A systematic review of diabetes disease management programs.

OBJECTIVE: To systematically evaluate and synthesize published evidence regarding the effect of disease management programs for patients with diabetes mellitus on processes and outcomes of care. STUDY DESIGN: Systematic literature review and meta-analysis. PATIENTS AND METHODS: Computerized databases were searched for English-language controlled studies assessing the effect of diabetes disease management programs published from 1987 to 2001. Two reviewers extracted study data using a structured abstraction form. Pooled estimates of program effects on glycated hemoglobin were calculated using an empirical Bayes model. RESULTS: The pooled estimate of program effects on glycated hemoglobin was a 0.5-percentage point reduction (95% confidence interval, 0.3 to 0.6 percentage points), a modest but significant improvement. Evidence also supports program benefits in improving screening for retinopathy and foot lesions. CONCLUSIONS: Diabetes disease management programs can improve glycemic control to a modest extent and can increase screening for retinopathy and foot complications. Further efforts will be required to create more effective disease management programs for patients with diabetes mellitus.

The association between quality improvement activities performed by managed care organizations and quality of care.

PURPOSE: Little data are available to assess the efforts of managed care organizations to improve quality of care. This analysis assessed differences in performance rates between organizations with and without quality improvement activities. METHODS: We reviewed 399 self-reported quality improvement activities submitted by organizations seeking accreditation by the National Committee for Quality Assurance. Processes or outcomes assessed in quality improvement activities were linked to corresponding measures in the effectiveness-of-care database of the Health Plan Employer Data and Information Set (HEDIS). Performance rates for managed care organizations with and without quality improvement activities were then compared. RESULTS: The cross-sectional analysis included 79 quality improvement activities from 50 organizations, covering 12 effectiveness-of-care categories. Each activity had a matching performance score in the database. Financial incentives for providers were associated with substantially higher performance rates in organizations employing this type of intervention. Eight effectiveness-of-care categories had at least four organizations reporting specific quality improvement activities for the care category of interest; statistically significant improvements were observed for follow-up visits for patients after hospitalization for mental illness, checkups after delivery, and screening for cervical cancer. CONCLUSION: Based on objective and audited information, the estimated effects of self-reported quality improvement activities were often small and inconsistent. In some instances, the observed effect was contrary to the expected direction. Limitations of the available dataset and the caveats of a cross-sectional study design precluded a number of analytical options. Longer-term, prospective studies are needed to explore further the relation between quality improvement activities and objective measures of clinical performance.

Does disease management improve clinical and economic outcomes in patients with chronic diseases? A systematic review.

PURPOSE: To assess the clinical and economic effects of disease management in patients with chronic diseases. METHODS: Electronic databases were searched for English-language articles from 1987 to 2001. Articles were included if they used a systematic approach to care and evaluated patients with chronic disease, reported objective measurements of the processes or outcomes of care, and employed acceptable experimental or quasi-experimental study designs as defined by the Cochrane Effective Practice and Organization of Care Group. RESULTS: Two reviewers evaluated 16,917 titles and identified 102 studies that met the inclusion criteria. Identified studies represented 11 chronic conditions: depression, diabetes, rheumatoid arthritis, chronic pain, coronary artery disease, asthma, heart failure, back pain, chronic obstructive pulmonary disease, hypertension, and hyperlipidemia. Disease management programs for patients with depression had the highest percentage of comparisons (48% [41/86]) showing substantial improvements in patient care, whereas programs for patients with chronic obstructive pulmonary disease (9% [2/22]) or chronic pain (8% [1/12]) appeared to be the least effective. Of the outcomes more frequently studied, disease management appeared to improve patient satisfaction (71% [12/17]), patient adherence (47% [17/36]), and disease control (45% [33/74]) most commonly and cost-related outcomes least frequently (11% to 16%). CONCLUSION: Disease management programs were associated with marked improvements in many different processes and outcomes of care. Few studies demonstrated a notable reduction in costs. Further research is needed to understand how disease management can most effectively improve the quality and cost of care for patients with chronic diseases.

Effectiveness of proton pump inhibitors in nonerosive reflux disease.

BACKGROUND & AIMS: Little information is available about the efficacy of proton pump inhibitors (PPIs) in patients with nonerosive reflux disease (NERD). We aimed to synthesize available data and determine the effectiveness of PPIs on symptom resolution in patients with NERD. METHODS: A systematic review of the literature identified studies reporting the effects of PPIs in patients with NERD. Heartburn resolution data were pooled across studies. The effectiveness of PPI therapy in inducing complete heartburn resolution was compared in patients with NERD vs. erosive esophagitis (EE). RESULTS: Seven trials evaluating heartburn resolution in NERD were identified. Higher proportions of patients reported achieving sufficient heartburn resolution compared with complete heartburn resolution. The effect of PPIs on sufficient heartburn resolution was observed sooner than was complete heartburn resolution. Therapeutic gain of PPI therapy over placebo ranged from 30% to 35% for sufficient heartburn control and from 25% to 30% for complete heartburn control. Pooled response rates at 4 weeks were significantly higher for patients with EE compared with NERD (56% vs. 37%, P < 0.0001). CONCLUSIONS: PPIs provide a more modest therapeutic gain in patients with NERD as compared with those with EE. A trend in increased therapeutic gain for NERD patients was shown throughout the 4 weeks, suggesting that 4 weeks of follow-up evaluation may be insufficient to show full therapeutic gain in this patient population.

Reading and interpreting economic evaluations in rheumatoid arthritis: an assessment of selected instruments for critical appraisal.

OBJECTIVE: To describe and compare the relative attributes (reliability, ease of use, applicability, and relevance) of different assessment tools for economic analyses as they pertain to rheumatoid arthritis (RA) literature. METHODS: An expert panel, comprising rheumatology researchers and clinicians, operationalized 2 economic appraisal instruments and applied them to 11 articles used for analysis. Each expert reviewed 3 articles, with each article independently reviewed by a pair of experts. A summary score for each article per appraisal instrument was calculated by dividing the number of items that received a "positive" response by the total number of items in the appraisal instrument. RESULTS: Scores for each article were similar across reviewers and appraisal instruments. CONCLUSION: There is a need for a more comprehensive approach for evaluating this rapidly growing body of economic literature that is not only valid and reliable, but also easy to apply and understand. Although consistency between reviewers was good on both guidelines, inter-guideline discrepancies were noted and reviewers reported some difficulty in using the operationalized format.