Medical crisis counseling in a health maintenance organization: Preventive intervention.

Mental health clinicians can play a cost-effective role in reducing distressing psychological symptoms accompanying diagnosis of chronic illness. Medical crisis counseling (MCC) is a focal short-term intervention directly addressing illness-related psychosocial problems. A randomized clinical trial tested the effectiveness of MCC. Counseling was offered to patients who had cancer that was newly diagnosed, 1st heart attacks, or adult-onset diabetes and was contrasted with a control group receiving an HMO's standard mental health care. Significant reductions in distress attributable to MCC were noted in some patient groups. No increases in overall medical costs and some decreased mental health utilization and costs were noted with MCC use. Practitioners can easily apply MCC to improving patients' quality of life and mental health, without adding to health care costs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Costs of acid-related disorders to a health maintenance organization

BACKGROUND: Little is known about the economic impact of the acid-related disorders (ARDs), which include dyspepsia, gastritis, gastroesophageal reflux disease (GERD), and peptic ulcer disease (PUD), in managed care patient populations. OBJECTIVES: To describe the prevalence of medically attended ARDs, and their direct medical costs from the perspective of a large health maintenance organization (HMO). METHODS: A total of 1,550 ARDs subjects (age > or = 18 years), were randomly sampled from outpatient diagnosis and pharmacy databases of the Kaiser Permanente Medical Care Program of Northern California and verified by chart review. Five age- and gender-matched controls were identified per subject. One-year prevalence, excess annual costs, and initial 6-month costs for incident cases were estimated using the HMO cost accounting system. RESULTS: Total ARDs prevalence (5.8%) increases with advancing age. GERD is the most common ARD (2.9% overall prevalence). Annual per person attributable costs were $1,183, $471, and $431 respectively for PUD, GERD, and gastritis/dyspepsia. Excess inpatient costs for PUD explain its higher costs. Outpatient costs were somewhat higher for GERD ($279) than for PUD or gastritis/dyspepsia. Pharmacy costs were relatively low for each condition, in part because many patients were treated with generic cimetidine. Total annual HMO expenditures for ARDs were $59.4 million, with 40.6%, 36.8%, and 22.6% respectively for GERD, PUD, and gastritis/dyspepsia. CONCLUSIONS: Acid-related disorders, particularly GERD and PUD, contribute substantially to the direct costs of medical care in this managed care population.     

Short-term group therapy for couples in a health maintenance organization.

Describes a 15-session group treatment program for couples in a health maintenance organization (HMO). The program demonstrates principles of efficiency, economy, integration of services, and prevention in an HMO. It is argued that the location of the program in a comprehensive organized health care setting enhances the efficacy of the treatment. (14 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Alcohol consumption and utilization of health services in a health maintenance organization

OBJECTIVES: This study examined the relation between alcohol use and utilization of health services during a 3-year period in a sample of 4,264 adult respondents to a member health survey in a health maintenance organization. METHODS: Respondents were categorized as abstainers (no drinks in the past year, n = 1,139), lighter drinkers (less than seven drinks/week, n = 2,330), moderate drinkers (seven to 13 drinks/week, n = 498), and heavier drinkers (> or =14 drinks/week, n = 297). Each drinker group was compared with abstainers on outpatient visits, hospital days, and number of hospitalizations controlling for age, race, and health plan membership. RESULTS: The mean number of outpatient visits was inversely related to the amount of alcohol consumed. Significant differences also were found for mean number of hospitalizations and mean days hospitalized per year. Compared with the three drinker groups, abstainers were significantly higher on both inpatient measures. CONCLUSIONS: These results might be explained by the inclusion in the abstainer group of exdrinkers who quit because of illness, inattention to health problems by heavier drinkers, or lower rates of illness among drinkers. The findings underscore the importance of replicating our study in other cohorts in which problem drinkers can be identified and compared with non-problem drinkers and in which lifelong abstainers can be separated from exdrinkers in the analysis.     

Community disasters: Primary prevention and treatment in a health maintenance organization.

