Disease Management Advisor, August 2008

Inside:

Playing to good health

Study affirms connection between diabetes, depression

Care management shows benefits

Bringing programs together improves results

Five questions with … Keith R. Dunleavy, MD

Playing to good health

Program tests gaming’s positive effects

The Nintendo Wii has taken the country by storm and is being promoted as a healthier alternative to video game consoles that don’t require full-body participation.

Now, health leaders are exploring whether gaming has a place in healthcare, most notably in chronic care and in teaching children about healthy living.

Using games to improve health turns the negative perception of video games on its head. Until recently, parents and health advocates railed against the correlation between playing video games and lack of exercise.

However, with 70% of American heads of household and millions of children playing computer and video games, the gaming industry and healthcare system are considering gaming as a possible way to improve health.

“Games are not just looked at as evil media that hurt you. Now there is an appreciation that you can design games that are not harmful, but can be beneficial,” says Debra Lieberman, PhD, communication researcher at the University of Santa Barbara’s (CA) Institute for Social, Behavioral, and Economic Research.

Games do not simply teach; they also engage users. If a company creates a health-related video game that is boring, no one will want to play it, and the chance for engagement is lost.

One example of a health-related video game is HopeLab’s Re-Mission, which was developed for teens and young adults with cancer.

The game is a 20-level third-person shooter video game in which the players portray a nanobot named Roxxi. In that role, players shoot to kill cancer cells in the fictional cancer patients and defend against bacterial infections and side effects. A study of the game showed that users learned about cancer and adhered to their treatment regimens. In 2007, CIGNA began offering Re-Mission free to cancer patients who requested the game.

The Robert Wood Johnson Foundation understands the potential of gaming in health. Lieberman is heading the foundation’s national Health Games Research program, which supports research to enhance the quality and effectiveness of interactive games to improve health. The foundation plans to give $8.25 million to researchers looking at how games can improve health and healthcare.

In the first round of grants, the foundation gave $2 million to 12 teams that are researching games to help people with dietary behavior issues, glycemic control in diabetes, and chronic mobility and balance deficits after a stroke, as well as gauge the effectiveness of social mobile-network games in promoting active lifestyles for wellness. The foundation received 112 research proposals submitted by universities, medical centers, and game industry organizations.

The foundation plans to give another $2 million in grants in January 2009.

The researchers are not only exploring video games, but other types of technology as well, such as cell phones. “What’s kind of neat is you don’t have to create a console game that could cost millions of dollars to give people a really compelling experience,” Lieberman says.

The foundation also wants to strengthen the evidence base, investigate health game design principles, demonstrate effectiveness and improve future games, and set a standard for theory-based design.

In addition to grants, the foundation is helping game developers and health experts collaborate and share best practices.

Lieberman says a benefit to video games is the immediacy. The user instantly knows whether he or she has the correct answer to a problem.

“We’re in the early days in the arena of games for health, but I think there is a lot of potential there to shift the health education paradigm from the walls of a medical center or patient handouts to a real-time simulated environment,” says Trinton Histon, PhD, director of Kaiser Permanente’s (KP) Weight Management Initiative in Oakland, CA.

“Human beings are just playful creatures. As much as we can combine that play with something healthy … that is a wonderful, powerful concept,” says Carolina Barnes, executive producer and owner of Digital Dream Forge, a gaming company in Tucson, AZ, that helped develop KP’s The Incredible Adventures of the Amazing Food Detective.

Food Detective

Pint-sized Columbos are on the case. KP launched its The Incredible Adventures of the Amazing Food Detective on its Web site in September 2007. The game, geared to 9- and 10-year-olds, teaches children about nutrition and physical fitness.

Rather than rely strictly on educational pamphlets, KP decided to harness the Internet’s power and deliver the health message in a new way.

The game builds upon the work of KP’s Healthy Eating Active Living and Community Health Initiatives to provide broader outreach to children and families. Childhood obesity in the United States has tripled in the past 15 years. Nearly 9 million children are overweight or obese, and research shows that the vast majority of those children will grow up to be overweight or obese adults, which is a pathway to diabetes, coronary artery disease, hypertension, and several other chronic illnesses.

Histon says KP chose to focus on the 9- and 10-year-olds because those children are old enough to exercise authority over their lives. When creating the game, KP was inspired by its educational theater program, which conducts two- to three-hour school programs on healthy eating and physical activity issues.

One of the skits is “The Incredible Adventures of the Amazing Food Detective.” The actors take on different health or nutritional problems, such as not eating enough protein or not getting enough exercise, and the children help the detective solve the problem.

