Health Maintenance Organization Setting Research Articles

Burnout in a Sample of HMO Pharmacists Using the Maslach Burnout Inventory

The objective was to measure the three aspects of burnout-emotional exhaustion, depersonalization, and reduced personal accomplishment-using the Maslach Burnout Inventory in a sample of health maintenance organization (HMO) pharmacists. The specific objectives were to: 1) investigate the relationship of individual demographic and job-related variables and a career-related variable to the three aspects of burnout; 2) obtain a profile of the respondents susceptible to the three aspects of burnout; and 3) solicit comments from the respondents about the pharmacist's job environment and suggestions to improve it. A survey was mailed to 251 pharmacists practicing in HMO settings from a list supplied by Medicom International, Inc. The survey collected information about burnout in terms of emotional exhaustion, depersonalization, and reduced personal accomplishment; information on the individual and career- and job-related characteristics of each respondent; and comments about the HMO pharmacists' job environment and suggestions to improve it. Eighty-three useable responses were obtained, representing a useable response rate of 33.6%. Overall, the respondents experienced moderate levels of emotional exhaustion and depersonalization, and high levels of personal accomplishment. Staff pharmacists had significantly higher emotional exhaustion and depersonalization scores than those in a supervisory capacity. Unmarried respondents with lower annual salaries had significantly higher emotional exhaustion and depersonalization scores than married/higher-salaried pharmacists, respectively. Respondents with three or more children had lower depersonalization levels than those with no children, while those who had worked for five years or more in their current job had higher emotional exhaustion scores than those who had worked in their current job for fewer years. Respondents who worked between 35 and 40 hours per week in the HMO setting had higher personal accomplishment scores than those who worked 34 hours or less per week. Profiles of pharmacists most susceptible to the three aspects of burnout were obtained: those who had no children, an annual salary of $49,999 or less, and worked for five or more years in their current job were more susceptible to emotional exhaustion. Respondents who had no children and an annual salary of $49,999 or less were more susceptible to depersonalization. Those who spent 1 %-25% of their time processing prescriptions were less susceptible to burnout, while those who worked 34 hours or less were more susceptible to burnout on the personal accomplishment subscale. Results concerning the relationship of individual, job-related, and a career-related variable to the three aspects of burnout were obtained. A profile of HMO pharmacists susceptible to the three aspects of burnout was also obtained. This information can be useful in the development of stress management programs designed to minimize the level of chronic stress that can potentially lead to burnout among HMO pharmacists.

Primary Prevention and Rubella Immunity

Objective To determine the knowledge of rubella immune status among practicing obstetrician-gynecologists in the United States and of rubella immunity policies covering healthcare workers in the obstetric-care office setting. Design Mailed survey questionnaire, August through December 1994. Setting Physicians from multiple-practice sites including private office, public institution, university or teaching hospital, and closed panel health maintenance organization settings. Participants 3,302 practicing obstetrician-gynecologists, chosen by a systematic random sample from the AMA national physician database. Main outcome measures Participants were defined as rubella immune if they reported knowledge of prior rubella vaccination or positive antibody titer. Knowledge of a policy for documenting rubella immunity among employees in the office-based practice setting also was assessed. Results Questionnaires were returned from 50% (1,666) of the 3,302 surveyed, and 96% (1,599) were evaluable. Approximately 20% (304/1,599) of the responding obstetrician-gynecologists did not have knowledge of documented rubella immunity, and the majority of office-based practices did not require documentation of rubella immunity in the following groups: physicians, 66% (723/1,094); office nurses, 62% (666/1,070); and other office staff, 69% (728/1,063). Sixty-two percent (993/1,599) of responding physicians had individual rubella serologies performed, with 916 known to be positive, 53 reported negative, and 24 reported unknown. Fifty-seven percent (918/1,599) reported receiving monovalent rubella vaccine or trivalent measles-mumps-rubella vaccine. Multiple logistic regression analysis revealed the following to be independent predictors of positive immune status among respondents: female gender (odds ratio [OR], 2.4; 95% confidence interval [CI95], 1.8-3.1), medical school graduation since 1980 (OR, 2.6; CI95, 2.0-3.3), providing obstetric or fertility services (OR, 1.5; CI95, 1.2-1.9), and group practice setting (> or = 5 physicians; OR, 1.2; CI95, 1.1-1.4). Conclusions Nationally, nearly one of every five practicing obstetricians may not have documented rubella immunity, and the majority of office-based practices have no system for assuring such immunity. Rubella immunity should extend beyond the hospital setting, with consideration for requiring rubella immunity as a condition for employment. Methods for effective implementation and documentation of current guidelines need to be addressed, particularly in the office setting.

