Identification and treatment of mental and substance use conditions: health plans strategies

BACKGROUND: Mental health and substance use conditions are under-recognized and under-treated. Private health plans may be able to affect the extent of screening and, thus, identification of enrollees who need treatment. OBJECTIVES: The goals of this study were to determine strategies used by health plans to identify mental health and substance use conditions; and describe the characteristics of health plans associated with use of these strategies. METHODS: In 2003, we conducted a nationally representative survey of private health plans regarding behavioral health services. A total of 368 health plans (83% response rate) provided information about their managed care products: health maintenance organization (HMO), point-of-service (POS), or preferred provider organization (PPO) products (812 in total). MEASURES: We asked whether plans verify primary care providers' screening for mental health or substance use conditions, screen outside of primary care, and distribute practice guidelines. We characterized each product in terms of "carve-out" to a specialty behavioral health vendor, tax status, and region and market area population. RESULTS: Thirty-four percent of products verify primary care providers' screening for mental health, but only 8% verify alcohol or drug screening. Outside of primary care, 31% conduct screening through the mail, phone, or internet. Depression guidelines are distributed to primary care providers by 78% of managed care products: alcohol or drug guidelines are distributed by 33%. In multivariate analyses, specialty contracting was positively associated, and PPO product type was negatively associated with these strategies. CONCLUSIONS: Most health plans use multiple strategies to improve identification of behavioral health conditions, but use of such strategies was greater for mental health than for substance use conditions.     

Chronic care clinics for diabetes in primary care: a system-wide randomized trial

OBJECTIVE: To evaluate the impact of primary care group visits (chronic care clinics) on the process and outcome of care for diabetic patients. RESEARCH DESIGN AND METHODS: We evaluated the intervention in primary care practices randomized to intervention and control groups in a large-staff model health maintenance organization (HMO). Patients included diabetic patients > or = 30 years of age in each participating primary care practice, selected at random from an automated diabetes registry. Primary care practices were randomized within clinics to either a chronic care clinic (intervention) group or a usual care (control) group. The intervention group conducted periodic one-half day chronic care clinics for groups of approximately 8 diabetic patients in their respective doctor's practice. Chronic care clinics consisted of standardized assessments; visits with the primary care physician, nurse, and clinical pharmacist; and a group education/peer support meeting. We collected self-report questionnaires from patients and data from administrative systems. The questionnaires were mailed, and telephoned interviews were conducted for nonrespondents, at baseline and at 12 and 24 months; we queried the process of care received, the satisfaction with care, and the health status of each patient. Serum cholesterol and HbA1c levels and health care use and cost data was collected from HMO administrative systems. RESULTS: In an intention-to-treat analysis at 24 months, the intervention group had received significantly more recommended preventive procedures and helpful patient education. Of five primary health status indicators examined, two (SF-36 general health and bed disability days) were significantly better in the intervention group. Compared with control patients, intervention patients had slightly more primary care visits, but significantly fewer specialty and emergency room visits. Among intervention participants, we found consistently positive associations between the number of chronic care clinics attended and a number of outcomes, including patient satisfaction and HbA1c levels. CONCLUSIONS: Periodic primary care sessions organized to meet the complex needs of diabetic patients imrproved the process of diabetes care and were associated with better outcomes.     

Use of ambulatory health care services in a preferred provider organization

The organization of the delivery of health care can have significant cost-saving implications, but few of the available studies have made adequate comparisons of costs across plans. Furthermore, new organizational types such as independent practice associations and preferred provider organizations have not yet been studied in detail. This paper examines ambulatory utilization in a preferred provider organization (PPO) for Uniformed Services beneficiaries at Pacific Medical Center (PMC) in Seattle. The utilization in the PPO is compared with the results of a recently reported study of three other organizationally different Seattle plans: a Blue Cross/Blue Shield plan (BC), a closed-panel health maintenance organization (HMO), and an independent practice association (IPA). The PPO was similar to the IPA and the HMO in having a high percent of patients with any ambulatory use and had standardized ambulatory costs per user which were lower than BC but higher than the HMO. Thus, this particular type of PPO may have cost-saving features, particularly because the Uniformed Services population is known to use more health services than the general population. Methodological issues for future utilization research across organizations are also discussed.     

