Contemporary Disease Management in Quebec

Amédé Gogovor, Michelle Savoie, Yola Moride, Marilyn Krelenbaum and Terrence Montague

Healthcare Quarterly, 11(1) 2008: 30-37

Health or disease management (DM) has emerged as a promising solution to improve the quality of healthcare and patient outcomes in a cost-efficient way. This solution is particularly relevant in the care of our increasing, and aging, patient populations with multiple chronic diseases. This article reviews the recent history and current status of DM in the province of Quebec and summarizes its evolving perspectives and future prospects. Most DM projects in Quebec have developed from a public-private partnership, and they have addressed several disease states. The results of completed programs confirmed the presence of care gaps - the differences between best and usual care in several disease states. They also identified process changes leading to improved practices and enhanced professional satisfaction among stakeholders. Priorities identified for further research include increased knowledge of the underlying causes of care gaps and greater concentration on the measurement of clinical, humanistic and fiscal outcomes and their causal links to DM structures and processes. Although still embryonic in Quebec and Canada, the available evidence suggests that DM partnerships are practical and functional vehicles to expedite knowledge creation and transfer in the care of whole populations of patients. Future projects offer the promise of updated knowledge and continuously improved care and outcomes.

The companion challenges of ever-increasing costs and sub-optimal quality in modern health systems, particularly for the expanding patient populations with chronic diseases, have driven the growth of disease management (DM) programs. These programs are seen as one solution for improving the quality of patient care and outcomes in a cost-efficient way. Despite the absence of unequivocal evidence regarding cost savings, or positive return on investment (ROI), DM has essentially become an industry in the United States (Bodenheimer 2000; Norris et al. 2003) and is steadily increasing its presence in Canada (Montague 2004).

The Disease Management Association of America (DMAA) working definition of DM is increasingly considered the reference bracketing statement (DMAA 2005). Briefly, it characterizes DM as a system of coordinated interventions and communications for populations in which self-care and empowerment are prominent and where evidence-based practices, as well as economic and humanistic outcomes, are fostered, measured and fed back to participating partners. As defined by the DMAA, a DM organization is one that provides full health service components, while a service provider offers only some components of care (DMAA 2004a).

At least three organizations in the United States have defined standards for DM programs and are providing accreditation to DM providers. DM programs are initiated and implemented mainly by healthcare organizations and health plans but also by pharmaceutical companies and academic medical centres. According to a recent survey of commercial health plan members in the United States, the majority of responders expressed differential satisfaction with regard to DM outcomes: satisfaction was highest for clinical outcomes and less for improved resource utilization and cost reduction (Fitzner et al. 2005).

In Canada, there are no commercial DM organizations. However, many DM partnerships and projects have been initiated over the past decade, primarily supported by the pharmaceutical industry in conjunction with academic, government and/or community partners. A Canadian Council for Research in DM has also recently been created by a group of Canada's research-based pharmaceutical companies. Government-funded DM programs at the provincial level are beginning in some provinces, as are programs at the regional and clinic levels.

In Quebec, the importance of integrated health services and DM was outlined by the Commission of Study for Health and Social Services in 2000. The Commission recommended an increase in public/private partnerships in order to position Quebec as a leader in the field of DM, particularly in exploring the optimal use of medicines (Commission of Study for Health and Social Services 2000). In the province's updated drug policy released in early 2007, the Ministry of Health and Social Services of Quebec reiterated the importance of DM programs, as well as the necessity to develop a framework for future projects (Ministry of Health and Social Services 2007). The University of Montreal has also launched a DM research group (Groupe de recherche en gestion thérapeutique, or GRGT), which has, as part of its mission, the goal of fostering the advance of community-based and patient-centred DM programs in Quebec and elsewhere (Montague et al. 2007).

The purpose of this article is to review and summarize the recent past history and current status of DM partnerships and projects in the province of Quebec, to serve as a practical benchmark comparator for future DM projects in Quebec and Canada.

Methods
Various sources were used to collect data about DM programs in Quebec. They included repeated knowledge exchange sessions of GRGT members, literature and database searches (MEDLINE, PubMed, CINAHL, WebSPIRS, ABI/INFORM [ProQuest], ISI Web of Science) and phone and e-mail contacts with DM program investigators and coordinators.

