Abstract
Objective: To evaluate a pneumonia disease management programme in a naturalistic setting.
Design and Setting: A 300 000 member managed-care organisation introduced an antibacterial treatment guideline designed to change antibacterial prescribing by physicians. A relational database was created to measure changes in healthcare resources, use of antibacterials and health event profiles. One year of data before and after promoting the treatment guideline was compared.
Intervention: The primary disease management intervention was the promotion of the guideline through mailings and face-to-face interventions by 2 disease management specialists.
Participants: All patients with pneumonia diagnoses on the medical claims database were included in the analysis.
Results: The study demonstrated that medical costs increased by 5 to 10% after the treatment guideline was implemented. Health event analysis demonstrated changes in antibacterial prescribing and average cost per antibacterial selected. In both years, the highest success rate was with the amoxicillin group. Although there were fewer patients, doxycycline also had success rates of at least 70%. The econometric model demonstrated that holding other variables constant, including patient age and the presence of any comorbidities, treatment with amoxicillin was associated with a statistically significant reduction in health event costs.
Conclusions: The study identified the need for validating treatment guidelines with results from actual practice. The data also demonstrate the use and importance of measuring clinical and economic outcomes from disease management interventions by using databases readily available within most managed-care organisations. In addition, the econometric model was useful in comparing different drug groups with these retrospective data.
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References
Gurnee MC, DaSilva RV. Constructing disease state management programs. Manag Care Pharm Pract 1995 Jul/Aug: 30–8
Zalta E, Eichner H, Henry M. Implications of disease management in the future of managed care. Med Interface 1994; 66–9, 78
Armstrong EP, Langley PC. Disease management programs. Am J Health Syst Pharm 1996; 53: 53–8
Brabowski H, Mullins CD. Pharmacy benefit management, cost-effectiveness analysis and drug formulary decisions. Soc Sci Med 1997; 45: 535–44
Holdford DA. Barriers to disease management. Am J Health Syst Pharm 1996; 53: 2093–6
Zitter M. Disease management: a new approach to health care. Med Interface 1994 Aug: 70-6
Harris Jr JM. Disease management: new wine in new bottles? Ann Intern Med 1996; 124: 838–42
Landis NT. Disease management entries multiply, diversify. Am J Health Syst Pharm 1995; 52: 1268, 1271–2
Epstein RS, Sherwood LM. From outcomes research to disease management: a guide for the perplexed. Ann Intern Med 1996; 124: 832–7
Schectman JM, Kanwal NK, Schroth WS, et al. The effect of an education and feedback intervention on group-model and network-model health maintenance organization physician prescribing behavior. Med Care 1995; 33: 139–44
Summers KH. Measuring and monitoring outcomes of disease management programs. Clin Ther 1996; 18: 1341–8
Ellrodt G, Cook DJ, Lee J, et al. Evidence-based disease management. JAMA 1997; 278: 1687–92
Curtiss FR. Lessons learned from projects in disease management in ambulatory care. Am J Health Syst Pharm 1997; 54: 2217–29
Sisk JE. How are health care organizations using clinical guidelines? Health Affairs 1998; 17: 91–109
Gehlback SH, Wilkinson WE, Hammond WE, et al. Improving drug prescribing in a primary care practice. Med Care 1984; 22: 193–201
Armstrong EP. Monitoring and evaluating disease management: information requirements. Clin Ther 1996; 18: 1327–33
American Thoracic Society. Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. Am Rev Respir Dis 1993; 148: 1418–26
Anderson G, Esmonde TS, Coles S, et al. Acomparative safety and efficacy study of Clarithromycin and erythromycin sterate in community-acquired pneumonia. J Antimicrob Chemother 1991; 27 Suppl. A: 117–24
Chien SM, Pichotta P, Siepman N, et al. Treatment of community-acquired pneumonia. A multicenter, double-blind, randomized study comparing Clarithromycin with erythromycin. Chest 1993; 103: 697–701
Gray J. Treatment of pneumonia in the elderly: pharmacological considerations. Semin Respir Infect 1990; 5: 295–302