Is documentation and quality assessment associated with patient satisfaction in benign prostate hypertrophy?

Generally, in Europe quality assurance is demanded increasingly in health care settings. European Health Act specifies new demands concerning quality assurance through documentation, monitoring of health services and follow-up considering patient flow and optimal use of resources. The aim of this study was to investigate the agreement between European guidelines and clinical practice and the association between patient satisfaction and level of documentation, recommendations and improvements of voiding function in patients with benign prostate hypertrophy (BPH). The study population encompassed men between 60 and 80 years referred to specialist treatment due to lower urinary tract symptoms. Random samples of 250 medical records were extracted from national registers. Indicators were reported as proportions. Bivariate and multivariate analyses were reported as odds ratio with a 95% confidence interval. A total of 178 patient pathways were included, and the overall documentation rate was 77%. Agreement between national recommendations and clinical practice was found in 38%. No significant associations were found regarding patient satisfaction and level of documentation, adherence to national guidelines and improvements of the voiding function. There is a need for stringency in quality assessment and reporting indicators to national databases and increased application of European evidence-based guidelines. More complete are necessary for decision-makers in the future to qualify management of BPH rehabilitation ensuring the quality of the individual patient pathways.     

Costs and survival of patients with colorectal cancer in a health maintenance organization and a preferred provider organization

BACKGROUND: Colorectal cancer is relatively frequent among adults of working age, yet few studies have examined treatment, outcomes, and costs for people under 65 years of age with this disease. OBJECTIVE: The objective of this study was to compare the initial treatments, survival, cancer-related medical costs, and overall medical costs for working-aged persons with colorectal cancer in 2 large health insurance plans in Washington State, one a preferred provider organization (PPO) and the other a group model health maintenance organization (HMO). STUDY POPULATION: This study consisted of patients, aged 20-64 years, diagnosed with colorectal cancer in both health plans from 1996 to 1998. For each cancer case, up to 5 control subjects, matched on age and sex, were selected for the analysis. METHODS: We calculated unadjusted, attributable, and overall medical costs using the Kaplan-Meier sample average estimator. We calculated relative mortality rates using Cox regression. We used propensity scores to adjust overall costs and survival for potential confounding factors. RESULTS: Two hundred ten persons in the PPO and 136 persons in the HMO, aged 20-64 years, were diagnosed with cancer over the observation period and included in this study. Patients in the PPO were more likely to have local excision of their tumor (16% compared with 11%) and were less likely to receive chemotherapy (48% compared with 60%). The overall medical costs for the cancer cases were $46,000 in the HMO and $46,400 in the PPO (95% confidence interval for the difference: -$19,300 to 20,100). The cancer-attributable medical costs over 2 years were $40,400 in the HMO and $44,300 in the PPO (95% confidence interval for the difference: -$17,400 to 25,200). Survival was similar in the 2 health plans: the hazard ratio was 0.89 for those enrolled in the PPO (95% confidence interval: 0.50 to 1.59). Adjustment for potential confounding factors altered the results little. CONCLUSIONS: There were differences in the initial treatment of the patients in each health plan, but costs and survival were not significantly different between the 2 plans.     

Exploring indicators of telephone nursing quality

To explore whether documentation, use of clinical guidelines, and nurse competency are the best indicators of quality telephone nursing, this study examined the relationship between these commonly cited indicators and the characteristics of a telephone nursing call. This study, done at a large health maintenance organization (HMO), found: accompanying symptoms played a major role in telephone nursing assessment; call length was related to documentation process and to number of visits to a health care facility after a call; nurses' interpersonal skills and ability to determine urgency of a call are related to the documentation process but not to outcomes of the call; time of a call is related to disposition; and disposition is related to number of visits after a call.     

