Drinking patterns, health care utilization, and costs among HMO primary care patients.

A survey of 8,034 primary care patients in a health maintenance organization examined the relationship between alcohol consumption and health care costs and service use. Costs were estimated from service use data for 1 year before and 2 years after study enrollment. No strong, consistent relationships were identified between multiple indicators of drinking patterns and either health care costs or service use. Compared with total costs among very light drinkers, former drinkers were higher, lifetime abstainers were similar, and persons in the higher drinking levels tended to have lower but not significantly different costs. Drinking patterns did not appear to be an important predictor of short-term health care costs or service use in this setting. Further study of former drinkers is warranted to examine the role of alcohol-related illnesses in the decision to quit drinking.

The health and health behaviors of people who do not drink alcohol.

BACKGROUND: Compared to abstention, moderate drinking has been linked to better health, and heavy and hazardous drinking to increased morbidity and mortality. Many studies have failed to account for heterogeneity in health and drinking history among nondrinkers, however. If former drinkers quit in response to ill health, this could increase the risk in the nondrinker category and underestimate the effects of alcohol if illnesses leading to abstention are alcohol-related. In addition, health behaviors may vary with drinking status, affecting health outcomes often attributed to drinking. METHODS: Survey data were collected from a probability sample of a large health maintenance organization's membership. Regression analyses assess the relationship between drinking status (adjusting for covariates), mental and physical health and functioning, and health behaviors. RESULTS: Former drinkers and lifelong abstainers had worse health and functioning than current drinkers and, comparatively, former drinkers had worse health than lifelong abstainers. Former drinkers did not differ from light-to-moderate drinkers in regard to health behaviors (except for smoking), although lifelong abstainers and heavier drinkers were less likely to use preventive care or try to improve their health behaviors. CONCLUSIONS: Consistent with hypotheses that former drinkers may stop drinking because of poor health, former drinkers were less healthy than current drinkers and had slightly worse health than lifelong abstainers, compared to light-to-moderate drinkers. Former drinkers did not appear to be at risk because of poorer health behaviors (except smoking), but lifelong abstainers and heavier drinkers might benefit from outreach designed to increase use of preventive care and improve health behaviors.

Caregiving, alcohol use, and mental health symptoms among HMO members.

Using data from a survey of 5841 HMO members, we examined alcohol consumption, depression and anxiety symptoms, and health services use among 689 informal caregivers. Characteristics of caregivers included whom they cared for, types of care provided, number of people cared for, and whether care was provided in the caregiver's home. Outcome measures in hierarchical linear and logistic stepwise regression models included indicators of alcohol drinking pattern, symptoms of anxiety and depression, role limits due to emotional problems and self-reported doctor's visits. Adjusting for age and gender differences, caregivers reported more bodily pain, worse role functioning related to emotional problems, were more likely to screen as depressed, and were more likely to report symptoms of anxiety. Older caregivers, and those with greater vitality, had better mental health outcomes; caregivers with higher levels of education reported better psychological well-being and less interference with role functioning due to emotional problems. Caregivers did not make more doctor's visits than non-caregivers. No caregiving characteristics were consistently associated with both mental health and alcohol consumption outcomes. The relationship of the care recipient to the caregiver predicted mental health outcomes better than either the type of care, number cared for, or location of care. Both the type of care and relationship to the care provider were associated with alcohol consumption, and several gender interactions were identified. Our results confirm previous findings of greater mental health problems among caregivers, yet suggest that caregivers may not be seeking services commensurate to their needs.

Gender and alcohol use: the roles of social support, chronic illness, and psychological well-being.

Men and women differ in their use of alcohol, in their rates of chronic illnesses and psychological symptoms, and in the social support they receive. In this paper, we assess how the latter three factors are associated with alcohol use, and how these associations differ by gender. Respondents were 3,074 male and 3,947 female randomly selected Health Maintenance Organization members who responded to a mail survey in 1990. Hierarchical multiple regression analyses indicate that social support is associated with alcohol consumption in similar ways for both genders, yet the associations between some demographic, physical health/functioning, and psychological well-being measures are different for men and women. Men with fewer role limits due to physical health drank more, while women with better psychological well-being drank less. Poor psychological well-being may be a modifiable risk factor for increased alcohol use among women; practitioners should be alert for greater consumption among men with few functional limitations and good health.

Screening and brief intervention for hazardous drinking in an HMO: effects on medical care utilization.

