Testing the Efficacy of PATH Type Clinical Interventions

Copyright © 2006 PATH Institute Corporation

1

Testing the Efficacy of PATH Type® Clinical Interventions: Disease Management (DM) Experimental Trial

Executive Summary

Main Outcomes:

• Clinician performance and evaluations

– Fair levels of consistent application

– Extremely high satisfaction with PATH type® training

and interventions

– Positive Clinician reports of improved patient

interactions

• Results: Impacts on Client Engagement

– 9% to 19% Improvements in client engagement as

reflected in improved connectivity, longer calls, and

higher achievement of care goals

• Results: Impact on total costs

– $326 pmpy dollar reduction in total costs among

experimental group equivalent to a real reduction of

$533,662

– Largest impact on hospital admission costs ($259

reduction pmpy) and pharmacy claims ($136 pmpy

reduction)

– Trial ROI est. $533,662/$120,000 = 4.4:1

Frederick Navarro, PhD (909) 272-1170 mobile


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Executive Summary

PATH Type® is an assessment of structure of individual health-related behavior

across different contexts. PATH Type assessment has two main capabilities: 1) as

tool to predict disease prevalence and medical costs based on individual fit to nine

core prototypes, and 2) as tool that can enhance clinician-patient communications and

patient and through tailored health communications and promotion.

The objectives of the experiment were limited to the application of PATH Type as a

communications aid between clinician and patient. The questions to be addressed

were: a) can PATH Type insights improve the effectiveness of clinician

communications to patients, and b) will improved clinician communications lead to

greater impact on clinical and financial measures? This experiment was conducted

with the support of a major international disease management (DM) company.

Method

Approximately 8,000 DM patients were drawn from an existing population of the DM

company’s patients who had already been receiving DM interventions for an

unspecified length of time. These patients were profiled using the PATH Type

assessment. The questionnaire was delivered to patients using interactive voice

response (IVR) after a live-transfer from a nurse. The sample of 8,000 patients was

randomly split into two groups of 4,000. One group was designated as the

experimental group and the other the control group. During data collection, 10

clinicians received 16 hours of training in the PATH Type® model and in how to tailor a

range of communications tactics to each patient. Following the training, all clinicians

received a guide book containing a summary of all of the PATH Type-based

communication tactics. Only the 10 PATH Type® trained clinicians worked with the

population assigned to the experimental group.

Results

Statistically significant improvements in patient engagement ranging from 9% to 19%.

All clinicians in the experimental group solidly endorsed the PATH Type® training and

its effectiveness in helping clinicians improve patient interactions. Total costs

reductions of $326 per patient in the experimental group, representing an ROI of 4.4:1.


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Experimental Design

PATH Profiling

Assignment to experimental conditions

Pre-Intervention Observations

Interventions Post-Intervention Observations

All subjects Random Experimental group PATH customized

Comparisons

Random Control group General

Pre-Intervention Analysis Random Assignment Post-Intervention Analysis

Conducted on entire sample of 8,000+ subjects:

PATH profile all subjects

Determine existing risk and severity levels

Determine existing risk and severity levels by PATH group

Develop hypotheses of intervention effectiveness and outcomes by PATH group between experimental and control group

Experimental Group (N=4,000, PATH profiled)

Assess PATH mix

Severity levels

Apply normal Healthways risk prioritization and interventions

Add PATH customized communication interventions

Compare and Contrast Experimental and Control Group outcomes including: Pre- and Post- Repeated Measures Comparisons: Changes in risk severity measures, cost differences, engagement levels Subject Attrition Subject attrition during the trial resulted in the loss of 61% of the original sample. Pre-post intervention analysis was therefore limited to the remaining 3,148 subjects (1,637-experimental, 1,511-control)

Control Group (N=4,000 PATH Profiled)

Assess PATH mix

Severity levels

Apply normal Healthways risk prioritization and interventions

Clinician Performance in applying PATH Type Interventions

Clinicians were the most consistent in applying the PATH Type recommended interventions

around the tasks of Learning, Communication, and Prevention. They showed the least success

with the suggested interventions in the context of Nutrition. This may be a function of the amount

of time given to this topic (as well as to Exercise) in the DM company’s overall scheme of

interventions.


