Health care use and costs for participants in a diabetes disease management program, United States, 2007-2008.

INTRODUCTION: The Disease Management Association of America identifies diabetes as one of the chronic conditions with the greatest potential for management. TRICARE Management Activity, which administers health care benefits for US military service personnel, retirees, and their dependents, created a disease management program for beneficiaries with diabetes. The objective of this study was to determine whether participation intensity and prior indication of uncontrolled diabetes were associated with health care use and costs for participants enrolled in TRICARE's diabetes management program. METHODS: This ongoing, opt-out study used a quasi-experimental approach to assess program impact for beneficiaries (n = 37,370) aged 18 to 64 living in the United States. Inclusion criteria were any diabetes-related emergency department visits or hospitalizations, more than 10 diabetes-related ambulatory visits, or more than twenty 30-day prescriptions for diabetes drugs in the previous year. Beginning in June 2007, all participants received educational mailings. Participants who agreed to receive a baseline telephone assessment and telephone counseling once per month in addition to educational mailings were considered active, and those who did not complete at least the baseline telephone assessment were considered passive. We categorized the diabetes status of each participant as "uncontrolled" or "controlled" on the basis of medical claims containing diagnosis codes for uncontrolled diabetes in the year preceding program eligibility. We compared observed outcomes to outcomes predicted in the absence of diabetes management. Prediction equations were based on regression analysis of medical claims for a historical control group (n = 23,818) that in October 2004 met the eligibility criteria for TRICARE's program implemented June 2007. We conducted regression analysis comparing historical control group patient outcomes after October 2004 with these baseline characteristics. RESULTS: Per-person total annual medical savings for program participants, calculated as the difference between observed and predicted outcomes, averaged $783. Active participants had larger reductions in inpatient days and emergency department visits, larger increases in ambulatory visits, and larger increases in receiving retinal examinations, hemoglobin A1c tests, and urine microalbumin tests compared with passive participants. Participants with prior indication of uncontrolled diabetes had higher per-person total annual medical savings, larger reduction in inpatient days, and larger increases in ambulatory visits than did participants with controlled diabetes. CONCLUSION: Greater intensity of participation in TRICARE's diabetes management program was associated with lower medical costs and improved receipt of recommended testing. That patients who were categorized as having uncontrolled diabetes realized greater program benefits suggests diabetes management programs should consider indication of uncontrolled diabetes in their program candidate identification criteria.

Disease management 360 degrees: a scorecard approach to evaluating TRICARE's programs for asthma, congestive heart failure, and diabetes.

OBJECTIVE: To assess the effect of TRICARE's asthma, congestive heart failure, and diabetes disease management programs using a scorecard approach. EVALUATION MEASURES: Patient healthcare utilization, financial, clinical, and humanistic outcomes. Absolute measures were translated into effect size and incorporated into a scorecard. RESEARCH DESIGN: Actual outcomes for program participants were compared with outcomes predicted in the absence of disease management. The predictive equations were established from regression models based on historical control groups (n = 39,217). Z scores were calculated for the humanistic measures obtained through a mailed survey. DATA COLLECTION METHODS: Administrative records containing medical claims, patient demographics and characteristics, and program participation status were linked using an encrypted patient identifier (n = 57,489). The study time frame is 1 year prior to program inception through 2 years afterward (October 2005-September 2008). A historical control group was identified with the baseline year starting October 2003 and a 1-year follow-up period starting October 2004. A survey was administered to a subset of participants 6 months after baseline assessment (39% response rate). RESULTS: Within the observation window--24 months for asthma and congestive heart failure, and 15 months for the diabetes program--we observed modest reductions in hospital days and healthcare cost for all 3 programs and reductions in emergency visits for 2 programs. Most clinical outcomes moved in the direction anticipated. CONCLUSIONS: The scorecard provided a useful tool to track performance of 3 regional contractors for each of 3 diseases and over time.

Outpatient evaluation, recognition, and initial management of pediatric overweight and obesity in U.S. military medical treatment facilities.

BACKGROUND AND PURPOSE: As childhood obesity is a concern in many communities, this study investigated outpatient evaluation and initial management of overweight and obese pediatric patients in U.S. military medical treatment facilities (MTFs). METHODS: Samples of 579 overweight and 341 obese patients (as determined by body mass index [BMI]) aged 3-17 years were drawn from MTFs. All available FY2011 outpatient records were searched for documentation of BMI assessment, overweight/obesity diagnosis, and counseling. Administrative data for these patients were merged to assess coded diagnostic and counseling rates and receipt of recommended laboratory screenings. CONCLUSIONS: Generic BMI documentation was high, but BMI percentile assessments were found among fewer than half the patients. Diagnostic recording or recognition totaled 10.9% of overweight and 32.0% of obese. Counseling rates were higher, with 46.4% and 61.0% of overweight and obese patients, respectively, receiving weight related counseling. Among patients 10 years of age or older, rates of recommended lab screenings for diabetes, liver abnormality, and dyslipidemia were not greater than 33%. BMI percentile recording was strongly associated with diagnostic recording, and diagnostic recording was strongly associated with counseling. IMPLICATIONS FOR PRACTICE: Improvements to electronic health records or implementation of local procedures to facilitate better diagnostic recording would likely improve adherence to clinical practice guidelines.