Results
Seven Quebec-based DM projects were identified. They are outlined below in detail, and an overview summary is presented in Table 1.


[Table 1]


CURATA
CURATA (Concertation pour une Utilisation Raisonnée des Anti-inflammatoires dans le Traitement de l'Arthrose [An Integrated Approach to Improving the Appropriate Utilization of Anti-inflammatory/Analgesic Medications in the Treatment of Osteoarthritis in Quebec]) was developed in 2000 by the Association of Rheumatologists, in partnership with Merck Frosst Canada (Beaulieu et al. 2004). The aim was to improve primary care physicians' ability to identify patients with osteoarthritis (OA) and to choose appropriate pharmacological and non-pharmacological therapies using an evidence-based decision support algorithm.

The program had several interventions: assessment of the state of care of OA patients by physicians; development of the evidence-based treatment algorithm, as well as other educational tools for pharmacists and patients; small group training workshops for physicians; and outcomes evaluation tools. The governance involved professional associations of specialist and generalist physicians, pharmacists, physiotherapists and occupational therapists, as well as patient advocacy groups, the Health and Social Services Ministry of Quebec, Merck Frosst Canada and the University of Montreal.

Based on a pre-post design, evaluation revealed a significant improvement of physicians' level of knowledge and on prescription-on-evidence patterns (Beaulieu et al. 2004; Rahme et al. 2002). This was achieved via measurement and feedback of actual practice patterns - which revealed gaps between best care and usual care - supported by the education/training workshops that were centred on the optimal treatment algorithm.

LOYAL
Lowering blood pressure by improving compliance with hypertension therapy through the assistance of technology-enhanced tools (LOYAL) was conceived in 2002 by the Research Centre of the University of Montreal Hospitals (CHUM) with funding support from Pfizer Canada. The objective was to improve the health and well-being of hypertensive individuals and reduce therapeutic non-compliance among patients at risk for cardiovascular disease.

The LOYAL patients are randomly assigned to interventional or usual care groups. In the interventional group, patients are provided with blood pressure monitors, access to an integrated telephone support system for automated reminder and feedback and education material on hypertension and its complications. The system keeps the involved physicians and pharmacists abreast of their patients' progress in controlling their hypertension, and provides patients a direct link to their physician or pharmacist.

The governance structure is composed of CHUM clinician investigators and provider partners and collaborators from Tagge Medical Solutions, Laval's Cité de la Santé and the Centre hospitalier ambulatoire de la région de Laval, with additional partners from the Fonds de la recherche en santé du Québec, the Heart and Stroke Foundation of Quebec, the Quebec Diabetes Association, the Canadian Hypertension Society, the Laval Regional Health Board, Pfizer Canada and the Faculties of Pharmacy and Nursing of the Université de Montréal.

LOYAL was launched in 2004, and patient recruitment is ongoing. At the end of study, the clinical and economic outcomes of the two groups will be compared regarding patient, provider and system impacts (Pfizer Canada 2002).

MOXXI
Medical Office of the Twenty-First Century (MOXXI) is an interactive system of electronic prescribing and integrated drug and disease management. Its objective is to reduce the risk of drug-related illness and to improve the management of chronic diseases that depend heavily on regular and appropriate medication use. The project has had sequential steps, MOXXI I, MOXXI II and MOXXI III, financed by Canadian Health Infostructure Partnership Program (CHIPP). MOXXI is heavily focused on the application of information technology to drug and care management and consists of many components: electronic prescribing, improvement of medication compliance due to feedback and patient self-management and reminders for physicians, as well as an advanced decision-support system utilizing evidence-based asthma and diabetes guidelines.

This project was initiated and implemented by McGill University researchers, along with many partners and collaborators in the academic, public and private sectors (University of Montreal; CHIPP; Collège des Médecins du Québec; Ordre des pharmaciens du Québec; Association des Bannières et Chaînes de Pharmacie du Québec; Association Québécoise des Pharmaciens Propriétaires; Société Informatique des Pharmaciens Inc.; Informatique Demers, Lambert, et Desrochers Inc.; Bell Mobility; Hewlett Packard; Pharmaprix; Jean Coutu Group; TAGGE Medical Solutions; Syscor; and Astra-Zeneca).

