Medication adherence, molecular monitoring, and clinical outcomes in patients with chronic myelogenous leukemia in a large HMO.

OBJECTIVE: Our objective was to examine the association between adherence to tyrosine kinase inhibitors (TKIs) and molecular monitoring and the risk of disease progression or mortality among patients with chronic phase chronic myeloid leukemia (CML). DESIGN: We assembled a retrospective cohort of patients with CML (chronic phase, no prior cancer history, and confirmed to be Philadelphia chromosome positive) using data from electronic health records and chart reviews. Medication possession ratio (MPR) was used to measure drug adherence. SETTING: A large, community-based, integrated health plan in Southern California. PARTICIPANTS: The cohort consisted of 245 adult patients (≥18 years old) with Philadelphia positive chronic phase CML diagnosed from 2001 to 2012 and followed through 2013. MAIN OUTCOME MEASURES: In survival analyses, we examined the association of TKI adherence (MPR) and polymerase chain reaction (PCR) monitoring test frequency with the composite clinical outcome, progression to accelerated phase disease-blast crisis or mortality (progression-free survival). The cohort was followed for a maximum of 13 years (median 4.6 years). RESULTS: Over 90% of the cohort initiated TKI therapy within 3 months of diagnosis, and the mean MPR was 88% (SD 18%). Virtually all patients (96%) started on imatinib. The rates of progression to accelerated phase-blast crisis and mortality were lower in patients with greater TKI adherence (20.4/1000 person-years) versus lower adherence (27.0/1000 person-years). Patients who underwent PCR monitoring had a significantly reduced risk of progression or mortality, which was seen in patients with high and low TKI adherence status from both the groups (hazard ratio [HR] 0.07 [95% CI 0.03-0.19 if MPR >90%] and HR 0.70 [95% CI 0.02-0.21 if MPR<90%]). CONCLUSION: Our results suggest that close clinical monitoring, which includes PCR monitoring in patients with high and low TKI drug adherence, is associated with a lower risk of progression or mortality.

Acupuncture and chiropractic care: utilization and electronic medical record capture.

OBJECTIVES: To describe acupuncture and chiropractic use among patients with chronic musculoskeletal pain (CMP) at a health maintenance organization, and explore issues of benefit design and electronic medical record (EMR) capture. STUDY DESIGN: Cross-sectional survey. METHODS: Kaiser Permanente members meeting EMR diagnostic criteria for CMP were invited to participate. The survey included questions about self-identified presence of CMP, use of acupuncture and chiropractic care, use of ancillary self-care modalities, and communication with conventional medicine practitioners. Analysis of survey data was supplemented with a retrospective review of EMR utilization data. RESULTS: Of 6068 survey respondents, 32% reported acupuncture use, 47% reported chiropractic use, 21% used both, and 42% used neither. For 25% of patients using acupuncture and 43% of those using chiropractic care, utilization was undetected by the EMR. Thirty-five percent of acupuncture users and 42% of chiropractic users did not discuss this care with their health maintenance organization (HMO) clinicians. Among chiropractic users, those accessing care out of plan were older (P < .01), were more likely to use long-term opioids (P = .03), and had more pain diagnoses (P = .01) than those accessing care via clinician referral or self-referral. For acupuncture, those using the clinician referral mechanism exhibited these same characteristics. CONCLUSIONS: A majority of participants had used acupuncture, chiropractic care, or both. While benefit structure may materially influence utilization patterns, many patients with CMP use acupuncture and chiropractic care without regard to their insurance coverage. A substantial percentage of acupuncture and chiropractic use thus occurs beyond detection of EMR systems, and many patients do not report such care to their HMO clinicians.

[Predicting individual risk of high healthcare cost to identify complex chronic patients]. / Predicción del riesgo individual de alto coste sanitario para la identificación de pacientes crónicos complejos.

