Secondary prevention of diabetes through workplace health screening

Background

Workplace health screening offers a unique opportunity to assess individuals for type 2 diabetes mellitus.

Aims

To evaluate the association between workplace diabetes screening, subsequent diagnosis and changes in fasting plasma glucose (FPG), glycated haemoglobin (HbA1c) and body mass index (BMI) among individuals who screened positive for diabetes.

Methods

Employees without a prior diagnosis of diabetes participated in workplace health screening by 45 employers throughout the USA. Individuals screened positive for diabetes based on standard criteria (≥126 mg/dL FPG or ≥6.5% [48 mmol/mol] HbA1c). Diabetes diagnoses were identified after screening using claims-based ICD9-CM diagnosis codes. Discrete-time survival analysis estimated the monthly rate of new diabetes cases after screening, relative to the time period before screening. Paired t-tests evaluated 1-year changes in blood glucose measures and BMI among individuals with positive screenings.

Results

Of 22790 participating individuals, 900 (4%) screened positive for diabetes. A significantly greater rate of new diabetes diagnoses was observed during the first month after screening, compared to the 3-month period before screening (odds ratio [OR] 2.65, 95% confidence intervals [CIs] 2.02-3.47). Among 538 individuals with diabetes who returned for workplace screening 1 year later, significant improvements were observed in BMI (mean ± SD = -0.63 ± 2.56 kg/m2, P < 0.001) and FPG levels (mean ± SD = -9.3 ± 66.5 mg/dL, P < 0.01).

Conclusions

Workplace screening was associated with a reduction in the number of undiagnosed employees with diabetes and significant improvement in FPG and BMI at 1-year follow-up.

Relationship between chronic conditions and patient satisfaction with managed care

The objective of this study was to compare the level of satisfaction among members with and without chronic health conditions (asthma, diabetes, hypertension, and elevated plasma lipoprotein) in a large California managed care organization. One year's worth of member satisfaction survey data was analyzed. Results showed that a high percentage of members were satisfied with the health plan and with their access to care. Members with chronic conditions were significantly more satisfied with their access to care than were members without such conditions.

Adherence to asthma controller medication regimens

BACKGROUND

Improved adherence to inhaled corticosteroids (ICS) is recognized as an important factor in reduced morbidity, mortality and consumption of health care resources. The present study was designed to replicate previous reports of patient adherence with fluticasone/salmeterol in a single inhaler (FSC), fluticasone and salmeterol in separate inhalers (FP+SAL), fluticasone and montelukast (FP+MON), fluticasone alone (FP) and montelukast alone (MON).

METHODS

A 24-month observational retrospective study was conducted using administrative claims data. Subjects were 12 years old with 24 months of continuous enrollment; had 1 asthma claim (ICD-9: 493), 1 short-acting beta(2)-agonist claim, and 1 FSC, FP, SAL, or MON claim. Outcomes included asthma medication refill rates and persistence measured by treatment days. This study was designed with a unique population of patients with asthma from different health plans to validate previous findings.

RESULTS

A total of 3,503 subjects were identified based on their index medication: FSC (996), FP+SAL (259), FP+MON (101), FP (1254) and MON (893). Mean number of prescription refills for FSC (3.98) was significantly higher than FP (2.29) and the FP component of FP+SAL (2.36), and FP+MON (2.15), P<0.05. No significant differences were observed between FSC and MON fill rates (4.33). Mean number of treatment days was greater for FSC compared to FP, FP+SAL, and FP+MON (P<0.0001).

CONCLUSION

This study confirms a previous report that adherence profiles of fluticasone and salmeterol in a single inhaler are significantly better when compared to the controller regimens of fluticasone and salmeterol in separate inhalers, fluticasone and montelukast, or fluticasone alone and similar to montelukast alone.

Cardiovascular disease risk stratification and comparison in a California population

This study was designed to identify the need for primary prevention of cardiovascular disease in an HMO population and to develop appropriate interventions for individuals in different risk groups, based on risk stratification and comparison. The analysis is based on a cross-sectional survey of the HMO members of a large employer group. Respondents (n=17,878) were stratified based on the Framingham model; 34% of respondents without cardiovascular disease were classified as moderate to high attributable risk for the disease, and 66% were classified as low attributable risk. Results of logistic regression analyses suggest that, compared with respondents with pre-existing cardiovascular disease, moderate- to high-risk respondents are more likely to smoke, have unhealthy diets, and be overweight, hypertensive, and hypercholesterolemic. More low-risk respondents had unhealthy diets than did those with pre-existing cardiovascular disease. There were no differences between these groups for physical activity and stress. Respondents had fewer modifiable risk factors and healthier lifestyles than did those who were at risk. These findings suggest that primary prevention should be enhanced, especially among those with significantly increased risk for the disease. Moreover, the approaches of this project-population-based risk assessment, stratification, and comparison-were instrumental in identifying the target population and designing appropriate interventions. (c) 2001 by CHF, Inc.

