Optimizing treatment of dyslipidemia in patients with coronary artery disease in the managed-care environment (the Rocky Mountain Kaiser Permanente experience).

Rocky Mountain Kaiser Permanente has taken aggressive steps to ensure optimal treatment of all modifiable cardiac risk factors, especially low-density lipoprotein (LDL) cholesterol, in patients with coronary artery disease. In this article, we are presenting (1) the basic rationale for our approach, (2) the critical steps translating philosophy into practice, and (3) justification for all health plans to pursue a similar course. The continuum of physician-directed disease management systems that have evolved in our region-one administered by cardiology nurses in the perihospitalization period and the other by pharmacists in the long-term, outpatient setting-is then detailed. Although the relatively short duration that our comprehensive systems have been in place precludes any assessment of their impact on cardiac death, coronary artery disease events, or coronary artery disease procedure rates, the improvements in intermediate surrogate outcomes are promising. Virtually all surveyed patients participating in our management systems have been "very" or "extremely" satisfied with their experience. The LDL-cholesterol screening rate in the approximately 2,500 participants in the programs to date has reached 97%. Of these patients, 84% have LDL cholesterol <130 mg/dL and 48% <100 mg/dL, and only 15% of those few with LDL cholesterol >130 mg/dL (2.5% overall) are currently not receiving lipid-lowering therapy. The proportions of patients on aspirin/antiplatelet and beta-blocker therapy after myocardial infarction are 97% and 92%, respectively. The lipid-screening and treatment rates, especially, represent significant improvement from our own baseline, and compare favorably with outcomes from other practice settings. In conclusion, health maintenance organizations have tremendous incentive and the unique opportunity and ability to develop systems to better manage large numbers of individuals with coronary artery disease.

Validity of self-reported colorectal cancer screening behavior.

End points for trials promoting cancer screening are often based on self-reported screening behavior. This study was designed to evaluate and optimize the reliability of a computer-assisted telephone interview for collecting self-reported colorectal cancer screening behavior. Cases who had received a fecal occult blood test (FOBT), flexible sigmoidoscopy, and/or colonoscopy, and controls who had no record of colorectal screening were identified among 40-75-year-old members of the Denver Kaiser Permanente Health Care Program and were contacted by telephone. Sensitivities and specificities of self-reported screening were calculated by comparison of subjects' recall with Kaiser Permanente records. The questionnaire was revised based upon results of the pilot phase of the study. Using the revised questionnaire, the sensitivity of self-reported screening was 96.2% for the FOBT, 94.9% for flexible sigmoidoscopy, 88.7% for colonoscopy, and 96.2% for either endoscopic screening test. The specificity of self-reported screening was 85.9% for the FOBT, 92.2% for flexible sigmoidoscopy, 96.8% for colonoscopy, and 92.0% for either endoscopic screening test. No marked differences in the accuracy of the self-reports were detected as a function of gender, age, ethnicity, or family history of colorectal cancer of the participants. Self-reports of colon cancer screening behavior can be reliably used as end points for intervention trials when carefully phrased questions are used.

Validation of self-reported chronic conditions and health services in a managed care population.

BACKGROUND: Self-reported data are commonly used to estimate the prevalence of health conditions and the use of preventive health services in the population, but the validity of such data is often questioned. METHODS: The Behavioral Risk Factor Survey (BRFS) was admin istered by telephone to a stratified, random sample of health maintenanc e organization (HMO) subscribers in Colorado in 1993, and self-reports w ere compared with HMO medical records for 599 adults aged >21. Sensitivity and specificity were calculated for three chronic conditions and use of six preventive services. RESULTS: Sensitivity was highest for hypertension (83%), moderate for diabetes (73%), and lowest for hypercholesterolemia (59%); specificity was >80% for all three conditions. Sensitivity ranged from 86% to 99% for influenza immunization, clinical breast examination, blood cholesterol screening, mammography, Pap test, and blood pressure screening; specificity was <75% for all preventive services. CONCLUSIONS: Self-reports are reasonably accurate for certain chronic conditions and for routine screening exams and can provide a useful estimate for broad measures of population prevalence.