OBJECTIVE: To develop a predictive model for the risk of high consumption of healthcare resources, and assess the ability of the model to identify complex chronic patients. METHODS: A cross-sectional study was performed within a healthcare management organization by using individual data from 2 consecutive years (88,795 people). The dependent variable consisted of healthcare costs above the 95th percentile (P95), including all services provided by the organization and pharmaceutical consumption outside of the institution. The predictive variables were age, sex, morbidity-based on clinical risk groups (CRG)-and selected data from previous utilization (use of hospitalization, use of high-cost drugs in ambulatory care, pharmaceutical expenditure). A univariate descriptive analysis was performed. We constructed a logistic regression model with a 95% confidence level and analyzed sensitivity, specificity, positive predictive values (PPV), and the area under the ROC curve (AUC). RESULTS: Individuals incurring costs >P95 accumulated 44% of total healthcare costs and were concentrated in ACRG3 (aggregated CRG level 3) categories related to multiple chronic diseases. All variables were statistically significant except for sex. The model had a sensitivity of 48.4% (CI: 46.9%-49.8%), specificity of 97.2% (CI: 97.0%-97.3%), PPV of 46.5% (CI: 45.0%-47.9%), and an AUC of 0.897 (CI: 0.892 to 0.902). CONCLUSIONS: High consumption of healthcare resources is associated with complex chronic morbidity. A model based on age, morbidity, and prior utilization is able to predict high-cost risk and identify a target population requiring proactive care.

Racial and ethnic differences in health care utilization and outcomes among ulcerative colitis patients in an integrated health-care organization.

BACKGROUND: Current knowledge of racial disparities in healthcare utilization and disease outcomes for ulcerative colitis (UC) is limited. We sought to investigate these differences among Caucasian, African American, Asian, and Hispanic patients with ulcerative colitis in Kaiser Permanente, a large integrated health-care system in Northern California. METHODS: This retrospective cohort study used computerized clinical data from 5,196 Caucasians, 387 African-Americans, 550 Asians, and 801 Hispanics with prevalent UC identified between 1996 and 2007. Healthcare utilization and outcomes were compared at one and five-year follow-up by use of multivariate logistic regression analysis. RESULTS: Compared with whites, the male-to-female ratio differed for African-Americans (0.68 vs. 0.91, p < 0.01) and Asians (1.3 vs. 0.91, p < 0.01). Asians had fewer co-morbid conditions (p < 0.01) than whites, whereas more African-Americans had hypertension and asthma (p < 0.01). Use of immunomodulators did not differ significantly among race and/or ethnic groups. Among Asians, 5-ASA use was highest (p < 0.05) and the incidence of surgery was lowest (p < 0.01). Prolonged steroid exposure was more common among Hispanics (p < 0.05 at 1-year) who also had more UC-related surgery (p < 0.01 at 5-year) and hospitalization (<0.05 at 5-year), although these differences were not significant in multivariate analysis. CONCLUSIONS: In this population of UC patients with good access to care, overall health-care utilization patterns and clinical outcomes were similar across races and ethnicity. Asians may have milder disease than other races whereas Hispanics had a trend toward more aggressive disease, although the differences we observed were modest. These differences may be related to biological factors or different treatment preferences.

Patient satisfaction and perceived success with a telephonic health coaching program: the Natural Experiments for Translation in Diabetes (NEXT-D) Study, Northern California, 2011.

INTRODUCTION: Health coaching can improve lifestyle behaviors known to prevent or manage chronic conditions such as diabetes. However, little is known about the patient experience with telephonic coaching programs in real-world care settings. We examined patient satisfaction, patient's perceived success in achieving program goals, and the patient-level correlates of these outcomes in a voluntary telephonic coaching program at a large integrated health care delivery system in northern California. METHODS: Kaiser Permanente Northern California patients who participated in a telephonic coaching program in 2011 were sent a cross-sectional survey about their satisfaction with health coaching and perceived success with program goals. We examined associations with patient characteristics. RESULTS: The survey response rate was 34%; analyses were based on the 32% who completed the survey. Of those who had completed 2 or more sessions (n = 232 [52%]), most reported being satisfied (70%) or neutral (20%) with the program, and 71% would recommend health coaching. Healthy weight, healthful eating, and physical activity were the most common topics discussed (88%). Adjusting for demographic characteristics, 73% of those who had 2 or more sessions reported that health coaching helped achieve their weight-related goal. Outcomes were positively correlated with patient activation but not consistently correlated with patient demographic characteristics. CONCLUSION: Levels of satisfaction and perceived success with telephonic health coaching provided by a health plan were high and positively correlated with the number of sessions completed and patient activation. Voluntary telephonic health coaching programs should promote retention and assess patients' activation levels.

Breast cancer screening in an insured population: whom are we missing?

