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Health Maintenance Organization (health + maintenance_organization)
Kinds of Health Maintenance Organization Selected AbstractsPatient Knowledge and Awareness of Hypertension Is Suboptimal: Results From a Large Health Maintenance OrganizationJOURNAL OF CLINICAL HYPERTENSION, Issue 4 2003Mark Alexander PhD; Patient knowledge and awareness of hypertension are important factors in achieving blood pressure control. To examine hypertensive patients' knowledge of their condition, the authors randomly surveyed 2500 hypertension patients from a large health maintenance organization; questionnaires were supplemented with clinic blood pressure measurements. Approximately 72% of the subjects completed surveys. Of patients with uncontrolled hypertension (systolic blood pressure [SBP] 140 mm Hg and/or diastolic blood pressure [DBP] 90 mm Hg), only 20.2% labeled their blood pressure as "high" and 38.4% as "borderline high." Forty percent of respondents couldn't recall their most recent clinic-based SBP and DBP values. Overall, 71.7% and 61% were unable to report a target SBP or DBP, respectively, or identify elevated targets based on the sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) criteria. Most patients perceived DBP to be a more important risk factor than SBP. Hypertensive patients' awareness of blood pressure targets and current hypertension control status, particularly with respect to SBP, is suboptimal. The authors' findings support the need to improve patient education for better management of hypertension. [source] Demographic Characteristics, Life Context, and Patterns of Substance Use Among Alcohol-Dependent Treatment Clients in a Health Maintenance OrganizationALCOHOLISM, Issue 12 2000Tammy W. Tam Background: Although individuals dependent only on alcohol and those dependent on both alcohol and drugs typically are not studied together in clinical trials, they are treated together in most treatment programs. In this study we compared epidemiological characteristics of the alcohol-only and alcohol-and-drug dependents in a treatment sample to assess differential treatment needs. Method: Patients admitted to treatment at a health maintenance organization's chemical dependency program were sampled and interviewed by using a structured questionnaire. The sample included 491 alcohol-only and 217 alcohol-and-drug dependents. Demographic characteristics, lifetime and current substance use, Addiction Severity Index composite scores, and DSM-IV criteria for alcohol and drug dependence were assessed at admission . Results: The odds of alcohol-and-drug dependence were higher among males, African Americans (when compared with whites), those who were younger, and those with less than college education. The risk was also higher among those who initiated heavy drinking or drug use before the age of 18. Increased psychiatric and family/social problems also were associated with combined dependence. Conclusions: Even in this relatively homogeneous socioeconomic status population, demographic characteristics were important predictors of type of dependence. Treatment programs which provide services that address prevention and psychosocial problems should pay attention to age of initiation as well as psychiatric and social problems. [source] A specially structured nonlinear integer resource allocation problemNAVAL RESEARCH LOGISTICS: AN INTERNATIONAL JOURNAL, Issue 7 2003Kurt M. Bretthauer Abstract We present an algorithm for solving a specially structured nonlinear integer resource allocation problem. This problem was motivated by a capacity planning study done at a large Health Maintenance Organization in Texas. Specifically, we focus on a class of nonlinear resource allocation problems that involve the minimization of a convex function over one general convex constraint, a set of block diagonal convex constraints, and bounds on the integer variables. The continuous variable problem is also considered. The continuous problem is solved by taking advantage of the structure of the Karush-Kuhn-Tucker (KKT) conditions. This method for solving the continuous problem is then incorporated in a branch and bound algorithm to solve the integer problem. Various reoptimization results, multiplier bounding results, and heuristics are used to improve the efficiency of the algorithms. We show how the algorithms can be extended to obtain a globally optimal solution to the nonconvex version of the problem. We further show that the methods can be applied to problems in production planning and financial optimization. Extensive computational testing of the algorithms is reported for a variety of applications on continuous problems with up to 1,000,000 variables and integer problems with up to 1000 variables. © 2003 Wiley Periodicals, Inc. Naval Research Logistics 50: 770,792, 2003. [source] Evaluation of gestational age and admission date assumptions used to determine prenatal drug exposure from administrative data,PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 12 2005Marsha A. Raebel PharmD Abstract Objective Our aim was to evaluate the 270-day gestational age and delivery date assumptions used in an administrative dataset study assessing prenatal drug exposure compared to information contained in a birth registry. Study Design and Setting Kaiser Permanente Colorado (KPCO), a member of the Health Maintenance Organization (HMO) Research Network Center for Education and Research in Therapeutics (CERTs), previously participated in a CERTs study that used claims data to assess prenatal drug exposure. In the current study, gestational age and deliveries information from the CERTs study dataset, the Prescribing Safely during Pregnancy Dataset (PSDPD), was compared to information in the KPCO Birth Registry. Sensitivity and positive predictive value (PPV) of the claims data for deliveries were assessed. The effect of gestational age and delivery date assumptions on classification of prenatal drug exposure was evaluated. Results The mean gestational age in the Birth Registry was 273 (median,=,275) days. Sensitivity of claims data at identifying deliveries was 97.6%, PPV was 98.2%. Of deliveries identified in only one dataset, 45% were related to the gestational age assumption and 36% were due to claims data issues. The effect on estimates of prevalence of prescribing during pregnancy was an absolute change of 1% or less for all drug exposure categories. For Category X, drug exposures during the first trimester, the relative change in prescribing prevalence was 13.7% (p,=,0.014). Conclusion Administrative databases can be useful for assessing prenatal drug exposure, but gestational age assumptions can result in a small proportion