Springer Science and Business Media LLC

Background: Effective influenza surveillance and communication of influenza activity are crucial for the management of influenza outbreaks. The accuracy of clinical diagnoses can be enhanced if the influenza virus is known to be circulating in the community. Objective: To report on the development of a new influenza surveillance system in Germany (2001–2002) based on consultation rates and near patient test results using the Influenza A/B Rapid Test (IRT) and RealFlu™ Surveillance methodology. Methods: This is the first internationally standardized, rapid influenza surveillance system providing harmonized influenza-specific information. RealFlu™ Surveillance is unique in its approach by generating two baselines: one with morbidity rates and one with specific influenza activity based on near patient test results. The baselines are set independently for each participating country and its constituent regions, thereby allowing monitoring of national as well as regional influenza activity. The system is highly specific and sensitive to influenza and differentiates between three levels of the RealFlu™ Surveillance influenza activity: (i) no/sporadic activity; (ii) moderate activity; and (iii) high activity. Weekly activity is presented in graphs, maps, and data tables with daily updates and comments. In this report, data collected during the influenza season 2001–2002 in Germany are presented. Results: The RealFlu™ Surveillance system has been running for four consecutive influenza seasons since 1999. The first increase in influenza circulation was seen from week 2 (from year start) to week 4. In week 5, a steep increase in influenza positives was observed. A significant amount of excess morbidity was seen from week 7, peaking in week 11. The season started in western regions of Germany and ended in eastern regions of Germany. Regional outbreaks were detected also when the aggregated country data did not indicate any significant increase in influenza activity. Conclusion: By providing specific, real-time monitoring of regional and national influenza outbreaks, the RealFlu™ Surveillance system complements existing schemes and presents a practical surveillance methodology for countries where influenza surveillance does not exist.

In view of sweeping health and human service reforms around the US and abroad, program performance standards, their measurement, and their application in program accountability have become critical functions. Measuring the performance of healthcare systems has added a new dimension to the evaluation and management of acute care. Multiple-level evaluation approaches — including randomized controlled trials, cohort, case control and retrospective studies, economic modeling and cost-effectiveness analyses, and case studies — will be necessary to persuade diverse groups of stakeholders, particularly when the interventions are multi-faceted. The goal of multi-level evaluation approaches is to develop an internally consistent set of findings that produce a preponderance of evidence in support of a particular management strategy. Such an approach should also eliminate alternative explanations. The management of certain infectious diseases such as pulmonary tuberculosis (TB) has refocused the attention of performance evaluators upon the concept of continuum of care. Multiple-level evaluation approaches consistently underscore a case management approach based on the use of comprehensive, community-based, patient-centered directly observed therapy (DOT) programs for achieving the highest treatment completion rates for patients with pulmonary TB. As lengths of stays in hospitals continue to shorten, it has become apparent that clinical outcomes cannot be measured during the hospitalization episode(s) alone. This paper discusses the evidence-based case management of pulmonary TB, concluding that patient-centered approaches involving DOT provide the most effective care and disease prevention. Health and public healthcare systems should adopt such patient-centered approaches when managing resurgent infectious diseases such as pulmonary TB.

Neonatology has become a prime target for specialty care management or population management services. As the cost of caring for the neonatal intensive care unit (NICU) population steadily rises, with no accompanying increase in quality information, health plans and large self-insured groups have increasingly taken notice. Some plans have attempted to manage this challenging population on their own; others have sought outside solutions. One such program is that developed by Paidos Health Management Services, founded in 1996. This article identifies the key issues surrounding neonatology and medically complex newborns and suggests factors that need to be addressed by a comprehensive neonatal care management program. It explains elements of the Paidos program and how this model becomes operational. Using key program elements including a specific patient grouper system, clinical management guidelines, physician advisory boards, outcome measurements and family satisfaction, the success of the program is described. Wide variation in clinical practice is demonstrated by the duration of methyl-xanthine therapy with a 2-fold difference seen in various regions. The cornerstone of improvement in practice is the use of sound clinical management guidelines. As documentation that improvement can be made, a revised feeding guideline improved the time to first feeds by as much as 50% at certain gestational ages. Guideline compliance overall averaged greater than 90%. This success was achieved by developing these evidence-based guidelines in cooperation with practicing physicians. With a fully implemented program, cost savings can reach 10% but vary depending on hospital contracts. Absolute reduction in length of stay and leveling of care are components of cost reductions. For those health plans lacking different contracted levels, there exist opportunities in future contracting with the level-of-care approach. Timely discharge of an infant depends on competent, high quality home care services being available. The high degree of family satisfaction with the program indicates that measures to contain utilization as part of the care management process are not burdensome. There are significant barriers and challenges to overcome when establishing a neonatal care management program. These include the relatively closed practice style of neonatology, financial concerns of physicians and hospitals and the issues of ‘control’ over what is best for the patient. However, given the current climate of managed care, a comprehensive, integrated approach can offer a successful solution.