In March 1977, members of the Hanafi Muslim sect seized and held hostages at three sites in Washington, D. C. The greatest number, over 100 persons, were held in the B'Nai B'rith National Headquarters for 39 hours. Many of these hostages suffered emotional aftereffects from this ordeal. The mental health staff of a Washington area health maintenance organization (HMO), to which many of the B'Nai B'rith hostages belonged, made its services available to all these men and women, regardless of their health insurance coverage. The symptoms covered a wide spectrum of modalities and ranged in severity and persistence. The case example of a 42-year-old female employee is presented. Treatment interventions followed a primary prevention model using a broad-spectrum behavioral group approach. This article advocates a primary prevention model for the delivery of services in crisis situations. Such a model is also advisable for services provided in an HMO. (5 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Acceptability of a substitution of estrogen replacement therapy to women enrolled in a health maintenance organization

This research examines the implications of an aging society on the demand for prehospital emergency medical services (EMS). Using a large comprehensive set of population-based EMS utilization data (N = 73874) and population data from the 1990 Census for the City of Dallas, Texas, rates of utilization for eight age groups were computed for total EMS incidents, incidents requiring transport services, and a sub-category of transport services for individuals requiring services for life-threatening conditions. The pattern of utilization associated with age was found to be tri-modal with rates rising geometrically with age for individuals aged 65 and over. Compared to the age group 45 to 64 years of age, rates of utilization for those aged 85 years and older were 3.4 times higher (P < 0.001) for total EMS incidents, 4.5 times higher (P < 0.001) for emergency transports and 5.2 times higher (P < 0.001) for incidents of a life-threatening nature. A broad categorization of all EMS incidents by reason for requiring services indicates that the observed age-associated increase in utilization is due primarily to medical conditions rather than incidents arising from trauma. Finally, gender and racial/ethnic differences in utilization are briefly considered.     

Metabolites of ebrotidine, a new H2-receptor antagonist, in human urine

The clinical application of ultrasonographic contrast agents in colour Doppler flow imaging of hepatic tumours is receiving increasing attention. Levovist is a suspension of galactose microparticles that provides reproducible concentrations of stabilized air bubbles with transpulmonary stability. Its effect on colour Doppler imaging was assessed in 26 patients with colorectal cancer and histologically proven hepatic metastases. Colour Doppler flow imaging was performed before and after intravenous injection of 10 ml Levovist 300 mg/ml. At 5-10 s after injection there was significant enhancement of the hepatic lesions with colour Doppler signals in 23 patients, lasting for a mean(s.d.) of 180(45) s. A consistent pattern of colour Doppler signal was observed, with increased enhancement predominantly around the tumour periphery and little or no central enhancement. These data suggest that Levovist may increase the sensitivity and specificity of colour Doppler flow imaging of colorectal hepatic metastases.     

Temporal trends in hospital-based episodes of asthma care in a health maintenance organization

Studies reporting increased asthma hospitalizations and mortality in the United States and abroad have heightened concern about the changing epidemiology of asthma. We studied 20-yr patterns of acute asthma care occurring at two large community hospitals among members of a large health maintenance organization. The presentation focuses on the conceptualization and operationalization of an "episode" of asthma care, defined as a collection of encounters (emergency room visits, urgency care visits, and hospital admissions) that cluster in time, as well as on changes in episode rates over time. We found a statistically significant increase in asthma episodes among boys younger than 5 yr of age that continued unabated from 1967 to 1987 despite a drop in asthma hospitalization rates starting in 1985. We hypothesize that this difference may reflect a change in emergency room management practices and not a true change in the underlying epidemiology of asthma. The concept of an episode of acute asthma care has not been studied in the literature and represents a potentially useful methodologic innovation. Particularly in the context of managed health care systems, studies of such episodes may be less sensitive than studies of hospital admissions to changes in the organization and delivery of acute asthma care, and thus may be better suited for studying changes in the epidemiology of asthma.     

Base rates of postconcussive symptoms in health maintenance organization patients and controls.