of misclassification. Copyright © 2005 John Wiley & Sons, Ltd. [source] Welfarism Versus ,Free Enterprise': Considerations Of Power And Justice In The Philippine Healthcare SystemBIOETHICS, Issue 5-6 2003Peter A. Sy ABSTRACT The just distribution of benefits and burdens of healthcare, at least in the contemporary Philippine context, is an issue that gravitates towards two opposing doctrines of welfarism and ,free enterprise.' Supported largely by popular opinion, welfarism maintains that social welfare and healthcare are primarily the responsibility of the government. Free enterprise (FE) doctrine, on the other hand, maintains that social welfare is basically a market function and that healthcare should be a private industry that operates under competitive conditions with minimal government control. I will examine the ethical implications of these two doctrines as they inform healthcare programmes by business and government, namely: (a) the Devolution of Health Services and (b) the Philippine Health Maintenance Organization (HMO). I will argue that these doctrines and the health programmes they inform are deficient in following respects: (1) equitable access to healthcare, (2) individual needs for premium healthcare, (3) optimal utilisation of health resources, and (4) the equitable assignment of burdens that healthcare entails. These respects, as considerations of justice, are consistent with an operational definition of ,power' proposed here as ,access to and control of resources.' [source] Managed health care plans in Southern United States municipalities: empirical evidence on choice of planINTERNATIONAL JOURNAL OF HEALTH PLANNING AND MANAGEMENT, Issue 2 2005Christopher G. Reddick Abstract This study examines factors that influence choice of Southern municipal government health care plans in the United States. Using survey data, this article specifically examines the managed care offerings of Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO) and Point of Service (POS) plans. Some of the more interesting empirical results indicate that HMO plans are associated more with employee satisfaction; PPO plans are associated with cost containment; and POS plans are more likely to provide health care benefits to part-time employees. Empirical evidence also indicates that employee satisfaction is increased when there is a greater choice of managed care plans available to municipal governments. Copyright © 2005 John Wiley & Sons, Ltd. [source] Differentiation and Competition in HMO MarketsTHE JOURNAL OF INDUSTRIAL ECONOMICS, Issue 4 2003David Dranove This paper examines how differentiation among Health Maintenance Organizations (HMOs) affects local market competition. Most markets for HMOs appear sufficiently unconcentrated; however, differences among HMOs may make competition less intense than the number of competitors would suggest. To investigate this possibility, we distinguish HMOs that serve only local markets from those that operate regional or national networks. We analyze how HMOs of one type affect the profitability of the other using an equilibrium model of entry and product choice. While the two types of HMOs have strong competitive effects within segments, the competitive effect of differentiated firms is negligible. [source] The Relationship Between Glycemic Control and Falls in Older AdultsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 12 2007Joan M. Nelson RN OBJECTIVES: To determine whether glycemic control contributes to fall risk in frail and nonfrail elderly adults with diabetes mellitus. DESIGN: Retrospective, case-controlled design. SETTING: Health maintenance organization in the Denver, Colorado, metropolitan area. PARTICIPANTS: One hundred eleven community-dwelling adults aged 75 and older who receive care through Kaiser Permanente of Colorado. All subjects had been diagnosed with diabetes mellitus, had at least one hemoglobin A1C (HbA1c) measurement in the previous 12 months, and were using oral hypoglycemic medication or insulin to control their diabetes mellitus. MEASUREMENTS: Measurements of risk factors (Vulnerable Elders Survey (VES-13) with a cutpoint of 3 to determine frailty status, self-reported number of falls over the prior 12-month period, HbA1c, fasting low-density lipoprotein cholesterol, average blood pressure, and other factors related to fall risk) were obtained through telephone interview and medical chart review. The outcome measure was falls. RESULTS: Bivariate analyses to assess correlations between falls and risk factors determined that only HbA1c, frailty, and peripheral neuropathy were significantly associated with falls. A stepwise logistic regression determined that fall risk markedly increased when HbA1c was 7 or below, regardless of frailty status. CONCLUSION: In this retrospective study of a convenience sample of frail older adults with diabetes mellitus, tighter glycemic control was associated with greater risk of falling. Prospective studies that further evaluate the risks and benefits of relaxed glucose control in high-risk older adults are needed to confirm this finding. [source] Physician Recognition of Cognitive Impairment: Evaluating the Need for ImprovementJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 7 2004Joshua Chodosh MD Objectives: To assess physician recognition of dementia and cognitive impairment, compare recognition with documentation, and identify physician and patient factors associated with recognition. Design: Survey of physicians and review of medical records. Setting: Health maintenance organization in southern California. Participants: Seven hundred twenty-nine physicians who provided care for women participating in a cohort study of memory (Women's Memory Study). Measurements: Percentage of patients with dementia or cognitive impairment (using the Telephone Interview of Cognitive Status supplemented by the Telephone Dementia Questionnaire) recognized by physicians. Relationship between physician recognition and patient characteristics and physician demographics, practice characteristics, training, knowledge, and attitudes about dementia. Results: Physicians (n=365) correctly identified 81% of patients with dementia and 44% of patients with cognitive impairment without definite dementia. Medical records documented cognitive impairment in 83% of patients with dementia and 26% of patients with cognitive impairment without definite dementia. In a multivariable model, physicians with geriatric credentials (defined as geriatric fellowship experience and/or the certificate of added qualifications) recognized cognitive impairment more often than did those without (risk ratio (RR)=1.56, 95% confidence interval (CI)=1.04,1.66). Physicians were more likely to recognize