Health Maintenance Organization Members Research Articles

The Prevention Index: using technology to improve quality assessment.

To improve quality of care assessment for preventive medical services and reduce assessment costs through development of a comprehensive prevention quality assessment methodology based on electronic medical records (EMRs). Random sample of 775 adult and 201 child members of a large nonprofit managed care system. Problems with current, labor-intensive quality measures were identified and remedied using EMR capabilities. The Prevention Index (PI) was modeled by assessing five-year patterns of delivery of 24 prevention services to adult and child health maintenance organization (HMO) members and comparing those services to consensus recommendations and to selected Health Plan Employer Data and Information Set (HEDIS) scores for the HMO. Comprehensive chart reviews of 976 randomly selected members of a large managed care system were used to model the Prevention Index. Current approaches to prevention quality assessment have serious limitations. The PI eliminates these limitations and can summarize care in a single comprehensive index that can be readily updated. The PI prioritizes services based on benefit, using a person-time approach, and separates preventive from diagnostic and therapeutic services. Current methods for assessing quality are expensive, cannot be applied at all system levels, and have several methodological limitations. The PI, derived from EMRs, allows comprehensive assessment of prevention quality at every level of the system and at lower cost. Standardization of quality assessment capacities of EMRs will permit accurate cross-institutional comparisons.

Adverse childhood experiences and the risk of depressive disorders in adulthood

Background: Research examining the association between childhood abuse and depressive disorders has frequently assessed abuse categorically, thus not permitting discernment of the cumulative impact of multiple types of abuse. As previous research has documented that adverse childhood experiences (ACEs) are highly interrelated, we examined the association between the number of such experiences (ACE score) and the risk of depressive disorders. Methods: Retrospective cohort study of 9460 adult health maintenance organization members in a primary care clinic in San Diego, CA who completed a survey addressing a variety of health-related concerns, which included standardized assessments of lifetime and recent depressive disorders, childhood abuse and household dysfunction. Results: Lifetime prevalence of depressive disorders was 23%. Childhood emotional abuse increased risk for lifetime depressive disorders, with adjusted odds ratios (ORs) of 2.7 [95% confidence interval (CI), 2.3–3.2] in women and 2.5 (95% CI, 1.9–3.2) in men. We found a strong, dose–response relationship between the ACE score and the probability of lifetime and recent depressive disorders ( P<0.0001). This relationship was attenuated slightly when a history of growing up with a mentally ill household member was included in the model, but remained significant ( P<0.001). Conclusions: The number of ACEs has a graded relationship to both lifetime and recent depressive disorders. These results suggest that exposure to ACEs is associated with increased risk of depressive disorders up to decades after their occurrence. Early recognition of childhood abuse and appropriate intervention may thus play an important role in the prevention of depressive disorders throughout the life span.

Angiotensinogen Met235Thr polymorphism, angiotensin-converting enzyme inhibitor therapy, and the risk of nonfatal stroke or myocardial infarction in hypertensive patients

Background The ThrThr genotype of the angiotensinogen (AGT) Met235Thr polymorphism has been associated with elevated AGT levels, hypertension, increased heart disease risk, and improved blood pressure (BP) response to angiotensin-converting enzyme (ACE) inhibitors. We hypothesized that risk of stroke or myocardial infarction (MI) associated with ACE inhibitor use varies by AGT genotype, with a larger protective effect of ACE inhibitors in individuals with the ThrThr genotype than individuals who are carriers of the Met allele. Methods We conducted a population-based case-control study. Participants were health maintenance organization members aged 30 to 79 years with treated hypertension. Those who survived incident stroke (n = 116) or MI (n = 208) during the study period were designated as cases. Control subjects (n = 717) were randomly sampled and frequency-matched to MI cases on age, sex, and calendar year. Health history, medication use, and AGT genotype were assessed. Results ThrThr genotype was present in 21% of stroke cases, 26% of MI cases, and 19% of control subjects. Compared with nonuse, ACE inhibitor use was associated with lower stroke risk among Thr homozygotes (odds ratio [OR] = 0.37, 95% CI = 0.14 to 0.99) than among Met carriers (OR = 1.4, 95% CI = 0.88 to 2.4; P for interaction = .02). Compared with nonuse, ACE inhibitor use was associated with similar MI risk among Thr homozygotes (OR = 0.90, 95% CI = 0.62 to 1.3) and among Met carriers (OR = 1.2, 95% CI = 0.60 to 2.5; P for interaction = 0.5). Conclusions In this hypertensive population, the association of ACE inhibitor use with risk of nonfatal stroke varied by genotype. The protective association between ACE inhibitor use and nonfatal stroke risk among individuals with ThrThr genotype was not observed for nonfatal MI.

