Impact of office systems and improvement strategies on costs of care for adults with diabetes

Booster visits in the management of the acute musculoskeletal injuries: Transforming care to improve outcomes-A perspective review

The current healthcare delivery system for patients with acute musculoskeletal injury is failing. Current rehabilitation management of acute musculoskeletal injury typically includes physical therapy, focused on management of impairments, with an eventual transition to functional activities and release to prior level of function. At that point, formal physical therapy is often discontinued, despite the knowledge that a high percentage of patients fail to maintain preinjury level of activity and often reduce participation in regular physical activity. Further, for those who attempt to return to prior levels of pivoting and cutting activities, there is a high second injury rate. The long-term human experience is compromised by the current model of care which terminates at the point of transition to activity. This model of care fails to meet the continued needs of these patients and may result in long term deficits and potential disability. Extended care models include intermittent follow up visits after discharge from an acute episode of care and have been efficacious and cost effective in some patient populations with musculoskeletal conditions. Specifically, a type of extended care model, labeled "booster sessions," represents an opportunity to provide structured, intermittent care to assist in a smooth transition back to function, following an acute episode of care and promote a healthier life outcome. This perspective review will discuss the opportunity to transform acute musculoskeletal care to booster visit care model in an attempt to develop a more efficacious and cost-effective system of care which could be generalizable to all musculoskeletal conditions.

Economic aspects of the association between diabetes and depression: a systematic review

BACKGROUND

The importance of co-morbid diabetes and depression is gaining increased attention. Quantifying the socio-economic and clinical impacts of co-morbidity is important given the high costs of these diseases. This review synthesised evidence on the economic impact of co-morbidity and potential cost-effectiveness of prevention and treatment strategies.

METHODS

11 databases from 1980 until June 2011 searched. In addition, websites and reference lists of studies scrutinised and hand search of selected journals performed. Reviewers independently assessed abstracts, with economic data extracted from relevant studies.

RESULTS

62 studies were identified. 47 examined the impact of co-morbidity on health care and other resource utilisation. 11 of these included productivity losses, although none quantified the impact of mortality. Most demonstrated an association between co-morbidity and increasing health service utilisation and cost. Adverse impacts on workforce participation and absenteeism were found. 15 economic evaluations were also identified. Most focused on primary care led collaborative and/or stepped care, suggesting actions may be cost effective. We did not identify any studies looking at actions to reduce the risk of diabetes in people with depression.

LIMITATIONS

Most studies are set in the US, which may be due to focus on English language databases. Few studies looked at impacts beyond one year or outside the health care system.

CONCLUSIONS

There is an evidence base demonstrating the adverse economic impacts of co-morbid diabetes and depression and potential for cost effective intervention. This evidence base might be strengthened through modelling studies on cost effectiveness using different time periods, contexts and settings.

Cost-effectiveness of an electronic medical record based clinical decision support system

BACKGROUND AND OBJECTIVE

Medical groups have invested billions of dollars in electronic medical records (EMRs), but few studies have examined the cost-effectiveness of EMR-based clinical decision support (CDS). This study examined the cost-effectiveness of EMR-based CDS for adults with diabetes from the perspective of the health care system.

DATA SOURCES/SETTING

Clinical outcome and cost data from a randomized clinical trial of EMR-based CDS were used as inputs into a diabetes simulation model. The simulation cohort included 1,092 patients with diabetes with A1c above goal at baseline.

STUDY DESIGN

The United Kingdom Prospective Diabetes Study Outcomes Model, a validated simulation model of diabetes, was used to evaluate remaining life years, quality-adjusted life years (QALYs), and health care costs over patient lifetimes (40-year time horizon) from the health system perspective.

PRINCIPAL FINDINGS

Patients in the intervention group had significantly lowered A1c (0.26 percent, p = .014) relative to patients in the control arm. Intervention costs were $120 (SE = 45) per patient in the first year and $76 (SE = 45) per patient in the following years. In the base case analysis, EMR-based CDS increased lifetime QALYs by 0.04 (SE = 0.01) and increased lifetime costs by $112 (SE = 660), resulting in an incremental cost-effectiveness ratio of $3,017 per QALY. The cost-effectiveness of EMR-based CDS persisted in one-way, two-way, and probabilistic sensitivity analyses.