The relationship between obesity and medical utilization among women in a primary care setting

Objective This project was designed to explore the utilization of specific health care resources by obese compared with nonobese women in a primary care setting. Method: Eighty-three obese women, consecutively identified during nonemergent appointments in a primary care health maintenance organization (HMO) setting, were compared with 111 nonobese women with regard to several parameters of health care utilization. All participants' medical records were reviewed for the preceding 12 months for the number of diagnoses, combined telephone and physician contacts with the facility, different physicians seen, and prescriptions. Results: Increasing body mass index (BMI) was predictive of a greater number of diagnoses, contacts with the facility, total number of prescriptions, and number of different physicians seen. After controlling for the number of diagnoses, BMI remained predictive of the number of different physicians seen. Discussion: Our findings indicate that increasing BMI is associated with greater health care utilization, primarily through greater morbidity. Additionally, there may also be particular psychosocial and illness factors which contribute to obese women's patterns of physician contact. © 1998 by John Wiley & Sons, Inc. Int J Eat Disord 23:161–167, 1998.

Children's health care use in the Healthy Kids Program.

In 1990, the Florida Legislature established the Florida Healthy Kids Corporation to implement the concept of school enrollment-based health insurance coverage for children. The county school districts are used as a grouping mechanism to negotiate health insurance policies. The Florida Healthy Kids Corporation negotiates contracts with health maintenance organizations (HMOs) to assume financial risk and to provide health care services at each program site. In 1994, there were five sites with four different participating HMOs. Assessing quality of care is particularly important when contracting with HMOs because of the perception that financial and utilization review arrangements may restrict the enrollees' access to needed health care. One essential component of health care quality is the extent to which health care services are used in a manner consistent with the expected pattern of use for the population of enrolled children. The purpose of this study is to compare children's health care use across five different Florida Healthy Kids Program sites. Specifically, we compare the enrollees' actual health care use across HMO settings and program sites to the expected health care use based on the enrollees' case-mix. Each HMO provided child-specific health care use data including Physician's Current Procedural Terminology codes and International Classification of Diseases, 9th Revision codes. We used the Ambulatory Care Groups (ACGs) software to compare the children's actual health care use to the expected health care use at each site adjusted for case-mix. Several steps were then taken to determine if the children were receiving the anticipated number of health care visits based on their diagnoses. First, we divided the average number of encounters at each site by the group average across all of the sites, without adjusting for the case-mix of the enrollees. We then divided the average number of visits at each site by the expected number of visits based on the case-mix adjustment. A value of 1.00 means that the actual use and the expected use are identical. Values below 1 indicate underuse and values over 1 indicate overuse of health care services. Statistical comparisons of the actual versus expected average health care use across the five sites were performed by deriving the appropriate chi2 statistics. A census of all children (N = 14 688) enrolled in the Florida Healthy Kids Program at each of the sites for 6 months or longer were included in the analysis. The average number of health care encounters across all sites for a 12-month time period was 2.98 +/- 4.6 visits. After adjusting for the case-mix of the enrollees in each site using the ACG software, several of the five sites differed from one in a statistically significant way. However, these statistical assessments must be tempered with assessing the practical magnitude of the observed differences. The number of public and private efforts to insure children who are not eligible for Medicaid and whose parents cannot purchase private insurance has grown dramatically. These programs are vital for ensuring financial access to care for uninsured children. However, it is essential that such programs are not viewed as merely cost containment efforts. Assessing the degree to which children receive the health care services they need across multiple delivery settings is an essential yet challenging component of quality assurance. Generally, our analysis indicates that children in the Florida Healthy Kids Program are receiving the amount of health care expected based on their health care needs; which is one component of a high-quality health care program.

