The Impact of CMSA's Case Management Adherence Guidelines and Guidelines Training on Case Manager—Reported Behavior Change

PURPOSE/OBJECTIVES

The Case Management Society of America (CMSA) developed evidence-based guidelines (Case Management Adherence Guidelines, CMAG) for case managers to support increased efficacy of case managers in helping patients become more adherent to medication regimens. The effort was in response to documented high levels of nonadherence, and evidence demonstrating that lack of adherence negatively impacts patient health status. The CMSA engaged in a massive training program to support case manager adoption of the CMAG tools and approaches to improve patient knowledge and motivation. This article reports on findings of a follow-up survey that evaluated case manager's use of the tools and strategies discussed in the CMAG.

PRIMARY PRACTICE SETTING(S)

Seven hundred fifty case managers from all settings were trained in the use of the CMAG.

FINDINGS/CONCLUSIONS

In a follow-up survey, 42% of respondents reported that there has been a very, or fairly, significant impact of using their new skills to increase their effectiveness in helping patients reach their outcome improvement goals. In addition, 43% reported that there has been a very, or fairly, big improvement in patient adherence since they took the training, while 39% did not see a major impact. At the time of the survey (up to 1 year after training), 43% of respondents indicated that the training was very valuable; another 39% reported that it was fairly valuable. Participants continue to use the skills and information adopted in the training sessions: 26% report that they currently use at least some of the information and skills very often, while another 49% use them fairly often. Sixty-six percent of respondents indicated that they specifically use motivational interviewing to help address patient knowledge and motivation regarding medication adherence.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Medication adherence is a key issue in case management practice; efforts to positively impact low patient knowledge and motivation can be frustration for case managers. The CMAG offer evidence-based assessment tools to evaluate patient knowledge of medications and their motivation to adhere, and recommend the strategy of motivational interviewing to help case managers address adherence more effectively with patients. A 1-time training on the CMAG and motivational interviewing had some effect on self-reported case manager effectiveness in addressing medication adherence. Case managers appreciated the training; many reported that they continue to use skills and that they have observed changes in patient outcomes. Additional training, skill building, and reinforcement may help case managers apply CMAG and motivational interviewing effectively to support patients' adherence to medication regimens. The CMSA may continue to evaluate the impact of the CMAG and CMAG training to refine the tools and the training approach.

Aggressive interactions between Solenopsis invicta and Linepithema humile (Hymenoptera: Formicidae) under laboratory conditions

The Argentine ant, Linepithema humile (Mayr), and the red imported fire ant, Solenopsis invicta Buren, are natural agonists in their country of origin. Since the first report of L. humile in California in 1907 its range expanded statewide, displacing native ant species wherever it spread. Since the discovery of established populations of S. invicta in southern California in 1998, it has been restricted to discrete areas of southern California. However, as these discrete populations expand, they are encountering large populations of L. humile, which are effective competitors for available resources and are particularly aggressive in their encounters with other ant species such as S. invicta. Most Dolichoderine ants such as L. humile do not prefer to forage on baits made with defatted corn grit and soybean oil typically used in red imported fire ant control programs. Applications of these baits in areas where distributions of these species overlap might selectively affect populations of S. invicta and give L. humile a competitive advantage. Three laboratory experiments were conducted to determine the competitive outcomes between S. invicta pitted against L. humile: 1) agonistic behavior of workers in small arenas, 2) colony interactions with different population ratios, and 3) the effects of pyriproxyfen on the competitiveness of S. invicta against L. humile. Populations of S. invicta consisting of major workers killed more L. humile than did minors or a mixture of majors and minors. When paired against L. humile colonies consisting of 1,100 workers, colonies consisting of 38 S. invicta workers were easily defeated by L. humile. Colonies consisting of 450 S. invicta workers plugged their nest entrances, but they were ultimately defeated by L. humile after 13 d. The S. invicta colonies consisting of 1,100 workers took control of the bridge connecting the colonies, invaded the L. humile colony, killed the Argentine ant queens, and removed their brood. Pyriproxyfen-treated fire ant workers took significantly longer to chase the Argentine ants from a connecting bridge than did untreated fire ants. Thus, fire ant baits may have long-term effects on intercolonial aggression between S. invicta and L. humile, especially when Argentine ant populations are high in the summer.

