The American Journal of Managed Care, September 2004, Volume 10, Issue 9 Abstract

Offering Telephone Counseling to Smokers Using Pharmacotherapy

Boyle R, Solberg L, Pronk N, Enstad C, Boucher J, Asche S


Raymond G. Boyle, PhD, MPH, HealthPartners Research Foundation, PO Box 1524, MS#21111R, Minneapolis, MN 55440. E-mail: raymond.boyle@healthpartners.com.

Background: Telephone counseling has generated widespread popular interest as a treatment modality for smoking cessation. We are currently testing the potential of telephone counseling offered proactively in a health plan setting.

Objective: To report the 3-month outcomes of a telephone counseling smoking cessation program.

International Classification of Diseases, 9th Edition–Clinical Modification

Methods: Project Help is a randomized trial of the effectiveness of an invitation to participate in telephone counseling among members of a large mid-western health plan. Health plan members who filled a prescription for Zyban or nicotine replacement were mailed a letter describing available resources for smoking cessation, including telephone counseling. An equal number of these smokers with and without an code for a chronic disease affected by smoking were randomly selected to be invited by telephone to participate in a telephone course for smoking cessation.

Results: More than 1300 smokers were included in the trial, and 76% completed a follow-up survey at 3 months. In this paper we use an intent-to-treat analysis to report the outcomes at three months by invitation group and across chronic condition.

Conclusions: We will report the benefits and limitations of telephone counseling provided to smokers after they begin using medications to quit smoking. In addition we will discuss the policy implications of linking medication use with telephone counseling.

Influence of Body Mass Index (BMI) on Perceptions of Motivators, Barriers, and Ability to Increase Vegetable Intake in a Cancer Prevention Intervention Trial

Alexander G, Johnson CC, Sankey S, Strecher V


Gwen L. Alexander, PhD, MPH, Henry Ford Health System, 1 Ford Place, Suite 5C, Detroit, MI 48202. E-mail: galexan2@hfhs.org.

Background: Lower body mass index (BMI) and a diet rich in vegetables are known to reduce cancer risk.

Objective: To evaluate the relationship between BMI and perceptions related to increasing vegetable intake.

Methods: Adults enrolled in a trial to improve modifiable cancer risk factors, whose chosen behavior at baseline was to increase vegetable intake, were included. Participants (n = 906) were classified into low (< 24.9 [26.4%]), middle (25.0—29.9 [35.0%]), and high (> 30 [38.6%]) BMI. Chi-square tests and ANOVA were used to compare motivators and barriers to behavior change.


Results: No differences by BMI were found for barriers including expense, taste, shopping, knowing how to prepare, and family food preferences. Top motivators were to "feel healthier" (55%) and to "set a good example for family members" (40%). Motivators did not vary by BMI except for "weight control or loss" ( < .0001). No difference was found by BMI in ratings of self-efficacy or confidence in ability to increase vegetable intake.

Conclusions: Perceived ability or barriers to change dietary patterns did not differ by BMI. This analysis suggests that those at highest health risk (BMI > 30) are unrealistic about their ability to make nutritional changes that decrease cancer risk.

Cluster-Randomized Controlled Trial of 3 Different Interventions to Improve Antihypertensive Prescribing in Primary Care

Simon SR, Majumdar SR, Kleinman KP, et al.


Steven R. Simon, MD, MPH, Department of Ambulatory Care & Prevention, Harvard Medical School, 133 Brookline Avenue, 6th Floor, Boston, MA 02215.

Background: Academic detailing, also called educational outreach, has been shown to improve individual physicians' prescribing practices but is perceived to be costly and labor intensive and, as a result, is not widely used.

Objective: To compare traditional one-on-one individual academic detailing (IAD) with group academic detailing (GAD), and compare these methods with mailed guideline dissemination (MG) within 1 large managed care organization to improve the use of antihypertensive medications in primary care.

Methods: We conducted a cluster-randomized controlled trial, allocating 3 practice sites to IAD (n = 235 prescribers and 2478 patients), 3 to GAD (n = 227 and 2352), and 3 to MG (n = 319 and 3575). The goal of the intervention was to increase the use of diuretics and beta-blockers (DIUR-BB), the guideline-recommended first-line agents. The IAD intervention consisted of a single physician visit following established principles of academic detailing; the GAD intervention was a single group session incorporating those principles, also led by a trained physician.

