Abstracts
from the HMO Research Network
11th
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
Group Health Center for Health Studies, Seattle, WA; University
of Washington, Seattle, WA
Effect
of Mindfulness-Based Stress Reduction on persons with chronic back
pain.
Cherkin
D, Sherman K, Erro J, Deyo R.
background:
Numerous therapies exist for treating chronic low back pain (CLBP)
but few, if any, have been found to be cost-effective. There remains
a need to identify treatments whose benefits outweigh their costs.
This pilot study evaluated the effect on CLBP of an inexpensive
and potentially life-changing training program, Mindfulness-Based
Stress Reduction (MBSR).
methods: Members of a large health plan with uncomplicated
low back pain persisting over three months were invited to participate
in a trial comparing MBSR (eight weekly 2.5 hour sessions) with
a book on self-management techniques. Forty-six volunteers were
randomized to MBSR (n = 22) or the book (n = 24). Outcomes measured
before randomization and after 12 and 26 weeks included function
(Roland) symptom bothersomeness (0 to 10 scale) and general health
status (SF-36). MBSR training participants were also asked about
its effect on their thoughts, feelings, reactions, or activities.
results:
Eighty-two percent of participants randomized to MBSR attended
at least one class (median seven classes). Adjusting for baseline
values, the MBSR group fared better than the book group by 1.9 points
on the Roland scale at 12 weeks (p > 0.05), but by only 0.3 points
at 26 weeks (p > 0.05). Differences in SF-36 and symptom bothersomeness
were small. However, at 26 weeks, all 16 respondents in the MBSR
group claimed to be practicing MBSR for an average of four days
per week and 20 minutes per day and to have experienced lasting
benefits, most commonly decreased stress, increased ability to relax,
increased mindfulness, and ability to cope.
conclusions:
Although this pilot study found only limited and temporary benefits
of MBSR on conventional CLBP outcomes (function, symptoms), informal
qualitative feedback suggests MBSR may have other important benefits
(eg, coping, attitude) for persons with CLBP and possibly for other
conditions caused or exacerbated by life stress.
From
HealthPartners Research Foundation
The boomers are coming: A total cost of care model of the impact
of population aging on the cost of chronic conditions in the US.
Garrett
N, Martini EM.
background:
This study estimates the impact of population aging on medical costs
over the next five decades in the US. The focus is on chronic and/or
expensive conditions often included in disease management programs:
coronary artery disease, congestive heart failure, diabetes, asthma,
obstetrics, psychiatry, and chemical dependency. We go beyond previous
macro-economic studies by modeling the effects of aging on medical
costs at a clinically meaningful level of detail.
methods: Our model applies estimated age-, gender-, and condition-specific
annualized costs to US population projections in each age and gender
group through 2050. This provides an estimate of future health care
costs, assuming the age, gender, and disease cost profiles remain
the same and holding other factors that could affect costs constant.
The primary data sources are pooled claims and membership for 2002-2003
for HealthPartners. Secondary sources are US annualized medical
costs and US Census Bureau demographic projections. Populations
used to create age-specific per capita costs include Commercial,
Medicaid, and Medicare. We group medical claims, pharmacy claims
and demographic information into clinically meaningful Symmetry
episode treatment groups (ETGs) representing complete episodes of
care. We aggregate selected ETGs into the conditions reported in
this study.
results:
We project that from 2000-2050 the aging of the population would
result in an 18% increase in overall medical costs over the next
five decades, with most of the change taking place from 2000-2030.
However, there is a great deal of variation of the impact of population
aging on specific chronic diseases. Diseases where the ratio of
costs for older vs younger ages is greater, such as CAD, CHF, and
diabetes will be affected most by population aging.
conclusions:
These disease-specific projections can inform health policy and
planning as providers of health care, health plans, and disease
management vendors anticipate meeting future US health care needs.
From
KPNW
Effectiveness
and acceptability of complementary and alternative medicine for
temporomandibular joint disorder among HMO members.
Vuckovic
NH, Gullion CM.
background:
We report on a study testing the feasibility, acceptability and
effects of CAM vs Usual Care as treatment for temporomandibular
joint disorder (TMD), a chronic, frequently intractable pain condition.
Although previous studies have indicated the extensive use of CAM
by the general public and by HMO members (including KPNW), as well
as the effectiveness of CAM for treating chronic pain, questions
remained regarding the willingness of HMO members to be randomized
to CAM as opposed to usual dental care for TMD, and about the effectiveness
of the modalities and protocols used in this study.
methods:
Participants were screened via self-report of pain and by a
clinical TMD exam. Eligible volunteers were randomized to either
acupuncture, acupuncture plus herbs, chiropractic, massage, or usual
care. Participants in the CAM arms received ten treatments following
protocols developed by CAM practitioners. Usual care participants
received standard care that included treatment in TMD clinic and
possible referral to classes, physical therapy and/or medications.
