0 Whats The Right Diabetes Disease Management Program For Your Patients

The answer is "it depends."

For a good example of why thats true, check out this hot-off-the-presses Health Affairs article that describes two parallel approaches to disease management.  Both were offered side by side to a largely Hispanic and socioeconomically disadvantaged population in Los Angeles (LA). 

One program was provided in the LA Department of Health Services primary care health centers. Patients with poor diabetes control were erred to a separate turn-key "one stop" care program with non-physician educators under the direction of an endocrinologist. Using a combination of in-person and telephonic management, patients were put through a six to nine month protocol designed to optimize their medication treatment plan, foster better living habits and improve self-care.  Nurse case loads averaged 125 patients.

In LAs independently-run community clinics (many of which are federally qualified health centers), case managers and clinical pharmacists were available on-site for lifestyle counseling, education on self-care and medication management that included initiating insulin and adjusting other drugs. Nurse case loads numbered 400 patients, while the pharmacists had about 200 patients.

Based on pre-post measurements involving hundreds of patients, both the LA health centers and community clinics patients experienced impressive improvements in blood glucose control and cholesterol levels.  Thats typical in disease management programs. 

However, there were some differences.  In the LA health clinics, the program was separate, overseen by a specialist, limited to patients with poor glucose control and involved a more intense program of patient education.  In the community health clinics, the nurses and pharmacists were "part" of the clinic and, based on the caseloads, were less labor-intensive.

Despite the differences, the DMCB couldnt really tell if one approach to diabetes care management was "better" than another.  There was little information on the content of the care plans and no information  on costs.  Yet, all things being equal, the DMCB suspects that architects of similar programs nationwide are ultimately selecting from a menu of care and staffing options based not only on patient need but highly subjective (or yet-to-be-investigated) perences based on local physician culture (sometimes specialist leadership is important), access to special resources (like pharmacists) and local budgetary realities.

The key lesson in this article is how two parallel clinic systems in the same population serving a similar population decided to deploy different disease management programs.  Both resulted in patient betterment.  Both had relative strengths and weaknesses.  Deciding which approach is "better" remains a matter of local judgement based on a complex number of factors.

In other words, it depends.

Image from the Kentucky Diabetes Resource Directory

0 Should Patients in Population Health Management Programs Have Access to Lay Care Coaches

Based on prior posts like this, the Disease Management Care Blog thinks the answer is yes. 

That being said, this hot-off-the-presses research paper shows just much we need to learn about this emerging approach to the care of persons with chronic conditions like diabetes, high blood pressure and chronic heart failure.

Lay Persons Educating Persons With Chronic Conditions in Primary Care Clinics

The paper was just published in the Annals of Internal Medicine. It was a one year randomized study involving the patients at six Allina Health primary care clinics. 

Twelve lay "care guides" had at least 2 years of college education and "strong interpersonal skills." They received two weeks of education that included setting goals, identifying and overcoming care barriers, behavior change techniques, the limits of scope of practice and how to use the electronic records to message physicians.  It was up to the care guides and the patients to decide on how often they needed to meet in face or by telephone. The guides were supervised by two RNs.

Active (i.e. seen in the clinics within 6 months) patients who agreed to be in the study with high blood pressure, diabetes or heart failure were allocated in a 2:1 ratio to either a "care guide" or usual care. Goals were proscribed and were the usual HEDIS-style outcomes, such as achieving blood pressure control, reaching an A1c level, getting an echocardiogram, being on beta-blocker medications or getting a pneumovax immunization.
 
The study was not "blinded," in that they and their providers were aware of the assignment. Recruitment began in July of 2010 and the study was completed in April of 2012. 6168 patients were screened, 2135 patients agreed to participate and 1423 and 702 completed the study from the care guide and usual care study arms.

Results?

One year later, 82.6% of the care guide patients achieved their selected care goals vs. 79.1% of the usual care patients. That 3.5% increase was statistically significant.

Most of that improvement was accounted by a higher rates of tobacco cessation, pneumovax immunization, getting persons with diabetes to get an eye exam as well as urine protein testing, and getting persons with heart failure to go through an echocardiogram.  There were no statistically significant impacts on blood pressure control, diabetes control, cholesterol control or medication prescribing.

The care guides interacted with their patients on average 7 times (2 face-to-face and 5 by telephone).  They messaged physicians an average of 4 times.  There was no difference between the two groups in primary care office visits. Estimated cost was $286 per patient per year.

The Disease Management Care Blogs take:

There is increasing interest in incorporating lay-persons in the outpatient care of persons with chronic conditions.  That makes sense, because much of the educational "payload" may be deliverable using far cheaper and more engaging "peer" members of the community who - literally - speak the patients language.  This is a nicely done randomized clinical trial done in a real world setting that adds to our understanding of this care option. The bottom line is that this study showed that the care guides had a real impact.

