Managed Care Providers Research Articles

Abstract 18944: Efficacy of Clinical Notifications to Health Care Providers in Management of Heart Failure Patients

Introduction: Adherence to guideline recommendations for patients with heart failure improves short and long-term outcomes, and can potentially reduce healthcare costs. Hypothesis: Written communication to care providers of individuals with heart failure with reduced systolic function (HFrEF) will result in better adherence to guidelines. Methods: We prospectively enrolled providers of all outpatients with HFrEF at Oregon Health and Science University in 2012. We reviewed adherence to six evidence-based HF therapies in each patient [ACE-I/ARB, beta blocker, aldosterone antagonist, anticoagulation therapy for atrial fibrillation or flutter, CRT, and ICD]. We excluded patients with destination therapy, resolution of HFrEF, lost to follow-up or death. After implementation of exclusion criteria, of 320 patients evaluated, 114 patients were ultimately included. These patients’ providers were randomized to either receiving a standardized written communication (intervention) or none (control). The letter highlighted 2013 ACCF/AHA heart failure management guidelines, and was sent by US mail to providers in intervention group. Six months later, we re-evaluated all patients according to the same criteria at the outset. Results: Optimal medical therapy (OMT) in intervention group improved in only 9% of patients who were previously sub-optimally treated (p 0.83), but 31% of patients who had already been on OMT experienced deescalated therapies despite no clear documentation (p 0.65). In control group, 11% of patients had increased treatment according to guidelines, and 9% of patients who had already been receiving OMT had deescalated treatment. There were no new ICDs implanted as a result of intervention, while 6.5% of patients in control group did receive ICD (p 0.46). Conclusions: Identification of patients with HFrEF and assessment of adherence to guideline-based therapies is now feasible via electronic medical record enquiry. Written notifications do not result in improved adherence to evidence-based guidelines, nor do these letters seem to alter provider behavior at all. We speculated that the lack of response is a direct result of “notification-fatigue”, and that alternative provider behavior modification techniques need to be evaluated.

Feasibility and acceptability of patient partnership to improve access to primary care for the physical health of patients with severe mental illnesses: an interactive guide.

IntroductionEven in countries with universal healthcare systems, excess mortality rates due to physical chronic diseases in patients also suffering from serious mental illness like schizophrenia is such that their life expectancy could be lessened by up to 20 years. The possible explanations for this disparity include: unhealthy habits (i.e. smoking; lack of exercise); side-effects of psychotropic medication; delays in the detection or initial presentation leading to a more advanced disease at diagnosis; and inequity of access to services. The main objective of this paper is to explore the feasibility and acceptability of patient partnership for developing an interactive guide to improve access to primary care providers for chronic diseases management and health promotion among patients with severe mental illnesses.MethodsA participatory action research design was used to engage patients with mental illness as full research partners for a strategy for patient-oriented research in primary care for persons with schizophrenia who also have chronic physical illnesses. This strategy was also developed in partnership with a health and social services centre responsible for the health of the population of a territory with about 100,000 inhabitants in East-end Montreal, Canada. A new interactive guide was developed by patient research partners and used by 146 participating patients with serious mental illness who live on this territory, for them to be better prepared for their medical appointment with a General Practitioner by becoming more aware of their own physical condition.ResultsPatient research partners produced a series of 33 short videos depicting signs and symptoms of common chronic diseases and risk factors for the leading causes of mortality and study participants were able to complete the corresponding 33-item questionnaire on an electronic touch screen tablet. What proved to be most relevant in terms of interactivity was the dynamic that has developed among the study participants during the small group learning sessions, a training technique designed for healthcare professionals that was adapted for this project for, and with patient partners.ConclusionThis research has shown the feasibility and acceptability of patient partnership and patient-oriented research approaches to the R&D process of a new medical tool and intervention for patients with serious mental illness, and its acceptability for addressing inequity of this disadvantaged population in terms of access to primary care providers.

The Saudi Clinical Practice Guideline for the treatment of venous thromboembolism. Outpatient versus inpatient management.