Service-level selection by HMOs in Medicare

In the federal Medicare program, contracting health maintenance organizations (HMOs) are paid on a capitated basis. There has long been concern that an “adverse selection” of risks remain in the traditional fee-for-service (FFS) sector, since beneficiaries with low costs may leave the FFS sector and join the HMOs. The distortion associated with this form of selection is that health plans may design their mix of health care services in order to effectuate favorable selection. This paper scrutinizes patterns of HMO membership and costs by service in the FFS sector for evidence consistent with the hypothesis that HMOs engage in service-level product distortion. We develop a multi-service model of choice between FFS and HMOs and show that if the HMO sector is underproviding (overproviding) a service relative to the FFS sector, we should observe a positive (negative) correlation between the HMO market share and average costs of those remaining in the FFS sector. We estimate the correlation between the HMO market share and the average FFS costs for different health care services using Medicare data for 1996. We find evidence indicating that there exists significant service-level selection by HMOs.

Child Maltreatment Appears Epidemic in U.S.

Child Maltreatment Appears Epidemic in U.S.

Physician performance assessment: nonequivalence of primary care measures.

Assessment of the performance of primary care physicians requires multiple, reliable measures. This article explores the appropriateness of selected Health Plan Employer Data and Information Set (HEDIS) measures, developed to assess health plans, to assess individual physician performance. To determine the consistency and reliability of 4 measures of primary care physician performance measures: cancer screening, diabetic management, patient satisfaction, and ambulatory costs. The study population consisted of all 194 family practitioners and general internists providing ambulatory services in 1998 to a defined patient panel of 320,000 adult health maintenance organization members. Administrative data on physician practice and performance were assessed with multiple regression and analysis of variance. Each performance measure was significantly related to 1 or 2 of the other measures: high cancer screening rates with good diabetic management and high patient satisfaction, good diabetic management with high cancer screening rates, high patient satisfaction with high cancer screening rates and high ambulatory costs, or high ambulatory costs with higher patient satisfaction. Although 76% of the physicians ranked in the highest third for at least 1 measure, 81% of these high performers ranked in the lower third for at least 1 other measure. Three percent of physicians ranked exclusively in the top or bottom third on all measures. Care should be taken in assessing physicians based on narrow performance measures. Assessments of individual physicians with current performance measures might identify areas in which improvement is needed and to provide feedback to improve performance quality and efficiency. However, assumptions should not be made from one measure of performance to another.

The impact of adverse childhood experiences on health problems: evidence from four birth cohorts dating back to 1900

Background We examined the relationship of the number of adverse childhood experiences (ACE score) to six health problems among four successive birth cohorts dating back to 1900 to assess the strength and consistency of these relationships in face of secular influences the 20th century brought in changing health behaviors and conditions. We hypothesized that the ACE score/health problem relationship would be relatively “immune” to secular influences, in support of recent studies documenting the negative neurobiologic effects of childhood stressors on the developing brain. Methods A retrospective cohort study of 17,337 adult health maintenance organization (HMO) members who completed a survey about childhood abuse and household dysfunction, as well as their health. We used logistic regression to examine the relationships between ACE score and six health problems (depressed affect, suicide attempts, multiple sexual partners, sexually transmitted diseases, smoking, and alcoholism) across four successive birth cohorts: 1900–1931, 1932–1946, 1947–1961, and 1962–1978. Results The ACE score increased the risk for each health problem in a consistent, strong, and graded manner across four birth cohorts ( P < 0.05). For each unit increase in the ACE score (range: 0–8), the adjusted odds ratios (ORs) for depressed affect, STDs, and multiple sexual partners were increased within a narrow range (ORs: 1.2–1.3 per unit increase) for each of the birth cohorts; the increase in risk for suicide attempts was stronger but also in a narrow range (ORs: 1.5–1.7). Conclusions Growing up with ACEs increased the risk of numerous health behaviors and outcomes for 20th century birth cohorts, suggesting that the effects of ACEs on the risk of various health problems are unaffected by social or secular changes. Research showing detrimental and lasting neurobiologic effects of child abuse on the developing brain provides a plausible explanation for the consistency and dose–response relationships found for each health problem across birth cohorts, despite changing secular influences.

