Randomized trial of case-finding for depression in elderly primary care patients.

OBJECTIVE: To determine the effect of case-finding for depression on frequency of depression diagnoses, prescriptions for antidepressant medications, prevalence of depression, and health care utilization during 2 years of follow-up in elderly primary care patients. DESIGN: Randomized controlled trial. SETTING: Thirteen primary care medical clinics at the Kaiser Permanente Medical Center, an HMO in Oakland, Calif, were randomly assigned to intervention conditions (7 clinics) or control conditions (6 clinics). PARTICIPANTS: A total of 2,346 patients aged 65 years or older who were attending appointments at these clinics and completed the 15-item Geriatric Depression Scale (GDS). GDS scores of 6 or more were considered suggestive of depression. INTERVENTIONS: Primary care physicians in the intervention clinics were notified of their patients' GDS scores. We suggested that participants with severe depressive symptoms (GDS score >/= 11) be referred to the Psychiatry Department and participants with mild to moderate depressive symptoms (GDS score of 6 -10) be evaluated and treated by the primary care physician. Intervention group participants with GDS scores suggestive of depression were also offered a series of organized educational group sessions on coping with depression led by a psychiatric nurse. Primary care physicians in the control clinics were not notified of their patients' GDS scores or advised of the availability of the patient education program (usual care). Participants were followed for 2 years. MEASUREMENTS AND MAIN RESULTS: Physician diagnosis of depression, prescriptions for antidepressant medications, prevalence of depression as measured by the GDS at 2-year follow-up, and health care utilization were determined. A total of 331 participants (14%) had GDS scores suggestive of depression (GDS >/= 6) at baseline, including 162 in the intervention group and 169 in the control group. During the 2-year follow-up period, 56 (35%) of the intervention participants and 58 (34%) of the control participants received a physician diagnosis of depression (odds ratio [OR], 1.0; 95% confidence interval [CI], 0.6 to 1.6; P =.96). Prescriptions for antidepressants were received by 59 (36%) of the intervention participants and 72 (43%) of the control participants (OR, 0.8; 95% CI, 0.5 to 1.2; P =.3). Two-year follow-up GDS scores were available for 206 participants (69% of survivors): at that time, 41 (42%) of the 97 intervention participants and 54 (50%) of the 109 control participants had GDS scores suggestive of depression (OR, 0.7; 95% CI, 0.4 to 1.3; P =.3). Comparing participants in the intervention and control groups, there were no significant differences in mean GDS change scores (-2.4 +/- SD 3.7 vs -2.1 SD +/- 3.6; P =.5) at the 2-year follow-up, nor were there significant differences in mean number of clinic visits (1.8 +/- SD 3.1 vs 1.6 +/- SD 2.8; P =.5) or mean number of hospitalizations (1.1 +/- SD 1.6 vs 1.0 +/- SD 1.4; P =.8) during the 2-year period. In participants with initial GDS scores > 11, there was a mean change in GDS score of -5.6 +/- SD 3.9 for intervention participants (n = 13) and -3.4 +/- SD 4.5 for control participants (n = 21). Adjusting for differences in baseline characteristics between groups did not affect results. CONCLUSIONS: We were unable to demonstrate any benefit from case-finding for depression during 2 years of follow-up in elderly primary care patients. Studies are needed to determine whether case-finding combined with more intensive patient education and follow-up will improve outcomes of primary care patients with depression.

Health practices of adults with elder care responsibilities.

BACKGROUND: This study examined health-risk behaviors and preventive health care activities among caregivers for older adults. METHODS: Survey questionnaires regarding health practices were completed by 272 caregivers and 917 noncaregivers selected through a stratified random sample of persons age 50 or older who were members of the Kaiser Foundation Health Plan in Northern California. RESULTS: Controlling for age, gender, race, education, marital status, and income level, caregivers were more likely than noncaregivers to eat breakfast daily, get flu shots, and receive pneumonia vaccines. Caregivers and noncaregivers did not differ significantly with regard to any of 10 other health practices or to the total number of positive health behaviors. Poorer health practices were associated with nonwhite racial identification, low income level, part-time employment, and health limitations. CONCLUSIONS: These findings suggest that, at least for caregivers who have access to the extensive health promotion resources of a large health maintenance organization, caregiving responsibilities may not always have the deleterious impact on health and health practices that had previously been assumed.

Senior Team Assessment and Referral Program--STAR.

