Abstracts
from the HMO Research Network
10th
Annual HMO Research Network Conference
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With
this issue we include abstracts from the 2005 11th Annual HMO Research
Network Conference, held in Santa Fe, New Mexico, that focused on
"Translating Research into Practice."
April
4-6, 2005 Santa Fe, NM
"Translating Research Into Practice--Scaling New Heights"
From
HMO Research Network Member: Kaiser Permanente Northern California
Division of Research
Chemical
dependency and psychiatric services for adolescents in managed care:
A research to practice integration model.
Sterling
S, Chi F, Weisner C.
background:
The chemical dependency (CD) field is concerned that much of what
we know about effective treatment is not applied in clinical practice,
particularly for adolescents. According to the literature many adolescents
with CD problems have psychiatric comorbidities, and these adolescents
have less successful treatment outcomes; yet research to practice
studies that address integrated treatment approaches are uncommon.
We examined the impact of psychiatric services on outcomes for adolescents
in CD treatment and discuss them in the context of a research to practice
model developed for adolescent CD treatment in a health plan.
methods:
Participants were 419 adolescents, aged 12-18, seeking treatment
at four CD programs of a nonprofit, group-model health system, and
a parent or guardian for each adolescent. We surveyed participants
at intake and six months, examined diagnostic clinical and administrative
data, and CD and psychiatric utilization, and conducted qualitative
interviews with health plan providers.
results:
Fifty-five percent of the treatment intakes had at least one psychiatric
diagnosis in addition to a substance use disorder. Thirty-one percent
of the full sample had psychiatric visits in the six months after
intake; among those with a psychiatric diagnosis, 54% had a psychiatric
visit. Girls and those with higher psychiatric severity were more
likely to have a psychiatric visit (OR = 2.27, p < .001 and OR
= 1.05, p < .0001). Adolescents receiving psychiatric services
were more likely to be totally abstinent than those not (OR: 1.57;
CI = 0.98, 2.5), and more likely to be alcohol abstinent (OR = 1.68;
CI = 1.00, 2.85). Those at co-located clinics had higher odds of abstinence
from both alcohol and drugs (OR = 1.57; CI = 1.03, 2.39), drugs (OR
= 1.84; CI = 1.87, 2.85), and of returning after intake to initiate
CD treatment than others (OR = 2.28; CI = 1.44, 3.61, p < .001).
conclusions:
Our findings on the high comorbidity of adolescents entering treatment,
their need for services in addition to CD treatment, and how providing
integrated psychiatric and CD services effects treatment outcomes
are enabling us to help shape adolescent health services within the
health plan.
From
HMO Research Network Member: Scott and White Health System
Dolasetron
and transdermal scopolamine vs dolasetron for prevention of postoperative
nausea and vomiting in outpatients undergoing laparoscopic surgery.
Meyer
T, Roberson C, McAllister R, McKinney R, Carl S, Rajab H.
introduction:
Transdermal scopolamine has been reported to be effective in the prevention
of postoperative nausea and vomiting (PONV) and may offer an advantage
as a post-discharge antiemetic for ambulatory surgical patients with
its long duration of action and antimotion sickness properties. Combining
this agent with a 5HT-3 receptor antagonist may provide improved outcomes
for patients undergoing day surgery. The purpose of the study was
to compare the effectiveness of transdermal scopolamine 1.5 mg patch
with dolasetron 12.5 mg IV vs dolasetron 12.5 mg IV alone when administered
for routine prophylaxis for PONV.
methods:
One hundred eighty-four consenting outpatients undergoing elective
laparoscopic surgery with general anesthesia were randomly assigned
to one of two antiemetic prophylaxis groups. Group 1 received transdermal
scopolamine patch two hours prior to surgery and dolasetron 12.5 mg
IV before the cessation of anesthesia. Group 2 received a placebo
patch two hours prior to surgery and dolasetron 12.5mg IV before the
cessation of anesthesia. A visual analog scale was used with a range
of 0 = no nausea to 10 = worst possible nausea. Episodes of nausea
and vomiting, nausea scores, time to first episode of emesis, time
in PACU, total recovery time and the need for rescue antiemetics were
recorded. The incidences of nausea and vomiting and nausea scores
were followed during the recovery period and 24 hours after surgery.
results:
There were no significant differences in the baseline characteristics.
The incidence of nausea and vomiting prior to discharge was less in
Group l (p = 0.02). PONV for the ride home was significantly less
in Group 1 also (p = 0.02). There were no differences in side effects.
Patients' satisfaction scores with their nausea and vomiting treatment
were similar in both groups.
conclusions:
The combination of transdermal scopolamine with dolasetron was
effective and decreased the incidence of PONV prior to discharge as
compared with dolasetron alone. This combination was also effective
in relieving PONV for the patient's car ride home.
