Health Maintenance Organization Setting Research Articles

Measles Experience, Practice, and Knowledge by Pediatricians in the Context of Resurgent US Outbreaks

To assess measles experience, practice, and knowledge by pediatricians in the context of resurgent US outbreaks in 2018-2019. A nationally representative network of pediatricians were surveyed by email and mail from January to April2020. The response rate was 67% (297 of 444). In the 3years preceding the survey, 52% of the respondents reported awareness of measles cases in/near their community. Most thought that media reports about recent measles outbreaks had decreased delay/refusal of measles, mumps, and rubella (MMR) vaccine (6% "greatly decreased"; 66% "moderately decreased"). More than 60% of the pediatricians responded correctly for 6 of 9 true/false measles knowledge items. Less than 50% responded correctly for 3 true/false items, including statements about pretravel MMR recommendations for a preschooler and measles isolation precautions. The most common resources that the pediatricians would "sometimes" or "often/always" consult for measles information were those from the American Academy of Pediatrics (72%), a state or local public health department (70%), and the Centers for Disease Control and Prevention (63%). More than 90% of the pediatricians reported correct clinical practice for MMR vaccination of a 9-month-old before international travel. More than one-third of the respondents did not have a plan for measles exposures in their clinic. Pediatricians aware of measles cases in/near their community in the previous 3years and those working in a hospital/clinic or Health Maintenance Organization setting were more likely to have a plan for measles exposures. During this time of heightened risk for measles outbreaks, there are opportunities to strengthen the knowledge and implementation of measles pretravel vaccination and infection prevention and control recommendations among pediatricians.

The Surveillance, Epidemiology, and End Results Cancer Survival Calculator SEER*CSC: validation in a managed care setting.

Nomograms for prostate and colorectal cancer are included in the Surveillance, Epidemiology, and End Results (SEER) Cancer Survival Calculator, under development by the National Cancer Institute. They are based on the National Cancer Institute's SEER data, coupled with Medicare data, to estimate the probabilities of surviving or dying from cancer or from other causes based on a set of patient and tumor characteristics. The nomograms provide estimates of survival that are specific to the characteristics of the tumor, age, race, gender, and the overall health of a patient. These nomograms have been internally validated using the SEER data. In this paper, we externally validate the nomograms using data from Kaiser Permanente Colorado. The SEER Cancer Survival Calculator was externally validated using time-dependent area under the Receiver Operating Characteristic curve statistics and calibration plots for retrospective cohorts of 1102 prostate cancer and 990 colorectal cancer patients from Kaiser Permanente Colorado. The time-dependent area under the Receiver Operating Characteristic curve statistics were computed for one, three, five, seven, and 10 year(s) postdiagnosis for prostate and colorectal cancer and ranged from 0.77 to 0.89 for death from cancer and from 0.72 to 0.81 for death from other causes. The calibration plots indicated a very good fit of the model for death from cancer for colorectal cancer and for the higher risk group for prostate cancer. For the lower risk groups for prostate cancer (<10% chance of dying of prostate cancer in 10 years), the model predicted slightly worse prognosis than observed. Except for the lowest risk group for colorectal cancer, the models for death from other causes for both prostate and colorectal cancer predicted slightly worse prognosis than observed. The results of the external validation indicated that the colorectal and prostate cancer nomograms are reliable tools for physicians and patients to use to obtain information on prognosis and assist in establishing priorities for both treatment of the cancer and other conditions, particularly when a patient is elderly and/or has significant comorbidities. The slightly better than predicted risk of death from other causes in a health maintenance organization (HMO) setting may be due to an overall healthier population and the integrated management of disease relative to the overall population (as represented by SEER).

Comparing characteristics of melanoma cases arising in health maintenance organizations with state and national registries.