Comparison of prevalence, cost, and outcomes of a combination of salmeterol and fluticasone therapy to common asthma treatments

OBJECTIVES

To compare a combination of salmeterol and fluticasone with common asthma pharmacologic regimens used in real-world clinical practice, and to evaluate the associated costs and outcomes of care.

STUDY DESIGN

Cross-sectional examination of medical and pharmacy claims.

METHODS

The study population included 33,939 adult asthmatics (at least 12 years of age) continuously enrolled in 1 of 4 participating health plans for the 6-month study period. Every subject was in 1 of 10 different pharmacotherapy treatment groups. Univariate and multivariate analyses were used to compare the rates and costs of pharmaceutical prescriptions and medical care services between patients on salmeterol plus fluticasone and patients with other pharmacologic therapies.

RESULTS

About 60.4% of the patients were on single controllers; the balance was on short-acting beta 2-agonists alone (23%) or double controllers (16.8%). The average overall cost of asthma care was approximately $228 per patient over the 6 months of the study. Pharmaceutical cost was the major cost driver, which was significantly lower for single-controller (mean = $134) than for double-controller therapies (mean = $325). However, total costs were $50-$200 lower (P < .029) for patients on salmeterol plus fluticasone and inhaled steroids plus mast cell stabilizing agents than for those on other double controllers.

CONCLUSIONS

Single-controller regimens and short-acting beta-agonists were less costly than double-controller regimens. Within the double-controller groups, salmeterol plus fluticasone appeared to be less costly than other double controllers, except inhaled steroids plus mast cell stabilizing agents.

Improving the quality of care of patients with asthma: the example of patients with severely symptomatic disease

The increasing economic burden of asthma care is incurred partly by patients with more severe symptoms. However, little is known about the characteristics of these severe asthma patients. This study examined sociodemographic, disease-specific characteristics and health care utilization that are related to asthma disease severity, for the purpose of identifying areas for treatment improvement. A total of 2927 asthma patients (12 years or older), who were continuously enrolled in one of three participating health plans for a 6-month study period and who responded to an asthma survey, were included in the study. Univariate and multivariate analyses were performed to examine the sociodemographic, disease-specific characteristics and health care utilization by asthma severity. About 25% of the patients reported experiencing severe asthma symptoms. They were more likely to be African-Americans, Hispanics, women, patients with less than a college education, residents in the south-west, current smokers, and those receiving care from non-specialists. Severe asthmatics reported having less of an understanding of the clinical manifestation of asthma and the means to manage asthma exacerbation. Outpatient contacts did not differ significantly between severe and other patients, although their utilization of emergency room and inpatient care was significantly greater. This study suggests that a significant proportion of asthma patients is experiencing severe symptoms and barriers other than access to care prevent appropriate control of asthma. Poor control appears to be related to smoking, deficits in knowledge about self-care, not receiving medical care from a specialist, and inadequate use of medications.

Mammography utilization among california women age 40-49 in a managed care environment

OBJECTIVE

To examine the utilization of screening mammography and the relationship between risk factors and mammography use in women age 40-49 in a managed care environment.

DESIGN

Retrospective observational study based on a mailed survey.

SETTING

A large HMO in California.

PATIENTS/PARTICIPANTS

The study population included respondents age 40-49 who completed a breast health assessment questionnaire mailed to all women age 34-49 and enrolled in a California HMO in early 1997.

MAIN RESULTS

About 67.6% of the 20,391 women age 40-49 had at least one mammogram during 1995 and 1996. Logistic regression revealed that women age 40-44 were less likely (odds ratio: 0.83-0.90) than women age 45-49 to obtain mammography. Family history of breast cancer (odds ratio: 1.12-1.16), breast biopsy (odds ratio: 1.14-1.18), and a mammogram in the previous three years (odds ratio: 1.15-1.18) were associated with an increased likelihood of taking a mammogram. However, monthly breast self-exams (odds ratio: 0.996-1.04), having a child at or after age 30 (odds ratio: 0.97-1.02), and having menarche at age 12 or younger (odds ratio: 0.96-1.01) had no significant effect on the screening mammography rates.