When the DMCB looks at the actual numbers, it is also clear that the study had an uphill climb.  Many of the baseline measures of blood pressure, diabetes and heart failure quality relatively high to begin with. The impact of the care guides may have been much greater in a population with a lower baseline (such as in this study) with more "room" to move.

Problems to think about for the next study.....

Not all outcomes are created equally: Unfortunately, this study was something of a disappointment because the improvements were spotty, relatively small and limited to lightweight "testing" outcomes vs. more -hard-to-achieve disease control outcomes.  It may one thing for a peer patient to talk a patient into a urine test or a heart scan, its another getting a patient to take more pills.  That may take a professional educator, a pharmacist or nurse.

What do the patients want: In addition, the goals were based on a one-size-fits-all HEDIS approach.  They were not adaptable, negotiable or subject to shared decision-making.  If that had been in the mix, patient engagement may have been an additional ingredient that could have pushed other outcome measures toward statistical significance.

What do the docs think: The DMCB notes that provider office visits did not go down among the care guide patients compared to the usual care patients. This makes the DMCB wonder if there wasnt enough physician buy-in: if there had been higher trust in the care guides ability to manage these patients, it would have been reflected in less need to see the patients for a separate appointment.

Predictive modeling to the rescue: Finally, there is the problem of treating all chronic illness patients the same. Not all patients with high blood pressure, diabetes or heart failure are as susceptible to behavior change, and not all patients who engage in behavior change achieve better outcomes.  The trick is to use risk stratification to find the patients with the greatest chance at benefit.  This study may have benefited from a more focused approach.

0 Cancer Patients Need Sports

Cancer patients usually undergo chemotherapy and radiation therapy treatments. Fatigue often hit after they run health care. But according to Josie Gardiner, special physical trainer of U.S. cancer patients, physical exercise is also needed for cancer patients.

Here are some health tips on a variety of sports that you think Gardiner is suitable for people with cancer, as quoted by Fox News.

1. aerobic

Cardio exercise definitely be one part of aerobic exercise, which allows a person to burn calories as much as possible. Reducing calories is also one of the prevention of cancer spread. Besides cardio exercise also makes a person physically stronger and tougher.

2. weight training

Chemotherapy and radiation therapy results in brittle bones, especially for women. For the light weight training is very important. It can make your bones and muscles strong again.

3. balance exercises

Treatment and care of cancer patients typically affect his future as reduced bone mass. Therefore, cancer patients need to train the body to balance routine, for better health performance.

4. relaxing the body

Some cancer patients who have undergone surgery typically experience pain in the scar. For that they can not choose a sport that is too heavy. For those who are in this condition, Gardiner suggested that exercise can train the body flexibility like yoga.

0 AIDS Patients Dramatic Recovery

Using an AIDS patients dramatic recovery to demonstrate the effect Topsy and its ARV treatment programme can have on those battling the advanced effects of HIV/AIDS. When treated, a person on the verge of death can return to health in a matter of months.

0 Food Should be Avoided by Arthritis Patients

Food Should be Avoided by Arthritis Patients | your patients with rheumatoid arthritis? careful with your diet, there are many foods that can make your illness can be severe. In this article we will discuss about the foods that should be avoided for patients with rheumatoid arthritis.

Food Should be Avoided by Arthritis Patients

Avoid Foods for People with Arthritis. There are some foods that should be avoided by patients with rheumatic diseases. These foods are as follows.

• Offal
• Pinhead
• Preserved fish, such as sardines
• Salted fish
• Smoked fish
• Cured meats (ham, sausage)
• Alcohol, preserved foods
• Nuts
• Asparagus
• kale
• Bamboo sprout
• Meat
• Goat
• Emping melinjo

The above list is important for you to note, because sometimes we forget to consume foods that are to be avoided for people with rheumatic.

0 Doctor Dont Distinguish Patients

Doctor Dont Distinguish Patients - A doctor at work, in addition to professional expected, also must not discriminate patients, both in terms of religion, ethnicity, class, or rich and poor, said the rector of Muhammadiyah University of Yogyakarta Dasron Hamid. "Suppose the patient is your own. Treat them regardless of religion, tribe, rich or poor," he said at the inauguration and oath doctors XXIX period of Faculty of Medicine and Health Sciences (FKIK) Yogyakarta Muhammadiyah University (in St. Louis) in Yogyakarta, Saturday (8/1/2011).

According to him, a doctor should treat patients in a professional, because basically what is done solely for the welfare and health of society as a whole. Representatives of the Central Executive Council Diktilitbang (PP) Muhammadiyah Murdiyanto Joko said the medical profession can not be separated from two things, namely professionalism and humanism.

"In this case, a doctor must give priority to the interests of others, for example, was awakened at one oclock in the morning, because there are sick people who ask for treatment, it must be willing to help. A doctor must work to serve," he said.

In addition, doctors also need to learn all the time to add knowledge and abilities. Doctors also have to establish good communication with patients and their families.

"So far, the problems between doctor and patient in the absence of good communication," he said.