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October 22, 2009 Volume VI, No. 23

HIN Communications Editor Jessica Papay

Dear Healthcare Intelligence Network Client,

Researchers are connecting the dots in their studies of Alzheimer's disease and dementia, learning how skills tests can be an indicator for Alzheimer's disease and why advanced dementia is considered a terminal illness.

Also in this week's DM Update, discover how lupus patients can better manage their condition and avoid cardiovascular disease.

Your colleague in the business of healthcare,
Jessica Papay
Editor, Disease Management Update

This week's DM news:

Table of Contents

  1. Skills Tests May Be Alzheimer's Indicator
  2. Study Says Dementia is a Terminal Illness
  3. Real ROI from DM
  4. Measuring Comorbidity Reduction in DM
  5. Healthcare Trends & Studies
  6. Preventing Cardiovascular Disease in Lupus Patients
  7. Healthcare Trends in 2010

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Skills Tests Like 'Connect the Dots' May Be Early Alzheimer's Indicator

A study of mental decline in the years prior to diagnosis of Alzheimer's disease suggests that changing the focus of testing may allow physicians to detect signs of the disease three years earlier. Current cognitive testing typically focuses on episodic memory, or the ability to remember things like word lists or information from a reading. But scientists at Washington University School of Medicine in St. Louis found that another class of mental abilities known as visuospatial skills begins to deteriorate up to three years prior to diagnosis. These skills are tested with tasks such as connecting the dots or using a guide to build a structure with blocks.

The researchers analyzed long-term data from volunteers at the Memory and Aging Project at Washington University's Alzheimer's Disease Research Center (ADRC). For three decades, researchers have been regularly conducting extensive testing of volunteers to uncover the factors associated with the normal, healthy retention of mental function in seniors. The new study analyzes data on 444 volunteers aged 60 to 101 that were gathered between 1979 and 2006. Scientists categorized cognitive testing results into a global measure of cognitive abilities as well as three specific types of mental skills: episodic memory, visuospatial skills and working memory, which assesses the ability to manipulate facts from memory, such as repeating a list of numbers backwards.

Declines in episodic memory and working memory became discernible a year before volunteers were diagnosed with Alzheimer's disease. Losses in the composite assessment of cognitive abilities were detectable two years prior to diagnosis, and visuospatial skills began to decay three years earlier. According to one scientist, the losses in visuospatial skills were particularly noticeable if testing tasks were timed. Researchers also analyzed the data using a new model that not only tracks the speed of decline in a mental ability but also the acceleration of the decline. Episodic memory's decline accelerated more slowly than that of both visuospatial skills and working memory, which declined the fastest.

To learn more about this research, please visit:

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Institute for Aging Research Study Says Dementia is a Terminal Illness

The clinical course of advanced dementia, including uncomfortable symptoms such as pain and high mortality, is similar to that experienced by patients of other terminal conditions, according to scientists at the Institute for Aging Research of Hebrew SeniorLife, an affiliate of Harvard Medical School. The study, published in an October issue of The New England Journal of Medicine, is the first to rigorously describe the clinical course of advanced dementia, a leading cause of death in the United States. Previous studies suggest that patients with advanced dementia are under-recognized as being at high risk of death and receive suboptimal palliative care, which aims to improve the comfort of terminally ill patients. The study underscores the need to improve the quality of palliative care in nursing homes to reduce the physical suffering of patients with advanced dementia, and to improve communication with their family members.

The “Choices, Attitudes and Strategies for Care of Advanced Dementia at the End-of-Life (CASCADE)" study prospectively followed the clinical course of 323 nursing home residents with advanced dementia living in 22 Boston-area nursing homes for up to 18 months. At the final stage of the disease, patients had profound memory deficits such that they could not recognize close family members, spoke fewer than six words and were non-ambulatory and incontinent.