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Beginning Sample

The beginning sample of 8,000 was reduced to 6,026 subjects due to the availability of

a complete panel of both clinical measures and financial measures. The DM company

analysts compared the two groups across demographic, financial and clinical

measures and found no statistically significant differences between them.

PATH TYPE Experimental Group Control Group

1 75 73

2 141 147

3 550 576

4 109 106

5 500 520

6 325 297

7 494 507

8 235 227

9 249 263

10 327 305

Total 3005 3021

Beginning Financials (PMPM)

PATH Type Experimental Group Control Group

1 $1,082.18 $598.07

2 $1,027.95 $603.70

3 $927.12 $966.49

4 $890.34 $712.03

5 $1,071.67 $908.71

6 $1,116.93 $752.11

7 $1,001.50 $1,172.42

8 $922.86 $649.58

9 $1,198.49 $1,146.51

10 $950.01 $856.15

Total $1,016.01 $915.25


Clinician Training

Clinicians trained in the PATH Type® model were given an array of communication

tactics (e.g., self-disclosure, repetitions, empathy building statements, use of peripheral

topics, appeals to authority, types of persuasion) and recommendations for their use

specific to each PATH Type. The training lasted 16 hours and was delivered over four

days.

Consistency of Delivering PATH Interventions by

Task

73% 78% 74%

47%

64%

22% 17%18%

18%

18%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

LEARNIN

G

CO

MM

UNIC

ATIO

N

PREVE

NTI

ON

NUTR

ITIO

NAL

EXE

RCIS

E

Most of the time

Always

Clinician Performance in applying

PATH Type Interventions

Clinicians were the most consistent in

applying the PATH Type® recommended

interventions around the tasks of

Learning, Communication, and

Prevention. They showed the least

success with the suggested interventions

in the context of Nutrition. This may be a

function of the amount of time given to

this topic (as well as to Exercise) in the

DM company’s overall scheme of

interventions.

Self-Reported Consistency in Delivering PATH

Interventions - Learning

87%

55%

60%

88%

71%

100%

100%

67%

0%

0%

36%

40%

13%

29%

0%

0%

33%

100%

0% 20% 40% 60% 80% 100%

C.Fletcher

B. McKay

C. Harbertson

C. Allman

L. Dirrim

B. Giordano

B. Boyle

M. Henrichs

S. Farnsworth

Always

Most of the time

Consistency

There was quite a bit of variability by

clinician in terms of how consistently the

PATH Type® interventions were

applied.

Among the top three reporting

clinicians, only Fletcher reported

“always” consistency levels above 80%

in the Learning context. Two clinicians

reported levels significantly lower at

55% and 60%, respectively.

Clinician Performance Findings

PATH Type® interventions were “always” applied about 70% of the time. Clinicians reported

applying them “most of the time” at 22%. Some clinicians reported “always” compliance rates

as low as 30%. It was estimated that from 30% to 40% of patients in the experimental trial

were not delivered PATH Type® based interventions in a consistent manner, especially in

interventions around nutrition. This suggests that PATH Interventions were applied in a blunt

versus sharp manner. This may mitigate the detection of a “PATH Type® effect” in the

experimental trial.

Clinician Performance

High Clinician Satisfaction

Clinician satisfaction with the PATH

Type® training and interventions was

near perfect both at the beginning and

end of the trial. Clinicians found great

benefit from the insights into the patient

that PATH Type® provided. Many

clinicians reported improved

intervention abilities, higher efficacy,

and improved patient exchanges (e.g.,

many more “thank you” s).


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Subject Attrition

Through the course of the year-long trial some subjects left the experiment due to

contractual issues resulting in a loss of over 50% of the original sample. At the end of

the trial 3,148 subjects remained with 1,511(50% retention) in the control group and

1,637 (54% retention) in the experimental group. All of the final experimental impacts

are analyzed using only data from subjects who remained in the trial throughout the

whole trial period.

