0 What Is The Difference Between Pay for Performance and Accountable Care Organizations

Wheres that evidence?

The Disease Management Care Blog has occasionally wondered about the difference between pay for performance (P4P) and accountable care organizations (ACOs).  While the latter involves a more explicit transfer of risk, it thinks the underlying logic for both is ultimately the same: better quality performance should translate into less sickness, fewer specialist physician visits and reduced hospitalizations which, in turn, should save money that can be shared with the providers.  Assuming thats true, the possibility of getting that kind of money should prompt physicians to prevent, coordinate, counsel, immunize and screen instead of treat, er, ignore, not immunize and hustle out the door.

Unfortunately, a recently published Cochrane Review says otherwise. 

The DMCB likes CRs because they are state-of-the-art and highly disciplined reviews of the worlds scientific medical literature.  In this instance, after an exhaustive examination of every published paper on the topic of P4P, the authors conclude....

"....there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care."

The DMCB will be the first to argue that academic, rigorously conducted, randomized and controlled clinical trials are not the final answer when it comes to managing the subtle complexities of physician behavior change.  The DMCB has run into some very smart and passionate physician leaders who have few doubts about the real world links between P4P, increased quality and reduced cost.

That being said, given the commonalities between P4P and ACOs, no one should assume that ACOs are going to succeed based on any notions of "evidence" that the promise of savings will translate into a changed physician workforce.   Cochrane says it just aint there.

0 Aggressive Insulin Treatment vs Pills for Diabetes with Athersclerotic Disease No Difference in Outcomes

When doctors and their patients review the treatment options for diabetes mellitus, a common question is "Why mess around?" If the blood glucose, thanks to a relative lack of the hormone "insulin," is "high," shouldnt the more "natural," tighter and physiologic answer be... insulin? While there are pills that can lower blood glucose levels and patients detest shots, its unclear if the long term clinical, economic and quality-of-life outcomes favor one approach (oral medications) over another (insulin).

The Disease Management Care Blog thinks that these are the issues that were explored by the important, international and huge multi-center "ORIGIN" Study.  The results have just been published by the New England Journal.

Over 12,000 persons over age 50 years with

1) impaired glucose control or "pre" diabetes (more on this topic here), or

2) just-diagnosed diabetes or,

3) well-controlled diabetes (A1c less than 8 to 9%) on no or just one oral medication

and

4) established heart or atherosclerotic vascular disease

were randomly assigned to insulin glargine (with dosing that aimed for a normal blood glucose of 95 mg.%) or usual care (that relied on physician judgement and local guidelines). 

After one year, 50% of the insulin group hit their targeted blood glucose level and their median A1c (a measure of average blood glucose control over time) was 5.9%.  The usual care group achieved a median glucose level of 123 mg.% and after one year the A1c was 6.2%.  The difference in A1cs persisted over the remainder of the study (Table here)

The mean age of the participants was 63 years with an impressive median follow-up of 6 years that yielded outcome results on 99% of the participants.

Results?  No difference in heart attacks or kidney disease.

When cardiovascular death, nonfatal heart attack, non-fatal stroke were combined, the incidence was the same in both groups - about 3% per year.  There was no difference in kidney outcomes including deterioration in function or need for dialysis.  Hospitalization rates for any cause were the same in both groups.  There was an isolated difference involving angina that, in the DMCBs mind, may have been a statistical fluke.  You can look at the outcomes for yourself here.

There was one important difference.  Among the 1456 persons without formal diabetes (the "impaired" group - see above), persons given the insulin were less likely to progress to a formal diagnosis of diabetes (25% vs. 31%).  Unfortunately, they paid a price, because they had a higher rate of insulin-induced low blood sugar reactions (an incidence of 17 vs. 5 per 100 person-years).

Based on these results, the DMCB thinks:

1. Turning to insulin treatment early in the course of pre or diabetes treatment for persons with heart disease doesnt appear to offer any important difference in macrovascular (heart attack and stroke) disease or kidney disease outcomes. However, thats only true among patients who have achieved an A1c below 7%.  (The DMCB cant figure out what happened to the patients with a baseline A1c in the 8% to 9% range who didnt get to an A1c below 7 - did insulin help them?)

2. Whats more, its possible that driving an A1c lower - once its below 7% - doesnt offer any additional outcomes advantage.

3.  While early insulin supplementation may prevent the "burn out" of the insulin-producing cells of the pancreas, the price for that is a higher incidence of low blood sugar reactions.  Even though this "cure" of diabetes may seem like a big deal, why bother if theres no difference in survivorship?

4. As the population health management service providers discuss care planning with their patients with diabetes and heart disease, the topic of early aggressive insulin may come up.  Heres an answer to that question.

5. If accountable or risk-assuming organizations believe that early aggressive insulin treatment will lower the direct costs attributable to heart disease among their patients and enrollees with diabetes, the answer is no.

That out-of-ate but compelling image is from a 2003 HHS website on why Prevention Makes Common Cents

0 Difference between Germs Virus and Bacteria

Difference between Germs, Virus and Bacteria - Microorganism cause of disease is everywhere, in the air, on food and beverages, in animals and other surfaces. If the immune system is weak and we are dealing with organisms whose immunity has not owned body, we get sick.
There are several types of disease-causing organisms, from bacteria, viruses, bacteria, fungi or worms. Actually, whats the difference?

1. Germ
Germ is the public term that identical to bacteria, namely single-celled organisms that can only be seen with the aid of a microscope. when the infection bacterial enter to body, the numbers will increase and potentially produce a number of powerful chemicals, called toxins, which can destroy certain cells in tissues that attacked so that makes us sick.

Not all harmful bacteria. Some bacteria that live in the body, such as the gut and mouth, even profitable. Diseases caused by bacteria such as pneumonia, acne, sore throat, cholera, etc., can be treated with antibiotics.

2. Virus

When attacking the human body, the virus enters to few cell in body and control it, ordered the cell "hosts" to produce the parts needed to reproduce themselves. In the process, the host cell eventually be eradicated. Polio, HIV/AIDS, influenza, measles, or meningitis is a disease caused by a virus. Treatment with antiviral.

3. Mushrooms

Single-celled organisms are slightly larger than bacteria. Actually, the fungus is not contagious, but there are certain types that can be transmitted, such as candida. Candida can cause thrush or canker sores. Meanwhile, the fungi become the biggest cause of diaper rash that causes the infection.

4. Worms

When this type of parasite or eggs entering the human body, usually he would stay in the intestinal tract, lung, liver, skin, or brain, and the life of existing nutrients in the human body.