Fluoride Varnish Application in the Primary Care Setting. A Clinical Study.

OBJECTIVES: The study objectives were twofold: 1. To examine how an intervention to apply fluoride varnish (FV) in a primary health setting to all young, low-income children was implemented and sustained and 2. To assess the feasibility of tracking medical care utilization in this population. STUDY DESIGN: The study included children age 1-5, insured through a government program, seen (7/1/2010-4/30/2012). Data on age, race, sex, clinic encounter, eligibility for and receipt of FV was obtained. The level of data in primary care, specialty care, urgent care and hospitalizations to assess feasibility of future patient tracking was also acquired.. RESULTS: Of 12,067 children, 85% received FV. Differences were found by age (youngest had highest rates). Small differences by race (81%-88%, highest in Blacks.) was found. No differences were found by sex. Ability to track over time was mixed. Approximately 50% had comprehensive data. However, primary care visit and hospitalization data was available on a larger percentage. CONCLUSIONS: FV programs can be introduced in the primary care setting and sustained. Further, long-term follow up is possible. Future study of such cohorts capturing health and cost benefits of oral health prevention efforts is needed.

Prevalence of excess lead absorption and associated risk factors in children enrolled in a midwestern health maintenance organization.

OBJECTIVE: To assess the prevalence of lead intoxication in children in a defined low-risk population at the new levels recommended by the Centers for Disease Control and Prevention. DESIGN: During an 11-month period, whole blood lead tests were performed on 4678 children at routine well-child visits at 9 months and 2 years of age. For the last 8 months of the study, parents were asked to complete a prescreening risk factor questionnaire at these visits. The questionnaire and blood lead results were then matched. Data were collected from October 1, 1991 through August 31, 1992. SETTING: The study subjects were all enrolled in Group Health, Inc, a large health maintenance organization. Its 17 staff model clinics serve urban and suburban populations in the Minneapolis-St. Paul area. More than 95% of the population had coverage based on employment, not Medicaid. RESULTS: Results indicated that 2.5% (n = 119) of the children had BPb levels > or = 10 micrograms/dL. Urban clinics had rates of elevated BPb levels three to eight times those of suburban clinics (P < .00001), but the number of elevated BPb levels at the suburban clinics was greater than expected. BPb levels were significantly higher in summer and fall (P < .00001). The prescreening questionnaire addressed five areas potentially associated with risk according to the literature: housing, siblings with lead poisoning, parental hobbies or work involving lead, proximity to highways, and use of cultural medicines. Positive correlations were found between elevated BPb levels and residences built before 1950 (P < .00001). For children living in housing built before 1950, positive correlations were found between elevated blood lead levels and peeling paint (P < .01) or remodeling (P < .0001). CONCLUSIONS: Children who are at low socioeconomic risk but who live in housing built before 1950 are at increased risk for lead poisoning. The risk is greater if the house has peeling paint and especially if there is recent or ongoing renovation. Recommendations based on these results and the Centers for Disease Control and Prevention guidelines are made for screening programs in similar populations, and for the need to increase community awareness concerning this issue.

What is the impact of osteoporosis education and bone mineral density testing for postmenopausal women in a managed care setting?

OBJECTIVE: To assess whether osteoporosis education, with and without bone mineral density (BMD) testing, increases the initiation of lifestyle changes and pharmaceutical treatment to prevent osteoporosis. DESIGN: A total of 508 women, aged 54-65, from a large managed care organization who were not on osteoporosis prevention therapy participated in an intervention study. Participants were randomly assigned to either an education class on osteoporosis (n = 301) or education plus BMD (n = 207). A control group of 187 women receiving no intervention were also surveyed to serve as comparison. Group differences and differences based on BMD test result were compared 6 months after education regarding self-reported changes in health behaviors using chi2 tests and logistic regression analyses. RESULTS: Of the 508 intervention participants, 455 (90%) responded to the follow-up survey. Initiation of hormone replacement therapy was reported by 9%, with 5% reporting starting alendronate. More than half reported changes in diet, exercise, or calcium intake. Forty-three percent increased their vitamin D intake. There were no significant group differences in behavior except with regard to pharmaceutical therapy; subjects with education plus BMD were three times more likely than those receiving education only to report starting hormone replacement therapy (p = 0.004). Low BMD scores were associated with increasing vitamin D intake (p = 0.03) and starting medication (p = 0.001). Women in the intervention groups were significantly more likely to report modifying their diet (p < 0.001), calcium (p < 0.01), and vitamin D intake (p < 0.0001) than women in the control group, not exposed to education. CONCLUSION: Education regarding osteoporosis prevention seems to encourage women to make lifestyle changes. The inclusion of BMD testing enhances the likelihood that women will consider pharmaceutical therapy.

