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July 22, 2010 Volume VII, No. 3

HIN Communications Editor Jessica Papay

Dear Healthcare Intelligence Network Client,

Care management is just one way to reduce healthcare costs for dementia patients, according to research from the Alzheimer's Association. Discover other tactics that can reduce costs for dementia patients in this week's issue, along with how exercising as a teenager can help prevent dementia risk in the future.

Also, can women with a history of gestational diabetes during their first and second pregnancies experience a recurrence of this disease?

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

This week's DM news:

Table of Contents

  1. Dementia Care Management & Cost
  2. Gestational Diabetes & Pregnancy
  3. HRAs for the Elderly
  4. Diabetes Medical Home & Medicaid Patients
  5. Populations Targeted by Telehealth
  6. Case Management Benchmarks
  7. Dementia Prevention & Exercise
  8. Reducing Avoidable ER Visits

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Publisher:
Melanie Matthews, mmatthews@hin.com

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Early Detection, Diagnosis and Care Management for Dementia Patients May Reduce Healthcare Costs

Early detection, diagnosis and care management for people newly diagnosed with cognitive impairment and dementia reduces outpatient costs by almost 30 percent, according to new research founded from the Dementia Demonstration Project (DDP). According to the Alzheimer's Association, dementia is a common, costly and often unrecognized problem in older adults. In order to provide better medical care and outcomes for people with Alzheimer's and other dementias, the conditions must first be detected and diagnosed, and needed care management must be provided. Generally, care management in Alzheimer's provides assistance for people with the disease and their families in finding resources, making decisions and managing stress. For example, a care manager can help families with decisions about in-home health services or long-term care whether at home or in a nursing facility.

The DDP was created to increase detection and diagnosis of dementia in primary care and provide information, support and care coordination for veterans with newly diagnosed dementia. An Advanced Practice Registered Nurse trained in dementia — the Dementia Care Coordinator — led a dementia care team that became part of a primary care clinic in each of the seven VA Medical Centers that participated in the project. The DDP added a brief, three-item memory test to regularly scheduled primary care visits for veterans age 70 and older without a diagnosis of Alzheimer's or another dementia. Among the 8,278 veterans who received the memory test, 26 percent failed. Thirty-four percent of those who failed the test returned for a comprehensive evaluation; 95 percent of that group were diagnosed with cognitive impairment, including 76 percent with dementia. In the DDP clinics, following evaluation, the dementia care team met with the patient and family to review the results, discuss the diagnosis and outline treatment recommendations. Interventions were targeted to the severity of dementia and the specific needs of the patient and their caregivers.

Healthcare costs data for one year before and after diagnosis were available for 347 DDP patients and 1,260 patients from non-DDP clinics in the same VA Medical Centers:

  • Veterans diagnosed in the DDP clinics saw their average outpatient healthcare costs decline by about 29 percent (-$1,991) in the year after diagnosis of cognitive impairment compared with the year before diagnosis.
  • Veterans diagnosed in the non-DDP clinics also saw declines in average outpatient healthcare costs, but not as much (-$406).
"In our study, the cost decreases were more dramatic in patients who were identified through cognitive evaluation and who subsequently had case management available by a dementia care team," said J. Riley McCarten, M.D., the project's lead physician. Dr. McCarten also added that the cost of the DDP intervention to the VA was captured in the patient care costs reported.

To learn more about this research, please visit:
http://www.alz.org/icad/2010_release...

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Women with Gestational Diabetes History Have Increased Risk of Recurrence in Subsequent Pregnancies

There is an increased risk of recurring gestational diabetes in pregnant women who developed gestational diabetes during their first and second pregnancies, according to a Kaiser Permanente study. Gestational diabetes mellitus (GDM) is defined as glucose intolerance that typically occurs during the second or third trimester of pregnancy. It causes complications in as many as 7 percent of pregnancies in the United States. It can lead to early delivery, cesarean sections and type 2 diabetes, and can increase the childís risk of developing diabetes and obesity later in life.