CONCLUSION

A relatively higher percentage of younger HMO members receive screening mammography than that of general population. However, some higher-risk groups, especially women whose first pregnancies were late in life, do not show a higher rate of using mammography.

Examining the use of breast-conserving treatment for women with breast cancer in a managed care environment

At a National Institutes of Health Consensus Conference in 1991, conservation treatment was considered preferable for patients with early-stage breast cancer. In the early and mid-1990s, however, less than half of the eligible patients received this treatment and the rates varied with patient and provider characteristics. This study explores whether more eligible patients with breast cancer received conservation treatment in recent years in a managed care environment compared to reports in the literature, and if patient and hospital characteristics affected the rate of acceptance. The study population included 753 women with breast cancer in clinical stages 0, I, or II. Patients with Stage III or IV tumors or with tumors larger that 5.0 cm were excluded. A multiple logistic regression incorporated in a mixed-effect model was used to estimate the effect of patient and facility characteristics on the likelihood of using breast-conserving surgery controlling for clinical stages and demographics such as age, race, and marital status. Among the 753 eligible patients, 474 (62.9%) received conservation surgery. Only Hispanic ethnicity and clinical stage significantly affected the likelihood of receiving conservation treatment. Factors such as patient age, hospital size, and teaching status that had been found to be significant predictors in earlier studies were not statistically significant in this study, although conservation treatment was more frequent in younger women and in teaching hospitals. A larger proportion of eligible patients received conservative treatment in this study than in previous reports. This treatment became available in a broader range of institutions, moving from large, academic teaching centers to smaller community hospitals.

Outcomes of a population-based asthma management program: quality of life, absenteeism, and utilization

BACKGROUND

Despite the availability of the National Asthma Education Program (NAEP) guidelines since 1991, asthma remains inadequately managed. To improve quality of life, functional status, and self-management behavior of asthma patients, a large health maintenance organization (HMO) in California implemented an asthma management program in 1996.

OBJECTIVE

To evaluate the effectiveness of an asthma management program in an HMO setting.

DESIGN AND SETTING

Prospective study. Survey data from members who participated in the intervention program and data from members who received usual care were analyzed using propensity score technique.

RESULTS

A total of 1,043 asthma patients who responded both baseline and follow-up survey were included in the analysis. From baseline to followup, participants in the in-home intervention program reported significant improvement in functional status (improvements range from 0.2 to 7.2), daily use of steroid inhaler (+4.1%), daily peak flow meter use (+6.4%), self-reported knowledge of what to do for an asthma attack (+12.4%), and feeling that their asthma was under control (+10.8%). Absenteeism (-11.8%) and hospitalization due to asthma (-3.5%) were significantly reduced from baseline to follow-up. Participants did not report significant changes in overuse of beta2-agonists and emergency room visits due to asthma. In comparison with the asthmatic patients who received usual care (non-participants), participants had significantly greater improvement on daily use of steroid inhaler (+4.0% versus -6.0%), daily use of home peak flow meter (+6.4% versus 1.9%) and self-reported knowledge on what to do for an asthma attack (+12.4% versus +5.4%).

CONCLUSION

These findings suggest that population-based programs can improve functional status, increase self-monitoring and knowledge about asthma, and decrease absenteeism and hospitalization for asthma by directly providing asthmatic patients with educational materials and self-monitoring tools. Such "direct-to-consumer" outreach programs may help bridge the gap between NAEPs 1991 practice guidelines and the reality of current asthma management.

Variation in managing asthma: experience at the medical group level in California

OBJECTIVE

To explore the degree of variation in the quality of asthma management among physician groups participating in a managed care network.

STUDY DESIGN

Cross-sectional observation.

PATIENTS AND METHODS

The study population consisted of patients with moderate or severe asthma identified through a pharmacy database from a managed care plan in 1996. The patients were surveyed to obtain their assessments of asthma care, including components on quality of care, quality of service, and outcomes of care. We selected 47 physician groups that provided services for at least 35 asthma patients who responded to the survey. Variations in the outcome variables across physician groups were described by quartile, range, and histogram.

RESULTS

Compliance with national guidelines varied among physician groups but was generally low. Physician group rates for patient use of steroid inhalers ranged from 10.7% to 45.5% and daily peak flow meter use ranged from 0% to 13.1%. Satisfaction ratings were higher, with overall satisfaction with the quality of asthma care ranging from 74.6% to 94.3%. Outcomes also showed considerable variation among groups. One-month absenteeism rates ranged from 32% to 61%, and 65.7% to 94.3% of respondents did not have an emergency room visit in the past year.