cognitive impairment in patients with a history of depression treatment (RR=1.3, 95% CI=1.03,1.45) or stroke (RR=1.37, 95% CI=1.04,1.45) and less likely to recognize impairment in patients with cognitive impairment without definite dementia than in those with dementia (RR=0.46, 95% CI=0.23,0.72) and in patients with a prior hospitalization for myocardial infarction (RR=0.37, 95% CI=0.09,0.88) or cancer (RR=0.49, 95% CI=0.18,0.90). Conclusion: Medical record documentation reflects physician recognition of dementia, yet physicians are aware of, but have not documented, many patients with milder cognitive impairment. Physicians are unaware of cognitive impairment in more than 40% of their cognitively impaired patients. Additional geriatrics training may promote recognition, but systems solutions are needed to improve recognition critical to provision of emerging therapies for early dementia. [source] Electrocardiogram Differentiation of Benign Early Repolarization Versus Acute Myocardial Infarction by Emergency Physicians and CardiologistsACADEMIC EMERGENCY MEDICINE, Issue 9 2006Samuel D. Turnipseed MD Abstract Objectives: ST-segment elevation (STE) related to benign early repolarization (BER), a common normal variant, can be difficult to distinguish from acute myocardial infarction (AMI). The authors compared the electrocardiogram (ECG) interpretations of these two entities by emergency physicians (EPs) and cardiologists. Methods: Twenty-five cases (13 BER, 12 AMI) of patients presenting to the emergency department with chest pain were identified. Criteria for BER required four of the following: 1) widespread STE (precordial greater than limb leads), 2) J-point elevation, 3) concavity of initial up-sloping portion of ST segment, 4) notching or irregular contour of J point, and 5) prominent, concordant T waves. Additional BER criteria were 1) stable ECG pattern, 2) negative cardiac injury markers, and 3) normal cardiac stress test or angiography. AMI criteria were 1) regional STE, 2) positive cardiac injury markers, and 3) identification of culprit coronary artery by angiography in less than eight hours of presentation. The 25 ECGs were distributed to 12 EPs and 12 cardiologists (four in academic medicine, four in community practice, and four in community academics [health maintenance organization] in each physician group). The physicians were informed of the patients' age, gender, and race, and they then interpreted the ECGs as BER or AMI. Undercalls (AMI misdiagnosed as BER) and overcalls (BER misdiagnosed as AMI) were calculated for each physician group. Results: Cardiologists correctly interpreted 90% of ECGs, and EPs correctly interpreted 81% of ECGs. The proportion of undercalls (missed AMI/total AMI) was 2.8% for cardiologists (95% confidence interval [CI] = 0.09% to 5.5%) compared with 9.7% for EPs (95% CI = 4.8% to 14.6%) (p = 0.02). The proportion of overcalls (missed BER/total BER) was 17.3% for cardiologists (95% CI = 11.4% to 23.3%) versus 27.6% for EPs (95% CI = 20.6% to 34.6%) (p = 0.03). The mean number of years in practice was 19.8 for cardiologists (95% CI = 19 to 20.5) and 11 years for EPs (95% CI = 10.5 to 12.0) (p < 0.001). Conclusions: Although correct interpretation was high in both groups, cardiologists, who had significantly more years of practice, had fewer misinterpretations than EPs in distinguishing BER from AMI electrocardiographically. [source] Association between Insurance Status and Admission Rate for Patients Evaluated in the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 11 2003Jennifer Prah Ruger PhD Abstract Objectives: To determine if differences exist in hospital and intensive care unit (ICU)/operating room admission rates based on health insurance status. Methods: This was a retrospective, cross-sectional study of data from hospital clinical and financial records for all 2001 emergency department (ED) visits (80,209) to an academic urban hospital. Hospital admission and intensive care unit (ICU)/operating room admissions were analyzed, controlling for triage acuity, primary complaint, diagnosis, diagnosis-related group (DRG) severity, and demographics. Multivariate logistic regression models identified factors associated with hospital admission for underinsured (self-pay and Medicaid) compared with other insured (private health maintenance organization, preferred provider organization, worker's compensation, and Medicare) patients. Results: Compared with the other insured group, underinsured patients were less likely, overall, to be admitted to the hospital (odds ratio [OR], 0.82; 95% CI = 0.76 to 0.90), controlling for all other factors studied. Subgroup analysis of common complaints showed underinsured patients with a chief complaint of abdominal pain (OR, 0.67; 95% CI = 0.55 to 0.80) or headache (OR, 0.61; 95% CI = 0.39 to 0.95) had the lowest adjusted ORs for admission to the hospital, compared with other insured patients. Underinsured patients with DRG of "menstrual and other female reproductive system disorders" (OR, 0.17; 95% CI = 0.06 to 0.51) or "esophagitis, gastroenteritis, and miscellaneous digestive disorders" (OR, 0.55; 95% CI = 0.28 to 0.96) also were less likely to be admitted compared with the other insured group. No significant differences in ICU/operating room admission rates were found between insurance groups. Conclusions: Whereas there was no difference in admission rates to the ICU/operating room by insurance status, this single-center study does suggest an association between insurance status and admission to a general hospital service, which may or may not be causally related. Factors other than provider bias may be responsible for this observed difference. [source] Risk Segmentation Related to the Offering of a Consumer-Directed Health Plan: A Case Study of Humana Inc.HEALTH SERVICES RESEARCH, Issue 4p2 2004Laura A. Tollen Objective. To determine whether the offering of a consumer-directed health plan (CDHP) is likely to cause risk segmentation in an employer group. Study Setting and Data Source. The study population comprises the approximately 10,000 people (employees and dependents) enrolled as members of the employee health benefit program of Humana Inc. at its headquarters in Louisville, Kentucky, during the benefit years starting July 1, 2000, and July 1, 2001. This analysis is based on primary collection of claims, enrollment, and employment data for those employees and dependents. Study Design. This is a case study of the experience of a single employer in offering two consumer-directed health plan options ("Coverage First 1" and "Coverage First 2") to its employees. We assessed the risk profile of those choosing the Coverage First plans and those remaining in more traditional