INTRODUCTION: Kaiser Permanente Colorado is an integrated health care system that uses automatic reminder programs and reduces barriers to access preventive services, including financial barriers. Breast cancer screening rates have not improved during the last five years, and rates differ between subgroups: for example, black and Latina women have lower rates of mammography screening than other racial groups. METHODS: We retrospectively evaluated data from 47,946 women age 52 to 69 years who had continuous membership for 24 months but had not undergone mammography. Poisson regression models estimated relative risk for the impact of self-identified race/ethnicity, socioeconomic characteristics, health status, and use of health care services on screening completion. RESULTS: The distribution of race/ethnicity among unscreened women was 55.5% white, 7.0% Latina, and 3.7% black, but race/ethnicity data were missing for 29%. Of these, no record of race/ethnicity was available for 86.7%, and for 5.1%, the data request was recorded but the women declined to identify their race/ethnicity. Nonwhite ethnicity increased risk of screening failure if black, Latina, "other" (eg, American Indian), or missing race/ethnicity. Population-attributable risks were low for minorities compared with the group for whom race/ethnicity data was missing. A greater number of office visits in any setting was associated with greater likelihood of undergoing mammography. Women with missing race/ethnicity data had fewer visits and were less likely to have an identified primary care physician. CONCLUSIONS: Greater improvement in mammography screening rates could be achieved in our population by increasing screening among women with missing race/ethnicity data, rather than by targeting those who are known to be of racial/ethnic minorities. Efforts to address screening disparities have been refocused on inreach and outreach to our "missing women."

The impact of EHR and HIE on reducing avoidable admissions: controlling main differential diagnoses.

BACKGROUND: Many medical organizations have invested heavily in electronic health record (EHR) and health information exchange (HIE) information systems (IS) to improve medical decision-making and increase efficiency. Despite the potential interoperability advantages of such IS, physicians do not always immediately consult electronic health information, and this decision may result in decreased level of quality of care as well as unnecessary costs. This study sought to reveal the effect of EHR IS use on the physicians' admission decisions. It was hypothesizing the using EHR IS will result in more accurate and informed admission decisions, which will manifest through reduction in single-day admissions and in readmissions within seven days. METHODS: This study used a track log-file analysis of a database containing 281,750 emergency department (ED) referrals in seven main hospitals in Israel. Log-files were generated by the system and provide an objective and unbiased measure of system usage, Thus allowing us to evaluate the contribution of an EHR IS, as well as an HIE network, to decision-makers (physicians). This is done by investigating whether EHR IS lead to improved medical outcomes in the EDs, which are known for their tight time constraints and overcrowding. The impact of EHR IS and HIE network was evaluated by comparing decisions on patients classified by five main differential diagnoses (DDs), made with or without viewing the patients' medical history via the EHR IS. RESULTS: The results indicate a negative relationship between viewing medical history via EHR systems and the number of possibly redundant admissions. Among the DDs, we found information viewed most impactful for gastroenteritis, abdominal pain, and urinary tract infection in reducing readmissions within seven days, and for gastroenteritis, abdominal pain, and chest pain in reducing the single-day admissions' rate. Both indices are key quality measures in the health system. In addition, we found that interoperability (using external information provided online by health suppliers) contributed more to this reduction than local files, which are available only in the specific hospital. Thus, reducing the rate of redundant admissions by using external information produced larger odds ratios (of the ß coefficients; e.g. viewing external information on patients resulted in negative associations of 27.2% regarding readmissions within seven days, and 13% for single-day admissions as compared with viewing local information on patients respectively). CONCLUSIONS: Viewing medical history via an EHR IS and using HIE network led to a reduction in the number of seven day readmissions and single-day admissions for all patients. Using external medical history may imply a more thorough patient examination that can help eliminate unnecessary admissions. Nevertheless, in most instances physicians did not view medical history at all, probably due to the limited resources available, combined with the stress of rapid turnover in ED units.

Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996-2010.