From
HMO Research Network Member: Harvard Medical School and Harvard Pilgrim
Health Care
Predictors
of antidepressant nonadherence in a managed care population.
Baumbauer
KZ, Adams AS, Soumerai SB, et al.
background:
Antidepressant management scores are one component of the Health Employer
Information Data Set (HEDIS) used by the National Center for Quality
Assurance (NCQA) to assess quality of care in managed care organizations
(MCOs). Harvard Pilgrim Health Care (HPHC), a New England MCO, was
interested in what factors predicted antidepressant adherence to target
interventions to improve depression treatment.
methods:
We used logistic regression to examine two antidepressant medication
management measures for 5107 HPHC enrollees age 18+ who initiated
antidepressant treatment from May 2002--November 2002. Patients were
included if they had an episode of antidepressant treatment preceded
by at least 100 days without antidepressant use. Only the first such
episode was included for each patient. Outcomes were based on days
of antidepressant dispensed during the episode. Patients were counted
as "acute phase failures" if they had gaps in coverage totaling
more than 30 days during the first 84 days of treatment, approximating
the HEDIS "effective acute phase treatment" measure. "Continuation
phase failures" were patients with gaps totaling more than 51
days during the first 180 days of treatment, approximating the HEDIS
"effective continuation phase treatment" measure. Predictors
included patient age (18-65 and 65+), gender, antidepressant use in
the previous six months, and total months' supply of other medications
dispensed during the six months prior to the episode.
results:
Thirty-five percent of patients failed to adhere to therapy during
the first 84 days of treatment, and 58% during the first 180 days.
History of prior antidepressant use (OR: 0.503, CI: 0.407-0.622) and
other medications used (OR: 1.056, CI: 1.004-1.110) were predictors
of acute phase treatment failure. Only prior antidepressant use (OR:
0.410, CI: 0.321-0.523) remained a predictor of adherence failure
in the continuation phase. Gender and age were not significant predictors
in either model, and other medications used was not a significant
predictor of continuation phase treatment failure.
conclusions:
Antidepressant adherence remains a challenging area for MCOs,
as demonstrated by low adherence rates in this study. Antidepressant
adherence programs should be targeted to patients without a previous
history of antidepressant use and patients with comorbid illness.
From
HMO Research Network Member: Kaiser Permanente Colorado Clinical Research
Unit
Outcomes
from a randomized control trial of an inpatient palliative care service.
Conner
D, McGrady K, Richardson R, Beane J, Venohr I, Gade G.
background:
Findings from previous research highlight the inadequacies of end-of-life
discussions and the management of pain and other symptoms common in
the hospital setting for persons who are nearing the end of life.
Inpatient palliative care programs have been proposed as a strategy
to improve the quality of care for hospitalized patients who are approaching
the end of life.
methods:
Five hundred and twelve patients from three Kaiser Permanente
regions were randomized to receive care from an inpatient palliative
care service (IPCS) consisting of a palliative care physician, nurse,
social worker and chaplain or usual care from a hospitalist. Outcomes
included: 1) changes in self-reported symptoms such as pain, nausea
and sob; 2) patient satisfaction with the care they received, 3) utilization
and costs for a six-month period following hospital discharge; and
4) survival, time to hospice admission, and hospice length of stay.
results:
IPCS patients reported better pain management and greater satisfaction
with symptom management, control over their health care choices, communication
with their health care providers, and had completed significantly
more advanced directives at hospital discharge. Usual care patients
had significantly fewer home health visits (p = .02) and hospital
outpatient visits (p = .001) than IPCS patients. IPCS patients had
significantly fewer ICU stays than did controls (p = .04). IPCS patients
also had significantly longer hospice lengths of stay (p = .01). IPCS
patients had significantly lower costs for hospital readmissions (p
= .001) and outside referrals (provider services outside of the health
plan, durable medical equipment, O2 services, radiology,
physician consults) (p = .03). Usual care patients had significantly
lower pharmacy (p = .04) and outpatient hospital costs (p = .05).
Overall there was a $65.18 per patient per day (p = .07) cost savings
for IPCS patients
conclusions:
IPCS patients reported decreased levels of pain, greater satisfaction
with symptom management, control over their health care choices, and
communication with their health care providers. Cost differences were
the result of more expensive visits/admissions not more visits/admissions.
The greatest cost saving was in hospital readmissions for IPCS patients.
The $65.18 total per patient per day cost savings was due primarily
to the IPCS savings in hospital readmission. These results were not
due to differences in survival between the IPCS intervention group
and usual care. IPCS teams have been operationalized as ongoing,
inpatient consultative service at all three sites.
