To evaluate predictors and burden of emergency colorectal cancer resection (E-CCR). 

Cross-sectional study of 127 975 discharges of patients with colorectal cancer undergoing resection. 

 We used the 2002 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project; E-CCR was identified based on the presence of bowel perforation, peritonitis, or obstruction. Bivariate and multilevel multivariable analyses were used to study the association between E-CCR and patient attributes, including demographics, insurance status, comorbidities, health status, and teaching hospital status. 

Among younger patients, Medicaid enrollees (adjusted odds ratio [AOR], 2.08; 95% confidence interval [CI], 1.68-2.58) and the uninsured [AOR], 2.62; 95% CI, 2.05-3.34) were at higher risk for E-CCR. Among older patients, those dually eligible for Medicare and Medicaid were at higher risk for E-CCR (AOR, 1.37; 95% CI, 1.11-1.70). Emergency colorectal cancer resection was associated with greater than 3-fold increased in-hospital mortality, 54 979 (95% CI, 38 731-71 226) excess hospital days as a result of longer lengths of stay, and more than $250 million (95% CI, $180 million-$334 million) in hospital charges. 

Targeted interventions to increase colorectal cancer screening in vulnerable subgroups of the population would reduce the substantial patient and societal burden associated with failure to screen 

Among a younger cohort (<65 years), Medicaid enrollees and the uninsured were at higher risk for emergency colorectal cancer resection (E-CCR).

Among an older cohort (>65 years), patients dually eligible for Medicare and Medicaid were at higher risk for E-CCR.

Emergency colorectal cancer resection was associated with greater than 3-fold increased in-hospital mortality, 54 979 excess hospital days, and more than $250 million in hospital charges.

In 2006, an estimated 148 610 individuals were affected by colorectal cancer.

It is the second leading cause of cancer-related deaths in the United States, claiming 55 170 lives in 2006 alone.

 The incidence of colorectal cancer increases with age,

and 94% of all cases are diagnosed in individuals older than 50 years.

Individuals with a family history of colorectal cancer, certain familial cancer syndromes, or inflammatory bowel disease are at increased risk for colorectal cancer.

Colorectal cancer is curable if detected at an early stage,

yet 40% of all patients presenting with colorectal cancer are beyond the stage at which a definitive cure is achievable.

Although colorectal cancer screening is recommended for persons 50 years and older,

especially among older individuals, those of minority descent, or persons with compromised access to preventive care.

Early detection and treatment can prevent potentially fatal complications of colorectal cancer, including bowel perforation, peritonitis, and obstruction. These complications, often associated with increased morbidity and mortality, are considered surgical emergencies and elicit the initial presentation of colorectal cancer in an estimated 15% to 30% of patients with colorectal cancer.

A clinical presentation necessitating emergency colorectal cancer resection (E-CCR) has been identified as "the clearest evidence on an individual level for a failure of screening,"

resulting from factors such as inadequate access to care or underutilization of cancer screening services and contributing to the disparities in colorectal cancer outcomes. 

exploring E-CCR originate from Europe. However, given important differences in the healthcare delivery and financing systems, as well as in the population characteristics between Europe and the United States, the generalizability of these studies to the United States is limited. In particular, the role of enabling factors such as insurance status relative to E-CCR and the health and economic burden of care associated with E-CCR have remained unexplored, to our knowledge. This study aims to identify predictors and burden of E-CCR relative to length of stay, hospital charges, and in-hospital mortality through the analysis of a large nationally representative sample of patients with colorectal cancer undergoing resection procedures. 

This was a cross-sectional study using data from the 2002 Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. This study was approved for institutional review board exemption at the University Hospitals of Cleveland. The NIS is a publicly available data set in which stratified random probability sampling was used to obtain a 20% subsample of nonfederal US community hospitals as defined by the American Hospital Association containing 7 853 982 discharges from 995 hospitals and 35 states in 2002. This sample can be generalized to 37 804 021 discharges using sampling weights. A more detailed description of the data set is available elsewhere.

The NIS data have been used in several population-based studies

on outcomes for hospitalized patients. Data quality and coding errors vary across hospitals, payers, and states,

with some variables being unavailable for discharges from certain states, as discussed herein. Despite these challenges commonly posed by the analysis of administrative data, the NIS is a unique data resource allowing for the analysis of outcomes regardless of payer status. 

International Classification of Diseases, Ninth Revision, Clinical

codes present in any of 15 fields in the data set were used to identify discharges for patients with colorectal cancer undergoing resection procedures (n = 26 269, which is representative of 127 975 discharges nationally). The codes used to identify patients with colorectal cancer included diagnosis codes for malignant neoplasms of the colon (codes 153.0-9) and rectum (codes 154.0-1). Procedure codes were used to identify patients with colorectal cancer who underwent resection. These codes include partial excision of the large intestine (code 45.7), total intra-abdominal colectomy (code 45.8), other operations on the intestine (codes 46.1-2), abdominoperineal resection of the rectum (code 48.5), anterior resection of the rectum with synchronous colostomy (code 48.62), and other anterior resection of the rectum (code 48.63). From these patients, a subset presenting with a diagnosis requiring E-CCR, including bowel perforation, peritonitis, or obstruction, was identified (n = 2753). The diagnosis codes used to determine which patients met these criteria included other specified intestinal obstruction (code 560.8), unspecified intestinal obstruction (code 560.9), peritonitis in infectious diseases (code 567.0), other suppurative peritonitis (code 567.2), other specified peritonitis (code 567.8), unspecified peritonitis (code 567.9), and perforation of the intestine (code 569.83). 

Sociodemographic and Insurance Status Variables.

 Patients were grouped into the following age categories: 0 to 44, 45 to 64, 65 to 74, 75 to 84, and 85 years and older. Because of differences in insurance status (ie, Medicare was the predominant payer among older persons), variations in healthcare utilization patterns, and disparities in treatment between younger and older patients, 2 subpopulations were defined by stratifying the population into those younger than 65 years and those 65 years and older. 

In the original data set, race/ethnicity was defined as white, African American, Hispanic, Asian or Pacific Islander, Native American, and other. Because of insufficient numbers of Asian or Pacific Islanders and Native Americans, we categorized race/ethnicity as white, African American, Hispanic, and other. In addition, several states participating in the Healthcare Cost and Utilization Project did not make the race/ethnicity variable available in the discharge data. As a result, almost one third of all records lacked race/ethnicity variables. Such cases were assigned the category of missing race/ethnicity, making it possible for us to account for them in the analyses. Income level was based on the median household income level within the patient's ZIP code. This variable had missing values in almost 2% of the cases. We included these cases in bivariate analyses but not in multivariable analyses. 

Insurance status was determined from the primary and secondary payers given in the original data. These payers were categorized as Medicare, Medicaid, private insurance (including health maintenance organizations), self-pay, no charge, and other. The self-pay and no charge groups in the primary payer variable were combined to represent the uninsured. For analyses pertaining to the older cohort, we combined information from the primary and secondary payer variables to create the following insurance status categories: Medicare only, Medicare or private insurance (including health maintenance organizations), Medicare or Medicaid (dually eligible), and Medicare or other. 