Datasets from large health maintenance organizations (HMOs), particularly those with established cancer registries that report to the Surveillance, Epidemiology, and End Results program, are potentially excellent resources for studying melanoma epidemiology and outcomes. However, generalizability of the findings beyond HMO-based populations has not been well studied. We compared melanoma patient, tumor, and treatment characteristics at Kaiser Permanente Northern California and Henry Ford Healthcare Systems with those of corresponding regional, state, and national registry-reported melanoma databases. We identified all melanoma cases diagnosed at Kaiser Permanente Northern California (1996-2009) and Henry Ford Healthcare Systems (1996-2007) and ascertained patient (age, sex, race, and ethnicity), tumor (site, size, laterality, invasiveness, depth, ulceration, subtype, and stage), and treatment (surgery and radiation) variables from health system cancer registries. Registry data were obtained from Surveillance, Epidemiology, and End Results databases for the reporting period ending in November 2011. We found that melanoma cases arising in HMO settings generally have comparable patient, tumor, and treatment characteristics to regional, state, and national cases. An important difference included improved reporting of race information at HMO sites. Melanoma studies using data derived from select HMOs are potentially generalizable to local, state, and national populations, and may be better situated for studying racial-ethnic disparities.

Substance Abuse Treatment Processes and Outcomes in Day/Outpatient Health Maintenance Organization Setting

Substance Abuse Treatment Processes and Outcomes in Day/Outpatient Health Maintenance Organization Setting

Substance abuse treatment processes and outcomes in day/outpatient health maintenance organization setting.

Previous research has determined that substance abuse treatment (SAT) is effective under managed care within residential treatment and outpatient treatment, but we have not followed patients after treatment completion. This study examined SAT in both an intensive day treatment and an outpatient treatment program in a large health maintenance organization, with mandatory 12-step participation. We conducted interviews (N = 72) at the beginning, upon completion, and 6 months after completion of treatment. Variables measured were substance use, quality of life, symptoms, functionality, and patient satisfaction as well as Drug Abuse Treatment and Assessment Resources (DATAR) score and treatment completion. Before treatment, DATAR scores were high: 7.68 on a scale of 1-9, indicating serious addictions. Patients showed significant improvement in all variables measured, upon completion of SAT, and additional improvement again 6 months later. Eighty-three percent of subjects completed treatment. Unique advantages of treatment in this setting were discussed, as well as the importance of referral and support from nurses and other healthcare professionals.

Statin Prescribing Patterns in a Cohort of Cancer Patients with Poor Prognosis

There are no evidence-based recommendations for statin continuation or discontinuation near the end of life. However, some expert opinion recommends continuing statins prescribed for secondary versus primary prevention of cardiovascular disease. Our aim was to explore statin prescribing patterns in a longitudinal cohort of individuals with life-limiting illness, and to evaluate differences in these patterns based on secondary versus primary prevention of cardiovascular disease. This study was a retrospective cohort analysis of 539 persons in an integrated, not-for-profit health maintenance organization (HMO) setting who were receiving statins at diagnosis of a cancer with 0% to 25% predicted 5-year survival. Of the cohort patients, 343 were taking statins for secondary prevention and 196 for primary prevention of cardiovascular disease. Measurements included number and timing of statin refills between diagnosis and date of death, disenrollment, or the end of the observation period. Four hundred and ninety-six cohort members died within the observation period. Fifty-eight percent of the secondary prevention and 62% of the primary prevention group had at least one statin refill after diagnosis. There were no significant differences between groups for number of days between diagnosis and last refill, or between last refill and death. Two deaths were attributable to cardiovascular causes in each group. Our retrospective cohort analysis of persons with incident poor-prognosis cancer describes diminished, but persistent statin refills after diagnosis. Neither timing of statin discontinuation nor cardiovascular mortality differed by prescribing indication. There may be an opportunity to reevaluate medication burden in persons taking statins for primary prevention, and it is unclear whether continuing statins prescribed for secondary prevention affects cardiovascular outcomes.

Can equitable care eliminate colon cancer disparities?