CONCLUSION

The quality of asthma care and service varied significantly across physician groups. Such reports for different physician groups make evidence-based outcomes information directly available to patients and physician groups, help patients make informed healthcare decisions, and stimulate quality improvement efforts by physician groups.

Disenrollment from an HMO and its relationship with the characteristics of Medicare beneficiaries

To examine the relationship between Medicare beneficiaries' characteristics and disenrollment, a longitudinal study was conducted in an HMO in California. Approximately 10 percent of the Medicare beneficiaries disenrolled within the first year of enrollment. There was no difference between those who continuously enrolled and those who disenrolled in terms of age, gender, mental and physical health status, previous utilization, and anticipated utilization in the coming year. However, people with limited social activities and people not living in a single-family house were more likely to disenroll. The authors also examined the disenrollment rates among physicians groups. The rates were significantly different.

Diabetes and disenrollment in a health maintenance organization setting: a 4-year longitudinal study with a matched cohort

OBJECTIVE

The increasing enrollment of Medicare beneficiaries in health maintenance organizations (HMOs) in recent years has caused concern about whether HMOs and their providers have created an unfavorable environment for members who are chronically ill. This study was designed to examine whether there are any differences in disenrollment rates among enrollees with diabetes and enrollees without diabetes.

RESEARCH DESIGN AND METHODS

This was a 4-year longitudinal follow-up study with a matched cohort. Medicare beneficiaries (aged > or =65 years) with diabetes identified through pharmacy records in 1994 were matched with a comparison group according to age, sex, comorbidities, and type of provider groups in an HMO in California.

RESULTS

The overall distribution of the characteristics of members in the diabetic and matched nondiabetic group is almost identical. The matched-pair chi2 tests indicated that there were no statistical differences in disenrollment rates between diabetic and nondiabetic members during all three follow-up periods (P = 0.16-0.85).

CONCLUSIONS

We found that the HMO members with diabetes did not disenroll from the HMO at a higher rate than those without diabetes. The findings should alleviate some of the concern that HMOs and their contracted providers have created an unattractive environment for members who have chronic diseases such as diabetes.

Compliance with US asthma management guidelines and specialty care: a regional variation or national concern?

The objective of this study was to examine the compliance with the National Asthma Education Program (NAEP) guidelines among asthmatic members of eight health plans (regions) in seven states, as well as the factors related to the compliance. Information was gathered by means of a cross-sectional survey in a managed care environment. The participants were 6703 respondents (ages 14-65) with moderate or severe asthma. The main outcome measures were compliance with the NAEP guidelines on the use of inhaled steroids, inhaled beta2-agonists, peak flow measurement, and allergy evaluations. Among the results of this survey we found that although these health plans are located from the West Coast to the East Coast and the socioeconomic status of their members varied greatly, compliance with the NAEP guidelines was low among asthmatic members across all geographical regions. The major areas of low compliance identified were inappropriate pharmacological therapy, lack of objective measurement of lung function through peak flow meter, and insufficient environmental trigger control. The regression analyses indicated that the effect of the health plan explained little of the variation in compliance across these regions (only 0.3% at maximum). Low compliance was associated with young age, smoking, moderate asthma, being asthmatic for a few years, currently working, and being treated by a generalist rather than a specialist. In conclusion, this study showed that the compliance with the national guidelines for asthma care was consistently low across different geographical regions in the nation. Improvement in care for asthmatics will require greater commitment and involvement by all stakeholders including physicians, patients, health plans, and employers. We suggest a need for a national strategy to disseminate clinical guidelines not only to the medical community but also to patients themselves.

Effect of multiple patient reminders in improving diabetic retinopathy screening. A randomized trial

OBJECTIVE

To determine whether multiple mailed patient reminders can produce an increase in the rate of diabetic retinal examinations (DRE) over that seen with a single reminder.

RESEARCH DESIGN AND METHODS

All diabetic members > or = 18 years who were enrolled in a large network-based health maintenance organization (HMO) in California from August 1996 to July 1997 were identified using claims and pharmacy databases. Members who had no record of DRE in the HMO's claims database were then randomized into two groups. Both groups received mailed educational materials and a reminder to obtain the examination. Their physician groups also received a letter explaining the program, current guidelines for DRE, and a list of their diabetes patients with their DRE status. The single intervention group received no additional reminders. The multiple intervention group received additional reminders at 3, 6, and 9 months after baseline if they continued with no record of service, as determined from the claims database.