A woman's own birth weight and gestational age predict her later risk of developing preeclampsia, a precursor of chronic disease.

Preeclampsia is a major complication of pregnancy and a predictor of future chronic disease. We investigated the hypothesis that a woman's own weight and gestational age as a newborn influence her risk of developing preeclampsia later in life. This case-control study used linked computerized birth registry data from the Colorado Department of Public Health and Environment. The study subjects were women ages 12-20 who were born in Colorado after 1974, each of whom delivered a live infant in Colorado between 1990 and 1995. Cases were subjects with a report of eclampsia and/or preeclampsia on the 1990-1995 birth records (N = 345). Controls were randomly selected from subjects with uncomplicated pregnancies who were frequency matched to cases by year of delivery (N = 3,995). Records from each subject's pregnancy (1990-1995) were then linked to those from her own birth (1975-1983). Birth weight and gestational age, as recorded on the subject's birth records, were independently associated with the risk of developing preeclampsia after adjustment for age, parity, race/ethnicity, and other risk factors. The risk of preeclampsia decreased with increasing gestational age in a dose-dependent fashion; relative to mothers born post-term, adjusted odds ratios for preeclampsia ranged from 3.62 [95% confidence interval (95% CI) = 1.27-10.28] for mothers born at less than 34 weeks gestational age to 1.45 (95% CI = 0.85-2.45) for those born at term. Relative to women who were born at 8.5 lb or more, those born in the lowest weight category (under 4.5 lb) appeared at greatest risk for preeclampsia (odds ratio = 5.16; 95% CI = 1.24-21.51), although no directional trend was apparent. These findings suggest that women born small or premature may be at increased risk of developing preeclampsia as teenagers or young adults.

Promoting cancer screening among the first-degree relatives of breast and colorectal cancer patients: the design of two randomized trials.

BACKGROUND: In this paper two large nationwide trials are described, both of which will test a comparable telephone-based counseling intervention to promote cancer screening among the first-degree relatives (FDRs) of breast and colorectal cancer patients. The unit of randomization will be the family unit of eligible FDRs. Access to FDRs will be obtained from their relatives with cancer. Selected intervention and design issues are reviewed, including how both projects will respond to FDRs who exhibit significant levels of cancer-specific anxiety or distress and how potential high-risk cancer families will be accommodated. METHODS: Pursuant to the development of both studies, two feasibility surveys were conducted to determine whether patients would grant access to their FDRs and whether the FDRS identified by these patients would be receptive to the telephone intervention. RESULTS: Approximately 80% (106 of 132) of breast cancer patients agreed to provide access to their eligible FDRs when contacted on-site at participating hospitals and clinics. Of those subsequently selected for telephone follow-up (n = 95 or 90%), 80% (n = 76) were successfully contacted by telephone, and of these 97% (n = 74) provided the names and telephone numbers of their FDRs. Among colorectal cancer patients contacted on-site (n = 46), 96% (n = 44) agreed to provide access to their FDRs, and of those contacted by telephone (n = 33 or 75%), 91% (n = 30) provided the requested information about their FDRs. Once contacted, 95% of breast cancer FDRs (55 of 58) and 91% of colorectal cancer patients (51 of 56) endorsed the intervention strategy. CONCLUSIONS: It is argued that this intervention, if proven effective, could provide an exportable strategy for reaching large numbers of high-risk individuals to promote cancer screening.

Randomized controlled study of customized preventive medicine reminder letters in a community practice.

OBJECTIVE: To test the effectiveness of customized, family-oriented reminder letters in activating patients to seek appropriate preventive services. DESIGN: Randomized clinical trial. One group received computer-generated, customized letters explaining recommended preventive procedures for each family member. A second group received a form letter listing recommendations for all preventive procedures for all age and sex groups. A third group (control group) received no letters. SETTING: A private medical centre, without university affiliation, in rural Quebec. PARTICIPANTS: From 8770 patients who met study criteria, 719 families were randomly selected. Data were available for 1971 of 1998 patients in these families. MAIN OUTCOME MEASURES: The Family Received Index is the proportion of all procedures for which a family was overdue that they received. The Family End-of-study Up-to-date Index is the proportion of procedures for which the family was eligible and for which they were up-to-date at the end of the study. RESULTS: The Family Received Index for families mailed customized letters was more than double the index for patients not mailed letters (Kruskal-Wallis P = .0139). Comparison of the Family End-of-study Up-to-date indices also demonstrated that families of patients sent customized letters were more likely to be up-to-date than families not sent letters (Kruskal-Wallis P = .0054). No statistically significant difference appeared between the number of preventive measures received by the control group and the form-letter group. CONCLUSIONS: This study demonstrates a clinically small but statistically significant value to customizing reminder letters.