KP developed the game by bringing together health educators, pediatrics, and Digital Dream Forge representatives to determine how to translate the live performance to the online environment. The group developed characters that mirror children in KP’s service area and included fitness and nutritional problems facing youths.

Digital Dream Forge and KP used that information to create the game in eight months. The game includes a health mystery for each child. For example, Cole eats too much junk food, Catherine is not very strong, and Althea skips breakfast. The player then uses that information to help the character make better decisions.

Once successful, the player is given an opportunity to print educational game materials as well as play health-related minigames.

KP also collaborated with educational publisher and media company Scholastic in New York City to create a healthy living lesson plan for teachers and bring the game into schools. “They knew what would resonate with children, but they also knew what would resonate with teachers,” Histon says.

Scholastic distributed supplementary educational materials that meet national learning standards along with CDs of the game to more than 5,000 public schools. The materials included a teaching guide with lessons and activities, family fun pages that reinforce what is being taught in the classroom, and a poster with a monthlong list of healthy ideas for the classroom.

“It could be either used in conjunction with the game in the classroom or as an aside,” says Histon. “It really taught kids about the building blocks of good nutrition and the importance of physical activity and sort of dispelled some of the misconceptions about nutrition—what’s healthy and what’s not healthy.”

Histon says the collaboration of KP, Digital Dream Forge, and Scholastic was key, as the health plan benefited from the gaming and education experts. “I think it was the sort of collaboration between those three entities that made it work. We could have done it, but I honestly don’t think it would have had the same impact,” Histon says. “It’s important to identify good partners from the get-go and then be thoughtful and collaborative as you move along the partnership.”

The game’s developers also needed to address a potential paradox: How would they create an online game about fitness in which children sit in front of a computer screen to play?

“One of our challenges was that games are part of the problem,” says Barnes. “We had to be very careful. We wanted to create a game that kids would want to play. But, if it was successful, we would contribute to the problem.”

The solution? KP, which suggests a one- to twohour limit to online use per day for children (including homework), decided to add a shut-off feature to the game so children can only play it for 20 minutes at a time.

KP distributed the game to 5,000 schools in its service area in September 2007, but has allowed those outside of KP’s area to download the game. The game’s learning materials have been downloaded 30,000 times. “We have had a lot more outreach than we would have expected,” says Histon.

The game has even reached Spain, where teachers have asked Kaiser for permission to make the Spanish version part of their curriculum.

Histon says it’s too early to gauge the game’s effect, but teachers have told KP that children are more engaged and better understand the importance of nutrition. “They are also choosing healthier snacks in their lunchbox,” she says.

The game has been recognized by several organizations, including iParenting Media and Interactive Media.

Additionally, the game is less than one year old, but KP has already seen the benefits and is exploring future avenues in gaming.

“I think we’re at the beginning of our journey in terms of really understanding this whole space of games for health, but it’s been very clear to me that we need to adopt a new paradigm on how we deliver both the nutritional and physical activity for children and their families,” says Histon.

Editor’s note: The Incredible Adventures of the Amazing Food Detective is at www.kp.org/amazingfooddetective.

Study affirms connection between diabetes, depression

Key factors in keeping diabetes under control is being active, keeping weight down, and eating properly, but for someone with depression, these tasks might seem impossible.

According to the American Diabetes Association (ADA), between one and three of every 10 people with diabetes has depression, and research has affirmed the connection. “Examining a Bidirectional Association Between Depressive Symptoms and Diabetes,” published in the June 18 Journal of American Medical Association, found that those with elevated depressive symptoms had a modest increased risk of developing type 2 diabetes, regardless of sociodemographics and metabolic factors.

The study also found that without elevated symptoms at baseline, “treated type 2 diabetes was associated with a significantly higher odds of developing depressive symptoms during follow-up, independent of [body mass index], socioeconomic status, and comorbidities.”

Sherita Hill Golden, MD, MHS, associate professor of medicine and epidemiology and director of inpatient diabetes management service at Johns Hopkins University School of Medicine in Baltimore and coauthor of the study, says healthcare should recognize that diabetes and depression are comorbid conditions and treatment programs are needed for both issues.

The connection might not be from the physical symptoms of diabetes, but the burden of caring for the disease.

“We hypothesize that the reason that treated diabetes, and not untreated diabetes or prediabetes, [is] associated with a higher risk of depression is that treatment for diabetes is associated with more monitoring, requires more medication adherence, and may be a marker of more severe disease with complications. This disease burden may lead to depression,” says Golden.