RESULTS

The study cohort comprised 19,523 diabetic members, which were randomized into single (n = 9,614) and multiple (n = 9,909) intervention groups. There was an increase in monthly DRE rates after the intervention in August 1996 for both intervention groups. After the second reminder was sent to the multiple intervention group, the percentage of diabetic members receiving DRE was higher than the single intervention group. Rates before and after the third intervention were not significantly different, nor were monthly differences found. There was a significant difference in overall annual DRE rates between the groups (P = 0.023).

CONCLUSIONS

Multiple patient reminders are more effective than single reminders in improving DRE rates in a managed care setting. However, the improvement noted was clinically small and appeared only after the second reminder; no incremental improvement was seen with additional reminders. Resources used for multiple reminders aimed at diabetic retinopathy might better be spent on other approaches to reducing complications of diabetes.

Expression of risk factors for breast cancer in women younger than 49

The definition of women younger than 49 who are at increased risk for breast cancer would enable intensified efforts in surveillance and use of preventive measures for this group. In this survey of 32,123 members of Health Net, an increased risk for breast cancer was related to age, breast cancer in the immediate family (mother, sister), and previous biopsies for cystic lesions of the breast. No increased risk was related to menarche, nulliparity, first pregnancy after age 30, or breast feeding.

Patients with newly diagnosed carcinoma of the breast: validation of a claim-based identification algorithm

The objectives of this study were to validate a claims-based algorithm for identification of patients with newly diagnosed carcinoma of the breast and to optimize the algorithm. Claims data from all females aged 21 years or older who enrolled in a large California health maintenance organization during the study period from October 1, 1994 through March 31, 1996 were analyzed. Medical records of the patients identified through the claims-based algorithm were reviewed to determine whether the patients were correctly identified. The initial algorithm had a positive predictive value of 84% which was similar to the previous study. The percentages of correct identification significantly increased with the patient's age at diagnosis. Other patient demographic characteristics and facility characteristics were not related to the accuracy of the identification. Using a classification tree procedure and additional information from the false-positive cases, the initial algorithm was modified for improvement. The best-modified algorithm had a positive predictive value of 92% while only 0.5% (4/837) of the true-positive cases were excluded. The results once again demonstrated that patients with newly diagnosed carcinomas of the breast can be identified using claims data. These databases provide an efficient and effective tool for performing health services studies on large patient populations.

Preventive pharmacologic therapy among asthmatics: five years after publication of guidelines

BACKGROUND

Guidelines from the National Heart, Lung, and Blood Institute first published in 1991 have recommended anti-inflammatory (AI) agents as a first-line therapy and the bronchodilator as an acute reliever of symptoms.

OBJECTIVE

To examine the current usage of anti-inflammatory steroids (inhaled corticosteroids, Cromolyn, systemic steroids) and bronchodilators and compare them with the national guidelines. The relationship between preventive AI usage and the characteristics of the asthma patients and their providers was also examined.

METHODS

Cross-sectional survey data linked with 6-month pharmacy claims of asthmatic members at an HMO in California.

RESULTS

AI usage increased with current severity (mild, 36.9%; moderate, 47.3%; and severe, 56.8%), though a large percentage are not receiving this emphasized treatment. Bronchodilators were used at a higher rate and 24% of asthmatics relied solely on bronchodilators. Use of bronchodilators without AI (BWAI) was present at all severity levels (mild, 19.5%; moderate, 24.6%; and severe, 24.7%). Advancing age, increasing severity, care by an asthma specialist, and not smoking increased the likelihood of using AIs. Increasing severity, longer duration of asthma, smoking, younger age group, care by a generalist, and no chronic bronchitis increased the likelihood of BWAI.

CONCLUSIONS

These results suggest that there is a low level of AI usage despite emphasis in guidelines. Current asthma management in a community-based setting depicts a significant underutilization of long-term control agents and, conversely, an overutilization of symptom relief agents compared with guidelines published 5 years ago. Actively involving patients in the guideline dissemination process, rather than just the medical community, may increase preventive medication usage.

Axillary node dissection in ductal carcinoma in situ

Intraductal carcinoma of the breast has become a well-defined entity that has been more frequently diagnosed since the introduction of mammography. For many years, the usual treatment has been mastectomy, often with axillary lymph node dissection. Concurrent with documentation that breast conservation treatment has been effective for many invasive breast cancers, such treatment has been introduced for noninvasive breast cancers (ductal carcinoma in situ and lobular cancer in situ). However, there is no basis for axillary dissection because tumor cells are contained by the basement membrane and should not metastasize. In this study, 107 axillary dissections were carried out, with an average of 20 nodes identified, and a single metastasis was identified.