Physicians Who Report Health Insurance Fraud and Their Practice Type: Health Maintenance Organization vs Fee-for-Service

Farber et al 1 found that physicians practicing in health maintenance organization (HMO) settings compared with those in fee-for-service settings were more likely to suggest reporting patients committing health insurance fraud in the scenarios presented in their questionnaire. In their discussion, the authors opine, Physicians who practice in staff-model HMOs... may feel more allegiance to third-party payers than physicians working primarily in a fee-for-service practice. In addition, physicians in an HMO setting may have a greater financial incentative to report insurance fraud, because their financial well-being is more directly related to the financial health of the third-party payers. An alternative hypothesis explaining the difference is that fee-for-service physicians, in reporting patients committing insurance fraud, may directly affect the likelihood that their fees will be paid. That is, fee-forservice physicians may find that their decision is more directly related the financial health of their own practice, whereas HMO physicians are watching

Primary prevention and rubella immunity: overlooked issues in the outpatient obstetric setting.

To determine the knowledge of rubella immune status among practicing obstetrician-gynecologists in the United States and of rubella immunity policies covering healthcare workers in the obstetric-care office setting. Mailed survey questionnaire, August through December 1994. Physicians from multiple-practice sites including private office, public institution, university or teaching hospital, and closed panel health maintenance organization settings. 3,302 practicing obstetrician-gynecologists, chosen by a systematic random sample from the AMA national physician database. Participants were defined as rubella immune if they reported knowledge of prior rubella vaccination or positive antibody titer. Knowledge of a policy for documenting rubella immunity among employees in the office-based practice setting also was assessed. Questionnaires were returned from 50% (1,666) of the 3,302 surveyed, and 96% (1,599) were evaluable. Approximately 20% (304/1,599) of the responding obstetrician-gynecologists did not have knowledge of documented rubella immunity, and the majority of office-based practices did not require documentation of rubella immunity in the following groups: physicians, 66% (723/1,094); office nurses, 62% (666/1,070); and other office staff, 69% (728/1,063). Sixty-two percent (993/1,599) of responding physicians had individual rubella serologies performed, with 916 known to be positive, 53 reported negative, and 24 reported unknown. Fifty-seven percent (918/1,599) reported receiving monovalent rubella vaccine or trivalent measles-mumps-rubella vaccine. Multiple logistic regression analysis revealed the following to be independent predictors of positive immune status among respondents: female gender (odds ratio [OR], 2.4; 95% confidence interval [CI95], 1.8-3.1), medical school graduation since 1980 (OR, 2.6; CI95, 2.0-3.3), providing obstetric or fertility services (OR, 1.5; CI95, 1.2-1.9), and group practice setting (> or = 5 physicians; OR, 1.2; CI95, 1.1-1.4). Nationally, nearly one of every five practicing obstetricians may not have documented rubella immunity, and the majority of office-based practices have no system for assuring such immunity. Rubella immunity should extend beyond the hospital setting, with consideration for requiring rubella immunity as a condition for employment. Methods for effective implementation and documentation of current guidelines need to be addressed, particularly in the office setting.