The study authors note the association between the two diseases and link the “psychological stress associated with diabetes management.” In addition, adults with treated type 2 diabetes may have comorbidities that could lead to more depressive symptoms.

The study, which the authors said was the first “population-based study to show a bidirectional longitudinal association between type 2 diabetes and elevated depressive symptoms within the same cohort,” concluded that a “modest association of baseline depressive symptoms with incident type 2 diabetes existed that was partially explained by lifestyle factors.” The study authors said the results corroborate previous findings that show that depressed patients “have higher calorie intake, are less physically active, and are more likely to be smokers.”

One possible explanation the study authors noted for the diabetes-depression connection is that “depressive symptoms are associated with several metabolic and behavioral risk factors for type 2 diabetes. First, depressed individuals are less likely to comply with dietary and weight loss recommendations and more likely to be physically inactive, contributing to obesity, a strong risk factor.”

They say the findings suggest that clinicians should understand the increased risk of elevated depressive symptoms in those with treated type 2 diabetes. They add that healthcare providers should consider routine screening for depressive symptoms among these patients.

Golden says physicians and mental health professionals must educate patients on both diseases and remove the stigma associated with treatments for depression.

“Physicians who take care of patients with diabetes should conduct depression screening, as the presence of high depressive symptoms may impair the patient’s ability to care for his/her diabetes,” says Golden.

Mental health providers should also understand the connection. “Psychiatrists/psychologists/social workers should be aware that depression can be a risk factor for type 2 diabetes, are more likely to engage in unhealthy behaviors (overeating, not exercising) and as a consequence are more likely to be obese. They should encourage their overweight patients to be screened for diabetes by their primary medical doctors,” Golden wrote in an e-mail.

Golden says she is hopeful that the study’s publication and other research in the diabetes-depression space will raise awareness of the diabetes-depression connection. “Many practitioners recognize that [the diseases] are linked, but depending on their subspecialty, they may be more likely to focus on one more than the other without recognizing that they are linked,” she says.

John B. Buse, MD, PhD, president of medicine and science at the ADA, says the diabetes-depression connection is well established. There is plenty of debate as to why the connection is present. “The thing that is unclear is whether it’s just a two-way street or whether they sort of share a common route system,” says Buse, who believes there is a biological connection. “There is a lot about the relationship that we don’t understand, but it does seem very clear that the relationship exists.”

Buse says the ADA recommends that physicians screen diabetes patients for depression. He adds that some health systems use screening questionnaires to identify people who are experiencing mental illness.

Most PCPs know about the connection between depression and diabetes, Buse adds, but the mental health professional side of care is more of a problem. This is partly because most psychologists’ offices don’t have nurses or equipment to medically test patients.

“It is something that needs to be addressed in the mental health system either by creating mechanisms that make sure problems are addressed by the primary care physician or setting up a system within the mental health system,” says Buse.

Study specifics

The authors of “Examining a Bidirectional Association Between Depressive Symptoms and Diabetes,” published in the June 18 Journal of American Medical Association, used repeated measures of fasting blood glucose and depressive symptoms over time to see whether depression predicted type 2 diabetes and whether those with type 2 diabetes at baseline were more likely to develop more severe depressive symptoms.

Unlike prior studies that examined the connection solely in the elderly population, the study authors opened it up to a wider age range. Between July 2000 and August 2002, the study authors recruited 6,814 men and women aged 45–84 who identified themselves as white, black, Hispanic, or Chinese and who were free of self-reported clinical cardiovascular disease. Those involved in the study came from the following communities: Baltimore City and Baltimore County; Chicago; Forsyth County, NC; Los Angeles; Northern Manhattan and the Bronx, NY; and St. Paul, MN.

To test for depression, the patients were assessed during the first and third doctor visits using the CES-D, a 20-item questionnaire to assess depression. The questions gauge depressed mood, feelings of worthlessness, feelings of hopelessness, loss of appetite, poor concentration, and sleep disturbance.

In addition to the depression evaluations, physicians checked the patients for impaired fasting glucose and type 2 diabetes status. Those with impaired fasting glucose and type 2 diabetes were more likely to be older, male, nonwhite, less physically active, and suffer from a higher body mass index, according to the study.

Additionally, those with untreated type 2 diabetes attained a lower educational level, had a lower annual income level, were more likely to have microalbuminuria and hypertension, and had lower high-density lipoprotein cholesterol and higher triglycerides.