BACKGROUND: Although comprehensive geriatric assessment has been found to improve health and function and decrease hospital admissions, most such programs are staff-intensive and take many hours or even days. The Senior Team Assessment and Referral Program (STAR) was developed to address these two issues by using a short but comprehensive outpatient health appraisal that required only a few health professionals to complete. METHODS: Six hundred forty-nine Kaiser Permanente health plan members aged 65 years or older who received their health care at the Kaiser Permanente Medical Center, San Jose, Calif, were randomly selected during the first 12 months of the study and invited by mail to participate in STAR. Of those members contacted, 326 agreed to join the study. A nurse practitioner evaluated the health, functional, and social status of each STAR participant at an office visit once each year for the next 3 years and provided case management for those participants found to be frail or in danger of becoming frail. A control group of 764 elderly (aged 65 years and older) Kaiser members with characteristics similar to those of the STAR participants was drawn from Kaiser Permanente health plan members in San Jose. They continued to receive usual medical care throughout the study. A medical-functional profile was developed to stratify each STAR participant's overall health and functional status at each visit and case management contact. The results were entered on a grid that was used as a tracking tool throughout the study. Utilization of medical services, changes in health and function, and effects of STAR interventions on participant health behaviors were measured, and primary care physician and participant satisfaction was assessed. RESULTS: Although short-term utilization of medical services increased in the STAR group, health, function, and health behaviors improved as a result of STAR interventions. Ninety-three percent of the STAR participants described a satisfactory experience, and 71 percent were very satisfied. Sixty-five percent of primary care physicians who responded to a satisfaction questionnaire found something useful for their patients in the STAR assessment. CONCLUSIONS: STAR offers an efficient, minimally staff-intensive model for evaluating the health, functional, and social status of the 65-year-old and older age-group and intervening when they are frail or at risk of becoming frail. The improved health, function, and healthy behaviors in STAR participants and the high satisfaction rates among participants and physicians suggest that STAR would be a useful addition to the health care environment.

Alcohol-related health services use and identification of patients in the emergency department.

STUDY OBJECTIVE: To determine the relationship between alcohol-related emergency department visits and alcohol-related outpatient visits and the extent of identification and referral of these ED patients for alcohol treatment. METHODS: A representative sample of ED patients in three medical centers of a large northern California health maintenance organization were interviewed and given breath alcohol tests, and their medical records were reviewed. An alcohol-related ED visit was defined as a visit meeting one or more of the following criteria: positive breath alcohol test result (.01 mg/dL or more), report of drinking in the 6 hours before the presenting injury or illness, ED visit for an alcohol-related problem, and a medical record notation of excessive alcohol use or an alcohol problem. RESULTS: Among 988 ED patients, 91 were found to have an alcohol-related ED visit. Of the 91, 6 made an alcohol-related outpatient visit in the 12 months before the ED visit, and 10 made such a visit in the following 6 months. Among the 91 patients, 10 were identified as having an alcohol problem by the ED staff, and 1 was referred for alcohol treatment. CONCLUSION: The ED is an important point for the early identification and referral for treatment of alcohol-dependent and problem drinkers. The patient may make an alcohol-related ED visit relatively early in the pattern of alcohol-related health care use.

Alcohol use and medical care utilization among health maintenance organization patients in the emergency department.

OBJECTIVE: To determine the association of an alcohol-related ED visit with medical care utilization during a two-year period surrounding the ED visit in an HMO. METHODS: A probability sample of ED patients were interviewed and underwent breath analysis in a large HMO in a Northern California county. Based on recent alcohol intake or documentation of an alcohol-related ED visit, the patients were assigned to an alcohol group (n = 91) or a non-alcohol group (n = 897). A 10% random sample of the health plan membership of the same county (n = 19,968) served as a comparison group. Utilization data were obtained from computerized files. Multiple linear regression was used to determine differences in subsequent outpatient visit rates between the alcohol and the non-alcohol groups. Logistic regression was used to compare the risks of hospitalization in the two groups. RESULTS: Annual outpatient visit rates were 7.8 in the alcohol group and 8.3 in the non-alcohol group (p = 0.65), controlling for gender, age, and injury status, and were significantly different from the visit rate of 5.5 for the random health plan sample (p = 0.0001). No difference was found between the alcohol and the non-alcohol groups for risk of hospitalization; however, those in the health plan sample were less than half as likely to be hospitalized as were those in the non-alcohol group (odds ratio 0.44, p = 0.002). CONCLUSIONS: No difference was found in utilization of medical services between the alcohol and the non-alcohol groups in this predominantly white, well-educated HMO ED population. However, both groups used significantly more inpatient and outpatient services than did the general HMO membership.

The effect of retirement on mental health and health behaviors: the Kaiser Permanente Retirement Study.