Pharmacoeconomic modeling of prior-authorization intervention for COX-2 specific inhibitors in a 3-tier copay plan.

To determine from a health plan perspective the cost-effectiveness of cyclooxygenase-2 (COX-2) specific inhibitors, with and without a prior-authorization (PA) process. A modeling exercise was employed, based on prescription drug claims for a managed care organization with 3.8 million health maintenance organization (HMO) and preferred provider organization (PPO) members. Drug claims revealed 96154 members (2.9% of the 3.3 million members with a pharmacy benefit) who received either one or more prescriptions for a COX-2 drug or a nonspecific nonsteroidal anti-inflammatory drug (NSAID). These patients were stratified into 2 groups for further analysis, those having a concurrent proton pump inhibitor (PPI) and those without a concurrent PPI. Decision analysis was used to estimate the cost-effectiveness of COX-2 therapy. Actual health plan drug claims data were used to determine utilization and prescribing patterns of nonspecific NSAIDs, COX-2 specific inhibitors, and PPIs. Results from the literature from 8 clinical trials were employed to determine the probability of a serious gastrointestinal (GI) event. Cost-effectiveness analysis (CEA) was used to determine the cost of each therapy, including the predicted cost to treat a serious GI event in a drug benefit design with PA versus a benefit design without PA. Cost-effectiveness analysis (CEA) showed that the cost per success no serious GI event) for Cox-2 specific inhibitors with PA was US dollars 278 versus US dollars 422 without PA. The one-year model predicted that costs associated with an increase in COX-2 utilization after removal of PA would exceed the costs to administer PA and treat NSAID-related serious GI events in the managed care population. Based upon this CEA, PA appears to be an effective tool to manage COX-2 pharmacy costs. Further examination of the medical claims would be useful to validate the assumed GI event rates with or without PA and to further demonstrate more definitively the value of a PA program for COX-2 drugs.

Tender points as predictors of distress and the pharmacologic management of fibromyalgia syndrome.

The object of this study was to determine the association between tender point pain ratings, tender point counts and distress in people with fibromyalgia and to review the pharmacotherapy of fibromyalgia. Demographic, psychosocial, and health status information was collected from 316 health maintenance organization members with fibromyalgia. A manual tender point exam was conducted. Tender point counts predicted 3.0%, and tender point severity ratings predicted 8.3%, of the variance in distress. Little difference was found between the variance predicted for physical versus psychologic distress. A principal components analysis of all measures produced four distinct factors: global-physical functioning, tender points, psychologic, and physical. Tender point pain ratings and counts predicted a small but significant amount of variance in distress. In addition, FMS involves at least four rather distinct factors, one of which is related to tender points. Pharmacotherapeutic management is provided on a patient-specific basis including pharmacokinetics, pharmacodynamic, pathophysiologic, and psychosocial needs designed and modulated for each individual patient.

Physical Therapist-Based Group Exercise/Education Program to Improve Functional Health in Older Health Maintenance Organization Members with Arthritis

Purpose: The purpose of this research was to investigate the effects of a group education/low to moderate intensity exercise intervention on the health status of older health maintenance organization (HMO) members with arthritis. Methods: 36 individuals (11 males, mean age = 76.8 ± 5.1 yrs; 25 females, mean age = 71.8 ± 6.4 yrs) with moderate to severe osteoarthritis or rheumatoid arthritis participated in the study. Participants had multiple comorbidities (mean =1.8 ± 1.0) and were taking multiple medications (mean = 4.2 ± 2.1). Participants were pretested and post-tested using the Physical Performance Test (PPT) and the Short Form (SF)-36 health status questionnaire. The intervention consisted of 90-minute classes held twice weekly for 9 weeks. The classes encompassed arthritis education and an exercise program (stretching, strengthening, endurance, and balance). Standing and sitting dynamic balance exercises were emphasized, including use of large therapy balls in sitting. Results: The PPT mean total scores improved significantly from pretest to post-test (p < .001). Scores on 7 of 9 PPT items improved significantly (p < .05). Scores improved on all 8 SF-36 scales, but the changes did not reach significance (p > .05) on the physical component scales. Significant improvement occurred on 3 of 4 of the mental health component scales of the SF-36 (p < 05). Conclusion: A group program of education and exercise led by physical therapists and an arthritis educator had a positive impact on physical performance and mental health in older persons with arthritis. The class may be a worthwhile adjunct to medical management of patients with arthritis.

