Janice L. Clarke

Evaluation of a comprehensive diabetes disease management program: Progress in the struggle for sustained behavior change

The successful management of diabetes with a goal of achieving near-normoglycemia requires patients to make multiple lifestyle changes as part of an intensive, complex, and coordinated therapeutic regimen aimed at reducing the risk of complications associated with the disease. The difficulty in creating and sustaining these lifestyle behavior changes is a major stumbling block in achieving the desired therapeutic goal. An underlying assumption of comprehensive disease management is that regular, personal contact with nurses and ancillary health professionals will facilitate these lifestyle behavior changes for program participants. The results of a survey of self-reported data from 750 participants in a comprehensive diabetes management program, reported on here, show strong perceptions of positive behavior change over the broad range of medical and lifestyle treatment areas associated with effective management of diabetes. These results suggest that diabetes disease management programs are an effective a...

Electronic personal health records come of age.

We are pleased to bring you this special supplement to the American Journal of Medical Quality (AJMQ) focused on the personal health record (PHR). This supplement is a timely follow-up to our previous report on e-health that documented progress on issues such as implementing electronic medical records (EMR) and forming regional health information organizations (RHIOs). Please see the November/December 2005 issue of AJMQ and the supplement titled “e-Health Initiative Update: Proceedings from the e-Health Technology Summit.” In September 2005, the National Committee on Vital and Health Statistics (NCVHS) determined that there is no uniform definition of a PHR in industry or government, and the concept continues to evolve. The committee noted that “experts often use the concept of the PHR to include the patient’s interface to a healthcare provider’s electronic health record. Others consider PHRs to be any consumeror patient-managed health record. This lack of consensus makes collaboration, coordination, and policy making difficult.” As a result, the NCVHS concluded that it is not possible or even desirable to attempt a unitary definition of a PHR at this time but noted that it was possible to characterize PHRs by their attributes (ie, scope or nature of the information contained, source of information, features and functions offered, owner of the record, type and location of data repository, technical approach to security, party authorizing access to the information). We have taken the NCVHS recommendations and observations to heart and present in this special supplement a detailed picture of the PHR using a company called InterComponentWare, Inc (ICW) as a concrete example. Why ICW? Because this international corporation is at the forefront of a number of global companies focused on developing PHR technologies and the platforms that facilitate universal connectivity. Through a nonrestricted educational grant, ICW enabled the Department of Health Policy at Jefferson Medical College to host an international advisory board meeting on the future of the PHR and, specifically, the LifeSensor product line from ICW. This special supplement, with contributions from faculty of the Department of Health Policy, as well as from industry leaders concerned about the future of the PHR, will form the foundation for an ongoing discussion about the strengths and limitations of our current technology. The supplement contains an overview of the PHR arena, detailed descriptions of ICW’s current PHR technology and experience in deploying systems in Western and Eastern Europe and other countries, and a candid exchange of ideas regarding the barriers and possible solutions to implementing this technology in the United States. Surely we recognize that there are different models for PHRs, and it is not our intention to promote any single platform. Rather, we are highlighting ICW’s technology as a fine example of a fully functional, globally implemented system. Finally, a note to our readers. This supplement extends our coverage of new technologies devoted to improving the quality and safety of medical care. As always, we are interested in your views, and I

Impact of appropriate pharmaceutical therapy for chronic conditions on direct medical costs and workplace productivity: a review of the literature.

This paper presents the findings of a literature review investigating the economic impact of appropriate pharmaceutical therapy in treating four prevalent chronic conditions - asthma, diabetes, heart failure, and migraine. The goal of the review was to identify high-quality studies examining the extent to which appropriate pharmaceutical therapy impacts overall medical expenditure (direct costs) and workplace productivity (indirect costs). The working hypothesis in conducting the review was that the costs of pharmaceuticals for the selected chronic conditions are offset by savings in direct and indirect costs in other areas. The literature provides evidence that appropriate drug therapy improves the health status and quality of life of individuals with chronic illnesses while reducing costs associated with utilization of emergency room, inpatient, and other medical services. A growing body of evidence also suggests that workers whose chronic conditions are effectively controlled with medications are more productive. For employers, the evidence translates into potential direct and indirect cost savings. The findings also confirm the importance of pharmaceutical management as a cornerstone of disease management.

The patient burden of screening mammography recall.

