HMO Primary Care Research Articles

Authors’ Response

To the Editor: We thank Horberg et al for their interest in our study (2005;32:207–213); however, the outcomes of our study were based on participants’ perceptions of their HIV testing experience in various HIV testing settings. We did not study the association between the HIV testing setting and HIV-positive clients’ proper clinical care follow up. We did comment in our conclusion that a poor counseling experience may directly or indirectly affect care-seeking behavior either by lowering self-efficacy or adversely affecting the motivation to seek care, but we did not identify one type of HIV testing setting as worse than others. We take exception to the authors’ notion that grouping together patients from HMOs and private physician offices is not intuitive. We agree that group-model HMOs have a different referral system from that of private physicians’ offices. We congratulate your HMO for staffing a care coordinator to ensure that HIV-positive patients are referred to appropriate follow-up care. However, the majority of HMOs are under the framework of a network HMO model whereby each network HMO primary care physician would only make referrals to HIV care. In physicians’ offices, patients with a network HMO insurance policy and patients with another type of insurance policy would not see differences in the primary care and referral services they do or do not receive. We did not claim to have a representative sample from each of the HIV test settings. We would agree that a sample of 13 is small, but it is sufficient for even the conservative lower value of the confidence interval for HMOs/private practices to be consistent with patients’ perceptions that in HMOs or private practices, not all their questions were answered and not enough time was spent with them. Reproducibility is of course important, and we encourage interested researchers to conduct other studies on the quality of HIV test counseling and its effect on follow-up care. Very little is known about the impact of perceived quality of posttest counseling on linkage to care. We hope this exchange will draw attention to the need for further research in this area.

Hazardous Drinkers and Drug Users in HMO Primary Care: Prevalence, Medical Conditions, and Costs

There exists substantial evidence that individuals with alcohol and drug disorders have heightened comorbidities and health care costs. However, little is known about the larger population of "hazardous" drinkers (those whose consumption increases their "risk of physical and psychological harm") and drug users. A sample of 1,419 patients from HMO primary care clinics was screened for hazardous drinking and drug use. Health plan databases were used to examine medical conditions and health care costs of hazardous drinkers and drug users in the year prior to screening, in comparison to 13,347 patients from the same clinics, excluding those screened. We found a prevalence of 7.5% for hazardous drinking and 3.2% for drug use in primary care (10% had at least one of the two problems). Hazardous drinkers and drug users had heightened prevalences for eight medical conditions, including costly conditions such as injury and hypertension, and psychiatric conditions. Medical costs for the year examined were not higher, except for those who also had psychiatric conditions. The prevalence of hazardous drinking and drug use was similar to hypertension and diabetes. Hazardous drinkers and drug users' heightened medical conditions, especially those related to alcohol and drug abuse, indicate that screening and brief intervention at this lower threshold of hazardous drinking and drug use will detect individuals with health risks sooner. Optimal treatment and prevention of some medical disorders may require identification and intervention of underlying hazardous alcohol or drug use.

The association of depression and perceptions of interpersonal relationships in patients with diabetes

Objective Using an instrument assessing interpersonal relationships in patients with diabetes, we hypothesized that a change in depression would be associated with a change in patients' perceptions of themselves and others in relationships. Methods Instruments assessing attachment, depression, and demographics were administered twice to 367 patients with diabetes in an HMO primary care setting, 10 months apart. We assessed change in capacity to rely on others (model of other) and to feel worthy of attention (model of self) according to depression change categories (unchanged, decreased, and increased depression). Results The degree to which patients reported being able to rely on others increased with a reduction in depressive symptoms ( P=.02). The degree to which patients endorsed a sense that they were not worthy of attention in relationships increased with an increase in depressive symptoms ( P=.02). Conclusion A change in depressive symptoms is associated with a change in perception of interpersonal relationships in patients with diabetes.

Drinking patterns, health care utilization, and costs among HMO primary care patients.

A survey of 8,034 primary care patients in a health maintenance organization examined the relationship between alcohol consumption and health care costs and service use. Costs were estimated from service use data for 1 year before and 2 years after study enrollment. No strong, consistent relationships were identified between multiple indicators of drinking patterns and either health care costs or service use. Compared with total costs among very light drinkers, former drinkers were higher, lifetime abstainers were similar, and persons in the higher drinking levels tended to have lower but not significantly different costs. Drinking patterns did not appear to be an important predictor of short-term health care costs or service use in this setting. Further study of former drinkers is warranted to examine the role of alcohol-related illnesses in the decision to quit drinking.

Development of a model for the detection and treatment of depression in primary care.

Development and implementation of a protocol for identifying and treating depressed patients in a busy, group model, HMO primary care practice is described. Initial results and barriers to implementation are reported. A simple depression screening tool was adapted and a protocol for using available primary care staff and resources was developed to efficiently integrate screening and treatment for depression into daily practice. Important components of the program included specification of the target population, adaptation of a patient self-report diagnostic and rating tool, a nurse-educator protocol for patient follow-up and telephone support, a database to track patient progress, training for primary care staff, and collaboration with specialty Behavioral Health Care. After piloting, plans were made for transferring the model to other practices. Although the protocol was seen as beneficial to the PCP, Nurses, and patients involved, the scarcity of resources in other primary care practices proved a major barrier to full implementation.

