Steven S. Foldes

Comorbidity: Implications for the Importance of Primary Care in ‘Case’ Management

BACKGROUND Although comorbidity is very common in the population, little is known about the types of health service that are used by people with comorbid conditions. METHODS Data from claims on the nonelderly were classified by diagnosis and extent of comorbidity, using a case-mix measure known as the Johns Hopkins Adjusted Clinical Groups, to study variation in extent of comorbidity and resource utilization. Visits of patients (adults and children) with 11 conditions were classified as to whether they were to primary care physicians or to other specialists, and whether they involved the chosen condition or other conditions. RESULTS Comorbidity varied within each diagnosis; resource use depended on the degree of comorbidity rather than the diagnosis. When stratified by degree of comorbidity, the number of visits for comorbid conditions exceeded the number of visits for the index condition in almost all comorbidity groups and for visits to both primary care physicians and to specialists. The number of visits to primary care physicians for both the index condition and for comorbid conditions almost invariably exceeded the number of visits to specialists. These patterns differed only for uncommon conditions in which specialists played a greater role in the care of the condition, but not for comorbid conditions. CONCLUSIONS In view of the high degree of comorbidity, even in a nonelderly population, single-disease management does not appear promising as a strategy to care for patients. In contrast, the burden is on primary care physicians to provide the majority of care, not only for the target condition but for other conditions. Thus, management in the context of ongoing primary care and oriented more toward patients’ overall health care needs appears to be a more promising strategy than care oriented to individual diseases. New paradigms of care that acknowledge actual patterns of comorbidities as well as the need for close coordination between generalists and specialists require support.

A Randomized Trial of a Pay-for-Performance Program Targeting Clinician Referral to a State Tobacco Quitline

BACKGROUND Tobacco quitlines offer clinicians a means to connect their patients with evidence-based treatments. Innovative methods are needed to increase clinician referral. METHODS This is a clinic randomized trial that compared usual care (n = 25 clinics) vs a pay-for-performance program (intervention) offering

The Economic Impact of Exposure to Secondhand Smoke in Minnesota

5000 for 50 quitline referrals (n = 24 clinics). Pay-for-performance clinics also received monthly updates on their referral numbers. Patients were eligible for referral if they visited a participating clinic, were 18 years or older, currently smoked cigarettes, and intended to quit within the next 30 days. The primary outcome was the clinics rate of quitline referral (ie, number of referrals vs number of smokers seen in clinic). RESULTS Pay-for-performance clinics referred 11.4% of smokers (95% confidence interval [CI], 8.0%-14.9%; total referrals, 1483) compared with 4.2% (95% CI, 1.5%-6.9%; total referrals, 441) for usual care clinics (P = .001). Rates of referral were similar in intervention vs usual care clinics (n = 9) with a history of being very engaged with quality improvement activities (14.1% vs 15.1%, respectively; P = .85). Rates were substantially higher in intervention vs usual care clinics with a history of being engaged (n = 22 clinics; 10.1% vs 3.0%; P = .001) or less engaged (n = 18 clinics; 10.1% vs 1.1%; P = .02) with quality improvement. The rate of patient contact after referral was 60.2% (95% CI, 49.7%-70.7%). Among those contacted, 49.4% (95% CI, 42.8%-55.9%) enrolled, representing 27.0% (95% CI, 21.3%-32.8%) of all referrals. The marginal cost per additional quitline enrollee was

Tobacco-use prevalence in special populations taking advantage of electronic medical records.

300. CONCLUSION A pay-for-performance program increases referral to tobacco quitline services, particularly among clinics with a history of less engagement in quality improvement activities.

The Relationship of Stage of Change for Smoking Cessation to Stage of Change for Fruit and Vegetable Consumption and Physical Activity in a Health Plan Population

OBJECTIVES Using the risk categories established by the 2006 US surgeon generals report, we estimated medical treatment costs related to exposure to secondhand tobacco smoke (SHS) in the state of Minnesota. METHODS We estimated the prevalence and costs of treated medical conditions related to SHS exposure in 2003 with data from Blue Cross and Blue Shield (Minnesotas largest insurer), the Current Population Survey, and population attributable risk estimates for these conditions reported in the scientific literature. We adjusted treatment costs to the state level by health insurance category by using the Medical Expenditure Panel Survey. RESULTS The total annual cost of treatment in Minnesota for conditions for which the 2006 surgeon generals report found sufficient evidence to conclude a causal link with exposure to SHS was

Modifiable health behaviors and short-term medical costs among health plan members.

228.7 million in 2008 dollars-equivalent to

The relationship between acculturation and knowledge of health harms and benefits associated with smoking in the Latino population of Minnesota.

44.58 per Minnesota resident. Sensitivity analyses showed a range from

Which enrollees bypass their gatekeepers in a point-of-service plan?

152.1 million to

Culture, acculturation and smoking use in Hmong, Khmer, Laotians, and Vietnamese communities in Minnesota

330.0 million. CONCLUSIONS The results present a strong rationale for regulating smoking in public places and were used to support the passage of Minnesotas Freedom to Breathe Act of 2007.

Medicaid Savings From The New York University Caregiver Intervention for Families with Dementia

BACKGROUND It is difficult and expensive to use surveys to obtain the repeatable information that is needed to understand and monitor tobacco prevalence rates and to evaluate cessation interventions among various subgroups of the population. Therefore, the electronic medical record database of a large medical group in Minnesota was used to demonstrate the potential value of that approach to accomplish those goals. METHODS The relevant variables for all medical group patients aged 18 and over were extracted from the record from a 1-year period. Rates of smoking prevalence were computed for the entire population as well as for those with various characteristics and combinations of characteristics of interest to tobacco-cessation advocates. These prevalence rates were also adjusted to control for the other characteristics in the analysis. RESULTS From March 2006 to February 2007, there were 183,982 unique patients with at least one office visit with a clinician, and a record of their tobacco-use status (90%). Overall, 19.7% with recorded status were tobacco users during this year, as were 24.2% of those aged 18-24 years, 16.0% of pregnant women, 34.3% of those on Medicaid, 40.0% of American Indians, 9.5% of Asians, and 8.5% of those whose preferred language was other than English. Combining characteristics allowed greater understanding of those differences. CONCLUSIONS Although there are limitations in these data, the level of detail available for this large population and the ease of repeat analysis should greatly facilitate targeted interventions and evaluation of the impact.