This study examined whether a brief intervention to reduce hazardous alcohol consumption among primary care patients reduced use of medical care. In a parent, randomized controlled trial, at-risk drinkers identified in HMO outpatient waiting rooms were randomly assigned to receive usual care or brief clinician advice plus a 15-minute motivational counseling session. The current study (n = 514) examined the groups' use of outpatient and inpatient medical services during two years after intervention. Although the intervention reduced alcohol consumption at six-month follow-up, intervention and control groups made similar numbers of outpatient visits (M = 17.7 vs. 18.3, respectively; p = .47), were equally likely to be hospitalized (21.2% vs. 22.0%; p = .81), and among those hospitalized, had similar lengths of stay (4.7 vs. 6.6 days; p = .37). Although brief interventions to reduce hazardous drinking may potentially reduce medical care utilization, more evidence is needed to substantiate their practicality and cost-effectiveness.

Adolescent health care visits: opportunities for brief prevention messages.

CONTEXT: It has been suggested that clinicians should increase efforts to modify and prevent risky behavior in adolescents. Professional organizations have proposed recommendations about access to care and preventive services, but it is difficult to know where and how to most effectively deliver such services. PRACTICE PATTERN EXAMINED: Clinic visits among adolescent HMO members (14 to 17 years of age). SETTING: Kaiser Permanente Northwest Division, a medium-sized, nonprofit, group-model HMO in the Pacific Northwest. DATA SOURCES: Two administrative databases (one for membership and one for outpatient utilization). RESULTS: A total of 22,626 adolescents who met the inclusion criteria were identified. Of these, 62% (more than 14,000 adolescents) were seen in a primary care clinic within 1 year; almost 83% (more than 18,000 adolescents) were seen within 2 years. There were several opportunities for follow-up for adolescents who had at least one visit in 1995: 60% had more than one visit during 1995, and 80% had more than one visit over the 2-year span of 1995 and 1996. The largest number of adolescent visits occurred in August through November, and most visits took place in the afternoon. CONCLUSIONS: Primary care visits in an HMO present an excellent opportunity to reach many teenagers outside of a school setting. Short-term educational or prevention programs would be optimal during late summer and fall; additional staff members may be able to present these programs after school once school begins.

Brief intervention in a primary care setting for hazardous drinkers.

INTRODUCTION: The study was designed to test a brief intervention for reducing alcohol consumption among moderate to heavy (hazardous) drinkers in a busy HMO primary care setting. METHODS: In a randomized controlled trial, hazardous drinkers (n = 516) were identified by the AUDIT screening questionnaire. Intervention included brief clinician advice (30 seconds), a 15-minute motivational session by counselors, and printed materials. RESULTS: At six-month follow-up, intervention subjects reported fewer total standard drinks in the past three months (176 versus 216, P = .04, one-tailed) and fewer drinking days per week (2.8 versus 3.3, P = .02) than controls, but similar drinks per drinking day (3.3 versus 3.5; P = .13). At 12 months, intervention subjects again reported fewer drinking days per week (2.7 versus 3.1; P = .04) than controls, but similar numbers of standard drinks (157 versus 179; P = .13) and drinks per drinking day (3.6 versus 3.3; P = .20). Intervention subjects were somewhat more likely than controls to report drinking within daily recommended limits (< or = 3 for men, < or = 2 for women) at both six months (79% versus 71%; P = .06) and 12 months (80% versus 73%; P = .07), but did not differ significantly from controls on other drinking outcomes (percent abstinent, frequency of drinking > or = 6 drinks per drinking occasion, estimated peak blood alcohol concentration), or use of medical care in the year following intervention. CONCLUSIONS: A one-time, brief motivational intervention using minimal clinician time supplemented by trained counselors resulted in a modest reduction in frequency of alcohol consumption in a busy primary care population. Future research should focus on strengthening and maintaining intervention effects.

Adolescent drug misuse treatment and use of medical care services.

Research on adults has documented that use of medical services decreases after initiation of treatment for alcohol problems, but little is known about this relationship among adolescents. We studied utilization and costs of care following participation in the Adolescent Chemical Health Program (ACHP) of Kaiser Permanente, Northwest Region, in 1986-88. Three groups of adolescents (and their parents) were identified: adolescents who were assessed and initiated treatment in ACHP (n = 561), adolescents who were assessed and recommended for treatment but did not return for treatment (n = 278), and adolescents with no known substance use problems (n = 381). Medical records were reviewed for 1 year pre- and 1.5 years postassessment. After adjusting for preassessment medical visits, severity of alcohol and drug use, gender, and age, analyses suggested that substance user treatment was not associated with reduced use of medical services or costs by either adolescents or parents.

Health care use by frequent marijuana smokers who do not smoke tobacco.

