-color: white;"><span style="color: #333333; font-family: inherit;"><span style="line-height: 20.000499725341797px;">This is not the sort of process that most practices can do on their own. It requires some infrastructure and more than a little staff time to do all that communicating and engaging! </span></span><a href="http://www.patientengagementsystems.com/" style="color: #333333; font-family: inherit; line-height: 20.000499725341797px;" target="_blank">Patient Engagement System</a><span style="color: #333333; font-family: inherit;"><span style="line-height: 20.000499725341797px;">s offers a software-as-a-service solution that allows you to connect to your patients, keep them engaged in their care, and has been proven to improve outcomes and reduce the total cost of care. As more and more practices, payers and Accountable Care Organizations realize they need to increase engagement on a large scale to </span></span><span style="color: #333333;"><span style="line-height: 20.000499725341797px;">improve</span></span><span style="color: #333333; font-family: inherit;"><span style="line-height: 20.000499725341797px;"> quality and reduce costs, they are turning to automated systems to do the job.</span></span></span>Ben Littenberghttp://www.blogger.com/profile/06057049894764818725noreply@blogger.com1tag:blogger.com,1999:blog-5926291957387696577.post-77180107602487660812014-06-29T17:56:00.001-07:002014-06-29T17:56:52.728-07:00Diabetes prevalence goes up - again!<br />
The good folks at the Centers for Disease Control recently put out the <a href="http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf" target="_blank">2014 National Diabetes Statistics Report</a>. They estimate that over 29 million Americans have diabetes. That puts the overall prevalence at 9.3% or more than one in 11 people. The vast majority of them are adults, with prevalence rising to over 25% after age 65. There are 1.7 million new cases per year. In addition to the huge burden of illness, disability and premature death, the current cost of the diabetes epidemic is $245 trillion per year.<br />
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But there is some good news. Patients with diabetes who are engaged in their care, especially with primary care services, have better outcomes and require a lot less time in the hospital. Their costs are thousands of dollars lower per patient. The tools to do this are available at remarkably low cost in just about any kind of primary care setting.<br />
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New payment structures mean that the incentives to reduce costs and improve quality are in place. Accountable Care Organizations (ACOs) can't just pass the costs of bad quality along; they need to capture the savings that have been proven to occur with this kind of Patient Engagement, and they are starting to do it.<br />
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<span style="font-family: inherit;">If you know of an ACO (or other practice setting) that is motivated to reduce total utilization for diabetes and other chronic conditions without disrupting provider workflow, please let them know about <a href="http://www.patientengagementsystems.com/" target="_blank">Patient Engagement Systems</a>. Call <span style="background-color: white; color: #666563; line-height: 17px;">Toll-free: (855) 870-4337</span><span style="background-color: white; color: #666563; line-height: 17px;"> o</span><span style="background-color: white; line-height: 17px;">r email </span><a class="linkorange" href="mailto:contactus@ptengage.com" style="background-color: white; line-height: 17px; text-decoration: none;">contactus@ptengage.com</a>.</span><br />
<br />Ben Littenberghttp://www.blogger.com/profile/06057049894764818725noreply@blogger.com0tag:blogger.com,1999:blog-5926291957387696577.post-46668024179708758912014-04-17T05:07:00.000-07:002014-04-17T05:07:23.876-07:00Winning the war against kidney failure<b>Ed Gregg</b>, the master of diabetes epidemiology, and his team from the CDC, just published their latest report on the state of the nation's epidemic of diabetes. The good news is that the rates of diabetic complications - heart attacks, amputations, kidney failure, fatal hyperglycemic crisis, stroke - have fallen quite a bit since 1990. This is almost certainly do to the widespread application of practice guidelines by specialists and especially primary care providers. Monitoring and managing A1C, blood pressure, lipids and early renal damage is paying off at the national scale.<br />
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What about adults without diabetes?<br />
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<span style="background-color: white; color: #333333; font-family: arial, sans-serif; font-size: 13px; line-height: 18.211200714111328px;">"Trends in the population of adults without diabetes were generally not as promising as those in the population with diabetes, with smaller reductions in the rate of acute myocardial infarction, no significant change in rates of stroke and lower-extremity amputation, and an increase in the rate of end-stage renal disease."</span></blockquote>
An <b><i>increase</i></b> in end-stage renal disease? At the same time that we were making significant inroads against renal failure in diabetes (-28% drop in the rate), we see a swelling of the rates in non-diabetic adults by a whopping 65%. Why is this?<br />
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First, early stage chronic kidney disease is often un-noticed by providers who may not understand the implications of apparently small increases in serum creatinine. Second, proteinuria, the hallmark of treatable early renal damage, may not even be sought. Third, blood pressure is hard to reduce, often requiring multiple medications and persistent, frequent monitoring. You can't prevent the progression of early chronic kidney disease with once-a-year visits.<br />
