de Brantes F, Wickland PS, Williams JP. The value of ambulatory care measures: a review of clinical and financial impact from an employer/payer perspective [Internet]. Am J Manag Care. 2008 Jun ;14(6):360-8.[cited 2008 Oct 1 ]

The subtitle of this article might be, “what performance measures should employers be tracking and paying for in ambulatory care”

The article was passed to me by Sophia Chang, MD, at the California Healthcare Foundation, who has been advising and supporting on our Connectivity for Californians work, and is a nice economic study of 62 performance measures used in specialty recertifcation program and pay-for-performance initiatives.

The measures will look familiar to anyone who works in quality improvement - everything from blood pressure management, to retinal eye screening, all the way through to some measures that have less data associated with them, such as “plan of care for hypertension.” What the authors did was grade the evidence of effectiveness, add cost and benefit data based on meta-analyses and derive a “savings per patient” for each measure.

There are a few critical assumptions made, including full adherence to therapy (they used the term “compliance” which is no longer recommended), and most importantly, no quantification of indirect costs. In other words, this is not a study of presenteeism, only direct medical costs.

What came out near the top of measures with the most impressive savings profile? Hypertension management. Here’s the detailed analysis:

This study has a specific informative value in my mind - which is to encourage employers’ engagement around the performance measures that will likely result in a return on investment for them. This is not a call to action for the health system to reorient its priorities for maintaining community health. I think the idea is that if an employer has an interest in promoting efficient use of the health care dollars they spend on behalf of employees, an analysis like this provides an idea of where to start.

Incidentally, when I did the same analysis using my own literature review, but without the complex analysis employed here, I came to the exact same conclusion around hypertension, which surprised me. I thought I would become an expert in remote monitoring of congestive heart failure or coronary artery disease. The data led me a different way.

See what you think.

Rickerby, J, and J Woodward. “Patients’ experiences and opinions of home blood pressure measurement.” J Hum Hypertens 17, no. 7 (0): 495-503.

Pare, Guy, Mirou Jaana, and Claude Sicotte. “Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base.” J Am Med Inform Assoc 14, no. 3 (May 1, 2007): 269-277

Little, Paul, Jane Barnett, Lucy Barnsley, Jean Marjoram, Alex Fitzgerald-Barron, and David Mant. “Comparison of acceptability of and preferences for different methods of measuring blood pressure in primary care.” BMJ 325, no. 7358 (August 3, 2002): 258-259.

Not pictured: Port, Kristjan, Kairit Palm, and Margus Viigimaa. “Daily usage and efficiency of remote home monitoring in hypertensive patients over a one-year period.” J Telemed Telecare 11, no. suppl_1 (July 1, 2005): 34-36.

There’s a potentially serious gap in the Connectivity for Californians initiative that we are addressing. Here’s a quote that illustrates it:

It is very clear from the interview data that patients have their own ideas, and spend a lot more time thinking about their BP than is apparent in the average 10-min consultation in general practice.

The gap is patient involvement in the design and planning of this initiative, or any healthcare initiative for that matter. Patients have many more ideas about what the problems are to be solved than can be gleaned even from articles like this - the articles simply show that the ideas are out there. Fortunately, we are committing ourselves to have a patient representative involved from the beginning, and that is coming together before any work is started.

The quote above is from the first paper by Rickerby, et. al (click on the images to the right to review any of the papers yourself), which described a qualitative study to look at a small number of patients’ attitudes toward monitoring their own blood pressure, in a practice that routinely recommends this.

The question (#1)

The reason I have reviewed these particular papers is because of the commonly posed question to me over the past several months, in the form of, “Ted, will/are patients really motivated to check their own blood pressure?” with the implication that they are not and they won’t. It’s a fair question that deserves an informed response. Several of the readers on this blog have given me some information from their own lives. These papers add to that knowledge.

The answer (#1)

They are and they will.

The question (#2)

This came up during reading of the papers. Does patient engagement come from having knowledge? Or does knowledge come from being engaged? This came up because patients in the first study who did not have knowledge about why they should monitor their blood pressure or how to do it seemed less engaged.

The answer (#2)

Unclear, with the implication being about whether to work to engage patients with more knowledge or use knowledge as a means test for engagement. I think regardless of the answer, there’s no reason not to provide information to patients. That answer is good enough in this case.

Read on for more conclusions….

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