Hyslop DL. Efficacy and safety of loracarbef in the treatment of pneumonia. Am J Med 1992; 92: 65S–9S
Wijnands GJ. Diagnosis and interventions in lower respiratory tract infections. Am J Med 1992; 92: 91S–7
Yangco BG, Lowe J, Nolen TM, et al. A multicenter trial comparing the efficacy and safety of cefuroxime axetil and Cefaclor in pneumonia of adults. Clin Ther 1990; 12: 440–6
Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997; 336: 243–50
Stone RA, Obrosky DS, Singer DE, et al. Propensity score adjustment for pretreatment differences between hospitalized and ambulatory patients with community-acquired pneumonia. Med Care 1995; 33: AS56–66
Lave JR, Fine MJ, Sankey SS, et al. Hospitalized pneumonia. Outcomes, treatment patterns, and costs in urban and rural areas. J Gen Intern Med 1996; 11:415–21
Hasley PB, Albaum MN, Li YH, et al. Do pulmonary radiographic findings at presentation predict mortality in patients with community-acquired pneumonia? Arch Intern Med 1996; 156: 2206–12
Bartlett JG, Mundy LM. Community-acquired pneumonia. N Engl Med 1995; 333: 1618–23
Minogue ME, Coley CM, Fine MJ, et al. Patients hospitalized after initial outpatient treatment for community-acquired pneumonia. Ann Emerg Med 1998; 31: 376–80
Metlay JP, Fine MJ, Schulz R, et al. Measuring symptomatic and functional recovery in patients with community-acquired pneumonia. J Gen Intern Med 1997; 12: 423–30
Whittle J, Lin CJ, Lave JR, et al. Relationship of provider characteristics to outcomes, process, and costs of care for community-acquired pneumonia. Med Care 1998; 36: 977–87
Metlay JP, Schulz R, Li YH, et al. Influence of age on symptoms at presentation in patients with community-acquired pneumonia. Arch Intern Med 1997; 157: 1453–9
Halm EA, Fine MJ, Marrie TJ, et al. Time to clinical stability in patients hospitalized with community-acquired pneumonia. Implications for practice guidelines. JAMA 1998; 279: 1452–7
Metlay JP, Kapoor WN, Fine MJ. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA 1997; 278: 1440–5
Meehan TP, Fine MJ, Krumholz HM, et al. Quality of care, process, and outcomes in elderly patients with pneumonia. JAMA 1997; 278: 2080–4
Fine MJ, Hough LJ, Medsger AR, et al. The hospital admission decision for patients with community-acquired pneumonia. Results from the pneumonia patient outcomes research team cohort study. Arch Intern Med 1997; 157: 36–44
Fine MJ, Medsger AR, Stone RA, et al. The hospital discharge decision for patients with community-acquired pneumonia. Arch Intern Med 1997; 157: 47–56
Gleason PP, Kapoor WN, Stone RA, et al. Medical outcomes and antimicrobial costs with the use of the American Thoracic Society Guidelines for outpatients with community-acquired pneumonia. JAMA 1997; 278: 32–9
Bartlett JG, Breiman RF, Mandell LA, et al. Community-acquired pneumonia in adults: guidelines for management. Clin Infect Dis 1998; 26:811–38
Gilbert K, Gleason PP, Singer DE, et al. Variations in antimicrobial use and cost in more than 2,000 patients with community-acquired pneumonia. Am J Med 1998; 104: 17–27
Cunha B. The antibiotic treatment of community-acquired, atypical, and nosocomial pneumonias. Med Clin North Am 1995; 79:581–97
Cunha BA. Community-acquired pneumonia. Cost-effective antimicrobial therapy. Postgrad Med 1996; 99: 109–22
Davey PG. Cost management in community-acquired lower respiratory tract infections. Am J Med 1995; 99 Suppl. 6B: 20S–23S
Armstrong EP, Manuchehri F. Ambulatory care databases for managed care organizations. Am J Health Syst Pharm 1997; 54: 1973–83
Beto JA, Geraci MC, Marshall PA, et al. Pharmacy computer prescription databases: methodologic issues of access and confidentiality. Ann Pharmacother 1992; 26: 686–91
Selby JV. Linking automated databases for research in managed care settings. Ann Intern Med 1997; 127: 719–24
Armstrong EP, Langley PC. The impact of a disease management intervention on the treatment of infectious disease in a managed care organization. Dis Manage. In press
Schulman KA, Yabroff KR, Kong J, et al. A claims data approach to defining an episode of care. Health Serv Res 1999; 34: 603–21
Lewis NJW, Patwell JT, Briesacher BA. The role of insurance claims databases in drug therapy outcomes research. Pharmacoeconomics 1993; 4: 323–30
Lohr KN. Use of insurance claims data in measuring quality of care. Int JTech Assess 1990; 6: 263–71
