Evaluation of a primary care nurse case management intervention for chronically ill community dwelling older people.

AIM: The purpose of this study was to test the effectiveness of a collaborative primary care nurse case management intervention emphasising collaboration between physicians, nurses and patients, risk identification, comprehensive assessment, collaborative planning, health monitoring, patient education and transitional care on healthcare utilisation and cost for community dwelling chronically ill older persons. BACKGROUND: Primary care teams comprised of nurses and primary care physicians have been suggested as a model for providing quality care to the chronically ill, but this type of intervention has not been systematically evaluated. DESIGN: A non-randomised, 36 month comparison of two geographically distinct primary care populations was conducted. METHODS: Six hundred and seventy-seven persons aged 65 and older were determined to be at high-risk for mortality, functional decline, or increased health service use. The treatment group (n = 400) received the intervention and the comparison group (n = 277) received usual care. Health plan claims files provided data on number of hospitalisations and bed days, emergency department (ED) visits, physician visits and total cost of care. RESULTS: After adjustment for baseline variables, there were no significant differences between the treatment and comparison group in the percentage of patients hospitalised or ED visits. However, among those hospitalised in the treatment group, the likelihood of being re-hospitalised was significantly reduced by 34% (p = 0·032). After adjusting for the cost of the intervention, although not statistically significant, the reduced hospital use resulted in cost savings of $106 per patient per month in the treatment group. CONCLUSIONS: The results indicate that a collaborative primary care nurse case management intervention has the potential to be an effective alternative to current primary care delivery system practice. RELEVANCE TO CLINICAL PRACTICE: The study suggests that a chronic care intervention emphasising collaboration between physicians, nurses and patients, may be more effective when implemented in integrated provider networks.

Cardiovascular effects of sibutramine in the treatment of obese adolescents: results of a randomized, double-blind, placebo-controlled study.

BACKGROUND: Adolescent obesity is a major public health problem. Treatment options in addition to behavioral therapy could include pharmacotherapy with sibutramine. OBJECTIVES: Concerns regarding increases in blood pressure and heart rate after sibutramine treatment in some adult patients precipitated the present analysis, which evaluated the cardiovascular safety of sibutramine plus a behavioral therapy program in obese adolescents. PATIENTS AND METHODS: With this 12-month, randomized, double-blind, placebo-controlled trial in 33 US clinics we studied 498 adolescents aged 12 to 16 years with multiethnic backgrounds and BMIs of 28.1 to 46.3 kg/m2. RESULTS: The subjects were randomly assigned to behavioral therapy plus 10 mg of sibutramine or behavioral therapy plus placebo daily. At the end point, there was a mean treatment group difference in BMI of 2.6 kg/m2 in favor of sibutramine. Small mean decreases in blood pressure and pulse rate were seen in both sibutramine and placebo groups at the end point (systolic blood pressure: -2.1 vs -2.1 mmHg; diastolic blood pressure: -0.1 vs -1.1 mmHg; pulse rate: -0.2 vs -1.8 bpm). In both treatment groups, these reductions in vital signs were greater at the end point when BMI reduction was > or = 5% compared with < 5%. CONCLUSIONS: Sibutramine may have some direct cardiovascular effects on obese adolescents. These cardiovascular effects may be balanced by a reduction in BMI, which, in adolescents, seems to be greater than that observed in adults.

The MMPI-2 in sexual harassment and discrimination litigants.

In order to understand patterns of respondents on validity and clinical scales, this study analyzed archival Minnesota Multiphasic Personality Inventory 2s (MMPI-2s) produced by 192 women and 14 men who initiated legal claims of ongoing emotional harm related to workplace sexual harassment and discrimination. The MMPI-2s were administered as a part of a comprehensive psychiatric forensic evaluation of the claimants' current psychological condition. All validity and clinical scale scores were manually entered into the computer, and codetype and cluster analyses were obtained. Among the women, 28% produced a "normal limits" profile, providing no MMPI-2 support for their claims of ongoing emotional distress. Cluster analysis of the validity scales of the remaining profiles produced four distinctive clusters of profiles representing different approaches to the test items.

A New Tool for Encouraging Activity.

In brief Promoting physical activity among patients is an essential role for physicians. Project PACE (Physician-based Assessment and Counseling for Exercise) is a practical system of matching physician counseling with patient readiness for physical activity. The PACE counseling approach will help physicians attain national goals for health promotion for the year 2000.