health maintenance organization (HMO) and preferred provider organization (PPO) coverage. Risk was measured using prior claims (in dollars per member per month), prior utilization (admissions/1,000; average length of stay; prescriptions/1,000; physician office visit services/1,000), a pharmacy-based risk assessment tool (developed by Ingenix), and demographics. Data Collection/Extraction Methods. Complete claims and administrative data were provided by Humana Inc. for the two-year study period. Unique identifiers enabled us to track subscribers' individual enrollment and utilization over this period. Principal Findings. Based on demographic data alone, there did not appear to be a difference in the risk profiles of those choosing versus not choosing Coverage First. However, based on prior claims and prior use data, it appeared that those who chose Coverage First were healthier than those electing to remain in more traditional coverage. For each of five services, prior-year usage by people who subsequently enrolled in Coverage First 1 (CF1) was below 60 percent of the average for the whole group. Hospital and maternity admissions per thousand were less than 30 percent of the overall average; length of stay per hospital admission, physician office services per thousand, and prescriptions per thousand were all between 50 and 60 percent of the overall average. Coverage First 2 (CF2) subscribers' prior use of services was somewhat higher than CF1 subscribers', but it was still below average in every category. As with prior use, prior claims data indicated that Coverage First subscribers were healthier than average, with prior total claims less than 50 percent of average. Conclusions. In this case, the offering of high-deductible or consumer-directed health plan options alongside more traditional options caused risk segmentation within an employer group. The extent to which these findings are applicable to other cases will depend on many factors, including the employer premium contribution policies and employees' perception of the value of the various plan options. Further research is needed to determine whether risk segmentation will worsen in future years for this employer and if so, whether it will cause premiums for more traditional health plans to increase. [source] Evaluation of the Effect of a Consumer-Driven Health Plan on Medical Care Expenditures and UtilizationHEALTH SERVICES RESEARCH, Issue 4p2 2004Stephen T. Parente§ Objective. To compare medical care costs and utilization in a consumer-driven health plan (CDHP) to other health insurance plans. Study Design. We examine claims and employee demographic data from one large employer that adopted a CDHP in 2001. A quasi-experimental pre,post design is used to assign employees to three cohorts: (1) enrolled in a health maintenance organization (HMO) from 2000 to 2002, (2) enrolled in a preferred provider organization (PPO) from 2000 to 2002, or (3) enrolled in a CDHP in 2001 and 2002, after previously enrolling in either an HMO or PPO in 2000. Using this approach we estimate a difference-in-difference regression model for expenditure and utilization measures to identify the impact of CDHP. Principal Findings. By 2002, the CDHP cohort experienced lower total expenditures than the PPO cohort but higher expenditures than the HMO cohort. Physician visits and pharmaceutical use and costs were lower in the CDHP cohort compared to the other groups. Hospital costs and admission rates for CDHP enrollees, as well as total physician expenditures, were significantly higher than for enrollees in the HMO and PPO plans. Conclusions. An early evaluation of CDHP expenditures and utilization reveals that the new health plan is a viable alternative to existing health plan designs. Enrollees in the CDHP have lower total expenditures than PPO enrollees, but higher utilization of resource-intensive hospital admissions after an initially favorable selection. [source] Factors Associated with Physician Interventions to Address Adolescent SmokingHEALTH SERVICES RESEARCH, Issue 3 2004Tammy H. Sims Objective. To determine the percent of adolescent Medicaid patients with medical record documentation about tobacco use status and cessation assistance; and factors associated with providers documenting and intervening with adolescent smokers. Data Source. Secondary analysis of data collected in 1999 from medical records of Wisconsin Medicaid health maintenance organization (HMO) recipients 11 to 21 years old. Study Design. Random reviews and data collection were related to visits from January 1997 to January 1999. Data collected included patient demographics, provider type, number of visits, and whether smoking status and cessation interventions were documented. Data Extraction Methods. Medical charts were reviewed and a database was created using a data abstraction tool developed and approved by a committee to address tobacco use in Medicaid managed care participants. Principal Findings. Among adolescents seen by a physician from 1997 to 1999, tobacco use status was documented in 55 percent of patient charts. Most often tobacco use status was documented on history and physical or prenatal forms. Of identified adolescent smokers, 50 percent were advised to quit, 42 percent assisted, and 16 percent followed for smoking cessation. Pregnant patients were more likely to have tobacco use documented than nonpregnant patients (OR=10.8, 95 percent CI=4.9 to 24). The odds of documentation increased 21 percent for every one-year increase in patient age. Conclusions. Providers miss opportunities to intervene with adolescents who may be using tobacco. Medical record prompts, similar to the tobacco use question on prenatal forms and the tobacco use vital sign stamp, are essential for reminding providers to consistently document and address tobacco use among adolescents. [source] Assessing the Validity of Insurance Coverage Data in Hospital Discharge Records: California OSHPD DataHEALTH SERVICES RESEARCH, Issue 5 2003Thomas C. Buchmueller Objective. To assess the accuracy of data on "expected source of payment" in the patient discharge database compiled by the California Office of Statewide Health Planning and Development (OSHPD). Data Sources. The OSHPD discharge data for the years 1993 to 1996 linked with administrative data from the University of California (UC) health benefits program for the same years. The linked dataset contains records for all stays in California hospitals by UC employees, retirees, and spouses. Study Design. The accuracy of the OSHPD data is assessed using cross-tabulations of insurance type as coded in the two data sources. The UC administrative data is assumed to be accurate, implying that differences between