Krikor Soghikian

HOME BLOOD PRESSURE MONITORING : EFFECT ON USE OF MEDICAL SERVICES AND MEDICAL CARE COSTS

The objective of this study was to determine whether a hypertension management program in which patients monitor their own blood pressure (BF) at home can reduce costs without compromising BP control. The prospective, randomized, controlled 1-year clinical trial was conducted at four medical centers of the Kaiser Permanente Medical Care Program in the San Francisco Bay Area. Of 467 patients with uncomplicated hypertension who were referred by their physicians, 37 declined to participate in the study; 215 were randomly assigned to a Usual Care (UC) group and 215 to a Home BP group. Twenty-five UC patients and 15 Home BP patients did not return for year-end BP measurements. Patients in the UC group were referred back to their physicians. Patients in the Home BP group were trained to measure their own BP and return the readings by mail. Patients were given a standard procedure to follow in case of unusually high or low BP readings at home. The number and type of outpatient medical services used were obtained from patient medical records for the study year and the prior year. Costs of care for hypertension were calculated by assigning relative value units to each outpatient service. Trained technicians measured each patients BP at entry into the study and 1 year later. Home BP patients made 1.2 fewer hypertension-related office visits than UC patients during the study year (95% confidence interval (CI): 0.8,1.7). Mean adjusted cost for physician visits, telephone calls, and laboratory tests associated with hypertension care was

Randomized trial of case-finding for depression in elderly primary care patients.

88.76 per patient per year in the Home BP group, 29% less than in the UC group (95% CI:

Alcohol-Related Health Services Use and Identification Of Patients in the Emergency Department

16.11,

Alcohol problems and sense of coherence among older adults

54.74). The annualized cost of implementing the home BP system was approximately

Senior Team Assessment and Referral Program—STAR

28 per patient during the study year and would currently be approximately

Health Conditions and Service Utilization of Adults with Elder Care Responsibilities

15. After 1 year, BP control in men in the Home BP group was better than in men in the UC group; BP control was equally good in women in both groups. Management of uncomplicated hypertension based on periodic home BP reports can achieve BP control with fewer physician visits, resulting in substantial cost savings.

Health Status, Retirement Plans, and Retirement The Kaiser Permanente Retirement Study

OBJECTIVE: To determine the effect of case-finding for depression on frequency of depression diagnoses, prescriptions for antidepressant medications, prevalence of depression, and health care utilization during 2 years of follow-up in elderly primary care patients.DESIGN: Randomized controlled trial.SETTING: Thirteen primary care medical clinics at the Kaiser Permanente Medical Center, an HMO in Oakland, Calif, were randomly assigned to intervention conditions (7 clinics) or control conditions (6 clinics).PARTICIPANTS: A total of 2,346 patients aged 65 years or older who were attending appointments at these clinics and completed the 15-item Geriatric Depression Scale (GDS). GDS scores of 6 or more were considered suggestive of depression.INTERVENTIONS: Primary care physicians in the intervention clinics were notified of their patients’ GDS scores. We suggested that participants with severe depressive symptoms (GDS score ≥ 11) be referred to the Psychiatry Department and participants with mild to moderate depressive symptoms (GDS score of 6–10) be evaluated and treated by the primary care physician. Intervention group participants with GDS scores suggestive of depression were also offered a series of organized educational group sessions on coping with depression led by a psychiatric nurse. Primary care physicians in the control clinics were not notified of their patients’ GDS scores or advised of the availability of the patient education program (usual care). Participants were followed for 2 years.MEASUREMENTS AND MAIN RESULTS: Physician diagnosis of depression, prescriptions for antidepressant medications, prevalence of depression as measured by the GDS at 2-year follow-up, and health care utilization were determined. A total of 331 participants (14%) had GDS scores suggestive of depression (GDS ≥ 6) at baseline, including 162 in the intervention group and 169 in the control group. During the 2-year follow-up period, 56 (35%) of the intervention participants and 58 (34%) of the control participants received a physician diagnosis of depression (odds ratio [OR], 1.0; 95% confidence interval [CI], 0.6 to 1.6; P=.96). Prescriptions for antidepressants were received by 59 (36%) of the intervention participants and 72 (43%) of the control participants (OR, 0.8; 95% CI, 0.5 to 1.2; P=.3). Two-year follow-up GDS scores were available for 206 participants (69% of survivors): at that time, 41 (42%) of the 97 intervention participants and 54 (50%) of the 109 control participants had GDS scores suggestive of depression (OR, 0.7; 95% CI, 0.4 to 1.3; P=.3). Comparing participants in the intervention and control groups, there were no significant differences in mean GDS change scores (−2.4±SD 3.7 vs −2.1 SD±3.6; P=.5) at the 2-year follow-up, nor were there significant differences in mean number of clinic visits (1.8±SD 3.1 vs 1.6±SD 2.8; P=.5) or mean number of hospitalizations (1.1±SD 1.6 vs 1.0±SD 1.4; P=.8) during the 2-year period. In participants with initial GDS scores >11, there was a mean change in GDS score of −5.6±SD 3.9 for intervention participants (n=13) and −3.4±SD 4.5 for control participants (n=21). Adjusting for differences in baseline characteristics between groups did not affect results.CONCLUSIONS: We were unable to demonstrate any benefit from case-finding for depression during 2 years of follow-up in elderly primary care patients. Studies are needed to determine whether case-finding combined with more intensive patient education and follow-up will improve outcomes of primary care patients with depression.

