Richard E. Johnson

Health Care Episodes: Definition, Measurement and Use

*Senior Investigator, Kaiser Permanente Center for Health Research, Portland, Ore.; Associate Professor, Department of Community Health Care Systems, School of Nursing, The Oregon Health Sciences University, Portland. †Internist, Northwest Permanente, P.C., Physicians and Surgeons, Portland, Ore.; Adjunct Senior Investigator, Kaiser Permanente Center for Health Research, Portland; Clinical Associate Professor of Medicine, School of Medicine, The Oregon Health Sciences University, Portland. ‡Senior Investigator, Kaiser Permanente Center for Health Research, Portland, Ore. Health care differs from other commodities because it is

Comparing Sources of Drug Data about the Elderly

Objective: This project assessed the extent of agreement between drug‐taking data obtained from an in‐home assessment and that obtained from an automated outpatient pharmacy system and from a mail questionnaire.

The Effect of Increased Prescription Drug Cost-sharing on Medical Care Utilization and Expenses of Elderly Health Maintenance Organization Members

OBJECTIVES The nature and extent of prescription drug benefits for the elderly are a continuing concern for health-care managers and policy makers. This study examined the impact of increased prescription drug cost-sharing on the drug and medical care utilization and expenses of the elderly. METHODS Two groups of well-insured Medicare risk-based members of a large health maintenance organization (HMO) had their copayments increased in different years during a 3-year period. Four 2-year analysis periods were established for comparing these elderly groups. During one analysis period, copayments did not change in either group. RESULTS Moderate increases of from

Replicating the chronic disease score (CDS) from automated pharmacy data

1 to

Controlled Trials of CQI and Academic Detailing to Implement a Clinical Practice Guideline for Depression

3, from

Benzodiazepine exposure and functional status in older people

3 to

Health Status and Social Factors in Nonprescribed Drug Use

5 per copayment, and from 50% per dispensing to 70% per dispensing with a maximum payment per dispensing resulted in lower annual per capita prescription drug use and expenses. No consistent annual changes were observed in either medical care utilization (office visits, emergency room visits, home health-care visits, hospitalizations) or total medical care expenses across analysis periods. CONCLUSIONS No consistent relationships were observed between increased copayments per dispensing and medical care utilization and expense. Future research needs to address the impact on the classes of medications received and related health status, and the impact of larger increases in copayments per dispensing on medical care and health-related factors.

Course and prognosis of sarcoidosis in a nonreferral setting. Analysis of 86 patients observed for 10 years

Michael Von Korff and colleagues at the Center for Health Studies, Group Health Cooperative (GHC) of Puget Sound created a measure of chronic disease status (CDS) using automated outpatient pharmacy data. They reported the measure appeared to provide a stable and valid measure of health status. The availability of such a measure could become a new tool for a variety of applications, including screening, resource allocation, and quality assurance. The measure was replicated for its reliability and construct and predictive validity in the KPNW membership using automated pharmacy data. Reliability and validity were tested using correlation and regression techniques. The CDS showed test-retest reliability over time. It showed construct validity with the RAND-36 instrument and the BSI-8 depression screener. It showed predictive validity with health care visits and hospitalizations. The results were similar to those at GHC. The findings indicated that the CDS can serve, with certain precautions, as a readily accessible low cost measure of health status.

β-Blockers and Depression: The More the Murkier?

BACKGROUND The release of the Agency for Health Care Policy and Research (AHCPR)s Guideline for the Detection and Treatment of Depression in Primary Care created an opportunity to evaluate under naturalistic conditions the effectiveness of two clinical practice guideline implementation methods: continuous quality improvement (CQI) and academic detailing. A study conducted in 1993-1994 at Kaiser Permanente Northwest Division, a large, not-for-profit prepaid group practice (group-model) HMO, tested the hypotheses that each method would increase the number of members receiving depression treatment and would relieve depressive symptoms. METHODS Two trials were conducted simultaneously among adult primary care physicians, physician assistants, and nurse practitioners, using the same guideline document, measurement methods, and one-year follow-up period. The academic detailing trial was randomized at the clinician level. CQI was assigned to one of the settings two geographic areas. To account for intraclinician correlation, both trials were evaluated using generalized equations analysis. RESULTS Most of the CQI teams recommendations were not implemented. Academic detailing increased treatment rates, but--in a cohort of patients with probable chronic depressive disorder--it failed to improve symptoms and reduced measures of overall functional status. CONCLUSIONS New organizational structures may be necessary before CQI teams and academic detailing can substantially change complex processes such as the primary care of depression. New research and treatment guidelines are needed to improve the management of persons with chronic or recurring major depressive disorder.

ANALYSIS OF THE COSTS OF NSAID-ASSOCIATED GASTROPATHY: EXPERIENCE IN A US HEALTH MAINTENANCE ORGANISATION

OBJECTIVE: To determine the association between benzodiazepine exposure and functional status in older patients.