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

Can Non-Nurse Professionals Coach Patients With Depression?

The Disease Management Care Blog is in San Diego on the eve of the annual DMAA Forum. What better way to prepare for all the learning that is going to happen tomorrow than to briefly share an important and recently published study on disease management for depression?

The article 'Case management for depression by health care assistants in small primary care practices' by Gensichen et al is in the latest Annals of Internal Medicine. You need a subscription to get to the entire manuscript, but the DMCB is ready to summarize the more important insights for you. The bottom line is that telephonic care management for depression may not require reliance on nurses.

This was a two year ‘pragmatic’ cluster randomized trial involving 74 small and often rural German primary care practices. The clinics, not the patients, were randomly assigned to having depression care for patients supplemented by specially trained ‘health care assistants’ (who were trained for a total of 17 hours) versus usual physician-only depression care. To be eligible for the trial, patients had to be referred into the study by their physician (presumably for suspected depression) and score high on a depression survey (the 27 point PHQ-9; ten points or higher suggests depression). 3051 patients were referred and 1671 scored high enough on the survey. For a variety of reasons (including withholding consent) 555 patients made it into the trial.

The health care assistants were non-physician non-nurse office ‘assistants’ who were described as first contact care workers who 'need not be college graduates.' They contacted patients twice a week for the first month and then once a month for the remaining year. Not only did they formally monitor the depression, but they monitored medication adherence, ‘encouraged self management activities’ and provided patient information back to the physician.

Twelve months later, the intervention group scored better on the follow-up PHQ-9 by 1.4 points (10.7 vs. 12.3) and had greater medication adherence according to a ‘Morisky Score.’ Over the year, both groups averaged about 6 visits with their primary care doctor and about 2 visits with psychiatrists.

The DMCB likes this study because it showed that success can be achieved with non-nurses. It always wondered if any caring and educated voice at the other end of the line was enough to shift patient behavior and medication adherence in the right direction. It suspects the same is true when it comes to other chronic illnesses. Ideally such a system in the U.S. would rely on nurse back-up and the right kind of attention to the U.S.' scope of practice laws and regulations.

Some other points to keep in mind:

The effect size was small (1.5 points on a 27 point scale and the means were still in the depressed range of greater than 9). We still have a long way to go.

Presumably, physicians only chose patients they thought were good candidates for the trial. We don't know if this would work on all patients with depression. Plus, if you run a disease management program and are stymied by poor recruitment and high drop out rates, welcome to the club. Even in a well run research program, patient leakage can be very high.

This study occurred in Germany. Differences in culture and how health care is regulated should be kept in mind while generalizing this to the U.S.

One problem among persons with depression is the occurence of suicidality. It's not clear how this was managed in this study, but imagine how thorny things can get if a patent expresses an intent to harm themselves over the phone.

There was no discussion of costs.

While the DMCB likes the study, it doesn't like how the authors 'framed' their manuscript and how the editors of the Annals let them get away with it. In fact, there is an accompanying editorial 'Progress on primary care management of depression' by Allen J. Dietrich of Dartmouth (which also needs a subscription). According to the authors and the editorialist, this use of non-nurse care management is further evidence of the merits of The Patient Centered Medical Home.

While the intervention did involve personnel that were physically located in the doctor's offices, the reason this worked is because someone was telephoning the patients. The DMCB doesn't understand why that function necessarily has to be physically located in each doctor's office; in fact, consolidating it may be more efficient. There is nothing in the manuscript that describes the linkages between the health care assistants and their assigned physicians, or why those linkages would better than those found in typical disease management programs.

The authors also conveniently and totally ignore the similarity of their intervention with traditional telephonic, disease management-based and insurer-sponsored patient coaching. The success of their non-physician supportive approach has been matched in the U.S. for years and in many respects, this Annals lead article is old news. In fact, the DMCB believes telephonic-based coaching and follow-up of patients with depression should be considered standard operating procedure.

Rather than compare their approach with usual care, the real question is whether non-nurses can perform as well as nurses in reducing depression symptoms and increasing medication compliance. Perhaps this should be a topic of investigation in comparative effectiveness research.

Deng Xiaoping, a former leader in Communist China, famously signalled his country's economic flexibility with the observation that it doesn't matter if a cat is black or white so long as it catches mice. The same may true when it comes to nurses vs. non-nurses and this part of reducing the burden of depression.

Norwegians, Depression and Lifemasters' New Depression Program

Yes, that is a disturbing painting, isn’t it? 'Madonna' is by the Disease Management Care Blog’s fellow Norseman Edvard Munch, who is probably best known for his infamous 'The Scream' (or ‘Skrik,’ better translated as Shriek). Based on these and his other artworks, the DMCB suspects Edvard was not a very happy person. In fact, art historians have pointed to his family history, traumatic childhood, likely alcoholism and recurrent depression as major forces that shaped his artistic genius.

And why not? Edvard was born in Norway, which is rainy, cold and dark for half of the year. In addition to the weather, turn of the century Scandinavian culture is not known for its party animals. Or, maybe there’s something in the water or the genes. So it was with some interest that the DMCB noted LifeMasters’ latest entry into a population that may include some of Edvard’s descendants. We’re talking about Minnesota, the land made famous by widespread disdain for Christopher Columbus, deserved admiration for the stoic Norwegians that inspired Garrison Keillor’s Lake Wobegon and the inexplicable persistence people who still eat lutefisk.

But seriously, suicide rates in Norway are lower compared to other parts of the world and Minnesota’s depression rates are not comparatively high either. The DMCB interprets this to mean that programs that improve the detection and treatment of depression are needed as much in Minnesota as anywhere else. That’s especially true considering how ‘usual medical care’ performs in this area and the considerable literature that supports the use of disease management.

According to the press release, the disease management company LifeMasters has used some newly infused money to build a depression program. One buyer is Preferred One Health Plan in Minnesota. Along with other managed care organizations, Preferred One has case managers that are tasked to depression care in its network. Lifemasters provides the telephonic care.

Interested in learning more, the DMCB contacted Lifemasters. They will also perform claims analyses and predictive modeling to identify Preferred One enrollees at greatest risk. Accordingly, patients will be recruited into the program; patients may also self refer and physicians can also. Depending on clinical need and severity, patients may be followed by the case managers or the Lifemasters nurses. There will also be hand offs, depending on how well the patients are doing. This program is in its earliest phases, just having gone through a pilot phase. There’s no information on Lifemasters’ web site, but ‘more information will be made available in the future.’ As for peer review publications so the DMCB can help its readers assess the impact on outcomes, ‘not yet.’

The DMCB recalls that physicians may chafe over the prospect of their patients being ‘cold’ contacted over a possible condition of depression using claims, pharmacy or other relatively inexact data. Some patients are undoubtedly destined to be upset also. However, depression is prevalent, burdensome, costly as well as treatable. Disease management has a track record of success. 'Nuff said.

Lastly, this is another example of an emerging pattern of collaborative integration of program components that blur the distinction between carve outs, carve ins, managed care, provider networks and disease management.

The DMCB wishes Preferred One and Lifemasters good luck on this. Hopefully we’ll hear more on how this initiative is progressing and how Edvard’s relatives and the rest of the clan are doing.

May 31: In the original post, the title ascribed the new program to Healthways. It's obviously Lifemasters. The DMCB regrets the error.