Hypertension study

Care management shows benefits

A recent study could provide a look into the future of care management.

Rather than using the regular call center–based care management program, “Effectiveness of Home Blood Pressure Monitoring, Web Communication, and Pharmacist Care on Hypertension Control,” published in the June 25 Journal of American Medical Association, analyzed a program delivered through secure Web communication and found that the program improved BP in hypertension patients.

The study involved more than 700 hypertension patients in the Group Health plan in Seattle who did not have a comorbidity such as diabetes or heart failure.

The results found that a Web-based care program nearly doubled the percentage of hypertension patients whose BP was controlled.

“Those with the most severe hypertension had such significant drops to their blood pressure,” says Beverly Green, MD, MPH, a family physician and investigator at Group Health who coauthored the study.

“They had more room to go, but it was pretty dramatic. It made me think … that there are just things that are falling through the cracks that are not hard to fix if you’re paying attention,” she adds.

The study outcomes showed that:

Web-based pharmacist care, in addition to home BP monitoring and Web training, resulted in 25% more patients with controlled BP than the control group and 20% more patients with controlled BP compared to the home BP monitoring and Web training–only group.

The home BP monitoring and Web training–only group had a significant improvement and a modest reduction in systolic BP.

Compared to the usual care group, the home BP monitoring and Web training plus pharmacist care group was 1.8 times more likely to control its BP. Those in the home BP monitoring and Web training group were 1.2 times more likely to control their BP than the usual care group.

Improvements in the number of classes of antihypertensive medications, aspirin use, body mass index, physical activity, health-related quality of life, satisfaction with the health plan, and use of the healthcare services from baseline until the 12-month follow-up.

For more results, see the charts on MDM pp. 2–3 of the PDF of this issue.

“Our study findings support previous research that demonstrates encouraging patients to participate more actively in their own care, combined with care management, including assisted patient review of paper medical records, leads to improved health outcomes. Our intervention extends this work by connecting patients and care managers through a shared [electronic medical record (EMR)] over the Web. In our study, providing home BP monitors and Web training alone did not significantly improve BP control, despite trends in that direction,” the study authors wrote.

Green says having a Web connection to patients is important because much of the day-to-day care for chronic conditions, such as hypertension, is done at home. “The Web is a very convenient way to provide support that is required for self-management and also for improving care,” she says.

Green says researchers tackled the issue of hypertension because it is one of the most common diagnoses at primary care visits. In fact, almost one in three U.S. adults has hypertension, which is considered a sustained systolic and diastolic BP of 140 and 90 mm Hg or higher, respectively, according to the study.

Successful strategies to lower BP include educating patients and encouraging self-monitoring or adding a healthcare team member to focus on hypertension. The Group Health program took the plan’s existing EMRs and secure patient Web site so patients could view portions of their medical record, access healthcare services, and communicate with their healthcare team online, according to the study.

The study authors noted that a Web-based solution to the hypertension epidemic could be successful because more than 75% of U.S. adults have Internet access, most people want to use that technology to contact physicians and receive laboratory results, and the at-home system allows physicians to measure BP longitudinally. Self-monitored BP devices are accurate and less expensive than usual care and provide direct feedback for hypertension patients, according to the study.

Existing Web portal

Green says the program used an existing Group Health Web portal, and the hypertension program encouraged more care coordination between the patient and the care team. “The pharmacists were the glue to make sure that happened,” says Green, adding that Group Health’s pharmacists already perform some care management roles.

Adding pharmacist care to the program “allowed the Chronic Care Model to be integrated with further increases in securing messaging, more antihypertensive medical classes being added, and larger reductions in both systolic and diastolic BP,” according to the study.

The Chronic Care Model uses seven domains: self-management, clinical information systems, delivery system redesign, decision support, healthcare organization, community resources, and care partnership support.

“We believe the pharmacists were successful because they provided planned care to a defined population, consistently applied stepped medical protocols, and used comprehensive information systems, a patient-shared EMR, and Web communications to collaborate with patients and their physicians,” according to the study. Pharmacists communicated with the patients’ physicians at the start of the program and then only if there was a clinical concern. Program organizers wanted to limit the amount of communication with physicians because they are already bombarded with information, says Green.

Care management through the Internet will become more common as more people become accustomed to computers, Green says. “Once patients are used to it and they use the Internet, they seem to adapt very quickly. I have been amazed at some patients I thought would never expect to be able to use it,” she says.

