Random fluctuations and validity in measuring disease management effectiveness for small populations.

One objective of a disease management (DM) program is the reduction of members' claims costs. A considerable amount of effort has been dedicated to standardizing the outcomes of DM measurement. An area that has not received as much attention is that of random fluctuations in measured outcomes and the related issue of the validity of outcomes subject to random fluctuation. From year to year, large random fluctuations in claims costs can increase or reduce actual savings from a DM program. Sponsors of DM programs want to know how large a group or sample is necessary to prevent the effect of random fluctuations from overwhelming the effect of claims reductions. In this paper, we measure the fluctuations in calculated DM savings in a large commercial population using an adjusted historical control methodology--the methodology that has become the industry standard and which is codified by DMAA's Guidelines. We then determine the sample size necessary to demonstrate DM program savings at different levels of confidence and model the effect on fluctuations in observed outcomes under different methods of choosing trend, different levels of truncation, and for different estimates of program savings. Some groups, particularly employers, will be smaller than the minimum size required for credible outcomes measurement. For groups smaller than this minimum size, we suggest a utilization-based outcomes measure that can be used as a proxy. For both claims- and utilization-based calculations, we provide confidence intervals to be placed around savings estimates. We do this for group sizes ranging from 1000 to 100,000 members.

The use and influence of employee incentives on participation and throughput in a telephonic disease management program.

Participation rates are often viewed by vendors and employer-based disease management (DM) services as an important benchmark of successful program implementation. Although participation is commonly understood to vary widely between and within employer groups, little is known about the role of incentives on rates of participation and graduation from DM programs. This study examined the use of incentives, employer characteristics, and perceptions of employee-employer communication on participation and program throughput. The relationship between incentive use and rates of participation and throughput among 87 employer groups from the 2004 company portfolio were assessed using existing account information. Detailed information on the highest and lowest third of the sample was obtained through interviews with account representatives. Wilcoxon, chi square, and regression analyses were used to examine the influence of employer characteristics and incentive factors on enrollee participation rates and program completion. Fifty-two percent of the accounts offered incentives for participation. From 1% to 23% of the eligible employees enrolled and completed the DM program. Incentives had a direct impact on participation, with amounts greater than $50 the most effective. Participation increased with communication tools including e-mail, high-blast (repeated) communications, and health fairs. Results suggest that cash incentives and communication play a significant role in rates of participation and program completion.

Impact of behavioral adherence on clinical improvement and functional status in a diabetes disease management program.

A prospective, observational study of 1289 members completing an evidence-based diabetes management program was evaluated for clinical effectiveness and cost impact. The program consisted of direct contacts by nurse educators who worked with members to complete modules in a specific order based on the individual's readiness to change and specific standards of diabetes care behaviors lacking adherence. A total of 668 members were at HbA1c target values (HbA1c 7%) at baseline. At follow-up 899 members had either reached the target level or improved their values by 1 percentage point. At baseline, 516 members recorded normal blood pressure; at follow-up 755 members either met the target level of less than 130/80 mmHg or reduced their blood pressure by at least 10/5 mmHg. Claims data indicated that 89% (n = 233) of those who had a hospitalization in the prior year did not have a hospitalization in the program year, compared to 3% (n = 32) who did not have a hospitalization in the previous year but needed a hospital visit in the program year. There were statistically significant improvements in other health behaviors and quality of life measures. Cost avoidance was estimated at $7,402,578 for the 1289 members who completed the program and reported their results. This figure includes those who were in compliance prior to the start of the intervention. The study supported the results from large multicenter trials on diabetes management when translated to an intervention.