Person-centred, integrated and pro-active care for multi-morbid elderly with advanced care needs: a propensity score-matched controlled trial.

BACKGROUND: Person-centred care (PCC) focusing on personalised goals and care plans derived from "What matters to you?" has an impact on single disease outcomes, but studies on multi-morbid elderly are lacking. Furthermore, the combination of PCC, Integrated Care (IC) and Pro-active care are widely recognised as desirable for multi-morbid elderly, yet previous studies focus on single components only, leaving synergies unexplored. The effect of a synergistic intervention, which implements 1) Person-centred goal-oriented care driven by "What matters to you?" with 2) IC and 3) pro-active care is unknown. METHODS: Inspired by theoretical foundations, complexity science, previous health service research and a patient-driven evaluation of care quality, we designed the Patient-Centred Team (PACT) intervention across primary and secondary care. The PACT team collaborate with the patient to make and deliver a person-centred, integrated and proactive multi-morbidity care-plan. The control group receives conventional care. The study design is a pragmatic six months prospective, controlled clinical trial based on hospital electronic health record data of 439 multi-morbid frail elderly at risk for emergency (re) admissions referred to PACT and 779 propensity score matched controls in Norway, 2014-2016. Outcomes are emergency admissions, the sum of emergency inpatient bed days, 30-day readmissions, planned and emergency outpatient visits and mortality at three and six months follow-up. RESULTS: The Rate Ratios (RR) for emergency admissions was 0,9 (95%CI: 0,82-0,99), for sum of emergency bed days 0,68 (95%CI:0,52-0,79) and for 30-days emergency readmissions 0,72 (95%CI: 0,41-1,24). RRs were 2,3 (95%CI: 2,02-2,55) and 0,9 (95%CI: 0,68-1,20) for planned and emergency outpatient visits respectively. The RR for death at 3 months was 0,39 (95% CI: 0,22-0,70) and 0,57 (95% CI: 0,34-0,94) at 6 months. CONCLUSION: Compared with propensity score matched controls, the care process of frail multi-morbid elderly who received the PACT intervention had a reduced risk of high-level emergency care, increased use of low-level planned care, and substantially reduced mortality risk. Further study of process differences between groups is warranted to understand the genesis of these results better. TRIAL REGISTRATION: ClinicalTrials.gov (identifier: NCT02541474 ), registered Sept 2015.

Impact of poorly controlled hypertension on healthcare resource utilization and cost.

OBJECTIVE: To examine the relation between blood pressure (BP) control and utilization and cost of healthcare resources. STUDY DESIGN: A retrospective database study of managed care patients in New Mexico from January 1, 1996, to December 31, 1997. PATIENTS AND METHODS: We stratified 1000 hypertensive patients into categories based on average and maximum BP. Antihypertensive medication use and cost, number of physician visits, and interval between hypertension-related physician visits were determined. RESULTS: Medication costs increased progressively across all BP categories from lowest to highest, and higher average systolic BP (SBP) was significantly correlated with increased cost (P < .001). There were significant correlations between higher maximum BP and greater number of hypertension-related physician visits (P < .001). Mean number of visits for BP groups was 5.5 for patients with a maximum diastolic BP (DBP) < 85 mm Hg and 10.0 for those with a maximum DBP > or = 100 mm Hg (P < .001). Patients with a maximum SBP > or = 180 mm Hg averaged 9.7 visits, whereas those with a maximum SBP < 120 mm Hg averaged 4.1 visits (P < .001). Both SBP and DBP were significantly correlated with time to next visit (P < .001). Mean visit intervals ranged from 44 days for patients with an SBP < 85 mm Hg to 25 days for those with an SBP > or = 180 mm Hg (P < .001). A similar association was found between DBP and visit interval. CONCLUSIONS: Poor control of hypertension is associated with higher drug costs and more physician visits. Aggressive treatment might help reduce managed care costs and resource utilization.

Health care utilization in chronic obstructive pulmonary disease. A case-control study in a health maintenance organization.