the two sources represent measurement error in the OSHPD data. We cross-tabulate insurance categories and analyze the concordance of dichotomous measures of health maintenance organization (HMO) enrollment derived from the two sources. Principal Findings. There are significant coding errors in the OSHPD data on expected source of payment. A nontrivial percentage of patients with preferred provider organization (PPO) coverage are erroneously coded as being in HMOs, and vice versa. The prevalence of such errors increased after OSHPD introduced a new expected source of payment category for PPOs. Measurement problems are especially pronounced for older patients. Many patients over age 65 who are still covered by a commercial insurance plan are erroneously coded as having Medicare coverage. This, combined with the fact that during the period we analyzed, Medicare HMO enrollees and beneficiaries in the fee-for-service (FFS) program are combined in a single payment category, means that the OSHPD data provides essentially no information on insurance coverage for older patients. Conclusions. Researchers should exercise caution in using the expected source of payment in the OSHPD data. While measures of HMO coverage are reasonably accurate, it is not possible in these data to clearly identify PPOs as a distinct insurance category. For patients over age 65, it is not possible at all to distinguish among alternative insurance arrangements. [source] Gender difference in the prevalence of eating disorder symptoms,,INTERNATIONAL JOURNAL OF EATING DISORDERS, Issue 5 2009Ruth H. Striegel-Moore PhD Abstract Objective: This study examined gender differences in prevalence of eating disorder symptoms including body image concerns (body checking or avoidance), binge eating, and inappropriate compensatory behaviors. Method: A random sample of members (ages 18,35 years) of a health maintenance organization was recruited to complete a survey by mail or on-line. Items were drawn from the Patient Health Questionnaire and the Body Shape Questionnaire. Results: Among the 3,714 women and 1,808 men who responded, men were more likely to report overeating, whereas women were more likely to endorse loss of control while eating. Although statistically significant gender differences were observed, with women significantly more likely than men to report body checking and avoidance, binge eating, fasting, and vomiting, effect sizes ("Number Needed to Treat") were small to moderate. Discussion: Few studies of eating disorders include men, yet our findings suggest that a substantial minority of men also report eating disorder symptoms. © 2008 by Wiley Periodicals, Inc. Int J Eat Disord 2009 [source] Blood Pressure and Brain Injury in Older Adults: Findings from a Community-Based Autopsy StudyJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 11 2009Lucy Y. Wang MD OBJECTIVES: To examine correlations between blood pressure (BP) and dementia-related pathological brain changes in a community-based autopsy sample. DESIGN: Prospective cohort study. SETTING: A large health maintenance organization in Seattle, Washington. PARTICIPANTS: A cohort of 250 participants aged 65 and older and cognitively normal at time of enrollment in the Adult Changes in Thought (ACT) Study and who underwent autopsy. MEASUREMENTS: BP and history of antihypertensive treatment were taken at enrollment. A linear regression model was used to examine the relationship between BP (systolic (SBP) and diastolic (DBP)) at enrollment and pathological changes in the cerebrum (cystic macroscopic infarcts, microinfarcts, neuritic plaques, neurofibrillary tangles, and cortical Lewy bodies). RESULTS: The presence of more than 2 microinfarcts, but not any other pathological change, was independently associated with SBP in younger participants (65,80, n=137) but not in older participants (>80, n=91). The relative risk (RR) for more than two microinfarcts with each 10-mmHg increase in SBP was 1.15 (95% confidence interval (CI)=1.00,1.33) in the younger participants, adjusted for age at entry, sex, and time to death. This RR was particularly strong in younger participants not taking antihypertensive medications (RR=1.48, 95% CI=1.21, 1.81); significant associations were not observed in participants treated for hypertension. Findings for DBP were negative. CONCLUSION: The association between high SBP and cerebrovascular damage in untreated older adults (65,80) suggests that adequate hypertension treatment may reduce dementia risk by minimizing microvascular injury to cerebrum. [source] Fatigue Predicts Mortality in Older AdultsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 10 2008Susan E. Hardy MD OBJECTIVES: To determine the association between fatigue and survival over 10 years in a population of older community-dwelling primary care patients. DESIGN: Prospective cohort study. SETTING: Medicare health maintenance organization and Veterans Affairs primary care programs. PARTICIPANTS: Older primary care patients (N=492). MEASUREMENTS: Fatigue, operationalized as feeling tired most of the time, was assessed at baseline. Mortality was ascertained from the National Death Index. Covariates included demographics, comorbidity, cognitive function, depressive symptoms, body mass index, self-rated health, functional status, and gait speed. RESULTS: Mortality rates at 10 years were 59% (123/210) for older adults with fatigue, versus 38% (106/282) for those without fatigue (P<.001). After adjustment for multiple potential confounders, participants who were tired at baseline had a greater risk of death than those who were not (hazard ratio=1.44, 95% confidence interval=1.08,1.93). CONCLUSION: A single simple question "Do you feel tired most of the time?" identifies older adults with a higher risk of mortality. Further research is needed to identify and characterize the underlying mechanisms of fatigue, to develop and test specific treatments, and to determine whether improvement leads to decreased morbidity and mortality. [source] Age-Varying Association Between Blood Pressure and Risk of Dementia in Those Aged 65 and Older: A Community-Based Prospective Cohort StudyJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2007Ge Li MD OBJECTIVES: To assess variation in the association between blood pressure (BP) and risk for dementia across a spectrum of older ages and to examine BP changes before dementia onset. DESIGN: Prospective cohort study. SETTING: A large health maintenance organization in Seattle, Washington. PARTICIPANTS: A cohort of 2,356 members of a large health maintenance organization aged 65 and older who were initially without dementia. MEASUREMENTS: Dementia diagnosis was assessed biennially, and systolic (SBP) and diastolic