Collaborative Care, Anyone?

What would you think about having someone coordinate medical care for someone with two or more chronic health conditions?  Sounds like duh to me, as I state in this week's podcast, but a study doing just that can be found in this issue of the New England Journal of Medicine.  It merited publication in this most august of journals.  Why?

Turns out that this study implemented some very critical interventions that others have not in attempting to integrate care.  People with so-called 'comorbidities' of diabetes, coronary heart disease or both, along with depression, were cared for in person by a trained, physician-supervised nurse in the patient's primary care setting.

Over 200 patients were ultimately enrolled.  Managing their conditions was intense, with nurses first attending a training course, then designing and implementing a tailored approach to each patient, engaging the patient in the process.  Goals were established with regard to managing depression, blood sugar, blood pressure and lipid control and participants were monitored at visits every two to three weeks. This continued for 12 months.

If patients failed to meet goals nurses employed a number of methods to help them, including motivational coaching.  Once the patient reached targeted goals a maintenance plan was developed collaboratively with the nurse, and included stress reduction, behavioral goals, continued use of medications, and guidance on how to spot potential problems and intervene early.

People who completed the study improved in all outcome measures of disease management, including blood sugar control, high blood pressure, lipid profile and depression score.  Moreover, they were more satisfied with their care and quality of life.  Sounds like a win-win, doesn't it?

Not so fast, Rick points out.  Here's the rub:  who's buying?  Such care, predictably, adds costs to the bottom line of caring for patients, at least in the short term.  Long term outcome measures aren't available and although it stands to reason that collaborative care should reduce the need for very expensive interventions such as coronary artery bypass surgery or kidney transplantation or any of the other consequences of aberrant lipids or uncontrolled high blood pressure, we've certainly seen strategies that would intuitively seem to be effective turn out not to be when subjected to rigorous study.  What to do?

Enter the Affordable Care Act, which mandates development of 'accountable care organizations.'  We discuss these organizations in the podcast as well as does a Perspective in this week's NEJM, but one distinct upside of their existence would be the role collaborative care would no doubt occupy in their structure.  And that would give us real life data on how effective such an approach is in the long haul.

Other topics in this week's podcast include another Perspective in NEJM on sleep deprived surgeons and informed consent, and vitamin D levels in cord blood at birth and respiratory infections in this issue of Pediatrics.  Until next week, y'all live well.

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Jaundalynn September 3, 2011 at 8:31 pm

Gee whiz, and I thoghut this would be hard to find out.


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