Feature Articles: Disease ManagementDisease Management or Patient Management?In this issue of Jacksonville Medicine you will be introduced to a variety of approaches to the management of specific diseases. The new vocabulary of disease management and categorization of population, case pathways and process management may tend to confuse you initially but, on review, I believe each of you will be able to understand the concepts behind the words. While you might consider that these disease management approaches offer nothing new to what a physician does in practice, on reflection, the processes described represent a very different way of managing a group of patients with the same or similar diagnosis, yet maintaining the individuality of the patient. Disease Management has evolved as hospitals, group practices, and/or hospital plans have wrestled with our fragmented health care system. It represents the directed efforts of health professionals to coordinate the case of and achieve superior outcomes for patients through a pro-active systematic approach. Dr. George Mayzell treats us to a description of the disease management process and its component parts. He points out the importance of accurate patient identification and stratification as to severity of a particular disease or condition. This allows for targeted and cost effective intervention, in effect, the application of resources when needed the most. He cites results published in refereed journals for the reported success of such programs as asthma, diabetes and smoking cessation. There are four additional articles, each dealing with a specific disease or condition management program. The first by Dr. Mark Broderson at Mayo and St. Luke's Hospital describe the management of Total Joint Arthroplasty. Using an inpatient setting, Mark shares with us the value of a team approach to process improvement around a surgical procedure. By establishing a care pathway for joint arthroplasty the team was able to focus on particular steps in the pathway and streamline the process from a patient's point of view. The Healthy Addition program, presented by Kim Brew, focuses on pregnancy and its risk management. Implemented by Blue Cross Blue Shield of Florida throughout the state, this program spans the entire continuum of the 9-month pregnancy. The emphasis is on early and frequent risk assessment with interventional strategies coordinated by a case manager and the attending obstetrician. The results after 4 years of using this approach have been encouraging. Dr. Chuck Tomlinson describes the Aetna program dealing with low back pain. While all components of a disease management process are evident, the focus is primarily on outpatient practice guidelines (algorithms) and reliable educational materials for the patient with back problems. There are no quantitative results listed but the literature abounds with successful study outcomes using clinical guidelines. The published algorithms should prove useful to practicing physicians. Lastly, a very well studied and detailed program of managing congestive heart failure patients is presented by Russell and Chambers. This pilot program was completed in 1997 and has been subsequently replicated throughout the state of Florida by Blue Cross Blue Shield of Florida. The value of coordinated care by a case manager and compliance to a set of clinical guidelines is demonstrated not only by well documented utilization numbers but also high patient satisfaction and quality of life enhancement compared to a control group. Each article and this entire journal are intended to highlight a significant trend in the future case management of patients. We will see more of the early identification and stratification of patients for targeted management, a greater emphasis on proactive care coordination, and the use of clinical pathways/guidelines. Through evidence based medicine our clinical practice will become more standardized in terms of the scientific approach to disease and condition management. The public will expect us to follow clinically validated guidelines. Hopefully, these articles demonstrate the economics and improved health outcomes resulting from these efforts. Larry Tremonti, M.D. September, 1999/ Jacksonville MedicineWhat's New
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