Results: At baseline, sociodemographic characteristics and rates of prescribing DIUR-BB among newly diagnosed and treated patients with hypertension were almost identical in the 3 experimental groups: IAD = 57.6%, GAD = 59.1%, and MG = 57.6%. In the 9-month period following the intervention, rates of DIUR-BB use increased by 21.7% in IAD, 22.3% in GAD, and 10.8% in MG. Compared with MG patients, DIUR-BB use among patients with newly diagnosed hypertension was more likely in both IAD (OR 1.40; 95% CI, 1.07-1.84) and GAD (OR 1.30; 95% CI, 0.89-1.90), controlling for physician-level clustering. The effects of IAD and GAD were of similar magnitude. There was no apparent effect of the intervention on continued rates of switching patients previously treated with medications other than DIUR-BB to the guideline-recommended agents.

Conclusion: Both IAD and GAD improve antihypertensive prescribing over and above the dissemination of guidelines. If GAD is confirmed to be as effective and less expensive than IAD, it may represent a more attractive option for improving practice.

Results of a Randomized, Controlled Trial to Improve the Management of Osteoporosis After Fracture

Feldstein AC, Elmer PJ, Smith DH, et al.


Adrienne C. Feldstein, MD, MS, Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave., Portland OR 97227-1110. E-mail: adrianne.c.feldstein@kpchr.org.

Background: Prior work found that 54% of women do not receive guideline-recommended bone mineral density (BMD) measurement or medication for osteoporosis after a fracture.

Objective: To report 6-month data from the Re-Fracture Intervention Trial (REFIT), which was designed to evaluate methods to increase the proportion of these patients who receive BMD measurement or a medication for osteoporosis.

Methods: The study enrolled 311 female Kaiser Permanente Northwest members aged 50-89 who had recently suffered an osteoporotic fracture but who had not received a BMD measurement or a medication for osteoporosis. The participants were randomly assigned to usual care or 1 of the 2 interventions: 1) patient-specific clinical guideline advice to the primary care provider (PCP) delivered through an electronic medical record in-basket message (EMR reminder); or 2) EMR reminder plus an advisory letter with educational materials mailed to the patient (patient reminder). We collected baseline and follow-up data from a questionnaire and our electronic databases. We used logistic regression to evaluate the response to the interventions. The primary outcome was BMD measurement or a medication for osteoporosis at 6 months.




Results: At 6 months, EMR reminder alone resulted in 51% of patients receiving a BMD measurement or an osteoporosis medication as compared with 6% in usual care ( < .0001). Electronic medical record reminder plus patient reminder resulted in 43% receiving a BMD measurement or an osteoporosis medication as compared with 6% in usual care ( < .0001). The effect of the EMR reminder alone was not significantly different from the EMR reminder plus patient reminder ( = .23). Fracture type, age, weight <127 lb, and diagnosis of osteoporosis were not significantly associated with response to the intervention. Participants with a higher Charlson comorbidity index were less likely to receive a BMD test measurement.

Conclusions: REFIT Phase I demonstrated that patient-specific clinical guideline advice to the PCP through an EMR in-basket message following a fracture is highly effective for increasing use of BMD measurement and osteoporosis medication. As EMRs become more widely adopted, this intervention could significantly improve the management of osteoporosis for many postfracture patients. The direct-to-patient intervention will need to be strengthened to improve outcomes.

Improving Osteoporosis Screening Among Elderly Women

Muma B, Lafata JE, Kolk D, Peterson E


Jennifer Elston-Lafata, PhD, Center for Health Services Research, Henry Ford Health System, 1 Ford Place, 3A, Detroit, MI 48202. E-mail: jlafata1@hfhs.org.

Background: The US Preventive Services Task Force and the National Osteoporosis Foundation recommend that women age 65 years or older be screened routinely for osteoporosis. Current estimates are that only 20% of this population has received a bone density test. Thus, a large number of elderly women are at risk of avoidable late-stage osteoporosis and its consequences.

Objective: To report preliminary findings of a randomized prospective study designed to evaluate strategies to enhance the quality of care for osteoporosis in this high-risk population.