Provider attitudes and self-reported behaviors related to hormone replacement therapy.

OBJECTIVE: The purpose of this study was to survey providers within a large health maintenance organization regarding their attitudes and practice patterns related to counseling women about hormone replacement therapy (HRT). DESIGN: A total of 260 providers from gynecology (n = 81), family practice (n = 96), and internal medicine (n = 83) from owned and contracted clinics were surveyed. Each was asked about prescribing philosophies, behaviors, and barriers to providing counseling regarding HRT. RESULTS: Respondents reported HRT's greatest benefit to be in the prevention of osteoporosis (99%) and cardiovascular conditions (96%). Gynecologists were more likely to report the benefits of HRT for Alzheimer's than were clinicians in internal medicine or family practice (p < 0.05), and women providers were more likely than men to report this (p < 0.01). There was no statistical difference based on years in practice. Providers did not vary significantly by specialty or sex in their concerns of risk for breast cancer of endometrial cancer. However, those in family practice and internal medicine were significantly more likely to report concern about thromboembolism (p < 0.01). Only 42% of physicians claimed to initiate discussion with their patients more than 75% of the time. The two factors most often mentioned as barriers to counseling were time and lack of adequate knowledge. CONCLUSIONS: Providers want to be an integral part of their patient's education regarding HRT; however, time constrains and a need for adequate information make this difficult. Now health systems must examine models of education for both providers and patients to ensure that women have access to current information with which to make informed decisions.

Clinical detection of depression among community-based elderly people with self-reported symptoms of depression.

BACKGROUND: Depression is under-diagnosed and under-treated in the primary care sector. The purpose of this study was to determine the association between self-reported indications of depression by community-dwelling elderly enrollees in a managed care organization and clinical detection of depression by primary care clinicians. METHODS: This was a 2-year cohort study of elderly people (n = 3410) who responded to the Geriatric Depression Scale (GDS) at the midpoint of the study period. A broad measure of clinical detection was used consisting of one or more of three indicators: diagnosis of depression, visit to a mental health specialist, or antidepressant medication treatment. RESULTS: Approximately half of the community-based elderly people with self-reported indications of depression (GDS > or = 11) did not have documentation of clinical detection of depression by health providers. Physician recognition of depression tended to increase with the severity of enrollees' self-reported feelings of depression. Men 65-74 years old and those > or = 85 years old were at highest risk for under-detection of depression by primary care providers. CONCLUSIONS: Clinical detection of depression of elderly people living in the community continues to be a problem. The implications of failure to recognize the possibility of depression among elderly White men suggest a serious public health problem.

Exemplary programs on midlife women's health issues in managed care settings.

OBJECTIVE: To identify exemplary programs on midlife women's health issues that have been developed and implemented in managed care settings. METHODS: Members of The American Association of Health Plans (AAHP) were invited by mail to submit information on their exemplary programs on midlife women's health issues. AAHP and HealthPartners Research Foundation established 12 criteria by which to evaluate the programs submitted. Following telephone interviews with representatives of eligible programs, they were asked to complete an extensive survey about their successful practices. The Women's Health Task Force of AAHP then reviewed and evaluated every program submission and selected 4 model programs on midlife issues for women. RESULTS: The 4 model programs included the use of health assessment questionnaires to assist providers in identifying risk areas and patients' needs for information; group educational sessions focusing on midlife issues related to lifestyle and hormone replacement therapy; a module-based curriculum syllabus; and an osteoporosis disease management program. All groups utilize multidisciplinary teams to develop and promote educational programs. CONCLUSIONS: As study findings add to our knowledge of menopause treatment approaches and as new information and products become available, some managed care plans are using innovative channels of communication to keep women informed.