One-year results from a brief, computer-assisted intervention to decrease consumption of fat and increase consumption of fruits and vegetables

Background Current cancer prevention recommendations include reducing consumption of fat and increasing consumption of fruits and vegetables. Methods Healthy women health maintenance organization members ( n = 616) ages 40–70 were randomly assigned to either a nutrition intervention or a control intervention unrelated to diet. Intervention included two 45-min counseling sessions plus two brief follow-up telephone contacts. Counseling sessions included a 20-min, interactive, computer-based intervention using a touch-screen format. Intervention goals were reducing dietary fat and increasing fruit and vegetable consumption. Outcome measures included a food frequency questionnaire and the Fat and Fiber Behavior Questionnaire (FFBQ). Total serum cholesterol was also measured at baseline and 12 months. Results Twelve-month follow-up data showed improvements on all dietary outcome variables. Compared to the control, intervention participants reported significantly less fat consumption (3.75 points less for percentage of energy from fat), significantly greater consumption of fruit and vegetables combined (0.93 more servings per day), and a significant reduction in a behavioral measure of fat consumption (0.20 point change in the FFBQ). Group differences in total serum cholesterol, while in the desired direction, were not significant. Conclusions In appropriate circumstances, moderate-intensity dietary interventions can show significant effects for periods of at least 1 year.

Irritable bowel syndrome, health care use, and costs: a U.S. managed care perspective.

We performed an evaluation of patient symptoms, health care use, and costs to define the burden of illness of irritable bowel syndrome (IBS) and the relation to the severity of abdominal pain/discomfort in a large health maintenance organization. All 6500 adult health maintenance organization members who had undergone flexible sigmoidoscopy in the year 2000 were mailed a questionnaire that elicited Rome I symptom criteria and severity ratings for abdominal pain/discomfort. Multiple health care use measures were obtained from various administrative databases. IBS patients were compared with a control group of non-IBS subjects, and analyses were adjusted for age and sex. We received 2613 (40.2%) responses. Compared with non-IBS subjects over 2 yr, IBS patients had more outpatient visits (medical, surgery, and emergency, p < 0.05), were hospitalized more often (p < 0.05), and had more total outpatient prescriptions (p < 0.05) and IBS-related prescriptions (p < 0.05). Over 1 yr, total costs were 51% higher in IBS patients, who also had higher costs for outpatient visits, drugs, and radiology and laboratory tests (p < 0.05). Total costs were increased by 35%, 52%, and 59% in IBS patients with mild, moderate, and severe symptoms of abdominal pain/discomfort compared with non-IBS subjects (p < 0.05). Using Rome I symptom criteria, we found that IBS is associated with a broad pattern of increased health care use and costs. The severity of abdominal pain/discomfort is a significant predictor of health care use and costs for patients with IBS compared with non-IBS subjects.

Unadjusted and adjusted prevalence of diagnosed depression in type 2 diabetes.

To estimate the prevalence of diagnosed depression in a large population of individuals with type 2 diabetes, compared to a matched control group, and to estimate the extent of depression that is independently associated with diabetes. We compared the prevalence of diagnosed depression in all 16180 full-year health maintenance organization members in 1999 who had been diagnosed with type 2 diabetes and in 16180 comparison members without diabetes matched for age and sex. We ascertained diagnoses from the Kaiser Permanente Northwest Region's electronic medical record. Using multiple logistic regression, we adjusted the prevalence estimates for the presence of cardiovascular disease, age, sex, and body weight. Depression was more common in individuals with type 2 diabetes than among matched control subjects (17.9 vs. 11.2%; P < 0.001). Women in both groups were nearly twice as likely to be depressed as men; however, the relative difference in depression prevalence between subjects with and without diabetes was greater in men. In the multivariate model for women, body weight was a much stronger predictor of depression than diabetes status. This study further documents the association between depression and diabetes, providing unadjusted population-based estimates in a large sample. Depression remained associated with diabetes after adjustment for several other possible causes. The association among diabetes, cardiovascular disease, depression, and obesity are multifaceted and differ for men and women.