91 Background: Previous studies suggest lack of insurance and variations in quality of care may drive disparities in colon cancer (CC), but equitable care may close these gaps. To clarify the role of equitable care on racial disparities, we compared CC survival in one of California’s largest Health Maintenance Organization (HMO) to survival in all other hospitals across the state. We hypothesized that disparities would be less pronounced in the HMO. Methods: All CC cases treated from 1996-2006 were identified in the California Cancer Registry linked to hospital discharge abstracts from the Office of Statewide Health Planning and Development. Enrollees in the state’s largest HMO were identified as such. Five year mortality was compared between HMO enrollees and all other patients using Cox proportional hazard models. Results: 62,184 CC records were included. 25% were HMO enrollees. The HMO treated a higher percent of black patients (9.2% versus 5.5%) and fewer Medicaid patients (2.1% versus 4.5%). There was no disparity in the HMO setting blacks as compared with whites (HR 0.90 95% CI 0.79-1.02); but black patients fared worse in the non-HMO settings (HR 1.15 95% CI 1.07-1.23). Conclusions: CC disparities are differentially distributed across California hospitals systems. Since there were no disparities in California’s large HMO, where care is typically protocol-driven, our findings suggest delivery of equitable care may eliminate disparities. These findings are consistent with other studies in the literature. Future research should assess the effect of emerging Accountable Care Organizations on the elimination of racial disparities in other cancers and diseases.

Does patient trust promote better care?

Information asymmetries favouring the supplier in the production of good health have long been acknowledged as an anomaly in medical markets creating the potential for inefficiency. Such asymmetries may undermine the physician/patient relationship. And given these asymmetries, patient trust may play an important role in successful physician/patient relationships. This agency relationship has been studied for many years in the context of Fee-for-Service (FFS) reimbursement. But the market has changed considerably given the combination of an influx of information and the penetration of managed care - both of which have shifted some decision-making power away from the physician. An additional important factor in the physician/agency relationship that is also changing is patient trust. Where patient trust was implicit in the system with predicted positive effects on health outcomes when FFS was the norm, now trust itself is not a given, and its effect on the doctor–patient relationship may be evolving. We study how trust impacts patients’ perceptions about quality of care, and whether these relationships differ by health insurance type. We find that Health Maintenance Organization (HMO) patients have significantly lower trust in their primary care physicians than those with more traditional coverage. Using a multi-dimensional index of patients’ perceptions about the quality of care they receive from their physicians, we also find that trust has no significant effect on perceived quality for non-HMO patients, but significantly improves perceived outcomes for HMO patients. We conclude that trusting patients are more likely to have a better doctor-patient relationship than those who are skeptical in the HMO setting. Perhaps given lack of provider choice, it requires a level of trust in general to be compliant and satisfied with assigned physicians. In the non-HMO setting where consumers are now armed with more information and free to make choices, trust becomes less important. These results have implications for how decisions are made in the market for health services we face today and ultimately for public health policy.

Cognitive behavioral guided self-help for the treatment of recurrent binge eating.

Despite proven efficacy of cognitive behavioral therapy (CBT) for treating eating disorders with binge eating as the core symptom, few patients receive CBT in clinical practice. Our blended efficacy-effectiveness study sought to evaluate whether a manual-based guided self-help form of CBT (CBT-GSH), delivered in 8 sessions in a health maintenance organization setting over a 12-week period by master's-level interventionists, is more effective than treatment as usual (TAU). In all, 123 individuals (mean age = 37.2; 91.9% female, 96.7% non-Hispanic White) were randomized, including 10.6% with bulimia nervosa (BN), 48% with binge eating disorder (BED), and 41.4% with recurrent binge eating in the absence of BN or BED. Baseline, posttreatment, and 6- and 12-month follow-up data were used in intent-to-treat analyses. At 12-month follow-up, CBT-GSH resulted in greater abstinence from binge eating (64.2%) than TAU (44.6%; number needed to treat = 5), as measured by the Eating Disorder Examination (EDE). Secondary outcomes reflected greater improvements in the CBT-GSH group in dietary restraint (d = 0.30); eating, shape, and weight concern (ds = 0.54, 1.01, 0.49, respectively; measured by the EDE Questionnaire); depression (d = 0.56; Beck Depression Inventory); and social adjustment (d = 0.58; Work and Social Adjustment Scale), but not weight change. CBT-GSH is a viable first-line treatment option for the majority of patients with recurrent binge eating who do not meet diagnostic criteria for BN or anorexia nervosa.