BACKGROUND: Information about health care utilization and costs among patients with chronic obstructive pulmonary disease (COPD) is needed to improve care and for appropriate allocation of resources for patients with COPD (COPD patients or cases) in managed care organizations. METHODS: Analysis of all inpatient, outpatient, and pharmacy utilization of 1522 COPD patients continuously enrolled during 1997 in a 172,484-member health maintenance organization. Each COPD case was matched with 3 controls (n = 4566) by age (+/-5 years) and sex. Information on tobacco use and comorbidities was obtained by chart review of 200 patients from each group. RESULTS: Patients with COPD were 2.3 times more likely to be admitted to the hospital at least once during the year, and those admitted had longer average lengths of stay (4.7 vs 3.9 days; P<.001). Mean costs per case and control were $5093 vs $2026 for inpatient services, $5042 vs $3050 for outpatient services, and $1545 vs $739 for outpatient pharmacy services, respectively (P<.001 for all differences). Patients with COPD had a longer smoking history (49.5 vs 34.9 pack-years; P =.002) and a higher prevalence of smoking-related comorbid conditions and were more likely to use cigarettes during the study period (46.0% vs 13.5%; P<.001). CONCLUSIONS: Health care utilization among COPD patients is approximately twice that of age- and sex-matched controls, with much of the difference attributable to smoking-related diseases. In this health maintenance organization, inpatient costs were similar to and outpatient costs were much higher than national averages for COPD patients covered by Medicare.

A comparison of two methods for estimating the health care costs of epilepsy.

PURPOSE: Previous studies have estimated medical care costs of epilepsy by applying unit costs to estimated utilization or by summing costs for (a) ambulatory care and hospitalizations coded as epilepsy and (b) procedures and drugs specifically associated with the diagnosis or treatment of epilepsy. These methods may underestimate the cost of medical care for epilepsy. Two methods for estimating the medical care costs of epilepsy ("epilepsy-attributable cost method" and "case-control cost method") were compared. METHODS: The study population was 655 individuals with an epilepsy diagnosis enrolled in a managed care plan in the southwestern United States. The epilepsy-attributable costs were determined by summing costs for inpatient and outpatient encounters coded as epilepsy, procedures for the diagnosis or treatment of epilepsy, and drugs used to treat epilepsy. The case-control method determined costs by calculating the difference in total costs between cases and 1,965 age- and gender-matched controls. RESULTS: The case-control epilepsy costs were $2,923 per case compared with epilepsy-attributable costs of $1,335 per case. The case-control method found statistically significant differences in costs between cases and controls for inpatient care, prescription drugs, and 8 of 11 categories of outpatient care. The largest contributors to the discrepancy between estimates were inpatient care, emergency department care, laboratory tests, and "other specialist" care. CONCLUSIONS: Epilepsy-attributable costs accounted for only 46% of the total difference in costs between epilepsy cases and controls. Persons with epilepsy use more medical services than controls, but a substantial portion of this care is not coded to epilepsy.

Utilization in COPD: patient characteristics and diagnostic evaluation.

STUDY OBJECTIVES: Information on current practices of COPD diagnosis and treatment is needed to identify opportunities for improving care. This study describes the clinical characteristics and diagnostic evaluations of COPD patients in a health maintenance organization (HMO) and a university-affiliated county medical center (UMC). DESIGN: Cross-sectional survey performed in a 174,484-member regional HMO and in The University of New Mexico Hospitals and Clinics (UNMH). PATIENTS: Two hundred COPD patients from each system randomly selected from administrative databases based on discharge diagnoses. RESULTS: COPD patients in the UMC, compared to those in the HMO, were younger (mean age, 59.3 vs 66.9 years, respectively), were more likely to be using home oxygen (33% vs 20%, respectively), and had fewer chronic medical conditions (mean number of conditions, 3.1 vs 3.7, respectively) (p < 0.01 for all differences). Approximately half of the COPD patients in both groups continued to smoke cigarettes during the study year. Only 38% of patients in the HMO and 42% in the UNMH system had spirometry results documented in their medical records. CONCLUSIONS: The demographic and clinical characteristics of the COPD patients in these two health-care systems were very different, but smoking status and utilization of diagnostic tests were similar. The diagnosis of COPD in most patients was based only on a history of chronic respiratory symptoms and smoking; spirometry often was not used to confirm the diagnosis. An increased emphasis on smoking cessation and more effective utilization of spirometry are needed to improve the management of COPD in these health-care systems.

Use of services by diabetes patients in managed care organizations. Development of a diabetes surveillance system. CDC Diabetes in Managed Care Work Group.