BP (DBP) were measured at baseline and at four follow-up assessments. Cox proportional hazards models were used to estimate hazard ratios (HRs) for dementia and Alzheimer's disease (AD) associated with baseline BP in different age groups. RESULTS: Within the youngest age group (65,74 at enrollment) a greater risk for dementia was found in participants with high SBP (,160 mmHg) (hazard ratio (HR)=1.60, 95% confidence interval (CI)=1.01,2.55) or borderline-high DBP (80,89 mmHg) (HR=1.59, 95% CI=1.07,2.35) than for those with normal BP (SBP <140 mmHg and DBP <80 mmHg). The dementia risk associated with SBP declined with increasing age (SBP-by-age interaction, P=.01). SBP declined similarly with aging in subjects who developed dementia and those who did not. Thus, in this sample, the association between SBP and dementia risk was not dependent on when BP was measured in relation to onset of dementia. CONCLUSION: High SBP was associated with greater risk of dementia in the young elderly (<75) but not in older subjects. Adequate control of hypertension in early old age may reduce the risk for dementia. [source] Randomized Trial to Improve Prescribing Safety in Ambulatory Elderly PatientsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 7 2007Marsha A. Raebel PharmD OBJECTIVES: To determine whether a computerized tool that alerted pharmacists when patients aged 65 and older were newly prescribed potentially inappropriate medications was effective in decreasing the proportion of patients dispensed these medications. DESIGN: Prospective, randomized trial. SETTING: U.S. health maintenance organization. PARTICIPANTS: All 59,680 health plan members aged 65 and older were randomized to intervention (n=29,840) or usual care (n=29,840). Pharmacists received alerts on all patients randomized to intervention who were newly prescribed a targeted medication. INTERVENTION: Prescription and age information were linked to alert pharmacists when a patient aged 65 and older was newly prescribed one of 11 medications that are potentially inappropriate in older people. MEASUREMENTS: Physicians and pharmacists collaborated to develop the targeted medication list, indications for medication use for which an intervention should occur, intervention guidelines and scripts, and to implement the intervention. RESULTS: Over the 1-year study, 543 (1.8%) intervention group patients aged 65 and older were newly dispensed prescriptions for targeted medications, compared with 644 (2.2%) usual care group patients (P=.002). For medication use indications in which an intervention should occur, dispensings of amitriptyline (P<.001) and diazepam (P=.02) were reduced. CONCLUSIONS: This study demonstrated the effectiveness of a computerized pharmacy alert system plus collaboration between healthcare professionals in decreasing potentially inappropriate medication dispensings in elderly patients. Coupling data available from information systems with the knowledge and skills of physicians and pharmacists can improve prescribing safety in patients aged 65 and older. [source] Reductions in Costly Healthcare Service Utilization: Findings from the Care Advocate ProgramJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 7 2006George R. Shannon PhD OBJECTIVES: To determine whether a telephone care-management intervention for high-risk Medicare health maintenance organization (HMO) health plan enrollees can reduce costly medical service utilization. DESIGN: Randomized, controlled trial measuring healthcare services utilization over three 12-month periods (pre-, during, and postintervention). SETTING: Two social service organizations partnered with a Medicare HMO and four contracted medical groups in southern California. PARTICIPANTS: Eight hundred twenty-three patients aged 65 and older; eligibility was determined using an algorithm to target older adults with high use of insured healthcare services. INTERVENTION: After assessment, members in the intervention group were offered mutually agreed upon referrals to home- and community-based services (HCBS), medical groups, or Medicare HMO health plan and followed monthly for 1 year. MEASUREMENTS: Insured medical service utilization was measured across three 12-month periods. Acceptance and utilization of Care Advocate (CA) referrals were measured during the 12-month intervention period. RESULTS: CA intervention members were significantly more likely than controls to use primary care physician services (odds ratio (OR)=2.05, P<.001), and number of hospital admissions (OR=0.43, P<.01) and hospital days (OR=0.39, P<.05) were significantly more stable for CA group members than for controls. CONCLUSION: Results suggest that a modest intervention linking older adults to HCBS may have important cost-saving implications for HMOs serving community-dwelling older adults with high healthcare service utilization. Future studies, using a national sample, should verify the role of telephone care management in reducing the use of costly medical services. [source] Footwear Style and Risk of Falls in Older AdultsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 9 2004Thomas D. Koepsell MD Objectives: To determine how the risk of a fall in an older adult varies in relation to style of footwear worn. Design: Nested case-control study. Setting: Group Health Cooperative, a large health maintenance organization in Washington state. Participants: A total of 1,371 adults aged 65 and older were monitored for falls over a 2-year period; 327 qualifying fall cases were compared with 327 controls matched on age and sex. Measurements: Standardized in-person examinations before fall occurrence, interviews about fall risk factors after the fall occurred, and direct examination of footwear were conducted. Questions for controls referred to the last time they engaged in an activity broadly similar to what the case was doing at the time of the fall. Results: Athletic and canvas shoes (sneakers) were the styles of footwear associated with lowest risk of a fall. Going barefoot or in stocking feet was associated with sharply increased risk, even after controlling for measures of health status (adjusted odds ratio=11.2, 95% confidence interval (CI)=2.4,51.8). Relative to athletic/canvas shoes, other footwear was associated with a 1.3-fold increase in the risk of a fall (95% CI=0.9,1.9), varying somewhat by style. Conclusion: Contrary to findings from gait-laboratory studies, athletic shoes were associated with relatively low risk of a fall in older adults during everyday activities. Fall risk was markedly increased when participants were not wearing shoes. [source] Effects of Provider Practice on Functional Independence in Older AdultsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2004Elizabeth