Patient-Reported Outcomes: You'll Get a Lot More Response if You Make It Fun To Do.

It may seem obvious, but people are more likely to remain engaged in an activity if they find it enjoyable-and outcomes back this up. Among the more than 1,000 patients who enrolled in our multiple sclerosis registry, 95% remained active after one year.

PATIENT WEB PORTALS AND PATIENT-PROVIDER RELATIONSHIPS: A SUMMARY PERSPECTIVE.

OBJECTIVES: Patient Web portals (PWPs) have been gaining traction as a means to collect patient-reported outcomes and maintain quality patient care between office visits. PWPs have the potential to impact patient-provider relationships by rendering additional channels for communication outside of clinic visits and could help in the management of common chronic medical conditions. Studies documenting their effect in primary care settings are limited. This perspective aims to summarize the benefits and drawbacks of using PWPs in the management of chronic conditions, such as diabetes mellitus, hypertension, and asthma, focusing on communication, disease management, compliance, potential barriers, and the impact on patient-provider dynamic. After a review of these topics, we present potential future directions. METHODS: We conducted an exploratory PubMed search of the literature published from inception through December 2015, and focused our subsequent searches specifically to assess benefits and drawbacks of using PWPs in the management of diabetes mellitus, hypertension, and asthma. RESULTS: Our search revealed several potential benefits of PWP implementation in the management of chronic conditions with regards to patient-provider relationships, such as improved communication, disease management, and compliance. We also noted drawbacks such as potentially unreliable reporting, barriers to use, and increased workload. CONCLUSIONS: PWPs offer opportunities for patients to report symptoms and outcomes in a timely manner and allow for secure online communication with providers. Despite the drawbacks noted, the overall benefits from successful PWP implementation could improve patient-provider relationships and help in the management of chronic conditions, such as diabetes mellitus, hypertension, and asthma.

Oncology Care Model Headed for Shades of Gray.

Regardless of your politics, the motivation behind a program designed to curtail cancer costs is clear. Cancer epidemiology (the old are disproportionately affected), coupled with 21st century demography (longer life expectancy, aging boomers), means cancer costs are going up.

Colorectal cancer: complexities and challenges in managed care.

BACKGROUND: Managed care weighs advances and associated costs to determine whether the combination of longer life at sometimes significantly increased cost represents value. The price of treatment is only 1 factor. OBJECTIVE: To review treatment decision processes for oncologic agents in managed care environments. SUMMARY: Price can be exceptionally high for individuals. But if the population size is low, the per-member-per-month (PMPM) impact can be almost negligible, unlike treatments that have moderate costs but are used ubiquitously. Cancer therapies have, for the most part, escaped managed care's notice. For 2007, the national Cancer Institute projects that antineoplastic agents will consume almost a quarter of the overall drug spend. The Medicare population is a unique concern with regard to cancer. Traditionally, Medicare reimbursement of chemotherapeutic agents was based on average wholesale price (AWP) discounting, not the oncologist's purchasing cost. This allowed oncologists to use reimbursement for infusions to support their medical practices. The proposed plan of the Center for Medicare & Medicaid Services (CMS) to use average sales price (ASP) plus 6% to reimburse for drugs used in the office setting leads to significant problems. Pharmacy and therapeutics committees will also face challenges: fewer data are available for some agents because they have become available through the U.S. Food and drug administration's Fast Track, Priority review, or accelerated approval processes. CONCLUSION: Oncology disease management programs must reach out to patients and not necessarily deal with oncology issues directly, but address tangential issues that impact care, especially depression and pain management.

Multiple vaccines: how do we choose?

