InFocus                          Vol. 5, Issue 3 Winter 2003

InFocus Archives

CLINICAL NEWS FOR OUR PARTICIPATING HEALTH CARE PRACTITIONERS

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InFocus Archives

Best Practice: MedStar Health Offers Expert Care
Recent Literature on: Asthma, Coronary Artery Disease, Congestive Heart Failure, Diabetes and Cancer
Detect and Prevent CHD and Atherothrombotic Events
Condition Centers Help Members Manage Chronic Diseases
New and Emerging Technologies
Medical Record Documentation Review for 2003
Postpartum Depression: Prevention Program Initiative
Program Helps Ensure Great Beginnings
2003 MHCC HMO Report Cards Released
Talking to Adolescent Patients About Health Issues

Best Practice: MedStar Health Offers Expert Care

The following is presented in an effort to highlight hospital “best practice” around the region. CareFirst BlueCross BlueShield (CareFirst) wants to share with you the innovative ways in which Maryland, Virginia and Washington, D.C. hospitals are improving quality of care while controlling the rising cost of health care. Look for additional “best practice” features in future issues of InFocus.

MedStar Health (MedStar) is a community based, nonprofit health care organization that includes seven major hospitals in CareFirst’s service area. MedStar offers an array of programs to meet the various needs of patients who benefit from the system. MedStar hospitals are comprised of teaching and community hospitals, some of which were named in U.S. News and World Report’s 2003 edition of America’s Best Hospitals.

Below are some of the innovative programs implemented by MedStar hospitals.

Medication Safety Program
In 1999, the National Academy of Sciences’ Institute of Medicine estimated that more Americans die from preventable medical errors, which include medication errors, than from workplace injuries. This costs the nation $29 billion in health care costs. As a result, MedStar developed a program to report errors and potential errors during the medication process. MedStar defines the steps of the medication
process as follows:

MedStar’s staff can anonymously report errors or potential errors for which either they or a colleague is responsible. The anonymity of the program provides a safe environment for employees who report occurrences. Some changes made because of the reporting program include:

• Supplying more information on certain drugs to providers
• Using safer packaging
• Implementing a pilot program for electronic prescribing capabilities in physician practices and expanding protocol-driven medication orders in MedStar hospitals

Ensuring medication safety is an ongoing task and the responsibility is constant. “Medication safety is a journey, not a destination,” said MedStar’s Senior Vice President for Integrated Operations Steven Cohen.

Union Memorial’s Curtis National Hand Center
The Curtis National Hand Center (CNHC), based at Union Memorial Hospital, is staffed by certified hand surgeons and physical and occupational therapists who provide specialized rehabilitation for patients with hand or upper extremity injuries/ conditions.

Congenital Differences
CNHC holds a free congenital clinic, available to adults and children, the second Thursday of every month (except for July, August and November 2004). Multiple surgeons “…provide …a consensus opinion on a recommended treatment plan, type of surgery (if needed), and advice on what age the surgery should be performed,” said Raymond A. Wittstadt, M.D., Hand Surgeon, Curtis National Hand Center. “This benefits the family by reducing the need for second opinions.”

After an evaluation with a multi-disciplinary team that includes hand surgeons, therapists and a pediatric geneticist, an individualized plan of care is determined for each patient and forwarded to the referring physician to implement as desired. Physical treatment options for these patients include therapy, prostheses and surgical intervention. Early surgical intervention might be necessary for cases with constriction band syndrome or syndactyly. Surgery is usually unnecessary when the patient is able to compensate for the deformity.

“Allowing a patient to live their life in a productive manner, never having to compromise what they want to pursue personally or professionally is one of the highest callings in our specialty,”said Thomas J. Graham, M.D., Chief of the Curtis National Hand Center.

If you know of a patient that would like to attend and would benefit from CNHC’s clinic, have the patient or a patient’s guardian call 410-235-5405 and CNHC will help them schedule an appointment at the clinic. Appointments are necessary because only four patients are evaluated at the clinic per month.

Curtis Work Rehabilitation Services
The Curtis Work Rehabilitation Services (CWRS) program offers assessment and rehabilitation for workers with all conditions, not just those involving the hand or upper extremity, that affect job performance. The program offers on-site workplace evaluations that identify risk factors for cumulative trauma and other work-related injuries. CWRS also offers on-site educational programs for employers and employees designed to establish/ improve ergonomic programs that help decrease workplace injuries.

