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 HealthPartners Research Foundation
Colon cancer surveillance in survivors.
Rolnick S, Kucera GP, Alford SH, et al.

background: The purpose of this analysis is to describe, among a multiethnic HMO population, the compliance of colorectal cancer survivors with postdiagnosis surveillance recommendations.
methods: Subjects were identified as part of the Cancer Research Network's study of colorectal cancer survivors. To be eligible for the main study, patients had to be part of the staff model components of health maintenance organizations in southeastern Michigan and Minnesota. Using computerized databases, individuals were identified who were 40 years or older with incident local or regionally invasive colorectal cancer diagnosed between January 1, 1990 and December 31, 2000. Using data current through 2002, we analyzed the cohort using actuarial tables and Cox proportional hazard models to understand variations in postdiagnostic surveillance practices. We defined compliance to be the receipt of a complete colonic surveillance exam within 24 months after diagnosis and compared the characteristics of those who were and were not compliant. We also included an analysis comparing those who received an exam and those who didn't regardless of exam timing.
results: A total of 995 patients were eligible for the main study. Of these, 964 (97%) were included in this analysis. Twenty-five percent of subjects were African-American, 42% were female, and 62% were 65 years or older. The proportion who received an exam within 24 months was 68%. The Cox proportional hazards model for compliant exams and overall examinations both showed that African Americans and those 65 at the time of diagnosis were statistically less likely to receive an exam. However, among those who received an exam there is not a clinically meaningful difference in the month until exam by race (14 vs 16).
conclusion: Our data indicate that colorectal cancer survivors who are 65 at the time of diagnosis or who are African American are less likely to be compliant with postdiagnostic surveillance recommendations. Whether these differences are due to system- or patient-level barriers needs further study.

From Henry Ford
Cord blood stimulated t-cell interferon--production varies by race in an HMO-based birth cohort.
Johnson CC, Maliarik MM, McCabe M, et al.

background: The prevalence of allergic disorders has risen worldwide. One facet of the Hygiene Hypothesis proposed to account for this increase is that infants destined to be atopic are more likely to have a Th2 rather than Th1 helper cell predilection. African-American children have higher total IgE at birth and a heightened risk of asthma, which could be explained by a muted Th1cytokine response. Using the recently established Detroit area WHEALS birth cohort, we analyzed, by race, the level of CD4+ and total cell production of interferon-gamma (IFN-gamma) in cord blood as an early marker for Th1 propensity.
methods: Pregnant women residing in a geographically circumscribed urban and suburban area attending four medical group clinics and due to deliver after 8/31/03 were recruited and interviewed. Cord blood samples were obtained and IFN-gamma production by stimulated lymphocytes was measured using a whole blood assay. Intracellular cytokine production by CD4+ and CD4- lymphocytes was detected by antibody staining and flow cytometry. Two sample Mann Whitney tests were used to compare mean IFN-gamma levels.
results: Cord blood IFN-gamma was measured in 54 white and 62 African-American newborns. Babies of European descent had a statistically significantly different mean IFN-gamma level produced by CD4+ cells, 1.28%, compared to African Americans, 0.67% (p < 0.041), a pattern also found for total IFN-gamma production.
conclusions: IFN-gamma, a Th1 marker potentially indicating lower risk for atopic disorders, was found to be higher in newborns of European compared to African descent in this population-based birth cohort.

From HealthPartners Research Foundation
Identifying depression cases from clinician notes using natural language processing.
Fischer LR, Rush WA, Kluznik JC, et al.

background: In research studies in health care systems, depression cases can be identified through diagnosis (ICD-9) codes. However, because most encounters have only one or two ICD-9 codes, it is likely that depression often is under-coded. Clinician notes offer an alternative source for identifying depression. While traditional chart audits are time-consuming and costly, natural language processing (NLP) tools can be used to enhance case identification where clinician notes are available in electronic form.
methods: An ACCESS-based computer tool was developed to elicit key terms in open-ended text data. The tool has the capability to track key terms (words, parts of words or phrases), link these terms with identifiable clinician notes, and create a list of phrases with the key term embedded. A qualitative analysis was used to identify key terms and exclusion terms. To test the viability of this approach, a random sample of 1000 adult HMO patients with no ICD-9 code for depression was selected in 2001, along with 100 patients with a depression ICD-9 code. Using a list of phrases that included the embedded term "depression," a researcher coded all cases with an appropriate indication of depression, excluding inappropriate uses of the terms ("denies depression," "depression fracture," "no history of depression" ...).
results: Of 1000 patients with no depression code, 133 (13%) had no encounter. Among the 867 remaining cases, depression was noted for 51 patients--that is, 5% of this sample had at least one depression-related encounter but would have been missed by ICD-9 codes alone. The term "depression" was used in 91 of 100 cases with an IDC-9 code for depression.
conclusions: ICD-9 codes for depression miss substantial numbers of cases. The NLP tool provides an efficient way to enhance the identification of cases. This tool could also be used for other diagnoses. Further, as more and more medical providers establish paperless offices, NLP will be increasingly useful in both research studies and clinical practice.