The zeitgeist of online health search. Implications for a consumer-centric health system

BACKGROUND

Health care queries rank among the most frequent topics of information-seeking activity initiated by users of commercial search engines. The quality of information located through existing search engine technology has received little attention, especially when considering the widely varied knowledge levels of internet users.

OBJECTIVE

This study sought to create a benchmark technology assessment of online health search trends and practices, with corresponding evaluation of its applicability within the Federal Health Architecture (FHA) plan for a nationwide, interoperable health information infrastructure.

DESIGN

Exploratory technology assessment, analyzing focus group participants' views on barriers to effective health information searching, using existing commercial search engine technologies and methods.

SETTING AND PARTICIPANTS

Focus group, national leaders in electronic health care (e-health).

RESULTS

A variety of web-based assessment tools are available for consumers to be able to identify reliable health websites; however, many may be too difficult for the layperson to use or understand. Existing search technologies are increasingly powerful, although the expanding volume of information on the internet suggests the need for better mediated searching. Search engines provide consumers a means for quickly bypassing information that appears too technical for their individual knowledge level, and at times, searchers often overlook critical information most relevant to their needs. Overall, existing search technologies need to be more interactive, visible, and context-driven, and supported by better technology assessment methodologies, scalability of information, and enhanced access by underserved subgroups.

CONCLUSION

Future technology assessments are needed to provide structure for interoperability of health information systems, especially where consumers, providers, and payer systems intersect. State-of-the-art search engine technologies are still not widely available to those who can benefit most from them.

Patient Safety Systems for Case Management

Patient safety is an important concern of many healthcare stakeholders, including patients, providers, employers, health plans, and insurers. In 2003, URAC conducted a qualitative study to examine the role of utilization management programs as part of a systemic approach to promoting patient safety. Many of URAC's findings are applicable to case management as well. URAC found that most medical management companies address patient safety indirectly, as part of a global quality management program. Even so, the study identified a number of strengths that could be deployed by medical management organizations to more systematically promote patient safety. For example, case management organizations use decision support tools to assist frontline practitioners in conducting assessments and tracking interventions. Such systems could be programmed to flag safety concerns and guide interventions. The study also found that commonly used case management assessment protocols could be adapted to routinely assess for high priority safety concerns. URAC concluded that each stage of the medical management process offers opportunities for data collection and clinical interface to promote patient safety. Case managers have key positions interfacing between patients, providers, and the healthcare system. Development of safety indicators and training of staff are key elements needed to effectuate a safety program in medical management. Case management leaders in each organization and at the national level should make patient safety a priority, and define the processes for implementing safety systems wherever case management is practiced.

Setting the public agenda for online health search: a white paper and action agenda

Background

Searches for health information are among the most common reasons that consumers use the Internet. Both consumers and quality experts have raised concerns about the quality of information on the Web and the ability of consumers to find accurate information that meets their needs.

Objective

To produce a national stakeholder-driven agenda for research, technical improvements, and education that will improve the results of consumer searches for health information on the Internet.

Methods

URAC, a national accreditation organization, and Consumer WebWatch (CWW), a project of Consumers Union (a consumer advocacy organization), conducted a review of factors influencing the results of online health searches. The organizations convened two stakeholder groups of consumers, quality experts, search engine experts, researchers, health-care providers, informatics specialists, and others. Meeting participants reviewed existing information and developed recommendations for improving the results of online consumer searches for health information. Participants were not asked to vote on or endorse the recommendations. Our working definition of a quality Web site was one that contained accurate, reliable, and complete information.

Results

The Internet has greatly improved access to health information for consumers. There is great variation in how consumers seek information via the Internet, and in how successful they are in searching for health information. Further, there is variation among Web sites, both in quality and accessibility. Many Web site features affect the capability of search engines to find and index them.

