Alcohol consumption patterns and health care costs in an HMO.

We examined the relationship between patterns of alcohol consumption and health care costs among adult members of the Kaiser Permanente Medical Care Program (KPMCP) in Northern California. A telephone survey of a random sample of the KPMCP membership aged 18 and over was conducted between June 1994 and February 1996 (n=10,175). The survey included questions on sociodemographic characteristics, general and mental health status, patterns of past and current alcohol consumption; inpatient and outpatient costs were obtained from Kaiser Permanentes cost management information system. Results showed that current non-drinkers with a history of heavy drinking had higher health costs than other non-drinkers and current drinkers. The per person per year costs for non-drinkers with a heavy drinking history were $2421 versus $1706 for other non-drinkers and $1358 for current drinkers in 1995 US dollars. A history of heavy drinking has a significant effect on costs after controlling for sociodemographic characteristics, health status and health practices. Current drinkers have the lowest costs, suggesting that they may be more likely than non-drinkers to delay seeking care until they are sick and require expensive medical care.

Improving primary care for depression in late life: the design of a multicenter randomized trial.

BACKGROUND: Late life depression can be successfully treated with antidepressant medications or psychotherapy, but few depressed older adults receive effective treatment. RESEARCH DESIGN: A randomized controlled trial of a disease management program for late life depression. SUBJECTS: Approximately 1,750 older adults with major depression or dysthymia are recruited from seven national study sites. INTERVENTION: Half of the subjects are randomly assigned to a collaborative care program where a depression clinical specialist supervised by a psychiatrist and a primary care expert supports the patient's regular primary care provider to treat depression. Intervention services are provided for 12 months using antidepressant medications and Problem Solving Treatment in Primary Care according to a stepped care protocol that varies intervention intensity according to clinical needs. The other half of the subjects are assigned to care as usual. EVALUATION: Subjects are independently assessed at baseline, 3 months, 6 months, 12 months, 18 months, and 24 months. The evaluation assesses the incremental cost-effectiveness of the intervention compared with care as usual. Specific outcomes examined include care for depression, depressive symptoms, health-related quality of life, satisfaction with depression care, health care costs, patient time costs, market and nonmarket productivity, and household income. CONCLUSIONS: The study blends methods from health services and clinical research in an effort to protect internal validity while maximizing the generalizability of results to diverse health care systems. We hope that this study will show the cost-effectiveness of a new model of care for late life depression that can be applied in a range of primary care settings.

The outcome and cost of alcohol and drug treatment in an HMO: day hospital versus traditional outpatient regimens.

OBJECTIVE: To compare outcome and cost-effectiveness of the two primary addiction treatment options, day hospitals (DH) and traditional outpatient programs (OP) in a managed care organization, in a population large enough to examine patient subgroups. DATA SOURCES: Interviews with new admissions to a large HMO's chemical dependency program in Sacramento, California between April 1994 and April 1996, with follow-up interviews eight months later. Computerized utilization and cost data were collected from 1993 to 1997. STUDY DESIGN: Design was a randomized control trial of adult patients entering the HMO's alcohol and drug treatment program (N = 668). To examine the generalizability of findings as well as self-selection factors, we also studied patients presenting during the same period who were unable or unwilling to be randomized (N = 405). Baseline interviews characterized type of substance use, addiction severity, psychiatric status, and motivation. Follow-up interviews were conducted at eight months following intake. Breathanalysis and urinalysis were conducted. Program costs were calculated. DATA COLLECTION: Interview data were merged with computerized utilization and cost data. PRINCIPAL FINDINGS: Among randomized subjects, both study arms showed significant improvement in all drug and alcohol measures. There were no differences overall in outcomes between DH and OP, but DH subjects with midlevel psychiatric severity had significantly better outcomes, particularly in regard to alcohol abstinence (OR = 2.4; 95% CI = 1.2, 4.9). The average treatment costs were $1,640 and $895 for DH and OP programs, respectively. In the midlevel psychiatric severity group, the cost of obtaining an additional person abstinent from alcohol in the DH cohort was approximately $5,464. Among the 405 self-selected subjects, DH was related to abstinence (OR = 2.1; 95% CI = 1.3, 3.5). CONCLUSIONS: Although significant benefits of the DH program were not found in the randomized study, DH treatment was associated with better outcomes in the self-selected group. However, for subjects with mid-level psychiatric severity in both the randomized and self-selected samples, the DH program produced higher rates of abstention and was more cost-effective. Self-selection in studies that randomize patients to services requiring very different levels of commitment may be important in interpreting findings for clinical practice.