CONTEXT: Use of diagnostic imaging has increased significantly within fee-for-service models of care. Little is known about patterns of imaging among members of integrated health care systems. OBJECTIVE: To estimate trends in imaging utilization and associated radiation exposure among members of integrated health care systems. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of electronic records of members of 6 large integrated health systems from different regions of the United States. Review of medical records allowed direct estimation of radiation exposure from selected tests. Between 1 million and 2 million member-patients were included each year from 1996 to 2010. MAIN OUTCOME MEASURE: Advanced diagnostic imaging rates and cumulative annual radiation exposure from medical imaging. RESULTS: During the 15-year study period, enrollees underwent a total of 30.9 million imaging examinations (25.8 million person-years), reflecting 1.18 tests (95% CI, 1.17-1.19) per person per year, of which 35% were for advanced diagnostic imaging (computed tomography [CT], magnetic resonance imaging [MRI], nuclear medicine, and ultrasound). Use of advanced diagnostic imaging increased from 1996 to 2010; CT examinations increased from 52 per 1000 enrollees in 1996 to 149 per 1000 in 2010, 7.8% annual increase (95% CI, 5.8%-9.8%); MRI use increased from 17 to 65 per 1000 enrollees, 10% annual growth (95% CI, 3.3%-16.5%); and ultrasound rates increased from 134 to 230 per 1000 enrollees, 3.9% annual growth (95% CI, 3.0%-4.9%). Although nuclear medicine use decreased from 32 to 21 per 1000 enrollees, 3% annual decline (95% CI, 7.7% decline to 1.3% increase), PET imaging rates increased after 2004 from 0.24 to 3.6 per 1000 enrollees, 57% annual growth. Although imaging use increased within all health systems, the adoption of different modalities for anatomic area assessment varied. Increased use of CT between 1996 and 2010 resulted in increased radiation exposure for enrollees, with a doubling in the mean per capita effective dose (1.2 mSv vs 2.3 mSv) and the proportion of enrollees who received high (>20-50 mSv) exposure (1.2% vs 2.5%) and very high (>50 mSv) annual radiation exposure (0.6% vs 1.4%). By 2010, 6.8% of enrollees who underwent imaging received high annual radiation exposure (>20-50 mSv) and 3.9% received very high annual exposure (>50 mSv). CONCLUSION: Within integrated health care systems, there was a large increase in the rate of advanced diagnostic imaging and associated radiation exposure between 1996 and 2010.

Evaluation of the PHQ-2 as a brief screen for detecting major depression among adolescents.

OBJECTIVE: To examine the validity of the Patient Health Questionnaire 2 (PHQ-2), a 2-item depression-screening scale, among adolescents. METHODS: After completing a brief depression screen, 499 youth (aged 13-17 years) who were enrolled in an integrated health care system were invited to participate in a full assessment, including a longer depression-screening scale (Patient Health Questionnaire 9-item depression screen) and a structured mental health interview (Diagnostic Interview Schedule for Children). Eighty-nine percent (n = 444) completed the assessment. Criterion validity and construct validity were tested by examining associations between the PHQ-2 and other measures of depression and functional impairment. RESULTS: A PHQ-2 score of > or =3 had a sensitivity of 74% and specificity of 75% for detecting youth who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for major depression on the Diagnostic Interview Schedule for Children and a sensitivity of 96% and specificity of 82% for detecting youth who met criteria for probable major depression on the Patient Health Questionnaire 9-item depression screen. On receiver operating characteristic analysis, the PHQ-2 had an area under the curve of 0.84 (95% confidence interval: 0.75-0.92), and a cut point of 3 was optimal for maximizing sensitivity without loss of specificity for detecting major depression. Youth with a PHQ-2 score of > or =3 had significantly higher functional-impairment scores and significantly higher scores for parent-reported internalizing problems than youth with scores of <3. CONCLUSIONS: The PHQ-2 has good sensitivity and specificity for detecting major depression. These properties, coupled with the brief nature of the instrument, make this tool promising as a first step for screening for adolescent depression in primary care.

Quality of surveillance for stage I testis cancer in the community.

PURPOSE: Patients with clinical stage I testicular germ cell tumors have been managed with adjuvant radiotherapy, chemotherapy, or retroperitoneal lymph node dissection (RPLND). The use of surveillance-only strategies at referral centers has yielded survival outcomes comparable to those achieved with adjuvant therapy. We evaluated compliance with follow-up protocols developed at referral centers within the community. METHODS: We identified patients with stage I testis cancer within a large private insurance claims database and calculated compliance of follow-up test use with guidelines from the National Comprehensive Cancer Network. RESULTS: Surveillance was widely used in the community. Compliance with surveillance and postadjuvant therapy follow-up testing was poor and degraded with increasing time from diagnosis. Nearly 30% of all surveillance patients received no abdominal imaging, chest imaging, or tumor marker tests within the first year of diagnosis. Patients who elected RPLND were most compliant with recommended follow-up testing within the first year. Recurrence rates were consistent with previously reported literature, despite poor compliance. CONCLUSION: Surveillance is a widely accepted strategy in clinical stage I testicular cancer treatment in the community. However, follow-up care recommendations developed at referral centers are not being adhered to in the community. Although recurrence rates are similar to those of reported literature, the clinical impact of noncompliance on recurrence severity and mortality are not known. Further prospective work needs to be done to evaluate this apparent quality of care problem in the community.

