Disease management strategies: managing care giving in managed care.

The rapid rate of change in health care delivery systems has challenged and troubled health care providers. Some new health care delivery systems primarily emphasize the economics of medical care and leave providers with a sense that their profession has strayed from its mission. In addition, there is an increasing demand by payers and the public for public accountability for the quality and expense of clinical services. One response to these changes in health care is the use of disease management strategies. There is a growing body of knowledge regarding disease management strategies and practice guidelines in the literature. This article discusses how a provider group can implement improvement in the clinical process successfully by applying techniques of disease management.

Feeling hopeless and helpless. When anxiety symptoms coexist with depressive disorder.

Among patients with psychiatric disorders, a significant number have a depressive disorder and coexisting symptoms of anxiety. The overlapping conditions present physicians with a confusing array of symptoms that, in the past, has made diagnosis and therapy difficult. Although the anxiety symptoms may not be sufficient to meet diagnostic criteria for an anxiety disorder, they can have a profound influence on the severity of and prognosis for the depressive illness. To clarify diagnosis when symptoms of both depression and anxiety are present, it is important to consider elements such as predominant mood, sleep patterns, psychomotor signs, and suicidal ideation, which serve to differentiate between the two disorders. Once a diagnosis is established, appropriate use of pharmacotherapy (especially antidepressant agents that have anxiolytic side effects) and psychotherapy can help relieve symptoms and lead to a favorable outcome.

Management of depression in patients with coexisting medical illness.

Depressive illness is common in the general population, with a prevalence of 5 percent. However, 10 to 15 percent of any general medical population has clinically significant depression; in patients with selected chronic illnesses, prevalence rates between 25 to 50 percent are noted. In patients with coexisting medical illness, the diagnosis of depression requires differentiating symptoms of the medical illness from symptoms of the comorbid depression. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) can be helpful in this endeavor. An understanding of the effect of particular medications on neurotransmitters is required and can guide the clinician in selecting therapeutic agents that have a low incidence of side effects and toxicity.

St. Anthony's Fire: diagnosis and management of erysipelas.

Erysipelas, a beta-hemolytic streptococcal infection of the skin and subcutaneous tissue, was once a common disease but nearly disappeared after the advent of antibiotics. In the past few years, however, the incidence of erysipelas has been increasing. At particular risk for infection are young patients, elderly patients and immunocompromised patients. The diagnosis is confirmed by the typical appearance of erythema and fever, constitutional symptoms and laboratory findings indicative of streptococcal infection. Penicillin and close follow-up can prevent significant morbidity and possible mortality. The prognosis for patients with erysipelas is excellent.

Ascariasis. An infection to watch for in immigrants.

Infection with Ascaris lumbricoides, a roundworm that invades the human digestive tract, affects about 25% of the world's population. Manifestations of ascariasis vary and include constitutional symptoms, particularly pulmonary and gastrointestinal complaints. Complications include pneumonitis, intestinal obstruction, and damage to vital organs. Diagnosis is made in most cases by sampling stool for ova and parasites. Treatment with an anthelmintic agent is usually effective in mild cases, and prognosis is excellent. More severe infection may cause significant morbidity and require surgical intervention.

Pharmacologic treatment of COPD. Optimum therapy for ambulatory patients.

Chronic obstructive pulmonary disease (COPD) has a wide variety of pathophysiologic mechanisms that involve the bronchi, bronchioles, and acini. For typical patients, first-line treatment with inhaled beta 2-selective agonists or ipratropium bromide (Atrovent) significantly improves lung function with minimal side effects. Theophylline is no longer routinely used as a first-line agent for the treatment of COPD but may be a useful addition to therapy if proper attention is given to serum drug levels and symptoms of toxicity. Oral prednisone is useful as an adjunctive agent for patients with serious disease who do not respond to other agents; a therapeutic trial showing objective evidence of benefit from this drug is essential. Mucolytics have recently been shown to have a role in improving lung function and also may be useful as adjunctive therapy.

Intrapartum intervention and delivery outcome in low-risk pregnancy.

A retrospective cohort study of 1597 low-risk pregnancies assessed the effects of obstetrical intervention using logistic regression. Both maternal and neonatal morbidity were low (15.2 percent and 3.8 percent, respectively). Epidural analgesia, oxytocin, or both, were associated with worse maternal outcome, and neonatal outcome was worse when oxytocin was used. However, epidural analgesia seemed to provide a protective neonatal effect when oxytocin was used during labor. Both elective and medically necessary use of these interventions were associated with increased morbidity. If obstetrical interventions, particularly oxytocin and epidural analgesia, are applied in low-risk pregnancies, labors must be monitored carefully and the risk-benefit ratios judged advantageous.

