Women's use of complementary and alternative therapies in reproductive health care

Numerous studies have documented that health care consumers all over the world are spending money out of pocket for alternative therapies and that billions of dollars are spent in the United States alone. In this article, the use of complementary and alternative therapies by women health care consumers is discussed, particularly as this phenomenon relates to women's reproductive health in the United States. Women use conventional health care services more frequently than men; thus, it is not surprising that women account for approximately two thirds of health care appointments for complementary and alternative therapies. The traditional conceptual frameworks of herbal medicine, homeopathy, acupuncture, and acupressure are presented, and common clinical applications to women's reproductive care are discussed.     

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.     

Race, prostate cancer survival, and membership in a large health maintenance organization

BACKGROUND: Population-based cancer registry data have shown that black men with prostate cancer have poorer stage-specific survival than white men, while studies in equal-access health care systems have not found racial differences in stage-specific survival. This study was designed to test the hypothesis that black men and white men with prostate cancer have equal stage-specific survival in equal-access health care systems. METHODS: We conducted a cohort study using cancer registry data from all incident cases of prostate cancer occurring in a five-county San Francisco Bay Area region. Incident cases occurred among members (5263 cases, from January 1973 through June 1995) and nonmembers (16,019 cases, from January 1973 through December 1992) of the Kaiser Permanente Medical Care Program, a large health maintenance organization. Death rate ratios (DRRs, black men versus white men) for Kaiser members and nonmembers were computed for all stages combined (adjusting for age and stage) and for each stage (adjusting for age). RESULTS: Among Kaiser members, adjusted DRRs comparing black men with white men were as follows: all stages combined, 1.28 (95% confidence interval [CI] = 1.14-1.44); local stage, 1.23 (95% CI = 1.01-1.51); regional stage, 1.30 (95% CI = 0.97-1.75); and distant stage, 1.27 (95% CI = 1.07-1.50). Corresponding DRRs for nonmembers were as follows: all stages combined, 1.22 (95% CI = 1.14-1.30); local stage, 1.24 (95% CI = 1.09-1.41); regional stage, 1.48 (95% CI = 1.29-1.68); and distant stage, 1.01 (95% CI = 0.91-1.12). CONCLUSIONS: These results show poorer prostate cancer survival for black men compared with white men in an equal-access medical care setting. The findings are most consistent with the hypothesis of increased tumor virulence in blacks.     

Use of alternative health care practitioners by Canadians

Non-invasive acoustic airway monitoring was evaluated in an experimental study. Recording amplitude and travel time of acoustic pulse response, an area-distance function of the cross sectional dimensions of the endotracheal tube and the adjacent airway was calculated to obtain an acoustic pattern of the airway. Measurements on models and excised human cadaver lungs were performed to discover whether displacement or obstruction of the artificial airway can be detected in the acoustic equivalent. Regression analysis revealed a close correlation between displacement of tracheostomy tubes and the shifting of the acoustic area-distance function (corr. coeff. 0.97-1). Dispersion analysis confirmed reasonable reliability (coeff. of variation 0.6-2.1%). Location and amount of obstruction could likewise be identified. Thus acoustic mapping provides an adequate approximation of the true geometry of tracheostomy and endotracheal tubes. We conclude that acoustic monitoring may provide a powerful tool to achieve primary prevention of airway disturbances in intubated and mechanically ventilated patients, as geometrical changes of airway configuration can be detected even before they cause substantial effects on respiratory metabolism.     

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.     

Untreated anxiety among adult primary care patients in a Health Maintenance Organization

BACKGROUND: Untreated anxiety may be particularly difficult for primary care physicians to recognize and diagnose because there are no reliable demographic or medical profiles for patients with this condition and because these patients present with a high rate of comorbid psychological conditions that complicate selection of treatment. METHOD: A prospective assessment of untreated anxiety symptoms and disorders among primary care patients. RESULTS: Approximately 10% of eligible patients screened in clinic waiting rooms of a mixed-model health maintenance organization reported elevated symptoms and/or disorders of anxiety that were unrecognized and untreated. These patients with untreated anxiety reported significantly worse functioning on both physical and emotional measures than "not anxious" comparison patients; in fact these patients reported reduced functioning levels within ranges that would be expected for patients with chronic physical diseases, such as diabetes and congestive heart failure. The most severe reductions in functioning were reported by untreated patients whose anxiety was mixed with depression symptoms or disorders. CONCLUSION: Primary care physicians may benefit from screening tools and consultations by mental health specialists to assist in recognition and diagnosis of anxiety symptoms and disorders alone and mixed with depression.     