Even though marijuana smoke contains carcinogens and more tar than tobacco smoke and marijuana intoxication has been implicated as a risk factor for injuries, relatively little epidemiologic evidence has identified marijuana use as a risk factor for ill health. This study is the first to examine the health effects of smoking marijuana by comparing the medical experience of "daily" marijuana smokers who never smoked tobacco (n = 452) with a demographically similar group of nonsmokers of either substance (n = 450). Marijuana smoking status was determined during multiphasic health checkups at Kaiser Permanente medical centers between July 1979 and December 1985. Medical records were reviewed for as long as 2 years after the checkups. Frequent marijuana smokers had small increased risks of outpatient visits for respiratory illnesses (relative risk [RR] = 1.19; 95% confidence interval [CI] = 1.01, 1.41), injuries (RR = 1.32; CI = 1.10, 1.57), and other types of illnesses (RR = 1.09; CI = 1.02, 1.16) compared with nonsmokers; their risk of being admitted to a hospital was elevated but not statistically significant (RR = 1.51; CI = 0.93, 2.46). Analyses were adjusted for sex, age, race, education, marital status, and alcohol consumption. Daily marijuana smoking, even in the absence of tobacco, appeared to be associated with an elevated risk of health care use for various health problems.

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.

The risk of miscarriage and birth defects among women who use visual display terminals during pregnancy.

Use of visual display terminals (VDTs) was examined in a case-control study of pregnancy outcome among 1,583 pregnant women who attended three Kaiser Permanente obstetrics and gynecology clinics in Northern California, 1981-1982. We found a significantly elevated risk of miscarriage for working women who reported using VDTs for more than 20 hr per week during the first trimester of pregnancy compared to other working women who reported not using VDTs (odds ratio 1.8, 95% CI: 1.2-2.8). This risk could not be explained by age, education, occupation, smoking, alcohol consumption, or other maternal characteristics. No significantly elevated risk for birth defects was found among working women although odds ratios were 1.4 for both moderate and high VDT exposure, compared with no exposure (95% CI: 0.7-2.7 and 0.7-2.9, respectively). One possible explanation for these findings is that women who had adverse pregnancy outcomes may have overreported their exposures to VDTs and/or women with normal births may have underreported theirs. The findings may also be due to unmeasured factors confounded with high VDT use such as poor ergonomic conditions or job-related stress. That VDTs themselves are hazardous to the pregnant operator remains a possibility. Our results underscore the need for large cohort studies of working women that will provide objective measures of VDT exposures, ergonomic factors, and stress.

US Preventive Services Task Force. Automobile injury--selected risk factors and prevention in the health care setting.

Every year, highway crashes cause tens of thousands of deaths and millions of nonfatal injuries, many of which can be prevented. Following a mandate from the US Preventive Services Task Force, in this article we describe the magnitude of the automobile injury problem, identify injury risk factors that might be reduced by clinically based preventive programs, and review reports of interventions by health professionals to promote the use of child restraint devices, the only area in which we found published evaluations. We conclude that despite the lack of experimental evidence of the long-term effectiveness of clinically based efforts to promote occupant restraint use, such efforts may be warranted because of the enormous social and economic costs of automobile injury. In addition, physicians and other health professionals are urged to consider promoting nonclinical automobile injury prevention measures.

Smoking habits among multiphasic examinees, 1979 to 1984.

In tabulating the smoking habits of 95,744 residents of the San Francisco Bay Area, as reported between July 1979 and June 1984 at multiphasic health checkups, the prevalence of current smoking was found to be higher in men than in women aged 30 years and above, but in those younger than 30 the reverse was true. In every age group, compared with male smokers, female smokers tended to smoke fewer cigarettes per day, to inhale less and to smoke cigarettes with lower tar and nicotine yield. Blacks showed the highest percentage of smokers, whites were second highest and Asians were lowest, with Asian women being substantially lower than other race-sex groups. On average, white smokers smoked more cigarettes per day and inhaled more than did black smokers, but whites were more apt to smoke low-yield cigarettes. Compared with a 1964 to 1968 study in the same setting, there has been a decrease in the prevalence of cigarette smokers but, among smokers, a higher proportion in 1979 to 1984 smoked at least 20 cigarettes per day. During the 1979 to 1984 period, there were small downward trends in the prevalence of cigarette smoking in men and white women and in the prevalence of heavy smoking among male smokers, but there was no apparent increase in the use of lower-yield cigarettes by smokers. Although this study group contained relatively fewer smokers, most of the age, sex and racial differences and long-term trends parallel what has been observed nationally.

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.