Clinical Management of Glomerular Diseases.

Progressive glomerular damage can occur as a result of various etiologic factors including infections, medications, diseases, and autoimmune disorders. This article discusses the clinical management of the leading conditions associated with glomerular disease, including glomerulosclerosis, diabetic nephropathy, focal segmental glomerulosclerosis, and membranous nephropathy. Glomerular damage and disease progression may lead to end stage renal disease. Clinical management is individualized, as based on causative factors and clinical manifestations, with the overall goal of limiting glomerular damage. Collaborative and comprehensive care is imperative to improving patient outcomes.

The Role of Pain Classification Systems in Pain Management.

Pain is a multidimensional experience that can significantly impair an individual's quality of life. This article describes the pain classification systems, including anatomic, etiologic, intensity, duration, pathophysiological, and conditions that are not easily classified. A holistic approach is taken by addressing key components to assist with effective pain management, including the psychological and spiritual aspects of care. A case study scenario demonstrates the implementation of pain classifications in pain management. Also discussed are current controversies, potential genetic impacts, and the barriers chronic pain sufferers face, including addiction, diversion, and socioeconomic factors.

Embracing change.

This article challenges the way nurses have thought about the business of nursing practice and education, while exposing emerging innovations that are calling nurses to action. Several quality measurement programs and the Affordable Care Act are discussed in relation to changes in nursing practice that will be required to meet the challenges of an evolving health care system. Using a change theory as the framework to guide both transformational and incremental planned change will increase the chance of success. Selected change theories are considered and one theory is used to illustrate usefulness in facilitating change in nursing practice.

Ultrasound studies.

This article focuses on the clinical use of ultrasound with the obstetric, gynecologic, and trauma patient by reviewing recent case studies of the use of ultrasound for diagnostic purposes. The article also summarizes the American Institute of Ultrasound in Medicine (AIUM) guidelines for use in several types of patients. The AIUM is a multidisciplinary association whose purpose is to "advance the art and science of ultrasound in medicine and research through educational, scientific, literary, and professional activities." The organization provides guidelines in conjunction with many professional organizations, such as the American College of Cardiology and the American College of Obstetrics and Gynecology. AIUM also serves as an accrediting body for ultrasound practices.

Is pharmacologic care of chronic obstructive pulmonary disease consistent with the guidelines?

Chronic obstructive pulmonary disease (COPD) is a common chronic illness that affects an estimated 210 million people worldwide, including 12 million people in the United States. National and international guidelines for treatment of COPD recommend use of certain medications, especially bronchodilators and corticosteroids, but the extent to which these are used appropriately is largely unknown. The objective of this study was to determine the extent to which pharmacotherapy for COPD is consistent with guidelines. Individuals with COPD (N = 2272), enrolled for at least 2 years in a large midwestern managed care organization, were identified from medical claims data. Medications dispensed in 2003 were examined using National Drug Codes from dispensation records. Quality indictors, developed from guidelines, focused on (1) use of bronchodilators, (2) use of inhaled corticosteroids (ICS) for patients with frequent exacerbations, and (3) use of systemic corticosteroids for acute exacerbation of COPD (AE-COPD). A total of 2272 subjects aged 45 years or older with a diagnosis of COPD were identified. Seventy-two percent of subjects with COPD received at least 1 bronchodilator; 64% of subjects with frequent prior exacerbations (> or =3 in the past year) received ICS; and only 51% of subjects with AE-COPD during the study year received systemic corticosteroids. Although most patients received 1 or more respiratory medications recommended by the guidelines, there were gaps in care including limited use of systemic corticosteroids for AE-COPD and ICS for patients with frequent exacerbations. Greater use of appropriate medications could lead to improved health for patients with COPD.

Increased adherence to cardiac standards of care during participation in cardiac disease management programs.

Adherence to cardiovascular disease standards of care is critically important for minimizing the risk of mortality and morbidity for individuals with coronary heart disease (CHD) and heart failure (HF). The purpose of this study was to assess the ability of cardiac disease management (DM) programs to assist members with their adherence to evidence-based medicine for cardiovascular diseases. A total of 20,202 members with CHD and/or HF were evaluated 12 months prior to the start of DM programs and during their first 12 months of participation in the programs. Members were assessed for their adherence to appropriate cardiac medications. In addition, low-density lipoprotein (LDL) testing rates and clinical control of LDL values (defined as <100 mg/dL) were measured. The association between LDL control and use of lipid-lowering statins also was assessed. During participation in the cardiac programs, members achieved significant improvement in their adherence to angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and beta-blockers (P < 0.0001). The cardiac population also achieved a significant increase in LDL testing rates and statin use (P < 0.0001). More members attained appropriate LDL control in year 1 compared to baseline (36% relative increase), and this improvement was associated with a 40% relative increase in statin use. In summary, participation in these cardiac DM programs assisted members to improve their adherence to cardiac medications and standards of care guidelines. Such improvements in cardiovascular disease care are likely associated with improved quality of life and reduced risk for mortality.

Impact of telephonic interventions on glycosylated hemoglobin and low-density lipoprotein cholesterol testing.