To assess the short-term effect of retirement on mental health and health behaviors of members of a health maintenance organization aged 60-66, questionnaires were completed in 1985 and 1987 by employed members planning to retire during the study period and those not planning to retire. Mental health and health behaviors of members who actually retired (n = 320) were compared with those members who did not retire (n = 275). Using logistic regression controlling for age, gender, marital status, and education, we found that retired members were more likely to have lower stress levels and to engage in regular exercise more often as compared to those who did not retire during the study period. Retired women were more likely to report no alcohol problems as compared to nonretired women. There were no differences between the groups on self-reported mental health status, coping, depression, smoking, alcohol consumption, and frequency of drunkenness. These findings underscore the importance of assessing positive benefits associated with retirement and call for further evaluation of whether these benefits persist over time.

Health conditions and service utilization of adults with elder care responsibilities.

This study examines health conditions and health care services utilization rates of 628 caregivers and 6,599 noncaregivers age 50 or older who were members of Kaiser Foundation Health Plan in Northern California. Controlling for age, gender, and race, caregivers were more likely than noncaregivers to report backaches, insomnia, arthritis, rectal problems, and hearing problems; they were also more likely to report having two or more current health conditions of any kind. However, caregivers and noncaregivers did not differ significantly with regard to the number of outpatient medical visits or with regard to the number of outpatient psychiatry visits.

Home blood pressure monitoring. Effect on use of medical services and medical care costs.

The objective of this study was to determine whether a hypertension management program in which patients monitor their own blood pressure (BP) at home can reduce costs without compromising BP control. The prospective, randomized, controlled 1-year clinical trial was conducted at four medical centers of the Kaiser Permanente Medical Care Program in the San Francisco Bay Area. Of 467 patients with uncomplicated hypertension who were referred by their physicians, 37 declined to participate in the study; 215 were randomly assigned to a Usual Care (UC) group and 215 to a Home BP group. Twenty-five UC patients and 15 Home BP patients did not return for year-end BP measurements. Patients in the UC group were referred back to their physicians. Patients in the Home BP group were trained to measure their own BP and return the readings by mail. Patients were given a standard procedure to follow in case of unusually high or low BP readings at home. The number and type of outpatient medical services used were obtained from patient medical records for the study year and the prior year. Costs of care for hypertension were calculated by assigning relative value units to each outpatient service. Trained technicians measured each patient's BP at entry into the study and 1 year later. Home BP patients made 1.2 fewer hypertension-related office visits than UC patients during the study year (95% confidence interval (CI): 0.8, 1.7). Mean adjusted cost for physician visits, telephone calls, and laboratory tests associated with hypertension care was $88.76 per patient per year in the Home BP group, 29% less than in the UC group (95% CI: $16.11, $54.74). The annualized cost of implementing the home BP system was approximately $28 per patient during the study year and would currently be approximately $15. After 1 year, BP control in men in the Home BP group was better than in men in the UC group; BP control was equally good in women in both groups. Management of uncomplicated hypertension based on periodic home BP reports can achieve BP control with fewer physician visits, resulting in substantial cost savings.

Alcohol problems and sense of coherence among older adults.

The relation between alcohol problems and sense of coherence (SOC), a salutogenic model developed by Antonovsky, was assessed on a sample of 952 older members of a health maintenance organization. Data on alcohol problems (5-item index) and SOC (9-item scale) were obtained from mailed questionnaires. Multiple regression analyses indicated that SOC was a significant negative predictor of alcohol problems while controlling for alcohol consumption level, frequency of drunkenness and demographic characteristics. In addition, SOC scores were significantly higher for a subsample of lighter drinkers who reported no alcohol problems in the last year and had not been drunk in the last year (n = 419) as compared to heavier drinkers who reported at least one alcohol problem in the last year, and reported being drunk at least once in the last year (n = 107). These findings emphasize the importance of assessing factors which contribute to healthier behaviors as opposed to focusing exclusively on predictors of pathogenic outcomes.

The effect of retirement on health services utilization: the Kaiser Permanente Retirement Study.

The relationship of retirement and use of medical services was investigated among members of the Kaiser Permanente Medical Care Program in Northern California. A mailed survey of a 10 percent random sample of members 60-66 years old (N = 10,202) was followed by a telephone interview of (a) all respondents who had planned to retire in the next year, and (b) a random sample of respondents who had not planned to retire: 253 had retired (Retired group) and 238 were still working 20 hours a week or more (Not Retired group). Medical charts were reviewed for one year before and after the retirement date for the Retired group and for one year before and after a randomly assigned anchor date for the Not Retired group. With the exception of urgent care and emergency visits, no significant difference was found between the two groups in overall use of outpatient and inpatient services following retirement.

Health status, retirement plans, and retirement. The Kaiser Permanente retirement study.