Final Sample

PATH Type Experimental Control

1 39 42

2 77 70

3 308 286

4 52 55

5 264 256

6 186 148

7 274 247

8 133 113

9 124 139

10 180 155

Total 1637 1511


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Sample Attrition Cost Impacts

The sample attrition had an influence on the baseline total costs between the

experimental group and the control group. In many of the financial measures, the

patients that remained in the experimental group had lower base line costs. This lack

of equivalence between the experimental and control groups in terms of costs was

handled in analysis by judging the net differences between the beginning base line

cost levels and the 1 year costs levels for each group. For example, if the base line

costs in the experimental group and control group were $10 and $15 dollars,

respectively, and the year 1 costs were $20 and $22 dollars, respectively, the net

difference in the experimental group of a $10 dollar increase is greater than the net

difference of a $7 dollar increase in the control group.


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Findings


Successful Calls

3.80

4.00

4.20

4.40

4.60

4.80

5.00

5.20

Base succ calls Year 1 succ calls

Nu

mb

er

of

Su

ccessfu

l C

all

s

Control

Experimental

Call Time

60.0

65.0

70.0

75.0

80.0

85.0

Base call time Year 1 call time

Min

ute

s

Control

Experimental

Goals

26

26.5

27

27.5

28

28.5

29

29.5

base goals Year 1 goals

Nu

mb

er

of

Go

als

Control

Experimental

Successful Calls

The net increase in

successful calls among the

experimental group was

about 13% by the end of the

trial. (p=0.0001)

Subjects in the experimental

group showed a higher

willingness to accept DM

calls. This is evidence of

improved engagement

resulting from clinician

knowledge of PATH Type

dynamics.

Call Time

The net increase in call time

among the experimental group

was about 19% by the end of

the trial. (p=0.0001)

This is the result of the

combined effect of increasing

engagement in the

experimental group and

decreasing engagement in the

control group. Clinician

knowledge of PATH Type not

only improved engagement

but prevented engagement

decay.

Goals

The net increase in achieving

goals among the experimental

group over the control group

was about 9% by the end of

the trial. (p=0.0001)

This is the result of the

combined effect of increasing

goal achievement in the

experimental group and

decreasing goal achievement

in the control group. Clinician

knowledge of PATH Type not

only improved engagement

but prevented relationship

decay.

Impacts on Engagement


Rx Costs

The rate of increase in Rx costs was lower

in the experimental group equivalent to a

savings of $136 pmpy.

Impact on Financials

Rx Costs

$1,700.00

$1,800.00

$1,900.00

$2,000.00

$2,100.00

$2,200.00

$2,300.00

$2,400.00

$2,500.00

$2,600.00

$2,700.00

Base Rx costs Year 1 Rx costs

Avg

Co

sts

Control

Experimental

PV_PC_Costs

$220.00

$230.00

$240.00

$250.00

$260.00

$270.00

$280.00

$290.00

$300.00

$310.00

Base_pv_pc_cost Year1_pv_pc_cost

Av

g. C

os

ts

Control

Experimental

PV_SP_Costs

$800.00

$850.00

$900.00

$950.00

$1,000.00

$1,050.00

$1,100.00

Base_pv_sp_cost Year1_pv_sp_cost

Avg

. S

P C

osts

Control

Experimental

Primary Care Costs

The rate of increase in primary care costs

was lower in the experimental group and

reflected an actual cost decrease as opposed

to just a reduction in the rate of increase. The

experimental group showed an actual cost

reduction of $36 pmpy as compared to a rate

increase of $58 pmpy in the control group.

Specialist Care Costs

The rate of increase in specialist care costs

was lower in the experimental group

representing a savings of $52 pmpy.


Hospital Admission Costs

The rate of increase in hospital admission

costs was dramatically lower in the

experimental group equivalent to a savings

of $259 pmpy.