OBJECTIVES: To determine whether diabetes disease management (DM) programs are able to improve adherence to glycosylated hemoglobin (A1C) and low-density lipoprotein cholesterol (LDL-C) clinical testing in a nonadherent population and to quantify the efficacy of telephonic interventions in improving clinical testing rates. STUDY DESIGN: Retrospective, observational cohort study before and after DM program implementation. METHODS: A baseline cohort of members with diabetes (n = 5640) was identified from among large-scale diabetes DM programs administered for 13 geographically diverse health plans. Members were defined by nonadherence at baseline to A1C and/or LDL-C testing, grouped together based on how long they had participated in the program, divided retrospectively into telephonically contacted and uncontacted groups, and analyzed in the subsequent 12-month implementation period for testing rates. Subgroups defined by disease burden at baseline and frequency of telephonic interactions were analyzed to determine achievement of guideline-based A1C and LDL-C testing rates. RESULTS: Participation in diabetes DM programs was associated with improved A1C and LDL-C testing rates in previously nonadherent members. Calling nonadherent members improved A1C testing by 30.2% and LDL-C testing by 10.9% compared with testing rates for members who were not called. Members with high disease burden benefited even more from the diabetes intervention. Frequency of telephonic contacts with nonadherent individuals demonstrated a linear relationship with improved rates of adherence to A1C and LDL-C testing guidelines, and markedly improved testing rates compared with a not-called group. CONCLUSION: Telephonic interventions as part of comprehensive DM programs are associated with improved disease-monitoring testing.

Association between frequency of telephonic contact and clinical testing for a large, geographically diverse diabetes disease management population.

Diabetes disease management (DM) programs strive to promote healthy behaviors, including obtaining hemoglobin A1c (A1c) and low-density lipoprotein (LDL) tests as part of standards of care. The purpose of this study was to examine the relationship between frequency of telephonic contact and A1c and LDL testing rates. A total of 245,668 members continuously enrolled in diabetes DM programs were evaluated for performance of an A1c or LDL test during their first 12 months in the programs. The association between the number of calls a member received and clinical testing rates was examined. Members who received four calls demonstrated a 24.1% and 21.5% relative increase in A1c and LDL testing rates, respectively, compared to members who received DM mailings alone. Response to the telephonic intervention as part of the diabetes DM programs was influenced by member characteristics including gender, age, and disease burden. For example, females who received four calls achieved a 27.7% and 23.6% increase in A1c and LDL testing, respectively, compared to females who received mailings alone; by comparison, males who were called achieved 21.2% and 19.9% relative increase in A1c and LDL testing, respectively, compared to those who received mailings alone. This study demonstrates a positive association between frequency of telephonic contact and increased performance of an A1c or LDL test in a large, diverse diabetes population participating in DM programs. The impact of member characteristics on the responsiveness to these programs provides DM program designers with knowledge for developing strategies to promote healthy behaviors and improve diabetes outcomes.

Improvement of LDL-C laboratory values achieved by participation in a cardiac or diabetes disease management program.

Poor lipid control is a risk factor for cardiovascular diseases and diabetes complications. Frequently, however, patients with these diseases do not achieve blood lipid levels recommended by current standards of care. A retrospective study of 67,244 members eligible for disease management (DM) was initiated to evaluate the ability of interventions to promote improvement in low-density lipoprotein cholesterol (LDL-C) laboratory values for people with cardiovascular diseases or diabetes. The baseline trend in improving LDL-C values in the absence of DM was established. A two-year period prior to the start of the DM intervention was examined to measure the mean percent change in LDL-C values that was occurring in the population. The mean percent change observed for this pre-intervention group was then compared to the change in LDL-C values observed during the DM study period. A significant reduction in elevated LDL-C values (F-test; p < 0.0001) was observed for members who participated in the DM interventions, even when elevated LDL-C was defined as low as > or =70 mg/dL. Members with LDL-C values within threshold limits maintained these levels during the DM program. The significant reduction in elevated LDL-C values and maintenance of optimal values (< 100 mg/dL) was observed over the course of 3 years of participation in a DM program. A subset of the population also was examined to assess the impact of telephone intervention on reducing elevated LDL-C values. A significant relationship between receiving care calls and reduction in elevated LDL-C levels was observed; members who received calls achieved up to a 32.5% relative reduction in elevated LDL-C values compared to members who did not receive calls. In conclusion, these findings demonstrate the ability of DM interventions to assist a large, geographically diverse member population in reducing a clinical laboratory value.

A focused telephonic nursing intervention delivers improved adherence to A1c testing.

Compliance with hemoglobin A1c (A1c) testing is suboptimal despite the clear national recommendations and guidelines established for care of patients with diabetes. Recent studies have demonstrated a relationship between participation in a diabetes disease management (DM) program and improved adherence to A1c testing. A focused intervention study was initiated to investigate the ability of a DM program to drive improvement in A1c testing. A cohort of 36,327 members experienced a statistically significant increase (29%) in A1c testing while participating in the 6-month focused intervention. This finding demonstrated that a focused DM intervention is able to deliver improvement in a clinical process metric critical for managing patients with diabetes, thereby reducing their risk of disease exacerbation.

Remote physiological monitoring: clinical, financial, and behavioral outcomes in a heart failure population.

This article reports on the outcomes associated with remote physiological monitoring (RPM) conducted as part of a heart failure disease management program. Claims data, medical records, data transmission records, and survey results for 91 individuals ages 50-92 (mean 74 years) successfully completing a heart failure RPM program were analyzed for time periods before, during, and after the monitoring intervention. The program was associated with significant reductions in per member per month costs and emergency room and hospital utilization. More detailed analyses were performed for specific gender and age subgroups. Participant surveys indicated high levels of satisfaction, and improvements in self-perceived health status, self-efficacy, and self-management behaviors. This study is the first to assess the impact of a RPM program following removal of the monitoring equipment. The results indicate that RPM, as a component of a traditional disease management program, has a sustained, beneficial effect on participants' lifestyles after the monitoring period has ended.

Case study of American Healthways' diabetes disease management program.

Disease management has been defined as a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant (Disease Management Association of America, 2005). The purpose of this article is to provide an overview of the diabetes disease management program offered by American Healthways (AMHC) and highlight recently reported results of this program (Villagra, 2004a; Espinet et al., 2005).