Irritable bowel syndrome, health care use, and costs: a U.S. managed care perspective

Objective We performed an evaluation of patient symptoms, health care use, and costs to define the burden of illness of irritable bowel syndrome (IBS) and the relation to the severity of abdominal pain/discomfort in a large health maintenance organization. Methods All 6500 adult health maintenance organization members who had undergone flexible sigmoidoscopy in the year 2000 were mailed a questionnaire that elicited Rome I symptom criteria and severity ratings for abdominal pain/discomfort. Multiple health care use measures were obtained from various administrative databases. IBS patients were compared with a control group of non-IBS subjects, and analyses were adjusted for age and sex. Results We received 2613 (40.2%) responses. Compared with non-IBS subjects over 2 yr, IBS patients had more outpatient visits (medical, surgery, and emergency, p < 0.05), were hospitalized more often ( p < 0.05), and had more total outpatient prescriptions ( p < 0.05) and IBS-related prescriptions ( p < 0.05). Over 1 yr, total costs were 51% higher in IBS patients, who also had higher costs for outpatient visits, drugs, and radiology and laboratory tests ( p < 0.05). Total costs were increased by 35%, 52%, and 59% in IBS patients with mild, moderate, and severe symptoms of abdominal pain/discomfort compared with non-IBS subjects ( p < 0.05). Conclusions Using Rome I symptom criteria, we found that IBS is associated with a broad pattern of increased health care use and costs. The severity of abdominal pain/discomfort is a significant predictor of health care use and costs for patients with IBS compared with non-IBS subjects.

Predictors of broad-spectrum antibiotic prescribing for acute respiratory tract infections in adult primary care.

Broad-spectrum antibiotics are commonly prescribed, but little is known about the physicians who prescribe and the patients who take these agents. To identify factors associated with prescribing of broad-spectrum antibiotics by physicians caring for patients with nonpneumonic acute respiratory tract infections (ARTIs). Cross-sectional study using data from the National Ambulatory Medical Care Survey between 1997 and 1999. Information was collected on a national sample of 1981 adults seen by physicians for the common cold and nonspecific upper respiratory tract infections (URTIs) (24%), acute sinusitis (24%), acute bronchitis (23%), otitis media (5%), pharyngitis, laryngitis, and tracheitis (11%), or more than 1 of the above diagnoses (13%). Prescription of broad-spectrum antibiotics, defined for this study as quinolones, amoxicillin/clavulanate, second- and third-generation cephalosporins, and azithromycin and clarithromycin. Antibiotics were prescribed to 63% of patients with an ARTI, ranging from 46% of patients with the common cold or nonspecific URTIs to 69% of patients with acute sinusitis. Broad-spectrum agents were chosen in 54% of patients prescribed an antibiotic, including 51% of patients with the common cold and nonspecific URTIs, 53% with acute sinusitis, 62% with acute bronchitis, and 65% with otitis media. Multivariable analysis identified several clinical and nonclinical factors associated with choice of a broad-spectrum agent. After adjusting for diagnosis and chronic comorbid illnesses, the strongest independent predictors of broad-spectrum antibiotic prescribing were physician specialty (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.6-3.5 for internal medicine physicians compared with general and family physicians) and geographic region (OR, 2.6; 95% CI, 1.4-4.8 for Northeast and OR, 2.4; 95% CI, 1.4-4.2 for South [both compared with West]). Other independent predictors of choosing a broad-spectrum agent included black race, lack of health insurance, and health maintenance organization membership, each of which was associated with lower rates of broad-spectrum prescribing. Patient age, sex, and urban vs rural location were not significantly associated with prescribing choice. Broad-spectrum antibiotics are commonly prescribed for the treatment of ARTIs, especially by internists and physicians in the Northeast and South. These high rates of prescribing, wide variations in practice patterns, and the strong association of nonclinical factors with antibiotic choice suggest opportunities to improve prescribing patterns.