Based on the criteria already described, an indicator variable for the presence or absence of E-CCR was created and was defined based on the presence of any of the diagnosis codes indicating bowel perforation, peritonitis, or obstruction in any of the 15 fields in the data set. Length of stay was provided as a continuous variable in the data set representing the number of days from admission to discharge. Hospital charges was a continuous variable representing the total charges in dollars for the patient's entire hospital admission. In-hospital mortality as provided in the original data set was a dichotomous variable indicating whether the patient died in the hospital or was alive at discharge. To satisfy the normality assumption of linear regression analysis, length of stay and hospital charges were logarithmically transformed to correct for the skewed distributions. 

Comorbidity and Health Status Variables. 

International Classification of Diseases, Ninth Revision

The disease severity measures file available through the 2002 NIS was used as a source for variables reflecting comorbidities, health status, and metastatic cancer. These conditions, which were based on 

 diagnosis codes documented for each discharge, were adapted from a comorbidity index incorporating 30 conditions as described by Elixhauser et al

in 1998. Metastatic cancer and solid tumor without metastasis were not included in our count of comorbidities. Rather, metastatic cancer was considered a separate variable, and its association with E-CCR was tested in bivariate and multivariable analyses. Despite the limitations of claims-based variables in determining cancer stage,

 and the fact that metastatic cancer may reflect metastasis from anatomic sites other than the colon or rectum, we opted to explore its association with E-CCR, with the hypothesis that metastatic cancer would be strongly and positively associated with E-CCR and the other outcomes of interest. 

have identified the health status of the patient as an important predictor of surgical morbidity and mortality. Conditions most indicative of the health status of the patient at the time of presentation were considered separately from other comorbidities to determine their independent effect on the likelihood of presenting as a surgical emergency. We created a dichotomous variable (yes or no), referred to as compromised health status, indicating the presence of any of the following conditions: weight loss, electrolyte disorders, blood loss anemia, deficiency anemia, and coagulation disorders. All other conditions noted in the listing by Elixhauser et al

were considered comorbidities. A 4-category summary variable was created as a count of the total number of comorbidities, categorized as 0, 1, 2, or 3 or more. 

Relevant variables in the NIS disease severity measures file were unavailable for the state of Pennsylvania. These discharges, accounting for 5% of the total, were considered in bivariate analyses but not in multivariable analyses. In assessing disease burden, however, we applied estimates obtained from the multivariable analyses to the total number of admissions, including ones from Pennsylvania. 

This dichotomous variable was retrieved from the NIS hospital weights file. Teaching hospital status indicates that a hospital has an American Medical Association-approved residency program, is a member of the Council of Teaching Hospitals, or has a ratio of fulltime-equivalent interns and residents to beds of at least 0.25. 

 Patients were stratified into younger (<65 years) and older (=65 years) cohorts. Bivariate and multivariable analytic methods were used to determine the effect of teaching hospital status and patient-level characteristics, including demographics, comorbidities, health status, and metastatic cancer on the likelihood of E-CCR. Given the multilevel nature of the data and the variations within and across hospitals, we used hierarchical nonlinear and linear models, respectively, for dichotomous and continuous outcomes. Dichotomous outcomes included E-CCR and in-hospital mortality. Continuous outcomes included log-transformed length of stay and hospital charges. 

Results obtained from multivariable models were used to assess the burden of E-CCR relative to length of stay, hospital charges, and in-hospital mortality. A retransformation method incorporating a smearing function, described by Duan

in 1998, was used to estimate the mean length of stay and hospital charges for patients who did and did not undergo E-CCR. These predicted means accounted for hospital-and patient-level characteristics considered in the models. SAS software version 9.1 (SAS Institute, Cary, NC) was used for data management and in bivariate analyses using the procedures surveyfreq and surveymeans to account for weighted data. HLM software version 6.0 (Scientific Software International, Lincolnwood, Ill) was used in multilevel multivariable analyses, also incorporating sample weights. 

Two thirds of discharges for colorectal cancer resections were among individuals 65 years and older. Characteristics of individuals in the younger and older cohorts are given in the 

The proportions of individuals undergoing E-CCR are given in 

. For most of the covariates that we considered in the study, we observed statistically significant differences in the proportions undergoing E-CCR. The proportion undergoing E-CCR in the younger cohort was highest among the uninsured compared with the privately insured (19.9% vs 8.5%); compromised health status and metastatic cancer were associated with high rates of E-CCR (16.4% vs 7.9% for noncompromised health status and 13.9% vs 7.3% for absence of metastatic cancer). The number of comorbidities was negatively and significantly associated with E-CCR, with the proportion undergoing E-CCR decreasing with increasing numbers of comorbidities. The results in the older cohort were similar to those in the younger cohort. Of note is the association of E-CCR with older age, with the oldest age group (=85 years) undergoing more E-CCR. 

Results from the multivariable multilevel logistic regression analyses were consistent with those of the bivariate analyses (

). In the younger cohort, Medicaid enrollees (adjusted odds ratio [AOR], 2.08; 95% confidence interval [CI], 1.68-2.58) and the uninsured (AOR, 2.62; 95% CI, 2.05-3.34) were at higher risk for E-CCR compared with privately insured patients. Those with compromised health status (AOR, 2.16; 95% CI, 1.86-2.51) or metastatic cancer (AOR, 1.91; 95% CI, 1.66-2.20) were significantly more likely than their healthier counterparts to undergo E-CCR. Compared with those with no documented comorbidities, patients with 3 or more comorbidities were almost half as likely to undergo ECCR (AOR, 0.53; 95% CI, 0.37-0.77). 

In the older cohort, compared with those aged 65 to 74 years, individuals 85 years and older were at higher risk for E-CCR (AOR, 1.44; 95% CI, 1.26-1.66) (

). Compared with those with Medicare only, those who were dually eligible for Medicare and Medicaid were at significantly increased risk for E-CCR (AOR, 1.37; 95% CI, 1.11-1.70). African American race/ethnicity was associated with increased risk for E-CCR in the older cohort (AOR, 1.22; 95% CI, 1.01-1.49). Results relative to compromised health status, metastatic cancer, and comorbidities were consistent with those observed in the younger cohort. Of note are the results indicating that women were significantly less likely to undergo E-CCR, a finding that held true in the younger and older cohorts. 

When the effects of patient demographics, comorbidities, health status, metastatic cancer, and teaching hospital status were controlled for in multivariable analyses, E-CCR remained a significant predictor of length of stay, hospital charges, and inhospital mortality (Table 3). In particular, compared with those undergoing elective colorectal cancer resection, patients presenting with a diagnosis requiring emergency surgery had a mean predicted length of stay that was 4 days longer than that of the nonemergency patients. Emergency colorectal cancer resection was associated with mean excess hospital charges of $19 073, and patients undergoing E-CCR were more than 3 times as likely to die in the hospital, statistics that held true in the younger and older cohorts (

). In 2002, the mean excess length of stay and hospital charges associated with ECCR, compared with nonemergency colorectal cancer resection, amounted to 54 979 hospital days and more than $250 million. 