Venous thromboembolism (VTE) including deep vein thrombosis (DVT) and pulmonary embolism (PE) is commonly encountered in daily clinical practice. After diagnosis, its management frequently carries significant challenges to the clinical practitioner. Treatment of VTE with the inappropriate modality and/or in the inappropriate setting may lead to serious complications and have life-threatening consequences. As a result of an initiative of the Ministry of Health of the Kingdom of Saudi Arabia, an expert panel led by the Saudi Association for Venous Thrombo-Embolism (a subsidiary of the Saudi Thoracic Society) and the Saudi Scientific Hematology Society with the methodological support of the McMaster University Guideline working group, this clinical practice guideline was produced to assist health care providers in VTE management. Two questions were identified and were related to the inpatient versus outpatient treatment of acute DVT, and the early versus standard discharge from hospital for patients with acute PE. The corresponding recommendations were made following the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach.

Centers for medicare and medicaid services: using an episode-based payment model to improve oncology care.

Cancer is a medically complex and expensive disease with costs projected to rise further as new treatment options increase and the United States population ages. Studies showing significant regional variation in oncology quality and costs and model tests demonstrating cost savings without adverse outcomes suggest there are opportunities to create a system of oncology care in the US that delivers higher quality care at lower cost. The Centers for Medicare and Medicaid Services (CMS) have designed an episode-based payment model centered around 6 month periods of chemotherapy treatment. Monthly per-patient care management payments will be made to practices to support practice transformation, including additional patient services and specific infrastructure enhancements. Quarterly reporting of quality metrics will drive continuous quality improvement and the adoption of best practices among participants. Practices achieving cost savings will also be eligible for performance-based payments. Savings are expected through improved care coordination and appropriately aligned payment incentives, resulting in decreased avoidable emergency department visits and hospitalizations and more efficient and evidence-based use of imaging, laboratory tests, and therapeutic agents, as well as improved end of life care. New therapies and better supportive care have significantly improved cancer survival in recent decades. This has come at a high cost, with cancer therapy consuming $124 billion in 2010. CMS has designed an episode-based model of oncology care that incorporates elements from several successful model tests. By providing care management and performance based payments in conjunction with quality metrics and a rapid learning environment, it is hoped that this model will demonstrate how oncology care in the US can transform into a high value, high quality system.

A critique of Dr. Miguel Faria′s Book, Vandals at the Gates of Medicine

A critique of Dr. Miguel Faria′s Book, Vandals at the Gates of Medicine

205-POS

Objectives To assess the feasibility of a multi-country Community Level Interventions for Pre-eclampsia (CLIP) Trial in the African and South Asian contexts. Methods A mixed methodology approach guided by normalization process theory was used in Nigeria, Mozambique, Pakistan, and India. Multiple methods of data collection were employed to explore enabling and impeding factors for the CLIP package utilization. Qualitative data were collected through participatory observation, document review, focus group discussions and in-depth interviews with diverse groups of community members, key informants at community level, healthcare providers, and policy makers. Quantitative data were collected through health facility assessments and community health workers’ assessments, self-administered questionnaires, and community surveillance. Qualitative thematic analysis was conducted using QSR NVivo v10. Quantitative descriptive analyses was performed on SPSS v19/Epi Info 7. Results Qualitative themes underscored knowledge deficits about pre-eclampsia and poor understanding of progression of illness from pre-eclampsia to eclampsia. Myths and misperceptions widely prevailed surrounding the causes of pre-eclampsia, whereas community practices related to prevention, as well as, case management were deeply rooted in their cultural beliefs, past experiences and perceptions of severity of pre-eclampsia/eclampsia. The quantitative findings from survey highlighted areas for health system capacity building needed to ensure availability of magnesium sulfate at health facilities, equipping community care providers with blood pressure monitoring devices, and training of care providers for diagnosis and management of hypertensive disorders during pregnancy. Conclusions Feasibility assessment for the CLIP Trial was a resource-intensive, but essential, exercise to understand communities prior to the trial. The methodology used in our research work, can be used to inform future trials of this magnitude in high burden countries and elsewhere. Disclosure A.R. Khowaja: None.