Have your patients call 410-554-2170 for work rehabilitation services and 410-554-2976 for career assessments.

Good Samaritan’s Good Health Center
The Good Health Center, based at Good Samaritan Hospital, allows patients to take control of their health by providing continuous free health enhancement services, including:

• Blood Pressure Screenings
• Audiology Screenings
• Skin Cancer Screenings

Have patients call 410-532-GOOD for more information on these free services, as well as other, low-cost evaluations. The Center also offers individual and group instruction for Diabetes Self-Management. For more information on this program, call 410-532-4550.

Good Samaritan mails a newsletter, Good Health, to neighboring communities that features articles related to health care, a question and answer section and a pullout calendar with dates and times to take advantage of free and/ or low-cost classes.

Franklin Square Hospital’s Oncology Program
Franklin Square Hospital’s Oncology Program is recognized by the American College of Surgeons for overall excellence in oncology and was awarded accreditation at the teaching hospital level.

Franklin Square Hospital’s Center for Gynecologic Oncology and Center for the Diagnosis and Treatment of Digestive Cancers give patients access to a growing number of treatment options, including new medications and chemotherapy advances, through clinical trials.

Franklin Square is currently conducting more than 70 cancer-related clinical trials. These include studies for the National Surgical Adjuvant Breast and Bowel Project, the Gynecological Oncology Group, the Southwest Oncology Group, the National Cancer Institute’s Gynecologic Oncology Group and Institutional Review Board-approved pharmaceutical studies. Patients benefit from being able to enroll in the research protocols, as well as the knowledge providers gain from the studies.

The Harry and Jeanette Weinberg Cancer Center, Franklin Square Hospital’s upcoming addition to the Oncology Program, is scheduled to open in 2004. The new state-of-the-art facility will give providers opportunity for collaboration because a full-range of oncology services will be housed under the same roof.

Breast and Cervical Cancer Program
Women between the ages of 50-64 who are uninsured or under-insured and have a limited income are eligible to receive free mammograms, breast exams and Pap tests.

Baltimore City Residents should call—

• Harbor Hospital and Union Memorial Hospital at 410-350-2001
• Franklin Square Hospital at 410-887-3432

To find out where other free screenings are available, call 800-477-9774.

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Recent Literature on: Asthma, Coronary Artery Disease, Congestive Heart Failure, Diabetes and Cancer

By T.A. Dadisman, MD, CareFirst Medical Director, Preventative Medicine and Health Promotion

This article is intended to call your attention to recent information you may have missed on issues concerning asthma, coronary artery disease, congestive heart failure, diabetes and cancer.

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Detect and Prevent CHD and Atherothrombotic Events

By David H. Madoff, M.D., Ph.D., Chief, Division of Endocrinology and Metabolism, The Good Samaritan Hospital of MD, Inc., Assistant Professor of Medicine, The Johns Hopkins University of Medicine

About 2.2 million myocardial infarctions occur each year in the United States— 25-30 percent of which are fatal. These catastrophic events are often the first indication of Coronary Heart Disease (CHD). Since a majority of patients will suffer from an atherothrombotic event (i.e., MI, stroke, PVD) in their lifetime, it is the physician’s responsibility to determine the likelihood of an event and prepare a comprehensive preventative regimen.

Detecting an Event
Framingham Risk Assessment Tool
The Framingham Risk Assessment Tool determines the 10-year risk of an atherothrombotic event by considering—

• patient’s age
• LDL-cholesterol
• HDL-cholesterol
• blood pressure
• smoking behavior

If the 10-year risk is >20 percent, then the patient is considered to have a CDH risk equivalent. A CHD risk of 10-20 percent is classified as intermediate, while a CHD risk of <10 percent is considered relatively low.

According to the Framingham Risk Assessment Tool, if a patient has diabetes, a risk of an event >20 percent in 10 years or atherothrombotic disease in a non-coronary vascular bed, then he/ she is considered to have a CHD risk equivalent and should be treated as if he/ she has coronary artery disease (e.g., LDL cholesterol <100 mg/dL).