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These problems in the quality of care are very much like those that beset diabetes 20 years ago, but we have made great strides by becoming aware of the problem, deciding as a profession that we should and shall do something about it, and marshalling all our resources - guidelines, educators, non-physician providers, reminders, lifestyle changes, new medications - and building them into our ongoing processes of care. In many practices, the optimal care of diabetes is a stated goal and the office uses standing orders, automated reminders and all the tricks of modern systems management to reliably deliver state-of-the-art care for diabetes. It's time to do that for early kidney disease.<br />
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<b><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1310799" target="_blank">Changes in Diabetes-Related Complications in the United States, 1990–2010</a></b><br />
<a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1310799" target="_blank">Edward W. Gregg, Ph.D., Yanfeng Li, M.D., Jing Wang, M.D., Nilka Rios Burrows, M.P.H., Mohammed K. Ali, M.B., Ch.B., Deborah Rolka, M.S., Desmond E. Williams, M.D., Ph.D., and Linda Geiss, M.A.</a><br />
<a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1310799" target="_blank"><i>N Engl J Med</i> 2014; 370:1514-1523 April 17, 2014 DOI: 10.1056/NEJMoa1310799</a>Ben Littenberghttp://www.blogger.com/profile/06057049894764818725noreply@blogger.com0tag:blogger.com,1999:blog-5926291957387696577.post-74294385981738336382014-04-10T04:30:00.000-07:002014-04-10T04:30:33.501-07:00Patient Engagement for Suicide PreventionYou can't manage what you can't measure is a truism in quality improvement. In mental health, it goes even further: You can't manage what you won't even talk about. Although lots of barriers have fallen in the realm of acceptable topics for conversation between doctors and patients - we no longer avoid saying "cancer" like the wor<span style="font-family: inherit;">d itself was the disease - suicide is still a particularly difficult topic for providers to broach. No doubt training the doctors to deal with this sticky area head on can help, but it takes two to tango, and physicians hate to initiate a difficult discussion as much as anyone else.</span><br />
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<span style="font-family: inherit;">So, <b>Ruby Shah</b>, <b>Richard Kravitz</b> and the good folks at UC Davis went at the problem from the other end. They used patient engagement techniques - a tailored interactive media program shown in the waiting room - to activate the patient to discuss their symptoms (both <span style="background-color: white; color: #333333; line-height: 20.799999237060547px;">emotional and physical) including thoughts of self-harm, and the possibility that those symptoms were due to depression. </span></span><span style="background-color: white; color: #333333; font-family: inherit; line-height: 20.799999237060547px;">Among patients with mild depression, there was little impact, perhaps because there was little need. But among patients with moderate to severe depression, the probability that suicide would at least be discussed went from 40% to 58%. </span><br />
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<span style="background-color: white;"><span style="color: #333333; font-family: inherit;"><span style="line-height: 20.799999237060547px;">Is this enough to make a difference? Talking about the issue is only the first step. Did it result in appropriate action? </span></span><span style="color: #333333;"><span style="line-height: 20.799999237060547px;">Kravitz</span></span><span style="color: #333333; font-family: inherit;"><span style="line-height: 20.799999237060547px;"> and company already reported in JAMA that the engagement approach increased treatment (or referral for treatment) from 16% to 26%. So, the intervention works in the sense that it sometimes stimulates the necessary discussion and appropriate treatment. However, the depression scores 12 weeks later were not better in the engagement group and were even a bit worse. Increased prescribing for non-depressed patients raises the possibility that the engagement program actually made things worse for some patients.</span></span></span><br />
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<span style="background-color: white;"><span style="color: #333333; font-family: inherit;"><span style="line-height: 20.799999237060547px;">This study was excellent science, but not a clear cut success for patient care. The tailored messaging had an impact on behavior and resulted in treatment changes. However, some of those treatment changes could have made things worse, not better. Twelve weeks later, there was little evidence that the patients felt better - probably because depression is hard to treat, especially with medications.</span></span></span><br />
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<span style="color: #333333; font-family: Arial, Helvetica, sans-serif;"><span style="line-height: 13px;"><a href="http://www.ncbi.nlm.nih.gov.ezproxy.uvm.edu/pubmed/24710994" target="_blank">Shah R, Franks P, Jerant A, Feldman M, Duberstein P, Y Garcia EF, Hinton L,</a></span></span><br />
<span style="color: #333333; font-family: Arial, Helvetica, sans-serif;"><span style="line-height: 13px;"><a href="http://www.ncbi.nlm.nih.gov.ezproxy.uvm.edu/pubmed/24710994" target="_blank">Strohecker L, Kravitz RL. The Effect of Targeted and Tailored Patient Depression </a></span></span><br />