Partnership for better patient outcomes: home health and HMO collaboration

This article describes the evolution of a collaborative model of quality improvement between an HMO and six contracted home health agencies using OASIS items to measure patient outcomes. The results showed that when agencies completed quality improvement activities independently, HMO patients' outcomes did not improve substantially. In contrast, when the HMO and agencies collaborated, patient outcomes improved as much as 19% in 1 year. This collaborative model can help purchasers and providers to share responsibility for improvement in patient outcomes.     

How healthy are our emergency departments?

Objective: To demonstrate a comprehensive workplace health survey is able to identify indicators that contribute to staff workplace welfare. Methods: Analysis of a VicHealth workplace health survey distributed to seven suburban emergency departments. Respondents rated multiple workplace health indicators in terms of perceived importance and perceived performance. A satisfaction rating and performance gap for each indicator was calculated. Results: There was a 64% response rate to 500 surveys. Staff rated a safe environment, professional standards, and staff morale the most important factors for workplace health. They were most satisfied with the flexibility of work arrangements (85.6%) and leadership (79.9%), and were least satisfied with the performance management of staff (68.5%) and job satisfaction and morale (67.2%). The largest gaps between perceived importance and performance were in the provision of safe well‐lit parking, staff morale, and the use of reward and recognition systems. Conclusion: The VicHealth survey was an effective tool in identifying indicators that contribute to staff workplace health. Quantifiable findings allowed interdepartmental comparison and may be useful in focusing on improvements in organizational structure.     

Sharing specialist skills for diabetes in an inner city: a comparison of two primary care organisations over 4 years

OBJECTIVE: To evaluate the effects of organizational change and sharing of specialist skills and information technology for diabetes in two primary care groups (PCGs) over 4 years. METHODS: In PCG-A, an intervention comprised dedicated specialist sessions in primary care, clinical guidelines, educational meetings for professionals and a shared diabetes electronic patient record (EPR). Comparison was made with the neighbouring PCG-B as control. In intervention and control PCGs, practice development work was undertaken for a new contract for family doctors. Data were collected for clinical measures, practice organizational characteristics and professional and patient views. RESULTS: Data were analysed for 26 general practices including 17 in PCG-A and nine in PCG-B. The median practice-specific proportions of patients with HbA1c recorded annually increased in both areas: PCG-A from median 65% to 77%, while PCG-B from 53% to 84%. For cholesterol recording, PCG-A increased from 50% to 76%, and PCG-B from 56% to 80%. Organizational changes in both PCGs included the establishment of recall systems, dedicated clinics and educational sessions for patients. In both PCGs, practices performing poorly at baseline showed the greatest improvements in organization and clinical practice. Primary care professionals' satisfaction with access and communication with diabetes specialist doctors and nurses increased, more so in the intervention PCG. Only 16% of primary care professional respondents used the diabetes EPR at least monthly. Patient satisfaction and knowledge did not change. CONCLUSIONS: Improvements in practices' organizational arrangements were associated with improvements in clinical care in both PCGs. Sharing specialist skills in one PCG was associated with increased professional satisfaction but no net improvement in clinical measures. A shared diabetes EPR is unlikely to be used, unless integrated with practice information systems.     

Using theory and evidence to drive measurement of patient,nurse and organizational outcomes of professional nursing practice

An evolving body of literature suggests that the implementation of evidence based clinical and professional guidelines and strategies can improve patient care. However, gaps exist in our understanding of the effect of implementation of guidelines on outcomes, particularly patient outcomes. To address this gap, a measurement framework was developed to assess the impact of an organization‐wide implementation of two nursing‐centric best‐practice guidelines on patient, nurse and organizational level outcomes. From an implementation standpoint, we anticipate that our data will show improvements in the following: (i) patient satisfaction scores and safety outcomes; (ii) nurses ability to value and engage in evidence based practice; and (iii) organizational support for evidence‐informed nursing care that results in quality patient outcomes. Our measurement framework and multifaceted methodological approach outlined in this paper might serve as a blueprint for other organizations in their efforts to evaluate the impacts associated with implementation of clinical and professional guidelines and best practices.     