Green says people living with chronic disease find health Web access helpful for their daily care. “Why shouldn’t it be part of medical care? It’s just a natural thing that needs to happen because it does improve care. We know it and this has helped prove it,” says Green.

The study’s coauthors acknowledged there were limitations to the study, most notably that the hypertension patients needed Internet and e-mail access. The researchers are going to investigate how factors such as not having computer skills played into the results, Green says, adding that she thinks computer barrier issues will subside.

“That won’t be a problem in a few years because middle-age people who are already using it at work will be 65 pretty soon,” says Green about the computer literacy of baby boomers.

Patients separated into three groups

“Effectiveness of Home Blood Pressure Monitoring, Web Communication, and Pharmacist Care on Hypertension Control,” published in the June 25 Journal of American Medical Association, is the first large randomized controlled trial to test the use of care management over the Web and the first randomized controlled trial that applied the Chronic Care Model to hypertension.

The patients in the trial were from 10 medical centers within Seattle-based Group Health, which provides coverage and care to more than 540,000 residents of Washington state and Idaho. Patients were separated into the following three groups:

Usual care

Training for home BP monitoring and patient Web site

Home BP monitoring and Web training plus pharmacist care intervention

All patients were given access to an electronic medical record (EMR) and patient Web site at the beginning of the study. Group Health’s Web services allow patients to refill medications, make appointments, view portions of their EMR (which includes laboratory results, immunizations, current health conditions, and medications), and communicate with members of the healthcare team. After the first randomization, the people assigned to the usual care group were told their BP was not under control and encouraged to speak with their physicians to improve the numbers. Patients received the following additional interventions depending on their group:

Patient training for home BP monitoring and Web site. Patients were given a home BP monitor, trained on its use, and told to check their BP at least two days per week and enter the numbers into their online record. They were also trained on how to use the Web site, including using its secure e-mail, refilling medications, viewing portions of the medical record, and finding links to resources for lifestyle and behavioral change.

Patient training for home BP monitoring and Web training plus pharmacist care intervention. Patients in this group were assigned a Group Health pharmacist to assist with team-based care management activities, including collaborating with the patient’s physician. After an initial phone call to obtain a detailed medical history, the pharmacists and patients with high BP communicated every two weeks via the EMR until the BP was under control. The pharmacists also received two half days of additional training on evidence-based care of hypertension, medical protocols, and patient-centered techniques for addressing behavioral issues related to adherence and lifestyle change.

Prenatal care and substance abuse treatment

Bringing programs together improves results

Integrating substance abuse treatment with prenatal visits brings positive results to maternal and newborn health, according to a study published June 26 on the online Journal of Perinatology. The study, “Substance Abuse Treatment Linked with Prenatal Visits Improves Prenatal Outcomes: A New Standard,” reviewed Kaiser Permanente’s Early Start program—an obstetric clinic–based prenatal substance abuse treatment program that tests all expectant mothers for drug use.

Nancy C. Goler, MD, regional medical director of the Early Start program for Northern California at Kaiser Permanente Medical Group in Vallejo, CA, and coauthor of the study, says testing for drug use should be as routine as treating diabetes. “[Testing] needs to be universal and as nonjudgmental and nonpunitive as possible,” says Goler.

The study authors tracked nearly 50,000 women who completed prenatal substance abuse screening questionnaires, had urine toxicology screening tests, and live births or intrauterine fetal demises (IUFD).

The women were separated into the following four groups:

SAT—Women who screened/assessed positive and were treated by Early Start

SA—Women who screened/assessed positive without treatment

S—Women who screened positive

The control group—Women who screened negative

The results showed that:

SAT women had similar or slightly higher rates than the control group for most outcomes, but significantly lower rates than S women

SA women generally had intermediate rates to the SAT and S groups

The S group had significantly worse outcomes than the SAT group, including preterm delivery, placental abruption, and IUFD

(For more information about the results, see “Adjusted odds ratios for neonatal and maternal outcomes by study group” below.)

“The women and babies served by Early Start are healthier; therefore, the impact of the program reaches beyond them to also positively influence the health and well-being of the community at large and, consequently, must also be considered from a public health perspective. The results of this study reflect the importance of widespread implementation of this model of care as a national standard,” the authors wrote.

Cigarette, alcohol, and drug use by mothers have long-lasting health effects on a child’s health and development and create more health-related costs in the long run. The Centers for Disease Control and Prevention (CDC) reports that smoking before and during pregnancy is the most preventable cause of illness and death among mothers and