 |
InFocus Archives
| CLINICAL NEWS FOR OUR PARTICIPATING HEALTH CARE PRACTITIONERS |
Best Practice: Area Facilities Assess Cardiac Care Quality
Recent Literature Related to: CareFirst and CareFirst BlueChoice Disease Management Initiatives
Disease Management Enhances Services
Medication for Patients in Need
Member Access to Behavioral Health Care Practitioners
New and Emerging Technology
The Internet- An Important Tool for Providers
Patient Safety- Increasing Awareness
CareEssentials: Essential Tools for Patient Care
Philosophy of Care
Best Practice: St. Agnes HealthCare's Blood Management Program
The following is presented in an effort to highlight hospital “best practices” around the region. CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (CareFirst BlueChoice) want 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.
The Mid-Atlantic Blood Management Center (MBMC) at St. Agnes HealthCare is a comprehensive, hospital-wide blood management program that strives to avoid the use of banked blood, when possible, and provide safe blood to patients in need. MBMC also provides a safe haven for patients who refuse blood transfusions for religious or personal reasons.
The program is patient-focused and uses individualized patient transfusion planning. As a hospital-wide program, blood use, related outcomes, cost and the effect on safe and effective health care are regularly assessed. The Center’s basic principle is primum non nocere (i.e., first, do no harm) by providing maximum benefit with minimum risk.
MBMC Medical Director Dr. Richard Spence believes that “blood management should not be viewed as an option, but as a standard of care,” given the risk benefit profile of allogeneic blood transfusion.
There are many reasons to address total blood management, including:
- blood risks
- uncertain blood efficacy
- increasing blood shortages and costs
- patient choice
Medical Concerns
Blood risks (e.g., disease transmission) can be inherent and can be user-dependent (i.e., transfusion reactions). Most evidence that blood is life-saving originates from the use of fresh, whole blood during wartime. However, stored blood is very different from fresh blood. It has less ability to release oxygen and contains toxic red cell and white cell breakdown products that:
- suppress endogenous red cell production,
- initiate the systemic inflammatory response syndrome (SIRS) and
- are associated with both an increased risk of serious, post-operative infection and shortened survival after cancer surgery.
Several studies of intensive care patients show that liberal transfusion of red blood cells does not improve survival and may actually increase risk. P.C. Hebert et. al.’s multi-center, randomized, controlled study of two transfusion triggers— one restrictive, 7-9 gm/dL and one liberal, 10-12 gm/dl— in the treatment of similar patients showed no difference in ICU 30-day and 120-day mortality. A subgroup of these patients with severe ischemic heart disease (N=257) had a higher mortality if transfused to 10 gm/dl, although the difference has no statistical significance.1 In a prospective, multi-center, observational study of 4,892 ICU patients, Corwin et. al. showed that after correcting for baseline hemoglobin and severity of illness, the greater the number of RBC units transfused, the worse the clinical outcome.2
SIRS is the starting point in the cascade of serious infection, prolonged ICU and hospital stays and increased mortality. A recent meta-analysis of 23 studies that included 13,152 patients showed that the risk of getting a serious infection was 3.45 times greater with transfusions. Seventeen of the 20 studies demonstrated a value of p < 0.05.3 The authors concluded that the results provide “overwhelming evidence” that blood transfusion significantly increases the risk of postoperative bacterial infection in the surgical patient. Given this evidence, the only certain way to attain zero risk is to avoid allogeneic blood.
Patient Concerns
Some patients are concerned about blood risks and want safe alternatives. Experience shows that most medical and surgical patients can be treated successfully without the use of blood, regardless of hemoglobin level. St. Agnes HealthCare's goal is to provide patients with a choice of safe, bloodless management that includes individualized combinations of alternatives, such as hemodilution, cell salvage, advanced surgical techniques and pharmacotherapy.
MBMC is currently gathering data on the changes in transfusion practices due to blood management. Quarterly analysis of this data will provide information on both clinical and financial outcomes that will be used to deliver evidence-based, cost-effective care at St. Agnes HealthCare. MBMC and St. Agnes HealthCare plan to share their best practices with the health care community so that the benefits of blood management can be extended to all patients.
Future Plans
In the future, St. Agnes HealthCare hopes to create a rapid response approach to gastrointestinal bleeding treatment to stop hemorrhage quickly and avoid the need for transfusion.
Successful Blood Management
To correct anemia over time and avoid blood transfusion, St. Agnes HealthCare instituted a pilot study of protocol-driven iron and erythropoietin orders in its ICU patients to provide maximum benefit and avoid inappropriate and costly prescription drug use.
Iron,Vitamin B12, folic acid and erythropoietin outpatient therapy can correct anemia, avoiding transfusion and its risks. The MBMC staff works with physicians and patients to provide this treatment in anticipation of scheduled surgery or in conjunction with ongoing medical treatment. This helps reduce risk exposure and shorten length of stay.
ICU patients typically do not manufacture new red blood cells as a result of their illness. The combination of iron and erythropoietin restarts red cell production and corrects anemia over time, thus avoiding the need for transfusion. Reticulocyte counts are tracked to monitor response to therapy.
St. Agnes HealthCare's experience shows that red blood cell counts rise within 72 hours after three daily doses of iron and a single dose of erythropoietin on the first day. A stable patient with a rising reticulocyte count can safely be discharged from the ICU. Patients who do not respond can be given a second dose of erythropoietin. This strategy helped reduce inappropriate use of erythropoietin, promote early discharge from the ICU and avoid the transfusion risks.