Comparison of Laboratory Test Frequency and Test Results Between African-Americans and Caucasians With Diabetes: Opportunity for Improvement: Findings from a large urban health maintenance organization

To compare African-American and Caucasian patients with preexisting diabetes in a health maintenance organization (HMO) on: 1) frequency with which they received a subset of recommended laboratory tests according to the American Diabetes Association (ADA) consensus guidelines and 2) the results of laboratory test values (glycosylated hemoglobin, cholesterol, and creatinine). A cross-sectional study of 2,312 HMO members with diabetes continuously enrolled during 1991 was conducted using computerized medical record and billing data. Receipt of the ADA recommended tests for glycosylated hemoglobin, cholesterol, and creatinine was compared between African-Americans and Caucasians, stratified by insulin requirements. In addition, group comparisons were made based on the laboratory test results. Less than 20 percent of all subjects received the recommended number of ADA tests. This did not differ by race except for creatinine and cholesterol testing in insulin users only, where African-Americans had more tests. On average, after adjusting for covariates, African-Americans had significantly higher glycosylated hemoglobin and creatinine laboratory values. Both groups had elevated cholesterol values. The opportunity exists to improve the process of care for both African-Americans and Caucasians with diabetes in an HMO setting. The need to improve glycosylated hemoglobin results and subsequently limit complications is especially pressing among the African-American population.

Status of the medical oncology workforce. The American Society of Clinical Oncology.

A survey was designed to determine accurately the number of full-time equivalent medical oncologists in the United States, to determine how medical oncologists in different work settings divide their professional activities, and to determine whether medical oncology represents a primary care specialty in the minds of practicing oncologists. A questionnaire was mailed to the 4,239 members of the American Society of Clinical Oncology (ASCO) who identified themselves as medical oncologists or hematologists/oncologists and were current residents of the United States. Follow-up letters, which included a second copy of the questionnaire, were sent to nonresponders. A third mailing, followed by a telephone reminder, was sent to a randomly selected subset of 300 nonresponders to be certain that the initial responders were similar in practice patterns and attitudes to those individuals who had not initially completed the survey. A total of 2,540 physicians responded to the first mailing and an additional 187 to the second (64% response rate); a further 196 individuals who were directly contacted completed the survey document. Practitioners appear to see 160 to 200 different patients per month and to devote approximately 72% of their time to patient care activities. Research and teaching comprised only 3% to 4% of professional time for physicians in private practice or Health Maintenance Organization (HMO) settings, in contrast to 16% for those who worked in community hospitals. Medical oncologists frequently serve the role of principal care giver while patients are undergoing cancer treatment. However, medical oncologists devote minimal time providing primary care services to patients and, if required to increase their clinical volume, would prefer to care for more cancer patients than enhance their primary care activities. It is estimated that the present full-time equivalent number (ie, the conglomorate number of oncologists based on 100% professional effort devoted to clinical care) of medical oncologists is approximately 3,600 individuals. This translates into 1.8 medical oncologists per 100,000 adult Americans. The medical oncology community devotes the majority of its time to providing oncologic patient care and does not provide or appear to wish to provide what the public defines as primary care. The survey estimate of 1.8 medical oncologists per 100,000 adult Americans is in close accord with HMO estimates of the number of desired oncologists. Consequently, the supply appears consistent with the anticipated demand. There does not appear to be an oversupply of medical oncologists in the United States.

Psychometric properties of a decision-support tool for the era of managed care.

This article reports psychometric properties of a decision-support scale designed to quantify the decision-making process for allocating psychiatric care. The authors developed a scale to evaluate the level of care needed for patients requiring psychiatric treatment in a health maintenance organization (HMO) setting. This study examines the reliability and validity of that scale by measuring interrater agreement among utilization reviewers from the HMO and between those reviewers and the clinicians who evaluated the patients directly. Agreement (kappa) among the five clinical raters acting in a utilization review capacity on dimensions of the scale ranged from .71 to .98. Kappas for agreement between the treatment intensity proposed by the reviewer/rater and used by the treating clinician were .41, .38, .40, .35, .36, and .39, respectively. The scale is reliable in the hands of trained personnel. Although there were important differences between clinicians' ratings and those of utilization review raters, these differences do not suggest that use of the scale would limit patient access to care.