Compliance with national asthma management guidelines and specialty care: a health maintenance organization experience

BACKGROUND

To improve asthma disease management, the National Asthma Education Program (NAEP) Expert Panel published Guidelines for the Diagnosis and Management of Asthma in 1991.

OBJECTIVES

To compare the current status of asthma disease management among patients in a large health maintenance organization with the NAEP guidelines and to identify the factors that may be associated with medical care (eg, emergency department visits and hospital admissions) and adherence to the guidelines.

METHODS

Analyses of 1996 survey data from 5580 members with asthma (age range, 14 to 65 years) covered by a major health maintenance organization in California (Health Net).

RESULTS

In general, adherence to NAEP guidelines was poor. Seventy-two percent of respondents with severe asthma reported having a steroid inhaler, and of those, only 54% used it daily. Only 26% of respondents reported having a peak flowmeter, and of those, only 16% used it daily. Age (older), duration of asthma (longer), increasing current severity of disease, and treatment by an asthma specialist correlated with daily use of inhaled steroids. Ethnicity (African American and Hispanic) correlated negatively with inhaled steroid use but positively with emergency department visits and hospital admissions for asthma. Increasing age and treatment by an asthma specialist were also identified as common factors significantly related to the daily use of a peak flowmeter and, interestingly, to overuse of beta2-agonist metered-dose inhalers.

CONCLUSIONS

Although the NAEP guidelines were published 7 years ago, compliance with the guidelines was low. It was especially poor for use of preventive medication and routine peak-flow measurement. Furthermore, the results showed that asthma specialists provided more thorough care than did primary care physicians in treating patients with asthma. Combining the results of the regression analyses revealed that some of the variation in rates of emergency department visits and hospitalizations among some subpopulations can be explained by the underuse of preventive medication. This study serves the goal of documenting the quality of care and services currently provided to patients with asthma through a large health maintenance organization and provides baseline information that can be used to design and assess effective population-based asthma disease management intervention programs.

Hospital- and patient-related characteristics determining maternity length of stay: a hierarchical linear model approach

OBJECTIVES

The purpose of this study was to identify factors related to pregnancy and childbirth that might be predictive of a patient's length of stay after delivery and to model variations in length of stay.

METHODS

California hospital discharge data on maternity patients (n = 499,912) were analyzed. Hierarchical linear modeling was used to adjust for patient case mix and hospital characteristics and to account for the dependence of outcome variables within hospitals.

RESULTS

Substantial variation in length of stay among patients was observed. The variation was mainly attributed to delivery type (vaginal or cesarean section), the patient's clinical risk factors, and severity of complications (if any). Furthermore, hospitals differed significantly in maternity lengths of stay even after adjustment for patient case mix.

CONCLUSIONS

Developing risk-adjusted models for length of stay is a complex process but is essential for understanding variation. The hierarchical linear model approach described here represents a more efficient and appropriate way of studying interhospital variations than the traditional regression approach.

Validity of clinical information from a maternity survey

This research was designed to validate data collected through a survey--an inexpensive way to provide information for quality measurement. The survey was sent to health maintenance organization (HMO) enrollees who had given birth(s) between October 1, 1994, and May 31, 1995. The responses were compared with the medical records. A sample of 407 women was randomly selected from the completed surveys. Medical records were reviewed for 89.9% (362/407) of the sample based on medical record availability. Over 98% of responses agreed with the medical record information regarding whether there were cesarean sections for previous deliveries (kappa = 1.0), cesarean section for recent delivery (kappa = 0.95), and vaginal birth after cesarean section (kappa = 0.96). Over 99% of the mothers agreed with the information regarding whether the newborn birth weight was under 2500 g (kappa = 0.91). The findings strongly support the validation of this instrument. Using this validated instrument enables health plans to cost-effectively obtain crucial information.

Satisfaction with access to and quality of health care among Medicare enrollees in a health maintenance organization

This study was designed to determine the levels and predictors of Medicare enrollees' satisfaction with access to medical care and quality of health care in a health maintenance organization. Data collected by an instrument adapted from the Group Health Association of America's Consumer Satisfaction Survey were analyzed after being linked with administrative data. In general, Medicare enrollees reported high satisfaction with both access to and quality of health care. Most members (96%) rated skill, experience, and training of physicians and the friendliness and courtesy of the staff favorably. A lower percentage of members (77%) rated favorably the ability to contact a physician after hours. Levels of satisfaction were essentially not explained by patient characteristics such as age, sex, geographic region, medications, or utilization. Stepwise regression identified the ease of arranging appointments as the strongest predictor of satisfaction, with access to care and outcomes of medical care as the strongest predictor of overall satisfaction with quality of health care. These findings indicate that items that members rated least favorably, such as ability to contact a physician after hours, added little to the prediction of satisfaction with access to and quality of health care.