Extending health maintenance organization insurance to the uninsured. A controlled measure of health care utilization.

OBJECTIVE: To investigate the utilization of health care services of previously uninsured low-income patients after becoming insured by a health maintenance organization (HMO). DESIGN: Retrospective study of utilization in a previously uninsured study group compared with an age- and sex-matched randomly selected control group of commercial HMO enrollees. SETTING: Group model HMO. PATIENTS: A study group of 346 previously uninsured low-income patients and 382 controls. MEASURES: utpatient visits for primary and specialty care, outpatient pharmacy, laboratory, and radiology use, and inpatient admissions and hospital days over a 2-year period. Self-reported health status measures were obtained to control for differences in health status. PRINCIPAL FINDINGS: There were no differences between the study and control groups in hospital admissions, hospital days, and measures of outpatient laboratory, pharmacy, and radiology use. The odds of having an outpatient visit per patient per month was 30% higher for the study group. Approximately half the increase in the odds ratio for outpatient visits was related to the worse self-perceived health status of the study group. While both groups utilized more services in the early phase of their enrollment, the intensity of this start-up effect was similar for both groups. CONCLUSIONS: Compared with a commercial group of the same age and sex, the patterns of utilization were similar and the financial costs of care were only moderately more for a previously uninsured group provided with comprehensive HMO insurance. With the growth of managed care, these data should be beneficial in the development of health care programs for the growing number of uninsured Americans.

Is syncope related to moderate altitude exposure?

STUDY OBJECTIVE: To investigate factors related to syncope occurring on recent ascent to moderate altitude. DESIGN: A 1-year retrospective case-control study, using local acclimatized residents as a control group. SETTING: The two main ambulance destinations for Summit County, Colorado (elevation, 2770 m). PATIENTS: All patients with a diagnosis of syncope, near-syncope, or fainting whose medical records were available for review. RESULTS: There was a significant relationship (P less than .05) between syncope of unknown origin and recent arrival at altitude (less than 24 hours), and a significant inverse relationship (P less than .05) between syncope of unknown origin and arterial oxygen saturation as measured by pulse oximetry. CONCLUSIONS: Short-term exposure to moderate altitude may be related to otherwise unexplained syncope in healthy young adults. We suggest the name high-altitude syncope for this entity and encourage further research in this area.

Injuries to children and adolescents: impact on physical health.

Disability resulting from injuries was examined in a health maintenance organization population of children and adolescents 0 through 19 years of age. The physical health status instrument from the Rand Health Insurance Study was used to evaluate functional outcome of patients seen in the emergency room and outpatient clinic. Overall, 55.1% of individuals had limitations in their usual activities during the week following injury; 16.4% and 3.8% were not yet back to full activities after 1 week and 1 month, respectively. Individuals 10 years of age and older had more functional impairment than did younger children. Restrictions were greatest for fractures/dislocations and sprains and for injuries due to sports, play/recreational activities, and falls.

Methods of surveillance for HIV infection in primary care outpatients in the United States.

Primary care outpatients provide a good sentinel population for monitoring levels and trends of HIV infection in the United States. Because a broad cross section of the population seeks primary medical care, excess blood from specimens routinely collected for other purposes is available for anonymous, unlinked HIV testing, and all age groups and both sexes can be sampled. The CDC family of surveys includes two surveys of primary care outpatients: (a) a survey of 100,000 blood specimens per year submitted by more than 6,000 primary care physicians to a national diagnostic laboratory for complete blood count or hematocrit and (b) a survey of approximately 10,000 blood specimens per year from a network of 242 primary care physicians. Each survey has different advantages: the laboratory-based survey has a large sample from a large population base, and the physician network survey has a well-defined patient population in which each patient's clinical condition can be determined. In the primary care physician network, a concurrent study of clinical patterns of disease in patients with recognized HIV infection provides additional information on the clinical syndromes associated with HIV infection and estimates of the occurrence of unrecognized HIV infection.