Postdischarge follow-up of psychiatric inpatients and readmission in an HMO setting.

This study examined the relationship between follow-up and rehospitalization of inpatients discharged from treatment in two divisions of a health maintenance organization (HMO). Among 580 patients discharged, two-thirds made a follow-up visit within 30 days. Slightly less than a third were readmitted within six months. Readmission was less likely for patients who made a follow-up visit and for men. Patients who had a preadmission relationship with a mental health practitioner were more likely to make a follow-up visit and were more likely to be readmitted. Follow-up was also associated with diagnoses of adjustment and affective disorders.

California Pediatricians' Knowledge of and Response to Recommendations for Universal Infant Hepatitis B Immunization

To assess California pediatricians' level of agreement with and implementation of universal infant hepatitis B immunization. Mailed questionnaire in the summer and fall of 1993 to a random sample of 1030 California pediatricians to determine whether they universally immunize infants with hepatitis B vaccine. The response rate was 71%. More than 81% said they universally immunize infants against hepatitis B infection; however, 18.3% stated that they do not. Pediatricians were more likely to immunize infants universally against hepatitis B if they (1) agreed with the recommendations (90% vs 54%, P < .01), (2) practiced in a health maintenance organization setting vs private group practice (92% vs 79%, P < .05), or (3) practiced in settings with predominantly low-income patients (89% vs 78%, P = .01). Pediatricians who universally immunize infants against hepatitis B virus were in practice an average of 1.7 years longer than those who do not (13.3 years vs 11.6 years, P = .01). In multivariate analyses, the most powerful predictor of universal immunization was agreement with the recommendations. Among those who disagreed with the recommendations, the most common reasons for disagreement included the following: (1) the long-term efficacy of hepatitis B vaccine is not proved--54%; (2) an additional immunization would make the visits too costly--53%; and (3) three shots would be too much at one visit--53%. A majority (81.6%) of our sample of California pediatricians universally immunize infants against hepatitis B; however, a significant minority (18.4%) do not agree with the recommendations and do not plan to implement them. Many of their objections are being addressed through combination vaccine development and ongoing research; however, alternative policies and additional research should also be considered.

The effects of psychological research on the continuity of the patient-physician relationship in a primary care health maintenance organization setting

This project was designed to explore the impact of sensitive psychological research on the continuity of the relationship between the patient and the physician researcher in a primary care health maintenance organization setting. Subjects were 134 women who participated in a sensitive psychological research project that was conducted by a female family physician researcher. Subjects were matched by height and weight, length of the study interval, and type of medical service with 127 female controls who were seen by a male family physician during the same period in the same health maintenance facility. Participants were compared for patient-initiated changes in primary care physicians during equalized follow-up periods. No significant differences between subjects and controls were found. These results suggest that sensitive psychological research does not appear to deter patients who are research participants from continuing their professional relationship with the physician researcher.

Primary care performance in fee-for-service and prepaid health care systems. Results from the Medical Outcomes Study

<h3>Objective.</h3> —To examine differences in the quality of primary care delivered in prepaid and fee-for-service (FFS) health care systems. <h3>Study Design.</h3> —Longitudinal study of 1208 adult patients with chronic disease whose health insurance was through a traditional indemnity (FFS) plan, an independent practice association (IPA), or a health maintenance organization (HMO). Both IPA and HMO represent prepaid care systems. Patient- and physician-provided information was obtained by self-administered questionnaires. <h3>Setting.</h3> —A total of 303 physician offices (family medicine, general internal medicine, endocrinology, or cardiology) in solo and group practices in three US cities. <h3>Outcomes Measures.</h3> —Seven indicators of primary care quality—accessibility (financial and organizational), continuity, comprehensiveness, coordination, and accountability (interpersonal and technical) of care. Performance on each was evaluated in FFS, IPA, and HMO settings. Analyses controlled for patient and physician characteristics. <h3>Results.</h3> —Financial access was highest in prepaid systems. Organizational access, continuity, and accountability were highest in the FFS system. Coordination was highest and comprehensiveness was lowest in HMOs. <h3>Conclusions.</h3> —The results mark notable differences in core dimensions of primary care quality in each of three payment systems and raise questions regarding the associated cost inefficiencies and outcomes of care. In the current health care delivery reform climate, these findings call for consideration of the relative strengths and weaknesses of each system. We suggest strategies for elevating performance in each. (<i>JAMA</i>. 1994;271:1579-1586)