Usual care was provided in KPNW TMD clinic; CAM treatments occurred
in practitioners' offices. Study outcomes of change from baseline
in usual and worst pain was measured by self-report questionnaire.
Acceptability of treatment was measured by adherence to treatment,
self-report, and qualitative interviews.
results:
Of the 216 participants randomized, 17 refused initial treatment.
Of the remaining 199 participants, 165 completed the intervention.
We used an intent-to-treat analysis using mixed model analysis of
variance with restricted maximum likelihood estimation to analyze
the effects of treatment. Analysis indicates that CAM treatments
reduced usual and worst pain as well as or better than usual care.
Most patients indicated they would go back to their study provider
or to another CAM provider for TMD treatment in the future.
conclusions:
The apparent positive effects of CAM for chronic pain and its
acceptability and desirability among members suggest that managed
care organizations should consider CAM as a viable service option.
From
Henry Ford Health Systems
Patient-physician
colorectal cancer discussions in primary care.
Lafata
JE, Moon C, Divine G, Williams LK
background:
Routine screening is known to reduce colorectal cancer (CRC)
morbidity and mortality. Yet, many people (including those receiving
routine primary care) fail to receive recommended screening. How
physicians and patients discuss CRC screening and how these discussions
impact screening use is not known.
methods:
We mailed surveys to 4966 HMO enrollees aged 50-80 years with a
recent visit to a PCP. The survey collected information on the content
of CRC screening discussions (including the "5 As": Assess,
Advise, Agree, Assist, and Arrange) as well as patient preferences
for shared decision making. Survey responses were linked with five-year
claims data on prior CRC screening use. We estimate the proportions
of primary care patients receiving recommended CRC screening, discussing
CRC screening with their physician and, among those discussing CRC
with their physician, reporting different elements of discussion
content.
results:
Among the 2513 survey respondents (50.6% response rate), 58.7% were
female, 68.1% were married, and 34.4% were African American. Fifty-four
percent received recommended CRC screening and 79.6% reported discussing
CRC screening with their physician. The most frequently discussed
screening modality was colonoscopy (70.7%), followed by sigmoidoscopy
(41.4%) and fecal occult blood testing (40.6%). Approximately two
thirds indicated discussing their interest in screening ("assess"),
36.1% reported being offered a choice among different screening
modalities ("advise") and 31.1% were asked about their
preferences for different types of tests ("agree"). Over
half (55.5%) reported receiving help making an appointment ("assist")
and 60.9% indicated receiving information on how to get test results
("arrange"). Three quarters of respondents indicated they
were involved in the CRC screening decision-making process as much
as they wanted and 13.9% indicated there was information they wanted
but not discussed with their physicians.
conclusions:
The majority of primary care patients report discussing CRC screening
with their physicians. Yet, the content of these discussions varies
and almost half have not received recommended CRC screening. Given
the limited time PCPs and patients have to discuss CRC screening,
it is important that discussions be as productive as possible. Whether
the use of a shared decision-making process and the "5 As"
lead to improved CRC screening adherence remains an important question.
From
HealthPartners Research Foundation
Relationship of psychosocial and health factors and continuity of
care to ED use among seniors.
Whitebird
RR, Gunnarson TM, Flottemesch TJ, Asche SE, Martinson BC, Degelau
JJ.
background:
This study examines the relationship between Emergency Department
(ED) use and health status, psychological, social factors, and continuity
of primary care in a senior population of HMO members.
methods:
An observational study using survey data and two-year prospective
administrative data in a sample of 11,338 seniors enrolled in an
HMO from 1995 through 1997. The study used multinomial logistic
regression analysis to model relationships between biopsychosocial
factors, continuity of care and ED utilization. Health status and
social support measures were collected by survey. Depression was
measured with administrative data using ICD9 codes. Continuity of
primary care was calculated based on the number of visits with a
single primary care provider for patients with two or more primary
care visits.
results:
The mean age of the study population was 73 years of age, 42% were
male, 27% reported living alone, 13% had a Charlson score of two
or greater, 29% of the population had ED use during the two-year
study period. Results showed that advanced age, male gender, Charlson
score, poor perceived health, higher medication use, falls within
the prior six months, need for assistance with activities of daily
living, and use of assistive devices were significantly related
to one ED visit. Age > 75, multiple medications, depression,
low social contact, living alone, bereavement in the prior six months,
and low continuity of primary care were related to multiple ED visits.
conclusion:
ED use among seniors is correlated with a complex of physical, health
status and psychosocial factors. Psychosocial factors and low continuity
of primary care were strongly related to multiple ED visits. Interventions
directed to ED use among seniors should include components that
address these psychosocial issues and improve continuity in the
provision of primary care, in addition to the management of chronic
conditions and declining health status.