Over the course of the study, 177 patients died. The researchers found that the most common complications were pneumonia, fevers and eating problems, and that these complications were associated with high six-month mortality rates. Uncomfortable symptoms, including pain, pressure ulcers, shortness of breath and aspiration were also common and increased as the end of life approached. Lead author Susan L. Mitchell, M.D., M.P.H., a senior scientist at the Institute for Aging Research, said that she and her team found that while 96 percent of the patients’ healthcare proxies believed that comfort care was the primary goal of care for their loved one, nearly 41 percent of patients who died during the study underwent at least one intervention, including hospitalization, an ER visit, intravenous therapy or tube feeding in the last three months of life. However, patients whose healthcare proxies understood the clinical course of the disease were less likely to receive aggressive treatment near the end-of-life.

To learn more about this research, please visit:

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Real ROI from DM

Nightly data mining has helped Vanderbilt University and Medical Center identify and make contact with high-risk high-volume patients, explains Dr. Dexter Shurney, a strategy that has vastly improved patient outcomes and closed care gaps. But the medical director of Vanderbilt's Employee Health and Care Plan would like to see even more data put in front of physicians at the point of care — especially regarding certain patients with no claims history. Dr. Shurney describes the impact of these "bombs waiting to explode," the effect of the patient-centered medical home (PCMH) model of care on DM and why wellness and prevention services may be the best responses to individuals with comorbidities.

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Measuring Comorbidity Reduction in DM

Each week, healthcare professionals respond to a reader's query on an industry issue. This week's expert is Chad Boult, M.D., M.P.H., M.B.A., professor of public health, medicine and nursing and director of the Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health.

Question: What is the best way to measure the impact of comorbidity reduction in DM?

Response: It sounds as though the question is asking about reducing the multi-morbidity itself. It’s important to point out that these people have chronic diseases, and very few of them are ever cured. We’re not likely to reduce people’s morbidity itself. We can’t cure these diseases, but we certainly can improve the quality of the care they get. You can measure that by HEDIS or the Patient Assessment of Chronic Illness Care (PACIC) instrument, and you can improve some of the outcomes of care, like quality of life for the patients and cost for the insurer.

For more information on comorbidity care models, please visit:

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Health Coaching in 2009 — Banking on Behavior Change

How do healthcare organizations use health coaching, and on which key behaviors do coaching interventions focus? By which modalities do they administer and monitor health coaching in their populations and how do they measure its effectiveness? The Healthcare Intelligence Network set out to answer these questions and others during its annual Health Coaching e-survey. This executive summary of responses from 212 healthcare organizations identifies emerging trends in the field of health coaching and its effect on healthcare utilization and spend.

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Preventing Cardiovascular Disease in Lupus Patients

According to a new study by Hospital for Special Surgery investigators, most lupus patients are not aware that their condition puts them at a higher risk for cardiovascular disease and a counseling program is a valuable way to promote education and lifestyle change.

Launched in March 2009, the Cardiovascular Disease Prevention Counseling Program for Lupus Patients helps lupus patients think beyond their primary condition and take steps for future wellness. To assess the impact of the program, patients were given satisfaction surveys at the end of their initial visit and asked to rate aspects of the program, including quality of counseling and educational materials, likelihood of recommending the program to others, and improvement in the patient’s knowledge about cardiovascular risk. Overall, the results of the survey showed that patients were well satisfied with the free counseling program.

Based on their chart and information gained during the appointment, patients may also be referred to a nutritionist or a physical therapist to help them make changes that will lower their risk for cardiovascular disease. The authors say that their study highlights that programs designed to help patients understand the cardiovascular risks associated with lupus are very well received by patients. The counseling helps patients increase their knowledge and begin to make behavior changes.

To learn more about this research, please visit:

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Healthcare Trends in 2010

Healthcare reform, a fragile economy, high numbers of uninsured, the lingering threat of H1N1 and emerging care models are just a few factors that promise to drive changes in the healthcare industry in the coming year. To learn how other healthcare organizations are preparing for 2010, complete HIN's fifth annual survey on Healthcare Trends in 2010 by October 30 and receive a free executive summary of the compiled results. Your responses will be kept strictly confidential.

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