<span style="color: #333333; font-family: Arial, Helvetica, sans-serif;"><span style="line-height: 13px;"><a href="http://www.ncbi.nlm.nih.gov.ezproxy.uvm.edu/pubmed/24710994" target="_blank">Engagement Interventions on Patient-Physician Discussion of Suicidal Thoughts: A </a></span></span><br />
<span style="color: #333333; font-family: Arial, Helvetica, sans-serif;"><span style="line-height: 13px;"><a href="http://www.ncbi.nlm.nih.gov.ezproxy.uvm.edu/pubmed/24710994" target="_blank">Randomized Control Trial. <i>J Gen Intern Med</i>. 2014 Apr 8. [Epub ahead of print]</a></span></span><br />
<span style="color: #333333; font-family: Arial, Helvetica, sans-serif;"><span style="line-height: 13px;"><a href="http://www.ncbi.nlm.nih.gov.ezproxy.uvm.edu/pubmed/24710994" target="_blank">PubMed PMID: 24710994.</a></span></span><br />
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<a href="http://www.ncbi.nlm.nih.gov.ezproxy.uvm.edu/pubmed/24193079" target="_blank"><span style="font-family: Arial, Helvetica, sans-serif;">Kravitz RL, Franks P, Feldman MD, et al. Patient Engagement Programs for Recognition and Initial Treatment of Depression in Primary Care: A Randomized Trial. JAMA. 2013;310(17):1818-1828. doi:10.1001/jama.2013.280038</span></a><span id="goog_1010317997"></span><span id="goog_1010317998"></span><a href="https://www.blogger.com/"></a>Ben Littenberghttp://www.blogger.com/profile/06057049894764818725noreply@blogger.com0tag:blogger.com,1999:blog-5926291957387696577.post-45001714201315537192014-03-30T15:22:00.000-07:002014-03-30T15:22:38.233-07:00Is depression a link between diabetes and kidney disease?A team of epidemiologists and nephrologists led by<b> Margaret K. Yu </b>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.<br />
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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? <br />
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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.<br />
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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!<br />
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Yu MK<span style="background-color: white; line-height: 16.613815307617188px;">,</span><span style="font-family: inherit;"><span style="background-color: white; line-height: 16.613815307617188px;"> </span>Weiss NS<span style="background-color: white; line-height: 16.613815307617188px;">, </span>Ding X<span style="background-color: white; line-height: 16.613815307617188px;">, </span>Katon WJ<span style="background-color: white; line-height: 16.613815307617188px;">, </span>Zhou XH<span style="background-color: white; line-height: 16.613815307617188px;">, </span>Young BA<span style="background-color: white; line-height: 16.613815307617188px;">. </span></span><span style="background-color: white; font-family: inherit; line-height: 1.125em;">Associations between Depressive Symptoms and Incident ESRD in a Diabetic Cohort. </span><span role="menubar" style="background-color: white; font-family: inherit; line-height: 15.956525802612305px;"><a abstractlink="yes" alsec="jour" alterm="Clin J Am Soc Nephrol." aria-expanded="false" aria-haspopup="true" href="http://www.ncbi.nlm.nih.gov/pubmed/24677559?dopt=Abstract#" role="menuitem" style="border-bottom-width: 0px; color: #660066;" title="Clinical journal of the American Society of Nephrology : CJASN.">Clin J Am Soc Nephrol.</a></span><span style="background-color: white; font-family: inherit; line-height: 15.956525802612305px;"> 2014 Mar 27. [Epub ahead of print]</span>Ben Littenberghttp://www.blogger.com/profile/06057049894764818725noreply@blogger.com0tag:blogger.com,1999:blog-5926291957387696577.post-70071449536519363282014-03-23T15:59:00.000-07:002014-03-24T04:25:16.646-07:00Stories from the Experts by Experience<b>Pat Salber</b> at <a href="http://www.thedoctorweighsin.com/experts-experience-patients-talk-worked-didnt/" target="_blank">The Doctor Weighs In blog</a> reviewed a publication called <i><a href="http://www.slideshare.net/TeamInspire/inspire-stanfordexpertsbyexperiencereport" target="_blank">Experts by Experience</a></i> 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!<br />
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(Hat tip to Bob Beltran at the <i>Latino Medical Journal</i> for pointing this out to me!)Ben Littenberghttp://www.blogger.com/profile/06057049894764818725noreply@blogger.com0tag:blogger.com,1999:blog-5926291957387696577.post-10897469147512204692014-03-12T06:24:00.000-07:002014-03-12T06:24:22.163-07:00Why is it so hard to communicate with cancer patients?<b style="color: #222222; white-space: pre-wrap;">Carolyn D. Prouty</b><span style="background-color: white; color: #222222; white-space: pre-wrap;"> 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. </span><br />
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<a href="http://www.ncbi.nlm.nih.gov/pubmed/24599795" target="_blank"><span style="background-color: white; color: #222222; white-space: pre-wrap;">Prouty CD, Mazor KM, Greene SM, Roblin DW, Firneno CL, Lemay CA, Robinson BE, </span><span style="background-color: white; color: #222222; white-space: pre-wrap;">Gallagher TH. Providers' Perceptions of Communication Breakdowns in Cancer Care. <i>J Gen Intern Med.</i> 2014 Mar 6. [Epub ahead of print]</span></a>Ben Littenberghttp://www.blogger.com/profile/06057049894764818725noreply@blogger.com0tag:blogger.com,1999:blog-5926291957387696577.post-86075909745819364682014-03-03T17:42:00.002-08:002014-03-03T17:42:36.655-08:00The cost of diabetes care goes...down!In a very surprising report in the <i>American Journal of Managed Care</i>, <b>Peter Cunningham </b>and <b> Emily Carter</b> 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!<br /><br /><a href="http://www.ajmc.com/publications/issue/2014/2014-vol20-n2/Trends-in-the-Financial-Burden-of-Medical-Care-for-Nonelderly-Adults-with-Diabetes-2001-to-2009">P. Cunningham and E. Carrier, “Trends in the Financial Burden of Medical Care for Nonelderly Adults with Diabetes, 2001 to 2009,”<i>American Journal of Managed Care</i>, Feb. 2014 20(2):135–42.</a>Ben Littenberghttp://www.blogger.com/profile/06057049894764818725noreply@blogger.com0tag:blogger.com,1999:blog-5926291957387696577.post-71984172987895197062014-03-02T13:38:00.000-08:002014-03-02T13:38:11.427-08:00DPS Health's Virtual Lifestyle Management Program<a href="http://www.dpshealth.com/" target="_blank"><b>DPS Health</b></a> 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.<br />