BACKGROUND: As preventive medicine is a cornerstone of managed care, most health plans have traditionally featured automatic vaccine coverage routed through the medical benefit. However, with the advent of emerging vaccines, managed care stakeholders must revise decision-making processes and choose among multiple products targeting the same disease. OBJECTIVE: To review the motivating forces behind traditional vaccine coverage in managed care and discuss the need for managed care organizations (MCOs) to subject their vaccine policies to greater examination in the changing landscape of emerging vaccines. SUMMARY: While variable vaccine coverage or choices in vaccine coverage is a relatively novel concept in managed care, the evaluation of vaccines in this setting is usually most effectively performed via a traditional route for MCOs: the Pharmacy & Therapeutics (P&T) committee. In some cases, a technology assessment committee is a more appropriate avenue for evaluation, depending on the disease state, administration, and plan infrastructure. Through these routes of evaluation, criteria similar to those used for other pharmaceutical agents under review should be employed in the review of vaccine options. The primary criteria evaluated include safety, efficacy, cost, and value. In addition, a set of miscellaneous factors must also be considered, including both tangible and intangible components. For example, the relevance of an agent to the specific covered population, compliance costs offsets, quality-of-life considerations, and both patient and provider demand should all be taken into account. Human papillomavirus vaccination provides a pragmatic example for applying the aforementioned strategy for vaccine evaluation in managed care. CONCLUSION: The changing landscape of vaccine coverage in managed care, particularly in the availability of novel agents, demonstrates a need for MCOs to subject their vaccine policies to much greater examination. Through traditional avenues such as P&T and technology assessment committees, stakeholders should seek to evaluate standard criteria such as safety, efficacy, and cost-effectiveness, with additional considerations made for factors unique to the preventive nature of vaccines.

Physician alerts to increase antidepressant adherence: fax or fiction?

BACKGROUND: Many managed care organizations use feedback based on electronically maintained claims data to alert physicians to potential treatment problems, including patient medication nonadherence. However, the efficacy of such interventions for improving adherence among patients treated for depression is unknown. METHODS: We examined an antidepressant compliance program consisting of faxed alerts to physicians beginning May 2003 using interrupted time series analysis to evaluate its impact on rates of antidepressant adherence between May 2002 and May 2004 among members of the managed care plan of Harvard Pilgrim Health Care, which is a health plan operating in 3 states in New England, with corporate headquarters in Wellesley, Mass. The program alerted prescribing physicians to patients with gaps of more than 10 days in refilling antidepressant prescriptions during the first 180 days of treatment. Our outcome measures were rates of nonadherence among patients with refill gaps of more than 10 days ("delayed refill") and proportion of days without treatment within the first 180 days of treatment. RESULTS: A total of 13 128 patients (> or = 18 years of age) who were starting treatment with antidepressants met the study criteria. Rates of nonadherence among patients with delayed refills remained constant (P = .22) over the 2-year study period, averaging 75% (95% confidence interval, 72.7%-77.3%). Rates of antidepressant nonadherence significantly increased over time (P = .04), with an average of 40% (95% confidence interval, 38.4%-41.6%) of days without dispensed antidepressants available during treatment episodes. CONCLUSIONS: Using real-time pharmacy information to alert physicians regarding patient adherence was not successful in increasing antidepressant adherence rates among members of the managed care plan. Effectiveness of electronically triggered, patient-specific, faxed feedback should be carefully evaluated before widespread implementation, because faxes are insufficient as a stand-alone policy tool.

Recommendations for best practices in the treatment of Alzheimer's disease in managed care.

BACKGROUND: Alzheimer's disease and related dementias (ADRDs) are increasingly recognized as important causes of impaired cognition, function, and quality of life, as well as excess medical care utilization and costs in the elderly Medicare managed care population. Evidence-based clinical practice guidelines for ADRDs were published in 2001. More recent studies have resulted in the approval of new agents and demonstrated an expanded role for antidementia therapy in various types of dementia, settings of care, stages of disease, and the use of combination therapy. However, these clinical guidelines have not been updated in the past few years. OBJECTIVE: The goal of this article was to provide practical recommendations developed by a panel of experts that address issues of early diagnosis, treatment, and care management of ADRDs. The panel also addressed the societal and managed care implications. METHODS: A panel of leading experts was convened to develop consensus recommendations for the treatment and management of dementia based on currently available evidence and the panel's informed expert opinion. The panel comprised 12 leading experts, including clinical investigators and practitioners in geriatric medicine, neurology, psychiatry, and psychology; managed care medical and pharmacy directors; a health systems medical director; and a health policy expert. In addition, articles were collected based on PubMed searches (2000-2005) that were relevant to the key issues identified. Search terms included Alzheimer's disease, dementia, clinical practice guidelines, clinical trials, screening and assessment, and managed care. RESULTS: ADRDs represent a significant clinical and economic burden to individuals and society, including Medicare managed care organizations (MCOs). Appropriate utilization of antidementia therapy and care management is vitally important to achieving quality of life and care for dementia patients and their caregivers, and for managing the excess costs of Alzheimer's disease. The recommendations address relevant, practical, and timely concerns that are faced on a daily basis by practitioners and by Medicare MCO medical management programs in the care of dementia patients. These consensus recommendations attempt to describe a reasonable current standard for the provision of quality care for patients with dementia. The panel recommendations support the use of screening for cognitive impairment and the use of antidementia therapy for ADRDs in different stages of disease and types of dementia in all clinical settings. The panel members evaluated the use of the 3 marketed cholinesterase inhibitors-donepezil, galantamine, and rivastigmine-as well as the N-methyl-D-aspartate antagonist memantine. Recommendations for using these medications are made with an appreciation of the difficulties in translating the results from investigational clinical trials into clinical practice. CONCLUSIONS: The recommendations of the expert panel represent a clear consensus that nihilism in the diagnosis, treatment, and management of ADRDs is unwarranted, impairs quality of care, and is ultimately not costeffective.

