Diabetes Disease Management Results in Hispanic Medicaid Patients

1
Diabetes Disease Management Results in Hispanic
Medicaid Patients

• Esteban R. López, MD, MBA, FAAP
• Program Director and Medical Director, McKesson
  Health Solutions
• National Hispanic Medical Association
• March 20, 2011
• Washington, DC

2
Objective of Presentation

• To present medical service utilization from a
  telephonic nursing disease-management program for
  Medicaid patients with diabetes residing in
  Puerto Rico
• Published in Journal of Health Care for the Poor
  and Underserved
• May 2009

3
Road Map of Presentation

• Diabetes Disease Management
• Methods
• Results
• Discussion

4
Disease Management

• Care Continuum Alliance (CCA) disease management
  definition
• Supports the physician/practitioner patient
  relationship and plan of care
• Emphasizes prevention of exacerbation and
  complications utilizing evidence-based practice
  guidelines and patient empowerment strategies
  and
• Evaluates clinical, humanistic, and economic
  outcomes on an on-going basis with the goal of
  improving overall health

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Components of Disease Management

• Disease management components include
• Population identification process
• Evidence-based practice guidelines
• Collaborative practice models (physicians and
  others)
• Patient self management education
• Process and outcomes measurement, evaluation, and
  management
• Routine reporting/feedback loop

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Diabetes Disease Management
 

• Previous research shows that an increased number
  of patients can be managed in an ambulatory care
  setting through
• Increased understanding of pathophysiology of
  diabetes
• Pharmacological interventions
• Non-pharmacological intervention
• Goals are
• Increased quality of life and less expensive
  health care

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Diabetes Disease Management

• Centers for Medicare and Medicaid Services (CMS)
• Recognize burden of chronic diseases
• Will pilot differing disease management
  strategies
• Previous research finds a multidisciplinary
  approach has increased QOL and reduce overall
  medical costs through
• Disease management nurses
• Frequent physician office visits
• Telephone contact systems

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Diabetes Disease Management

• Limitations of Previous Research
• Pre/Post Evaluations
• Least rigorous study methodology
• Clinic-based interventions
• Not representative of community of diabetes
  patients
• Costs are not clearly delineated
• This Research
• Uses a more rigorous study methodology
• More representative of community of diabetes
  patients

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Methods Study Population

• Diagnosed with Diabetes through administrative
  claims
• Medicaid plan in Puerto Rico
• Age 1-64

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Methods Study Population
 

• Excluded people
• Those engaged in a local formal diabetes program.
• Members age 65 or over
• Members with less then three months eligibility
  prior to their study start date or less than
  three months eligibility after their study start
  date.
• ESRD, Dialysis, Transplants, HIV/AIDS
• Hospice
• SNF
• Intervention group members with less than three
  months participation in the disease management
  program.

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Methods Study Population

• Sample of 490 diabetes participants and 490
  matched non-participants
• Matched non-participants drawn from sample of
  7,966

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Methods Intervention

• Created a customized self-management intervention
  plan
• Risk stratification
• Formal scheduled nurse education sessions
• 24 hour access to nurse counseling and symptom
  advice
• Printed action plans
• Workbooks
• Individualized assessment letters
• Medication compliance reminders and vaccine
  reminders
• Physician alerts

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Methods Intervention

• Guidelines used
• The American Diabetes Association

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Methods Intervention

• Changes in medical service utilization is
  expected to result from improvements in patients
  
• Knowledge
• Behavior
• Health status

15
Methods Study Design

• Alternatives include
• Randomized control trial
• Matched two-group cohort
• Population based pre/post
• Participant only pre/post
• Others
• We used a 12 month, matched-cohort study.

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Results
Medical service utilization (annualized rate per 1000) Study group Control group P-value Change ()
Inpatient admits 174 268.4 0.112 -35.2
Inpatient bed days 920.3 1,770.00 0.021 -48
Emergency Department visits 773.6 758.3 0.778 2
Physician evaluation management visit 5,153 4,651.80 0.649 10.8
Pharmacy scripts 39,530.40 40,932.90 0.704 -3.4
Diabetes inpatient admits 39.8 14.90 0.437 167.2
Diabetes inpatient bed days 148.8 108.60 0.699 37
Diabetes Emergency Department visits 81.8 95.80 0.603 -14.7
Cardiac inpatient admits 25.2 98.00 0.001 -74.3
Cardiac inpatient bed days 134.2 528.20 0.002 -74.6
Cardiac Emergency Department visits 16.8 12.80 0.591 31.2
Inpatient 30 day readmits 29.4 42.60 0.635 -31.1
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Results
Prescription drugs ( of people who have) Study group Control group P-value Change ()
ACE inhibitor () 31.6 25.7 0.041 23
Beta blocker () 27.6 25.7 0.516 7.1
Antihypertensives () 54.9 49.8 0.11 10.2
Diuretics () 45.3 36.1 0.004 25.4
Cardiac glycosides () 5.1 6.3 0.409 -19.4
Blood glucose regulators () 90.4 90.4 1,000 0
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Results
Procedures performed ( of people who have) Study group Control group P-value Change ()
Hemoglobin A1c 21.2 16.5 0.061 28.4
Lipid panel 28 23.7 0.126 18.1
Eye examination 16.3 13.9 0.285 17.6
Maculopathy 3.9 3.5 0.734 11.8
Microalbumin 1.4 1.2 0.78 16.7
Echocardiography 4.9 7.6 0.086 -35.1
Cardiac catheterization 1.2 5.7 0 -78.6
Myocardial imaging/ perfusion 1.8 2 0.817 -7.1
Influenza immunization 7.1 2.4 0.001 191.7
Pneumococcal immunization 2.9 1 0.037 180
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Results
Average costs Study group Control group P-value Change ()
Monthly medical costs () 74.5 154.66 0.001 -51.8
Monthly pharmacy costs () 79.25 80.11 0.848 -1.1
Monthly total costs () 153.75 234.78 0.002 34.5
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Discussion

• Drugs and device manufactures often subject their
  products to clinical research to determine
• Safety
• Efficacy
• Healthcare services are rarely subject to similar
  levels of clinical research
• Some exceptions
• CMS randomized pilot
• HealthDialog has a randomized trial published in
  NEJM

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Discussion

• 75 of managed care plans report having
  comprehensive disease management programs as
  defined by CCA
• Industry growth likely due to
• Frustration with pace of guideline adoptions
• Guaranteed financial savings by DM companies
• High patient satisfaction
• Other reasons

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Discussion

• Although Propensity Scores balance observable
  variables, unobservable variables may not be
  balanced
• Motivation
• Psycho-social factors
• No drug information for this study
• Selection Bias?
• Is selection determined by observable or
  unobservable variables?
• If by unobservable, then bias may exist