Access intervention in an integrated, prepaid group practice: effects on primary care physician productivity.

OBJECTIVE: To estimate the joint effect of a multifaceted access intervention on primary care physician (PCP) productivity in a large, integrated prepaid group practice. DATA SOURCES: Administrative records of physician characteristics, compensation and full-time equivalent (FTE) data, linked to enrollee utilization and cost information. STUDY DESIGN: Dependent measures per quarter per FTE were office visits, work relative value units (WRVUs), WRVUs per visit, panel size, and total cost per member per quarter (PMPQ), for PCPs employed >0.25 FTE. General estimating equation regression models were included provider and enrollee characteristics. PRINCIPAL FINDINGS: Panel size and RVUs per visit rose, while visits per FTE and PMPQ cost declined significantly between baseline and full implementation. Panel size rose and visits per FTE declined from baseline through rollout and full implementation. RVUs per visit and RVUs per FTE first declined, and then increased, for a significant net increase of RVUs per visit and an insignificant rise in RVUs per FTE between baseline and full implementation. PMPQ cost rose between baseline and rollout and then declined, for a significant overall decline between baseline and full implementation. CONCLUSIONS: This organization-wide access intervention was associated with improvements in several dimensions in PCP productivity and gains in clinical efficiency.

Complementary and alternative medicine use and cost in functional bowel disorders: a six month prospective study in a large HMO.

BACKGROUND: Functional Bowel Disorders (FBD) are chronic disorders that are difficult to treat and manage. Many patients and doctors are dissatisfied with the level of improvement in symptoms that can be achieved with standard medical care which may lead them to seek alternatives for care. There are currently no data on the types of Complementary and Alternative Medicine (CAM) used for FBDs other than Irritable Bowel Syndrome (IBS), or on the economic costs of CAM treatments. The aim of this study is to determine prevalence, types and costs of CAM in IBS, functional diarrhea, functional constipation, and functional abdominal pain. METHODS: 1012 Patients with FBD were recruited through a health care maintenance organization and followed for 6 months. Questionnaires were used to ascertain: Utilization and expenditures on CAM, symptom severity (IBS-SS), quality of life (IBS-QoL), psychological distress (BSI) and perceived treatment effectiveness. Costs for conventional medical care were extracted from administrative claims. RESULTS: CAM was used by 35% of patients, at a median yearly cost of $200. The most common CAM types were ginger, massage therapy and yoga. CAM use was associated with female gender, higher education, and anxiety. Satisfaction with physician care and perceived effectiveness of prescription medication were not associated with CAM use. Physician referral to a CAM provider was uncommon but the majority of patients receiving this recommendation followed their physician's advice. CONCLUSION: CAM is used by one-third of FBD patients. CAM use does not seem to be driven by dissatisfaction with conventional care. Physicians should discuss CAM use and effectiveness with their patients and refer patients if appropriate.

A comparison of health care utilization and costs of children with and without autism spectrum disorders in a large group-model health plan.

OBJECTIVE: Data on the current costs of medical services for children with autism spectrum disorders are lacking. Our purpose for this study was to compare health care utilization and costs of children with and without autism spectrum disorders in the same health plan. PATIENTS AND METHODS: Participants included all 2- to 18-year-old children with autism spectrum disorders (n = 3053) and a random sample of children without autism spectrum disorders (n = 30529) who were continuously enrolled in the Kaiser Permanente Medical Care Program in northern California between July 1, 2003, and June 30, 2004. Data on health care utilization and costs were derived from health plan administrative databases. MAIN OUTCOME MEASURES: Outcome measures included mean annual utilization and costs of health services per child. RESULTS: Children with autism spectrum disorders had a higher annual mean number of total clinic (5.6 vs 2.8), pediatric (2.3 vs 1.6), and psychiatric (2.2 vs 0.3) outpatient visits. A higher percentage of children with autism spectrum disorders experienced inpatient (3% vs 1%) and outpatient (5% vs 2%) hospitalizations. Children with autism spectrum disorders were nearly 9 times more likely to use psychotherapeutic medications and twice as likely to use gastrointestinal agents than children without autism spectrum disorders. Mean annual member costs for hospitalizations (550 dollars vs 208 dollars), clinic visits (1373 dollars vs 540 dollars), and prescription medications (724 dollars vs 96 dollars) were more than double for children with autism spectrum disorders compared with children without autism spectrum disorders. The mean annual age- and gender-adjusted total cost per member was more than threefold higher for children with autism spectrum disorders (2757 dollars vs 892 dollars). Among the subgroup of children with other psychiatric conditions, total mean annual costs were 45% higher for children with autism spectrum disorders compared with children without autism spectrum disorders; excess costs were largely explained by the increased use of psychotherapeutic medications. CONCLUSIONS: The utilization and costs of health care are substantially higher for children with autism spectrum disorders compared with children without autism spectrum disorders. Research is needed to evaluate the impact of improvements in the management of children with autism spectrum disorders on health care utilization and costs.