Objectives: The purpose of this study was to evaluate the effects of a recently implemented disease management programme [Asthma Control and Education Program (ACE)] on patient outcomes (clinical and functional) and on resource utilisation in socio-economically disadvantaged (and largely Hispanic) individuals with asthma treated at Hartford Hospital. Design and Setting: Using standardised measures (i.e. the Health Status Questionnaire [HSQ] and the Center for Epidemiologic Studies Depression Scale) and conducting serial assessments the investigators determined: (i) functional status at intake and follow-up; (ii) change in the level of illness severity over time; (iii) patientss’ acquisition of self-management skills; and (iv) the type and frequency of acute care services utilised pre- and post-enrolment in ACE. Patient Population:The study participants consisted of consenting individuals, aged 18 years or older, enrolled in ACE from 1 January 1997 to 30 September 1998. Each individual had a comprehensive intake interview (data collected included clinical and financial status) followed by 3 educational sessions. Results: While only 34.7% (n = 282) of the 813 patients referred from Hartford Hospital to physicians or emergency department services elected to participate in the programme, 60% of participants completed the educational sessions. 73% of these enrollees returned for the 3-month follow-up. On the HSQ, the mean Physical Composite Summary (PCS) scores increased from 33.3 ± 10.01 at baseline to 41.6 ± 11.48 at the 3-month follow up and 45.3 ± 10.30 at the 6-month follow-up. In an analysis using only those patients (n = 50) with HSQ scores at baseline and 3- and 6-month follow-ups, there were statistically significant increases in both the PCS and the Mental Composite Summary scores (p < 0.001). For the 68 patients with severity data at baseline, 3 months and 6 months there was a statistically significant improvement over time (p < 0.001). For example, 4.4% had severe disease at 6 months versus 69.1% at baseline. A subset of 73 patients for whom pre-ACE data were available realised a 37% reduction in emergency department use and a 52% reduction in in-patient visits. Conclusions: The evaluation of disease management programmes requires outcomes data. The results of this study of an asthma disease management programme indicate there was an improvement in overall functioning, illness severity, self-management, and utilisation of inpatient and emergency department services. Although a cause and effect relationship could not be assumed, the results suggest that the disease management model is an effective one for the studied population of inner-city patients, socioeconomically disadvantaged individuals previously identified as high utilisers of healthcare services and as having significant environmental exposures problematic for patients with asthma. As currently designed, however, this programme does not address the healthcare needs of the large number of referred patients who choose not to enrol or the enrollees (40%) who do not complete the education and follow-up sessions.

Mood disorders are serious chronic illnesses that are the leading cause of disability worldwide. Up to two-thirds of all people with a mood disorder are undiagnosed. In the US, there are three suicides for every two homicides, with 70% of these deaths attributed to untreated depression. Mental health advocacy organizations play an important role in the management of these disorders by urging those who are undiagnosed or untreated to seek treatment. Stigma is the number one barrier to mental healthcare, according to the US Surgeon General. Advocacy groups work to eliminate the stigma surrounding mental illness in order to encourage more people to seek treatment. They have a role in disease management as they enhance communication between patients and healthcare providers, an area in which studies have shown a significant gap in perceptions. Advocacy groups educate people so that they can play an active role in their own treatment plans. It has been demonstrated that participation in patient support groups increases patient compliance with treatment plans and decreases incidences of hospitalization for the illnesses. A critical role in disease management is patient advocacy for improved access to care, so that those needing treatment can actually receive it. Finally, mental heath advocacy groups have a role in managing the disease through ‘grassroots’ efforts to promote expanded research for better treatments, and eventually cures, for mental illnesses.

To determine whether participation in a six-session behavioral medicine group program was associated with a post-intervention decrease in health costs among participants. A retrospective study conducted in a convenience sample of 295 high utilizers of healthcare at a health maintenance organization in northeast USA. High utilizers were considered to be those patients with at least $US1500 in utilization costs (excluding eye care, dental services and pharmacy services) in the 12 months prior to the course. Five patients with $US20 000 or more in utilization costs for any 6-month period were excluded from the analysis because of the occurrence of severe acute medical illnesses. The intervention group comprised 114 patients who completed at least four of six behavioral medicine group sessions in the Personal Health Improvement Program (PHIP). The comparison group (n = 176) consisted of those patients who were referred but declined participation. Healthcare utilization for both groups was measured for two epochs: the 12 months before the referral and the 12 months following the referral for the control group, or the 12 months following completion of the program for the PHIP group. The PHIP course significantly decreased utilization from an average of $US4079 prior to course participation to an average of $US2462 in the 12-month period after the course, a decrease of $US1616 (p < 0.0001). Utilization in the comparison group decreased by $US608 (from $US4347 before referral to $US3739 12 months after referral). Post-intervention health costs were $US1008 less than those observed in the control group during the same time period. There was a mean decrease in costs from baseline of 25% for the PHIP group and less than 1% for the control group (p = 0.031, one-tailed). This cost saving, if attributable to a direct impact of PHIP on morbidity and a subsequent reduction in healthcare utilization, would represent roughly a 25% saving in health costs. The study was limited by the non-random assignment to condition and the resulting potential for selection bias, as well as other possible confounds. However, the present finding of lower health costs after PHIP participation is consistent with earlier studies showing reductions in ambulatory visit rates following PHIP. Taken together, these findings suggest that the integration of behavioral medicine group programs into primary care will benefit patients and clinicians as well as help to control health costs.