Impact of birthweight on healthcare charges within a managed care organization.

OBJECTIVE: To determine the rate of low-birthweight (LBW) births and the association of LBW with utilization and healthcare charges in a managed care organization. DESIGN: Observational study of computerized and medical record data. PATIENTS AND METHODS: We assessed the rate of LBW (weight < 2500 g) for singleton infants born during 1993 and 1995 at 2 hospitals (1993, N = 3212; 1995, N = 3073). For a subset of infants born during 1995 (n = 1273), we examined differences in utilization and medical charges, by birthweight category (moderately LBW [MLBW; 1500 to 2499 g] vs normal birthweight [NBW]), at 1 year postdischarge. RESULTS: In both 1993 and 1995, 3% of singleton infants were LBW infants, and 2% to 3% were macrosomic (> or = 4500 g). Complete data for analyses of utilization and healthcare charges were available on 1273 infants who were enrolled for the entire postdischarge year. The use of outpatient, emergency department (ED), and subspecialty care by MLBW infants and by NBW infants was similar. However, MLBW was associated with an increased rate of rehospitalization during the first year of birth (P < .01). MLBW infants' medical care charges were 46% higher than those of NBW infants (P = .0125). CONCLUSIONS: MLBW infants and NBW infants had similar outpatient and ED service use during the first year after hospital discharge. Excess charges incurred by MLBW infants were primarily due to higher rates of rehospitalization. Of the 38 admissions, 21 were related to infection or fear of infection, and 4 were due to congenital malformations.

The role of depression in the association between self-rated physical health and clinically defined illness.

We enrolled 543 elderly participants of a managed care organization in a cross-sectional study to test whether the association between self-rated physical health and clinically defined illness differs for persons who are not depressed compared with persons with minor or serious depression. Depression was measured with the Diagnostic Interview Schedule (DIS). Clinically defined illness was measured with the Chronic Disease Score (CDS), a pharmacy-based measure. Additional variables included age, sex, and self-reported pain and physical function. Self-rated physical health was associated with both minor and serious depression, independent of clinically defined illness; minor depression was no longer significant when self-reported pain and physical function were added to the model. A significant negative correlation between self-rated physical health and clinically defined illness was observed for minor and no depression, but no correlation was seen for serious depression. These results confirm the association between depression and self-rated physical health and emphasize that, for persons with serious depression, self-rated health provides a less accurate picture of clinically defined illness at both ends of the spectrum. Also, a diagnosis of minor depression should not forestall investigation of inconsistencies between patient report and clinical evidence.

Assessing the impact of clinical guidelines: research lessons learned.

Clinical guidelines are proliferating. Here, a theoretical and practical perspective is presented on how to evaluate the effectiveness of guidelines and lessons learned from impact studies conducted. A nosology of guidelines is presented, along with the rationale for evaluating key dimensions, including degree of implementation, impact on process, outcomes, and cost of care, as well as provider and patient satisfaction. Key methodologic problems in evaluation and some possible ways to address them are addressed. Rapid and practical evaluation of clinical guidelines is a critical step that can both confirm their usefulness and direct their revision and improvement.

Interventions to implement a clinic-based smoking cessation guideline within a staff model HMO.

Smoking cessation guideline development has become widespread, outpacing guideline implementation efforts. To address this problem, HealthPartners undertook a randomized trial of strategies to enhance compliance of a smoking cessation guideline. The intervention aimed at clinic leadership resulted in significantly more compliance, as measured by physicians coding "tobacco use" on a billing form. The intervention aimed at all clinic physicians had no significant effect. The study suggests that smoking cessation guideline efforts should focus on clinic leadership and system changes rather than on all staff physicians.

Conducting randomized, controlled trials. Experience with the dysfunctional uterine bleeding intervention trial.