Primary Care Performance in Fee-for-Service and Prepaid Health Care Systems

To examine differences in the quality of primary care delivered in prepaid and fee-for-service (FFS) health care systems. Longitudinal study of 1208 adult patients with chronic disease whose health insurance was through a traditional indemnity (FFS) plan, an independent practice association (IPA), or a health maintenance organization (HMO). Both IPA and HMO represent prepaid care systems. Patient- and physician-provided information was obtained by self-administered questionnaires. A total of 303 physician offices (family medicine, general internal medicine, endocrinology, or cardiology) in solo and group practices in three US cities. Seven indicators of primary care quality--accessibility (financial and organizational), continuity, comprehensiveness, coordination, and accountability (interpersonal and technical) of care. Performance on each was evaluated in FFS, IPA, and HMO settings. Analyses controlled for patient and physician characteristics. Financial access was highest in prepaid systems. Organizational access, continuity, and accountability were highest in the FFS system. Coordination was highest and comprehensiveness was lowest in HMOs. The results mark notable differences in core dimensions of primary care quality in each of three payment systems and raise questions regarding the associated cost inefficiencies and outcomes of care. In the current health care delivery reform climate, these findings call for consideration of the relative strengths and weaknesses of each system. We suggest strategies for elevating performance in each.

Formulary Management from a Health Maintenance Organization (HMO) Perspective

With the rise of managed care, formularies are being increasingly employed in the outpatient setting to manage use and control costs of prescription drugs. The formulary management policies of various managed care organizations are widely diverse and are largely dependent on the organizational structure of the managed care program. Although reasons for choosing certain types of formulary systems will be briefly explored, this article primarily focuses on formulary management tools used in the group model HMO setting. Various aspects of the formulary process that require ongoing management are described, including non-formulary drug usage, drug restrictions, drug use review, adverse drug reaction reporting, education of the professional staff, reporting of drug use data to physicians, and visitation by pharmaceutical sales representatives.

Cholesterol: myth vs reality?

Of the four articles about cholesterol in the April 1993 issue ofAJDC, two present new data. Mietus-Snyder et al1report that nutritional counseling in a pediatric lipid clinic had virtually no effect on the children's serum lipid levels: the average change in low-density lipoprotein cholesterol levels was an increase of 0.03 mmol/L (1 mg/dL). Bachman et al2report that, even in their health maintenance organization setting where all services were offered at no cost to patients, most families did not comply with recommendations for cholesterol testing and treatment. To identify 25 children at high risk, they reviewed more than 1000 questionnaires, measured 369 cholesterol levels (160 subjects refused testing) and performed 58 full lipid panels (35 subjects refused follow-up testing). The 25 children with elevated low-density lipoprotein cholesterol levels were then invited to attend a nutritional program. Sixteen of the 25 children did not attend any of

Managing low back pain: attitudes and treatment preferences of physical therapists.