Many evaluations have been done, including evaluations of education workshops for physicians and pharmacists. The majority of physicians reported a high satisfaction with the quality of care provided to patients (87%), their interaction with patients (73%) and their relationship with pharmacists (75%), despite low actual use of computers in their clinical practice (Health Canada, Health and the Information Highway Division 2004). To test MOXXI interventions for enhancement of medication compliance, patients have been randomly assigned to receive automated telephone support for refills and reminders of the need to take their medications. A cost-effectiveness analysis of the improvement in medication compliance vis-à-vis emergency room visits and hospitalizations will also be done. It is predicted by the investigators that the decrease in medication mistakes using electronic prescribing, as well as the anticipated improvements in prescription adherence, will likely produce cost-benefit system results (Health Canada, Health and the Information Highway Division 2004). There is also an anticipation that the impacts may be expandable to chronic diseases other than the initial disease targets, asthma and diabetes.

PRIISME
PRIISME (Programmes régionaux intégrés d'information, de suivi médical et d'enseignement) was launched in 1999, with a non-restricted research grant from GlaxoSmithKline (GlaxoSmithKline 2003). The program was intended to improve the management of certain chronic diseases - namely asthma, chronic obstructive pulmonary disease (COPD) and diabetes - including patients' perceptions of quality of life; to reduce the utilization of healthcare services associated with chronic diseases; and to ensure the optimal use of medication through the dissemination of clinical practice guidelines.

The different components of the PRIISME program include initial information sessions for all stakeholders of chronic DM, continuing education for all health professionals, initial personalized DM education for patients and their families and follow-up sessions. Governance is by a steering committee of regional health authority representatives, health institutions, community groups, private medical clinics and individual providers and GlaxoSmithKline.

Pre- and post-evaluations of the asthma component of the program have shown an increase in the quality of life for patients, an improved knowledge of asthma and its treatment among physicians and other health professionals and a decrease of >30% in emergency room visits and hospitalizations for asthma-related illnesses (Cimon 2003).

ROCQ
Started in 2003, the objective of Recognizing Osteoporosis and its Consequences in Quebec (ROCQ) is to improve the diagnosis and treatment of osteoporosis in women aged 50 years and older with fragility fractures and a high risk of further osteoporosis-based complications. The ongoing program has several phases: identification of patients with bone fragility; assessment of the gap between current usual care and evidence-based optimal care, followed by elaboration of individual educational material and intervention evaluation; global program evaluation based on diagnosis and treatment rates; and readjustment of intervention methods. The project partners included academic and community physicians across the province, osteoporosis associations and an alliance of industry partners (Merck Frosst Canada, Sanofi-Aventis Group, Procter and Gamble Pharmaceuticals, Eli Lilly Canada and Novartis Pharma Canada).

The first phase of ROCQ, with baseline recruitment of patients and analyses of the population rates and characteristics of fractures, is ongoing. At the end of enrolment, the patients will be randomized into either the educational interventional or control group. It is anticipated that the program will improve the knowledge and care of high-risk patients with osteoporosis in Quebec (Brown et al. 2003, 2005; Montague 2004).

SIPA
SIPA (System of Integrated Services for the Frail Elderly) is a model of integrated care for the frail elderly developed by the McGill University-Université de Montréal Research Group on Integrated Services for Older Persons. The demonstration project ran from 1999 to 2001 on the Island of Montreal. Its aims included responding appropriately to the needs of older persons with disabilities; optimizing their use of community, hospital and institutional resources; and evaluating organization and costs of the services and quality of care for the intervention and control groups.

The project was based on multidisciplinary care provider teams in the Centre local de services communautaires (CLSC) setting where case managers played a pivotal role in the coordination and follow-up of interdisciplinary protocol interventions, including hospital discharge planning, ongoing evaluation of patient needs and updating of the program information system. Active participation of the patients' family physicians, with financial incentives via capitation, was also part of the interventions. The coordinators and partners of the project came from McGill University, the University of Montreal, the Montreal Geriatric Institute and the Health and Social Services Board.