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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 <a href="http://www.dpshealth.com/images/downloads/summary_geha_cca_poster.pdf" target="_blank">here</a>.<br />
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We are so impressed by DPS that my company, <a href="http://www.patientengagementsystems.com/" target="_blank">Patient Engagement Systems</a>, <a href="http://www.patientengagementsystems.com/news/pr/PES_DPS_12814.pdf" target="_blank">recently announced</a> 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.<br />
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<br />Ben Littenberghttp://www.blogger.com/profile/06057049894764818725noreply@blogger.com0tag:blogger.com,1999:blog-5926291957387696577.post-26924681658092367832014-02-28T08:11:00.000-08:002014-02-28T08:11:29.591-08:00Engaging patients in screening for colon cancerColon cancer runs in families. If you have a relative with colon cancer, your chances of getting the disease are markedly higher than if you don't. The good news is that if you get a screening test periodically, the disease can be found early, treated relatively easily, and you can go about your business. The bad news is that we don't do enough screening, especially of first-degree relatives and especially in rural areas where the long drive to colonoscopy is a barrier.<br />
<b>Anita Kinney</b>, a nurse and epidemiologist in Utah, led a teem of researchers from five states in testing whether telephone outreach could get more high-risk patients screened. They found patients at elevated risk of cancer by recruiting the relatives of diagnosed patients. They either got a mailed brochure or a 40 minute telephone call with a genetic counselor plus a follow-up letter (with a copy to their primary provider). This was a carefully designed and executed randomized controlled trial with 481 subjects, so the improvement in colonoscopy from 16% to 25% is not only statistically significant (<i>P</i><0.001), but unlikely due to bias or confounding. Interestingly, the effect of the telephone intervention was about the same in rural, urban, high income, and low income groups.<br />
Although this is an impressive and clinically important effect, this intervention is a bit costly. The authors don't provide details, but these counselors are highly-trained and sophisticated providers and it takes a lot of their time to handle each case. I have to agree with the authors that this intervention should probably be part of a stepped strategy with the genetic counseling reserved for those who don't get screened after less expensive methods are tried first, especially since they had such a nice response from their brochure.<br />
Now the challenge will be how to integrate this proven intervention into an ongoing delivery model, and that means, an ongoing business model. Who will pay for the outreach and the colonoscopy, especially if the index patient has different coverage than their relatives?<br />
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<a href="http://www.ncbi.nlm.nih.gov.ezproxy.uvm.edu/pubmed/24449229" target="_blank">Kinney AY, Boonyasiriwat W, Walters ST, Pappas LM, Stroup AM, Schwartz MD, Edwards SL, Rogers A, Kohlmann WK, Boucher KM, Vernon SW, Simmons RG, Lowery JT, Flores K, Wiggins CL, Hill DA, Burt RW, Williams MS, Higginbotham JC. Telehealth Personalized Cancer Risk Communication to Motivate Colonoscopy in Relatives of Patients WithColorectal Cancer: The Family CARE Randomized Controlled Trial. <i>J Clin Oncol.</i> 2014 Mar 1;32(7):654-62. doi: 10.1200/JCO.2013.51.6765. Epub 2014 Jan 21.</a><br />
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Ben Littenberghttp://www.blogger.com/profile/06057049894764818725noreply@blogger.com0tag:blogger.com,1999:blog-5926291957387696577.post-72457007561213966902014-02-25T11:52:00.003-08:002014-02-25T11:57:44.037-08:00The Power of Small DataBig data is the uncharted territory of our time. Vast, multiple exabyte-sized data sets are like new continents that will, upon exploration, yield insights into all manner of human affairs. This is all well and good. But in the meantime, how about applying the latest tools and techniques of Big Data to much smaller data sets, say an insurer's chronic disease patients?<br><br>
Today, with high speed data exchange and processing, it is possible to comb through millions of lab tests to find the results of eligible patients, monitor their timing and values, and provide nearly instantaneous feedback to patients and providers. This is the power of Small Data. <br><br>
Small data connects people with timely, meaningful insights. It is organized and visually presented to be accessible, understandable, and actionable for everyday tasks. <br><br>
Small data is the right data. You shouldn't need to be a data scientist to understand or apply it for everyday tasks. <br><br>
Paraphrasing Joseph C. Kvedar, MD, the Founder and Director of the Center for Connected Health, Big Data will guide policy makers, but it's Small Data that will help patients get better.<br><br>
Living with and managing a chronic disease, such as chronic kidney disease, is complicated. Small Data can deliver the right information to patients and providers at the right time so that they can do the right thing.