This study identified predictors of emergency presentation in a nationally representative sample of patients with colorectal cancer undergoing resection and determined its health and economic burden relative to length of stay, hospital charges, and in-hospital mortality. The results showed significant effects of patient age and insurance status on the risk of presenting with colorectal cancer as surgical emergency, placing 

Medicaid enrollees, the uninsured, and older persons at high risk for E-CCR (Table 2). Interventions to facilitate or improve access to screening in these vulnerable subgroups of the population may lead to decreased E-CCR. 

patients who underwent E-CCR had extended lengths of stay, increased hospital charges, and substantially higher in-hospital mortality. This placed an excess burden on the healthcare system of 54 979 hospital days and more than $250 million in hospital charges in 2002 (Table 4). 

Compromised health status proved to be significantly and positively associated with E-CCR. Such presentation, which is suggestive of advanced-stage cancer, may place patients at increased risk for surgical complications or for poor surgical outcomes. Early detection of disease may enable patients to avoid E-CCR, unfavorable surgical outcomes, and health status decline. A significantly negative association was found between greater numbers of comorbidities and ECCR in the older cohort. As speculated in a previous study,

 frequent contact with the healthcare system may increase the probability of early detection of cancer. However, it is also possible that sicker patients in whom resection could not be performed safely or those who elected not to undergo resection may not have been represented in our study population. 

A study of Medicare beneficiaries by Cooper et al

in 1996 found decreased rates of surgery and increased mortality among African Americans with colorectal cancer. In our younger and older cohorts, African Americans had the highest proportions of E-CCR compared with other racial/ethnic groups. In multivariable analyses, this association proved to be statistically significant in the older cohort but not in the younger cohort. Racial/ethnic disparities may be explained by variations in patient attributes. A significant predictor of emergency presentation in this study was insurance status, the inclusion of which in the multivariable models may have masked the effect of race/ethnicity relative to E-CCR. In our study population, higher proportions of uninsured patients and Medicaid enrollees were observed among African Americans (16.9% and 8.6%, respectively) and among Hispanics (19.1% and 12.8%, respectively) compared with among whites (6.5% and 4.0%, respectively). However, the unfavorable case mix by insurance status negatively affected African Americans but not Hispanics, as evidenced by the significantly lower proportions of E-CCR among the latter subgroup. Possible explanations include the much-debated Hispanic paradox

and the fact that the study population was limited to patients undergoing colorectal cancer resection, as already discussed. 

of patients with colorectal cancer conducted in the United Kingdom found that socioeconomic status was significantly related to having more advanced disease at presentation and to having a lower likelihood of survival. While this association was not confirmed in our study, the lack of significance of income level may be potentially explained by the fact that income level was measured based on ZIP code. Because there can be wide variation in income levels within a ZIP code, individual differences related to emergency resection may have been masked. 

To our knowledge, this is the first population-based study of patients undergoing E-CCR in the United States. This study not only identified predictors of E-CCR but also quantified its burden on the healthcare system, filling an important gap in the literature. Several limitations should be borne in mind when interpreting the findings, however. 

First, our study used hospital discharge data, the quality of which may not be comparable to that of medical records. The stage of the tumor at presentation could not be determined from these data, and there was no information available to distinguish between resection procedures of curative vs palliative intent. One study

found that up to 29% of patients presenting in surgical emergency settings received palliative care only. 

Second, because the study population was limited to those undergoing resection procedures, many patients presenting in emergency settings may have been unrepresented in the study population, as already noted. These might have comprised severe cases in which surgical resection may have been indicated but was unlikely to be successful, the health status of the patient was unsuitable for surgery, the patient refused treatment, or some interim measure was completed in the emergency setting with a resection being scheduled electively. This selection bias may have led to an underestimation of particular characteristics of the study population, including the rates of comorbidity and mortality. Of note is our use of a variable for metastatic cancer, although it might reflect the presence of any metastatic cancer, not just colorectal cancer. As noted earlier, rather than considering this variable as a comorbidity, we chose to use it as a separate covariate in our multivariable models. Limitations of claims data relative to their ability to identify cancer stage have been documented previously.

 However, as hypothesized, we found a positive and significant association between metastatic cancer and E-CCR. 

Third, the study used cross-sectional data, which did not allow us to distinguish between patients presenting as emergencies because of improper management and those presenting because of failure of screening or diagnosis or because of recurrence of a previously treated malignancy. Also, given the nature of the data, mortality statistics presented in this study cannot be extended to the postdischarge period. 

Fourth, there was differential reporting of some variables across states, including race/ethnicity, insurance status, and diagnosis and procedure codes. There were up to 15 diagnosis codes used in this data set; however, some states reported only 10 diagnosis codes and 6 procedure codes, while others reported as many as 30 diagnosis codes and 21 procedure codes. There may be additional bias in reporting health status indicators and comorbidities, especially common conditions such as hypertension, which may be underreported in the presence of a more severe diagnosis such as colorectal cancer. 

Fifth, the insurance status is likely to reflect health coverage at the time the patient underwent resection for colorectal cancer, warranting caution in interpreting the association between insurance status and E-CCR. This is particularly relevant to Medicaid enrollees, as it has been shown that longer periods of enrollment in Medicaid are likely to be associated with greater use of screening mammography.

In addition, individuals enrolled in Medicaid around the time of diagnosis or after being diagnosed as having cancer are more likely than those enrolled in Medicaid before a cancer diagnosis to be diagnosed as having advanced-stage breast

In closing, failure to screen, as evidenced by E-CCR, results in significant but preventable costs economically and in terms of morbidity and mortality. Early identification of patients most at risk for E-CCR, particularly older persons, those without private insurance, and others with limited access to care may reduce the disparities and decrease the burden of these procedures on patients and on the healthcare system. 

We thank Amy Storfer-Isser, MS, for her statistical analysis input and 2 anonymous reviewers for their helpful comments and suggestions. 

From the Department of Epidemiology and Biostatistics, School of Medicine (JCD, FX, MD, GSC, SMK), Division of Gastroenterology, Department of Internal Medicine, University Hospitals of Cleveland (GSC), and Case Comprehensive Cancer Center (GSC, SMK), Case Western Reserve University, Cleveland, Ohio. 

This study was supported by institutional training grant T32 HS00059 from the Agency for HealthCare Research and Quality (JCD), by Established Investigator Award K05 CA90677 from the National Cancer Institute (GSC), by Career Development Award K07 CA96705 from the National Cancer Institute (SMK), and by Aging-Cancer Research Program Development pilot project investigator grant P20 CA103736 from the National Cancer Institute (SMK). 

Articles

MANAGERIAL

Failure to Screen: Predictors and Burden of Emergency Colorectal Cancer Resection

To obtain feedback from contracted health plan (HP) clinicians responsible for implementing preventive services regarding an established set of priority guidelines identified by a coalition of medical directors and to identify barriers to and facilitators of the implementation of these priority guidelines in clinician practice. 

