Facbook has trickled down into the diseases management space for diabetics, while a study examining a chronic care program for heart disease shows that a sophisticated approach to harmonizing care can reduce health costs.

To some, both endeavors marked a new shift in how patients understand and manage certain chronic conditions.

Three years ago, CVS Caremark teamed up with Brigham and Women's Hospital in Boston and Harvard to better understand patient behavior, with a focus on issues around adherence.

Part of the initiative involved looking "into the growing area of social media and how it is being used in the health care arena," explains Dr. Troyen A. Brennan, executive vice president and chief medical officer at CVS Caremark.

In analyzing 15 diabetes-related Facebook sites with an average of 9,289 participants and 690 individual wall posts written by 480 users, researchers found one in four comments on the sites "were promotional in nature and generally for non-FDA approved products."

"To the best of our knowledge, this is the first study to analyze in detail the quality of the information that people with diabetes are sharing with each other through Facebook," says Dr. William H. Shrank, senior author of the study.

"There are certainly public health benefits that can be garnered from these sites - but patients and doctors need to know it is really the Wild West out there," he adds.

While its tempting to fight diabetes by any means necessary - diabetics on average have medical expenses that are approximately 2.3 times higher than those without diabetes, and the disease accounts for hundreds of millions of lost or reduced productivity days each year, the American Diabetes Association reports - researchers urge physicians and patients to be more aware of how social media is being used by patients and others.

The study recommends that patients pay attention to the sources of information on social media sites and suggests that they rely on sites sponsored by legitimate and recognized organizations.

"The study does not recommend action by employers, because they were not a focus of the research, but the conclusion that people should be aware of how Facebook is being used in both positive, such as education and support, and not-so-positive - undisclosed marketing or clinical recruitment - ways is a universal lesson," explains Brennan.

Even without wading through the pages of information available through social media platforms, it can be pretty confusing being a patient with a chronic condition who is looking for information, so searching for a trusted source for information is going to be critical.

"This is where employers can help, given that employers are always communicating information to workers. Employers are a trusted channel and source, and their ability to recommend and reinforce is key," says Dr. Paul Wallace, medical director for health and productivity management programs for The Permanente Federation.

Wallace leads Kaiser Permanente's effort to further develop and integrate wellness, health maintenance and productivity enhancement interventions with population-based care. Neither he nor his organization is connected with the study.

Although employers shouldn't get overly involved in how their workers spend their personal time on social media sites, companies should try to leverage that trust employees have with them as a way to help validate the different paths as they go forward, Wallace notes.

"We are going to learn a lot in the next two to three years about which social media platforms create the most value in terms of patients sticking with their regiments, understanding their disease and making the right choices," Wallace predicts. "For employers, it's going to be about listening to employees in terms of where they are finding information to help them manage their chronic condition."

Although patients with diabetes shared valuable insights into their conditions on the sites that normally bypass traditional medical channels, researchers found "tentative support for the health benefits of social media in the management of chronic disease."

And while Facebook sites dedicated to diabetes can offer users a venue for self-education, information sharing and community support, "we also saw little quality control around promotional and data-gathering activities, and patients and policymakers should take note of that," says Shrank.

He did add, though, that the research discovered little evidence of misleading or medically dangerous information on the sites.

"Social media is an evolving forum that clearly is attractive to people looking to share information and to find support and strategies for living with chronic disease," says Brennan. "This study shows the many ways that patients are benefiting from social networks, but it is critically important for patients to understand the need for fact checking."

The study, financed by CVS Caremark, is published online in The Journal of General Internal Medicine. Other key findings include:

* A majority of Facebook posts (66%) are by individuals describing their personal experiences with managing diabetes.

* Nearly one-quarter of posts (24%) represent sharing of personal information that is unlikely to be shared between patient and doctors, such as individuals discussing alcohol consumption.

* 29% of posts are by diabetic patients providing emotional support to others grappling with the disease.

* About 13% of posts provide specific feedback to information requests by others in the diabetic community.

* Nearly 27% of posts feature promotional activity and first person testimonials around non-FDA approved products and services.

No one-trick pony

Meanwhile, new research on disease management services deflates the argument that a comprehensive program might increase health care costs because of the increased services.