Anonymoushttp://www.blogger.com/profile/15051793358436225301noreply@blogger.com0tag:blogger.com,1999:blog-5926291957387696577.post-56109263562625078522014-02-19T14:21:00.002-08:002014-02-19T14:21:33.139-08:00Using hand-held technologies to engage patientsTwo recent articles take a look at how some small devices - smartphones and tablets - can be used to foster patient engagement.<br />
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<span style="font-family: inherit;">The smartphone project tackled a tough problem - supporting patients with chronic disease (in this case, HIV) and heavy alcohol use to reduce their drinking. Expanding on their previous approaches using Interactive Voice Response (IVR) telephone calls, <span style="background-color: white; border: 0px; line-height: 17.600000381469727px; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Deborah S Hasin</span><span style="background-color: white; line-height: 17.600000381469727px;">, </span><span style="background-color: white; border: 0px; line-height: 17.600000381469727px; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Efrat Aharonovich</span><span style="background-color: white; line-height: 17.600000381469727px;"> and </span><span style="background-color: white; border: 0px; line-height: 17.600000381469727px; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Eliana Greenstein</span> from Columbia University enrolled </span>43 alcohol dependent HIV-infected patients and followed them for 60 days. The average number of drinks fell from 9.3 per day to 3.9. An impressive 25.6% were alcohol-free at the end of the two months. You can get all the details from their report in <a href="http://www.ascpjournal.org/content/9/1/5/abstract" target="_blank">Addiction Science & Clinical Practice.</a><br />
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The second article provides the early experience with a tablet system that was given to 30 hospitalized patients at the University of California, San Francisco. The iPad2 tablets had an educational program about patient safety and a link to the hospital's patient web portal. The 30 patients were able to use the devices and liked having them. This preliminary report didn't address any changes in outcomes that wiring up inpatients might bring, so it is a little soon to endorse this approach, but they overcame the first hurdles (getting the machines in the hands of the patients and getting the patients to use them). The authors (S. Ryan Greysen, Raman R. Khanna, Ronald Jacolbia, Herman M. Lee, and Andrew D. Auerbach) do promise that they will investigate post-discharge outcomes in future work. You can find this in <a href="http://onlinelibrary.wiley.com/enhanced/doi/10.1002/jhm.2169" target="_blank">The Journal of Hospital Medicine.</a><br />
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These innovations have potential. I'm looking forward to some solid assessments (randomized clinical trials, anyone?) in the next few years to help us separate the effective approaches from the marketing chatter.Ben Littenberghttp://www.blogger.com/profile/06057049894764818725noreply@blogger.com0tag:blogger.com,1999:blog-5926291957387696577.post-60931514858621155272013-12-29T09:24:00.004-08:002013-12-29T09:24:54.110-08:00Telephone coaching doesn't work for diabetesA noble effort by the good folks at the General Practice and Primary Health Care Academic Centre at the University of Melbourne to demonstrate the effectiveness of telephone coaching by trained nurses in type 2 diabetes ended in disappointment.<br />
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As <a href="http://www.bmj.com/content/347/bmj.f5272" target="_blank">reported in the British Medical Journal</a>, they randomized 59 primary care practices with 473 adults with A1C above 7.5%. The nurses in the intervention practices were trained to make structured calls to their patients, engaging them in dealing with their chronic problems, managing stress, improving their lifestyle, self-monitoring their disease, and doing some other good things. The program included seven telephone coaching sessions over 10 months, a face to face coaching session at 12 months, and a final telephone session at 15 months. The nurses were paid to do the calls, overcoming an important barrier in many settings. In other words, this was a well-designed, fairly high-intensity intervention. And, the evaluation is very rigorous and well-designed with little room for random error or bias. These investigators are pros and it shows.<br />
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Unfortunately, it didn't work. After 18 months, the A1C in the intervention group was the same as the control group (<i>P=</i>.84). On the plus side, fewer intervention patients were overweight or obese (<i>P</i>=.03). However, some outcomes actually got worse: HDL-cholesterol (<i>P</i>=.05)<i> </i>and systolic blood pressure (<i>P</i>=.07). Given the very large number of secondary outcomes reported, and the lack of any big trends across the outcomes as a group, these apparent effects are probably random error due to multiple comparisons. All in all, there is no evidence that this intervention had important effects on the patients or the health care system.<br />
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This isn't the only evidence that high-intensity phone interventions don't work in this setting. Even if they were to generate some improvement, they are so expensive that they can only be used for the sickest patients. So for now, we are left with the proven beneficial effects of less intensive patient engagement techniques that seek to keep patients connected with the practice and activate them when they need to be, rather than educate and prepare them ahead of time. It looks like the "teachable moment" may be more valuable than all the that coaching and preparation.<br />
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Blackberry ID, Furler JS, Best JD, Chondros P, Vale M, Walker C, Dunning T, Segal L, Dunbar J, Audehm R, Liew D, Young D. <a href="http://www.bmj.com/content/347/bmj.f5272" target="_blank">Effectiveness of general practice based, practice nurse led telephone coaching on glycaemic control of type 2 diabetes: the Patient Engagement and Coaching for Health (PEACH) pragmatic cluster randomised controlled trial.</a> BMJ. 2013 Sep 18;347:f5272. doi: 10.1136/bmj.f5272.<br />
