• Home runs for home care

    h2_43.106.1I don’t have a sunny nature. That’s me to the right, at the beach with my dog. I recently shared my despair at the failure of an effectiveness trial of patient self-management.

    But today I bring tidings of great joy to all peoples. This week’s JAMA has two encouraging randomized clinical trials of home health care.

    McDermott and her colleagues tested an intervention for peripheral artery disease (PAD), a painful circulatory problem in which narrowed arteries reduce blood flow to your limbs. Among the best things to do for PAD is to walk, but the challenge is to get patients to do it, because when you have PAD it hurts to walk.

    What the investigators did was to engage PAD patients in a group that exercised together and supported each other in dealing with the pain.

    Our intervention applied principles from social cognitive theory, the group dynamics literature, and research on self-regulation to motivate participants to adhere to home-based walking exercise.

    PAD patients in a control group received usual care and attended weekly 60-minute group sessions in which health care professionals presented lectures on managing hypertension and other health topics.

    The primary outcome was the distance that patients were able to walk in 6 minutes. The control patients’ walking deteriorated from the pre-test to the post-test 6 months later (the red line below), while the intervention group improved substantially (the blue line).

    McDermott

    The second study by Margolis and her colleagues tested a program for hypertension. Patients measured their blood pressure at home and logged it using internet-mediated telemetry. The patients then received coaching based on the data.

    During the first 6 months of the intervention, patients and pharmacists met every 2 weeks via telephone until BP control was sustained for 6 weeks, and then frequency was reduced to monthly. During intervention months 7 through 12, telephone visits occurred every 2 months. After 12 months, patients discontinued use of the telemonitors, returned to the care of their primary physicians, and no longer received support from a study pharmacist.

    The telemonitored and coached patients lowered blood pressure significantly more than patients in usual care, including up to 6 months after the monitors were discontinued:

    Compared with the usual care group, systolic BP decreased more from baseline among patients in the telemonitoring intervention group at 6 months (−10.7 mm Hg [95% CI, −14.3 to −7.3 mm Hg]; P<.001), at 12 months (−9.7 mm Hg [95% CI, −13.4 to −6.0 mm Hg]; P<.001), and at 18 months (−6.6 mm Hg [95% CI, −10.7 to −2.5 mm Hg]; P = .004).

    Cardiovascular disease is the great killer of the developed world, so any success here is wonderful news. More generally, the studies show that we are beginning to learn how to  support patients in managing their chronic illnesses. To ‘manage’ a chronic disease, a patient has to change his behaviour. This sounds so easy and is so hard. The needed tools are those employed in McDermott’s and Margolis’s studies: effective home telemetry, health coaching, and patient group support.

    We do not yet know how to successfully implement patient self-management support at the population scale. It will likely need the context of integrated care systems within successful accountable care organizations. But studies like these give me hope that in the next decade, we can significantly improve the effectiveness of chronic health care at an acceptable cost.

    @Bill_Gardner

     

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    • For decades we have known that PAD is improved by walking. Incentives to make the patient walk on his own or with groups were lacking in part due to government intervention. Physicians, both Internists and surgeons, have been pushing patients to walk more and sometimes even providing training under Medicare. How will ACO’s solve the problem differently than before? I take note that HMO’s didn’t solve the problem either and there isn’t all that much difference (with regard to this disease) between HMO’s and ACO’s.

      • Emily,
        You raise a good question and my comment was too brief.

        First, I don’t know what “government intervention” means, but I would be interested to hear.

        Second, my sense is that internists pushing patients to walk more will never be enough — but programs like McDermott’s might work. So what is the business model to support them? My view is that the ACO would be the vehicle to get these programs up and running and incentivize internists to use them.
        thanks
        Bill

        • Bill, in a short space it is difficult to discuss the problem in detail, so I will agree that in theory one might believe that the ACO should “get these programs up and running”. However, if that were true then we should have seen this type of result with the HMO. After all the incentives of the ACO and HMO are almost identical. I would like to hear an evidence based debate as to why the ACO will do something the HMO failed to do.

          Government intervention has created the third party payor system along with a tremendous number of rules and regulations. This means that the payment mechanism has been placed under third party control. Where Medicare is concerned that payment mechanism is directly under government control while private payments are controlled indirectly through federal and state rules and regulations.

          There are convoluted rules that govern the behavior of physicians and hospitals set by third parties and government regulation. Taking a very complex question and shortening it I ask are physicians or hospitals able to change the payment mechanism to focus on specific problems that require more than the simple (widget like) office visit or surgery? No, not without considerable difficulty and possible legal problems.

          Let us use a Medicare example and say that Dr. X is the expert on a disease, but only treats his old Medicare patients on Medicare. He refuses to treat new Medicare patients because his emphasis on low tech treatments for this disease provides too little compensation. If patient Y who is on Medicare wishes to see him one would logically say let patient Y make up the difference of the extra costs out of pocket. That cannot be done. Thus patient Y and Dr. X decide by contract that patient Y will pay the full bill out of pocket and both will sign an agreement that no bills will be sent to Medicare so Medicare will not be paying for an additional service (Medicare will actually be paying less… no office visits and perhaps no surgery). Is that permissible?

          Absolutely not!

          • Thanks, Emily.