OBJECTIVE: To develop a diabetes surveillance system that estimates the prevalence of diabetes and characterizes service use in diverse managed care organizations (MCOs). RESEARCH DESIGN AND METHODS: Computerized inpatient, pharmacy, outpatient, and laboratory records were used to develop an algorithm to identify diabetes patients and to develop surveillance indicators common to the three participating MCOs. Using 1993 data, the availability, specifications, and limitations of various surveillance indicators were determined. RESULTS: An extensive set of diabetes surveillance indicators was identified from the four sources of data. Consistent data specifications across MCOs needed to consider variation in the type of data collected, a lack of documentation on level of coverage, differences in coding data, and different models of health care delivery. A total of 16,363 diabetes patients were identified. The age-adjusted prevalence of diabetes ranged from 24 to 29 per 1,000 enrollees. Approximately one-third of patients with diabetes (32-34%) were taking insulin. The majority had one or more visits to a primary care physician during the year (72-94%). Visits to specialists were less frequent. Ophthalmologists and optometrists were the most commonly used specialists: 29-60% of the patients with diabetes at the three MCOs had visited an ophthalmologist or optometrist. About one-fifth had an overnight hospital stay during the year. CONCLUSIONS: This diabetes surveillance system is a useful tool for MCOs to track trends in prevalence of diabetes, use of health services, and delivery of preventive care to individuals with diabetes. This system may also be useful for health care planning and for assessing use changes after new developments in diabetes care or new quality management initiatives.

Prevention of type 2 diabetes in childhood.

The incidence of type 2 diabetes has increased dramatically in the past decade in Pima (Akimel O'odham) children, aged 5-17 years, living in the Gila River Indian Community (GRIC). As a result, a diabetes primary prevention program called Quest was implemented in 1996 at an elementary school in the GRIC for students in kindergarten and grades 1-2. The Quest program has four components: (1) biochemical and anthropometric assessments, (2) classroom instruction about diabetes, (3) increased daily physical activity at school, and (4) a structured school breakfast and lunch program. Preliminary results of the program indicate that the school provides a stable environment for behavior change and interventions that slow weight gain in early childhood.

Acanthosis Nigricans as an early clinical proxy marker of increased risk of type II diabetes.

Diabetes affects 6% of the national population, yet approximately 50% of persons with diabetes remain undiagnosed and receive no treatment. In specific populations, Acanthosis Nigricans (AN) may serve as an early clinical proxy marker of increased risk of type II diabetes. The results of this pilot project to screen selected school age students in New Mexico for AN indicate that a large number of these students may be at increased risk for developing type II diabetes as young adults. The future burden of diabetes on individuals, families, communities, and health care systems may be greater than previously recognized.

Relationship of compliance with hormone replacement therapy to short-term healthcare utilization in a managed care population.

OBJECTIVE: To identify healthcare utilization characteristics that distinguish female members of a managed care organization (MCO) who remained compliant with hormone replacement therapy (HRT) from those who had poor compliance during an 18-month period and to estimate the cost of HRT to an MCO. STUDY DESIGN: A retrospective cohort design in a population of continuously enrolled female members of an MCO. METHODS: All female members of the Lovelace Health Plan 40 years of age or older who began HRT between January 1, 1993, and June 30, 1994 (n = 1158). Compliance was determined by calculating an estrogen medication possession ratio based on pharmacy fills over 18 months. "High compliers" (n = 427) were defined as those purchasing at least 80% of their recommended days supply, and "low compliers" (n = 269) as those purchasing less than 20%. Healthcare encounters and costs of high and low compliers were compared. RESULTS: High compliers were younger (P < 0.01), more likely to be non-Hispanic white than Hispanic (P < 0.0001), and had higher costs for obstetric/gynecologic care (P < 0.0001) and non-HRT prescriptions (P < 0.0001). Low compliers had higher point estimates of costs and encounters for all other categories of care, but differences were statistically significant only for emergency department visits (P < 0.001). CONCLUSIONS: The added cost of HRT did not result in higher total healthcare utilization and costs, as women who complied well with therapy had decreased utilization and costs in other categories of care. Differences in subcategories of healthcare utilization suggest that level of HRT compliance reflects differences in how women access healthcare.