OBJECTIVE: To conduct a randomized, controlled trial (RCT) to examine issues associated with therapeutic alternatives to standard hysterectomy for women with dysfunctional uterine bleeding. STUDY DESIGN: Participants were to be randomly assigned to one of three treatment groups: hysterectomy, endometrial ablation and medical management. Recruitment was targeted at 375 women. RESULTS: Despite multiple recruitment strategies, recruitment was weak, with only five women enrolled after six months. Providers and women screened for eligibility often expressed discomfort with randomization. The protocol was amended to an elective treatment cohort design with a randomization component. Recruitment improved, with 37 women enrolled after four months. CONCLUSION: The success of RCTs may be affected by multiple factors. Acceptance of the protocol by patients and providers is essential. The RCT may present providers with a conflict between the goals of research and of providing optimal individualized care. Thus, RCTs may not always be appropriate for studies designed to examine best treatments in clinical practice, and nonrandomized designs may provide appropriate alternatives in some cases.

Implementation of an active management of labor guideline in a managed care setting.

This article reports on a study assessing the impact of a clinical guideline for the active management of labor. Modest changes were noted in the process of care with minimal impact on outcomes. Results might have been enhanced if more systems had been in place and if provider training had involved more comprehensive discussion and feedback on each of the components.

Use of urokinase in pregnancy. Two success stories.

Use of urokinase in treatment of deep venous thrombosis in pregnancy has been limited because of concerns about teratogenic effects and potential hemorrhage before and after delivery. However, reports to date have been encouraging and our experience is supportive. In the cases described here, urokinase thrombolytic therapy was effectively used to treat deep venous thrombosis in two pregnant patients without any apparent complications.

Self-report compared to electronic medical record across eight adult vaccines: do results vary by demographic factors?

Immunizations are crucial to the prevention of disease, thus, having an accurate measure of vaccination status for a population is an important guide in targeting prevention efforts. In order to comprehensively assess the validity of self-reported adult vaccination status for the eight most common adult vaccines we conducted a survey of vaccination receipt and compared it to the electronic medical record (EMR), which was used as the criterion standard, in a population of community-dwelling patients in a large healthcare system. In addition, we assessed whether validity varied by demographic factors. The vaccines included: pneumococcal (PPSV), influenza (Flu), tetanus diphtheria (Td), tetanus diphtheria pertussis (Tdap), Human Papilloma Virus (HPV), hepatitis A (HepA), hepatitis B (HepB) and herpes zoster (shingles). Telephone surveys were conducted with 11,760 individuals, ≥18, half with documented receipt of vaccination and half without. We measured sensitivity, specificity, positive and negative predictive value, net bias and over- and under-reporting of vaccination. Variation was found across vaccines, however, sensitivity and specificity did not vary substantially by either age or race/ethnicity. Sensitivity ranged between 63% for HepA to over 90% (tetanus, HPV, shingles and Flu). Hispanics were 2.7 times more likely to claim receipt of vaccination compared to whites. For PPSV and Flu those 65+ had low specificity compared to patients of younger ages while those in the youngest age group had lowest specificity for HepA and HepB. In addition to racial/ethnic differences, over-reporting was more frequent in those retired and those with household income less than $75,000. Accurate information for vaccination surveillance is important to estimate progress toward vaccination coverage goals and ensure appropriate policy decisions and allocation of resources for public health. It was clear from our findings that EMR and self-report do not always agree. Finding approaches to improve both EMR data capture and patient awareness would be beneficial.

A comparison of costs of universal versus targeted lead screening for young children.

The purposes of this study were to compare universal blood lead screening for young children versus targeting by a risk assessment questionnaire and to examine the cost implications of each approach. Costs reflect the total number of blood tests required and cost of specimen collection, handling, and testing per elevated case. The setting included the metropolitan areas of Minneapolis and St. Paul, Minnesota. Children (N=9603) from 17 community organizations had blood tests. In addition, each child's parent or guardian completed a questionnaire assessing potential risk for lead poisoning. Four different screening approaches are presented. Each screening approach is presented with associated costs of overall screening and cost per child identified at blood levels of >/=10 microg/dl (N=1140) and >/=15 microg/dl (N=317). Based on the screening strategy selected and an estimate of $17 per blood test, total screening costs ranged from $91,596 to $165,945. The cost per child identified with elevated lead levels ranged from $361 to $523 at >/=15 and $105 to $146 at >/=10. Nine to 13% of children would not have been detected by policies other than universal screening. A geographically based approach was able to detect 90% of children with elevated blood levels at two-thirds the cost of universal screening. Blood tests would be taken for all children living within city limits. Those residing elsewhere would be tested only if answers to questionnaire items pertaining to age of housing, prior history of lead poisoning, or eating paint chips indicated risk. The new CDC guidelines suggest that screening be based on an assessment of housing, population demographics, and community risk and resources. This paper presents such an assessment.