An intervention for enhancing compliance with screening recommendations for diabetic retinopathy. A bicoastal experience

OBJECTIVE

To determine whether an intervention at both the provider and patient level can increase the utilization of diabetic retinal examination among diabetic patients and to compare the results from a comparable study conducted on the East Coast.

RESEARCH DESIGN AND METHODS

For the regional intervention study, all diabetic patients 18 years or older who enrolled in a large network-based health maintenance organization (HMO) in California were identified (n = 19,397). The identified diabetic patients received educational materials and a notification of their prior diabetic retinal examination status. Also, their primary care physicians received the current American Diabetes Association (ADA) guidelines for dilated retinal examinations and a list of patients due for diabetic retinal examination.

RESULTS

There were 25 and 27% increases in the percentage of diabetic patients who received diabetic retinal examinations in 1995 compared with the percentages in 1993 and 1994, respectively. The increase in diabetic retinal examinations was most significant after the intervention (odds ratio = 1.4). Furthermore, the improvements in compliance after the intervention were almost identical between the studies implemented on the East and West Coasts.

CONCLUSIONS

This study and the prior study demonstrate that such a "reminder" intervention can improve compliance with diabetic retinal screening recommendations. A generalizable intervention, such as this, may be applicable on a national level. For these programs to be successful, however, HMOs and physicians must have a collaborative relationship.

Identifying predictors of satisfaction with access to medical care and quality of care

Satisfaction with access to medical care and quality of care were compared using a survey instrument adapted from the Group Health Association of America Consumer Satisfaction Survey. Participants were members of a large health maintenance organization employed by an employer group (Company) and other non-company members (Control). Overall, members reported high satisfaction with both access to medical care and quality of care. There were no significant differences in satisfaction between Company and Control respondents. Stepwise regression identified the strongest predictor of satisfaction with access to care as ease of arranging appointments. Satisfaction with quality of care was predicted most strongly by outcomes of medical care. These findings indicate that items with which members are least satisfied (access to doctor after hours, office waiting time, and time for routine appointment) do not predict either satisfaction with access to care or satisfaction with quality of care. Managed care organizations must develop and utilize evidence-based evaluation tools such as this one to assess the quality of care.

Cost of breast cancer treatment. A 4-year longitudinal study

OBJECTIVE

To determine the longitudinal cost of the treatment of patients with breast cancer.

METHODS

An analysis was performed of 200 women with 205 newly diagnosed breast cancers during 1989 in a health maintenance organization population (US Healthcare, Blue Bell, Pa). Medical records and claims data were analyzed for the total costs of medical care during the 4-year period after diagnosis. The costs over time were analyzed for clinical stage and use of mammography screening.

RESULTS

The total costs of medical care during the 4-year period after diagnosis were strongly related to clinical stage at diagnosis, with higher total costs for patients with stages III to IV at diagnosis compared with patients with stages 0 to II at diagnosis. The cost for all stages of disease declined after years 1 to 2, with the exception of stage II, which increased slightly in years 3 to 4. The use of screening mammography was associated with a significant decrease in the cost of medical care during the 4-year study period.

CONCLUSIONS

The goal of mammography screening programs should be to achieve downstaging to stages 0 to 1 to achieve reduction in breast cancer mortality and to reduce the overall consumption of health care resources for the treatment of breast cancer. These cost data should be considered within the framework of future cost-effective analysis for screening mammography programs.

Quality of outpatient care provided to diabetic patients. A health maintenance organization experience

OBJECTIVE

To document the quality of diabetes care provided to patients in a large health maintenance organization (HMO) from 1 January 1993 to 1 January 1994 and compare it to the standards of the American Diabetes Association (ADA).

RESEARCH DESIGN AND METHODS

To meet a Health Plan and Employer Data Information Set (HEDIS) requirement, a major HMO in California identified 14,539 members with diabetes and randomly selected 384 individuals for review. Charts were available on 353 of these patients, and after obtaining the information for the HEDIS review, additional information was extracted from the charts by an outside chart reviewer. This data set was used for an analysis of the quality of diabetic care provided by the participating medical groups to these HMO members during 1 year. Documentation of follow-up and measures of glycemic and lipid control was examined both for absolute values and for the frequency of measurement over the year. These results were compared to the ADA standards of care.