The results demonstrated a decrease in the hospital wait times for nursing home placement and significantly improved home health and home social care access for the interventional group compared with the control group, with no increase in global costs, as well as a better integration and continuity of care (Béland et al. 2006a, 2006b, 2006c).

TEAM (VESPA)
The TEAM (Toward Excellence in Asthma Management) program, called VESPA (Vers l'Excellence dans les Soins aux Personnes Asthmatiques) in French, was primarily a joint venture among the Quebec Asthma and COPD Network (Réseau québécois de l'Asthme et de la MPOC [RQAM]), Merck Frosst Canada and Astra-Zeneca. The objectives of the TEAM program were to optimize asthma care, improve the quality of life of asthmatic patients and alleviate the socio-economic burden associated with the disease.

The program consisted of several phases, over several years: Phase I produced the cartography of the disease and its determinants in the province, including measures of regional variations of emergency visits for asthma care. Phase II highlighted the gap between current and evidence-based practice and its determinants in high-morbidity versus low-morbidity areas, as well as determinants of therapeutic adherence and levels of patient-physician relationships. Phases III and IV consisted of interventions, including continuing education for providers, patients and families of patients; therapeutic adherence improvement and patient environment management; emergency care; referral to asthma education centres; the use of spirometry in primary care on asthma centre attendance; and their evaluation. In addition to the providers, investigators and patients, many other partners were involved in the program, including regional health authorities, patient advocacy associations and the provincial asthma education network.

The results of the different phases have brought important contributions to the knowledge and care of the disease in Quebec. The impacts of the interventions on the rates of emergency room visits, hospital admissions and the general socio-economic burden of the disease are becoming clearer with each analysis and their publication and propagation of results. TEAM/VESPA experiences will be extended to current practice, through RQAM, the university-based networks of continuing education and the integrated clinical group practices (Boulet 2006; Boulet et al. 2002; Montague 2004).

It is worth noting that other DM projects and partnerships continued to be developed and launched as we conducted this review. For example, PERSISTANCE, a trial of patient-centred education to enhance persistence with prescribed therapy in the management of depression, and JOCOEUR, a worksite project of management of cardiovascular diseases, are both in an early stage. So, the evolution continues.

Discussion
Concisely defined, DM is a partnership-driven, intervention-focused and measurement-accounted integrated application of health resources to improve the care and outcomes of whole populations of patients. Overall, in Quebec, the contemporary experiences with the partnership and measurement paradigm of DM appear to be positive.

Recent and current projects have been public-private partnerships, developed and co-funded by the pharmaceutical industry in conjunction with public and academic healthcare institutions. All the projects were designed to integrate with, and practically extrapolate results to, existing healthcare infrastructures and processes. The programs reviewed used a number of study designs, including randomized controlled trials and pre-post outcomes comparisons of interventions. Most of the methodological considerations in DM project designs appear to revolve around balancing the primacy of need for high causal attribution for project interventions versus the primacy of attaining improved outcomes with lesser need for causal attribution (DMAA 2004b; Montague 2004).

In general, interventions and outcomes measurements in DM studies have tended to be clinically focused. This was certainly true for the programs assessed in this review. Except for SIPA, which targeted frailty and its many associated health and disease conditions, these DM projects targeted one or two specific chronic diseases. Although largely funded by the pharmaceutical industry, they were based on a diversified and equitable partnership arrangement, and academic leadership was provided by well-known academic researchers. Patients and their interests, and the objective of making things better for patients in terms of care and outcomes, appeared to be the common and dominant goals of all the partnerships and projects.

None of the reviewed projects evaluated global economic impact, including consideration of opportunity costs and net ROI for project expenditures in their various communities of practice. This is however an increasing area of interest for payers in the health system. For example, in the United States, the Medicare health plan is conducting such programs to demonstrate, or not, the economic benefits of DM programs (Centers of Medicare and Medicaid Services 2006). Similarly, in the United Kingdom, where commercial DM is developing, Greenhalgh and colleagues have drafted quality standards and recommendations for use by public sector organizations when considering packages for DM from companies with a commercial interest (Greenhalgh et al. 2000). Recently, the economic impact of the Improving Cardiovascular Outcomes in Nova Scotia DM project was assessed, and the results demonstrated a significant multiplier effect of the initial investment (Crémieux et al. 2007).