The purpose of this study was to assess the stability of short-term plans to retire and to evaluate the role of self-reported health status in predicting both plans to retire and actual retirement from a sample of 1,165 older members of a prepayment, group practice model, health maintenance organization. The study sample was derived from a random sample of members 60 to 66 years of age. Mailed questionnaires were completed that obtained data on the following variables: self-reported health status, work status, demographic variables, and plans to retire in the next year. Telephone interviews were conducted throughout the study period to determine dates of retirement from both those who planned to retire and those who had not. Results indicated that retirement plans were relatively stable for this population. Logistic regression analyses revealed that poorer health status was related to both retirement plans and actual retirement for women but not for men.

Methodologic issues in evaluating stop smoking programs.

Three methodologic issues (definitions of smoking, period of follow-up, composition of study group) were assessed in 426 persons five years after participation in a stop smoking program of a prepaid medical plan. When smoking was defined by measurement interval or by type or amount of tobacco smoked, smoking rates varied only slightly. Little information was gained by extending the follow-up period beyond the first year. However, study group composition (as defined by attendance at program sessions) had a pronounced effect on smoking rates. Those who attended fewer sessions were more likely to smoke during the follow-up period.

Clinical methods in smoking cessation: description and evaluation of a stop smoking clinic.

This study reports the results of the Kaiser-Permanente Stop Smoking Clinic and describes the philosophy and methods employed by the clinic in treating addictive smoking behavior. Of the 1,128 clients who registered for the group program, 57 per cent are abstinent six months after quitting smoking and 47 per cent are abstinent at one year. The clinic methods used are described in detail. They attempt to relate smoking behavior to the larger phenomenon of addiction.

The role of nurse practitioners in hypertension care.

1. Two groups of hypertensive patients, randomly assigned to either physician or nurse practitioner care, were compared, after two years of follow up, with respect to diastolic blood pressure reduction and utilization and costs of medical services. In addition, satisfaction with hypertension are was evaluated. 2. There was no statistical difference in mean diastolic blood pressure reduction between the physician and nurse practitioner groups. 3. Patients in the nurse practitioner group made more visits for hypertension care than those in the physician group; thus, even though the cost per nurse practitioner visit was lower than the cost per physician visit, the total annual cost of care per patient was higher in the nurse practitioner group. 4. Patients followed by nurse practitioners were very satisfied with their care. 5. Nurse practitioners provide excellent hypertension care and thereby save valuable physician time.

Influence of dosage and duration of therapy on the rate of response to methyclothiazide in essential hypertension.

One hundred twenty patients with essential hypertension were studied to determine whether patients who had not responded to the usual dose of a thiazide (methyclothiazide, 5 mg daily during a six-week drug trial) would respond to a higher dose (10 mg daily). The 14-week study was divided into three periods: (1) a two-week placebo period; (2) a six-week single-blind trial; and (3) a six-week period for double-blind dose comparison. Among the 77.3 percent of patients who responded to the drug, diastolic blood pressure was reduced to 90 mm Hg or lower. Two types of thiazide responders were identified-early and late. The early responders (50 percent of study patients), showed a significant reduction in diastolic blood pressure within four weeks; the late responders (27.3 percent) showed a modest reduction in diastolic blood pressure during the first four weeks of therapy, followed by a plateau lasting about two weeks, then a further significant reduction in blood pressure during the ensuing six weeks. Hypokalemia was more common in early responders. There were no significant differences in late response among patients who continued on the usual dose of methyclothiazide compared to those whose dosage was doubled, suggesting that the late response was not due to increasing the dose of the drug.

Pilot study of discussion groups of "worried well" patients in an ambulatory care setting.

Two pilot discussion groups were conducted for patients who met selected criteria indicating they were worried well patients (not requiring conventional medical care services). The objective of the groups was to explore and demonstrate the feasibility of utilizing an educational approach conducted by paraprofessional personnel, under physician supervision, for helping to meet the needs of such patients, thereby reducing utilization of more expensive physician resources. The findings indicated that 50 percent of the patients reduced the number of visits to the physician, and 60 percent perceived the experience as helpful.

Evaluation of an ambulatory medical-care delivery system.

We designed a medical-care-delivery system specifically to relieve the impaired access to care that has invariably assompanied the elimination of personal fees by prepaid plans, Medicare and other third-party payment plans. The solution involved the entry of patients through a paramedically staffed health-evaluation servece that effectively separated patients into three basic health-status groups-the well and worried well (68.4 per cent); the asymptomatic sick (3.9 per cent); and the sick (27.7 per cent)--a process that permitted matching the needs of each group with appropriate services. The system achieved increased physician accessibility to new patients by 20 times, reduced the waiting time for new appointments from six to eight weeks to a day or two, saved physician time and costs for entry work to a day or two, saved physician time and costs for entry work-up by 70 to 80 per cent reduced total resources used throughout the year by +32,550 per 1000 entrants, and proved very satisfactory to patients and generally so to staff.