Management of shoulder impingement syndrome and rotator cuff tears.

Rotator cuff impingement syndrome and associated rotator cuff tears are commonly encountered shoulder problems. Symptoms include pain, weakness and loss of motion. Causes of impingement include acromioclavicular joint arthritis, calcified coracoacromial ligament, structural abnormalities of the acromion and weakness of the rotator cuff muscles. Conservative treatment (rest, ice packs, nonsteroidal anti-inflammatory drugs and physical therapy) is usually sufficient. Some patients benefit from steroid injection, and a few require surgery.

A successful collaboration between a private nonprofit health plan and a state health department.

This article describes the experience of a private, nonprofit health plan in establishing a collaborative relationship with a state health department. Through a federal grant project, efforts toward assuring quality care for children with special health care needs in managed care settings provided unique opportunities to form partnerships between multiple health plans, community groups, and other stakeholders. Collaborative activities included (1) formation of a pediatric asthma task force and a performance measurement and quality assurance committee; (2) planning and execution of a statewide conference; (3) development of a teaching manual for incorporating asthma education into elementary classroom curricula; and (4) publication of a parent resource manual for health plan members. Key ingredients and influencing factors for successful public-private partnerships are discussed.

Nicotine replacement therapy in a group model HMO.

OBJECTIVE: To examine patient response to a smoking cessation program that combined a nicotine replacement system (patch) with telephone support. DESIGN: Randomized trial. SETTING: A large Midwestern HMO. PARTICIPANTS. Five hundred and nine smokers who attended orientation sessions where an overview of the study and the use of the nicotine patch was presented. INTERVENTION: All subjects received a prescription for a nicotine replacement patch (Prostep, Lederle Laboratories, Wayne, NJ). Participants were randomly assigned to one of three intervention groups. Group I participants (n = 166) received no additional support. Group II participants (n = 167) were registered with a 24-hour telephone hotline. Group III participants (n = 167) were registered with the 24-hour telephone hotline and received four follow-up telephone calls from health educators. OUTCOME MEASURE: The primary outcome measure was smoking cessation. Subject satisfaction with study components was also evaluated. RESULTS: Overall, there was no significant difference by group in smoking cessation rates: 20% of patients in all three groups were smoke-free after 12 months. Few patients (1%) used the telephone hotline. The telephone follow-up did not have an impact on cessation rates, and most patients (92%) reported that the orientation session was useful. CONCLUSIONS: The study experience has helped the HMO evaluate various study components and has had an impact on currently used telephone intervention strategies and educational materials.

A comparison of response rate, data quality, and cost in the collection of data on sexual history and personal behaviors. Mail survey approaches and in-person interview.

The authors examined differences in rate of response, data quality, and cost between mail approaches and in-person interview in the collection of data on sexual history and personal behaviors. A sample of women from a midwestern United States university (n = 342) was identified from health service medical records as having been seen for a sexually transmitted disease (cases) or a contraceptive visit (controls) during the latter half of 1985. The women were randomly assigned to one of three data collection strategies. A total of 268 subjects (78%) participated. Results indicated no differences in validity by method of data collection or by case-control status but there were significant differences in completeness, cost, and response rates. In-person interviews resulted in more complete data than mail approaches, although all instruments had low proportions of missing data (0.001-0.006). Response rate differences were not found when data collection methodologies were compared (75-82%) but were found in case-control analyses. Cases were consistently less likely to participate and significantly less likely to respond by mail (p less than 0.05). The cost of the in-person interview was approximately four times that of the mail survey for the data collection. Implications of the case-control response rate difference suggest that mail methodologies, although low in cost, may introduce sampling bias in studies of sexually transmitted diseases.