<br />Ben Littenberghttp://www.blogger.com/profile/06057049894764818725noreply@blogger.com0tag:blogger.com,1999:blog-5926291957387696577.post-87012669485412944252013-12-23T18:21:00.000-08:002013-12-23T18:22:02.846-08:00Missing the diagnosis of CKD<div class="cit" style="background-color: white; font-family: arial, helvetica, clean, sans-serif; line-height: 1.45em;">
<span style="line-height: 17px;">The good folks at the Oregon Rural Practice Based Research Network looked through their database of lab results and found 865 patients with laboratory evidence of chronic kidney disease (CKD). Of these, 52% had no documentation of the diagnosis in the chart. CKD in women was missed more often than in men. Importantly, the care of high blood pressure was better in those CKD patients where the provider had documented the diagnosis.</span></div>
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What's going on? Is this just a documentation issue? Probably not. We've seen the same phenomenon in several other clinical settings. It's related to the difficulty of interpreting serum creatinine levels, the complexity and relative newness of the diagnostic criteria for CKD, the permanent brain cramp for all things kidney that medical school renal physiology courses induce, and the presence of the creatinine test in larger panels that are used when kidney disease is not top of mind. So, like the Oregonians, we also found that the number of known CKD cases goes up by 80-100% when the creatinine is systematically looked at (in the form of the estimated GFR value).</div>
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You can't engage patients in the care of their kidney problems and prevent end-stage renal disease if you don't even recognize that the patient has kidney disease in the first place! Happily, there are <a href="http://www.patientengagementsystems.com/news/pr/ESRD%20Prevention.pdf" target="_blank">systems </a>to help, and they are effective, easy and inexpensive. Let me know if you want to know more.</div>
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<span style="background-color: white; font-family: Arial, Helvetica, sans-serif;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/23371962" target="_blank"><span style="color: #660066;"><span style="line-height: normal;">Rao MK</span></span><span style="line-height: normal;">, </span><span style="color: #660066;"><span style="line-height: normal;">Morris CD</span></span><span style="line-height: normal;">, </span><span style="color: #660066;"><span style="line-height: normal;">O'Malley JP</span></span><span style="line-height: normal;">, </span><span style="color: #660066;"><span style="line-height: normal;">Davis MM</span></span><span style="line-height: normal;">, </span><span style="color: #660066;"><span style="line-height: normal;">Mori M</span></span><span style="line-height: normal;">, </span><span style="color: #660066;"><span style="line-height: normal;">Anderson S</span></span><span style="line-height: normal;">. </span><span class="highlight" style="line-height: 1.125em;">Documentation</span><span style="line-height: 1.125em;"> and </span><span class="highlight" style="line-height: 1.125em;">management</span><span style="line-height: 1.125em;"> of </span><span class="highlight" style="line-height: 1.125em;">CKD</span><span style="line-height: 1.125em;"> in </span><span class="highlight" style="line-height: 1.125em;">rural</span><span style="line-height: 1.125em;"> </span><span class="highlight" style="line-height: 1.125em;">primary</span><span style="line-height: 1.125em;"> </span><span class="highlight" style="line-height: 1.125em;">care</span><span style="line-height: 1.125em;">. </span><span role="menubar" style="line-height: 1.45em;"><span style="color: #660066;">Clin J Am Soc Nephrol.</span></span><span style="line-height: 1.45em;"> 2013 May;8(5):739-48. doi: 10.2215/CJN.02410312. Epub 2013 Jan 31.</span></a></span></div>
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Ben Littenberghttp://www.blogger.com/profile/06057049894764818725noreply@blogger.com0tag:blogger.com,1999:blog-5926291957387696577.post-20794553103024140052013-12-22T18:58:00.000-08:002013-12-22T18:58:21.454-08:00Does CKD increase the risk for prostate cancer?<span style="font-family: inherit;">Here's one more reason to aggressively identify, manage, and stay connected to patients with chronic kidney disease (CKD): Prostate cancer. </span><br />
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<span style="font-family: inherit;">A recent <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1742-1241.2012.03014.x/abstract;jsessionid=AD254DAAB77460C528348CDC5F2DB4E3.f04t01" target="_blank">study</a> from Korea analyzed a group of men with elevated prostate-specific antigen levels (PSA 4-10 ng/ml). They were all biopsied, but those with stage 3-5 CKD (eGFR < 60) were more likely to have a cancer detected.</span><br />
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<span style="font-family: inherit;">Although I'm not sure that PSA screening is a good idea in this population (or any others, for that matter), these findings are certainly disturbing. What isn't clear is whether our strategies for slowing the progression of renal insufficiency (especially blood pressure control and angiotensin inhibition) can prevent the development of prostate cancer.</span><br />
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<span style="background-color: white;"><span style="font-family: inherit;"><a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Cho%20SY%5BAuthor%5D&cauthor=true&cauthor_uid=23679906" style="border-bottom-width: 0px; color: #660066;">Cho SY</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Park%20S%5BAuthor%5D&cauthor=true&cauthor_uid=23679906" style="border-bottom-width: 0px; color: #660066;">Park S</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Lee%20SB%5BAuthor%5D&cauthor=true&cauthor_uid=23679906" style="border-bottom-width: 0px; color: #660066;">Lee SB</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Son%20H%5BAuthor%5D&cauthor=true&cauthor_uid=23679906" style="border-bottom-width: 0px; color: #660066;">Son H</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Jeong%20H%5BAuthor%5D&cauthor=true&cauthor_uid=23679906" style="border-bottom-width: 0px; color: #660066;">Jeong H</a>. <span style="line-height: 1.125em;">Differences in prostate</span><span style="line-height: 1.125em;"> </span><span class="highlight" style="line-height: 1.125em;">cancer</span><span style="line-height: 1.125em;"> </span><span class="highlight" style="line-height: 1.125em;">detection</span><span style="line-height: 1.125em;"> </span><span style="line-height: 1.125em;">rates according to the level of glomerular filtration rate in patients with prostate specific antigen levels of 4.0-10.0 ng/ml. </span><span role="menubar" style="line-height: 19.625px;"><a abstractlink="yes" alsec="jour" alterm="Int J Clin Pract." aria-expanded="false" aria-haspopup="true" href="http://www.ncbi.nlm.nih.gov/pubmed/23679906#" role="menuitem" style="border-bottom-width: 0px; color: #660066;" title="International journal of clinical practice.">Int J Clin Pract.