We surveyed physical therapists about their attitudes, beliefs, and treatment preferences in caring for patients with different types of low back pain problems. Questionnaires were mailed to all 71 therapists employed by a large health maintenance organization in western Washington and to a random sample of 331 other therapists licensed in the state of Washington. Responses were received from 293 (74%) of the therapists surveyed, and 186 of these claimed to be practicing in settings in which they treat patients who have back pain. Back pain was estimated to account for 45% of patient visits. The McKenzie method was deemed the most useful approach for managing patients with back pain, and education in body mechanics, stretching, strengthening exercises, and aerobic exercises were among the most common treatment preferences. There were significant variations among therapists in private practice, hospital-operated, and health maintenance organization settings with respect to treatment preferences, willingness to take advantage of the placebo effect, and mean number of visits for patients with back pain. These variations emphasize the need for more outcomes research to identify the most effective treatment approaches and to guide clinical practice.

Effects of Cost Containment on the Care of Elderly Diabetics

Because of rising costs in the Medicare program, the elderly have been encouraged to enroll in health maintenance organizations (HMOs). To evaluate the quality of care in these HMOs, detailed criteria on the treatment of elderly diabetics were established by an expert panel. Approximately 20 months of care for elderly diabetics was reviewed by medical record abstractions with a historical cohort design. The care of elderly diabetics in eight HMOs was compared with the care received in fee-for-service (FFS) settings located in similar geographic areas. Elderly diabetics enrolled in HMOs (n = 158) were compared with similar diabetics (n = 134) in FFS settings. Diabetic HMO enrollees were more likely to have funduscopic examinations (48% in HMOs vs 30% FFS) and urinalyses (89% in HMOs vs 74% FFS) performed. Enrollees with poor diabetic control were also more likely than FFS diabetics to be referred to an ophthalmologist (45% in HMOs vs 11% FFS). However, influenza vaccinations were administered to diabetics more often in FFS settings than to diabetic enrollees (19% in HMOs vs 62% FFS). One fifth of diabetics in both groups were treated with insulin and two thirds were treated with oral hypoglycemic agents, though HMO enrollees were more likely to have medication changes. We conclude that most aspects of the quality of diabetic care were similar in HMO and FFS settings and were unaffected by this effort at cost containment.

Improving influenza vaccination performance in an HMO setting: the use of computer-generated reminders and peer comparison feedback.

We evaluated a program for improving influenza immunization performance in a health maintenance organization (HMO). The HMO implemented several interventions successively from 1984-87: a postcard reminder to members at high risk for complications of influenza, a computer-generated reminder to the physician at the time of any primary care visit by high-risk patients, performance feedback to chiefs of service, and, finally, retrospective feedback to each physician comparing his/her performance with that of the other physicians. We examined immunization rates for a group of members older than age 65, a high-risk group under age 65, and a group of diabetic members who had not been subject to the reminders (vs a group who had been covered by the program). Vaccination rates were increased in those diabetic members who received reminders. Nevertheless, among members younger and older than age 65 whose experience was observed over three flu seasons, a significant increase in vaccination rates was not achieved until physician feedback was added to the program. We conclude that each element of the reminder and feedback program has contributed to the overall increase in vaccination rates at the HMO and that effective ongoing influenza immunization programs can be implemented in practice settings with appropriate systems support.

Burnout among primary care physicians and mental health professionals in a managed health care setting.

This study assessed burnout within a large Health Maintenance Organization. Primary care physicians and one psychiatric clinic staff were studied. The Maslach Burnout Inventory was used to develop frequency data in the areas of emotional exhaustion, depersonalization, and personal achievement. Among the primary care physicians, moderate emotional exhaustion, and depersonalization were found. Personal achievement was high. Among the psychiatric staff, high emotional exhaustion and depersonalization were found. Again, personal achievement was high. The entire professional group, with the one exception, was significantly higher in emotional exhaustion, depersonalization, and personal achievement than Maslach's normative sample. Psychiatrists and social workers had significantly higher scores on depersonalization than the primary care physicians or psychologists. High burnout in a Health Maintenance Organization setting suggests that managed health care providers may be more prone to burnout than fee-for-service practitioners. Several suggestions were made for such organizations to help alleviate burnout in their staffs.