Request fulfillment in office practice: antecedents and relationship to outcomes.

BACKGROUND: Patients communicate their desires and expectations largely by making requests. However, the antecedents and consequences of request fulfillment have received limited attention. OBJECTIVE: To describe patient and physician characteristics associated with request fulfillment and to understand the consequences of request fulfillment and nonfulfillment on visit evaluations by patients and physicians, self-reported health care use, and health outcomes. DESIGN: Data were gathered from patient and physician surveys administered at several points before and after problem-driven outpatient visits. SETTING: The study was carried out in the office practices of 45 family practice, internal medicine, and cardiology physicians working either in a large multispecialty group practice or in a group-model health maintenance organization. PATIENTS: Data were collected at the index visit from 909 patients (cooperation rate, 68%; net response rate, 32%). A telephone follow-up survey was administered to 887 (98%) of these patients 2 weeks after the visit. MEASUREMENTS: Before the visit, patients provided ratings of their health concerns, physical functioning, role limitations, general health perceptions, and trust in the index physician. After the visit, patients reported on any request that they made, physician responses to these requests, and their satisfaction with care. At the 2-week follow-up evaluation, patients again reported on satisfaction, health concerns, health status, and self-reported postvisit health care use. RESULTS: Patients reported making at least one request in 84% of encounters; requests for medical information, examination, and tests or procedures were most common. Four-fifths of patients who made at least one request reported complete fulfillment of all requests. Perceived request fulfillment was significantly lower among patients with relatively low pr-visit trust in the treating physician. Higher request fulfillment was predictive of more positive patient evaluations of care. Visits in which requests could not be completely fulfilled were rated by physicians as more demanding and less satisfying. Request fulfillment was also positively associated with fewer health concerns and greater symptom improvement at follow up. Nonfulfillment of patient requests did not predict postvisit health care use. CONCLUSIONS: Request fulfillment affects patient and physician satisfaction and perceptions of health outcomes. New approaches that efficiently recognize and respond to patient requests are needed.     

Measuring and Improving Ambulatory Surgery Patients' Satisfaction

The pressure on perioperative services to improve quality for health care consumers creates both challenges and opportunities. To make positive changes, many health care organizations contract with Press Ganey (PG), which processes an extensive database of more than 9.5 million surveys annually and provides benchmark reports to same-type organizations. To measure and improve ambulatory surgery patient satisfaction at one health care network in northeastern Pennsylvania, the nursing leaders in the ambulatory surgery center and OR undertook a quality improvement project focused on educating perioperative nurses on the use of PG reports. After we reviewed the PG reports and implemented changes with nursing staff members in perioperative areas, PG patient satisfaction scores improved regarding information about delays (4.1%) and center attractiveness (0.2%).     

A view of prescriptive practice collaboration: perspectives of psychiatric-mental health clinical nurse specialists and psychiatrists

A majority of states require collaborative prescribing agreements between advanced practice nurses and physicians. Unfortunately, there is limited research describing the collaboration that occurs between the clinicians who have such prescribing agreements. This exploratory study identifies the characteristics, activities, and outcomes of collaboration between psychiatric-mental health clinical nurse specialists (CNSs) with prescribing agreements and their collaborating psychiatrists. Surveys were sent to all the 73 prescribing psychiatric-mental health CNSs identified by the Minnesota Board of Nursing in 1998 and their primary collaborating psychiatrists. Forty-nine CNSs and 32 psychiatrists returned the surveys with 31 matched collaborating dyads identified. Overall satisfaction with the collaborative relationship was high, CNSs (chi = 4.34/5) and psychiatrists (chi = 4.46/5). Good communication, trust, shared goals for patient outcomes, shared professional values, and respect for clinical competency were identified as important characteristics for effective collaboration. CNSs identified increased professional growth and job satisfaction as professional benefits, while psychiatrists reported shared workload responsibilities. Fewer than half of the CNSs and psychiatrists perceived professional liability as a professional constraint. Psychiatric-mental health CNSs and psychiatrists agreed that the continuity of patient care and efficient access to mental health care were patient benefits. The statistically significant differences between the CNSs' and psychiatrists' responses were related to the number of years they had been in practice, the number of years the CNS had been a prescriber, and the length of time the CNS and psychiatrist had worked together within a collaborative prescribing agreement.     