Researchers at Kaiser Permanente Colorado report that health care costs for patients enrolled in a comprehensive cardiac disease management program were, on average, $60 less each day, for an annual average of $21,900 per patient, per year, compared to those receiving standard care.

The study compared the health care expenditures associated with a group of 628 individuals enrolled in the Kaiser Permanente Collaborative Cardiac Care Service with 628 patients receiving standard care.

Researchers sought to determine if CCCS, an intensive disease management program, could yield more value than usual care in terms of health outcomes and costs.

In the study, discharged patients with a heart disease enrolled in the program for three to six months. The program adopts evidence-based services and is built around telephone health coaching that uses nurses and clinical pharmacy specialists who work under the direction of a physician.

After analyzing the data on utilization claims and electronic health records, the Kaiser team found that members participating in the disease management program had better cholesterol control, were more likely to be screened and adhere to important medications, and had far fewer hospitalizations, compared to patients in the other group.

According to the Kaiser Permanente team, patients in the program had an 89% reduction in overall mortality and an 88% reduction in cardiac mortality, compared with patients receiving standard care. Other comparative data on health costs between the two groups addressed:

* Medications, $4 per day, compared to $5 per day.

* Doctor's office visits, $7 per day, compared to $8 per day.

* Hospitalizations, $19 per day, compared to $69 per day.

"The goal of the [disease management program] is to get patients with heart disease on the right medications and deliver needed screenings and care, so one might expect to see health care costs go up with the increased service," says Dr. Tom Delate of Kaiser Permanente Colorado, who is the study's lead author.

"However, we found the opposite effect: the CCCS was able to keep patients so healthy that they were more likely to stay out of the hospital. At the end of the day, expenditures from this major cost-driver were reduced," Delate adds.

In addition, the aim of a disease management program, in part, is to recognize where there are gaps and unmet needs in care, so when employers find an unmet need or gap it's going to involve some activity to address those issues, explains Wallace.

"The balance points come in determining whether the gaps or unmet needs will lead to bigger expenses downstream or in the relatively near future. The whole rationale behind preventive and chronic care is finding the things that can be done upstream that are good investments, relative to the downstream risk," Wallace says.

The risk that can come with a disease management program is that it depends on a single type of intervention. The highest likelihood of success comes from "when you can have everyone singing the same tune, so that the prescription from the physicians is reinforced by the information the patient gets at the pharmacy," Wallace explains. "Also, you want to have the ability to contact the patient when he or she is at home to reinforce the value of that prescription."

"You increase the chances of a successful disease management program when the message that is coming to the patient, who is the place of control, is consistent and clear," he continues. It's important to use a team-based approach, with different members of the health care team reinforcing the same message.

The study findings are published in the November 2010 issue of the journal Pharmacotherapy.

Evaluating programs

To help employers understand how chronic care programs are evaluated among industry experts, the Care Continuum Alliance, which represents the wellness and health promotion industry, released the fifth volume of its "Outcomes Guidelines Report."

The report includes several new recommendations for the evaluation of chronic care and population health management programs. It also outlines considerations for evaluating medication adherence, overall program evaluation approaches and criteria for selecting disease-specific populations for evaluation.

"Employers recognize that chronic care and population health management programs have the capability to maintain and improve the health of the workforce and reduce medical cost trend. But, historically, they've perceived program evaluations as a 'black box' that can vary considerably from program provider to program provider," says Jason G. Cooper, co-chair of the Care Continuum Alliance outcomes steering committee.

"By offering employers a comprehensive guide to program evaluation, the hope is they will become more involved in the evaluation process and better understand all aspects of the program provider's evaluation," Cooper explains, who is also vice president of clinical analytics at CIGNA HealthCare and CareAllies.

"Overall, the section on evaluating chronic care management programs should help employers understand the intricacies of program evaluation and the multitude of considerations that must go into choosing the most appropriate evaluation approach for routine reporting," says David Veroff, co-chair of the Care Continuum Alliance's outcomes steering committee.

"In addition, employers should walk away with enough evaluation-approach knowledge to have an open and detailed discussion with their program provider on program outcome expectations," adds Veroff, who is also senior vice president of research and insights at Health Dialog.

The report is available for free on CCA's Web site, carecontinuum.org.

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