Toward the development of a lupus interactive navigator to facilitate patients and their health care providers in the management of lupus: results of web-based surveys.

BackgroundSystemic lupus erythematosus is an inflammatory autoimmune disease associated with high morbidity and unacceptable mortality. Information and management tools are needed to help persons with lupus cope with their illness and facilitate health care providers in the delivery of care.ObjectiveThe objective of the study was to assess the needs and find solutions to support persons with lupus and their health care providers.MethodsWeb-based surveys were distributed across Canada to persons with lupus and their relatives (n=3119), rheumatologists (n=517), and arthritis health professionals (AHPs) (n=226) by Lupus Canada, the Canadian Rheumatology Association, and the Arthritis Health Professions Association, respectively.ResultsThe survey sample comprised 665 (21.3%) persons with lupus, 98 (19.0%) rheumatologists, and 74 (32.7%) AHPs. Among the participants with lupus, 92.4% were female, the average age was 46.8 (SD 12.7) years, 79.2% were Caucasian, and 58.8% were employed. All Canadian provinces and territories were represented. The majority (43.3%) of respondents were from Ontario. Mean disease duration was 10.2 (SD 9.5) years, and 41.9% rated their global assessment as fair or poor. There was high agreement between lupus participants and health care providers regarding disease-specific information topics. All groups rated topics related to lupus, fatigue, medications, and stress as most important. Ratings differed among lupus participants and their health care providers regarding perceived helpfulness of some of the patient tools, such as the option to view test results. Needs differed for persons with lupus based on age, sex, depression, stress, and disease activity. Differences in health care provider needs were based on amount of experience in treating lupus.ConclusionsInformation and support tools needed for persons with lupus and their health care providers were identified. These results will help guide us in the development of a Web-based Lupus Interactive Navigator as an intervention tool to help persons with lupus self-manage their disease and to facilitate heath care providers in clinical management.

Cost-effectiveness of a community-integrated home-based depression intervention in older African Americans.

To test the cost-effectiveness of a home-based depression program: Beat the Blues (BTB). A cost-effectiveness analysis as part of a previously reported randomized controlled trial that compared BTB with a wait-list control group. Community. English-speaking, cognitively intact (Mini-Mental State Examination score ≥24), African Americans aged 55 and older with depressive symptoms (Patient Health Questionnaire score ≥5) (N = 129). Participants randomly assigned to BTB received up to 10 home visits over 4 months from licensed social workers who provided care management, referral and linkage, stress reduction, depression education, and behavioral activation to help participants achieve self-identified goals. Incremental cost-effectiveness ratios (ICERs) of BTB versus wait-list controls during the 4-month study period. The primary ICER was defined as cost per quality-adjusted life year (QALY) using the Euro Quality of Life 5D (EQ-5D) and secondarily using the Health Utilities Index-3 (HUI-3). Additional ICERs were calculated using clinical measures (cost per depression improvement, cost per depression remission). Costs included BTB intervention, depression-related healthcare visits and medications, caregiver time, and social services. BTB cost per participant per month was $146. Base case ICERs were $64,896 per QALY (EQ-5D) and $36,875 per QALY (HUI-3). Incremental cost was $2,906 per depression improvement and $3,507 per remission. Univariate and probabilistic sensitivity analyses yielded a cost/QALY range of $20,500 to $76,500. Based on the range of cost-effectiveness values resulting from this study, BTB is a cost-effective treatment for managing depressive symptoms in older African Americans that compares favorably with the cost-effectiveness of previously tested approaches.

Factors mediating the effects of a depression intervention on functional disability in older African Americans.

