Two New Studies Show Telephonic Disease Management Works

When skeptics think about 'disease management' (DM), they think about distant and nurse-filled cubicle farms that put unsuspecting patients through a speed dial version of education-lite. Plumbing the depths of these telephonic knockoffs, critics have made it abundantly clear that don't like what they see: a pseudoscience that confounds patients and antagonizes physicians. They're fed up with the lack of financial provider incentives, lagging technology and ineffective leadership support. It's so bad, 'how to' articles like this have become necessary to help address the physicians' loss of prestige, influence over patient care and income. Policy makers, academics and organized medicine groups have all agreed that the outrageous vendor fees could be better used for other stuff. Like vaccinating upper-class suburban tots. Or paying for motorized wheelchair scooters for affluent octagenarians. Or increasing primary care physicians' fees.

A pox on disease management you say? Stone them?

Think again. Two important publications in the mainstream peer-reviewed medical literature suggest that traditional telephonic disease management is quite effective.

The first is this article, in which researchers from the University of Pittsburgh report the results from a randomized control trial that compares telephonic "collaborative care' (CC) (N=150) versus usual care (N=152) for fresh heart surgery patients that were discharged from one of seven Pittsburgh area hospitals with a surprisingly common side effect of their treatment: active depression (1).

The CC nurses provided 'psychoeducation' in the intervention group that increased awareness of depression treatment options. Backed-up by a psychiatrist/internist team, the nurses also facilitated the patients' treatment decisions. The article includes a description of the CC nurses' roles could have been written as a job description by any of the current for-profit disease management vendors:

'Adheres to evidence-based treatment protocols, supports patients with timely education about their illness, considers patients' prior treatment experiences and current preferences, teaches self-management techniques, actively involves primary care physicians in their patients' care through regular exchanges of real-time information, proactively monitors treatment responses and suggests adjustments when indicated, and facilitates co-management or transfer of care to local mental health specialists when patients do not respond to treatment, have clinically complicated cases, or upon request by the patient or primary care physician.'

Using an approach that is quite similar to any typical disease management vendor program, patients were telephoned every other week for two to four months with calls lasting 15-45 minutes. This was followed by a 'continuation phase' with a call every one to two months. Eight months later, various mood tests showed that the CC group had a greater and statistically significant improvement in psychological well being compared to the usual care group. In looking at the graphs from the study, the Disease Management Care Blog was unable to discern any meaningful difference in the overall rehospitalization rate, though it looks (no 'p' value was reported) like rehospitalizations for cardiovascular disease were considerably lower in the CC patients. CC women were also more likely to being taking antidepressants.

The second is this article, where the Duke University primary care clinics randomly assigned 636 patients to one of four treatments: 1) a telephonic bimonthly 'behavioral intervention' that used the patients' perceived risks, memory ability, literacy, educational level and the quality of the doctor-patient relationship to tailor engagement in the DASH diet (N=160) 2) just a home blood pressure (BP) monitoring device (N=158), 3) both education and a BP device (N=159) or 4) neither (N=159). Two years later, there was an absolute 11% increase in the proportion of patients that had blood pressure under control vs. 7.6% in the blood pressure cuff group vs. 4.3% in the phone call only group. There was no impact on health care costs (2).

First of all, the Disease Management Care Blog thinks both studies are an affirmation of what the mainstream DM vendors have been doing for years. While post-heart surgery depression hasn't been a topic of research, telephonic-based DM for depression in other settings has been shown to have considerable merit. As for hypertension, managed care insurers have known for years that BP control in primary care settings is not what it should be. In response, many DM vendors are selling patient engagement programs that promote the DASH diet with or without blood pressure monitors. Based on the Duke study, it would appear that the managed care organizations can expect and have achieved better blood pressure control with hypertension DM.

Secondly, aha, you ask, but are we getting our money's worth? Neither study 'saved money.' If the cost of the nurses was included, both interventions described above would probably be rated as money losing. While that may be technically 'true,' a) neither study followed patients for a sufficient period of time - it can take longer for a pay-off to accrue, b) commercial DM vendors are much better at identifying, targeting and successfully managing the high risk patients with a higher likelihood of excess costs, c) the interventions above were just for depression or hypertension; modern DM vendors are able to fold in additional care management interventions for other co-morbid conditions that can lead to hospitalization or increase costs and d) maybe, just maybe, the ultimate purpose of DM is not to save money but to increase quality of care at a price point that yields the greatest bang for the dollar. In other words, if depression or hypertension is better treated, maybe it's worth it to pay for it. Stick with usual primary care and you get what you pay for.

Thirdly, critics may point out that both studies above originated in physician-owned, operated and led settings. Fair enough, says the DMCB, but it also knows that primary care physicians in large health care systems are not necessarily more loyal to the 'home office' than any external vendor . In fact, close reading of both studies fails to show that the UPMC or Duke nurses were really all that different from any other external care management initiative. The DMCB doesn't believe the location/ownership of the nurses is what's important. Rather, it's what they do and which patients they do it to.

The DMCB has pointed out for years that telephonic disease management is an important option in the suite of services for caring for populations with chronic illness. It's nice to see that there are now two studies that confirm that perspective.

1. Rollman, B, Herbeck Belnap B, LeMenager MS, Mazumdar S, Houck PR, Counihan PF et al: Telephone-Delivered Collaborative Care for Treating Post-CABG Depression: A Randomized Controlled Trial. JAMA 2009;302(19):2095-2103

2. Bosworth HB, Olsen MK, Grubber JM, Neary AM, Orr MM, Pwers BJ et al: Two Self-management Interventions to Improve Hypertension Control. A Randomized Trial. Ann Intern Med 2009 151(10):687-695

The Sauce vs. Soufflé Approach to Care Management: Implications for Health Reform

Thanks to all those cooking shows, the Disease Management Care Blog fancies kitchen metaphors. In thinking more about yesterday’s post on ‘care management,’ one allegory came to mind: the making of sauces versus soufflés. It occurred to the DMCB that care management, despite all the scientific trappings, is best thought of as a sauce. How well health reform can swallow that remains to be seen.