Conclusions

Research is needed to define quality elements of Web sites that could be retrieved by search engines and understand how to meet the needs of different types of searchers. Technological research should seek to develop more sophisticated approaches for tagging information, and to develop searches that "learn" from consumer behavior. Finally, education initiatives are needed to help consumers search more effectively and to help them critically evaluate the information they find.

Linking utilization management and patient safety

URAC recently completed a study funded by the Robert Wood Johnson Foundation to assess patient safety systems. URAC collected information from 31 separate UM companies. URAC also reviewed software capabilities from four commercial utilization management software vendors. This article describes how utilization management organizations use information technology and UM processes to systematically identify and manage potential patient safety problems. The study also identified research needs to promote future utilization management involvement in patient safety.

Assessing an educational intervention to improve physician violence screening skills

OBJECTIVES

Health professionals play an integral role in assessing the risk of violence in their patients. However, there have been few evaluations of violence prevention education programs for health care personnel. The objective of this study was to evaluate the effects of a violence-screening education program on pediatric residents' and medical students' comfort level and skills in the identification and management of violence risks.

SETTING

Adolescent clinic of a tertiary care pediatric hospital.

PARTICIPANTS

Fifty-six second-year residents and third-year medical students assigned to a 4-week adolescent clinic rotation.

DESIGN

Randomized, controlled comparison study conducted over a 1-year period.

INTERVENTION

On alternate months, medical students and residents in the intervention group participated in a 3-hour workshop on violence prevention. The workshop included a didactic session with an overview of firearm, media, and sexual violence; a discussion of risk factors for adolescent violence; and training on the approach to the adolescent interview. Participants also discussed violence risks in the community with a panel of teen health educators, engaged in one-on-one role play with the youth educators, and received feedback on their violence screening skills. The control group received the standard ambulatory clinic manual with articles on violence prevention.

EVALUATION METHODS

All participants completed prerotation and postrotation questionnaires assessing their self-reported screening practices, as well as perceived importance and confidence in violence screening. Participants also interviewed and examined an adolescent standardized patient (SP) in the clinic. SPs completed evaluations on the content of the residents' and students' screening, their interpersonal skills, and their skill in the identification and management of the violence-related problem.

RESULTS

Over 12 months, 30 control and 26 intervention participants were recruited. There were no differences in prerotation questionnaire scores for intervention and control groups in screening practices, perceived importance and confidence in violence screening. Postrotation intervention participants reported more screening compared with controls on violence in school/neighborhood and fighting history. There was also greater perceived importance in asking about access/use of weapons and violence in school/neighborhood. Intervention participants also had improved performance compared with controls on SP evaluations of screening for violence, identification and management of the violence-related scenario, and interpersonal skills.

CONCLUSION

A violence prevention education program with teen health educators improved participants' self-reported violence questioning, as well as increased perceived comfort and importance in violence screening. Participants in the program also improved their identification and management of a standardized violence-related scenario presented in an adolescent clinic setting. adolescent violence, physician education, violence risk screening.

Considerations in choosing a primary endpoint that measures durability of virological suppression in an antiretroviral trial

OBJECTIVES

At present, many clinical trials of anti-HIV-1 therapies compare treatments by a primary endpoint that measures the durability of suppression of HIV-1 replication. Several durability endpoints are compared.

DESIGN

Endpoints are compared by their implicit assumptions regarding surrogacy for clinical outcomes, sample size requirements, and accommodations for inter-patient differences in baseline plasma HIV-1-RNA levels and in initial treatment response.

METHODS

Virological failure is defined by the non-suppression of virus levels at a prespecified follow-up time T(early virological failure), or by relapse. A binary virological failure endpoint is compared with three time-to-virological failure endpoints: time from (i) randomization that assigns early failures a failure time of T weeks; (ii) randomization that extends the early failure time T for slowly responding subjects; and (iii) virological response that assigns non-responders a failure time of 0 weeks. Endpoint differences are illustrated with Agouron's trial 511.