This study was intended to provide a normative comparison for determining the base rates of postconcussive syndrome (PCS) symptoms in patients from 4 medical departments of a health maintenance organization (HMO) and in people without acute medical or psychological complaints (controls). Recent research suggests that both neurologic and psychosocial factors influence these symptoms. Participants were 1,116 individuals who were surveyed regarding various symptoms, including those reported to be common in the PCS. Endorsement rates are presented for each PCS symptom for controls, each medical sample, and those people with a recent history of being knocked unconscious (2.3%), bumping their heads without losing consciousness (7.4%), and lawsuit involvement (6.8%), which were independently related to most PCS symptoms. The data indicate that neurologic, psychological, and environmental variables are related to having PCS complaints, and such factors should be considered before PCS complaints are used as evidence for brain damage. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment of erosive reflux esophagitis resistant to H2-receptor antagonist therapy. Lansoprazole, a new proton pump inhibitor

Fifty-four patients with endoscopically documented therapy-resistant erosive reflux esophagitis were treated with lansoprazole, a new proton pump inhibitor, for up to 12 weeks. Prior to entry, all had remained unhealed after treatment with at least two histamine2-receptor antagonists, at therapeutic doses or higher, for at least 12 weeks. Patients were randomized to receive either 30 or 60 mg lansoprazole once daily. Endoscopy was performed and symptoms assessed at weeks 2,4,6,8 and 12. Fifty-nine percent of the 50 evaluable patients were healed (ie, no evidence of erosions) after only two weeks of lansoprazole. Cumulative endoscopic healing rates were 82% and 92% by week 4 and week 8, respectively, and the two doses were equally effective in healing. The 30- and 60-mg doses effected a decrease in the overall symptom score from 5.30 and 4.85 to 2.35 and 1.67, respectively, by the final treatment visit (P = 0.001). No clinically significant adverse events or changes in laboratory parameters were observed, and no patients withdrew prematurely from the study. This study demonstrates that lansoprazole therapy is highly effective in healing erosive reflux esophagitis resistant to therapy with histamine H2-receptor antagonists.     

Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. A randomized, controlled trial

A monomeric protein, the hemoglobin alpha chain, was used to compare four protocols for conjugation with diethylene triamine pentaacetic (DTPA) anhydride. Carbamylation and succinylation were also performed. The isoelectric point (pI) was 7.7 for the native protein versus only 5.5 to 7.3 for the five carbamylated derivatives and 4.0 to 7.0 for the six succinylated derivatives. With carbamylation or succinylation, increasing the molar ratio (agent/protein) was associated with a gradual downward pI shift producing trains of bands. This phenomenon did not occur with DTPA conjugation, whose results varied with the method used; only one derivate (pI 6.7) was produced by all four methods, and multiple fine bands with pH values in the vicinity of 3.6 were seen. For the protein, the pI shift varied with the number of groups inserted on the primary amine residues. Also, the shift was larger if the inserted groups carried electrically-charged moieties.     

Psychotherapy in a staff model health maintenance organization: Providing and assuring quality care in the future.

Discusses characteristics of effective health maintenance organization therapy. These characteristics include a problem-solving orientation, crisis intervention preparedness, clear definition of patient and therapist responsibilities, flexible and creative use of time, interdisciplinary cooperative treatments, use of multiple formats and modalities, a family practitioner model that allows for intermittent treatment throughout the life cycle, and quality assurance and utilization review procedures. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Antidepressant pharmacotherapy: economic evaluation of fluoxetine, paroxetine and sertraline in a health maintenance organization

The present study was designed to compare direct health service expenditures, for the treatment of depression, among patients enrolled in a health maintenance organization, and prescribed one of three selective serotonin reuptake inhibitors, fluoxetine, paroxetine or sertraline. Information regarding depression-related health service use was derived from the computer archive of a network-model health maintenance organization system serving 700,000 beneficiaries. A total of 744 health maintenance organization beneficiaries were found to satisfy the study selection criteria. Multivariate regression analysis was used to determine the incremental influence of selected demographic, clinical, financial and provider characteristics on health service expenditures related to the treatment of depression (ICD-9-CM, or DSM-IV code 296.2) 1 year after the start of antidepressant pharmacotherapy. Multivariate findings indicate that treatment with paroxetine increases average expenditures for physician visits ($31.93; P < or = 0.05), psychiatric visits ($19.33; NS), laboratory tests ($2.35; P < or = 0.05), hospitalizations ($85.33; P < or = 0.05), psychiatric hospitalizations ($82.01; P < or = 0.05), and antidepressant pharmacotherapy ($63.72; P < or = 0.05), for a total per capita increase in health service use of $284.68 (P < or = 0.05), compared with treatment with fluoxetine. Sertraline treatment increases average expenditures for physician visits ($21.74; P < or = 0.05), psychiatric visits ($56.79; P < or = 0.05), laboratory tests ($1.21; P < or = 0.05), hospitalizations ($70.59; P < or = 0.05), psychiatric hospitalizations ($95.75; P < or = 0.05), and antidepressant pharmacotherapy ($69.85; P < or = 0.05), for a total per capita increase in health service use of $315.96 (P < or = 0.05), compared with treatment with fluoxetine. Economic comparisons between paroxetine and sertraline did not demonstrate any significant differences in expenditures for the health services examined.     