CONCLUSIONS

Widespread adoption of sophisticated EMR-based CDS has the potential to modestly improve the quality of care for patients with chronic conditions without substantially increasing costs to the health care system.

Integrated care for chronic conditions: the contribution of the ICCC Framework

OBJECTIVE

The aim of this research is to highlight the current relevance of the Innovative Care for Chronic Conditions (ICCC) Framework, as a model for change in health systems towards better care for chronic conditions, as well as to assess its impact on health policy development and healthcare redesign to date.

METHODS

The authors reviewed the literature to identify initiatives designed and implemented following the ICCC Framework. They also reviewed the evidence on the effectiveness, cost-effectiveness and feasibility of the ICCC and the earlier Chronic Care Model (CCM) that inspired it.

RESULTS

The ICCC Framework has inspired a wide range of types of intervention and has been applied in a number of countries with diverse healthcare systems and socioeconomic contexts. The available evidence supports the effectiveness of this framework's components, although no study explicitly assessing its comprehensive implementation at a health system level has been found.

CONCLUSIONS

As awareness of the need to reorient health systems towards better care for chronic patients grows, there is great potential for the ICCC Framework to serve as a road map for transformation, with its special emphasis on integration, and on the role of the community and of a positive political environment.

As redes de atenção à saúde

As transições demográfica e epidemiológica significam um incremento relativo das condições crônicas. Tem sido assim, no Brasil, que apresenta uma situação de saúde de tripla carga de doenças, manifestada na convivência de doenças infecciosas, parasitárias e problemas de saúde reprodutiva, causas externas e doenças crônicas. Há uma crise dos sistemas de saúde contemporâneos que se explica pela incoerência entre uma situação de saúde com predomínio relativo forte de condições crônicas e uma resposta social através de sistemas fragmentados e voltados, principalmente, para as condições agudas e as agudizações das condições crônicas. Essa crise se manifesta em nosso país, tanto no setor público quanto no setor privado. A solução para essa crise está em recompor a coerência entre a situação de tripla carga de doenças com uma resposta social estruturada em sistemas integrados de saúde: as redes de atenção à saúde. Conclui-se que há evidências na literatura internacional de que as redes de atenção à saúde podem melhorar a qualidade dos serviços, os resultados sanitários e a satisfação dos usuários e reduzir os custos dos sistemas de atenção à saúde.

Defining and measuring the patient-centered medical home

The patient-centered medical home (PCMH) is four things: 1) the fundamental tenets of primary care: first contact access, comprehensiveness, integration/coordination, and relationships involving sustained partnership; 2) new ways of organizing practice; 3) development of practices' internal capabilities, and 4) related health care system and reimbursement changes. All of these are focused on improving the health of whole people, families, communities and populations, and on increasing the value of healthcare. The value of the fundamental tenets of primary care is well established. This value includes higher health care quality, better whole-person and population health, lower cost and reduced inequalities compared to healthcare systems not based on primary care. The needed practice organizational and health care system change aspects of the PCMH are still evolving in highly related ways. The PCMH will continue to evolve as evidence comes in from hundreds of demonstrations and experiments ongoing around the country, and as the local and larger healthcare systems change. Measuring the PCMH involves the following: Giving primacy to the core tenets of primary care. Assessing practice and system changes that are hypothesized to provide added value Assessing development of practices' core processes and adaptive reserve. Assessing integration with more functional healthcare system and community resources. Evaluating the potential for unintended negative consequences from valuing the more easily measured instrumental features of the PCMH over the fundamental relationship and whole system aspects. Recognizing that since a fundamental benefit of primary care is its adaptability to diverse people, populations and systems, functional PCMHs will look different in different settings. Efforts to transform practice to patient-centered medical homes must recognize, assess and value the fundamental features of primary care that provide personalized, equitable health care and foster individual and population health.

Cost and policy implications from the increasing prevalence of obesity and diabetes mellitus

BACKGROUND

The increasing prevalence of obesity and type 2 diabetes mellitus (DM), among children and adults, has posed important policy and budgetary considerations to government, health insurance companies, employers, physicians, and health care delivery systems.