</a></span><span style="line-height: 19.625px;"> </span><span style="line-height: 19.625px;">2013 Jun;67(6):552-7. doi: 10.1111/j.1742-1241.2012.03014.x.</span></span></span>Ben Littenberghttp://www.blogger.com/profile/06057049894764818725noreply@blogger.com0tag:blogger.com,1999:blog-5926291957387696577.post-30543723896020598512013-12-15T10:56:00.001-08:002013-12-15T10:56:37.850-08:00"By the way...": The pros and cons of incidental findings<span style="background-color: white; color: #292727; font-family: Georgia, 'Times New Roman', Times, serif; font-size: 13px;">Melissa Healy wrote</span> a very interesting <a href="http://www.latimes.com/science/sciencenow/la-sci-bioethics-incidental-findings-20131212,0,2784685.story" target="_blank">story for the LA Times</a> last week on what happens when a medical test reports something unexpected.You're looking for pneumonia and the chest x-ray shows a cancer in the spine, but you don't know where it came from. A head CT to rule out subdural hematoma after a head injury shows an aneurysm...that might or might not cause trouble one day. These "incidental findings" are disturbingly common.<br />
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High tech imaging tests like CT scans and MRIs are particularly prone to this because they are not very specific in their field of view and provide a huge amount of information. If you get a CT of the abdomen to look at the liver, you're going to get all sorts of information about the gallbladder, stomach, intestines, kidneys, pancreas, etc. <i>even if you don't want it. </i>In my experience, lungs and brains are particularly full of findings of "uncertain significance" that are time consuming, costly and difficult to evaluate. They certainly induce a huge amount of anxiety in the patient.Whole genome studies are going to be even worse. The vast majority of genetic information in a person is not interpretable with anything like the accuracy required for clinical decision making.<br />
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The new that stimulated Healy's article was that the <span style="background-color: white; font-family: Georgia, 'Times New Roman', Times, serif; font-size: 14px; line-height: 20px;">Presidential Committee for the Study of Bioethical Issues said professional organizations need to start writing guidelines for how to deal with these incidental results. In other words, we should stop treating them like they are not anticipated - we know we are going to get them even if we don't ask for them, so we better make a plan.</span><br />
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<span style="background-color: white; font-family: Georgia, 'Times New Roman', Times, serif; font-size: 14px; line-height: 20px;">I'm all for coming up with guidance on this tricky issue, especially in cases where the consequences of over-diagnosis and unnecessary work-ups are high and the benefits are low. </span><br />
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<span style="background-color: white; font-size: 14px; line-height: 20px;"><span style="font-family: Georgia, Times New Roman, Times, serif;">The unintended uses of diagnostic tests have a few other upsides to keep in mind, though. They can be used for public health surveillance to help develop strategies for the whole population of patients. This is done routinely with infectious disease tests, for instance, to alert us to new outbreaks. More recently, we have been systematically scanning commonly done blood and urine chemistry tests to identify patients with undiagnosed diabetes and kidney disease. In the case of chronic kidney damage especially, even the doctors don't always recognize the condition as present. By using an automated system to monitor laboratory results, we can identify patients who need extra attention, reach out to them, connect them to the resources they need and prevent emergencies and other complications.</span></span><br />
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<span style="background-color: white; font-size: 14px; line-height: 20px;"><span style="font-family: Georgia, Times New Roman, Times, serif;">If you have thoughts on this issue, do leave a comment!</span></span>Ben Littenberghttp://www.blogger.com/profile/06057049894764818725noreply@blogger.com0tag:blogger.com,1999:blog-5926291957387696577.post-29888975599844333942013-11-29T16:44:00.000-08:002013-11-29T16:44:43.308-08:00New data on quality of care and cardiovascular outcomes in diabetes<span style="font-family: Arial, Helvetica, sans-serif;">A recent report from <span style="background-color: white;"><span style="color: #333333;"><span style="line-height: 15px;">The Netherlands analyzed the </span></span><span style="color: #333333;"><span style="line-height: 15px;">relationship</span></span><span style="color: #333333;"><span style="line-height: 15px;"> between quality of care in diabetes and long-term cardiovascular outcomes. The authors had access to a large database of </span></span></span><span style="background-color: white; color: #333333; line-height: 18px;">10,058 patients with type 2 diabetes. They looked at a number of predictors including whether the patients were treated for high blood glucose, high cholesterol, high blood pressure and albuminuria (a marker of incipient kidney damage in diabetes). Over 3 years, treatment of high l</span><span style="background-color: white; color: #333333; line-height: 18px;">ipids and albuminuria were each associated with about a 25% reduction in cardiovascular events and all-cause mortality (HR = 0.77, 0.67–0.88; HR = 0.75, 0.59–0.94). Glucose lowering treatment status was associated with a similar effect, but only in patients with an elevated HbA1c level at baseline (HR = 0.72, 0.56–0.93). (Oddly, treatment of hypertension was not associated with better outcomes.)</span></span><br />