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.     

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)     

Couple therapy in a health maintenance organization (HMO).

Presents case examples of treatment for a 25-yr-old couple with a commitment impasse and a married couple with anxiety about becoming parents in a health maintenance organization setting. Such treatment requires conceptualizing the problem within a developmental framework, prompt identification of a focal issue, and emphasis on the couple's part in bringing about desired changes. (11 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patients' opinions of the role of primary care physicians and the organization of health care services

Patients' opinions of the role of the primary care physician were studied. The study population consisted of Hebrew-speaking members of the Clalit Sick Fund, aged 18+, who visited primary care and specialty clinics. Interviews took place during January-March 1995 in the Emek and Jerusalem, and during August-October 1995 in Beer Sheba. A total of 2,734 interviews were conducted, and the response rate was 88%. 64% of the respondents preferred the primary care physician as the first address for most problems occurring during the day. Multivariate analysis revealed that the variables predicting this reference were: being over age 45, having completed less than 12 years of schooling, being satisfied with the physician, and when a child's illness was involved. Whether the physician was a specialist had only a marginal effect. The findings also show that among those who did go directly to a specialist for the current visit, 49% would still prefer the primary care physician to be the first address for most problems. However, half of the respondents initiated the current visit to the specialty clinic themselves. The findings also showed that a preference for the primary care physician to be the first address had an independent and statistically significant effect on the following aspects of service consumption: taking the initiative to go to a specialist, the intention to return to the primary care physician or to the specialist for continuing care, and the patient's belief that referral to a specialist was needed. The findings of the study may be of assistance to policy-makers on the national level and to sick funds in planning the role of the primary care physician, so that it corresponds, on the one hand, to the needs of the sick funds and the economic constraints in the health system, and on the other, to the preferences of the patient.     

Prevalence of adult domestic violence among women seeking routine care in a Native American health care facility

OBJECTIVES: The purpose of this study was to determine the prevalence of, and sociodemographic factors associated with, adult domestic violence within a Native American community. METHODS: Adult women in the community were surveyed. RESULTS: Of 371 eligible women, 341 (92%) were surveyed. Among respondents, 179 reported a history of at least 1 episode of domestic violence. Fifty-six (16.4%) reported violence within the previous 12 months. Age under 40 years and living in a household receiving governmental financial assistance were independently associated with 1-year prevalence of adult domestic violence. CONCLUSIONS: Adult domestic violence is prevalent within this Native American community. Additional research is required to characterize further the relationship between domestic violence and socioeconomic status.     

Results of a radiology performance report for a health maintenance organization

PURPOSE: To present results with a radiology performance report to help evaluate utilization of radiologic examinations by primary-care practices (family practice, internal medicine, or pediatrics) in an independent practice association health maintenance organization (HMO). MATERIALS AND METHODS: Utilization reports for primary-care-physician practices (n = 5,000) over a 12-month period (July 1, 1993 through June 30, 1994) were derived from administrative data collected from claim and encounter forms submitted by radiologic practices. Data were divided into 22 measures to help define practice utilization. five overall measures helped evaluate procedures performed by HMO member or nonmember practices per 1,000 members. Twelve specific measures helped evaluate patterns of use of frequently ordered imaging procedures (eg, computed tomography, magnetic resonance imaging, bone scanning, cardiovascular nuclear imaging, nonobstetric ultrasound, and plain radiography). Five quality measures helped evaluate utilization of screening mammography in women aged 50-64 years (as a percentage of all women in the HMO aged 50-64 years) and of low-yield examinations (ie, sinus, rib, and skull radiography per 1,000 adult members). RESULTS: Individual practice utilisation mean results were compared with overall HMO mean results adjusted for practice type and age and sex of members. CONCLUSION: Utilization data are an integral part of evaluation of HMOs and their providers, and these results helped establish a baseline level of performance.     

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)     

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)     

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)     

Bioethics for clinicians: 17. Conflict of interest in research, education and patient care

A conflict of interest occurs in a situation in which professional judgement regarding a primary interest, such as research, education or patient care, may be unduly influenced by a secondary interest, such as financial gain or personal prestige. Conflicts of interest exist in every walk of life, including medicine and science. There is nothing inherently unethical in finding oneself in a conflict of interest. Rather, the key questions are whether one recognizes the conflict and how one deals with it. Strategies include disclosing the conflict, establishing a system of review and authorization, and prohibiting the activities that lead to the conflict.