Addiction severity index data from general membership and treatment samples of HMO members. One case of norming the ASI.

The Addiction Severity Index (ASI) is a widely used interview among substance-dependent populations in treatment. Its value as a treatment planning and evaluation tool has been diminished by the lack of comparative data from nonclinical samples. The present study included four scales from the ASI collected on samples of adult subscribers to a large health maintenance organization (HMO) in northern California, as well as an adult clinical sample from the same geographic region with the same HMO insurance, thereby offering informative contrasts. Interviews (N = 9,398) of non-alcohol-dependent or abuse adults from a random sample of members of a large HMO were analyzed. We collected complete ASI data on the alcohol, drug, medical, and psychiatric composite scales and partial data on the employment scale. A sample of 327 adult members of the same HMO from one of the counties included in the survey, who were admitted to treatment for alcohol and/or drug addiction, was administered the same ASI items at treatment admission. Analyses compare problem severities in the two samples by age and gender. The general membership reported some problems in most of the ASI problem areas, although at levels of severity that were typically far below those seen in the clinical sample. General membership and clinical samples were somewhat similar in medical status and in employment. As expected, alcohol, drug, and psychiatric status were much more severe in the clinical sample. The data from the HMO general membership sample provide one potential comparison group against which to judge the severity of problems presented by drug- and alcohol-dependent patients at treatment admission and at posttreatment follow-up. The authors discuss the implications for treatment planning and the evaluation of treatment outcome.

Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care.

BACKGROUND: Primary care treatment of depression needs improvement. OBJECTIVE: To evaluate the efficacy of 2 augmentations to antidepressant drug treatment. DESIGN: Randomized trial comparing usual care, telehealth care, and telehealth care plus peer support; assessments were conducted at baseline, 6 weeks, and 6 months. SETTING: Two managed care adult primary care clinics. PARTICIPANTS: A total of 302 patients starting antidepressant drug therapy. INTERVENTIONS: For telehealth care: emotional support and focused behavioral interventions in ten 6-minute calls during 4 months by primary care nurses; and for peer support: telephone and in-person supportive contacts by trained health plan members recovered from depression. MAIN OUTCOME MEASURES: For depression: the Hamilton Depression Rating Scale and the Beck Depression Inventory; and for mental and physical functioning: the SF-12 Mental and Physical Composite Scales and treatment satisfaction. RESULTS: Nurse-based telehealth patients with or without peer support more often experienced 50% improvement on the Hamilton Depression Rating Scale at 6 weeks (50% vs 37%; P =.01) and 6 months (57% vs 38%; P =.003) and on the Beck Depression Inventory at 6 months (48% vs 37%; P =. 05) and greater quantitative reduction in symptom scores on the Hamilton scale at 6 months (10.38 vs 8.12; P =.006). Telehealth care improved mental functioning at 6 weeks (47.07 vs 42.64; P =.004) and treatment satisfaction at 6 weeks (4.41 vs 4.17; P =.004) and 6 months (4.20 vs 3.94; P =.001). Adding peer support to telehealth care did not improve the primary outcomes. CONCLUSION: Nurse telehealth care improves clinical outcomes of antidepressant drug treatment and patient satisfaction and fits well within busy primary care settings.

Alcohol drinking patterns and medical care use in an HMO setting.

The objective of this study was to examine the association of medical care use (outpatient visits and hospitalization) with alcohol drinking patterns in a large health maintenance organization (HMO). Data were gathered from a random sample of 10,292 adult respondents through a telephone survey conducted between June 1994 and February 1996. Findings indicate that current nondrinkers with no past history of drinking had higher rates of outpatient visits and hospitalizations than current drinkers. Among current drinkers, medical care use declined slightly as drinking levels increased. Among nondrinkers, those with a drinking history exhibited significantly higher use of outpatient visits and hospital care than nondrinkers with no drinking history and current drinkers. Controlling for demographic and socioeconomic factors, health status, and common medical conditions in multivariate analyses suggests that nondrinkers with a drinking history use more services because they are sicker than other nondrinkers or current drinkers.

Drinking patterns and problems of the "stably insured": a study of the membership of a health maintenance organization.