Qualitative design using a focus group approach. 

Three focus group meetings among contracted HP clinicians were conducted in New Jersey in 3 geographic regions (northern, central, and southern New Jersey). Clinicians directly involved in delivering preventive services to pediatric, adult, and geriatric patients participated. 

Barriers to guideline implementation were identified by the clinicians regarding payment and cost, time, legal issues, inconsistency among HP tools, tracking, a lack of internalization, and the patient-clinician relationship. In addition, facilitators of guideline implementation, including HP support, patient materials, clinician awareness, and tool consistency, were identified. 

Clinicians' perceived barriers to guideline implementation are in themselves a barrier to the delivery of preventive care services. If clinicians perceive barriers to implementing priority recommendations, they may be unlikely to make the conscious effort to deliver preventive care. There needs to be better dialogue between HPs and contracted clinicians to minimize the perceptions of barriers and to increase clinician awareness of and sensitivity to preventive care for priority implementation. To improve the delivery of preventive services in clinician practice, competing HPs must communicate in a single voice with contracted clinicians in the area of preventive care. 

Studies are lacking in the area of barriers to and facilitators of guideline implementation when a collaboration of competing health plans (HPs) provides a consistent set of priority guidelines for preventive care.

This qualitative study examined contracted HP cliniciansâ€™ perceived barriers to and facilitators of the implementation of priority guidelines, providing HP medical directors with a better understanding of cliniciansâ€™ perceptions and with direction for quality initiatives and future collaboration.

Cliniciansâ€™ perceived barriers to guideline implementation are in themselves a barrier. If clinicians perceive barriers to implementing priority recommendations, they may be unlikely to deliver preventive services to their patients.

Preventive services for the early detection of disease have been associated with substantial reductions in morbidity and mortality.

Although scientific evidence exists for emphasizing prevention in clinician practice, studies

have shown that clinicians often fail to provide recommended clinical preventive services (CPS). A reason identified in the literature is that clinicians may be uncertain of or confused about which services to provide.

Clinicians are confronted with various (often conflicting) sets of clinical guidelines for the provision of preventive care given the number of health plans (HPs) they contract with. In addition, CPS recommendations are issued regularly by government health agencies, expert panels, medical specialty organizations, voluntary associations, other professional and scientific organizations, and individual experts,

which further adds to clinicians' confusion. 

In an attempt to address this problem, 8 medical directors from the largest HP in the state of New Jersey collaborated on improving the delivery of CPS among their contracted clinician base. These medical directors came to a consensus on a subset of the US Preventive Services Task Force guidelines for preventive care for priority implementation (

In doing so, it was anticipated that barriers of inconsistency and confusion about conflicting CPS recommendations put forth by each HP would be minimized. Therefore, the delivery of CPS in clinician practice would be improved. 

However, efforts to improve the delivery of CPS are limited by our understanding of how clinicians actually incorporate and deliver preventive services within the competing demands of their practices.

The objective of this study was to better understand the organizational features of primary care practice that may act as barriers to and facilitators of clinicians' delivery of priority guidelines in practice. Specifically, we asked the following questions: "What are the perceived barriers to the implementation of the priority CPS guidelines identified by the HP medical directors?" and "What are the perceived facilitators of the implementation of the priority CPS guidelines identified by the HP medical directors?" 

The literature suggests various barriers to and facilitators of the delivery of CPS in clinician practice.

However, studies are lacking in the area of barriers to and facilitators of guideline implementation when a collaboration of competing HPs provides a single consistent set of guidelines for preventive care. Knowledge of perceived barriers to and facilitators of the implementation of priority guidelines identified by the HP medical directors will provide HPs with a better understanding of clinicians' perceptions regarding the implementation of a consistent set of priority guidelines. It may suggest ways in which HPs may assist in the delivery of priority CPS guidelines in clinician practice. In addition, such knowledge will provide HP medical directors with an understanding of clinicians' perceptions, which could influence future collaborative activities. 

This qualitative study examined factors that affect the delivery of CPS in clinician practice. Focus groups were used to obtain clinician feedback. This design is ideal when there is a need to obtain a number of contrasting ideas or themes

 (in this case, barriers to and facilitators of the delivery of HPs' priority CPS guidelines). The study protocol was reviewed and approved by Rutgers, The State University of New Jersey Institutional Review Board. 

Three focus group meetings with a combined convenience sample of 26 primary care practitioners were conducted in New Jersey, 1 in each of 3 geographic regions (northern, central, and southern New Jersey). Focus groups were organized based on clinicians' geographic locations to minimize traveling distance and to facilitate participation. 

The nonrepresentative sample of clinicians was recruited by the project director (CGA) on the research team. Using member directories of participating HPs, clinicians directly involved in delivering preventive services to pediatric, adult, and geriatric patients were randomly selected for potential inclusion in the study. Invitations for participation, including a brief summary of the priority CPS guidelines identified by the HP medical directors, were sent to the selected clinicians until the targeted number of clinicians (n = 10) for each focus group volunteered to participate. Letters were followed up by a telephone call by the project director to determine interest. Fifty clinicians were contacted in total before obtaining the targeted number of clinicians. Thirty clinicians (10 per group) were recruited; of these, 26 clinicians participated. Of the 26 participants, 11 were internists, 7 were family physicians, 3 were obstetricians/gynecologists, 1 was a pediatrician, and 4 were nurse practitioners. 

Focus groups were moderated by a former HP medical director with expert knowledge of CPS guidelines and clinician practice and with previous facilitation experience. Each 1-hour session was audiotaped, and the project director, serving in an observer role, kept detailed notes to supplement audiotaped proceedings. 

Each focus group meeting began with an overview of the US Preventive Services Task Force guidelines

and of the value of using these evidence-based guidelines as the minimum level of preventive care to be delivered to the general population. Information regarding the HP medical directors' collaborative effort to identify a single consistent set of priority CPS guidelines, a description of the process used to facilitate consensus, and the list of priority guidelines were then presented. 

Following this presentation, the moderator asked the following questions to stimulate discussion: (1) "What do you perceive to be the barriers to your implementation of these guidelines?" and (2) "What do you perceive to be practices that would facilitate your implementation of these guidelines?" Throughout the discussion of each topic, the moderator used additional probes to stimulate discussion and to reach saturation (ie, the point at which no new additional information was forthcoming). Following completion of each focus group meeting, the audiotaped discussion was transcribed by the project director. Content analysis was performed on all 3 transcripts for the purpose of identifying and categorizing themes representative of barriers to and facilitators of CPS guideline implementation. 

The project director and 2 other members of the research team analyzed the discussions based on the method described by Strauss and Corbin.

This process involves breaking down, examining, comparing, conceptualizing, and categorizing data. Focus group audiotapes were transcribed; every line of the transcribed text was coded for relevant themes, and as themes developed, a working definition was assigned to each code. Constant comparison of codes of new transcripts with existing codes of previous transcripts allowed researchers to develop properties of overarching categories for the identified codes. This process was ongoing until saturation was reached. 