RESULTS

Although patients averaged 4.5 visits to their primary care physicians (PCPs) over the year, 21% had one or fewer visits per year. Glycated hemoglobin levels were not documented in 56% of patients (ADA recommends two to four measurements per year), and of those with a glycated hemoglobin level measured. 39% had at least one value > or = 10%. Fasting plasma glucose concentrations were not documented in 65% of patients (four to six per year recommended). Foot exams (which should be performed at each regular visit) were not documented for 94% of patients. Urine protein measurements were not performed in 52% of patients. Additionally, many patients had elevated and untreated lipid abnormalities.

CONCLUSIONS

In spite of the frequency of PCP visits during the year for many of these patients, diabetes management was inadequate. This lack of adequate preventive care will lead to an increased risk of the development of the acute and chronic complications of diabetes, creating an even greater future burden on the health care system and negative consequences for patients.

Increased ERCP rate following the introduction of laparoscopic cholecystectomy

Over the past 5 years there has been a remarkable change in the manner in which symptomatic gallstones are surgically managed. In this study we reviewed the experience of a large HMO to determine the relationship between the rate of increase of ERCP and that of cholecystectomy. All individuals enrolled in US Healthcare's HMO-PA, in the region of southeastern Pennsylvania from 1988 through 1993, were included in the analysis. Using the HMO claims database, patients who underwent an open or laparoscopic cholecystectomy during the study period were identified. We then identified those patients who had a pre- or post- operative ERCP. Over the study period, there has been a substantial increase in cholecystectomies per 1000 members-from 1.37 in 1988 to 2.16 (p < 0.0001) in 1993. In our study population there were 1261 ERCPs performed in 979 patients with an average of 1.3 ERCPs per patient during the study period. The ERCP rate per 1000 members has increased from 0.16 to 0.56 (p < 0.0001) from 1988 to 1993, at the same time that the cholecystectomy rate was substantially increasing. The correlation for the ERCP and cholecystectomy rates from 1988 to 1993 was 0.994 (p < 0.0001). Since the introduction of laparoscopic cholecystectomy in 1989-1990, many more ERCPs are now being performed. It is necessary to determine the implications related to the rapid diffusion of laparoscopic cholecystectomy, including the effect that this technology has had on other older and stable technologies such as ERCP. Our results describe the dramatic effect that laparoscopic cholecystectomy has had on the utilization of ERCPs.

Increased cholecystectomy rate after the introduction of laparoscopic cholecystectomy

OBJECTIVE

To examine if overall cost savings may fail to result from laparoscopic ("closed") cholecystectomy if it also results in an increased total rate of cholecystectomies or generates additional costs unassociated with the open procedure.

OUTCOME MEASURES

Inpatient and outpatient expenditures, incidence rates, and length of inpatient stay data for 6909 health maintenance organization enrollees with gallbladder complaints were analyzed from 1988 through 1992 using claims data from a large, private practice-based health maintenance organization.

RESULTS

The incidence of cholecystectomy and total health maintenance organization expenditures on gallbladder disease have increased since the introduction of laparoscopic closed cholecystectomy. The rate of cholecystectomy procedures per 1000 enrollees increased from 1.35 in 1988 to 2.15 in 1992 (P < .001). Total annual medical expenditures on gallbladder disease per 1000 enrollees (in 1992 dollars) rose 11.4% during the study period (P < .001), despite a concurrent 25.1% decline in the unit cost (physician and hospital cost) for cholecystectomy procedures (P < .001). During the same study period, no significant change was noted in the rate of appendectomy per 1000 enrollees (0.76 in 1988 to 0.73 in 1992), which is a measure of nonelective surgical care, or in the inguinal hernia repair rate (2.01 in 1988 to 2.19 in 1992), which has a physician and patient discretionary component similar to that of cholecystectomy.

CONCLUSIONS

The introduction of laparoscopic gallbladder surgery resulted in rising rates of cholecystectomy for a population of patients in a private, independent practice-based health maintenance organization. Such a rise was not seen for hernia repair surgery or appendectomy. It seems that the use of laparoscopic cholecystectomy, a new technology touted as reducing health care costs, may result in an increased consumption of health care resources due to changes in the indications for gallbladder surgery.

Performance-based hospital contracting for quality improvement

A carefully negotiated process that ties improvements in performance to additional compensation can align incentives and support efforts to improve care. Such a process needs to be objective, data-driven, and focused on issues that are important both to the purchaser and to the provider.