Evidence-based practice for acute low back pain in primary care: patient outcomes and cost of care

Provider adherence with clinical practice guidelines (CPGs) for acute low back pain (LBP) and its impact on clinical outcomes and cost are controversial. A panel and cross-sectional design was used to determine the rate of provider adherence to the Department of Defense/Veteran's Administration CPG for Acute LBP which included ergonomic and psychosocial intervention. The relationship among adherent care, patient satisfaction, general health, functional outcome, and cost was examined. Direct health services and patient survey data 1 year before and 3 years following guideline implementation were analyzed. The sample consisted of 15,789 LBP cases (CPG) and 14,409 upper extremity cases used as controls (no CPG). Ten to 40% of LBP cases received CPG-adherent care across the 4 years. No differences were found between LBP and upper extremity diagnoses groups in the rates of change in the four outcomes over years. Multivariable regression analyses controlling for demographic variables and perceived health indicated that CPG adherence was related to better functional outcomes, Odds ratio (OR)=1.45 [95% CI=1.31-1.60] and lower healthcare costs (beta=-230.15, p<0.001). Cases receiving more adherent care also reported higher levels of patient satisfaction (beta=0.09, p<0.05) and general health, OR=1.44 [95% CI=1.29-1.60]. Higher levels of adherent care which included efforts to address both ergonomic and psychosocial factors in the course of acute back pain were related to better clinical outcomes and lower costs.     

Sumatriptan treatment for migraine in a health maintenance organization: economic, humanistic, and clinical outcomes

This study was undertaken to assess the impact of 12 months of sumatriptan therapy (6 mg subcutaneously) for migraine on health care use, health-related quality of life, productivity, patient satisfaction with the medication, and clinical efficacy in a health maintenance organization (HMO). One hundred forty-eight patients received open-label sumatriptan for 12 months for the treatment of migraine. Medical records were reviewed to obtain information on the frequency of migraine-related health care use during the 12 months before and during sumatriptan treatment. Patients completed questionnaires on their productivity at work, health-related quality of life, and satisfaction with medication at baseline and after 3, 6, and 12 months of sumatriptan treatment. For each migraine, patients recorded pain severity scores before and after taking sumatriptan and the time between dosing and onset of meaningful relief. Sumatriptan was associated with significant reductions in migraine-related use of general outpatient services, telephone calls, urgent care services, and emergency department visits (P < 0.05); a significant increase in the use of pharmacy services (P < 0.05); and significant and sustained improvements in health-related quality-of-life scores compared with baseline (P < 0.001). Patients lost significantly less time from work and were significantly more satisfied with sumatriptan compared with their usual therapy (P < 0.05). Two hours after dosing, 81% of patients experienced reduction of moderate or severe pain to mild or no pain, and 90% of all patients experienced meaningful relief of pain. The use of sumatriptan for 12 months in an HMO was associated with reductions in health care use and improved health-related quality of life, productivity, and patient satisfaction with medication.     

Provision of feedback on perceived health status to health care professionals: a systematic review of its impact