OBJECTIVE: This article describes drinking patterns and examines the prevalence of heavy drinking and alcohol problems, and their association with other behavioral and social problems within the membership of a health maintenance organization, a setting in which increasing numbers of Americans receive services. METHOD: The sample is representative of the stably insured membership of the Northern California Region of Kaiser Permanente Medical Care Program; i.e., those who have been insured continuously under that plan for 30 months or longer. A telephone survey of the adult membership (N = 10,292) was conducted between June 1994 and February 1996. RESULTS: As in other studies, health and mental health status and smoking were related to drinking levels, with symptoms higher for those in the heaviest drinking group. However, in contrast to studies of those using medical services, demographic characteristics (e.g., young age) were not associated with heavy drinking in this population. When controlling for drug use and drinking, however, women and those reporting any mental health symptom were more likely to report alcohol problems. CONCLUSIONS: Findings suggest that in private managed care populations, particular behavioral indicators may be more important than demographic characteristics in screening for problem drinkers. The identification of individuals who report a mental health symptom, who drink a large number of drinks occasionally or who report any drug use may be important in a health maintenance approach to prevention and case finding.

Role of a psychiatric outcome study in a large scale quality improvement project.

A psychiatric outcomes study that examined caseload attributes, patterns of treatment, and clinical outcomes in 950 adult outpatients was conducted as part of a Quality Improvement (QI) initiative in a large HMO. Patients were assessed pre- and post-treatment with measures of symptomatology (SCL-90) and functioning (SF-36), plus pre-treatment measures of personality disorder, comorbid problems, and sociodemographic variables. Significant improvements in psychological functioning and symptomatology were seen for 39-50% of patients, while 4-11% had significantly worsened. The study not only provided the HMO with useful baseline information on the performance of its psychiatric services, but also provided important lessons in how to conduct outcomes projects relevant to QI efforts. The study should be seen as part of an early effort of a large organization to move from a paradigm of Quality Assurance to one of Quality Improvement in the area of mental health.

Treatment participation and outcome among problem drinkers in a managed care alcohol outpatient treatment program.

This article uses Markov analysis to investigate patterns of treatment participation of 361 patients treated in the alcohol and drug abuse programs of a large group model Health Maintenance Organization (HMO) to examine how participation is related to abstinence. Findings indicate that 82% of the patients in treatment one month after intake were in treatment three months later, and treatment retention dropped to 46% by month 6. Findings also indicate that 74% of patients abstinent and in treatment at month 1 remained so at month 3. Abstinence at the first three-month interval was a strong predictor of abstinence at later time periods. A multivariate analysis showed that an expressed desire to stop alcohol use upon entry into treatment was the most consistent predictor of both treatment participation and abstinence at most time points. Treatment participation was also a significant predictor of abstinence.

Developing a system for automated monitoring of psychiatric outpatients: a first step to improve quality.

OBJECTIVE: To evaluate an automated system of quality monitoring for psychiatric outpatients. DESIGN: Cross-sectional study. SETTING: Large outpatient psychiatry clinic in Kaiser Permanente--Northern California. PARTICIPANTS: Approximately 1500 new psychiatric patients and 20 clinicians. INTERVENTIONS: This system gave clinicians data on new patients from validated instruments before their intake interviews, measured outcomes for the depressed and panic-disordered patients, and monitored the clinic's case-mix. MAIN OUTCOME MEASURES: Clinic case-mix: Axis II disorders (Personality Disorder Questionnaire--Revised); emotional, social and physical functioning (Health Status Questionnaire 2.0); Axis I symptoms (Symptom Checklist-90); depression and panic disorder (Health Outcomes Institute Modules). Clinician reaction to system (telephone interview). RESULTS: The study population was 62.4% female; 73.9% Caucasian; 70% employed; 15.9% had evidence of personality disorder; 63% reduced daily activities because of emotional problems; 18% had depression; 7% had panic disorder. Over 75% of clinicians used the data reports and found them helpful; criticism focused on questionnaire length, inadequate training, numerous false-positives, and insufficient administrative support. CONCLUSION: An automated patient monitoring system can be implemented; clinician involvement needs to be significant; more research is needed to establish the usefulness of standardized data and outcomes management.

Culture shock and synergy. Academic/managed care/corporate alliances in outcomes management.