From Kaiser Permanente Northwest
Continuity of care, relationships with mental health providers, and recovery from severe mental illness.
Green CA, Polen MR, Wisdom JP, Vuckovic N, Perrin NA, Paulson RI.

background: A substantial majority of individuals with serious mental illness make either a full recovery or function well and contribute to society, yet little is known about factors that foster or impede the recovery process. Good relationships with mental health care providers and continuity of care have been identified as potential facilitators of better outcomes, but continuity of care findings have been inconsistent.
methods: Study participants are 178 Kaiser Permanente Northwest Members (93 women, 85 men) with serious mental illness (primarily schizophrenia, shizoaffective disorder, or bipolar disorder) in a longitudinal study of recovery. At baseline, participants completed two in-depth interviews detailing personal and mental health care history and current life circumstances, and a paper- and pencil questionnaire that included measures of satisfaction with mental health care providers, quality of life, symptom levels, and recovery status. Questionnaire data are linked to health plan records of services used and identifiers for providers of those services.
results: Preliminary analyses of qualitative data indicate that continuity of care and having a good relationship with one's provider have important independent positive impacts on recovery. Consumers fortunate enough to experience both components appear to have the best outcomes. Mental health providers who collaborate with consumers to develop and test plans of care acceptable to both clinician and consumer, particularly regarding medications, are seen as more helpful and more competent. Clinicians who are kind, caring, understanding, supportive, and interested in their patients as "persons" facilitate development of strong and trusting relationships that increase consultation and requests for help during periods of increased symptoms. Quantitative analyses show that good relationships with mental health care providers, and patient-directed recovery-oriented care lead to better quality of life and improved recovery, in part because of greater satisfaction with medications and lower levels of symptoms.
conclusions: Continuity of care, patient-directed recovery-oriented care, and positive relationships with mental health providers, facilitate recovery. Trusting relationships with providers may take significant time to develop, particularly when individuals have had bad experiences with care or have been treated involuntarily. Previous research examining continuity of care may not have followed people for periods long enough to observe these outcomes; lack of attention to the relationship between consumer and provider in the context of continuity of care may also have obscured findings.

From Meyers Primary Care Institute
Utility of referral and consultation letters between primary and specialty pediatricians.
Stille CJ, Mazor KA, Nagberg N, Grimes J, Wasserman RC.

background: Primary care (PCP)-to-specialist (SP) communication is essential in care coordination for children with special health care needs (CSHCN). To maximize the efficiency of communication, its optimal content must be determined. We investigated the relationship between content elements (CE) and value of letters sent between PCPs and SPs in specialties serving mainly CSHCN.
methods: PCP-to-SP and SP-to-PCP communication was abstracted from records of 82 patients newly referred to pediatric SPs in five specialties in an HMO and an academic medical center. Communication was independently reviewed by two pediatric nurse practitioners. Reviewers assigned a value for each PCP-to-SP and SP-to-PCP communication on a five-point scale from "not useful" to "very valuable." Values were averaged between reviewers. The presence of essential CE identified previously was most important for pediatricians also was noted, with disagreements decided by the principal investigator. Relationships between each CE and value were assessed using t-tests, and relationships between the number of CE in each communication and value using Pearson's R Significance was determined at p < .01.
results: Communication from PCP-to-SP was found in 21 (26%) visits, and from SP-to-PCP in 58 (71%). There were a mean of 3.6 + 1.4 out of six CE for each PCP-to-SP communication (mean value 3.2 + 1.0) and 8.1 + 2.0 out of 12 CE (mean value 4.0 + 0.7) for each SP-to-PCP communication. The number of CE correlated significantly with value for PCP-to-SP (r = .831) and SP-to-PCP (r = .725) communication. Most common PCP-to-SP CE were history (81%), lab results (81%) and reason for referral (76%). Ninety-one percent of SP-to-PCP letters had a diagnosis, while only 31% covered comanagement and 30% had education for the PCP, PCP-to-SP CEs associated with increased value were also the three most common CE above. Most SP-to-PCP CE were associated with increased value, with the strongest being education (p < .001, mean difference 1.04 points), diagnosis (p < .001, mean difference 0.93) and reasoning behind diagnosis (p < .001, mean difference 0.84).
conclusions: PCP-to-SP communication is uncommon but its content is appropriate. SP-to-PCP communication is more common but could be improved by more educational content.