For this study, researchers analyzed the EHRs of 65,132 women who delivered babies at Kaiser Permanente Southern California medical facilities between 1991 and 2008. The study found that compared to women without gestational diabetes in their first and second pregnancies, women who developed gestational diabetes during their first but not second pregnancies had a 630 percent increased risk for developing gestational diabetes during their third pregnancy. This risk was even more pronounced — 25.9-fold — in the third pregnancy for women who had gestational diabetes in their first and second pregnancies. The risk of gestational diabetes recurring was substantial among Hispanic and Asian Pacific Islander women compared with their white counterparts. Researchers also found that in this study population, gestational diabetes was more likely to occur in women who are aged 30 and older, and had a longer interval between any two of their successive pregnancies. The findings lend credence to the importance of educating and counseling pregnant women who have had previous pregnancy complications from gestational diabetes about the recurrence risk in subsequent pregnancies.

This is the first study to examine the race/ethnicity difference in the recurrence of gestational diabetes in the first-two or first-three pregnancies. Previous studies examined the recurrence of gestational diabetes in subsequent pregnancies without regard to their past gestational diabetes history (other than these two subsequent pregnancies.) This study shows that the magnitude of association of the recurrence risk of gestational diabetes in successive pregnancies varies depending on the number of successive pregnancies, and this risk differs by race/ethnicity.

This study is part of ongoing research at Kaiser Permanente to understand, prevent and treat gestational diabetes. A recent Kaiser Permanente study of 1,145 pregnant women found that women who gain excessive weight during pregnancy, especially in the first trimester, may increase their risk of developing diabetes later in their pregnancy. Another published Kaiser Permanente study of 16,000 women in Hawaii found that more than 10 percent of women of Chinese and Korean heritage may be at risk for developing gestational diabetes. Another published Kaiser Permanente study of 10,000 mother-child pairs showed that treating gestational diabetes during pregnancy can break the link between gestational diabetes and childhood obesity. That study showed, for the first time, that by treating women with gestational diabetes, the child's risk of becoming obese years later is significantly reduced.

To learn more about this research, please visit:
http://xnet.kp.org/newscenter/pressreleases/...

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Assessing and Predicting Health Risk in the Elderly

Even though more than a third of the elderly are online, they're not necessarily using the Internet to seek health assistance, explains Marcia Wade, M.D., F.C.C.P., M.M.M., senior medical director at Aetna Medicare. That's why Aetna delivers its health risk assessment for the elderly in an alternate format while making available other Web-based tools to web-savvy boomer beneficiaries. Dr. Wade also describes Aetna's user-friendly strategy for heading off high-risk complications among its elderly and how this contributes to an overall reduction in hospital readmissions.

To listen to this complimentary HIN podcast, please visit:
http://www.hin.com/podcasts/podcast.htm#111

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Engaging the Medicaid Population in the Diabetes Medical Home

Each week, healthcare professionals respond to a reader's query on an industry issue. This week's experts are Dr. James E. Barr, medical director for Partners in Care, and Roberta Burgess, registered nurse case manager for the Community Care Plan of Eastern Carolina with Heritage Hospital in Tarboro, North Carolina.

Question: The Medicaid population has many social barriers to care. How do you increase their engagement to allow the medical home model to be successful?

Response: (Roberta Burgess) Population management is something I do with my diabetic population or any other population that we work with. I send out materials on a monthly basis to my diabetics, and many times itís just education. Iíll say that this is an educational flier about your diabetes. Iíll also have at the bottom, "If you would like more information, contact me, and I can come see you one-on-one and we can talk about some other things." I get responses back from those letters — not a ton, but I get responses back saying "I got a letter from you about my diabetes. I need to know more about it." I also pick up the phone and call them, one at a time, until I get somebody. There is a barrier, but I pick up the phone and say, "My name is Roberta and Iím your case manager. I work for your medical home. Is there anything I can help you do today? How are you doing with your diabetes? Are you having any other problems that I might be able to help you with? I know all about the resources." That opens the door and lets them know that they can get care or help. Many times they may not get out because of transportation but I can provide them with transportation. It is one-by-one, and itís treacherous.