Health-related quality of life and future health care utilization for asthma

Although health-related quality of life (HRQL) has been increasingly used as an outcome in asthma, its utility for identifying patients at risk for adverse asthma outcomes has not been established. In a prospective cohort study, to evaluate the longitudinal impact of HRQL on future health care utilization and cost among adults with asthma, accounting for known risk factors for utilization. A stratified random sample of 3,482 adult Northern CA Kaiser Permanente members with asthma was selected using computerized utilization databases and a screening survey item. Subjects completed a mail survey that included measures of generic (SF-12) and asthma-specific HRQL (ITG-Asthma Short Form battery). During the 12 months after survey completion, computerized utilization and cost data were ascertained. Better baseline asthma-specific HRQL was associated with a decreased risk of asthma-related emergency department visit or hospitalization during longitudinal followup (odds ratio per 10-point score increment 0.84; 95% confidence interval [CI] 0.74 to 0.95), controlling for demographic and clinical factors. Better baseline generic physical HRQL was associated with a decreased risk of future all-cause hospitalization (odds ratio 0.68; 95% CI 0.60 to 0.77). More favorable asthma-specific HRQL scores were also related to decreased asthma-related health care costs during the ensuing year (-0.086 log-dollars per 10-point score increment; 95% CI -0.11 to -0.06). Better generic physical HRQL scores were associated with lower total costs (-0.24 log-dollars; 95% CI -0.32 to -0.17). In a large cohort of adult health maintenance organization members with asthma, asthma-specific HRQL was associated with future asthma-related utilization and cost.

Risk Factors for Hospitalized Upper or Lower Gastrointestinal Tract Bleeding in Treated Hypertensives

Background. We examined risk factors for hospitalized gastrointestinal bleeding among health maintenance organization (HMO) members with hypertension.Methods. Case subjects (n = 199) were patients with hypertension hospitalized for confirmed gastrointestinal bleeding in 1992–1994. Control hypertensive subjects (n = 821) were selected from ongoing studies. Medical records and computerized pharmacy data were used to assess risk factors. Adjusted relative risks (RRs) were estimated using logistic regression models.Results. In multivariate-adjusted models, significant risk factors for upper gastrointestinal bleeding (n = 111 cases) were hepatic disease (RR = 2.85), elevated creatinine (RR = 2.45), nonsteroidal anti-inflammatory drug use (RR = 2.28), smoking (RR = 1.93), cardiovascular disease (RR = 1.89), and physical inactivity (RR = 1.70). Risk factors for lower gastrointestinal bleeding (n = 43 cases) in multivariate-adjusted analyses were anticoagulant or thrombolytic therapy (RR = 3.80), elevated creatinine (RR = 2.31), and physical inactivity (RR = 2.10).Conclusions. This study confirmed several known risk factors for hospitalized gastrointestinal bleeding, including hepatic disease, renal dysfunction, and medication use, and also identified smoking and physical inactivity as independent risk factors. The magnitude of the relative risks associated with these behavioral factors suggests that lifestyle modification may substantially reduce the risk of gastrointestinal bleeding.

Health-related quality of life associated with irritable bowel syndrome: Comparison with other chronic diseases

Background: Despite the rapidly growing body of literature on health-related quality of life (HRQoL), placing the results in a context that is meaningful to clinicians and patients is often overlooked. Objective: This study sought to quantify the impact of irritable bowel syndrome (IBS) on HRQoL by comparing the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) scores of IBS patients with normative US data and with the scores of patients having other chronic gastrointestinal (GI) and non-GI disorders. Methods: Two IBS reference groups were identified from the published literature: a largely untreated community sample of health maintenance organization (HMO) members ( N = 92) and a sample of patients with IBS recruited through clinics and in the community ( N = 140). SF-36 scores for these groups were compared with published US population norms ( N = 2474) and with published scores for 3 other IBS samples ( N = 464); a sample with other chronic GI disorders (dyspepsia [ N = 126], gastroesophageal reflux disease [GERD] [ N = 516]); and samples with other chronic episodic disorders (asthma [ N = 375], migraine [ N = 303], panic disorder [ N = 73], rheumatoid arthritis [ N = 693]). Results: The scores of patients in both IBS reference groups were significantly lower on several SF-36 domains than those of the US normative population ( P < 0.003). Scores on several SF-36 scales were also significantly lower in the IBS reference groups compared with the GERD, asthma, and migraine samples ( P < 0.003). Depending on the IBS sample used, scores did not differ or were higher compared with those in the sample with dyspepsia. Relative to the samples with panic disorder and rheumatoid arthritis, the IBS groups had significantly higher scores on most SF-36 domains ( P < 0.003). Scores for the HMO reference group were generally higher than those for the clinic/community reference group. Conclusions: Based on the results of this analysis, IBS is associated with impairment of HRQoL relative to US population norms and to populations with GERD, asthma, or migraine. HRQoL appears to be greater in patients with IBS than in those with panic disorder or rheumatoid arthritis, although the relative symptom severity in these samples was not known.