NCEP ATP III Risk Factors
For patients without a CHD risk equivalent, physicians can consider the likelihood of an event using the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III) risk factors, which summarize the distinguishing factors that help identify a patient at high risk for an atherothrombotic event₁:

• age >45 for men or >55 for women
• family history of CHD (first degree relative)
• blood pressure >140/90 (i.e., hypertension)
• HDL-cholesterol <40 mg/dL
• smoking behavior

If your patient has <1 risk factor, then he/ she is at relatively low risk for an event.

A patient is considered to have the Metabolic Syndrome, which doubles cardiovascular risk, if he/ she has 3 or more of these risk factors—

• waist circumference >35 inches for women, or >40 inches for men (i.e., central obesity) and
• elevated triglycerides (>150 mg/dL) and
• HDL-cholesterol <40 mg/dL for men, or <50 mg/dL for women and
• blood pressure >130/ >85 mm Hg, or
• fasting plasma glucose >110 mg/dL

Prevention of CHD and Atherothrombotic Events
Treating patients at high risk involves a comprehensive regimen that can include—

• diet
• weight loss
• exercise
• relaxation
• smoking cessation
• aspirin
• statins and other lipid-lowering drugs
• antihypertensive therapy (including ACE-inhibitors or ARBs)
• fish oil
• certain diabetes medications (if necessary)

Judicious use of an aggressive regimen in a cohort of patients with Type 2 diabetes mellitus over 7.8 years resulted in a 53 percent reduction in atherothrombotic events and 60 percent reductions in retinopathy, nephropathy and autonomic neuropathy₃.

Aspirin therapy is indicated for all aspirin-tolerant patients with known CHD or a CHD risk equivalent >1.5 percent risk per 10 years; the optimal dose is 81 mg qD. If the 10-year risk of an atherothrombotic event is 0.7-1.4 percent according to the Framingham Risk Assessment Tool, then the risks and benefits of aspirin are about equal. Therefore, aspirin is not indicated for patients with a <0.6 percent risk, but the patient can take it if he/ she chooses to₄.

Data supports statin therapy as the mainstay of lipid lowering in most patients with known CHD or CHD risk equivalent (i.e., LDL cholesterol goal <100 mg/dL), as well as many high risk primary prevention patients. Based upon the algorithm above, all aspirin-tolerant patients placed on a statin should also take aspirin. A recent meta-analysis of five pravastatin trials that included 14,617 patients demonstrated a reduction of atherothrombotic events because of the clearly additive interaction between pravastatin and aspirin.

A new product, Pravigard, approved by the FDA at the beginning of July, contains a combination of essential anti-atherogenic medications and may substantially improve patients’ adherence.

CareFirst Preferred Drug List
Pravigard and Pravachol are on CareFirst’s Preferred Drug List.

References

1. Circulation (2002). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final Report, 106, 3143.
2. Ridker, P.M. (2001). Circulation. High-sensitivity C-reactive protein: Potential adjunct for global risk assessment in the primary prevention of cardiovascular disease, 103, 1813.
3. Gæde, P.,Vedel P., Larsen N., Jensen G.V.H., Parving H.H., & Pedersen O. (2003). New England Journal of Medicine.Multifactorial intervention and cardiovascular disease in patients with Type 2 diabetes, 348, 383-393.
4. Lauer, M.S. (2002) New England Journal of Medicine. Aspirin for primary prevention of coronary events, 346, 1468-1474.

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Condition Centers Help Members Manage Chronic Diseases

CareFirst offers Disease Management programs for eligible members with asthma, cancer, diabetes and heart conditions. All programs are designed to reinforce the physician’s plan of care. Services range from quarterly educational mailings to case management with 24-hour telephone access to a support nurse. Providers can direct members to our Disease Management Condition Centers.

Our Asthma, Diabetes and Heart Health Centers offer plenty of information and tools to help members manage their conditions. Members can—

• Read self-care tips and the latest news to learn more about their conditions.
• Take our monthly poll.
• Use our tools to track key health measures, like BMI, cholesterol readings, Hemoglobin A1c readings and blood sugar readings. My Care First can store this information on a secure server for future reference.
• Find out about classes and support groups in the area.

