Running head: JOURNAL REVIEW: EFFECTS OF CARE MGMT & TELEHEALTH 1

Journal Review of the Effects of Care Management and Telehealth

Crystal Liang

University of San Diego

MSNC 507 Statistics

Dr. Thidarat Tinnakornsrisuphap

July 8, 2019
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Effects of Care Management and Telehealth: A Longitudinal Analysis Using Medicare Data

Telehealth is an innovative method of health care delivery that was developed through

the means of health information technologies and telecommunications technologies. It was with

intent that I selected a study that analyzed and reflected the effectiveness of health-care

technology adoption in health care management. This study specifically evaluates the mortality

and healthcare utilization effects of an intervention that combines care management and

telehealth, targeting individuals with congestive heart failure, chronic obstructive pulmonary

disease, or diabetes. The importance of this study is that it can demonstrate whether this type of

health care management technology can actually improve the quality and safety of patient care.

This type of study can be used to support and evaluate the effects of information technology in

healthcare, and determine if patient care services can be improved through the advancements and

adoption of new technology.

The primary author, Laurence C. Baker, is Professor of Health Research and Policy,

Chair of the Department of Health Research and Policy, and a CHP/PCOR fellow at Stanford

University. He is an economist interested in the organization and economic performance of the

U.S. health-care system, and his research has investigated a range of topics including financial

incentives in health care, competition in health-care markets, health insurance and managed care,

and health-care technology adoption (Stanford Health Policy).

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How the research was conducted

The research was conducted by implementing the intervention—the Health Buddy

Program (HBP), which integrated a content-driven telehealth system with care management at

two multispecialty clinics located in Bend, Oregon, and Wenatchee, Washington. The study

targeted patients with congestive heart failure (CHF), chronic obstructive pulmonary disease

(COPD), or diabetes mellitus (DM), in which participants were selected and identified by

beneficiaries of the two clinics through Medicare records. An algorithm was developed to

identify participants who were loyal to a study clinic, more specifically, if they had 2 or more

visits at the clinic, or received more care from the clinic than any other, and did not have

conditions that would limit their interaction with HBP (e.g. dementia, blindness). Participants

were finally selected at two time points, into two cohorts. The first cohort comprised 763

beneficiaries in early 2006, while the second cohort consisted of 1,056 beneficiaries in early

2007 to expand the study (Baker et al, 2013).

The main measurement of the study was to examine the relationships between the HBP

and mortality and healthcare utilization, which included analyzing inpatient admissions, length

of stay, ED visits, and by comparing the selected intervention group with a propensity-matched

control group. The data of the intervention group came from finalized Medicare claims provided

by CMS, while the data of the control group came from Medicare claims from a 5% random

sample of all beneficiaries. To construct the propensity-matched control group, counties within

the Pacific Northwest similar to that of the two counties of the selected intervention clinics in

Bend, Oregon and Wenatchee, Washington were identified, and Medicare beneficiaries in the

CMS 5% sample residing in those areas were selected. Propensity-score matching was then

utilized to further select beneficiaries that most reflected the intervention participants using
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probit regression models for the respective cohorts. However, of the process of the data

collection, there were several problems that arose. It was discovered that 5% Medicare data

identifies dates of services at the quarter level, making analysis of readmissions impossible. In

addition, the data did not contain clinical or sociodemographic information (income, education,

etc.) because claims collected for administrative purposes were used (Baker et al, 2013).

Nevertheless, the measurement of mortality was observed from validated Social Security

Administration death records. Healthcare utilization was measured through inpatient admissions,

the length of stay, and ED visits, which were examined quarterly for each beneficiary and

aligned to match the start date of the intervention. Disease conditions were identified based on

diagnosis codes of the Medicare claims, and cox-proportional hazard models and negative

binomial regression models were used, controlling for demographic and health characteristics

that were statistically different between groups after matching (Baker et al, 2013).

Collected Data, Analysis, and Results

The demographics and clinical characteristics between the intervention group and

matched control group were similar, as shown on Table 1. The results in mortality rates of the

participants of the Health Buddy Program showed a lower risk in unadjusted survival analysis

(P= 0.01), as shown in Figure 1.

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HBP participants were associated with a 15% lower risk-adjusted probability of death

(Hazard ratio (HR) = 0.85, CI = 0.74—0.98, P = 0.03), and the overall lower probability of death
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was largest among the individuals with congestive heart failure (HR = 0.70, CI = 0.57—0.87, P <

0.001) (Baker et al, 2013). The results in healthcare utilization had shown an average of 0.179

admissions per quarter, and a total reduction of 0.035 per member per quarter as seen on Table 2.