The Behavioral Health Outcomes Study is a partnership in conducting outcomes measurement involving a corporate healthcare purchaser, five managed behavioral healthcare organizations and academic researchers. The goals of this study are to: evaluate the feasibility of incorporating patient self-reported data in outcomes research; identify factors that may be predictors of outcome; and evaluate the effectiveness of an employee-sponsored aftercare program. The differing perspectives and needs of the three partners have created a number of challenges in the areas of goals, confidentiality, proprietary vs. open access issues and methodology. However, after the study's first year, it is clear not only that outcomes research can be conducted under such a partnership, but that the partnership generates a kind of synergy in problem-solving.

Home blood pressure monitoring. Effect on use of medical services and medical care costs.

The objective of this study was to determine whether a hypertension management program in which patients monitor their own blood pressure (BP) at home can reduce costs without compromising BP control. The prospective, randomized, controlled 1-year clinical trial was conducted at four medical centers of the Kaiser Permanente Medical Care Program in the San Francisco Bay Area. Of 467 patients with uncomplicated hypertension who were referred by their physicians, 37 declined to participate in the study; 215 were randomly assigned to a Usual Care (UC) group and 215 to a Home BP group. Twenty-five UC patients and 15 Home BP patients did not return for year-end BP measurements. Patients in the UC group were referred back to their physicians. Patients in the Home BP group were trained to measure their own BP and return the readings by mail. Patients were given a standard procedure to follow in case of unusually high or low BP readings at home. The number and type of outpatient medical services used were obtained from patient medical records for the study year and the prior year. Costs of care for hypertension were calculated by assigning relative value units to each outpatient service. Trained technicians measured each patient's BP at entry into the study and 1 year later. Home BP patients made 1.2 fewer hypertension-related office visits than UC patients during the study year (95% confidence interval (CI): 0.8, 1.7). Mean adjusted cost for physician visits, telephone calls, and laboratory tests associated with hypertension care was $88.76 per patient per year in the Home BP group, 29% less than in the UC group (95% CI: $16.11, $54.74). The annualized cost of implementing the home BP system was approximately $28 per patient during the study year and would currently be approximately $15. After 1 year, BP control in men in the Home BP group was better than in men in the UC group; BP control was equally good in women in both groups. Management of uncomplicated hypertension based on periodic home BP reports can achieve BP control with fewer physician visits, resulting in substantial cost savings.

Methodologic issues in evaluating stop smoking programs.

Three methodologic issues (definitions of smoking, period of follow-up, composition of study group) were assessed in 426 persons five years after participation in a stop smoking program of a prepaid medical plan. When smoking was defined by measurement interval or by type or amount of tobacco smoked, smoking rates varied only slightly. Little information was gained by extending the follow-up period beyond the first year. However, study group composition (as defined by attendance at program sessions) had a pronounced effect on smoking rates. Those who attended fewer sessions were more likely to smoke during the follow-up period.

Frequency of urolithiasis in a prepaid medical care program.

The rate of occurrence of stones of the urinary tract was assessed in a large population served by the Northern California Kaiser Foundation Health Plan. The study involved three separate groups. First, data were obtained by questionnaire from approximately 175,000 adults who took a multiphasic health checkup in the period 1964-1972; of these generally well adult members, 26.2/1000 persons (32.0/1000 men and 21.0/1000 women) reported having ever been told by a physician that they had a urinary tract stone. Second, data were obtained from 139,000 persons served by the San Francisco outpatient facility in 1970-1972; 1.22/1000 per year (1.81/1000 men and 0.59/1000 women) had an initial diagnosis of a "new or recurrent" stone of the upper urinary tract. The third set of data was procured from the entire Northern California region in 1971-1975; 0.36/1000 (0.52/1000 men and 0.19/1000 women) were discharged from a hospital each year with a diagnosis of upper urinary tract stone. All rates were age-adjusted to the 1960 US Census population. Of these three rates, the rate derived from the outpatient visit record most closely estimates incidence, since nearly all persons who are hospitalized are first seen as outpatients. Rates of kidney stone diagnosis were three times more common in men and, although rare before 20 years of age, the frequency increased rapidly and peaked in the age group 40 to 59 years. Rates were approximately twice as high in whites as in blacks and Orientals; the frequency of stones was inversely related to socioeconomic status as measured by level of education. Over 90% of stones occurred in the upper urinary tract, and the majority contained calcium oxalate. Population-based rates of occurrence of kidney stones are not generally available in the United States. Comparisons with the few available studies indicate that rates in the Kaiser Foundation Health Plan population may be high.