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<span style="background-color: white; color: #333333; line-height: 18px;"><span style="font-family: Arial, Helvetica, sans-serif;">This report is important for several reasons. First, it serves to validate that we are probably measuring the right things when we do quality improvement based on the Medicare 5-star program or other quality measurement initiatives based on the HEDIS criteria.</span></span><br />
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<span style="background-color: white;"><span style="color: #333333; font-family: Arial, Helvetica, sans-serif;"><span style="line-height: 18px;">Second, it points out how soon we get the payoff. The effect of high quality management is apparent within 3 years, probably sooner. (Unfortunately, the report does not provide information on exactly when the effects were seen, only that they occurred over the course of the 3-year study.) You don't need to wait 20 years to see the benefits in terms of mortality, morbidity and costs.</span></span></span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Third, this study emphasizes the big opportunity represented by untreated albuminura. Primary care in the US is generally fair to good at tracking A1C and cholesterol in diabetes patients, but our track record with monitoring and managing albuminuria is much worse. So, a big take-home message for me is to work hard on urine monitoring.</span><br />
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<span style="background-color: white; color: #333333; line-height: 18px;"><a href="http://www.plosone.org/article/info%3Adoi/10.1371/journal.pone.0078821" target="_blank"><span style="font-family: Arial, Helvetica, sans-serif;">Sidorenkov G, Voorham J, de Zeeuw D, Haaijer-Ruskamp FM, Denig P (2013) Do Treatment Quality Indicators Predict Cardiovascular Outcomes in Patients with Diabetes? PLoS ONE 8(10): e78821. doi:10.1371/journal.pone.0078821</span></a></span>Ben Littenberghttp://www.blogger.com/profile/06057049894764818725noreply@blogger.com0tag:blogger.com,1999:blog-5926291957387696577.post-65130607830365166352013-11-22T09:42:00.000-08:002013-11-27T06:27:23.279-08:00Screening Asymptomatic Adults for Chronic Kidney Disease (CDK) <span style="color: #444444; font-family: Arial, Helvetica, sans-serif;"><b:skin>
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This month has seen a scuffle of sorts between the American College of Physicians (ACP), representing America's internists and with a viewpoint largely derived from the primary care providers who make up much of its membership, and the American Society of Nephrology (ASN), a group of sub-specialty kidney physicians. It started when the ACP released one of their hallmark practice guidelines. This one was about screening and management of early stage chronic kidney disease (CKD) and came to the conclusion that screening of asymptomatic adults for CKD was not warranted, largely because it has never been shown to be effective and there are clearly potential downsides. (ACP guidelines are not just evidence-based, they are downright evidence-driven.) The ASN took exception to this guideline and published a flurry of press releases calling for screening.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Full disclosure: I am a Fellow of the ACP and a big proponent of evidence-based medicine. However, I don't have a horse in this race, other than my desire to not see CKD become an inter-specialty football.) The ASN is right that lots of CKD is not being diagnosed or managed to prevent progression, but neither screening nor ignoring the problem may be the best way forward.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">In my experience setting up chronic disease registries and decision support systems, 40-50% of the people in primary care with undiagnosed CKD have had an abnormal blood or urine test in the past two years. These tests weren't done for screening, and although abnormal, they didn't trigger a diagnosis by the provider. (The reasons for this are many, including the tricky nature of the serum creatinine in older adults and uncertainty about the diagnostic criteria on the part of the providers.) So, rather than go out and screen a new batch of folks and figure out how to get them plugged into care, the first thing to do is identify all the patients already in the practice with evidence of CKD and start managing them. These patients are currently under care for something, so we don't have to find them a provider. What we do need to do is build systems to identify them, bring them to the attention of their providers, and support them and the practices as they develop plans to prevent progression.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Very few practices have the tools to manage this job now. Screening a whole new population of CKD patients will just make the situation worse until we have systems in place to not only identify these patients, but engage them and their providers in the long-term process of averting, delaying, and mitigating progression to renal failure. Although Electronic Medical Records (EMRs) can help, none of the currently available EMR systems has the capacity to manage chronic care in a way that doesn't create a lot of extra work for the practice. Happily, there are systems that can do this at low cost and with good results, including documented reductions in overall utilization.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">So, rather than argue about whether we should find more patients with CKD, let's work together to take better care of the patients we already have with undiagnosed and unmanaged disease.</span><br />
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You can read the ACP's Clinical Practice Guidelines in <a href="http://bit.ly/1cFcxxh" target="_blank">Annals of Internal Medicine</a>.
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<span style="font-family: Arial, Helvetica, sans-serif;">Also see the <a href="http://bit.ly/1b5V7x4" target="_blank">ASN's Press Release here</a>.
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