To determine factors mediating the effects of a depression intervention for older African Americans on functional disability and, secondarily, whether functional improvements mediate intervention effects on depressive symptoms. Structural equation modeling to examine mediators in a secondary analysis of a randomized trial with 4-month follow-up. Philadelphia region. Community-dwelling African Americans (≥55) with depressive symptoms living in an urban area (N = 208). Up to 10 one-hour sessions over 4 months conducted by licensed social workers who provided care management, referrals and linkages, stress reduction techniques, depression knowledge and symptom recognition, and behavioral activation techniques. Main outcome was self-reported functional difficulty level for 18 basic activities. Mediators included depression severity (Patient Health Questionnaire), depression knowledge and symptom recognition, behavioral activation, and anxiety. At 4 months, the intervention had positive effects on functional difficulty and all mediators (P < .001). Separate structural equation models indicated that two factors (reduced depressive symptoms (23.5% mediated) and improved depression knowledge and symptom recognition (52.9% mediated)) significantly mediated the intervention's effect on functional disability. Enhancing behavioral activation and decreasing anxiety were not found to mediate improvements in functional disability. The two significant mediators jointly explained 62.5% of the intervention's total effect on functional disability. Functional improvement was not found to mediate the intervention's effect on depressive symptoms. This multicomponent depression intervention for African Americans has an effect on functional disability that is driven primarily by enhancing symptom recognition and decreasing depressive symptoms. Reduction of functional difficulties did not account for improvements in depressive symptoms. Nonpharmacological treatments for depressive symptoms that enhance symptom recognition in older African Americans can also reduce their functional difficulties with daily living activities.

Caring for patients with melanoma in the primary care setting.

The incidence of melanoma is steadily rising and mortality continues to increase. This article describes types of melanoma and the role of primary care providers in the long-term management and follow-up of patients diagnosed with melanoma.

Proliferative Verrucous Leukoplakia: An elusive disorder

Proliferative Verrucous Leukoplakia (PVL) is a multifocal form of progressive leukoplakia with a high rate of malignant transformation that requires early recognition by oral health care providers for proper management. Background and PurposePVL will frequently appear as an innocuous white lesion or lesions that can easily be overlooked or considered clinically insignificant, yet it has a high rate of malignant transformation. There is limited in-depth knowledge about the pathobiology of PVL. Oral health care providers lack familiarity with this lesion; consequently the intent of this article is to increase awareness of the clinical aspects of PVL. MethodsCase reports, case series and review articles provide a profile of PVL. ConclusionIt is essential that health care providers performing intraoral examinations are aware that PVL is a distinct and rare form of multifocal oral leukoplakia. PVL commonly affects females above the age of 62. Currently, little is known about its etiopathogenesis. Additionally, no specific treatment modality has proven to be effective in aborting its progression. Because of its high recurrence potential and relentless progression to squamous cell carcinoma, all recurrent and multifocal white lesions of the oral cavity should be viewed with suspicion.

The National Commission on Physician Payment Reform: Recalibrating Fee-for-Service and Transitioning to Fixed Payment Models

The National Commission on Physician Payment Reform: Recalibrating Fee-for-Service and Transitioning to Fixed Payment Models

Spinal surgery for low back pain: a way forward

Spinal surgery for low back pain: a way forward

Home Blood Pressure Monitoring

See related article, p 675–682 Measurement of blood pressure outside of the clinic is recognized for providing superior accuracy in predicting future fatal and nonfatal cardiovascular and renal disease. The gold standard for these predictions is 24-hour ambulatory blood pressure monitoring that measures daytime and night- time pressures.1 Home blood pressure monitoring has rapidly made progress because devices for recording pressures taken at home have improved and become widely available.2 The advantages for this strategy are that pressures can be recorded during many days, weeks, and months. The newer devices can send results to a data center or individual care providers for review and management.3 In this sense, telemedicine has arrived for care of hypertension and seems to have made a successful landing. With the increasing need for primary care physicians, especially in the United States, telemedicine for hypertension may become a valuable alternative for management of hypertension.4 An important issue for management of hypertension has been whether the relationship between the clinic pressures and out-of-clinic pressures provides useful information. When this comparison discloses that clinic pressure is significantly higher than out-of-office pressure, that is, a white- coat effect, is the prognosis truly better? When the office pressure is lower than the out-of-office pressure (masked effect), is the predicted outcome worse? The accuracy of these classifications …

An overview of medical abortion for clinical practice.