The following 7 themes emerged that represented barriers to implementation: (1) payment and cost issues, (2) time factors, (3) legal issues, (4) inconsistency among HP tools with various CPS recommendations, (5) tracking of CPS already delivered to patients, (6) a lack of internalization of guidelines, and (7) the patient-clinician relationship (

). In terms of facilitators, the following 4 themes emerged: (1) HP support, (2) patient materials, (3) clinician awareness and sensitivity, and (4) tool consistency. 

Payment and cost barriers were the most cited obstacles to guideline implementation. Clinicians noted a lack of reimbursement for time spent providing preventive screenings such as counseling. They said that these services would take time away from seeing other patients and would result in a loss of income. They also cited an increase in office overhead associated with recommendations such as performing flexible sigmoidoscopies at their offices. A lack of reimbursement for fiber-optic equipment and the time that performing flexible sigmoidoscopies would take away from seeing other patients would result in financial loss. One clinician said: "I'm spending more money and my nurse's time. I'm not getting reimbursed a cent more. I'm losing money each time I do it. It's a problem." 

Clinicians described techniques used by their practices to ensure payment for their services. Several clinicians indicated that they sometimes ask a patient to schedule a separate wellpatient care visit to provide him or her with preventive services, particularly with a patient being seen for the management of a chronic condition. To ensure reimbursement, they play what they refer to as "billing code games" in scheduling a well-patient care appointment. One clinician explained: "When someone wants preventive services, I tell them to schedule a physical, and then under my physical code, I can order a bunch of things, and I know it will be covered. On the other hand, if someone just wants a separate service each time, it really takes a lot more ingenuity to make sure it's covered by the coding." 

Time spent performing preventive services was an identified barrier to guideline implementation. A clinician pointed out that, when a patient comes into the office with multiple complaints resulting in 5 different diagnoses, there is no time nor is it a priority to discuss prevention such as wearing seatbelts. The clinician elaborated: "When you have someone telling you about their fifth problem and you're trying to deal with all 5, the last thing you want to do then is, after you're running late, flip to the front and say ‘what preventive service can I give you today?'" 

Time spent making referrals to specialized treatment facilities and time spent looking up billing codes to ensure reimbursement from HPs were also identified as barriers. In addition, clinicians noted that it would be time-consuming to assess the effectiveness of initiatives relative to their practice. One clinician said: "I think, what I struggle with a lot...um...quite honestly, I never know where my practice is, and benchmarking a practice in terms of implementing these guidelines is very difficult and very time-consuming." 

Concerns about liability were identified as a barrier. For example, clinicians expressed concern about increased liability as a result of performing flexible sigmoidoscopies in their practice. They would rather refer their patients to see a gastroenterologist than perform these procedures in their offices. Several clinicians questioned the wording of several guidelines (such as "refer" to treatment centers and "prevent" motor vehicle injuries). They thought that the wording of these guidelines placed legal burden on them, and they expressed concern about liability if services were not implemented. One explained: "...[T]o throw in ‘refer' makes an imperative to refer them. You're saying you must refer. I think a lot of us would object to that because that then becomes a medical legal issue." 

Inconsistency Among Health Plan Tools With Various

Clinical Preventive Services Recommendations. 

Inconsistency among HP tools was an identified barrier. Clinicians expressed frustration about HPs having different tools for various guidelines. Several clinicians admitted choosing a form and discarding all others. One clinician bantered: "Sometimes a good flowsheet gets buried under another good flowsheet, which gets buried under another good flowsheet." 

Tracking of Clinical Preventive Services Already

Tracking patients' preventive services was also identified as a barrier to guideline implementation. Clinicians noted that patients often are unaware of what services have already been provided. This is especially true when the patient changes insurance carriers because of a move or a job change. In addition, clinicians noted that the patients who need preventive screenings the most are often individuals who do not come into the office. One clinician said: "People change practices, jobs, they move, insurance they change, they change PCPs, and never get updated. You know. You kind of lose track of who's where and when. I mean, my adult patients, you ask ‘did you have your pneumococcal vaccine?' Most of them kind of know. Some of them don't." 

Failing to internalize guidelines into clinician practice was also identified as a barrier to guideline implementation. Clinicians may not be aware of the specific CPS that they are accountable for in delivering to their patients. Therefore, they may only deliver preventive care services for which they are audited. 

Finally, several clinicians expressed concern about the patient-clinician relationship. Clinicians thought that by discussing seatbelt use or alcohol intake with adult patients, they might be perceived as lecturing or as being offensive. A clinician complained: "A lot of patients would take offense to you lecturing about car restraints for adults, about alcohol, the use of alcohol and driving, and it creates a negative in the doctorpatient relationship." 

Clinicians said that HPs should provide organizational support to deliver CPS in their practices. A lack of reimbursement was a concern among clinicians. They said that HPs need to assess their policies and payment procedures to make sure they are in line with priority recommendations. Clinicians also suggested tools (such as easy-to-read charts) for rapid coding of preventive services. 

In light of their concern about liability, clinicians suggested that the wording of some guidelines (such as "refer" and "prevent") be changed to "recommend." If referral is expected, clinicians suggested that HPs improve access to these services. Clinicians also noted that HPs should provide statistical tools to assess the current status of their practice and any needed improvement. 

In tracking their patients' preventive care services, clinicians suggested that HPs send reminders to their members. Clinicians also indicated that they should be provided with patient materials such as immunization cards to give to their patients for tracking these services. 

To minimize the barrier of time factors, particularly time spent counseling, clinicians suggested the use of handouts or pamphlets. Clinicians were of the opinion that HPs should provide bilingual and age-appropriate materials to offer to their patients. They noted that this strategy would not only save time but also decrease office overhead. 

Strategies to increase awareness and sensitivity of clinicians in practice were also identified as a facilitator of guideline implementation. Clinicians discussed the need to know what they will be audited for. A suggestion was made that clinicians audit other practices to familiarize themselves with this process and to internalize guidelines. In addition, they noted that incentives would facilitate implementation and internalization of these guidelines. 

Finally, clinicians identified consistency among HP tools as a facilitator. They suggested that universal sheets (brightly colored and user-friendly) for all participating HPs be placed in patients' medical records. 

Although focus groups were suited to the objectives of our study, the use of such groups had limitations. These were nonrepresentative groups of clinicians who participated in the focus groups. Therefore, findings are not generalizable to the population of contracted HP clinicians providing care to the general population. Despite this limitation, data obtained from the focus groups provide valuable insights for tool development and for future research. Another limitation was that the moderator was a medical director of an HP that participated in the development of the priority CPS guideline set. Therefore, bias may have been introduced into the discussion, and clinicians may have been hesitant to share negative feedback with an individual in an administrative position within the HP with which they may have contracted. 

clinicians in our focus groups identified perceived barriers to implementing a consistent set of CPS guidelines. The present study demonstrates the need to address perceived barriers among clinicians to implementing CPS guidelines to improve delivery through the use of a consistent set of priority guidelines. 