A. Phelan MD Objectives: To examine provider determinants of new-onset disability in basic activities of daily living (ADLs) in community-dwelling elderly. Design: Observational study. Setting: King County, Washington. Participants: A random sample of 800 health maintenance organization (HMO) enrollees aged 65 and older participating in a prospective longitudinal cohort study of dementia and normal aging and their 56 primary care providers formed the study population. Measurements: Incident ADL disability, defined as any new onset of difficulty performing any of the basic ADLs at follow-up assessments, was examined in relation to provider characteristics and practice style using logistic regression and adjusting for case-mix, patient and provider factors associated with ADL disability, and clustering by provider. Results: Neither provider experience taking care of large numbers of elderly patients nor having a certificate of added qualifications in geriatrics was associated with patient ADL disability at 2 or 4 years of follow-up (adjusted odds ratio (AOR) for experience=1.29, 95% confidence interval (CI)=0.81,2.05; AOR for added qualifications=0.72, 95% CI=0.38,1.39; results at 4 years analogous). A practice style embodying traditional geriatric principles of care was not associated with a reduced likelihood of ADL disability over 4 years of follow-up (AOR for prescribing no high-risk medications=0.56, 95% CI=0.16,1.94; AOR for managing geriatric syndromes=0.94, 95% CI=0.40,2.19; AOR for a team care approach=1.35, 95% CI=0.66,2.75). Conclusion: Taking care of a large number of elderly patients, obtaining a certificate of added qualifications in geriatrics, and practicing with a traditional geriatric orientation do not appear to influence the development of ADL disability in elder, community dwelling HMO enrollees. [source] A Population-Based Osteoporosis Screening Program: Who Does Not Participate, and What Are the Consequences?JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 7 2004Diana S. M. Buist PhD Objectives: To describe differences in osteoporosis risk factors and rates of fracture and antiresorptive therapy use in women who did and did not participate in an osteoporosis screening program. Setting: Group Health Cooperative, a health maintenance organization in western Washington state. Participants: A total of 9,268 women (aged 60,80) who were not using any antiresorptive therapy were invited to participate in an osteoporosis screening program. This study compares the 35% who participated with the 65% who did not. Design: This observational cohort study of women invited to participate in a randomized, controlled trial of an osteoporosis screening program provided all participants with personalized feedback on their risk of osteoporosis. Some participants also received bone density testing. Automated administrative data were used to examine differences between participants and nonparticipants in fracture outcomes and medication initiation before and after invitation. Results: Baseline fracture rates did not differ between participants and nonparticipants. After age adjustment, nonparticipants had a higher hip fracture rate (14.1 vs 8.3 per 1,000) and a lower rate of initiating any antiresorptive therapy (10.3 vs 17.9 per 100) than participants after an average of 28 to 29 months of follow-up. Conclusion: Participants had reduced hip fracture rates and increased initiation of antiresorptive therapy compared with nonparticipants. It was not possible to determine whether participating in the screening program, unmeasured confounding, or selection bias accounted for differences in hip fracture or therapy initiation rates. These results suggest that women who do not participate in osteoporosis screening should be pursued to idenepsy individuals who could benefit from primary and secondary osteoporosis prevention. [source] Establishing a Case-Finding and Referral System for At-Risk Older Individuals in the Emergency Department Setting: The SIGNET ModelJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 10 2001Lorraine C. Mion PhD Older emergency department (ED) patients have complex medical, social, and physical problems. We established a program at four ED sites to improve case finding of at-risk older adults and provide comprehensive assessment in the ED setting with formal linkage to community agencies. The objectives of the program are to (1) improve case finding of at-risk older ED patients, (2) improve care planning and referral for those returning home, and (3) create a coordinated network of existing medical and community services. The four sites are a 1,000-bed teaching center, a 700-bed county teaching hospital, a 400-bed community hospital, and a health maintenance organization (HMO) ED site. Ten community agencies also participated in the study: four agencies associated with the hospital/HMO sites, two nonprofit private agencies, and four public agencies. Case finding is done using a simple screening assessment completed by the primary or triage nurse. A geriatric clinical nurse specialist (GCNS) further assesses those considered at risk. Patients with unmet medical, social, or health needs are referred to their primary physicians or to outpatient geriatric evaluation and management centers and to community agencies. After 18 months, the program has been successfully implemented at all four sites. Primary nurses screened over 70% (n = 28,437) of all older ED patients, GCNSs conducted 3,757 comprehensive assessments, participating agency referrals increased sixfold, and few patients refused the GCNS assessment or subsequent referral services. Thus, case finding and community linkage programs for at-risk older adults are feasible in the ED setting. [source] Patient Knowledge and Awareness of Hypertension Is Suboptimal: Results From a Large Health Maintenance OrganizationJOURNAL OF CLINICAL HYPERTENSION, Issue 4 2003Mark Alexander PhD; Patient knowledge and awareness of hypertension are important factors in achieving blood pressure control. To examine hypertensive patients' knowledge of their condition, the authors randomly surveyed 2500 hypertension patients from a large health maintenance organization; questionnaires were supplemented with clinic blood pressure measurements. Approximately 72% of the subjects completed surveys. Of patients with uncontrolled hypertension (systolic blood pressure [SBP] 140 mm Hg and/or diastolic blood pressure [DBP] 90 mm Hg), only 20.2% labeled their blood pressure as "high" and 38.4% as "borderline high." Forty percent of respondents couldn't recall their most recent clinic-based SBP and DBP values. Overall, 71.7% and 61% were unable to report a target SBP or DBP, respectively, or