Sexually Transmitted Diseases and Managed Care: An Inquiry and Review of Issues Affecting Service Delivery

To understand the potential role of managed care organizations (MCOs) in prevention and control of sexually transmitted diseases (STDs), we conducted a systematic review of articles on STDs and managed care and sought qualitative information from MCOs on STD-related activities. The review focused on prevention, risk assessment, patient education, counseling, screening, and costs of care, but revealed relatively few published articles. Barriers to STD service delivery included competing priorities, lack of time or supporting organizational structures, and differing mandates of health departments and MCOs. Facilitators included collaboration between health departments and MCOs, regulatory and performance incentives, buy-in from key stakeholders, availability of infrastructure to support data collection, and inclusion of chlamydia screening in the Health Employer Data and Information Set to monitor plan performance. Because of the shift of STD service delivery from the public to private sector, incentives need to maximize interest and cooperation of patients, clinicians, and MCOs in STD prevention.

Unanticipated benefits of CAM therapies for back pain: an exploration of patient experiences

OBJECTIVES

The goal of this research was to provide insight into the full range of meaningful outcomes experienced by patients who participate in clinical trials of complementary and alternative medicine (CAM) therapies.

DESIGN

Data for this study were assembled from five randomized trials evaluating six different CAM treatments for back pain. A conventional qualitative content analysis was conducted on responses to open-ended questions asked at the end of telephone interviews assessing treatment outcomes.

SUBJECTS

A total of 884 study participants who received CAM therapies completed post-treatment interviews. Of these, 327 provided qualitative data used in the analyses.

RESULTS

Our analysis identified a range of positive outcomes that participants in CAM trials considered important but were not captured by standard quantitative outcome measures. Positive outcome themes included increased options and hope, increased ability to relax, positive changes in emotional states, increased body awareness, changes in thinking that increased the ability to cope with back pain, increased sense of well-being, improvement in physical conditions unrelated to back pain, increased energy, increased patient activation, and dramatic improvements in health or well-being. The first five of these themes were mentioned for all of the CAM treatments, while others tended to be more treatment specific. A small fraction of these effects were considered life transforming.

CONCLUSIONS

Our findings suggest that standard measures used to assess the outcomes of CAM treatments fail to capture the full range of outcomes that are important to patients. In order to capture the full impact of CAM therapies, future trials should include a broader range of outcomes measures.

HIV prevention in primary care: impact of a clinical intervention

Discomfort, lack of confidence in skills, and environmental constraints may cause primary care providers to miss opportunities to discuss human immunodeficiency virus (HIV) risk with patients. We used a systems approach to address both intrapersonal and environmental barriers to HIV risk assessment and prevention counseling in a managed care clinical setting. The design was one-group pretest/posttest. The study took place in two primary care clinics of a large Pacific Northwest managed care organization. Participants (n = 49) included physicians, physician assistants, nurse practitioners, registered nurses, and social workers. The intervention included training, clarification of provider/staff roles, assess to tools and materials, and reminders/reinforcers. Outcome measures were provider attitudes, beliefs, outcome expectations, knowledge, confidence in skills, and perceived supports and barriers, measured by written pretest/posttest surveys administered 12 months apart. Seven months after the most intensive part of the intervention, providers' attitudes and beliefs were more favorable to HIV risk assessment and prevention counseling. They were less likely to express frustration with high-risk patients (decrease from 100% to 79% agreement, p = 0.001) and more confident that their advice would be effective with gay men and single adult heterosexuals (p = 0.002 and 0.005, respectively). They reported more confidence in their training in sexual history taking (p = 0.0003) and their skills assessing readiness for change (p = 0.007), and more support in practice environments. This study demonstrated that it is possible to affect important personal and environmental factors that influence primary care providers' HIV prevention behavior using an interactive, real-world systems approach. Further research is needed on providers' impact on patient behavior.