When the DMCB makes spaghetti sauce, it knows the red stuff basically involves tomatoes. Once that basic ingredient is fulfilled, the rest is a creative mix of spices, maybe some wine, chopped sweet peppers, mushrooms, onions, garlic, other stuff and what-the-heck whatever-this-is-from-the-fridge and then drinking some wine. Think The Godfather’s Peter Clemenza and his famous going to the mattresses recipe for 20 guys.

Then there are soufflés. The closest the DMCB ever got to that level of culinary expertise was when it tried to make crème brûlée. What unfolded early the next morning wasn’t pretty. The point is that the DMCB appreciates that soufflés require an extraordinary level of cookery. The ingredients have to be apportioned in exact amounts, their mixing has to be precise and the oven temperature and bake time must be unerring or the result will be a stone. In medicine, think the operating suite and making sure the same check list is completed all the time every time.

When guests sit down to the DMCB’s sauce n’ pasta, they know what it is and it usually does the job. In the world of case management, the red stuff (otherwise known as the key core ingredient) is the generalist registered nurses referred to in Dr. Bodenheimer’s New England Journal article on care management. The rest is based on nursing science, lots of opinion, local culture, available resources and what’s in the fridge.

Check out the peer-reviewed literature used by Dr. Bodenheimer to make the case for care management. There is one reference on advance practice nurses and the role they play in helping patients discharged from six city hospitals, another on ‘trained nurses’ using a Care Transitions protocol for recently discharged patients in Colorado and primary care-based registered nurses in Baltimore who had completed a course in ‘Guided Care Nursing .’ There are other examples used in the article, including a geriatrician-led high risk clinic doing home visits, a roving geriatric physician-two nurse team managing 300 patients and the CMS capitated benefit plan called PACE. All are unique, yet all share the key ingredient of nurses doing nursing stuff that help patients move from point A to point B. It’s what does the job.

In the DMCB’s recent American Journal of Managed Care editorial, it argued that population-based programs for the care of patients with chronic illness are necessarily varied. The core ingredient makes it recognizable but around it there is considerable creativity and flexibility. Dr. Bodenheimer’s article didn’t necessary address the non-uniformity of care management, but the references he used certainly speak to that dimension.

As a result, it will be very challenging for accreditation agencies, recognition programs, managed care and accountable care organizations as well as Federal health reform and all the necessary regulations that follow to accommodate all those excellent cooks and their wonderful savory creations in the delivery of care management. Hopefully, the powers-that-be will recognize the need for flexibility in this area.

Hopefully, they'll be less about soufflés and more about sauces.

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Post script: The closest Dr. Bodenheimer has come to endorsing disease management is also in this New England Journal article:

'Telephonic care management has been effective when combined with face-to-face visits but has not worked by itself.'

Welcome to the club, Dr. B. The DMAA's been pointing this out for over a year and regular readers of the DMCB have long been familiar with the concept.

The Definition of 'Care Management' Courtesy of the New England Journal

The Disease Management Care Blog appreciates it when a useful definition appears in the peer-review literature. It helps everyone in the population-health care business to agree on terms, concepts and principles. The definition of 'care management' has now appeared in an article* by Thomas Bodenheimer and Rachel Berry-Millett in the Sept. 30 New England Journal of Medicine. This quote and the reference can be used by population health warriors everywhere who are dealing with those upcoming responses to RFPs, business plans, presentations, learning sessions, staff meetings, PowerPoints, professional development classes and care initiatives:

Care management is a set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aims of improving patients’ functional health status, enhancing the coordination of care, eliminating the duplication of services, and reducing the need for expensive medical services.

There have been other definitions (for example, here and here) and they more or less support the same concepts, but this may turn out to be the oft-cited reference because:

a) let's face it, it's in the New England Journal. It looks good when you quote it.

b) the authors explicitly point out that care management is generally provided by a 'registered nurse.' The DMCB heartily agrees because it is a big fan of nurses and has witnessed repeatedly how their common sense and familiarity with the 'system' are invaluable to docs and patients alike. What's more, the article points out the value of non-specialty trained nurses, which makes sense: this is a role that often calls for generalism and a working knowledge of primary care.

c) the authors also point out that care management should not be applied 'to patients who are too sick to benefit.' While there is no citation for this particular assertion, the DMCB likewise not only agrees with that, but points out that regular DMCB readers are already long-familiar with the supporting peer review literature. The DMCB recalls numerous instances in which its health plan senior leaders insisted that care management nurses 'do something' about the catastrophically ill patients that had had numerous inpatient stays, required many specialty physician visits and used some very expensive medications. Experienced care management leaders already know that care management is best 'aimed' at patients that are in the sweet middle: not too well that their risk of an exacerbation is low, but not too sick that nothing could be done.

Now, in addition to quoting the oft Googled, widely read, sometimes quoted and always useful if humble DMCB about care management, you can also quote Dr. Bodenheimer and the Journal.

Here's the citation for your copying and pasting pleasure:

*Bodenheimer T, Berry-Millett R: Follow the money - Controlling expenditures by improving care for patients needing costly services. New Engl J Med 2009;361(16):1521-1523

And here's the pdf for printing or forwarding to your colleagues.