            I share your worry that ACOs may do nothing more than MCOs do. The theory is that they will different because they will have to meet quality targets. I hope that’s right.

            • Thanks Bill.

              My understanding is that Medicare HMO’s had to meet quality targets as well. Medicare HMO’s were also supposed to save Medicare 5% as they were paid per capita 5% less than what Medicare paid for their fee for service patients. Instead on a risk adjusted basis it appears, based upon the GAO study, that Medicare paid about 1/3 more than it did on its fee for service patients. Medicare HMO quality was inferior to Medicare fee for service. See the Ware study “Differences in 4-Year Health Outcomes for Elderly and Poor, Chronically Ill Patients Treated in HMO and Fee-for-Service Systems”. Conclusion: “During the study period, elderly and poor chronically ill patients had worse physical health outcomes in HMOs than in FFS systems”

              I won’t even discuss quality targets as our ability actually set and observe targets to assess these types of things is its infancy and can be gamed very easily. See any of the numerous studies on these targets. Some of the stuff used in the past by managed care was hilarious, but for the fact we were dealing with lives.

              The incentives of the HMO and ACO are virtually identical so I think you as a psychologist can easily understand my concern.

    • I’m surprised how little attention is devoted to chronic disease; surprised because the crisis in health care spending is mostly attributable to chronic conditions, conditions that at one time were a death sentence, but now are manageable, though manageable at a very high cost. Of course, it’s a “problem” only for those who have a chronic condition. This reminds me of a speech Ralph Nader made many years ago at my college while on a tour promoting his book, Unsafe at any Speed. He asked those in attendance to raise their hands if they had a family member or close friend who had died or suffered a serious injury in an auto accident. Everybody raised his or her hand. Today, who doesn’t have a family member who suffers from a chronic but manageable condition – and that’s without including old age as a chronic condition (which I do since old age isn’t curable). Most of the commentary about health care relates to health conditions that are temporary, an injury or curable disease. But that’s not what most of health care is about. Maybe it’s because we prefer to think of health care as curative when it’s not. Maybe it’s because we fear death panels. I don’t know. What I do know is that health care reform did not solve the “problem” of chronic conditions, at least not for those who suffer the chronic conditions who still face a future of depletion of their assets and eventual dependence on public assistance for health care. I suppose the self-management described by Gardner will improve the lives of those with chronic conditions, but it won’t avoid the loss of a lifetime’s worth of savings. Raise your hand if you have a family member or close friend who has suffered catastrophic financial loss due to a chronic condition.

    • That really is good news.

      My grad school advisor (in AI, in which I passed the quals and then ran out of energy) once said “all the easy AI programs have already been written”, and sometimes it seems medicine has a similar problem: the problematic diseases all seem very hard to treat (e.g. cancer mortality rates at the population level haven’t changed significantly in 40 years), leaving prevention the only thing. Heck, even if we were making progress on treatment, prevention would still be worth a lot more. So this is really big, especially considering how hard it is to quit smoking or for obese patients to lose weight.

    • a patient’s behavior is a large factor in the course and outcome of medical illness but patients are the target not a driving force in the medical insurance industrial complex which sees little economic gain in giving attention to, funding, supporting services that help patients learn to live with, adapt to, cope with chronic illness…..it fears these services preferring drug treatment and labels the services as costly

    • Emily,
      Thanks. Can you provide a reference or pointer to the GAO study?
      thanks again
      Bill

      • Bill, Sorry for the delay. I had responded immediately and more than once, but it seems that there were problems in posting that seem to have been satisfied.

        I wish I could easily provide the exact citation, but that data came out a long time ago so it might be hard to find it on the government web site, that is assuming they even keep that stuff available for public view after such a long time.

        You might be able to get exact information from the Texas Medical Society. There is a very well informed person working there that years ago seemed to have a firm understanding of that specific GAO report.

        Unlike previous responses the following do not provide the most specific answer to your question regarding what I said. Though below doesn’t state the exact percentage it discusses the problems with risk adjustment at the time.

        http://www.gao.gov/archive/1997/he97133t.pdf

        More discussion here (article later time period), but the exact GAO figure I don’t believe was mentioned anywhere in this citation. ” Estimates of the extent of historical overpayment have ranged from 5.7 percent to 50 to 74 percent (Brown et al. 1993; Langwell and Hadley 1989). For the post-BBA period, the impact of favorable HMO selection ” These numbers certainly fit within the parameters of the number I presented and range even higher than the number I provided.

        http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360925/

        I hope this helps. It certainly puts a damper on one’s optimism.

        Thank you for your courtesy.

    • Bill,

      Sorry to be late to the party but I just saw a reference to this post on John Goodman’s blog. The discussion between you and Emily is very interesting, but I would like to throw out a larger thought.

      ISTM that over the years we have expanded the definition of “health care” beyond all reason. It used to refer strictly to medical interventions, but today it includes anything that remotely affects health. If the kinds of programs you are reporting on are included, why should food consumption not be?

      It might be more productive to return to a medical standard for things that should be insured, and then add these kinds of lifestyle services as a wholly different program.

      There was a time in the United States when public health nurses would visit families of new immigrants to make sure they knew basic hygiene and diet. Maybe in this era of chronic conditions, that would be a more suitable model