Method: We identified women aged 65-89 who received their primary care from 15 ambulatory care clinics staffed by a large medical group in southeast Michigan between April 1, 2001 and March 31, 2003. The clinics were stratified by size and bone mineral densitometry (BMD) equipment availability, and randomized to 1 of 3 types of osteoporosis disease management strategies: (1) usual care; (2) mailed patient letters; and (3) mailed patient letters plus physician prompts. Women who received care from the clinics who had a BMD test, a diagnosis for osteoporosis, or a prescription drug claim for an osteoporosis-specific therapy (alendronate, risedronate, raloxifene, or calcitonin) were excluded. There were 10 565 eligible women included in the study, broken down as follows: Strategy 1 clinics (n = 3110); Strategy 2 clinics (n = 3368); and Strategy 3 clinics (n = 4087). Statistically significant differences in BMD testing rates were evaluated using generalized estimating equation approaches.



Results: Preliminary analyses indicate a BMD screening rate of 2% in the usual care group, compared to 2% in the mailed patient letter group and 9% in the mailed patient letter plus physician prompt group. Differences between usual care and patient mailed reminders alone were not statistically significant ( = .67). The use of patient mailed reminders plus physician prompts lead to significant improvements in BMD testing compared to both usual care and patient mailed reminders alone ( <.001). Results did not change with adjustments for clinic, race, or both.

Conclusion: Preliminary results indicate that the use of mailed patient reminders in combination with physician prompts can lead to significant increases in osteoporosis screening compared to usual care and the use of mailed patient reminders alone.

Effect of Changes in Medication Cost-Sharing on Oral Hypoglycemic Use Among Diabetes Patients

Roblin DW, Platt R, Goodman MJ, et al.


Douglas Roblin, PhD, Kaiser Permanente Georgia, 3495 Piedmont Rd. NE, Bldg 9, Atlanta, GA 30305. E-mail: douglas.roblin@kp.org.

Background: In recent years, health insurance plans have added pharmacy benefit options that substantially increase patient cost sharing. There are few current studies on how high levels of cost sharing might affect medication use by the chronically ill.

Objective: To compare change in oral hypoglycemic (OH) use among adults with diabetes mellitus (DM) who experienced increases in medication cost sharing compared with those who experienced constant medication cost sharing over a 12-month time period.

Methods: Quasi-experimental, time series with comparison group design. Adults with DM in 5 managed care organizations (MCOs) that experienced an increase in medication cost sharing (intervention, n = 13 407) were matched with those who had no increase (n = 13 407). All patients had sustained OH use in a 6-month pre-intervention period and a pharmacy benefit for the 12-month observation period. Patients were matched on pre-intervention benefit, type of OH use, and intervention year (1997-2000). The dependent variable was average daily dose (ADD) standardized to each patient's mean ADD in the 6-month pre-intervention period. The principal independent variable was change in patient cost per 30 days OH supply between the 6-month pre- and post-intervention periods. Effect of change in cost sharing on standardized ADD was estimated using both time series regression models and hierarchical linear models (to assess effects of patient covariates).




Results: At 6-months following an increase in cost-sharing, patients with >$10 increase ($20 median increase) had 20.0% lower mean standardized ADD ( < .05) than that predicted from their pre-intervention trend in standardized ADD. Patients either with no change in cost sharing or with a $1-$5 ($3 median) or a $6-$10 ($6 median) increase did not experience a significant change between the pre- and post-intervention periods in the expected trend of increasing OH dose. 11.5% of those with >$10 increase discontinued their pre-intervention OH medication compared with 6.0% of those with no increase ( < .05). Post-intervention mean standardized ADD among those with >$10 increase remained significantly ( < .05) lower than that among those with no cost-sharing change after adjusting for patient age, gender, concurrent insulin use, and imputed household income.

Conclusions: Large increases in medication cost sharing (>$10 increase per 30-days supply) were associated with significantly reduced OH use; more modest increases ($1-$10) were not. Whether these reductions in OH use are clinically important (eg, leading to worse glycemic control) remains to be investigated.

