Health for life

Its such a no-brainer, right?  If persons at risk for diabetes would only eat right and exercise more, theyd avoid the disease.  And for those who develop diabetes, diet and exercise will reduce death rates and complications.

Yes and no, say Elizabeth Sumamo Schellenberg and colleagues at the University of Alberta.  Their review of the mixed published scientific evidence on the topic appears in the October 15 issue of the Annals of Internal Medicine.  The purpose of their study was to ascertain the impact of diet and exercise on the prevention of "Type 2 diabetes," as well as lowering complications among persons with who had established Type 2 diabetes. 

To be included, studies had to be prospective and compare the outcomes from an intervention versus a randomly selected control group. The study could only be included if it examined the impact of exercise plus diet and "one other component," such as "counseling, smoking cessation and behavior modification."  The outcomes had to include the development of Type 2 diabetes (in the prevention trials) or complications (in the treatment trials).

1289 candidate studies were found but only 20 made the grade. Nine were prevention trials and 11 were treatment trials.

For the prevention trials:

The interventions lasted from 6 to 72 months, with follow-up going for 3 to 20 years for between 39 to 3234 participants.  The counseling varied and included group and/or individual with or without tobacco cessation, telephony, goal setting, cooking classes or pills involving a range of physician and non-physician professionals.

Results?

Seven of the nine studies showed that diabetes can be delayed. When the results were pooled, compared to the control patients, the risk of developing diabetes over 10 years was only a third and the difference was statistically significant.

But, there was no detectable impact on cardiovascular disease events or on eye, kidney or nerve damage. That may have been due to not all the studies including these outcomes as well as the time it takes for these complications to occur once diabetes develops.  With more patients or more time, a difference could have become apparent.
 
For the treatment trials:

The interventions lasted from 6 to 48 months with follow-up for 6 to 93 months. The counseling was as varied as the prevention trials but included glucose and blood pressure monitoring as well as stress management and, in one instance, a three day residential retreat. There was likewise the range of professionals who provided the interventions.

Results? 

Compared to the control patients, there was no statistically significant difference in all-cause mortality.  Some individual studies had beneficial outcomes involving cardiovascular events or diabetes complications, but they included the aggressive use of medications.  There were no sustained impacts on weight or dietary intake.  And if pills were not included, there was also no real improvement in measures of blood glucose control.

The Disease Management Care Blogs take?

The good news is that there is good evidence that exercise and diet can prevent diabetes.  The bad news is that it takes years for that "return on investment" to declare itself and typically involves interventions that fall outside the traditional health care delivery system.  Its unlikely, thinks the DMCB, that current iterations of payment orm (value based purchasing, bundled payments or upside risk) can be marshaled to make this a reality.  That being said, population health management (PHM) companies like Omada Health are making their evidence-based services available to, for example, employers who have a longer term commitment to the well being of their "human capital" outside of the traditional insurance market.

The bad news is that once diabetes declares itself, diet and exercise dont result in life extension, and control of complications as well as overall blood sugar levels is more a function of pills than lifestyle. Accordingly, expectations need to be realisitically shared with patients and PHM should emphasize taking the pills as prescribed.

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All aboard!

If you’re expecting your newly established Patient Centered Medical Home (PCMH), Accountable Care Organization (ACO) or Population-Care Management Program to reduce hospitalizations among persons with diabetes, you may want to sprinkle the acronym “PPH” into your business plans, talking points and meeting pitches. It stands for “potentially preventable hospitalizations.”  It’s not only a timely topic, but by brandishing the term “PPH,” compared to all those unfortunate knuckleheads who don’t read the Disease Management Care Blog, you’ll once again remind everyone about your health industry chops.

That’s why a look at this AJMC article examining “PPH” in a population of persons with diabetes may be worth your time.  555,538 California ’05-’06 hospitalizations for 361,858 persons aged 65 years or greater were examined for the presence of an "ambulatory care sensitive condition" or "ACSC".  The science underlying the use of ACSC metrics in this study has shown that the effective outpatient care of persons with certain concurrent ACSCs can reduce hospitalizations. The ACSCs used by the researchers in the AJMC article were bacterial pneumonia, dehydration, urine infection, COPD, heart failure, hypertension, diabetes complications and uncontrolled diabetes. 

In addition to ACSCs, the the authors looked at the impact of age, gender, race, neighborhood, income, insurance type (Medicare, Medicaid or commercial) and the number of other chronic conditions (as determined by insurance claims).

The results?  More than 112,000 (about 20%) of the hospitalizations were due to an ACSC and theore were PPHs.   The most common conditions were pneumonia and heart failure; the length of stay averaged 5 days with a per hospitalization cost of approximately $9900.  The authors estimated that PPHs resulted in 570,000 hospital days and a cost of more than $1.1 billion  Being female, Medicaid, rural dwelling, low income, having multiple co-morbidities and having to be admitted via the emergency room were all associated with PPHs.

How can this information help the PCMH-savvy, ACO-adroit and care management cognoscenti?  While the authors of the AJMC article vaguely suggest that better vaccination rates against flu and pneumonia may work, the DMCB offers up some additional observations:

1. Baseline:  Now readers have an idea of the extent of the problem in a diabetes population.  20% is a lot of PPHs, a lot of hospital days and a lot of money.

2. Reality Check:  In this study, 80% of the admissions for persons with diabetes were NOT potentially preventable.  This should give pause to anyone believing that their initiative can precipitously reduce hospitalization rates.  Doctors (the kind that actually take care of patients) will also tell you that many PPHs are not truly preventable also: many people get acute pneumonia and heart failure exacerbations despite the best of care. As a result, more than 90% of hospitalizations among elderly persons with diabetes may not be preventable.

3. Generalist Care Management, not just diabetes care: your organizations nursing care plans have to not only address blood glucose control, but a host of other co-morbidities that are the real short term drivers of inpatient use.

4. But, Cake and Eat It Too: There are scant data on this, but the DMCB believes that good blood glucose control leads to fewer infections and atherothrombotic complications.  If it is correct, good care management not only has to manage multiple co-morbidities (the cake) but achieve good blood sugar control (the eats).

5. ER Chicken and Egg:  Does becoming very ill with an ACSC make ER visits more likely which, in turn, makes a PPH more likely?  The DMCB agrees that that is one causal pathway accounting for the data above.  However, it also wonders if presenting to an ER with any ACSC at any stage of illness is more likely to lead to an admission.  If the DMCB is correct, it stands to reason that 1) developing initiatives that keep patients away from the ER (with outpatient care options) may materially reduce admissions and 2) putting care management resources in the ER to assist with discharge planning is an option because it may divert patients to the outpatient setting.