Rapid Implementation of a Robot-Assisted Prostatectomy Program in a Large Health Maintenance Organization Setting

We present the rapid implementation of a robot-assisted surgery program by one of the largest health maintenance organizations (HMOs) in the United States. A core group of 10 urologists were offered access to a new da Vinci S surgical system. A core group of five ancillary staff was assembled and trained at an Intuitive Surgical-designated training site. An experienced robotic surgeon acted as a proctor. Data regarding patient demographics, preoperative parameters, operative times, pathologic outcomes, and EPIC-26 quality-of-life questionnaires were collected prospectively and reviewed. All procedures were recorded on digital video disc as part of a quality assurance protocol. The core group reviewed complications monthly and received feedback on surgical techniques and pathologic outcomes. A total of 100 robot-assisted laparoscopic radical prostatectomies were performed from August to October 2008. The patient demographics, preoperative parameters, operative times, and pathologic outcomes of these first 100 procedures are outlined. We demonstrate the rapid implementation of an efficient multisurgeon HMO-based robot-assisted prostatectomy program with promising initial outcomes.

Optimal Preparation for ESRD

Clinical guidelines for the care of patients with progressive chronic kidney disease (CKD) have been developed by a broad range of organizations within the kidney community. Despite consensus among these guidelines and significant effort on the part of federal agencies, voluntary health organizations, and professional groups, existing data suggest that much work remains to achieve acceptable levels of recommended care. Several small studies have described CKD interventions to improve outcomes, but there are few examples of large-scale attempts to improve CKD care in a systematic way. Southern California Kaiser Permanente has developed a population management approach to CKD in a health maintenance organization setting that has improved outcomes. The Indian Health Service, an agency of the Public Health Service that provides direct care to American Indians and Alaska Natives, has enhanced its diabetes care delivery system to address the renal complications of diabetes. This effort may explain a significant decrease in the incidence rate of ESRD among American Indians with diabetes. Because much of the burden of CKD falls on ethnic and racial groups with decreased access to care, enhancing CKD care in the primary setting may offer the best opportunity to improve outcomes. The National Kidney Disease Education Program in collaboration with community heath centers has developed a model to improve outcomes through application of the chronic care model to CKD management in primary settings that serve high-risk populations.

Best practices for managing patient service expectations in a reproductive endocrinology (REI) and in vitro fertilization (IVF) program within a health maintenance organization (HMO) setting