Feasibility of Screening for Peripheral Arterial Disease in Populations Not Known to Have Cardiovascular Disease

Doubeni CA, Yood R, Emani S, Gurwitz JH


Chyke A. Doubeni, MD, MPH, Department of Family Medicine and Community Health, University of Massachusetts, 55 Lake Ave North, Worcester, MA 01655. E-mail: Chyke.Doubeni@umassmed.edu.

Objective: Peripheral arterial disease (PAD) is a coronary artery disease equivalent in the risk of future cardiovascular events. We assessed the feasibility of routine screening for PAD in patients not known to have coronary heart disease (CHD) in primary care settings.

Methods: We identified patients 50 years and older using administrative databases of a managed care organization in central Massachusetts. Patients were eligible for inclusion in the study if they were 70 years and older, or if they were aged 50 through 69 years with a diagnosis of diabetes mellitus, hyperlipidemia, hypertension, and/or cigarette smoking as documented in the administrative databases. Participants completed a telephone questionnaire to ascertain their medical history. We excluded patients with a diagnosis of CHD and/or PAD. Measurements of the ankle-brachial index (ABI) on persons at risk were taken; PAD was diagnosed if one or both legs had an ABI of 0.90 or less.




Results: ABI testing was performed on 717 subjects. PAD was diagnosed in 54 (7.5%, [95% CI, 5.6%-9.4%]) of the participants. Age was significantly associated with a diagnosis of PAD (&#967;2 = 35.6, < .0001). Persons 70 years and older had about a 6 times greater risk of having PAD compared to those aged between 50 and 69 years (12.5%, vs. 2.5%; unadjusted OR: 5.6; 95% CI, 2.7-11.6; < .0001). In the population studied, a history of smoking cigarettes (OR: 2.1; 95% CI, 1.2-3.9, = .01) was also a significant predictors of having PAD.

Conclusions: Undiagnosed PAD is common among older persons not known to have CHD, but screening for PAD should target only persons at high risk. More research is required to better define the role of routine ABI testing in primary care settings, especially among younger patient populations.

Colorectal Cancer Screening in Primary Care

Lafata JE, Divine G, Ben-Menachem T, Williams LK, Moon CH.


Jennifer Elston-Lafata, PhD, Center for Health Services Research, Henry Ford Health System, 1 Ford Place, 3A, Detroit, MI 48202. E-mail: jlafata1@hfhs.org.

Background: Despite evidence-based recommendations for colorectal cancer (CRC) screening, reported screening rates remain low and the factors associated with them are not well understood.

Objective: To estimate 5-year colorectal cancer screening procedure use and associated factors among insured, primary care patients.

Methods: Retrospective cohort analysis using automated clinical and administrative data. Eligible patients were aged 55-70 with a visit to a primary care (PC) clinic in 2002; had no history of CRC or related disease; and were continuously enrolled in an affiliated health plan for the 5-year period ending December 31, 2002 (n = 8256). Per evidence-based guidelines, CRC screeners were defined as those receiving at least 1 sigmoidoscopy, colonoscopy, or barium enema, or 3 or more fecal occult blood tests (FOBTs) within the prior 5 years. Generalized estimating equation approaches were used to test for adjusted and unadjusted associations with screening receipt.


Results: Average age of the cohort was 61 years; 59% were female, 34% African American, and 72% married. In 2002, 48.0% of the cohort met the criteria for CRC screening receipt. Of those, 6.4% had a colonoscopy, 17.1% a sigmoidoscopy, 1.9% a barium enema, 8.4% 3 FOBTs, and 14.2% a combination of these services. Although FOBT receipt increased over time (1998, 16.8%; 2002, 23.2%), on average individuals received <1 test and only 19.0% received 3 or more FOBTs during this period. In models that accounted for the nonindependence of patients receiving care from the same physician and that adjusted for age, sex, race, marital status, income, PC visit frequency, Charlson comorbidity index, and clinic, we found CRC screening was significantly ( < .05) associated with increasing age (OR = 1.03), being married (OR = 1.15), income (OR = 1.07 per $10 000), PC visits (OR = 1.06), decreasing Charlson score (OR = 0.98), and clinic affiliation.

Conclusions: Even among an insured population, less than half of patients presenting in a PC clinic had been screened for CRC. Specifically, younger, unmarried persons with relatively more comorbidities and fewer PC visits were less likely to have been screened. Also, those residing in low-income neighborhoods were less likely to have been screened. Addressing the CRC screening needs of both individuals with potentially competing comorbidities and those with relatively limited PC contact presents a challenge, particularly without overwhelming already busy PC practices.