Variation in diabetes care among states: do patient characteristics matter?

OBJECTIVE: To examine state variability in diabetes care for Medicare beneficiaries and the impact of certain beneficiary characteristics on those variations. RESEARCH DESIGN AND METHODS: Medicare beneficiaries with diabetes, aged 18-75 years, were identified from 1997 to 1999 claims data. Claims data were used to construct rates for three quality of care measures (HbA(1c) tests, eye examinations, and lipid profiles). Person-level variables (e.g., age, sex, race, and socioeconomic status) were used to adjust state rates using logistic regression. RESULTS: A third of 2 million beneficiaries with diabetes aged 18-75 years did not have annual HbA(1c) tests, biennial eye examinations, or biennial lipid profiles. There was wide variability in the measures among states (e.g., receipt of HbA(1c) tests ranged from 52 to 83%). Adjustment using person-level variables reduced the variance in HbA(1c) tests, eye examinations, and lipid profiles by 30, 23, and 27%, respectively, but considerable variability remained. The impact of the adjustment variables was also inconsistent across measures. CONCLUSIONS: Opportunities remain for improvement in diabetes care. Large variations in care among states were reduced significantly by adjustment for characteristics of state residents. However, much variability remained unexplained. Variability of measures within states and variable impact of the adjustment variables argues against systems effects operating with uniformity on the three measures. These findings suggest that a single approach to quality improvement is unlikely to be effective. Further understanding variability will be important to improving quality.

Smoking patterns among seniors and the medicare stop smoking program.

OBJECTIVES: To characterize smoking patterns in the older U.S. community-dwelling Medicare population at the national level and in states chosen to participate in the new Medicare Stop Smoking Program (MSSP) demonstration. To describe the MSSP. DESIGN: Data from the Behavioral Risk Factor Surveillance System (BRFSS) 1996 to 1999 were analyzed. SETTING: The BRFSS is a cross-sectional random-digit-dialed telephone survey conducted in all states plus the District of Columbia and Puerto Rico. PARTICIPANTS: BRFSS respondents aged 65 and older who self-identified as receiving Medicare benefits. MEASUREMENTS: Using BRFSS core questionnaire variables, recent trends in prevalence of current smoking and smoking cessation were estimated, as were prevalences by various demographic characteristics, for both the nation and the MSSP states as a group. RESULTS: As of 1999, an estimated 10.2% of this population were current smokers, with those aged 65 to 74 smoking at twice the rate (12.9%) of those aged 75 and older (6.1%) and blacks (14.7%) smoking more than whites (10.0%). Between 1996 and 1999, the prevalence of everyday smokers indicating they had attempted to quit for 1 day or longer in the past year rose from 37.1% to 42.2%. National patterns were mirrored in the states chosen to participate in the MSSP. CONCLUSIONS: Young-old Medicare recipients have a higher smoking prevalence, although interest in quitting appears to be rising. The chosen MSSP states appear to be a representative of national smoking patterns in the older Medicare population.

Smoking and functional status among Medicare managed care enrollees.

BACKGROUND: Smoking is a major determinant of health status and outcomes. Current smoking has been associated with lower scores on the Short Form-36 Health Survey (SF-36). Whether this occurs among the elderly and disabled Medicare populations is not known. This study assessed the relationships between smoking status and both physical and mental functioning in the Medicare managed-care population. METHODS: During the spring of 1998, data were collected from 134309 elderly and 8640 disabled Medicare beneficiaries for Cohort 1, Round 1 of the Medicare Health Outcomes Survey. We subsequently used these data to calculate mean standardized SF-36 scores, self-reported health status, and prevalence of smoking-related illness, by smoking status, after adjusting for demographic factors. RESULTS: Among the disabled, everyday and someday smokers had lower standardized physical component (PCS) and mental component (MCS) scores than never smokers (-2.4 to -4.5 points; p <0.01 for all). Among the elderly, the lowest PCS and MCS scores were seen among recent quitters (-5.1 and -3.7 points, respectively, below those for never smokers; p <0.01 for both), but current smokers also had significantly lower scores on both scales. For the elderly and disabled populations, MCS scores of long-term quitters were the same as nonsmokers. Similar patterns were seen across all eight SF-36 scales. Ever smokers had higher odds of reporting both less-than-good health and a history of smoking-related chronic disease. CONCLUSIONS: In the elderly and disabled Medicare populations, smokers report worse physical and mental functional status than never smokers. Long-term quitters have better functional status than those who still smoke. More effort should be directed at helping elderly smokers to quit earlier. Smoking cessation has implications for improving both survival and functional status.