Kennedy P. A guide to econometrics. 4th ed. Cambridge (MA): The MIT Press, 1998
Langley PC. The technology of metered-dose inhalers and treatment costs in asthma: a retrospective study of breath actuation versus traditional press-and-breathe inhalers. Clin Ther 1999; 21: 236–53
Thomson R, Lavender M, Maadhok R. How to ensure that guidelines are effective. BMJ 1995; 311: 237–4
Guyatt GH, Sackett DL, Sinclair JC, et al. Users’ guide to the medical literature. IX. A method for grading health care recommendations. JAMA 1995; 274: 1800–4
Granata AV, Hillman AL. Competing practice guidelines: using cost-effectiveness analysis to make optimal decisions. Ann Intern Med 1998; 128: 56–63
Wilson MC, Hayward RS, Tunis SR, et al. Users’ guides to the medical literature. VIII. How to use clinical practice guidelines. B. What are the recommendations and will they help you in caring for your patients? JAMA 1995; 274: 1630–2
Worrall G, Chaulk P, Freake D. The effects of clinical practice guidelines on patient outcomes in primary care: a systematic review. Can Med Assoc 1997; 156: 1705–12
Weiner JP, Starfield BH, Steinwachs DM, et al. Development and application of a population-oriented measure of ambulatory care case-mix. Med Care 1991; 29: 452–72
Starfield B, Mumford L. Ambulatory care groups: a categorization of diagnoses for research and management. Health Serv Res 1991; 26:53–74
McNeil BJ, Pedersen SH, Gatsonis C. Current issues in profiling quality of care. Inquiry 1992; 29: 298–307
Motheral BR, Fairman KA. The use of claims databases for outcomes research: rationale, challenges, and strategies. Clin Ther 1997; 19: 346–66
McDonald CJ, Overhage M, Dexter P, et al. A framework for capturing clinical data sets from computerized sources. Ann Intern Med 1997; 127: 675–82
Arnold RG, Kotsanos JG, Motheral B, et al. Panel 3: methodological issues in conducting pharmacoeconomic evaluations — retrospective and claims database studies. Value Health 1999; 2: 82–7
Weiner JP, Parente ST, Garnick DW, et al. Variation in officebased quality. A claims-based profile of care provided to medicare patients with diabetes. JAMA 1995; 273: 1503–8
Iezzoni LI. Assessing quality using administrative data. Ann Intern Med 1997; 127: 666–74
Chrischilles EA. The contribution of epidemiology to pharmacoeconomic research. Drug Inf J 1992; 26: 219–29
Hornberger J, Wrone E. When to base clinical policies on observational versus randomized trial data. Ann Intern Med 1997; 127: 697–703
Glauber HS, Brown JB. Use of health maintenance organization data bases to study pharmacy resource usage in diabetes mellitus. Diabetes Care 1992; 15: 870–6
Else BA, Armstrong EP, Cox ER. Data sources for pharmacoeconomic and health services research. Am J Health Syst Pharm 1997; 54: 2601–8
Ray WA. Policy and program analysis using administrative databases. Ann Intern Med 1997; 127: 712–8
Quam L, Ellis LBM, Venus P, et al. Using claims data for epidemiologic research. The concordance of claims-based criteria with the medical record and patient survey for identifying a hypertensive population. Med Care 1993; 131: 498–507
Palmer RH. Process-based measures of quality: the need for detailed clinical data in large health care databases. Ann Intern Med 1997; 127:733–8
Larson LN, Bjornson DC. Interface between pharmacoepidemiology and pharmacoeconomic s in managed care pharmacy. J Manage Care Pharm 1996; 2: 282–9
Weiner JP, Powe NR, Steinwachs DM, et al. Applying insurance claims data to assess quality of care: a compilation of potential indicators. Qual Rev Bull 1990; 16: 424–38
Piecoro LT, Wang LS, Dixon WS, et al. Creating a computerized database from administrative claims data. Am J Health Syst Pharm 1999; 56: 1326–9
Quenzer RW, Pettit KG, Arnold RJG, et al. Pharmacoeconomic analysis of selected antibiotics in lower respiratory tract infection. Am J Manage Care 1997; 3: 1027–36
Harrison DL, Draugalis JR. Critically evaluating research methods: an introduction. Manage Care Med 1996; 3: 23–7
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Armstrong, E.P., Langley, P.C. Treatment of Pneumonias in a Managed-Care Organisation. Dis-Manage-Health-Outcomes 6, 159–173 (1999). https://doi.org/10.2165/00115677-199906030-00005
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DOI: https://doi.org/10.2165/00115677-199906030-00005