RESULTS

In comparing high with low-dose nelfinavir (NFV) regimens in Agouron 511, the difference in Kaplan-Meier estimates of the proportion not failing by 24 weeks is 16.7% (P = 0.048), 6.5% (P = 0.29) and 22.9% (P = 0.0030) for endpoints (i), (ii) and (iii), respectively. The results differ because NFV suppresses virus more quickly at the higher dose, and the endpoints weigh this treatment difference differently. This illustrates that careful consideration needs to be given to choosing a primary endpoint that will detect treatment differences of interest.

CONCLUSION

A time from randomization endpoint is usually recommended because of its advantages in flexibility and sample size, especially at interim analyses, and for its interpretation for patient management.

Toxicity and repellency of borate-sucrose water baits to Argentine ants (Hymenoptera: Formicidae)

The oral toxicity of boron compounds to the Argentine ant, Linepithema humile (Mayr), was evaluated in laboratory tests. The ants were provided 25% sucrose water containing 0.5 and 1% boric acid, disodium octaborate tetrahydrate, and borax. Lethal times of these solutions were a function of the concentration of boron. In field tests, the ants showed no discrimination between disodium octaborate tetrahydrate and boric acid. There was a significant reduction in consumption of sucrose water with > 1% boric acid.

Teaching prevention in pediatrics

Pediatrics has attempted to inculcate the "culture of prevention" into practice, both through anticipatory guidance in well-child care and through behavioral interventions in sick care. The effectivenesses of many components of well-child care have not been conclusively demonstrated, particularly in health education, counseling, and anticipatory guidance, nor has teaching prevention in pediatrics been thoroughly evaluated. This article reviews methods of teaching prevention in pediatrics and highlights innovative programs. Teaching programs use the wide range of approaches now common in medical education, in a variety of inpatient and outpatient sites. Programs across the country are trying new approaches to teaching traditional topics or are introducing new topics into their curricula. Examples of specific programs are given, organized by the themes of the programs. The field needs to develop in three major directions. First, there is a need to develop competencies and curricula in prevention issues of contemporary importance, including the new morbidities, cross-cultural issues, cost-effectiveness, quality of care, and practice in managed care and other community settings. Second, further work is needed to evaluate programs and measure educational outcomes. This feedback must in turn be used to redefine competencies, curricula, and programs, Third, there needs to be an accessible clearinghouse, and educational tools need to be disseminated. To be effective, a curriculum for prevention in pediatrics cannot stand alone, but must be part of a vertically and horizontally integrated curriculum. Further, creating horizontally and vertically integrated curricula in prevention teaching across disciplines should be the standard.

Argentine ant (Hymenoptera: Formicidae) trail pheromone enhances consumption of liquid sucrose solution

We investigated whether the Argentine ant, Linepithema humile (Mayr), trail pheromone, Z9-16:Ald, could enhance recruitment to and consumption of liquid sucrose solutions. All tests were done as paired comparisons with a 10% sucrose solution as food. In the laboratory, mixing 20 microl of a 10-microg/ml solution of the pheromone with 50 microl of the 10% sucrose solution increased the number of ants feeding by >150%. In a field test, we combined the trail pheromone with a 10% sucrose solution in 50-ml vials. These vials were covered with a plastic membrane that has 1.5-mm-diameter holes punched uniformly across its surface. Ants could drink from the holes after the vials were inverted. For half of the vials, 1 microg of the pheromone was put onto the plastic membrane before the vials were filled with a 10% sucrose solution. The remaining vials had no pheromone on the plastic membrane. After 4 h we measured the consumption in each vial. Bait consumption with the pheromone was enhanced by 29%. In a 2nd series of tests, vials were left outside for 24 h. The consumption rate was 33% higher with the pheromone compared with the controls that didn't have pheromone.

Calf augmentation using free TRAM flap

Augmentation of the calf for correction of contour deformities has been most frequently performed utilizing silicone implants. Results of such implants have often been unsatisfactory. We report the case of a 27-year-old woman who chose the use of a transverse rectus abdominis myocutaneous (TRAM) free flap for correction of a left calf contour deformity from childhood polio. This is the first report of calf augmentation with the use of a TRAM free flap and excellent results were obtained.