Medical abortion is a safe, convenient, and effective method for terminating an early unintended pregnancy. Medical abortion can be performed up to 63 days from the last menstrual period and may even be used up to 70 days for women who prefer medical abortion over surgical abortion. Counseling on the adverse effects and expectations for medical abortion is critical to success. Medical abortion can be performed in a clinic without special equipment, and it is perceived as more "natural" than a surgical abortion by many women. Follow-up for medical abortion can be simplified to include only serum human chorionic gonadotropin measurements when necessary, although obtaining an ultrasound remains the criterion standard. Pain associated with medical abortion is best treated with nonsteroidal anti-inflammatory medications, possibly in combination with opioid analgesics. Medical abortion can contribute to continuity of care for women who wish to remain with their primary care providers for management of their abortion.

Level of distress, somatisation and beliefs on health-disease in newly arrived immigrant patients attended in primary care centres in Catalonia and definition of professional competences for their most effective management: PROMISE Project

BackgroundNewly arrived immigrant patients who frequently use primary health care resources have difficulties in verbal communication. Also, they have a system of beliefs related to health and disease that makes difficult for health care professionals to comprehend their reasons for consultation, especially when consulting for somatic manifestations. Consequently, this is an important barrier to achieve optimum care to these groups. The current project has two main objectives: 1. To define the different stressors, the level of distress perceived, and its impact in terms of discomfort and somatisation affecting the main communities of immigrants in our area, and 2. To identify the characteristics of cross-cultural competence of primary health care professionals to best approach these reasons for consultation.Methods/DesignIt will be a transversal, observational, multicentre, qualitative-quantitative study in a sample of 980 people from the five main non-European Union immigrant communities residing in Catalonia: Maghrebis, Sub-Saharans, Andean South Americans, Hindustanis, and Chinese. Sociodemographic data, level of distress, information on the different stressors and their somatic manifestations will be collected in specific questionnaires. Through a semi-structured interview and qualitative methodology, it will be studied the relation between somatic manifestations and particular beliefs of each group and how these are associated with the processes of disease and seeking for care. A qualitative methodology based on individual interviews centred on critical incidents, focal groups and in situ questionnaires will be used to study the cross-cultural competences of the professionals.DiscussionIt is expected a high level of chronic stress associated with the level of somatisations in the different non-European Union immigrant communities. The results will provide better knowledge of these populations and will improve the comprehension and the efficacy of the health care providers in prevention, communication, care management and management of resources.

Assessment of knowledge and skill of health care providers in management of child abuse in different level hospital in Bangladesh

Challenges to the health of our children have been changing in recent decades as we have taken control over different diseases through immunization and child health program . But newer problems are uncovered. Child Abuse and Neglect is one of them . World community has given emphasis on this very old but unnoticed problem ,this problem is received very less emphasis in South East Asia. With the objectives -to assess the knowledge and skill of working doctors and nurses of concern department in managing child abuse and to help the service providers to improve their knowledge and skill to deal with child abuse and to identify the laps and gaps in the area where abused children are dealt with, this study was carried out in two Medical College Hospitals, two District Hospitals and two Upazilla Health Complexes from November 2005 to July 2006. Selected departments for study were - Obstetrics &amp; Gynaecology, Paediatrics, Orthopaedics. Burn, Casualty, Psychiatry and OCC, (DMCH) in Medical College level; Obstetrics &amp; Gynaecology, Paediatrics, Surgery in district level and all from Upazilla level. Working doctors of all level and senior staff nurses were included in this study. Assessment of knowledge and skill was done before and after intervention by observation and face to face interview by using a pre tested prepared questionairre .Laps and gaps were identified by observation and interview. Intervention was given by a one day workshop in each level of hospital . About 155 care providers participated in pre and post intervention interview . Of them- 109 were doctor and 46 were nurses. Among them 71 (Doc. 55 + Nurse 16) from two Medical College Hospitals, 42 (Doc. 33 + Nurse 9) from two District Hospitals &amp; 42 (Doc. 21 + Nurse 21) from 2 Upazilla Health Complexes . It was surprising that only 11 % health care provides correctly knows that who are the children , only 10 % providers knows about the different types of abuse and only 15 % providers believe that they have sufficient knowledge to manage an abused child. Knowledge level is much higher among the doctors working in teaching hospitals and poorest in UHC. Nurses are less knowledgeable than doctors . Score of nurses is more or less similar in all level of hospitals. The pre and post intervention changes were analyzed by using unpaired student's t test and p value was significant .On job training of care providers on management of abused child is very important and inclusion of this issue in medical and nursing curricula is necessary. DOI: http://dx.doi.org/10.3329/jssmc.v1i1.12166 Journal of Shaheed Suhrawardy Medical College Vol.1, No.1, December 2009 p.2-5