Although clinicians have an obligation to act in patients’ best interests, patients frequently choose to act in ways that adversely affect health. Consequently, clinicians are often left questioning where the responsibility for optimum care lies. The criteria for determining responsibility (the Jonas criteria) are as follows: causality, control and foresight. Two types of choices lead to health problems — lifestyle and noncompliance. Patients are responsible to themselves and society for unhealthy lifestyles. Patients are subject to the consequences of unhealthy lifestyles in the form of suffering; society’s consequence is increased costs. Providers are not justified to increase an individual’s consequences because the degree of responsibility cannot be specified, and clinicians should not be deciding who deserves care. Society is justified in setting prospective consequences in the form of taxes, education and prevention. Noncompliance challenges the clinician’s duty to respect patient autonomy. Respect for autonomy requires clinicians to actively assist patients in making reasoned decisions about treatment and then to accept such decisions. The clinician must simultaneously assess patients’ competence to make decisions, and take increased responsibility for decisions when competence is impaired. Factors that need to be considered in determining an appropriate level of coercion include: the nature and degree of potential harm to the patient and to society from noncompliance; the likelihood of the harm’s occurrence; the intrusiveness of the planned coercive activity and; the degree to which the intervention is likely to be effective.

The National Lung Health Education Program (NLHEP) is a new healthcare initiative which encourages the early diagnosis of and intervention in patients who are in the process of developing chronic obstructive pulmonary disease (COPD) and related disorders. COPD is primarily a smoker’s disease. Lung injury is due to proteolytic and oxidative damage early in the course of disease and results in premature loss of lung function, as measured by forced expiratory volume in 1 second (FEV1). Smoking cessation will retard this rate of decline and improve prognosis. The most common cause of death in patients with early stage COPD is lung cancer. Thus, the possibility of lung cancer should be investigated in patients with early degrees of airflow obstruction. The NLHEP Spirometry Statement encourages testing of all smokers aged over 45 years, and anyone with cough, dyspnea, mucus hypersecretion, or wheeze. The spirometry industry has responded to the NLHEP by developing simple, accurate, reliable, and inexpensive office Spirometers for screening purposes. It is hoped that the widespread use of spirometry will begin to reduce the socioeconomic impact of COPD and related lung cancer. Managed care should endorse the goals and objectives of the NLHEP for the benefit of their patients, and to help contain costs.

In recent years, health plans have turned to disease management programs as a means of reducing inpatient utilization while promoting preventive outpatient services provided for patients with type 2 diabetes mellitus. The purpose of this study was to assess the association between four preventive diabetes screenings (retinal eye exams, glycosylated hemoglobin [HbA1c] testing, lipid testing, and albumin testing) in the base study period, and health services utilization patterns during a 24-month follow-up study period for 2641 patients with type 2 diabetes. Claims data from Regence BlueShield of Idaho for the three periods of 2000 (base period), 2001, and 2002 (results period) have provided the basis for this empirical analysis. Based on our review of the relevant literature and results from disease management and health plan management programs, the central hypothesis of this study was that the four preventive diabetes screenings in the base study period would be associated with lower inpatient utilization and greater preventive outpatient utilization during a 24-month follow-up study period. Simple linear association analysis was used to measure the relationship between the utilization of preventive diabetes screenings and subsequent utilization of emergency room, inpatient, and preventive outpatient services. The study results show that for patients who comply with recommended lipid screening services, health plans can expect to see a significant reduction in the number of inpatient admissions over the subsequent 2 years, while marginal inpatient reductions might be expected following HbA1c testing. Furthermore, for patients who comply with recommended screenings of either retinal eye exams or albumin testing, health plans can expect to see these patients utilizing preventive outpatient services more frequently in the subsequent 2 years. Pursuing a state- or federal-supported screening program for patients with type 2 diabetes could reduce frequent utilization of inpatient services. Furthermore, in support of the goal of disease management programs to reduce inpatient utilization and increase preventive outpatient service utilization among the increasing proportion of members with type 2 diabetes, health plans are encouraged to provide education about and monitor their patients’ compliance with recommended screenings in the future. Further studies should examine the role of lipid testing in reducing the risk of microvascular diseases. Future research should also pursue an understanding of how a reduction in inpatient utilization is associated with an increased emphasis on lipid screening.