identify elevated targets based on the sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) criteria. Most patients perceived DBP to be a more important risk factor than SBP. Hypertensive patients' awareness of blood pressure targets and current hypertension control status, particularly with respect to SBP, is suboptimal. The authors' findings support the need to improve patient education for better management of hypertension. [source] Social support in women with fibromyalgia: Is quality more important than quantity?JOURNAL OF COMMUNITY PSYCHOLOGY, Issue 4 2004Heather M. Franks The present study is an examination of the effects of quality and quantity of social support on the psychological and physical well-being of women with fibromyalgia syndrome (FMS). Participants were 568 women who were members of a health maintenance organization (HMO) with a confirmed diagnosis of FMS. Participants were administered a battery of questionnaires assessing their psychological and physical well-being. Measures of depression, self-efficacy, helplessness, mood disturbance, health status, impact of FMS, and social support were included. Regression analyses indicated that larger social support networks were associated with greater levels of self-efficacy for pain and symptom management, while the perceived quality of social support was associated with lower levels of depression, helplessness, mood disturbance, impact of FMS, higher levels of self-efficacy for function and symptom management, as well as overall psychological well-being. These findings indicate that the quality of social support is more important than quantity in determining outcomes in women with FMS. Thus, the quality of social support has important financial and psychosocial implications for the individual and for the community as a whole. Future research should examine longitudinal changes in quality of social support and the corresponding changes in health status and psychological well-being, as well as the effects of integrating manipulations designed to affect the quality of social support into community interventions designed to enhance the well-being of women with FMS. © 2004 Wiley Periodicals, Inc. J Comm Psychol 32: 425,438, 2004. [source] Effects of Managed Care on Alcohol and Other Drug (AOD) TreatmentALCOHOLISM, Issue 3 2002Stephen Magura The article represents the proceedings of a symposium at the 2001 RSA Meeting in Montreal, Canada. The organizer/chair was Stephen Magura. The presentations examined: (1) How managed care organization policies may affect enrollees' use of alcohol and other drug (AOD) treatment, by Constance Horgan and associates; (2) The determinants of patients' access to and utilization of AOD treatment in a large health maintenance organization, by Jennifer R. Mertens and Constance Weisner; (3) The impact on treatment access and costs of a statewide carve-out for AOD treatment for Medicaid, by Donald Shepard and associates; and (4) The predictive validity of a new patient assessment technology developed, in part, to better justify AOD treatment in response to the demands of managed care, by Stephen Magura and associates. [source] Implementing a Smoking Cessation Program for Pregnant Women Based on Current Clinical Practice GuidelinesJOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS, Issue 6 2002Lynne Buchanan APRN, PhDArticle first published online: 24 MAY 200 Purpose To describe the U.S. Department of Health and Human Services clinical practice guideline for treating tobacco use and dependence and demonstrate how the guideline was utilized in a pilot program for a small sample of pregnant women (n=20) to help them decrease smoking. Data Sources A convenience sample of 20 pregnant women was recruited from a health maintenance organization at their initial prenatal contact either by telephone or in person. A comparison group of pregnant women (n=28) was used for analysis of outcomes. Conclusions Clinical results showed better outcomes for women in the pilot program when compared to a similar group who did not participate in the program. There was a statistically significant difference between the two groups in average number of cigarettes smoked per day at delivery and two weeks after delivery with pilot program participants reporting less smoking (p<.05). Women in both groups showed a pattern of returning to smoking after delivery of the baby. Implications for Practice Although a few tobacco users achieve permanent abstinence in first or second attempts, the majority continue to use tobacco for many years and typically cycle through many lapse and relapses before permanent abstinence. Ambulatory care systems need to be developed and funded to treat tobacco use and dependence over the life span. Recognition of the chronic nature of the problem and development of long term care delivery systems are needed to assist clients to achieve goals of permanent abstinence and better personal and family health. This cycle of lapse and relapse before permanent abstinence is typical and demonstrates the chronic nature of tobacco use and dependence and the need for long term follow-up. [source] Costs of health care for irritable bowel syndrome, chronic constipation, functional diarrhoea and functional abdominal painALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 2 2007K. A. NYROP Summary Aim To provide estimates of actual costs to deliver health care to patients with functional bowel disorders, and to assess the cost impact of symptom severity, recency of onset, and satisfaction with treatment. Methods We enrolled 558 irritable bowel (IBS), 203 constipation, 243 diarrhoea and 348 abdominal pain patients from primary care and gastroenterology clinics at a health maintenance organization within weeks of a visit. Costs were extracted from administrative claims. Symptom severity, satisfaction with treatment and out-of-pocket expenses were assessed by questionnaires. Results Average age was 52 years, 27% were males, and 59% participated. Eighty percent were seen in primary care clinics. Mean annual direct health care costs were $5049 for IBS, $6140 for diarrhoea, $7522 for constipation and $7646 for abdominal pain. Annual out-of-pocket expenses averaged $406 for treatment of IBS symptoms, $294 for diarrhoea, $390 for constipation and $304 for abdominal pain. Lower gastrointestinal costs comprised 9% of total costs for IBS, 9% for diarrhoea, 6.5% for constipation and 9% for abdominal pain. In-patient care accounted for 17.5% of total costs (15.2% IBS). Conclusion Costs were affected by disease severity (increased), recent exacerbation of bowel symptoms (increased), and whether the patient was consulting for the first time (decreased). [source] | |||||||||||||||||||