Documentation of Tobacco Services in the Medical Record: Promoting Treatment and Quality of Care

Quinn VP, Stevens VJ, Smith KS, Ritzwoller D, on behalf of the HIT study investigators.


Virginia. P. Quinn, PhD, Sr. Scientist, Research & Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., Pasadena, CA 91188.

Background: The US Public Health Service clinical practice guideline for treatment of tobacco use calls for health systems and clinicians to identify, document, and treat every smoker seen in a healthcare setting. Health maintenance organizations can play an important role in addressing the substantial health and economic burdens associated with smoking. Documentation of the recommended "5 A" tobacco services (ask, advise, assess, assist and arrange) in the medical record facilitates identification and treatment of smokers, and is essential for continuity of care.

Objective: To assess clinician compliance with national and health plan tobacco control policies through review of the outpatient medical records of smokers.

Methods: The HMOs Investigating Tobacco (HIT) study was conducted in 9 nonprofit HMOs participating in the National Cancer Institute-funded Cancer Research Network. Together these health plans serve more than 8 million Americans and have a 30% minority enrollment. The HIT study reviewed the medical records of 2644 smokers identified in a mailed survey.

Results: In notations from 12 months of primary care utilization among smokers who reported making at least 1 visit, we found documentation that 89% of smokers were asked about smoking, 47% were advised to quit, 18% were assessed for their willingness to quit, 22% were assisted with self-help, behavioral, or pharmacotherapy treatments, and 1% had a follow-up contact arranged. These rates are substantially lower than those reported by the smokers. For example, we only found documentation of advice among half of the smokers who told us they were advised, and for assistance only among 26% who reported receiving treatment. Results from plans with electronic medical records were similar to results from plans with traditional paper charts.

Conclusions: All plans in the HIT study have clinical practice guidelines that call for the identification and treatment of tobacco use. Reports from smokers and evidence from the medical record reveal there is substantial room for improvement in delivery of the "5As." Documentation of tobacco services in the medical record remains a missed opportunity to improve tobacco control efforts and quality of care.

Self-Reported Effects of ED Cost Sharing in 2003: Delayed Care and Care Alternatives

Reed M


Mary Reed, MPH, Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA 94612. mer@dor.kaiser.org.

Background: There is limited information on patients' knowledge of their out-of-pocket costs for emergency care and patient behavior in response to this cost sharing.

Methods: We conducted a cross-sectional telephone-interview study among a random sample of adult integrated delivery system (IDS) members, with over-sampling of members age 65 years or older. Subjects reported their emergency department (ED) copayment, and then reported whether their copayment amount had caused them to seek care from places other than the ED (eg, primary care clinic, urgent care clinic, phone call to primary care physician, phone call to advice nurse). We also compared patients' self-reported copayment levels with their actual levels.

Results: The 926 subjects (response rate = 72%) had a mean age of 67 years, tended to be female (57%), and to have Medicare insurance (71%). In addition, 74% reported white race/ethnicity; 44% reported having "excellent" or "very good" health status; 67% reported less than a college-graduate education; and 43% reported an annual household income of less than $35,000. Furthermore, 31% reported having no copayment, 18% reported $1-19, 18% reported $20-49, 28% reported $50-74, and 6% reported a copayment &#8805;$75. Compared with actual benefits, 76% of subjects accurately reported whether they had any copayment or not; 41% accurately reported their exact copayment amount; 46% underestimated, and 13% overestimated. Overall, 16% of respondents reported that the copayment caused them to seek care from someplace other than the ED in the past 12 months. In multivariate analyses, higher self-reported ED copayment level, female gender, lower income, and lower self-reported health were significantly associated with patient reports of seeking alternative sources of care.

Conclusions: Patients appeared to have general knowledge of their copayment, but many patients underestimated the amount. Their perceived costs strongly influenced whether patients substituted emergency care with an alternative source of care. These preliminary findings suggest that as patients develop better knowledge of their actual costs, more patients might seek less expensive alternatives to emergency care. Further research is needed to assess the potential clinical and economic effects.