How safe is triage by an after-hours telephone call center?

OBJECTIVES: Our goals were to assess (1) compliance with nurse disposition recommendations, (2) frequency of death or potential underreferral associated with hospitalization within 24 hours after a call, and (3) factors associated with potential underreferral, for children receiving care within an integrated health care delivery organization who were triaged by a pediatric after-hours call center. METHODS: The study population included all pediatric patients enrolled in Kaiser Permanente Colorado whose families called the Children's Hospital after-hours call center in Denver, Colorado, during the period between October 1, 1999, and March 31, 2003. Postcall disposition recommendations were categorized as urgent (visit within 4 hours), next day (visit in > 4 hours but within 24 hours), later visit (visit in > 24 hours), or home care (care at home without a visit). Compliance with the nurses' triage disposition recommendations was calculated as the proportion of cases for which utilization data matched the disposition recommendations. RESULTS: Of the 32,968 eligible calls during the study period, 21% received urgent, 27% next day, 4% later visit, and 48% home care disposition recommendations. Rates of compliance with both urgent and home care disposition recommendations were 74%, and the rate of compliance with next day recommendations was 44%. No deaths occurred within < 1 week after the after-hours calls. The rate of potential underreferral with subsequent hospitalization was 0.2%, or 1 case per 599 triaged calls. In multivariate modeling, age of < 6 weeks or > 12 years and being triaged after 11 pm were associated with higher rates of potential under-referral. CONCLUSIONS: Approximately three fourths of families complied with recommendations for their child to be evaluated urgently or to be treated at home, with much lower rates of compliance with intermediate dispositions. The rate of potential underreferral with hospitalization was low, and age and time of call triage were associated with this outcome.

Use of raloxifene among women with a history of breast cancer.

PURPOSE: To examine raloxifene use among women with a history of breast cancer. METHODS: Kaiser Permanente tumor registry and membership files were used to identify women diagnosed with breast cancer after 1994 who were health plan members in 1998 or later, when raloxifene became available. Information on raloxifene treatment was obtained from computerized pharmacy records. Treatment patterns were examined and the characteristics of those who did and did not receive raloxifene were compared. RESULTS: Among the 17,968 women with a history of breast cancer, 711 (4.0%) had at least one prescription for raloxifene. Use among these women was more common than among similarly aged women in the health plan without a history of breast cancer, especially among those less than age 60 years. Among women with a history of breast cancer, raloxifene users were more than twice as likely as non-users to have had a bone mineral density test (60 versus 26%, p<0.0001) and, if tested, were more likely to have osteopenia or osteoporosis (80 versus 63%, p<0.0001). Compared to non-users, users had earlier stage breast cancer at diagnosis (80% versus 71% with local disease, p<0.0001). Raloxifene use was largely restricted to women whose initial breast cancer had not been treated with adjuvant tamoxifen or who had received less than 5 years of tamoxifen therapy. CONCLUSION: In this setting, raloxifene use among women with a history of breast cancer is related to stage at diagnosis and bone mineral density and is rare among women who have completed a 5-year course of adjuvant tamoxifen.

Food fortification with folic acid and rate of multiple births, 1994-2000.

