1. Diabetes Disease Management Results in Hispanic Medicaid Patients Esteban R. López, MD, MBA, FAAP Program Director and Medical Director, McKesson Health Solutions National Hispanic Medical Association March 20, 2011 Washington, DC

2. Objective of Presentation To present medical service utilization from a telephonic nursing disease-management program for Medicaid patients with diabetes residing in Puerto Rico Published in Journal of Health Care for the Poor and Underserved o May 2009

3. Road Map of Presentation Diabetes Disease Management Methods Results Discussion

4. Disease Management Care Continuum Alliance (CCA) disease management definition: o Supports the physician/practitioner patient relationship and plan of care o Emphasizes prevention of exacerbation and complications utilizing evidence-based practice guidelines and patient empowerment strategies; and o Evaluates clinical, humanistic, and economic outcomes on an on-going basis with the goal of improving overall health

5. Components of Disease Management Disease management components include: o Population identification process o Evidence-based practice guidelines o Collaborative practice models (physicians and others) o Patient self management education o Process and outcomes measurement, evaluation, and management o Routine reporting/feedback loop

6. Diabetes Disease Management Previous research shows that an increased number of patients can be managed in an ambulatory care setting through Increased understanding of pathophysiology of diabetes Pharmacological interventions Non-pharmacological intervention Goals are: Increased quality of life and less expensive health care

7. Diabetes Disease Management Centers for Medicare and Medicaid Services (CMS) Recognize burden of chronic diseases Will pilot differing disease management strategies Previous research finds a multidisciplinary approach has increased QOL and reduce overall medical costs through Disease management nurses Frequent physician office visits Telephone contact systems

8. Diabetes Disease Management Limitations of Previous Research Pre/Post Evaluations o Least rigorous study methodology Clinic-based interventions o Not representative of community of diabetes patients Costs are not clearly delineated This Research Uses a more rigorous study methodology More representative of community of diabetes patients

9. Methods: Study Population  Diagnosed with Diabetes through administrative claims  Medicaid plan in Puerto Rico  Age 1-64

10. Methods: Study Population Excluded people: Those engaged in a local formal diabetes program. Members age 65 or over Members with less then three months eligibility prior to their study start date or less than three months eligibility after their study start date. ESRD, Dialysis, Transplants, HIV/AIDS Hospice SNF Intervention group members with less than three months participation in the disease management program.

11. Methods: Study Population Sample of 490 diabetes participants and 490 matched non- participants Matched non-participants drawn from sample of 7,966

12. Methods: Intervention Created a customized self-management intervention plan o Risk stratification o Formal scheduled nurse education sessions o 24 hour access to nurse counseling and symptom advice o Printed action plans o Workbooks o Individualized assessment letters o Medication compliance reminders and vaccine reminders o Physician alerts

13. Methods: Intervention Guidelines used: The American Diabetes Association

14. Methods: Intervention Changes in medical service utilization is expected to result from improvements in patients’  Knowledge  Behavior  Health status

15. Methods: Study Design Alternatives include Randomized control trial Matched two-group cohort Population based pre/post Participant only pre/post Others We used a 12 month, matched-cohort study.

16. Results Medical service utilization (annualized rate per 1000) Study group Control groupP-value Change (%) Inpatient admits174268.40.112-35.2 Inpatient bed days920.31,770.000.021-48 Emergency Department visits773.6758.30.7782 Physician evaluation & management visit5,1534,651.800.64910.8 Pharmacy scripts39,530.4040,932.900.704-3.4 Diabetes inpatient admits39.814.900.437167.2 Diabetes inpatient bed days148.8108.600.69937 Diabetes Emergency Department visits81.895.800.603-14.7 Cardiac inpatient admits25.298.000.001-74.3 Cardiac inpatient bed days134.2528.200.002-74.6 Cardiac Emergency Department visits16.812.800.59131.2 Inpatient 30 day readmits29.442.600.635-31.1

17. Results Prescription drugs (% of people who have) Study group Control groupP-value Change (%) ACE inhibitor (%)31.625.70.04123 Beta blocker (%)27.625.70.5167.1 Antihypertensives (%)54.949.80.1110.2 Diuretics (%)45.336.10.00425.4 Cardiac glycosides (%)5.16.30.409-19.4 Blood glucose regulators (%)90.4 1,0000

18. Results Procedures performed (% of people who have) Study group Control groupP-value Change (%) Hemoglobin A1c21.216.50.06128.4 Lipid panel2823.70.12618.1 Eye examination16.313.90.28517.6 Maculopathy3.93.50.73411.8 Microalbumin1.41.20.7816.7 Echocardiography4.97.60.086-35.1 Cardiac catheterization1.25.70-78.6 Myocardial imaging/ perfusion1.820.817-7.1 Influenza immunization7.12.40.001191.7 Pneumococcal immunization2.910.037180

19. Results Average costs Study group Control group P- value Change (%) Monthly medical costs ($)74.5154.660.001-51.8 Monthly pharmacy costs ($)79.2580.110.848-1.1 Monthly total costs ($)153.75234.780.00234.5

20. Discussion Drugs and device manufactures often subject their products to clinical research to determine Safety Efficacy Healthcare services are rarely subject to similar levels of clinical research Some exceptions CMS randomized pilot HealthDialog has a randomized trial published in NEJM

21. Discussion 75% of managed care plans report having comprehensive disease management programs as defined by CCA Industry growth likely due to: Frustration with pace of guideline adoptions Guaranteed financial savings by DM companies High patient satisfaction Other reasons

22. Discussion Although Propensity Scores balance observable variables, unobservable variables may not be balanced Motivation Psycho-social factors No drug information for this study Selection Bias? Is selection determined by observable or unobservable variables? If by unobservable, then bias may exist