Smoking cessation in pregnancy: failure of an HMO pilot project to improve guideline implementation.

This pilot project investigated whether a system introduced by a health maintenance organization (HMO) could encourage obstetric providers to implement smoking-cessation guidelines in their offices. Staff from participating offices was trained in cessation counseling and paid $150 for each pregnant smoker counseled. Data were collected from chart review from participating physicians and a telephone survey of all HMO members giving birth before and after program implementation. Eighteen physician practices participated, representing 27 office sites and 80 physicians. Sixty-six staff members were trained in cessation counseling. Chart review revealed that identification of smoking status increased from 90% to 96% (p=0.03), but documentation of advice to quit worsened (62% vs. 24%, p=0.03). The HMO received claims for counseling from four pregnant smokers out of the 21 identified on chart review. The telephone survey revealed a similar prevalence of current smokers in the baseline and post-intervention samples (15% vs. 13%) but more former smokers (11% vs. 22%) in the follow-up. For the HMO as a whole, fewer smokers reported being advised to quit in the follow-up survey (86% vs. 65%). Few smokers reported being counseled to quit at baseline or follow-up (11% vs. 3%). None of the smokers who received obstetric care from a pilot group physician reported awareness of the smoking-cessation benefit despite the placement of brochures in participating offices advertising the program. This pilot project to reimburse for cessation counseling did not increase smoking-cessation advice or counseling in participating physician's offices. Smoking-cessation counseling worsened across the entire HMO obstetric community during the intervention. A more comprehensive systems approach and a larger HMO market share or a partnership among multiple HMOs may be required to increase smoking-cessation guideline implementation.

Completion of Advance Directives by Older Health Maintenance Organization Members: The Role of Attitudes and Beliefs Regarding Life‐Sustaining Treatment

This study examined whether older health maintenance organization (HMO) members' attitudes and beliefs regarding life-sustaining treatment were associated with their completion of advance directives (ADs). A mailed survey of 1,247 subjects, aged 75 and older, participating in a randomized trial comparing two educational interventions designed to increase AD completion: mailed written materials versus written materials plus a videotape. AD completion was documented by medical record review. The initial trial took place in October 1994 at a large group-model HMO in the Denver metropolitan area. The survey was mailed to participants 3 months after the trial. All HMO members aged 75 and older who received medical care at one of the medical offices (n = 1247) were mailed the survey. Participants were the 735 members who returned the survey. AD completers were compared with noncompleters on survey items pertaining to attitudes and beliefs regarding life-sustaining treatment. Of survey respondents, AD completers (n = 313) differed from noncompleters (n = 422) in their agreement with the following attitudinal/belief statements: (1) Putting my wishes for life-sustaining treatment in writing is too binding (completers = 12, noncompleters = 35); (2) I prefer that my family decide what kind of medical care is best for me if I should become unable to communicate my wishes (completers = 69, noncompleters = 88); and (3) My physician clearly understands my wishes for life-sustaining treatment (completers = 76, noncompleters = 43; all values, P< .0001). Completers were more likely to believe that their physicians understood their wishes and less likely to think that ADs are too binding. More noncompleters wanted their family to decide, even though an AD would increase their families' ability to do so. AD completion rates might increase if they were characterized as a way to preserve flexibility in a complex medical system, help families reach amicable decisions on behalf of their loved ones, and increase patients' confidence that their physician understands their wishes for life-sustaining treatment.