Outpatient Costs

The rate of increase in outpatient costs was

higher in the experimental group versus the

control group which reflected an actual

relative cost rate increase. This rate increase

is equivalent to a loss of $208 pmpy.

Emergency Room Costs

The rate of increase in emergency care costs

compared to the control group was slightly

higher in the experimental group representing

a loss of $7 pmpy.

Ambulance Costs

The difference in ambulance costs between

the experimental and control groups was

negligible.

Admit Costs

$1,500.00

$1,550.00

$1,600.00

$1,650.00

$1,700.00

$1,750.00

$1,800.00

$1,850.00

$1,900.00

$1,950.00

$2,000.00

Base_admit_cost Year1_admit_cost

Av

g. A

dm

it C

os

ts

Control

Experimental

OutPat Costs

$1,500.00

$1,550.00

$1,600.00

$1,650.00

$1,700.00

$1,750.00

$1,800.00

$1,850.00

$1,900.00

$1,950.00

Base_outpat_cost Year1_outpat_cost

Avg

. C

osts

Control

Experimenta

l

ER Costs

$190.00

$200.00

$210.00

$220.00

$230.00

$240.00

$250.00

$260.00

$270.00

Base_er_cost Year1_er_cost

Avg

. C

osts

Control

Experimental

Amb Costs

$15.00

$20.00

$25.00

$30.00

$35.00

$40.00

Base_amb_cost Year1_amb_cost

Avg

. C

osts

Control

Experimental


Total Costs

At trial’s end, the Year 1 total

cost among the experimental

group were a net savings of

$326 pmpy.

This represents about a 2%

reduction, which is right in line

with the high end goal of 2%

reduction sought for in the

original plan design.

The real cost saving in

experimental group as

compared to the control group

can be estimated at:

• $533,662


PATH DM Experimental Trial - Financial Findings

Control Experimental

Savings/

Costs

Sample 1,511 1,637

Base Rx costs 2,126.00$ 1,895.00$

Year 1 Rx costs 2,595.00$ 2,228.00$

Net difference 469.00$ 333.00$ 136.00$

Base_pv_pc_cost 244.00$ 288.00$

Year1_pv_pc_cost 302.00$ 252.00$

Net difference 58.00$ (36.00)$ 94.00$

Base_pv_sp_cost 870.00$ 822.00$

Year1_pv_sp_cost 1,053.00$ 953.00$

Net difference 183.00$ 131.00$ 52.00$

Base_admit_cost 1,626.00$ 1,516.00$

Year1_admit_cost 1,930.00$ 1,561.00$

Net difference 304.00$ 45.00$ 259.00$

Base_outpat_cost 1,767.00$ 1,515.00$

Year1_outpat_cost 1,923.00$ 1,879.00$

Net difference 156.00$ 364.00$ (208.00)$

Base_er_cost 199.00$ 231.00$

Year1_er_cost 225.00$ 264.00$

Net difference 26.00$ 33.00$ (7.00)$

Base_amb_cost 20.00$ 25.00$

Year1_amb_cost 31.00$ 37.00$

Net difference 11.00$ 12.00$ (1.00)$

Net Savings or Expense Per Person in Exp Group 326.00$


The analysis is based on a review of only those subjects who

remained in the trial throughout (N=3,148). Therefore, differences

between base line levels and 1 year levels cannot be attributed to

any affects of attrition. The calculated cost savings use only the

1,637 subjects making up the experimental group at the end of the

trial.

Experimental Group N = 1,637

Cost Reduction X $326

Total Savings = $533,662

*Lack of Statistical Significance and Power of the Test

Given the effect sizes the study was intended to detect (e.g., 1% to 2%

percent of additional claims reductions), the sample, limited to

approximately 1,400 to 1,600 subjects per treatment condition, was

known in advance to be insufficient to detect as statistically significant

the desired claims reduction at the 80%, 90% or 95% level of

confidence. The obtained real dollar differences was regarded on their

own merit apart from their statistical significance.

Impacts on Total Costs

Documents

Testing the Efficacy of PATH Type Clinical Interventions