OBJECTIVE: To assess the impact on the process and the outcomes of care of feeding back information on perceived health status to health care professionals in clinical practice. DESIGN: Systematic review of controlled trials. Data identification: Search in electronic databases (MEDLINE 1966-1997), manual searches, and requests to experts in the field. DATA ANALYSIS: Differences between intervention and control group were considered in process of care (use of health services, diagnosis, and treatment), patient outcomes (health status), and patient satisfaction. In a subgroup of 13 interventions that dealt with the provision of feedback about the patient's mental health, the impact on the process of care was subjected to meta-analysis. RESULTS: We identified 21 studies that satisfied the selection criteria. Eleven of 20 (55%) found significant differences (P <0.05) in at least 1 of the process indicators in favor of the intervention group. Of 11 trials that assessed patient outcomes, only 4 (36%) detected significant improvements. A similar trend but lower percentages were observed among the 8 interventions that provided general health status information. Eleven interventions that evaluated feedback information about the patient's mental health status showed a higher rate of diagnosis in the intervention group (combined odds ratio [OR]=1.91; 95% confidence interval [CI] 1.28 to 2.83). Seven of 9 studies evaluating treatment failed to show an effect on this indicator (combined OR=1.15; 95% CI 0.76 to 1.75). CONCLUSIONS: The provision of feedback on perceived health status to health professionals seems to have an effect on the process of care but not on patient functional or health status. This is especially true with regard to mental health status information. Nevertheless, there is still need for a more through evaluation of this type of intervention.     

The Rand Health Insurance Experiment and HMOs

The Rand Health Insurance Experiment (HIE) provides the most persuasive evidence to date on the relative effects of health maintenance organization (HMO) and fee-for-service care on utilization, costs, client satisfaction, and health care outcomes. Publications from the HIE have suggested that HMO care was associated with lower costs because of reduced hospitalizations, lower client satisfaction, and poorer health status among the subgroup with limited incomes and initial health status. In our view, the evidence justifies the conclusions related to utilization, costs, and satisfaction, but not the suggestion that HMO care had adverse health effects on low-income, sick individuals.     

Are Australian general practice nurses underutilised?: An examination of current roles and task satisfaction

BackgroundThe general practice nursing workforce in Australia has grown exponentially in the last fifteen years. To understand the contribution and issues relating to this workforce we need to explore the evolution of the nurses’ role and the nurses’ perceptions of the work that they undertake.AimTo describe trends in general practice nurse clinical activities, the extent to which GPNs use their knowledge and skills and their satisfaction with the general practice nurse role.MethodsWithin a larger mixed methods project, a national cross-sectional survey of Australian primary health care nurses was undertaken. This paper details the survey findings related to the role of nurses working in general practice, the extent to which they use their knowledge and skills and their satisfaction with their role. Data about nurse roles was compared with previous workforce data to elucidate changes over time.FindingsOf the 1166 primary health care nurses who responded to the survey, 950 reported being employed in general practice. Participants reported undertaking activities related to health promotion and chronic disease management more frequently now than previously. They identified a desire to spend the same or less time on administrative activities and more time on health promotion, patient education and patient assessment. Nearly half of participants reported that often they feel that they could do more, or most of the time they don’t use their skills to the full extent.ConclusionNurses working in general practice are increasingly undertaking activities related to health promotion and chronic disease management. However, these nurses remain underutilised. Having nurses working to their full scope of practice has the potential to increase job satisfaction and nurse retention, as well as improve patient health outcomes.     

Self-harm behavior and no-suicide contracting in psychiatric inpatient settings.

Although negotiation of no-suicide contracts is common practice, research regarding the outcomes of contracting is inadequate. The purpose of this retrospective review of medical records was to examine how no-suicide contracting affected the likelihood of self-harm behavior in psychiatric inpatient settings. Thirty-one patients (4.8%) engaged in self-harm behaviors representing 2.64% of all patients admitted to both study settings during the 6 (1/2)-month period from which data were collected. Approximately half of those patients expressed suicidal intent. Logistic regression analysis suggested that patients with no-suicide contracts and with higher levels of restriction had a significantly higher likelihood of self-harm behavior (OR = 7.43 and 2.47, respectively, p = .005). Consistency of nursing assignment is likely associated with a lower probability of self-harm (OR = .07) but p.068 when this variable was included in the model. Prevention of self-harm behaviors by the use of no-suicide contracting is not shown. Negotiation of a contract is likely a reflection of staff assessment that the patient was at high risk for suicide. These findings confirm the need for thorough, ongoing assessment of suicidal risk, whether or not a patient has agreed to a no-suicide contract.