Managing abnormal vaginal bleeding.

Abnormal vaginal bleeding is a diagnostic and therapeutic challenge. A carefully directed patient history and physical examination along with basic laboratory tests can lead to accurate diagnosis. In most cases, symptoms can be controlled with use of oral contraceptives, progesterone supplements, and/or nonsteroidal anti-inflammatory drugs.

Abnormal vaginal bleeding in perimenopausal women.

The incidence of abnormal vaginal bleeding increases as women approach the end of their reproductive years. In the perimenopausal age group, the most common cause of abnormal vaginal bleeding is anovulation. In most patients, diagnosis and management can be accomplished in a family physician's office.

Pseudoparasitism with Gordius robustus.

The Gordius worm is a parasite of crickets and other arthropods, but not of humans. In almost all cases, the association between humans and the Gordius species, such as Gordius robustus, is purely coincidental. Gordius pseudoparasitism must be distinguished from true helminthic disease to alleviate patient anxiety and to avoid an unnecessary course of antihelminthics.

The effects of epidural anesthesia on type of delivery.

A retrospective cohort study of 626 low-risk patients admitted for labor and delivery under the care of a family physician was designed to test the hypothesis that epidural anesthesia increases the frequency of instrumental and operative deliveries. The crude odds ratio of instrumental or operative delivery in women electing to have epidural anesthesia was 9.56 (95 percent confidence interval, 5.57 to 16.40; P less than 0.001). Controlling for bias by multivariate analysis did not change the conclusion indicated by the crude odds ratio--use of elective epidural anesthesia results in markedly increased odds of instrumental or operative delivery.

Office management of sexually transmitted disease and management of pelvic inflammatory disease in the ambulatory patient.

Sexually transmitted disease poses an increasing challenge for the clinician in the 1980s, with increasing numbers of pathogens and diseases. This article discusses the diagnosis and outpatient management of gonorrhea, herpes virus type II, chlamydia trachomatis, and condyloma accuminatum. In addition, the diagnosis and outpatient management of pelvic inflammatory disease is reviewed.

Influence of site of obstetric care and delivery on pregnancy management and outcome.

A retrospective cohort study of 863 pregnancies cared for by family physicians at three sites--rural-rural (RR), rural-urban (RU), and urban-urban (UU)--was designed to test the hypothesis that ready on-site access to perinatal subspecialists would improve pregnancy outcome. No differences in delivery type, length of gestation, birth weight, or nursery care were found. An Apgar score of less than 7 at 1 minute or less than 8 at 5 minutes was 2.17 and 2.31 times more likely at RU and 2.48 and 2.60 times more likely at UU, respectively, than at RR. The overall Cesarean section rate was 9.6 percent, forceps rate was 7.2 percent, and nonroutine nursery care rate was 7.9 percent. Neonatal and perinatal mortality rates were 3.5 and 4.6 per 1,000 live births. There is no evidence that on-site perinatal subspecialists improve perinatal outcome when care is provided by board-certified family physicians. Small obstetric centers provide quality perinatal care with outcome dependent on physician's skill rather than on technology.

Normal labor and the induction and augmentation of labor.

The management of labor is based on a sound understanding of labor's biochemistry and physiology. The interaction between prostaglandin synthesis and other mechanisms postulated to control the initiation of labor shows promise, but the definitive explanation for the initiation of labor awaits further research. The procedures associated with the management of routine labor, including perineal preparation and the use of enemas, intravenous fluids, and analgesics and anesthetics, are generally best applied on the basis of individual need rather than protocol. The Friedman labor curve and intrapartum risk scoring have proved to be useful indices in the evaluation of the course of labor. Oxytocin and prostaglandin are two clinically useful agents in the induction and augmentation of labor. Currently, prostaglandin is used generally in the induction of preterm labors with oxytocin reserved for the induction of labor at term. The effects and side effects of the medications may be controlled by careful use and monitoring. A protocol for the successful use of oxytocin includes careful fetal monitoring and control of intravenous infusion with careful incremental increases in the dose of oxytocin based on uterine response.