Risk of injury to children less than 5 years of age in day care versus home care settings.

Recent studies have suggested that day care may be a relatively unsafe environment. In this population-based study, the incidence of injuries in day care and home care were evaluated based on the number of hours children were exposed to each environment. In this population, 43.6% of children less than 5 years of age spent part of the year in day care. The rate of injuries in day care was 2.50 per 100,000 child-hours of exposure compared with a rate of 4.88 per 100,000 child-hours of exposure in the home environment. There were no differences in overall severity of injuries in the two groups. It was concluded that children are at no greater risk of injury in day-care settings than in the home environment.

A subsidized perinatal care program in a rural Colorado county.

A large number of medically indigent women in rural areas currently receive little or no prenatal care, raising major concerns regarding perinatal health. In Colorado, subsidized prenatal and labor/delivery programs have been instituted to address this problem. This article describes the implementation of two programs in one rural county. In these rural programs, private physicians, health department personnel, and social work staff at the local hospital collaborate to provide financial assistance, comprehensive health education, and quality medical care for eligible pregnant women. The identified benefits and barriers unique to the provision of quality perinatal care in rural settings are discussed.

Population-based study of unintentional injury incidence and impact during childhood.

We report a prospective study of medically treated unintentional injuries ascertained in an HMO population of children and adolescents 19 years of age and younger over a one-year period. The overall rate of medically treated injuries was 247 per 1,000, 147/1,000 for those treated in the clinic, and 100/1,000 for those treated in the emergency room (ER). Overall, 2.5 percent of patients were hospitalized. The highest rates of injury were for falls (60 per 1,000), recreational activities (57 per 1,000) and competitive sports (49 per 1,000). The site of care varied little by injury diagnosis or etiology, with the exception that sprains/strains, fractures, and injuries due to play and sports were more commonly treated in the clinic. The impact of trauma on activity was considerable, with 55.9 percent of injuries resulting in restricted activity, 10.6 percent in greater than or equal to 2 days of school missed, and 6.7 percent in greater than or equal to 2 days spent in bed.

Patients with new headache in primary care: a report from ASPN.

From a consecutive series of 3,847 headache patients, 1,331 patients who made first visits for new headache to 120 primary care physicians were studied for usual care over a 14-month period. Either tension or vascular headache was the initial diagnosis in 23.8 percent and 12.8 percent of patients, respectively. Nearly one half (47.8 percent) were classified as having headaches other than tension or vascular. A total of 15.3 percent of headaches were undiagnosed or were regarded as a mixture of traditional diagnostic designations. At first visit, most patients (76.6 percent) were managed without diagnostic tests. Drugs were prescribed for 73.6 percent, and advice was given for 58.6 percent. Only 2.0 percent of patients had computerized tomographic scanning ordered at first visit, although at least 46 percent met National Institutes of Health criteria, a finding with potential economic consequences of at least $2 billion. These findings suggest the need for reevaluation of diagnostic categories for headache, reevaluation of strategies for headache management, and further investigations of headache in primary care patients.

Topics for family medicine research in obstetrics.

Primarily because of improvements in care of the low-birthweight neonate, Canada's neonatal mortality rates have declined significantly over the last 20 years. To make further improvement, research is now focused on the prevention of prematurity. However, benefits from the implementation of such research and the maintenance of the current neonatal mortality rate depend on the availability of obstetric care providers in rural areas. The recent trend among family physicians to drop the practice of obstetrics significantly jeopardizes access to obstetric care for inhabitants of rural areas, and a significant body of literature suggests that such declines in access will be accompanied by an increase in the neonatal death rate. A logical research agenda for rural family physicians would include the forecasting of the effect of the decrease in obstetric care manpower, follwed by the study of factors behind this trend, and the evaluation programs designed to prevent family physicians abandoning obstetric practice.