‘Phantom Networks’ of Managed Behavioral Health Providers: An Empirical Study of Their Existence and Effect on Patients in Two New Jersey Counties

Managed care organizations often tout the availability of clinicians in their provider networks, yet their clients seeking mental healthcare may find it difficult to obtain such care in a timely and effective manner. Using comprehensive data from two counties in New Jersey, the authors examine the prevalence of phantom networks of managed care providers of behavioral health services and the effects of such networks on patients’ wait times and the availability of therapists treating children.

Symptomatic and palliative care for stroke survivors.

Stroke is the leading cause of disability and one of the most common causes of death worldwide. Outside the setting of acute management, secondary prevention and stroke rehabilitation, little has been written to address the ongoing symptomatic and palliative needs of these patients and their families. In this literature review, we look beyond secondary prevention with the aim of providing evidence-informed management guidelines for the myriad and often under-recognized symptomatic and palliative care needs of stroke survivors. Some of the most common and disabling post-stroke symptoms that are reviewed here include central post-stroke pain, hemiplegic shoulder pain, painful spasticity, fatigue, incontinence, post-stroke seizures, sexual dysfunction, sleep-disordered breathing, depression and emotionalism. We review the role of caregivers and explore ways to support them and, lastly, remind the reader to be perceptive to the patient's spiritual needs. The literature is most robust, including controlled trials, for central post-stroke pain and depression. Synthesis and discussion outside these areas are frequently limited to smaller studies, case reports and expert opinion. While some data exists to guide informed decision-making, there is an urgent need to document best practice and identify appropriate clinical standards for the full spectrum of symptoms experienced by stroke survivors. We present the current and established data to aid health care providers in symptomatic and palliative management of stroke survivors.

(P1-58) Frailty, Dementia and Disaster: An E-Learning Initiative for Health Care Providers

Frailty, Dementia and Disaster: an e-learning initiative for Health care providers D. Maltais1, M. Gibson2, L. Hardy3, S. Ruthe4, 1University of Quebec, Chicoutimi 2St. Joseph's Health Care London, London 3Health and Social Services, Yukon Territory Government, Whitehorse 4Emergency Program, Corporation of the District of Oak Bay, Victoria, Canada.This poster describes the development, piloting, evaluation, and dissemination of the e-learning tool: “Frailty, Dementia and Disasters: What Health Care Providers Need to Know”. The purpose of the e-learning tool is to contribute to international efforts to reduce the disproportionate vulnerability of older adults in emergencies and disasters. Key literature on geriatric emergency preparedness and response issues, including the roles and responsibilities of health care providers, was identified and synthesized. Content was piloted in a facilitated workshop in Ontario. A Canada-wide health provider reference group provided feedback on the transition from a traditional powerpoint presentation to an e-learning format. The evaluation process included facilitated review of the tool by health care providers in two in-person workshops in each of Yukon and Quebec and in an independent review by health care providers in British Columbia (virtual). The learning objectives of the e-learning resource are to help health care providers, administrators and policy makers understand the: · disproportionate vulnerability of older adults who are frail and those who have dementia, in emergencies and disasters; · components of the emergency management cycle and how they apply to this target population; · best practice resources that can be used to improve emergency preparedness, response, recovery and mitigation; and · role of health care organizations and providers in emergency management for these older adults. The e-Learning tool is hosted with open access on www.dementiaknowledgebroker.ca (DKB), a platform facilitated by the CDRAKE - the knowledge exchange theme of the Canadian Dementia Knowledge TranslationNetwork (CDKTN).