Where Does DM Need to Go?
Thus far, DM projects and research studies have tended to focus on measures of process and efficiency, with less attention to structure or measurement of interrelationships of structure, process and outcomes (Steuten et al. 2006). Although some causal links between the partnership structure, its knowledge translation processes and improved clinical, fiscal and humanistic outcomes have been suggested, much remains in the realm of hypothesis and requires further investigation (Montague 2004, 2006; Steuten et al. 2006). Even very basic structural concepts, such as the idea that networks, or provider teams, are more valuable than individuals in improving care, are more premise than evidence-based fact (Montague 2006).

In DM projects that have focused on measuring and improving patient outcomes, the contributory, or root, causes of traditional gaps in prescription, adherence, access and diagnosis have often been ignored and, thus, remain largely speculative. The underlying causes of the age-based differences in care remain a particularly counter-evidence conundrum, despite their wide prevalence and increasingly greater relevance for our aging population with chronic disease (McAlister et al. 1999; Montague 2004).

Thus, we need to reduce the knowledge deficits around root causes of care gaps, including the age gap, and determine the best interventions to cure them. We also need to determine the most efficacious processes for cross-disciplinary team building and functioning in DM. And, we need to determine how structure, process and outcomes are linked.

Ideally, we need to do these things to find solutions for multi-disease management. Because, if DM is to become more relevant for our changing demography, its programs must be able to deal successfully with an aging population with multiple, coexisting chronic diseases for whom knowledge-driven, patient-centred outcomes like improved quality of life and decreased need for re-hospitalization are seen as very valuable end points (Montague 2006).

There is also a need to promote the value of DM to all stakeholders in the chronic care model of DM. Patient safety initiatives come to mind as a particular field of opportunity. The strategic goals of patient safety are the reduction and mitigation of unsafe acts and the optimal use of best practices leading to optimal patient outcomes. The dominant culture that has evolved, however, is nearly exclusively focused on reducing sentinel adverse events. In other words, the contemporary patient safety culture is narrower than its strategy. The unintended, but adverse, outcome of this situation is that optimizing care and closing care gaps, the larger world of optimizing DM, are being largely ignored.

As we move beyond the acute care and individually centred models of health management to embrace the management of chronic care in whole population segments, there is a practical opportunity to combine research and community health goals (Montague et al. 2007). Succeeding in improving health and quality of life by providing patients with integrated care - without submitting them to multiple and competing programs - and simultaneously constraining or decreasing costs are definite challenges. It remains an open question as to whether the evolution of DM will contribute to the attainment of these goals in Quebec and in Canada. However, the future is promising; things can be better.

About the Author
Amédé Gogovor, DVM, MSc, is Research coordinator and secretary of the scientific committee, Health Management Research Group, Université de Montréal, Montreal, Quebec. You can contact Amédé Gogovor by phone at 514-343-6111, ext. 1853, by fax at 514-343-2448 or by e-mail at amede.gogovor@umontreal.ca.

Michelle Savoie, MBA, MPH, PhD, is Visiting Professor, Faculty of Pharmacy, Université de Montréal.

Yola Moride, PhD, FISPE, is Associate Professor, Faculty of Pharmacy, Université de Montréal.

Marilyn Krelenbaum, MSc, is consultant in design strategy and management of healthcare research projects and senior medical communications specialist, Health Management Research Group, Université de Montréal.

Terrence Montague, CD, MD, FRCPC, is Professor of Medicine and director, Health Management Research Group, Université de Montréal.

Acknowledgements
The authors wish to acknowledge the review and suggestions of the following persons toward the development of this manuscript: François Béland of the Department of Health Administration, University of Montreal; Louis-Philippe Boulet of Institut de cardiologie et de pneumologie de l'Université Laval; and Michèle Beaulieu of Patient Health Management Group, Merck Frosst Canada Ltd.

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