OBJECTIVE

This article examines issues that are common to obesity and DM, including cost, clinical research, and treatment barriers, and proposes health policies to address these issues.

METHOD

A manual review was performed of authoritative literature from peer-reviewed medical publications and recently published medical textbooks.

RESULTS

Obesity has been disproportionately prevalent among women and minorities, accompanied by an increased risk for DM. Women have experienced an increased risk for the metabolic syndrome, DM, and cardiovascular disease after onset of menopause. Obesity has been related to an increased risk for breast cancer among women, and may be a barrier that prevents women from being screened for colon and breast cancers. Maternal obesity has been a risk factor for gestational DM.

CONCLUSIONS

Obesity and DM represent crises for the health care system and the health of the public, incurring costs and disease burden for adults and children, with increasing costs and prevalence expected unless more coordinated efforts to address the causes of these conditions at the national level are implemented. An investment in infrastructure to promote increased physical activity and reward weight management may be budget neutral in the long term by reducing the costs of morbidity and mortality. About two thirds of the costs from DM complications could be averted with appropriate primary care.

Evidence on the Chronic Care Model in the new millennium

Developed more than a decade ago, the Chronic Care Model (CCM) is a widely adopted approach to improving ambulatory care that has guided clinical quality initiatives in the United States and around the world. We examine the evidence of the CCM's effectiveness by reviewing articles published since 2000 that used one of five key CCM papers as a reference. Accumulated evidence appears to support the CCM as an integrated framework to guide practice redesign. Although work remains to be done in areas such as cost-effectiveness, these studies suggest that redesigning care using the CCM leads to improved patient care and better health outcomes.

Chronic care model and shared care in diabetes: randomized trial of an electronic decision support system

OBJECTIVE

To assess the effect of a specialist telemedicine intervention for improving diabetes care using the chronic care model (CCM).

PARTICIPANTS AND METHODS

As part of the CCM, 97 primary care physicians at 6 primary care practices in Rochester, MN, referred 639 patients to an on-site diabetes educator between July 1, 2001, and December 31, 2003. On first referral, physicians were centrally randomized to receive a telemedicine intervention (specialty advice and evidence-based messages regarding medication management for cardiovascular risk) or no intervention, keeping outcome assessors and data analysts blinded to group assignment. After each subsequent clinical encounter, endocrinologists reviewed an abstract from the patient's electronic medical record and provided management recommendations and supporting evidence to intervention physicians via e-mail. Control physicians received e-mail with periodic generic information about cardiovascular risk reduction in diabetes. Outcome measures included diabetes care processes (diabetes test completion), outcomes (metabolic and cardiovascular risk factors, estimated coronary artery disease risk), and patient costs (payer perspective).

RESULTS

During the intervention, 951 (70%) of the 1361 endocrinology reviews detected performance gaps and resulted in a message; primary care physicians reported using 49% of messages in patient care. With a mean of 21 months' follow-up, the intervention, compared with control, did not significantly enhance metabolic outcomes or reduce estimated risk of coronary artery disease (adjusted mean difference, -1%; 95% confidence interval, -19% to 17%). The intervention group incurred lower costs (P=.02) but not in diabetes-related costs.

CONCLUSION

Specialty telemedicine did not significantly enhance the value of CCM in primary care.

Novel approaches to diabetes care: a population perspective

PURPOSE OF REVIEW

The purpose of this review is to outline the current state of diabetes in the United States and to explore novel, population-based approaches that involve the patient, provider and community, in the context of the health system, to improve diabetes care.

RECENT FINDINGS

Currently, there is sub-optimal delivery of diabetes processes and outcomes in the United States. The US healthcare system remains rooted in acute and episodic care, resulting in consistently low-quality healthcare, and is not equipped to handle the diabetes epidemic. Evidence demonstrates that models of chronic care are needed in order for system changes to occur. Recent studies that have implemented such models are beginning to demonstrate improvements in both process measures and clinical outcomes following interventions which incorporate a comprehensive approach to chronic illness care.

SUMMARY

Research over the past 5+ years demonstrates that a more comprehensive approach to diabetes care is needed. Only recently have studies been able to validate this concept, however. Applied research that strives to translate available knowledge and operationalize it in clinical and public health practice is needed in order for diabetes care to improve.