Marijuana use and injury events resulting in hospitalization.

PURPOSE: Information on the potential relation between marijuana use and the incidence of hospitalized injury is extremely limited. The purpose of this effort was to investigate the potential for this association. METHODS: A retrospective study was conducted in a large prepaid Northern California health care program cohort (n = 64,657) that completed baseline questionnaires about health behaviors, including marijuana use, and health status between 1979 and 1985. All injury hospitalizations through December 31, 1991, (n = 965) were identified and validated. RESULTS: Using Poisson regression modeling, increased rate-ratios and 95% confidence intervals were identified for all-cause injury hospitalizations for both men and women among current users (1.28; 1.01 to 1.61 and 1.37; 1.04 to 1.79, respectively) relative to nonusers, adjusted for age, cigarette and alcohol use, and other potential confounders. Increased rates of motor vehicle (1.96; 1.23 to 3.14), and assault (1.90, 1.16 to 3.15), injuries were identified among men who were current users; an increased rate of assault was suggestive in women (2.21; 0.92 to 5.19). CONCLUSIONS: Though the results must be viewed cautiously, they suggest that marijuana use may be independently associated with increased risk of hospitalized injury. Further study of the physiological and behavioral mechanisms is warranted [corrected].

Smoking-related attitudes and clinical practices of medical personnel in Minnesota.

CONTEXT: Effective clinic-based, smoking-cessation activities are not widely implemented. OBJECTIVE: To compare and contrast the smoking-cessation attitudes and clinical practices of five types of primary healthcare team members. DESIGN AND SETTING: From July to October 2002, a cross-sectional survey was mailed to randomly selected primary care physicians (MDs), advanced practice nurses (APRNs), registered nurses (RNs), licensed practical nurses (LPNs), and medical assistants (MAs). MAIN OUTCOME MEASURES: Factors associated with limited smoking-cessation service delivery. RESULTS: The overall response rate was 68% (n =3021). Most respondents reported that patients' smoking status was consistently documented at their clinic (79%); other system prompts were less common (30%). Many respondents reported documenting smoking status or recommending quitting; few reported consistently assessing, assisting, or arranging follow-up. The mean rank of smoking cessation as an important preventive service among nine preventive services declined from MDs (1.9) to APRNs (2.5), RNs (3.4), LPNs (4.2), and MAs (4.6). Smoking prevalence increased from 1% in MDs to 3% APRNs, 9% RNs, 17% LPNs, and 22% MAs. Those who reported no consistent smoking-cessation service delivery were more likely to be RNs, LPNs, or MAs, currently smoke, and work more hours. They were less likely to consider patients receptive to cessation messages, to consider themselves qualified to counsel on smoking, or to work in clinics that had smoking-cessation guidelines or system prompts such as chart reminders. CONCLUSIONS: Smoking-cessation service delivery may be enhanced if educational offerings, system changes, and training include all clinical staff members.

Early experience with employee choice of consumer-directed health plans and satisfaction with enrollment.

OBJECTIVE: To assess the initial impact of offering consumer-defined health plan (CDHP) options on employees. DATA SOURCES/STUDY SETTING: A mail survey of 4,680 employees in the corporate offices of Humana Inc. in June 2001. STUDY DESIGN: The study was a cross-sectional mail survey of employees aged 18 and older who were eligible for health care benefits. The survey was conducted following open enrollment. The primary outcome is the choice of consumer-directed health plan or not; the secondary outcome is satisfaction with the enrollment process. Important covariates include sociodemographic characteristics (age, gender, race, educational level, exempt or nonexempt status, type of coverage), health status, health care utilization, and plan design preferences. DATA COLLECTION METHODS: A six-page questionnaire was mailed to the home of each employee, followed by a reminder postcard and two subsequent mailings to nonrespondents. PRINCIPAL FINDINGS: The response rate was 66.2 percent. Seven percent selected one of the two new plan options. Because there were no meaningful differences between employees choosing either of the two new options, these groups were combined in multivariate analysis. A logistic regression modeled the likelihood of choosing the novel plan options. Those selecting the new plans were less likely to be black (odds ratio [OR] 0.46), less likely to have only Humana coverage (OR 0.30), and more likely to have single coverage (OR 1.77). They were less likely to have a chronic health problem (OR 0.56) and more likely to have had no recent medical visits (OR 3.21). They were more likely to believe that lowest premiums were the most important plan attribute (OR 2.89) and to think there were big differences in the premiums of available plans (OR 5.19). Employees in fair or poor health were more likely to have a difficult time during the online enrollment process. They were more likely to find the communications very helpful (OR 0.42) and the benefits information very understandable (OR 0.38). They were less likely to feel that they had enough time to make their enrollment decision (OR 0.47). CONCLUSIONS: Employees who were attracted to the new CDHP plan options valued the attributes that distinguished these plans from other choices. The shift to consumer-defined plans and to the electronic provision of information, however, requires a significant increase in the communication support for all employees, but particularly for those in fair or poor health whose information needs are the most complex and individualized.

Consumer response to a report card comparing healthcare systems.

OBJECTIVE: Report cards to date have focused on quality of care in health plans rather than within healthcare delivery systems. The purpose of this study was to evaluate consumer response to the first healthcare system-level report card. STUDY DESIGN: Qualitative assessment of consumer response. METHODS: We conducted 5 focus groups of community members to evaluate consumer response to the report card; 2 included community club members, 3 included community-dwelling retired persons. Discussions were audiotaped and transcribed; comments were categorized by topic area from the script, and common themes identified. RESULTS: Focus group participants, in general, were unaware of the current emphasis on medical quality improvement initiatives. However, they believed that the opinion that the descriptive clinic information and patient survey data contained in the report card would be most useful mainly for choosing a healthcare system if they were dissatisfied with current medical care, if their healthcare options changed, or if they were in poor health. Personal experience was considered a more trustworthy measure of healthcare quality than were patient survey results. Trustworthiness was perceived to be higher if the report card sponsor was not affiliated with the healthcare systems being evaluated. Participants also believed care system administrators should use the data to enact positive clinic-level and physician-level changes. CONCLUSIONS: Healthcare consumers appreciated the attention to patient experiences and supported healthcare quality improvement initiatives. Report cards were considered important for choosing a healthcare system in certain circumstances and for guiding quality improvement efforts at all levels.

Which enrollees bypass their gatekeepers in a point-of-service plan?

BACKGROUND AND OBJECTIVES: Like Health Maintenance Organizations, point-of-service (POS) health plans use primary care gatekeepers, and they permit self-referral to specialists at increased costs to the enrollee. The main objective of this study was to contrast patients who self-referred with those referred by their primary care physician. RESEARCH DESIGN: We conducted a cross-sectional telephone survey of 606 recent users of specialists in a large Midwestern POS health plan; response rate was 65%. We compared 148 enrollees who self-referred with 458 who had a physician referral. RESULTS: Self-referral was most common among those with a long-term relationship with a specialist (odds ratio [OR] = 2.08) and those dissatisfied with their primary care physician (OR = 3.65), and was rare among those with a long-standing relationship with a primary care physician (OR = 0.46). Most self-referred enrollees (68%) thought paying the additional cost for self-referral was worthwhile, and they were more dissatisfied with the quality and variety of the plan's specialist network. CONCLUSIONS: Continuity with a single physician influences how patients access specialty care. Expanding the panel of specialists in-network and encouraging long-term relationships with primary care physicians are likely to limit self-referral in a POS plan.