OBJECTIVE: Those familiar with HMOs know there are complexities in managing health care services within the managed care (MC) setting. To succeed in improving service within a fee-for-service (FFS) In Vitro Fertilization (IVF) program and a not-for-profit (NFP) Reproductive Endocrinology (REI) practice within a MC setting necessitates a remarkable degree of rigor in order to accomplish the merging of technology and medicine with exceptional quality outcomes. The objective of this abstract is to discuss best practices for managing a shared NFP REI practice and a FFS IVF program within the Kaiser Permanente (KP) HMO setting.DESIGN: Retrospective evaluation based on first-hand knowledge of clinic outcomes and management of a NFP REI practice and a FFS IVF program from January 2007 through May 2008.MATERIALS AND METHODS: Our goal in merging a NFP REI practice and a FFS IVF program was to provide a fuller spectrum of fertility services and continuity of care. Access: Focus on appointment (appt) demand, net loss and demand calculations allow for better appt utilization, access to services and decreased financial net loss. Quality: Quality standards from the IVF lab were established in parallel with the clinic side to maintain consistent quality practices. Staffing: Decentralization of IVF Case Management staff allows for a more consistent level of nursing care at local facilities, improved patient access, better service and physician satisfaction. Charting/Technology: Successful implementation of an electronic medical records program allows clinic to communicate patient information and improved standards of practice for REI and IVF throughout KP. Departmental re-structuring: New positions were developed to allow for a division of work, as well as better utilization of staff. Patient Satisfaction/Service: A variety of patient satisfaction surveys, service contests and team meetings for REI and IVF are used as quality care markers for ensuring consistent patient satisfaction and improved clinic efficiencies.RESULTS: With continued focus, our ability to deliver best practices for REI and IVF is evident by our clinical success rates, quality outcomes, viability of our program, in addition to KP's commitment to expanding both our REI and IVF services within KP.CONCLUSIONS: The nation's leading HMO, KP, has been able to continue to successfully integrate a viable FFS IVF program and NFP REI practice within the MC setting while maintaining the same level of quality, service and accessible personalized care for both. OBJECTIVE: Those familiar with HMOs know there are complexities in managing health care services within the managed care (MC) setting. To succeed in improving service within a fee-for-service (FFS) In Vitro Fertilization (IVF) program and a not-for-profit (NFP) Reproductive Endocrinology (REI) practice within a MC setting necessitates a remarkable degree of rigor in order to accomplish the merging of technology and medicine with exceptional quality outcomes. The objective of this abstract is to discuss best practices for managing a shared NFP REI practice and a FFS IVF program within the Kaiser Permanente (KP) HMO setting. DESIGN: Retrospective evaluation based on first-hand knowledge of clinic outcomes and management of a NFP REI practice and a FFS IVF program from January 2007 through May 2008. MATERIALS AND METHODS: Our goal in merging a NFP REI practice and a FFS IVF program was to provide a fuller spectrum of fertility services and continuity of care. Access: Focus on appointment (appt) demand, net loss and demand calculations allow for better appt utilization, access to services and decreased financial net loss. Quality: Quality standards from the IVF lab were established in parallel with the clinic side to maintain consistent quality practices. Staffing: Decentralization of IVF Case Management staff allows for a more consistent level of nursing care at local facilities, improved patient access, better service and physician satisfaction. Charting/Technology: Successful implementation of an electronic medical records program allows clinic to communicate patient information and improved standards of practice for REI and IVF throughout KP. Departmental re-structuring: New positions were developed to allow for a division of work, as well as better utilization of staff. Patient Satisfaction/Service: A variety of patient satisfaction surveys, service contests and team meetings for REI and IVF are used as quality care markers for ensuring consistent patient satisfaction and improved clinic efficiencies. RESULTS: With continued focus, our ability to deliver best practices for REI and IVF is evident by our clinical success rates, quality outcomes, viability of our program, in addition to KP's commitment to expanding both our REI and IVF services within KP. CONCLUSIONS: The nation's leading HMO, KP, has been able to continue to successfully integrate a viable FFS IVF program and NFP REI practice within the MC setting while maintaining the same level of quality, service and accessible personalized care for both.

Physicians' Shared Decision-Making Behaviors in Depression Care

Although shared decision making (SDM) has been reported to facilitate quality care, few studies have explored the extent to which SDM is implemented in primary care and factors that influence its application. This study assesses the extent to which physicians enact SDM behaviors and describes factors associated with physicians' SDM behaviors within the context of depression care. In a secondary analysis of data from a randomized experiment, we coded 287 audiorecorded interactions between physicians and standardized patients (SPs) using the Observing Patient Involvement (OPTION) system to assess physician SDM behaviors. We performed a series of generalized linear mixed model analyses to examine physician and patient characteristics associated with SDM behavior. The mean (SD) OPTION score was 11.4 (3.3) of 48 possible points. Older physicians (partial correlation coefficient = -0.29; beta = -0.09; P < .01) and physicians who practiced in a health maintenance organization setting (beta = -1.60; P < .01) performed fewer SDM behaviors. Longer visit duration was associated with more SDM behaviors (partial correlation coefficient = 0.31; beta = 0.08; P < .01). In addition, physicians enacted more SDM behaviors with SPs who made general (beta = 2.46; P < .01) and brand-specific (beta = 2.21; P < .01) medication requests compared with those who made no request. In the context of new visits for depressive symptoms, primary care physicians performed few SDM behaviors. However, physician SDM behaviors are influenced by practice setting and patient-initiated requests for medication. Additional research is needed to identify interventions that encourage SDM when indicated.