Our study results have important implications for the use of a consistent set of guidelines for preventive care and for the wider dissemination effort. This study identified the need to address clinicians' perceived barriers to guideline implementation by promoting their awareness of existing support by the HPs. For example, despite the fact that all of the priority CPS services were already covered by the HPs, clinicians described techniques (referred to as "billing code games") used to ensure reimbursement for some of the services identified. 

Medical directors overwhelmingly agree that preventive care services are underutilized by the general public, even among their managed care members.

The established set of priority CPS recommendations endorsed by that coalition of medical directors is intended to improve delivery of these services in clinician practice by minimizing barriers to implementation such as inconsistency and a lack of clinician awareness of and sensitivity to evidence-based guidelines. However, our study revealed that clinicians' perceived barriers to guideline implementation are in themselves a barrier to CPS delivery. If clinicians perceive barriers to implementing these recommendations, it may be difficult for them to deliver preventive care to their patients. Therefore, HPs must bridge the gap with contracted clinicians and demonstrate their efforts and support in facilitating guideline implementation. 

Health plans should assist clinicians in putting systems into place that provide additional support to the delivery of priority CPS guidelines. For instance, incentives should be offered for clinicians who use a shared decision-making model in their practice. Priority CPS guidelines are based on scientific evidence and should be used by clinicians to facilitate discussion with their patients. Health plans should provide tools to encourage use of the shared decision-making model in clinician practice. 

In addition to voluntary contribution of data for National Committee for Quality Assurance accreditation, commercial health maintenance organizations in New Jersey are required to submit Health Employer Data Information Set material for inclusion in the state's health maintenance organization report.

Health Plan Employer Data and Information Set measures that are collected do not reflect all CPS identified by the HP medical directors for priority implementation, nor are they practice specific. Therefore, category II 

codes that include all of the priority CPS guidelines should be used consistently across competing HPs as a performance measure. This would minimize administrative burdens on clinicians to assess the current status of their practice and how much improvement needs to be made regarding the delivery of these CPS. Because clinicians have enormous influence on patient adherence with CPS guidelines, improved communication with clinicians could increase the rates of preventive care services. There needs to be better dialogue between HPs and contracted clinicians to minimize the perceptions of barriers (particularly payment and cost concerns) and to increase clinician awareness of and sensitivity to preventive care for priority implementation. To improve CPS delivery in clinician practice, competing HPs need to communicate with contracted clinicians in a single voice in the area of preventive care. 

Improved communication could also be beneficial at the patient member level. Future activities should include collaboration among HPs to provide consistent messages to patient members that emphasize the importance of and the coverage for priority CPS. 

Medical directors should use the data collected from these focus groups to develop consistent tools and to support systems across their competing HPs to assist their clinicians' delivery of priority CPS. Future studies should include an evaluation of clinicians' perceptions of barriers to and facilitators of implementing the tools developed by HPs. Finally, there should be an evaluation of developed tools and systems to examine whether the delivery of priority CPS guidelines was improved. 

From Rutgers College of Nursing, Rutgers, The State University of New Jersey, Newark. 

Perceived Barriers to and Facilitators of the Implementation of Priority Clinical Preventive Services Guidelines

To evaluate the effect of a managed care organization's multifactorial intervention program in optimizing secondary prevention of coronary artery disease (CAD).

Retrospective observational analysis of claims-based data of health plan members with CAD receiving 1 or more prescriptions per year of any of the following classes of medications used for secondary prevention of CAD: lipid-lowering agents, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin receptor blockers (ARBs) and ÃƒÅ¸-blockers.

Claims-based data of members from 2000 to 2004 were analyzed to discover trends in the use of medications for secondary prevention of CAD. ?2 Test of proportion was used to determine whether the changes in the annual medication use rates were statistically significant.

The annual medication use rates improved consistently throughout each year of the study period. From 2000 to 2004, the medication use rates increased for lipid-lowering agents (from 55% to 71%), ACE inhibitors or ARBs (from 44% to 55%), and ÃƒÅ¸-blockers (from 36% to 47%). Changes in all 3 indicators were statistically significant at 

An integrated multifactorial approach is essential in addressing the underutilization of therapies available for secondary prevention of CAD. Managed care organizations are in a unique position to optimize the use of evidence-based pharmacological and behavioral therapies to effectively prevent and treat the underlying pathophysiology of CAD in member populations.

The American Heart Association predicts an epidemic of cardiovascular diseases because of an alarming increase in unattended risk factors in younger generations.

Lipid-lowering agents, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers are proven to be effective in secondary prevention of coronary artery disease (CAD).

Managed care organizations should use a multifactorial approach that optimizes membersÃ¢â‚¬â„¢ and providersÃ¢â‚¬â„¢ adherence to guidelines for secondary prevention of CAD.

The multifactorial intervention program of the Hawaii Medical Service Association comprises disease management programs, a practitioner and hospital performance incentive system, CAD-specific clinical practice guidelines, and value-added services for healthcare providers.

The American Heart Association has estimated that 71.3 million Americans (approximately 1 in 4 persons) have at least 1 form of cardiovascular disease (CVD) and that 13.2 million of those with CVD have coronary heart disease.

Coronary heart disease is the single largest killer of American men and women and causes 1 of every 5 deaths in the United States. An American will experience a coronary event approximately every 26 seconds, and someone will die of it about every minute. Coronary heart disease exerts a significant burden on the economy, costing an estimated $142 billion in direct and indirect expenditures in 2005. In 2002, an estimated 6.8 million inpatient cardiovascular operations and procedures were performed in the United States. The American Heart Association predicts that the epidemic of CVDs will continue for years to come because of the alarming increase in unattended risk factors in younger generations. Despite the magnitude of this problem, efforts to prevent or treat CVDs remain inadequate.

To prevent a first occurrence and recurrent episodes of ischemic coronary events, pharmacological therapies play an important role. Individual medications such as antiplatelet agents, statins, ÃƒÅ¸-blockers, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs) are proven to be effective in secondary prevention of coronary artery disease (CAD).

When coprescribed, many of these agents demonstrate an additive effect, and the benefits increase significantly.

 Despite the strong beneficial effect of these agents, secondary preventive therapies continue to be underused. Several articles in the literature point out that healthcare providers are missing valuable opportunities in secondary prevention of CAD with regard to the prescription of statins, ÃƒÅ¸-blockers, and ACE inhibitors.

The evidence for underutilization of life-saving medications in secondary prevention of CAD is further supported by analyses using administrative data sets. A medical record audit of 16 of 58 890 outpatients who had CAD or congestive heart failure showed that among 16 603 patients with congestive heart failure only 50% were taking an ACE inhibitor and only 26% of those achieved the recommended target dosage.

A subgroup analysis that examined 48 586 medical records of patients with CAD demonstrated that only 44% of patients had documented low-density lipoprotein cholesterol testing in the previous year, 39% were receiving lipid-lowering agents, and 25% had reached low-density lipoprotein cholesterol goals.