The educational adjunct to multiphasic health testing

STUDY OBJECTIVE To determine the relationship between alcohol-related emergency department visits and alcohol-related outpatient visits and the extent of identification and referral of these ED patients for alcohol treatment. METHODS A representative sample of ED patients in three medical centers of a large northern California health maintenance organization were interviewed and given breath alcohol tests, and their medical records were reviewed. An alcohol-related ED visit was defined as a visit meeting one or more of the following criteria: positive breath alcohol test result (.01 mg/dL or more), report of drinking in the 6 hours before the presenting injury or illness, ED visit for an alcohol-related problem, and a medical record notation of excessive alcohol use or an alcohol problem. RESULTS Among 988 ED patients, 91 were found to have an alcohol-related ED visit. Of the 91, 6 made an alcohol-related outpatient visit in the 12 months before the ED visit, and 10 made such a visit in the following 6 months. Among the 91 patients, 10 were identified as having an alcohol problem by the ED staff, and 1 was referred for alcohol treatment. CONCLUSION The ED is an important point for the early identification and referral for treatment of alcohol-dependent and problem drinkers. The patient may make an alcohol-related ED visit relatively early in the pattern of alcohol-related health care use.

The Effect of Retirement on Mental Health and Health Behaviors: The Kaiser Permanente Retirement Study

The relation between alcohol problems and sense of coherence (SOC), a salutogenic model developed by Antonovsky, was assessed on a sample of 952 older members of a health maintenance organization. Data on alcohol problems (5-item index) and SOC (9-item scale) were obtained from mailed questionnaires. Multiple regression analyses indicated that SOC was a significant negative predictor of alcohol problems while controlling for alcohol consumption level, frequency of drunkenness and demographic characteristics. In addition, SOC scores were significantly higher for a subsample of lighter drinkers who reported no alcohol problems in the last year and had not been drunk in the last year (n = 419) as compared to heavier drinkers who reported at least one alcohol problem in the last year, and reported being drunk at least once in the last year (n = 107). These findings emphasize the importance of assessing factors which contribute to healthier behaviors as opposed to focusing exclusively on predictors of pathogenic outcomes.

Health Practices of Adults with Elder Care Responsibilities

Background: Although comprehensive geriatric assessment has been found to improve health and function and decrease hospital admissions, most such programs are staff-intensive and take many hours or even days. The Senior Team Assessment and Referral Program (STAR) was developed to address these two issues by using a short but comprehensive outpatient health appraisal that required only a few health professionals to complete. Methods: Six hundred forty-nine Kaiser Permanente health plan members aged 65 years or older who received their health care at the Kaiser Permanente Medical Center, San Jose, Calif, were randomly selected during the first 12 months of the study and invited by mail to participate in STAR. Of those members contacted, 326 agreed to join the study. A nurse practitioner evaluated the health, functional, and social status of each STAR participant at an office visit once each year for the next 3 years and provided case management for those participants found to be frail or in danger of becoming frail. A control group of 764 elderly (aged 65 years and older) Kaiser members with characteristics similar to those of the STAR participants was drawn from Kaiser Permanente health plan members in San Jose. They continued to receive usual medical care throughout the study. A medical-functional profile was developed to stratify each STAR participants overall health and functional status at each visit and case management contact. The results were entered on a grid that was used as a tracking tool throughout the study. Utilization of medical services, changes in health and function, and effects of STAR interventions on participant health behaviors were measured, and primary care physician and participant satisfaction was assessed. Results: Although short-term utilization of medical services increased in the STAR group, health, function, and health behaviors improved as a result of STAR interventions. Ninety-three percent of the STAR participants described a satisfactory experience, and 71 percent were very satisfied. Sixty-five percent of primary care physicians who responded to a satisfaction questionnaire found something useful for their patients in the STAR assessment. Conclusions: STAR offers an efficient, minimally staff-intensive model for evaluating the health, functional, and social status of the 65-year-old and older age-group and intervening when they are frail or at risk of becoming frail. The improved health, function, and healthy behaviors in STAR participants and the high satisfaction rates among participants and physicians suggest that STAR would be a useful addition to the health care environment.