Incidence Rate of Anterior Cruciate Ligament Reconstructions

Anterior cruciate ligament (ACL) reconstructions are among the most common sports medicine procedures performed in the US each year. Differences have been reported in the incidence rates (IRs) of ACL tears among male and female national elite athletes. However, there is little information in the published literature that assesses IRs for ACL reconstructions done in the Health Maintenance Organization (HMO) setting specifically. Different populations may show variation in ACL reconstruction IRs. This study reports on the IR of ACL reconstructions in a predefined population and compares the differences in age and sex over time. A retrospective analysis of 4485 ACL reconstructions performed within Kaiser Permanente Southern California between 2001 and 2005 was completed by a query of an administrative database. Trends in IRs per 100,000 members were calculated and compared across age, sex, and the five-year study period. Linear regression was used to test trends in IR. Sex distribution was compared using the χ(2) test. Analysis of variance was used to compare the mean age from year to year in males and females. The independent sample t-test was used to compare mean age between males and females for each independent year. The IR of ACL reconstructions in females rose significantly (p = 0.010) from 14.4 in 2001 (95% confidence interval [CI], 12.6-16.3) to 19.3 in 2005 (95% CI, 17.2-21.5). Within specific age groups, IR increased significantly for females age 14 to 17 (p = 0.013), 18 to 21 (p = 0.017), and 45 to 49 years (p = 0.014). The most dramatic change was seen in the female age category of 14 to 17 years, which increased at a rate of 8.14 cases/100,000 members per year. Identifying the sex and age groups with most rapidly increasing rates of ACL reconstructions is important in implementing ACL injury-prevention programs.

Patient factors associated with hemoglobin A1C change with pioglitazone as adjunctive therapy in type 2 Diabetes Mellitus.

To identify patient factors associated with change in hemoglobin A1C (A1C) with adjunct pioglitazone therapy in routine clinical practice. This was a retrospective analysis of adult type 2 diabetes mellitus patients in a health maintenance organization setting who were newly-initiated on pioglitazone between January 2002 and December 2005. Eligible patients were receiving at least one other oral antihyperglycemic medication prior to initiating pioglitazone and maintained a stable dose of pioglitazone for 90 days. Data on eligible patients' characteristics, pharmacy purchases, comorbidities, and A1C measurement 90 days prior to the pioglitazone purchase date (baseline) and 90 days after achieving a stable dose (follow-up) were obtained from electronic records. Multivariate regression modeling was used to assess factors independently associated with: 1) absolute change in A1C, 2) achieving a ≥1 percentage point decrease in A1C, and 3) achieving an A1C<7%. Baseline and follow-up A1Cs were available for 128 patients. At baseline, mean age was 65 years, 38% were female, mean A1C was 8.4%, and 74% had an A1C>8%. At follow-up, the mean A1C change was -1.2 percentage points (interquartile range= -0.4, -2.1), 59% achieved a ≥1 unit decrease in A1C, and 44% achieved an A1C<7%. Independent predictors in all models were baseline A1C and time (in days) between baseline and follow-up A1C measurements (p<0.05). Adjunct pioglitazone therapy in routine clinical practice was associated with clinically meaningful reductions in A1C levels. Patients with higher baseline A1C achieved the greatest absolute reduction in A1C but were less likely to achieve levels <7%.

Perceptions of Human Immunodeficiency Virus Testing Services Among HIV-Positive Persons Not in Medical Care