Addressing the shortcomings in secondary prevention of CAD can produce significant clinical outcomes among patients. The Scandinavian Simvastatin Survival Study

 showed that secondary prevention for patients with CAD by means of lipid-lowering therapy using 20 to 40 mg/day of simvastatin resulted in improved clinical outcomes. During a median follow-up period of 5.4 years, there were 189 coronary deaths (8.5%) in the placebo group and 111 coronary deaths (5%) in the simvastatin group, while 622 patients (28%) in the placebo group and 431 patients (19%) in the simvastatin group had 1 or more major coronary events. These represent 42% and 32% reductions in the relative risks of coronary deaths and major coronary events, respectively. In addition to the benefits in coronary risk reduction, the Scandinavian Simvastatin Survival Study

showed that simvastatin therapy in patients with CAD reduced hospital admissions for acute CVD (including revascularization procedures) by 26%, the mean length of hospital stay by 10%, and the number of hospital days by 34% compared with the placebo group.

Managed care organizations (MCOs) have an important ethical obligation to improve the quality of care that their members receive. Increasingly, MCOs have initiated quality improvement programs to enhance the quality of care provided to members with chronic diseases. Among 6 commercial health plans in the state of Hawaii, the Hawaii Medical Service Association (HMSA) is the largest MCO and is an independent licensee of the BlueCross BlueShield Association. It has a membership of more than 700 000, representing more than half of the state's population.

In an effort to improve the quality of care and health outcomes in members with CAD, the HMSA has put into place a multifactorial approach that optimizes members' and providers' adherence to guidelines for secondary prevention of CAD. One of the primary objectives of this approach is to maximize the use of pharmacological therapy in secondary prevention for members with CAD. The main components of the HMSA's multifactorial intervention program are its disease management programs, practitioner and hospital performance incentive system, CAD-specific clinical practice guidelines, and value-added services for healthcare providers. The specific programs intended for members with CAD and their healthcare providers are described herein:

The HMSA operates 6 disease management programs, collectively known as Care Connection, to help members with chronic diseases lead healthy and productive lives. These programs are run in collaboration with Healthways, a leading provider of comprehensive health and care support programs and services. Among these disease management programs, Cardiac Care Connection targets members with CAD and congestive heart failure. It was initiated in 2000, and more than 10 000 members with CAD are under active management. Cardiac Care Connection is a comprehensive program that addresses all levels of care, including prevention, self-care, and outpatient services, along with extensive collaboration and coordination with members' healthcare providers. Members receive regular health educational mailings, telephone reminders, and support from clinicians. These clinicians help members understand their laboratory test results, medications, and effect of lifestyle choices on their disease progression and symptoms. The program also serves physicians by providing them with educational information such as newsletters, medication reports, and guidelines for care flowsheets. In addition, provider services managers, nurses, and dieticians visit the physicians and their office staff to provide information about the program, offer physician practice support, and collaborate on care coordination for members. Case managers also follow up with members when they are hospitalized to provide support, assist with care coordination, and ensure that they are followed up closely when discharged from the hospital.

The HMSA was one of the first health plans in the nation to initiate a pay-for-performance program in a preferred provider organization setting. The performance incentive system rewards the participating practitioners and hospitals that maintain a high level of patient care and service according to evidence-based practice guidelines.

The Practitioner Quality and Service Recognition program was developed in collaboration with Health Benchmarks, Inc, and initiated in 1998 to reward Hawaii's healthcare practitioners for the quality medical care they provide to their patients. As a pay-for-performance program, the Practitioner Quality and Service Recognition initiative translates accepted industry practices into standards that can be objectively measured through analyses of claims data and other verifiable criteria. More than 2400 participating physicians, psychologists, and optometrists (about 84% of those eligible) are enrolled in the Practitioner Quality and Service Recognition program. Three criteria pertaining to secondary prevention of CAD that are used in determining the awards for providers are the following: (1) the use of lipid-lowering agents, (2) the use of ACE inhibitors or ARBs, and (3) the use of ÃƒÅ¸-blockers. The mean amount of money awarded to providers participating in the Practitioner Quality and Service Recognition program is approximately $4800, and the largest award amounts to $16 000.

Working in tandem with the Practitioner Quality and Service Recognition program is the HMSA's Hospital Quality and Service Recognition program. The Hospital Quality and Service Recognition initiative rewards participating hospitals that achieve specified performance standards based on the best practice guidelines, one of which is Get With the Guidelines established by the American Heart Association.

 Hospitals are awarded monies in relation to their adherence to secondary prevention measures, namely, aspirin therapy on discharge, statin therapy on discharge, ACE inhibitor therapy on discharge, ÃƒÅ¸-blocker therapy on discharge, and smoking cessation counseling.

A third pay-for-performance initiative in the health maintenance organization setting, the Quality and Performance Program, serves more than 150 000 lives and provides monetary awards to health centers for adherence to secondary prevention in following CAD guidelines.

The HMSA's provider advisory committees recommend or amend national treatment guidelines to best fit Hawaii's population, and more than 220 local physicians participate on these committees to help ensure quality and cost-effective healthcare for members. In an effort to maximize the effectiveness of secondary prevention of CAD, the HMSA has developed clinical practice guidelines since 2001 for prevention and treatment of CVDs that conform to those established by the American Heart Association and the American College of Cardiology.

These clinical practice guidelines are continually updated by incorporating feedback from participating providers and through consultation with the provider advisory committees and are disseminated annually to providers.

added Services for Healthcare Providers. 

To provide physicians with support in their efforts to improve secondary prevention of CAD for their patients, the HMSA gives physicians reports concerning their prescribing of lipid-lowering agents, ACE inhibitors, and ÃƒÅ¸:-blockers. For each physician, the report includes the names of their patients who have CAD and 3 columns indicating whether these patients were taking each of the 3 types of medications. These reports use an algorithm similar to that used for the quality indicators in the Practitioner Quality and Service Recognition program. In addition, conferences are held for physicians that offer continuing medical education credits. At the meetings, experts review the literature on the importance of secondary prevention in patients with CAD, and physician-specific reports are distributed. Physicians who do not attend the meetings are mailed their reports.

We aimed to evaluate the effectiveness of the HMSA's multifactorial approach in secondary prevention for its members with CAD. Therefore, the following retrospective study was conducted.

A retrospective observational analysis of claims data was conducted to evaluate the effect of the HMSA's multifactorial approach on members' use of medications for the secondary prevention of CAD. The study included members of the HMSA aged 18 to 75 years who were continuously enrolled during the reporting year and who were identified as having CAD by satisfying at least 1 criterion from inclusion criteria A or from inclusion criteria B during the year before the reporting period through the end of the reporting period (the reporting period was 2000-2004).

Inclusion Criteria A (Evidence of Event). 

At least 2 diagnoses, on separate dates, of acute myocardial infarction, ischemic heart disease, old myocardial infarction, angina, chronic ischemic heart disease, or coronary artery bypass graft.