Patterns and determinants of multiple provider use in patients with acute low back pain.

To describe the patterns of provider use associated with an acute episode of nonspecific low back pain and their impact on cost. The analysis is based on a prospective cohort study of patients with acute low back pain followed until they recovered completely or to 6 months. Patients were followed after an initial visit to one of four provider types: private primary care physician, chiropractor, orthopedic surgeon, or HMO primary care physician. Follow-up interviews were conducted at baseline, 2, 4, 8, 12, and 24 weeks; 1,580 (97%) of the participants completed the 6-month follow-up. Seventy-nine percent of patients saw only the initial provider who began their care for low back pain. Logistic regression revealed that duration of pain prior to initial visit, sciatica, higher Roland disability score, days to functional recovery, interval to complete recovery, referral by initial provider, disk attribution, satisfaction, and the type of index provider were significantly (p < .05) associated with seeking care from multiple provider types. Age, race, gender, and education were not significant. The adjusted proportions of multiple provider type use were 14% (95% confidence interval [CI] 11%, 17%) for the private primary care provider stratum; 19% (95% CI 16%, 23%) for the chiropractic stratum; 30% (95% CI 23%, 37%) for the orthopedic stratum; and 9% (95% CI 5%, 14%) for the HMO primary care physician stratum. Cost of seeing only the index provider was $439 (95% CI $404, $475), and cost of seeing multiple provider types was $1,137 (95% CI $1,064, $1,211) based on the adjusted model. Use of multiple provider types, is associated with several factors, one of which is the initial provider type. The cost of such use is significant.

Physicians' changing attitudes toward guidelines.

The objective of the study was to measure the change in physicians' attitudes toward preventive care guidelines over a 2-year period. The study was conducted at a Southern California managed care medical group that was experiencing intense price competition. We analyzed individualized survey responses of 62 HMO primary care physicians over the study period. We found that physicians increasingly believed that clinical guidelines were being used for cost containment (first survey 71% vs second survey 92%, p < .005) and less for quality improvement (first survey 85% vs second survey 67%, p < .008) over time. These findings may create a barrier to physicians' adoption of practice guidelines.

At-risk drinking in an HMO primary care sample: prevalence and health policy implications.

This study was designed to determine the prevalence of at-risk drinking using varying alcohol use criteria. A period prevalence survey was conducted in 22 primary care practices (n = 19372 adults). The frequency of at-risk alcohol use varied from 7.5% (World Health Organization criteria) to 19.7% (National Institute on Alcohol Abuse and Alcoholism criteria). A stepwise logistic model using National Institute on Alcohol Abuse and Alcoholism criteria found male gender, current tobacco use, never married status, retirement, and unemployment to be significant predictors of at-risk alcohol use. Public health policy needs to move to a primary care paradigm focusing on identification and treatment of at-risk drinkers.

Brief Intervention in a Primary Care Setting for Hazardous Drinkers

The study was designed to test a brief intervention for reducing alcohol consumption among moderate to heavy (hazardous) drinkers in a busy HMO primary care setting. In a randomized controlled trial, hazardous drinkers (n = 516) were identified by the AUDIT screening questionnaire. Intervention included brief clinician advice (30 seconds), a 15-minute motivational session by counselors, and printed materials. At six-month follow-up, intervention subjects reported fewer total standard drinks in the past three months (176 versus 216, P = .04, one-tailed) and fewer drinking days per week (2.8 versus 3.3, P = .02) than controls, but similar drinks per drinking day (3.3 versus 3.5; P = .13). At 12 months, intervention subjects again reported fewer drinking days per week (2.7 versus 3.1; P = .04) than controls, but similar numbers of standard drinks (157 versus 179; P = .13) and drinks per drinking day (3.6 versus 3.3; P = .20). Intervention subjects were somewhat more likely than controls to report drinking within daily recommended limits (< or = 3 for men, < or = 2 for women) at both six months (79% versus 71%; P = .06) and 12 months (80% versus 73%; P = .07), but did not differ significantly from controls on other drinking outcomes (percent abstinent, frequency of drinking > or = 6 drinks per drinking occasion, estimated peak blood alcohol concentration), or use of medical care in the year following intervention. A one-time, brief motivational intervention using minimal clinician time supplemented by trained counselors resulted in a modest reduction in frequency of alcohol consumption in a busy primary care population. Future research should focus on strengthening and maintaining intervention effects.

Negotiating with the partners: a role of the HMO mental health director.

The mental health director in a health maintenance organization must successfully negotiate with a number of "partners" in the community and within the HMO in order to deliver high-quality services in a cost-effective fashion. These partners are companies whose employees are members, the members themselves, the HMO's primary care professionals, the mental health professionals, and the HMO administration. In addition, the models of treatment prevalent within a community constitute an intangible partner. Based on his experience in a mixed fee-for-service and HMO mental health department, the author describes negotiations of some difficult issues, which include whether patients can bypass their primary care physician and refer themselves to the mental health department, establishing co-payment rates for outpatient visits to prevent overutilization of mental health services, and dealing with companies who disagree with the HMO's treatment modalities. Although at times compromises are necessary, sometimes the mental health director must maintain a rigid position in order to protect a cost-effective program and promote smooth delivery of services.