To the Editor: We read with interest the article by Rudy et al, “Perceptions of Human Immunodeficiency Virus Testing Services Among HIV-Positive Persons Not in Medical Care” in the April 2005 issue of your journal.1 Although we strongly agree with the authors’ assertions that a proper HIV testing experience requires adequate counseling, education, and time for the newly diagnosed HIV-positive patient to fully understand his or her test results and referral needs, we take serious exception to their suggestion that patients testing positive for HIV in a health maintenance organization (HMO) or private care setting are the most likely to go without proper follow up. The authors report on data from an apparent convenience sample that was not collected specifically for the analysis described. To assess HIV testing services more convincingly, a study design that is more likely to reflect the patient populations of interest should have been used. The small sample size (n = 13 and wide confidence margins) cannot represent all HMO/private care patients. Furthermore, the patients studied were highly selected, generally disadvantaged, and all represent failures of follow up. Although lessons can be learned from such a group, it is important to view their experience in the context of all new positives, particularly if the authors want to draw such general conclusions. If the sample reported on was in fact representative, the relatively low frequency of HMO/private care HIV-positive patients out of care suggests that those care delivery settings are the most successful at providing follow up and keeping patients in care. Although many private physicians’ offices do not have care coordinators or HIV test counselors, many HMOs do. Even if the sample were representative, the rationale for grouping patients from HMOs and private offices together is not intuitive. Kaiser Permanente’s experience with HIV testing contradicts the results of this study. Although we do not have exact figures, it is policy in most of our clinical facilities to have HIV test results given by specially trained HIV test counselors (usually certified health educators). In all of our regions, HIV is now a medical subspecialty and patients are immediately referred to the HIV care team (often with a care coordinator) on diagnosis. In Kaiser Permanente’s Northern and Southern California regions combined, 94% (699 of 744) of patients newly diagnosed with HIV in 2004 were in care a year later and had at least 2 CD4 cell counts and 2 HIV viral loads in the first year of follow up—a marker for patients receiving proper follow up. This measure is in line with, if not superior to, the outcome of the intensive case management intervention arm of the main ARTAS study (the context of the Rudy article). We hope that your readers do not draw erroneous conclusions from the work of Rudy et al. Many HMOs, including Kaiser Permanente, provide excellent HIV care, from initial testing through comprehensive care management.

Effects of a brief computer-assisted diabetes self-management intervention on dietary, biological and quality-of-life outcomes

There is a need for practical, efficient and broad-reaching diabetes self-management interventions that can produce changes in lifestyle behaviours such as healthy eating and weight loss. The objective of this study was to evaluate such a computer-assisted intervention. Type 2 diabetes primary care patients (n=335) from fee-for-service and health maintenance organization settings were randomized to social cognitive theory-based tailored self-management (TSM) or computer-aided enhanced usual care (UC). Intervention consisted of computer-assisted self-management assessment and feedback, tailored goal-setting, barrier identification, and problem-solving, followed by health counsellor interaction and follow-up calls. Outcomes were changes in dietary behaviours (fat and fruit/vegetable intake), haemoglobin Alc (HbA1c), lipids, weight, quality of life, and depression. TSM patients reduced dietary fat intake and weight significantly more than UC patients at the 2-month follow-up. Among patients having elevated levels of HbA1c, lipids or depression at baseline, there were consistent directional trends favouring intervention, but these differences did not reach significance. The intervention proved feasible and was implemented successfully by a variety of staff. This relatively low-intensity intervention appealed to a large, generally representative sample of patients, was well implemented, and produced improvement in targeted behaviours. Implications of this practical clinical trial for dissemination are discussed.

Case management for the treatment of patients with major depression in general practices--rationale, design and conduct of a cluster randomized controlled trial--PRoMPT (PRimary care Monitoring for depressive Patient's Trial) [ISRCTN66386086]--study protocol.

BackgroundDepression is a disorder with high prevalence in primary health care and a significant burden of illness. The delivery of health care for depression, as well as other chronic illnesses, has been criticized for several reasons and new strategies to address the needs of these illnesses have been advocated. Case management is a patient-centered approach which has shown efficacy in the treatment of depression in highly organized Health Maintenance Organization (HMO) settings and which might also be effective in other, less structured settings.Methods/DesignPRoMPT (PRimary care Monitoring for depressive Patients Trial) is a cluster randomised controlled trial with General Practice (GP) as the unit of randomisation. The aim of the study is to evaluate a GP applied case-management for patients with major depressive disorder. 70 GPs were randomised either to intervention group or to control group with the control group delivering usual care. Each GP will include 10 patients suffering from major depressive disorder according to the DSM-IV criteria. The intervention group will receive treatment based on standardized guidelines and monthly telephone monitoring from a trained practice nurse. The nurse investigates the patient's status concerning the MDD criteria, his adherence to GPs prescriptions, possible side effects of medication, and treatment goal attainment. The control group receives usual care – including recommended guidelines. Main outcome measure is the cumulative score of the section depressive disorders (PHQ-9) from the German version of the Prime MD Patient Health Questionnaire (PHQ-D). Secondary outcome measures are the Beck-Depression-Inventory, self-reported adherence (adapted from Moriskey) and the SF-36. In addition, data are collected about patients' satisfaction (EUROPEP-tool), medication, health care utilization, comorbidity, suicide attempts and days out of work.The study comprises three assessment times: baseline (T0) , follow-up after 6 months (T1) and follow-up after 12 months (T2).DiscussionDepression is now recognized as a disorder with a high prevalence in primary care but with insufficient treatment response. Case management seems to be a promising intervention which has the potential to bridge the gap of the usually time-limited and fragmented provision of care. Case management has been proven to be effective in several studies but its application in the private general medical practice setting remains unclear.