Members can access condition centers via My Care First or they can key in the address of the appropriate condition center:

• www.carefirst.com/asthma
• www.carefirst.com/diabetes
• www.carefirst.com/heart

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New and Emerging Technologies

CareFirst's Technology Assessment Committee, which includes CareFirst physicians, CareFirst nurses and consulting physicians outside of CareFirst, reviews new and developing technologies. The committee relies on current medical literature, local expert consultants and physicians to determine whether those technologies meet CareFirst's criteria for coverage. Coverage policies applicable to national Blue Cross Blue Shield accounts and Federal Employees benefits programs may differ from those at the local account level. The review criteria can be found in the Providers & Physicians section of www.carefirst.com by clicking on Medical Policies. The Technology Assessment Committee recently made the following determinations.

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Medical Record Documentation Review for 2003

CareFirst BlueChoice annually assesses a random sample of primary care practitioners’ (PCP) medical records. This year, CareFirst BlueChoice found there are opportunities for improvement in medical record documentation. Quality Improvement (QI) nurses evaluated a sample of records for the adolescent care and adult hypertension HEDIS measures.

The following table shows there are opportunities to improve documentation for each of the elements related to health counseling for adolescents turning 13. Our 2005 performance goal is to improve documentation by 10 percentage points.

The following table shows there is an opportunity to improve the documentation of health counseling (e.g., counseling for diet and exercise) for patients with hypertension. Our 2005 performance goal is to improve health counseling documentation by 10 percentage points.

Providers should remember—

• That 12-13 year-old adolescents are generally old enough to receive health counseling for each of the elements.
• That adolescents may not feel comfortable discussing some health issues with a parent present.
• To always document counseling sessions.
• To take the opportunity to provide health counseling during visits for physicals or illnesses.
• That some companies’ medical record forms do not have enough space for the documentation of health counseling. To obtain our forms with sufficient space for documentation, call 410-528-7997 or 800-323-4472.

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Postpartum Depression: Prevention Program Initiative

As many as 12.5 percent of new mothers suffer from postpartum depression, which can negatively impact the well-being of growing families. CareFirst BlueChoice and Magellan Behavioral Health (Magellan) worked together to develop the Prevention Program Initiative to treat CareFirst BlueChoice members with postpartum depression.

CareFirst BlueChoice members who deliver healthy babies receive information packets that contain the Edinburgh Postpartum Scale questionnaire, a screening tool for postpartum depression.

During 2002, information packets were mailed to 1,190 CareFirst BlueChoice members. Of these members, 12 percent completed the Edinburgh Postpartum Scale questionnaire and returned it to Magellan for scoring and follow-up. Nearly 20 percent of these responses indicated the possibility of postpartum depression and 43 percent of these members accepted a referral to a behavioral health specialist for a more formal evaluation.

Because early detection, diagnosis and treatment of postpartum depression can significantly reduce morbidity and may prevent mortality from this serious condition, CareFirst BlueChoice and Magellan will continue to implement the program through 2004. CareFirst BlueChoice providers can help make the Prevention Program Initiative successful by encouraging new mothers to complete and return the Edinburgh Postpartum Scale questionnaire and get treatment, if appropriate. If you have questions or supportive information, contact the Magellan Postpartum Depression Preventive Health Workgroup at 410-423-6702 or Mid-AtlanticSCPreventiveHealth@Magellanhealth.com.

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Program Helps Ensure Great Beginnings

CareFirst and CareFirst BlueChoice designed Great Beginnings to supplement the prenatal care and education pregnant members receive from their doctors. The program screens members for high-risk characteristics and monitors their pregnancy to make sure they receive coordinated care. This prenatal care program helps members deliver healthier babies and avoid expensive emergency room admissions. When a member enrolls in Great Beginnings, a case manager contacts her to review her medical history and identify any other conditions that may affect her pregnancy.

Case Managers
Case Managers contact enrolled members each trimester to screen and assess pregnancy risk. Case Managers also work with physicians to coordinate an effective treatment plan based on the member’s individual needs. Members receive valuable information related to pregnancy and the baby’s development and learn about community resources, like available support groups during pregnancy and immediately after the birth. Case managers also help locate a nearby pediatrician to care for the new baby.

Goals
CareFirst and CareFirst BlueChoice hope this program:

• Promotes informed decision making and appropriate utilization of medical services.
• Reduces the number of days in the hospital/ neonatal intensive care unit, preserves pregnancy and decreases fetal/ maternal morbidity.