Analysis of the current care model of the COPD patient: a health outcomes assessment and economic evaluation.

OBJECTIVE: Because chronic obstructive pulmonary disease (COPD) is a common but serious illness affecting millions worldwide, we present an overview of the disease and discuss its underdiagnosis and treatment options. SUMMARY: COPD, a disease encompassing emphysema and chronic bronchitis, is associated with cigarette smoking, chronic exposure to environmental pollutants, and, occasionally, genetic conditions. The disease is severely underdiagnosed and underrecognized. The economic costs of COPD, which accounted for about 14 million office visits and 3.5 million hospital days in 1993, are estimated at more than $7 billion, and another $8 billion worth of productivity was lost to morbidity and mortality in the same year.1 The death rate from COPD is rising, principally among women. Uniform diagnosis and treatment standards are now being realized. The American Thoracic Society and European Respiratory Society recommend treatment, based on worsening symptoms, with bronchodilators and, in more advanced cases, inhaled corticosteroids. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) treatment algorithm also uses a step-care approach. The GOLD guidelines recommend a management program that prevents disease progression, relieves symptoms, improves exercise tolerance and health status, and prevents and treats complications and exacerbations, thereby reducing mortality. The GOLD guidelines recommend avoiding risk factors, using short- or long-acting bronchodilators, and adding rehabilitation and inhaled glucocorticoids. In severe cases, the GOLD guidelines recommend long-term oxygen administration and even surgery. Decisions in managing COPD require a consideration of multiple outcomes measures. Although spirometry remains the foundation for diagnosis and demonstration of efficacy, the patients and their families may be more concerned with symptoms, quality of life, and prevention of exacerbations. In patients with COPD, bronchodilators such as tiotropium produce significant improvements in all of these outcomes measures. CONCLUSIONS: COPD is a common disease that substantially affects patients, health care systems, and society. With increasing awareness of the disease, improved diagnostic guidelines, and newer cost-effective pharmacologic regimens, this chronic progressive disorder can be effectively recognized and treated, helping to improve patients. overall health and quality of life.

ADHD in managed care: an assessment of the burden of illness and proposed initiatives to improve outcomes.

Attention-deficit/hyperactivity disorder (ADHD) often results in persistent problems with attention and impulsivity; these problems, in turn, contribute to impairments in a wide range of functions that affect academic, social, and workplace performance. The chronic and cumulative effects of these difficulties can be overwhelming and outline the significant burden of illness associated with ADHD, which is realized in diminished quality of life for patients and their families and increasing costs or loss of revenue for payers and employers. This burden warrants significant consideration and action from managed care stakeholders to foster sound clinical practice and optimal care. For example, educational interventions and evidence-based tools can be implemented to assist providers with accurate diagnosis and more effective treatment. Furthermore, extensive data documenting the benefits of pharmacotherapy and provider follow-up have demonstrated that initiatives designed to encourage treatment adherence may be the best investment for managed care plans seeking to improve outcomes in patients with ADHD.

Medication reconciliation: Harvard Pilgrim Health Care's approach to improving outpatient medication safety.

Hospitals and long-term care facilities have been addressing the issue of patient safety for some time. As a result of the increasing number of outpatient medication errors leading to adverse drug events (ADEs), interest in preventing outpatient medication errors has increased. Research indicates that the rate of outpatient ADEs may be about four times as high as that reported in hospital studies and that more than one third of these events are preventable (Gandhi et al., 2003). Harvard Pilgrim Health Care introduced its Medication Reconciliation Program in an effort to enhance patient safety by improving medication use and safety.