Implementation of Evidence-Based Tobacco Use Cessation Guidelines in Managed Care Organizations

Background: Although managed care organizations (MCOs) may be optimal settings for implementing tobacco use cessation clinical guidelines, such guidelines remain poorly implemented in many MCO settings.Purpose: We examined issues related to the implementation of guidelines in MCOs, to provide examples of studies that have addressed issues related to guideline implementation and to suggest ways behavioral medicine researchers can play a role in examining issues of how guidelines can be better implemented.Methods: Surveys of clinical guideline implementation, studies from the Robert Wood Johnson Foundation addressing tobacco use cessation in a managed care database, selected to illustrate issues related to system-wide implementation.Results: Surveys show that effective tobacco use cessation interventions remain underutilized in MCOs. A few studies have evaluated and shown the benefit of insurance coverage for tobacco use and dependence treatments, clinician reimbursement and leadership incentives, practice feedback, and leveraging administrative data to create tobacco use tracking systems. The studies also point to the need for large-scale, multidisciplinary, methodologically rigorous studies that allow one to isolate the effects of promising strategies as well as to explore synergistic effects as different system changes are combined.Conclusions: Tobacco use cessation guidelines need to be better implemented in MCOs. Behavioral medicine research needs to move beyond treatment efficacy and effectiveness studies to focus on rigorous evaluations of these and other strategies to enhance guideline implementation and dissemination. This research was supported by grants from the Tobacco-Related Disease Research Program (Taylor) and from the Robert Wood Johnson Foundation (Taylor and Curry).     

Orbital volume measured by a low-dose CT scanning technique.

A method for measuring orbital volume using low-dose CT with contiguous 3 mm transaxial sections is described. The accuracy of the method is 1.6%, as demonstrated by comparing CT volume measurements with those derived directly from alginate impressions and on repeat scanning the precision of the measurement was judged as 1.3%. Within the same individual, the right and left orbital volumes were observed to be within 0.6 cm3 (s.d. +/- 0.33 cm3) of each other. This study demonstrates that low-dose CT scanning is a practical method of determining orbital volume and could be used to advantage in the management of traumatic enophthalmos and blow-out fractures of the orbit.     

Understanding NHS pensions.

How much pension will you receive from the NHS Superannulation Scheme upon retirement? Some hospital doctors do not have a clear idea of the likely benefits or indeed any appreciation of the ancillary features included in the NHSSS. It is therefore appropriate to begin this series of articles on pension options for doctors with an overview of the NHS Scheme.     

Prediction of Remission of Acute Posttraumatic Stress Disorder in Motor Vehicle Accident Victims

One hundred forty five individuals who sought medical attention as a result of a motor vehicle accident (MVA), and who were initially assessed 1 to 4 months post-MVA, were followed up prospectively for 6 months to determine how many of the 55 with posttraumatic stress disorder (PTSD) and the 43 with sub-syndromal PTSD would remit and what variables would predict remission. Thirty (55%) of those with initial PTSD had remitted at least in part by 6 months while 67% of those with sub-syndromal PTSD had remitted (and 5% had worsened). Four variables, including severity of initial symptoms, degree of initial physical injury, relative degree of physical recovery by 4 months and whether a close family member suffered a trauma during the follow-up interval, combined to classify 6-month clinical status of 84% of those with initial PTSD secondary to MVAs.     

Safe and effective, prolonged administration of epsilon aminocaproic acid in bleeding from the urinary tract

A total of 9 patients with macroscopic hematuria from various causes, none with evidence of disseminated intravascular coagulation, received low oral, divided doses (approximately 150 mg. per kg. per day) of epsilon aminocaproic acid for up to 21 consecutive days. The hematuria was controlled effectively without overt clinical reactions. Parameters of hepatic and renal function, indicators of muscular damage, were studied in detail in 3 patients. No significant abnormalities were found. The use of small doses of epsilon aminocaproic acid was not accompanied by significant complications and appeared to be effective in special situations for the control of urinary bleeding. This therapy may have indications in a number of urological states accompanied by excessive hematuria.     

Use of an enzyme immunoassay to detect serum IgG antibodies to Haemophilus ducreyi

An experimental enzyme immunoassay (EIA) for detecting serum IgG antibody to Haemophilus ducreyi was developed using an ultrasonicated whole-cell antigen. The mean optical densities (OD) for sera from men with proven chancroid from Nairobi (47 patients) and Bangkok (72 patients) were significantly higher than those obtained from Nairobi men with genital ulcers not due to H. ducreyi, from Nairobi men with urethritis, from pregnant women in Nairobi, and from European men with sexually transmitted disease. When an OD of 0.500 was taken as the cutoff value, 89% and 55% of men with proven chancroid in Nairobi and Bangkok, respectively, were positive for H. ducreyi antibody, as compared with 2%-17% in the control groups. A rise in OD was observed in five of 18 patients with clinical chancroid. These results confirm the development of circulating antibodies in chancroid and suggest that this EIA may be useful for the diagnosis and epidemiological study of H. ducreyi infection.     

Fatty acid profiles in response to soybean oil lipid emulsion infusions in essential fatty acid-deficient miniature swine

The ability of soybean oil lipid emulsions to affect essential fatty acid deficiency (EFAD) and plasma fatty acid distribution was studied in neonatal pigs. The test animals were maintained on a fat-free diet prior to administration of lipid emulsion. Plasma and red blood cell (RBC) membrane levels of essential [linoleic (C-18:2 omega 6) and arachidonic (C-20:4 omega 6)] and nonessential [palmitic (C-16, palmitoleic (C-16:1 omega 7), stearic (C-18), and oleic (C-18:1 omega 9)] fatty acids and the triene:tetraene ratio [5,8,11-eicosatrienoic acid (C-20:3 omega 9):arachidonic acid (C-20:4 omega 6)] were monitored to ascertain the establishment of EFAD and its correction. Nonessential fatty acids were studied, as these components of lipid therapy have received little attention. Results indicate that soybean oil emulsions are effective in reversing fatty acid profiles found in EFAD, and both essential and nonessential fatty acids are under strict metabolic control.     

Analysis of job-share as a process of change

This paper describes the introduction of a district nursing job-share in a primary health care team. Exploring change theory and different strategies for organizational change, the implications for members of the team are considered. In addition, changes in the balance of power which resulted in conflict within the district nursing team are discussed.