(Dr. James Barr) The process map that we utilize identifies every person that is in contact with this patient. The list includes the medical home doctor, all the specialists involved and a case manager if one exists. That list can continue and involve the family member who may have the most influence over this patient or will help with compliance, transportation or finances. There may be a financial assistance plan that can be implemented inside that patientís profile in order for them to get certain medications. It could involve a faith-based organization, a minister, or somebody with whom they have a relationship. Itís good to include anybody who has had a relationship with that patient so that when youíre having a problem, the map indicates resources to use to help this patient obtain the type of care they need.

For more information on the diabetes medical home, please visit:
http://store.hin.com/product.asp?itemid=3813

We want to hear from you! Submit your question for Disease Management Q&A to info@hin.com.

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Which Populations Are Targeted by Telehealth?

With so many healthcare organizations hotwired for telehealth and telemedicine, we wanted to find out which populations were being targeted by technologies such as remote monitoring and diagnostics, automated reminders and data sharing. See the responses we received from 139 healthcare organizations.


Click here to view the chart.

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Benchmarks in Healthcare Case Management

Healthcare case managers are playing a larger role in the coordination of all phases of patient cares. This HIN white paper examines the expanding focus, responsibilities and impact of case management in healthcare, from populations benefiting from case management to metrics on case loads, ROI and performance measurement through responses provided by 187 healthcare organizations.

To download this complimentary white paper, please visit:
http://www.hin.com/library/registerhcm.html

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Exercise in Youth Essential for Dementia Prevention

Women who are physically active at any age, but especially as teenagers, have better cognitive performance and a lower chance of cognitive impairment in old age, according to a new study from the Sunnybrook Health Sciences Centre. While teenage physical activity was most strongly associated with lower odds of late-life cognitive impairment, those women who were inactive as teenagers but became physically active in later life had lowered risk of cognitive impairment than those who remained inactive.

This study is the first to examine the association of physical activity at several ages across the life course with late life cognitive function. ďThis research provides evidence that physical activity earlier in life may be important in reducing the risk of cognitive impairment in late life. These results not only confirm that promoting physical activity is among the most promising strategies in the prevention of dementia in old age, but also stress that health promotion interventions targeting people earlier in life may be particularly important,Ē according to Dr. Laura Middleton, principal investigator of the study and postdoctoral fellow at the Heart and Stroke Foundation Centre for Stroke Recovery at Sunnybrook Health Sciences Centre.

The study examined over 9,000 women (at four U.S. sites between 1986 and 1988) aged 65 years or older who self-reported physical activity levels during teenage years age 30, 50 and in older age. The participants underwent a brief test of cognitive function that evaluates orientation, concentration, praxis and memory (modified Mini-Mental State Exam) and were classified as cognitively impaired based on low scores. Cognitive status was correlated according to patterns of physical activity at each age. The women who were physically active had significantly lower prevalence of cognitive impairment in late life compared to women who were inactive at each time, as follows: Teenage: 8.5 versus 16.7 percent; Age 30: 8.9 versus 12 percent; Age 50: 8.5 versus 13.1 percent; and Old age: 8.2 versus 15.9 percent.

The mechanisms by which physical activity across the life course is related to late life cognition are likely to involve a number of factors, such as increased neuroplasticity and repair in the brain. In addition, physical activity reduces rates and severity of vascular risk factors, such as hypertension, obesity and type II diabetes, which are each associated with increased risk of cognitive impairment. The prevalence of dementia is expected to rise dramatically in upcoming decades, primarily due to increased longevity.

To learn more about this research, please visit:
http://www.sunnybrook.ca/uploads/N100630(1).pdf

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Reducing Avoidable Emergency Room Visits

Inappropriate and preventable use of the hospital emergency department is a nationwide problem and a serious drain on healthcare resources. Many healthcare organizations have launched programs to reduce avoidable use of the hospital ER. Join the more than 75 organizations that have already completed our survey on reducing avoidable ER visits and get a FREE executive summary of the compiled results.

To participate in this survey and receive its results, please visit:
http://www.surveymonkey.com/s/ervisits

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