Photodynamic Therapy With Verteporfin

To assess adherence to Food and Drug Administration-approved indications and Centers for Medicare & Medicaid Services policy through June 2001 regarding the use of photodynamic therapy in Medicare beneficiaries. Systematic review of pretreatment fluorescein angiograms of 1245 consecutive Medicare patients who received photodynamic therapy from physicians in 3 contiguous Medicare coverage areas (fee-for-service arrangement) and in 136 consecutive patients in a Medicare health maintenance organization. In the 3 Medicare fee-for-service regions, payment denial due to nonconforming fluorescein angiograms ranged from 17% to 29% by region in 1245 beneficiaries. In the health maintenance organization setting, 60 (44%) of 136 submitted angiograms were nonconforming, including 8 in which the photographic quality was too poor to grade the lesion size, composition, or both. A substantial proportion of the actual or intended clinical application of photodynamic therapy with verteporfin was directed to patients who did not meet concurrent published clinical criteria associated with treatment benefit or national coverage policy. Although this policy has evolved, it still depends on fluorescein angiographic interpretation, suggesting that there is an opportunity to improve the cost-effectiveness of delivery of photodynamic therapy with verteporfin to Medicare beneficiaries.

Clinical outcomes in managed-care patients with coronary heart disease treated aggressively in lipid-lowering disease management clinicsThe alliance study

This study sought to determine if an aggressive, focused low-density lipoprotein cholesterol (LDL-C)-lowering strategy was superior to usual care for coronary heart disease (CHD) patients enrolled in health maintenance organization or Veterans Administration settings. Statin therapy benefits are well established. No prospective, randomized studies have tested strategies to optimize these benefits in a “real-world” setting. A total of 2,442 CHD patients with hyperlipidemia were randomized to either an aggressive treatment arm using atorvastatin or usual care and followed for 51.5 months on average. Atorvastatin-group patients were titrated to LDL-C goals of &lt;80 mg/dl (2.1 mmol/l) or a maximum atorvastatin dose of 80 mg/day. Usual-care patients received any treatment deemed appropriate by their regular physicians. End point assessments were complete in 958 atorvastatin-group and 941 usual-care patients. Partial assessments occurred in 259 patients in the atorvastatin group and 284 patients in the usual care group who did not complete four years of study participation because of adverse events, withdrawn consent, or follow-up loss. The primary efficacy parameter was time to first cardiovascular event. A total of 289 (23.7%) patients in the atorvastatin group compared with 333 (27.7%) patients in the usual care group experienced a primary outcome (hazard ratio, 0.83; 95% confidence interval 0.71 to 0.97, p = 0.02). This reduction in morbidity was largely due to fewer non-fatal myocardial infarctions (4.3% vs. 7.7%, p = 0.0002). Levels of LDL-C were reduced more (34.3% vs. 23.3%, p &lt; 0.0001) and National Cholesterol Education Program goals (LDL-C &lt;100 mg/dl) more likely met at end-of-study visits (72.4% vs. 40.0%) in patients receiving atorvastatin compared with those receiving usual care. An aggressive, focused statin therapy management strategy outperformed usual care in health maintenance organization and Veterans Administration clinic patients with CHD.