Inclusion Criteria B (Evidence of Intervention). 

(1) Status diagnosis of coronary artery bypass graft or percutaneous transluminal coronary angioplasty or (2) procedures for coronary artery bypass graft or percutaneous transluminal coronary angioplasty.

Based on the inclusion criteria, a study group of members with established CAD was identified. Among them, the following 3 indicators of quality of care were measured:

Those in the study group who filled 1 or more prescriptions for the following lipid-lowering agents during the reporting year: 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, niacin preparations, and bile salt sequestrants.

Those in the study group who filled 1 or more prescriptions for any of the ACE inhibitors or ARBs during the reporting year.

Those in the study group who filled 1 or more prescriptions for any of the ÃƒÅ¸-blockers during the reporting year.

Claims-based data of members with documented CAD were used to measure the percentages of members who met the criteria of filling 1 or more filled prescriptions for lipidlowering agents, ACE inhibitors or ARBs and ÃƒÅ¸-blockers used in secondary prevention of CAD. Percentages of patients in compliance were tracked over time from 2000 to 2004. The denominator was the number of members with documented CAD who were continuously enrolled in the plan during the reporting year. The numerators for each category were the numbers of members who filled at least 1 prescription of the respective medications during the reporting year. ?

Tests of proportion for statistically significant changes were performed for each calendar year from 2000 to 2004.

summarizes the characteristics of the study population. Fifty-seven percent of the study population was between the ages of 40 and 64 years, while 41.2% were 65 years or older. Thirty-four percent were female. Fifty-five percent had a major or severe morbidity rating, measured using the Johns Hopkins University Adjusted Clinical Group Case-Mix System (http://www.acg.jhsph.edu). Ninety-one percent were in the fee for service plan, while 9.2% were in the health maintenance organization plan.

The process outcomes demonstrated that the prescription rates for all 3 medications used in secondary prevention of CAD consistently improved from 2000 to 2004. The 

 shows the annual percentage changes in the prescription rates for these 3 medications during the reporting period. Use of lipid-lowering agents increased from 55% in 2000 to 71% in 2004 in a cross-sectional cohort consisting of a sample ranging from 12 421 to 13 408 members. Likewise, use of ACE inhibitors or ARBs increased consistently over time from 44% to 55% in a sample ranging from 12 421 to 13 408 members. Use of ÃƒÅ¸-blockers also increased from 36% to 47% in a sample ranging from 12 407 to 13 394 members. Changes in each measure were statistically significant at 

< .001 for each of the years during the study period.

Healthcare providers do not always consider secondary preventive therapy during a patient's hospital stay arising from an acute coronary event, missing an opportunity to improve outcomes. The literature suggests that initiation of these therapies in the inpatient setting aids long-term compliance with these therapies.

Practitioners lose a critical opportunity in secondary prevention of CAD by failing to provide patients with drug therapy during the important transition from hospital care to an outpatient setting. As a result, patients fail to receive medications intended for secondary prevention after an acute episode of CAD.

When patients are treated effectively using secondary prevention strategies, cardiovascular morbidity and mortality can be reduced in a population of patients with CAD. Managed care organizations are uniquely poised to provide their members with a multidisciplinary approach to improve the overall quality of healthcare. By optimizing secondary prevention of CAD, MCOs can expect fewer myocardial infarctions, revascularization procedures, hospitalizations, and deaths among their members.

Several MCOs have published their experience with programs to improve secondary prevention of CAD. The experience of United Healthcare of Illinois provides strong support for the effectiveness of intervention programs among its members with CAD.

The institution of secondary prevention programs and the establishment of diagnosis-related groups by United Healthcare of Illinois decreased hospitalization rates among these members by approximately 25%. In another study, Goff et al

examined the effectiveness of a quality improvement program to increase the use of pharmacological therapies among patients with coronary heart disease in a network-model managed care setting. An analysis of claims data for more than 700 patients from 1999 to 2002 showed that medication use rates increased steadily over time from 38.5% to 44.3% for ÃƒÅ¸-blockers and from 22.9% to 30.3% for ACE inhibitors; an exception was a decrease in statin use in the final year from 53.9% to 46.4%.

Although intervention programs aimed at improving secondary prevention of CAD vary in their effectiveness, researchers agree that multifaceted interventions are more likely to succeed than single strategies. Among combination strategies, those that focus on increased reimbursement for appropriate therapy seem to be more effective in improving adherence to performance measures than other methods such as centralized mailings of guideline summaries, performance feedback reports, and medical record reminders.

The American Heart Association has launched Get With the Guidelines,

an acute care hospital-based program that helps manage risk factors in patients with CAD and myocardial infarction. The HMSA has adopted the program's recommendations for patients in the general population identified as having CAD and has focused on the 3 components of lipid-lowering agent use, ACE inhibitor or ARB use, and ÃƒÅ¸-blocker use. The HMSA's multifactorial programs enable its members to receive evidence-based appropriate pharmacological and behavioral interventions to stabilize and prevent or delay deterioration of CAD. Medication use rates in our study showed consistent increases every year from 2000 to 2004 in the 3 classes of medications (from 55% to 71% for lipid-lowering agents, from 44% to 55% for ACE inhibitors or ARBs, and from 36% to 47% for ÃƒÅ¸:-blockers), suggesting the effectiveness of a multifaceted and integrated intervention program targeted at secondary prevention of CAD. In 2006, the HMSA's Health Plan Employer Data and Information Set performance ranked in the 90th percentile for CVD measures.

The primary limitation of our study is the use of administrative claims data, the validity of which may not be as robust as that of data in a controlled study. The absence of a control group of health plan members who were not part of the intervention program makes it difficult to determine to what extent the trend in medication use was due to the intervention or due to forces outside of the intervention. Measures for adherence to secondary prevention of CAD guidelines in this study represent a low threshold. They only required that a patient fill 1 or more prescriptions among target medications in a calendar year. A more stringent requirement would measure 80% medication possession ratios in the 3 therapeutic classes. Moreover, administrative claims data may underestimate medication use, as some members may receive samples from their physicians or medications through prescription benefits under a different insurer.

A Managed Care Organization's Use of Integrated Health Management to Improve Secondary Prevention of Coronary Artery Disease

To examine whether compliance with national indicators of care differed amongst hospitalists and nonhospitalists. 

Retrospective, observational cohort study. 

March 2007

Failure to Screen: Predictors and Burden of Emergency Colorectal Cancer Resection

Perceived Barriers to and Facilitators of the Implementation of Priority Clinical Preventive Services Guidelines

A Managed Care Organization's Use of Integrated Health Management to Improve Secondary Prevention of Coronary Artery Disease

Comparison of Hospitalists and Nonhospitalists Regarding Core Measures of Pneumonia Care

Should Mitigating Comorbidities Be Considered in Assessing Healthcare Plan Performance in Achieving Optimal Glycemic Control?

All-or-Nothing Treatment Targets Make Bad Performance Measures