Simulation of quitting smoking in the military shows higher lifetime medical spending more than offset by productivity gains.

Despite the documented benefits of quitting smoking, studies have found that smokers who quit may have higher lifetime medical costs, in part because of increased risk for medical conditions, such as type 2 diabetes, brought on by associated weight gain. Using a simulation model and data on 612,332 adult smokers in the US Department of Defense's TRICARE Prime health plan in 2008, we estimated that cessation accompanied by weight gain would increase average life expectancy by 3.7 years, and that the average lifetime reduction in medical expenditures from improved health ($5,600) would be offset by additional expenditures resulting from prolonged life ($7,300). Results varied by age and sex: For females ages 18-44 at time of cessation, there would be net savings of $1,200 despite additional medical expenditures from prolonged life. Avoidance of weight gain after quitting smoking would increase average life expectancy by four additional months and reduce mean extra spending resulting from prolonged life by $700. Overall, the average net lifetime health care cost increase of $1,700 or less per ex-smoker would be modest and, for employed people, more than offset by even one year's worth of productivity gains. These results boost the case for smoking cessation programs in the military in particular, along with not selling cigarettes in commissaries or at reduced prices.

Weight loss and lifetime medical expenditures: a case study with TRICARE prime beneficiaries.

BACKGROUND: TRICARE's Prime (managed care) plan spends more than $1 billion annually in medical expenditures attributed to overweight and obesity. PURPOSE: This study estimates change in lifetime disease prevalence and medical expenditures associated with weight loss for beneficiaries in TRICARE's Prime plan. METHODS: This 2010 analysis uses Markov Chain Monte Carlo simulation with demographics, biometrics, health behavior, and disease presence for 857,200 overweight and 521,800 obese beneficiaries aged 18-64 years in 2008 to model future onset of diseases linked to excess weight. Prediction equations in the simulation come from multiple sources: (1) regression analysis with longitudinal (2007-2008) TRICARE medical claims and electronic health records for 2.1 million beneficiaries; (2) regression analysis with Medical Expenditure Panel Survey (2002-2007) and National Health and Nutrition Examination Survey (1999-2008) data; (3) cancer and mortality risk from Surveillance, Epidemiology, and End Results data; and (4) published findings from clinical trials. RESULTS: Among overweight and obese beneficiaries, lifetime medical expenditures declined $440 (3% discount rate) for each permanent 1% reduction in body weight. This includes $590 in savings from improved health, offset by $150 in additional expenditures from prolonged life. Estimates range from $660 reduction for grossly obese adults aged <45 years to $40 gain from grossly obese adults aged 55-64 years (where expenditures from increased longevity exceed savings from improved health). If weight loss is temporary and regained after 24 months, lifetime expenditures decline by $40 per 1% reduction in body weight. CONCLUSIONS: Long-term benefits from weight loss are substantially greater than short-term benefits, underscoring the need for a societal perspective to combat obesity.

Outcomes and lessons learned from evaluating TRICARE's disease management programs.

OBJECTIVE: To share outcomes and lessons learned from an evaluation of disease management (DM) programs for asthma, congestive heart failure (CHF), and diabetes for TRICARE patients. STUDY DESIGN: Multiyear evaluation of participants in voluntary, opt-out DM programs. Patient-centered programs, administered by 3 regional contractors, provide phone-based consultations with a care manager, educational materials, and newsletters. The study sample consisted of 23,793 asthma, 4092 CHF, and 29,604 diabetes patients with at least 6 months' tenure in the program. METHODS: Medical claims were analyzed to quantify program effect on healthcare utilization, medical costs, and clinical outcomes. Multivariate regression analysis with an historical control group was used to predict patient outcomes in the absence of DM. The difference between actual and predicted DM patient outcomes was attributed to the program. A patient survey collected data on program satisfaction and perceived usefulness of program information and services. RESULTS: Modest improvements in patient outcomes included reduced inpatient days and medical costs, and (with few exceptions) increased percentages of patients receiving appropriate medications and tests. Annual per patient reductions in medical costs were $453, $371, and $783 for asthma, CHF, and diabetes program participants, respectively. The estimated return on investment was $1.26 per $1.00 spent on DM services. CONCLUSION: Findings suggest that the DM programs more than pay for themselves, in addition to improving patient health and quality of life. Lessons learned in program design, implementation, effectiveness, and evaluation may benefit employers contemplating DM, DM providers, and evaluators of DM programs.