OBJECTIVE The aim of this article is to evaluate the burden of direct and indirect costs borne by recalled patients after a false positive screening mammogram. METHODS Women aged 40-75 years undergoing screening mammography were identified from a U.S. commercial claims database. Women were required to have 12 months pre- and 6 months post-index enrollment to identify utilization and exclude patients with subsequent cancer diagnoses. Recall was defined as the use of diagnostic mammography or breast ultrasound during 6 months post-index. Descriptive statistics were presented for recalled and non-recalled patients; differences were compared using the chi square test. Out-of-pocket costs were totaled by utilization type and in aggregate for all recall utilization. RESULTS Of 1,723,139 patients with a mammography screening that were not diagnosed with breast cancer, 259,028 (15.0%) were recalled. Significant demographic differences were observed between recalled and non-recalled patients. The strongest drivers of patient costs were image-guided biopsy (mean

Conservative Spine Care: Opportunities to Improve the Quality and Value of Care

351 among 11.8% utilizing), diagnostic mammography (

Understanding patient options, utilization patterns, and burdens associated with breast cancer screening.

50; 80.1%), and ultrasound (

The American Opioid Epidemic: Population Health Implications and Potential Solutions. Report from the National Stakeholder Panel

58; 65.7%), which accounted for 29.9%, 29.0%, and 27.5% of total recall costs, respectively. For many patients the entire cost of recall utilization was covered by the health plan. Total costs were substantially greater among patients with biopsy; one-third of all patients experienced multiple days of recall utilization. CONCLUSION After a false positive screening mammography, recalled women incurred both direct medical costs and indirect time costs. The cost burden for women with employer-based insurance was dependent upon the type of utilization and extent of health plan coverage. Additional research and technologies are needed to address the entirety of the recall burden in diverse populations of women.

The effectiveness of heart failure disease management: Initial findings from a comprehensive program

Low back pain (LBP) has received considerable attention from researchers and health care systems because of its substantial personal, social, work-related, and economic consequences. A narrative review was conducted summarizing data about the epidemiology, care seeking, and utilization patterns for LBP in the adult US population. Recommendations from a consensus of clinical practice guidelines were compared to findings about the current state of clinical practice for LBP. The impact of the first provider consulted on the quality and value of care was analyzed longitudinally across the continuum of episodes of care. The review concludes with a description of recently published evidence that has demonstrated that favorable health and economic outcomes can be achieved by incorporating evidence-informed decision criteria and guidance about entry into conservative low back care pathways.

Improving awareness of best practices to reduce surgical site infection: a multistakeholder approach.

Despite ongoing awareness, educational campaigns, and advances in technology, breast cancer screening remains a complex topic for women and for the health care system. Lack of consensus among organizations developing screening guidelines has caused confusion for patients and providers. The psychosocial factors related to breast cancer screening are not well understood. The prevailing algorithm for screening results in significant rates of patient recall for further diagnostic imaging or procedures, the majority of which rule out breast cancer rather than confirming it. For women, the consequences of the status quo range from unnecessary stress to additional out-of-pocket expenses to indirect costs that are more difficult to quantify. A more thoughtful approach to breast cancer screening, coupled with a research agenda that recognizes the indirect and intangible costs that women bear, is needed to improve cost and quality outcomes in this area.

The accountability conundrum: staying focused, delivering results: a report on the UHC 2008 quality and safety fall forum.

The American Opioid Epidemic: Population Health Implications and Potential Solutions. Report from the National Stakeholder Panel Janice L. Clarke, RN, Alexis Skoufalos, EdD, and Richard Scranton, MD, MPH Editorial: David B. Nash, MD, MBA   S-1 Introduction   S-1 The Evolution of Opioid Use in the United States   S-2 Unintended Consequences of Postsurgical Pain Management   S-2 Pivotal Role of Postsurgical Prescribing Practices   S-3 • Population health and societal implications   S-4 The Case for Multimodal Pain Management for Surgical Patients   S-4 Optimizing Health Outcomes   S-4 • Emerging profile of opioids: pros and cons   S-5 • Planning for perioperative pain   S-5 • Minimizing risk of postsurgical overuse and misuse of opioids   S-5 Optimizing Economic Outcomes by Managing Pain Differently   S-6 Expert Panel Insights   S-7 Conclusion   S-7