A net decline of 0.032 (18%) average quarterly hospitalizations were shown for HBP

participants, compared to that of the control group, which was a decrease of 0.002 visits per

member per quarter (CI = -0.054 to -0.010, P = 0.005). Finally, there was no significant

relationship to be found in measuring the number of hospital days conditional on hospitalization

for ED visits. Among the disease conditions that were examined, the differences in reductions

between inpatient admissions of participants with chronic obstructive pulmonary disease were

larger than the difference in reductions between the overall intervention group and their matched

controls (P = .03) (Baker et al, 2013).

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Conclusions

Because of the growing prevalence of chronic conditions, more challenges have arisen

with the association with considerable morbidity, mortality, and increased costs. This study

investigated the effects of better disease management, and whether it can yield better health

outcomes. More specifically, the mortality and healthcare utilization effects of an intervention,

the Health Buddy Program, were closely examined among selected participants. The Health

Buddy Program (HBP) consists of a Health Buddy device—a telehealth device located in a

patient’s home and linked over the telephone to care managers to facilitate the information

exchange. It integrates a content-driven telehealth system with care management and allows the

patient to collect and report information regarding their symptoms, vital signs, mental health,

knowledge, and health behaviors. The system then identifies the need for intervention based on

the clinical signs, lack of response, or gaps in the patient’s behavior, and provides appropriate

feedback information about their health condition (Baker et al 2013).

To examine the effectiveness of this intervention, the following parameters of interest

were measured and analyzed within a two-year study period: mortality, inpatient admissions,

hospital days, and emergency department visits. Along with these parameters, specific

individuals with chronic conditions such as congestive heart failure, chronic obstructive

pulmonary disease, and diabetes mellitus were targeted to ultimately understand the effects that

telehealth technology may have on patient health outcomes.

The procedures to conduct this study involved a retrospective matched cohort study,

which consisted of the intervention participants, and the random selection of a control group,

both from the Pacific Northwest region of the United States. The control group was constructed

by participants within the Pacific Northwest counties, similar to the participants of the
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intervention group by matching propensity-score. The intervention and control participants were

then matched 1:1 based on closest propensity scores, and measured on mortality based on

validated date of death, quarterly measure of the number of inpatient admissions, hospital days

for those admitted, and emergency department visits.

The results concluded that after two years of collected data, the intervention group

utilizing the Health Buddy Program had 15% lower risk-adjusted all-cause mortality and a total

reduction in the number of quarterly inpatient admissions. Although there was no relationship

found between patients using HBP and the number of ED visits, results have also shown a strong

association with decreased admissions for patients with chronic obstructive pulmonary disease

and a decline in mortality for patients with congestive heart failure. Although these findings

suggest that effects of HBP differ according to disease subgroups, these statistical results has

lead the study to conclude that care management coupled with content-driven telehealth

technology has the potential to improve health outcomes in high-cost Medicare beneficiaries. By

integrating telehealth with care management, the HBP approach allows patients to understand

their medical conditions and consciously choose to improve their health behaviors. The HBP is

comparably beneficial for health care providers as well, as they are given better patient data in

which can allow them to provide better care and attention to the patient’s conditions (Baker et al

2013).

Strengths and Weaknesses of the Selected Statistical Methods

This study lacked a randomized control trial design, however, its strength is utilizing

statistical methods to compensate. It has yielded successful results in illustrating the overall

relationships between HBP, utilization, and mortality. However, there was insufficient data to

identify the underlying mechanisms for the observed effect.

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In addition, the study contained some limitations. Because claims collected for

administrative purposes were used, certain clinical and sociodemographic patient information

were not taken into consideration, such as the patient’s income or educational attainment.

Therefore any differences in these characteristics could not have been accounted for but could

have very much likely affected the outcome of the study. Furthermore, it should also be noted

that the 5% Medicare data only identifies dates of services at the quarter level, therefore it is

impossible to identify readmissions, which too, could have altered the results. Because this study

was designed to only compare an intervention that involved both telehealth and care

management to normal, traditional care, different patterns and usage of the HBP were not

investigated, which could have played a factor into affecting outcomes.

Ultimately, these findings were supported by valid statistical data and analysis. However,

similar to all studies that are developed on retrospective analysis of nonrandomized settings, the

study cannot prove causality with certainty. There is credible information to conclude that the

Health Buddy Program is strongly associated with a decrease in hospitalizations and longer

survival rates, within a group of Medicare beneficiaries diagnosed with complex chronic

conditions, in the Pacific Northwest Region of the United States.

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References

Baker LC, MacAulay DS, Sorg RA, Diener MD, Johnson SJ, Birnbaum HG. Effects of care

management and telehealth: A longitudinal analysis using medicare data. J. Am. Geriatr.

Soc. 2012;61(9):1560–1567. doi: 10.1111/jgs.12407.

Stanford Health Policy (2019). Laurence C. Baker, PhD. Retrieved from

https://healthpolicy.fsi.stanford.edu/people/laurence_c_baker