How reminders given to patients and physicians affected pap smear use in a health maintenance organization: results of a randomized controlled trial

BACKGROUND: Despite its effectiveness as a method of controlling cervical carcinoma, the use of Pap smear testing remains incomplete, and its promotion in the primary care setting provides an important opportunity for intervention. METHODS: The authors conducted a randomized controlled trial that involved three sites of a health maintenance organization (HMO) serving an urban minority population. Their aim was to evaluate the impact of reminders given to patients and physicians on site visitation by patients and Pap smear use. Eligible women (n=5801) were randomly assigned to 1 of 4 intervention combinations (in which reminders were given to either the patient or the physician, to both, or to neither). If they were ineligible for patient reminder intervention, patients were randomized only to physician reminder intervention (the presence or absence of it). The letter of reminder mailed to the patient invited women due for Pap smears to visit the HMO site, and the reminder for physicians was a medical record notice that a Pap smear was due. Logistic and survival analyses were used to investigate the correlation of intervention status with visitation, interval of time to a visit, and Pap smear use. RESULTS: In the primary intent-to-treat analysis, there was no significant effect of either patient or physician reminder interventions on rates of visitation or Pap smear completion. The secondary efficacy analyses demonstrated no overall effect of either patient or physician reminders, but effects among subgroups of women at individual HMO sites were noted. At Site 3, there was an apparent increase in time to the next visit among the subgroup of women with a chronic illness (16 weeks with intervention vs. 9 weeks without). With the physician reminder, the odds that a Pap smear would be given during the study year were increased among women without a previous Pap smear at Site 1 (adjusted odds ratio=1.39) and those with a chronic illness at Site 2 (adjusted odds ratio=3.38). CONCLUSIONS: Reminders given to patients and physicians had a limited impact on visitation by patients to the HMO sites or Pap smear completion. Although some subgroups of women may benefit, the authors also observed a possibly unfavorable impact among other subgroups. These results emphasize the importance of identifying more effective interventions, targeting them to women most likely to benefit, and not overlooking the possibility that preventive intervention will have an unanticipated adverse effect.     

Use of and interest in alternative therapies among adult primary care clinicians and adult members in a large health maintenance organization

It is now unquestionable that varicocele represents one of the main causes of male infertility, and thus requires appropriate surgical treatment. Inguinal and retroperitoneal methods have for some time been the most widely used. However, a significant postoperative morbidity and relatively long convalescence have prompted the search for alternative surgical techniques, such as percutaneous sclero-embolisation and microsurgery. Laparoscopic treatment of varicocele is a relatively recent surgical technique. The first studies by Sanchez de Badajoz date back to 1988 and to date a relatively small number of cases have been reported. The authors analyse the results in 54 patients treated over a period of two and a half years; 13 cases also presented inguinal hernia pathology which was treated during the same operation by applying a polypropylene graft again using a laparoscopic approach; the latter method has been routinely applied since 1992 in over 1000 cases with excellent results. The internal spermatic artery was always identified and preserved. No peri- or postoperative complications were observed. A follow-up was performed at 10 months after surgery and showed results which although referred to a relatively small series, were certainly better than those reported in the literature using traditional surgical techniques; in addition, this method also reveals interesting possibilities for the treatment of associated pathologies during the same operation, with obvious advantages in terms of costs and patient compliance.