BACKGROUND: Since fortification of cereal grain products with synthetic folic acid (FA) became mandatory in January 1998, women in the United States who have become pregnant have been exposed to a higher level of FA than women who became pregnant previously. Some studies have suggested that increased FA consumption might increase the risk of multiple gestation pregnancies. METHODS: Women who had a live birth in Kaiser Foundation Health Plan hospitals from January 1, 1994 through December 31, 2000; all multiple births; and the use of ovulation-inducing drugs were ascertained from electronic databases. Medical records of a sample of women with multiple births who did not use ovulation-inducing drugs were reviewed to determine whether they used assisted reproductive technology. Exposure to FA-fortified foods was based on date of delivery. RESULTS: The rate of multiple births increased from 13.6 to 14.8 per 1000 live births from 1994 through 2000. The percentage of women who had a multiple birth and who filled a prescription for an ovulation-inducing drug in the 12 months before delivery increased from a low of 6.6% in 1994 to a high of 14.9% in 2000. After excluding women using ovulation-inducing drugs, the increased rate of multiple births was no longer observed. CONCLUSIONS: While the rates of multiple births have increased since FA fortification became mandatory, this increase can be explained by the increased use of ovulation-inducing drugs. Our findings show no relationship between food fortification with FA and the rates of multiple births in this large, managed health care population.

Use of complementary and alternative medicine by the adult membership of a large northern California health maintenance organization, 1999.

Data from general health surveys completed by random samples of adult members of a large Northern California health maintenance organization in 1996 and 1999 were used to investigate (a) the prevalence of use of 15 complementary and alternative medicine (CAM) modalities by adult members in 1999, (b) how prevalence varied by age group and gender, and (c) which modalities were increasing in popularity. While Northern California is not representative of the nation as a whole, it tends to be a harbinger of trends to come. The most widely used modalities in 1999 were herbal and other nonvitamin/nonmineral nutritional supplements, prayer/spiritual healing done by oneself, chiropractic, massage therapy, and mind-body medicine modalities. However, use of the different modalities varied significantly by age and gender, and rates of use of nutritional supplements and the manipulatives were approximately doubled, when restricted to subpopulations at high risk, for use because of relevant health conditions. There appeared to be a statistically significant, but modest increase in CAM use, mostly due to a large increase in use of nutritional supplements. Implications for how CAM use should be tracked for ambulatory care populations and the importance of addressing nutritional supplement use in ambulatory clinical care are discussed.

Nonvitamin, nonmineral supplement use over a 12-month period by adult members of a large health maintenance organization.

OBJECTIVE: National survey data show an increase in the prevalence of nonvitamin, nonmineral (NVNM) supplement use among adults over the past 10 years. Concern over this trend is based in part on reports of potential drug-supplement interactions. The type and prevalence of supplement use by demographic and behavior characteristics were examined among members of a large group model health plan, including those with selected health conditions. DESIGN: Data on the use of herbal medicines and dietary supplements among survey respondents were analyzed. Questions employed a checklist for six specific NVNM supplements with optional write-ins. SUBJECTS/SETTING: A stratified random sample of 15,985 adult members of a large group model health maintenance organization in northern California, who were respondents to a 1999 general health survey. STATISTICAL ANALYSES PERFORMED: Analyses were conducted with poststratification weighted data to reflect the actual age, gender, and geographic distribution of the adult membership from which the sample was drawn. RESULTS: An estimated 32.7% of adult health plan members used at least one NVNM supplement. The most frequently used herbs were Echinacea (14.7%) and Gingko biloba (10.9%). Use of all NVNM supplements was highest among females, 45 to 64 years of age, whites, college graduates, and among those with selected health conditions. APPLICATIONS: Dietetics professionals need to uniformly screen clients for dietary supplement use and provide accurate information and appropriate referrals to users.

Managed care arrangements of health networks and systems. A review of the 1999 experience.

The 1990s witnessed various health provider efforts to integrate health care delivery with financing functions. Physician and hospital-led organizations developed their own insurance products and also contracted on a capitated or shared-risk basis with health maintenance organizations (HMOs). Several studies exist on the efforts of physician-led health organizations in these areas, but few studies exist on hospital-led organizations. We examined unique data on hospital-led health networks and systems for 1999 and found that about 60% had provider-owned insurance products and 50% held capitated contracts for their affiliates. In addition, these hospital-led organizations--especially health systems--had comparable levels of capitated contracting when compared to physician-led organizations. Although interest in capitation has waned, current economic realities may reignite interest in these arrangements given their potential for containing health expenditures without increasing consumer risk. In light of this, it is now a good time for physicians and medical group managers to reflect on their experiences in the 1990s and to assess the merits and shortcomings of different intermediary organizations with which they may align.