Outcomes
Currently, over 5,495 members have participated in Great Beginnings. Total cost savings since its launch in May, 2000 is $44.2 million dollars. There has been a positive trend in the following outcomes:

• 44% increase in enrollment
• 10% increase in Prenatal Care being initiated in the 1st trimester
• 1.88% decrease in the incidence of Fetal Demise
• 0.7% decrease in the incidence of Maternal Mortality
• 0.5% decrease in the incidence of Neonatal Mortality

If you have a patient that would like to enroll in the Great Beginnings prenatal care program, or to find out more about our program, providers and members can call 888-264-8648. A case manager will contact the member within two weeks of enrollment for an initial assessment.

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2003 MHCC HMO Report Cards Released

The Maryland Health Care Commission (MHCC) recently released its annual guide for consumers on the performance of eight Maryland Health Maintenance Organizations (HMOs). The MHCC report card rates each of the Maryland HMOs on:

• Frequency members obtain preventive and wellness services
• Member satisfaction with the health care they receive
• How customers feel about their health plan

Report card results are based on the Consumer Assessment of Health Plans Survey (CAHPS) and clinical data from Health Plan Employer Data Information Set (HEDIS) audits. The report card, The 2003 Consumer Guide to Maryland HMOs & POS Plans, is published in its entirety by MHCC and is available online or by calling the Commission at 877-245-1762. CareFirst BlueChoice submitted data for the 2003 MHCC report card.

CareFirst BlueChoice’s performance was rated above average or average in 20 of the 30 MHCC categories – 16 of 22 clinical and 4 of 8 service categories. Above average performances were demonstrated in well-child visits for infants/ children, comprehensive diabetes care and prenatal care and check-ups for new mothers. The health plan was named “Star Performer”for better-than-average performance over several years in well-child visits for infants/ children and prenatal care and check-ups for new mothers. The major improvements are as follows:

• 67% - Adult diabetic members’ cholesterol control* (59% in 2002)
• 91% - Cholesterol screening rate for adult diabetics (83% in 2002)
• 94% - Prenatal care (89% in 2002)
• 83% - Postpartum care (77% in 2002)
• 34% - Adolescent immunizations, a combination of MMR, Hepatitis B and Varicella, (28% in 2002)

While acknowledging these improvements, CareFirst BlueChoice continues to evaluate and implement new processes to improve care and services for its members and is committed to exploring additional initiatives to improve member satisfaction.

The National Committee for Quality Assurance (NCQA) also publishes HEDIS results and compares many HMOs on a national and regional basis in The State of Health Care Quality 2003, available on NCQA's Web site.

* Control defined as an LDL-C of <130mg/dl.

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Talking to Adolescent Patients About Health Issues

It is important to promote open discussions with adolescent patients about topics, such as drinking, drug use, smoking and sexual activity. The ability to anticipate patient’s needs and to be a safe, knowledgeable and available resource for guidance are vital. Early intervention is essential to prevent the development of serious problems among adolescents.

Communicate interest in the teenage patient by asking open-ended questions. Inquiring about school and peer issues make it clear that you are open to discussing difficult issues. Examples of questions include:

• How are things going in school or with your sports team?
• Do you have a lot of friends at school?
• Are there other things that you would like to talk about with me other than your sore throat?

Providing literature in your waiting room on issues, such as drugs, teenage sexuality, homosexuality, teenage pregnancy and STDs helps illustrate your knowledge of these subjects and that you are willing to discuss them. These brochures are available from organizations like the American Academy of Pediatrics.

Adolescent patients might be more willing to discuss uncomfortable issues if they know your office is a safe place to talk and that your goal is to have relationships with both the patient and the parent/ guardian. If the patient has concerns that he is reluctant to talk about with others present, suggest a confidential visit without a parent/ guardian. Some signs you should offer such a visit include:

• Something said confidentially to one of your staff members,
• Patient is anxious or avoids topics, or
• Uncharacteristic behavior for the particular patient.

Once a patient begins discussing his problems with you, careful listening is key. When rapport is established, you will have more success gaining additional information needed to clarify the scope/ nature of your patient’s difficulty. It is important to rule out whether the teen is in danger and requires immediate intervention, or if the teen is seeking information only, and immediate intervention is not necessary.

Depending on the issue, the patient may need help relating a problem to a parent/ guardian. Here are ways you can help:

• Suggest dialog the teen could have with his or her parents
• Offer to inform the parent with the teen’s consent
• Suggest that you or a member of your staff facilitate a meeting with the teen and the parents

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