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For more information, please contact St. Agnes HealthCare at 888-MBMC-SAHC (888-626-2724) or the Department of Surgery at 410-368-2712.
References:
- Hebert PC, Yetsir E,Martin C, Blajchman MA,Wells G,Marshall J, Tweedale M, Pagliarello G, Schweitzer I; The Transfusion Requirements in Critical Care Investigators for the Canadian Critical Care Trials Group. Is low transfusion threshold safe in critically ill patients with cardiovascular disease? Crit Care Med 2001;29(2):227-34
- Corwin HL, Gettinger A, Pearl RG, Fink MP, Levy MM, Abraham E,MacIntyre NR, Shabot MM, Duh MS, Shapiro MJ. The CRIT Study: Anemia and blood transfusion in the critically ill--current clinical practice in the United States. Crit Care Med. 2004 Jan;32(1):39-52
- Hill GE, Frawley WH, Griffith KE, Forestner JE, Minei JP. Allogeneic blood transfusion increases the risk of postoperative bacterial infection: a meta-analysis. J Trauma. 2003 May;54(5):908-14
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Recent Literature Related to: CareFirst and CareFirst BlueChoice Disease Management Initiatives
By T.A. Dadisman, MD, Medical Director, Preventive Medicine and Health Promotion
This article is intended to call your attention to recent information concerning diabetes, coronary artery disease, congestive heart failure and chronic obstructive pulmonary disease.
| Diabetes |
| What's Available |
Where to Find It |
| The authors of Screening for Diabetes: Can We Afford Not to Screen? discuss a study in the same issue of Annals of Internal Medicine, Screening for Type 2 Diabetes Mellitus: A Cost Effectiveness Analysis, and are concerned that “…The rationale for any screening program is that earlier identification results in interventions that will provide greater benefit than waiting for symptoms or complications to reveal the diagnosis. Unfortunately, the current state of delivery of care to persons with diagnosed diabetes in the United States does not bode well for the treatment of patients identified through screening. Many published 'report cards' of diabetes care have shown that the treatment of glycemia, hypertension and dyslipidemia and surveillance of foot and eye complications occur at far below recommended levels. Unless we optimize care after we diagnose diabetes, screening cannot be effective or cost-effective.” |
Annals of Internal Medicine 2004; 140 (9, 04 May): 756-758 |
| The authors of Problems Paying Out-of-Pocket Medication Costs Among Older Adults with Diabetes state in their results, “Only 32% of respondents who reported cutting back on medication use due to out-of-pocket costs reported telling a doctor or nurse in advance, and more than one in three (37%) reported never talking with clinicians about their medication cost problem at all. The most common reason that respondents gave for not talking with clinicians about medication cost problems was that clinicians never asked them (reported by 70%). Half (50%) of respondents who did not talk with clinicians about their cost-related adherence problems stated that they did not think that their health care providers could help them with medication costs, 39% did not think it was important enough to mention and 35% indicated that they felt embarrassed. A total of 30% of respondents indicated that they felt that there was insufficient time during their visits to raise this issue.” |
Diabetes Care 2004; 27 (2, Feb): 383-391
|
| In Poor Control of Risk Factors for Vascular Disease Among Adults with Previously Diagnosed Diabetes, national data were examined from the Third National Health and Nutrition Examination Survey (NHANES III, 1988-1994) and compared to the results of the latest survey, NHANES 1999-2000. Goal HbA1c of <7% was achieved in only 37% of participants (no difference between surveys). Goal BP of <130/ <80 was achieved in only about 36% of participants (no difference between surveys) – over 40% were hypertensive (>140/ >90). Total cholesterol of 200 or greater was present in almost 52% of participants in NHANES 1999-2000, compared to 66% in NHANES III. In total, only 7.3% of participants in NHANES 1999-2000 attained recommended goals of HbA1c, blood pressure and total cholesterol. |
Journal of the American Medical Association 2004;
291 (3, 21 Jan): 335-342 |
| Dr. Abrahamson of the Joslin Diabetes Center, the author of Optimal Glycemic Control in Type 2 Diabetes Mellitus – Fasting and Postprandial Glucose in Context concludes, “Both FPG and PPG contribute to the abnormal glycemic profile seen in patients with type 2 diabetes. Beyond its glucose-associated risk for diabetes complications, postprandial hyperglycemia is an independent risk factor for death and cardiovascular disease in patients with type 2 diabetes and IGT. Evidence from recent studies demonstrates that lifestyle modification with diet and exercise and the use of antihyperglycemic agents that reduce insulin resistance or delay carbohydrate absorption from the gastrointestinal tract can prevent the progression of IGT to type 2 diabetes mellitus. Although the relative contribution of FPG and PPG to HbA1c is uncertain, reduction in the levels of both of these components likely results in better overall metabolic control—the ultimate goal of therapy.” |
Archives of Internal Medicine 2004; 164 (5, 08 Mar): 486-491 |
| Coronary Artery Disease |
| What's Available |
Where to Find It |
Tracking Women’s Awareness of Heart Disease is an American Heart Association (AHA) National Study that examined the awareness and perceptions about CVD risk among American women, and evaluated trends since 1997, which is when the AHA initiated a national awareness campaign. Since 1997, there has been a 16% improvement in awareness with 46% of 2003 respondents identifying heart disease as the leading cause of death in women. Black and Hispanic women and women <45 years old had lower awareness than white women and women older than 45. Nearly all women were comfortable discussing heart disease prevention with their doctors, but only 38% of women said that their doctors had ever discussed heart disease with them.
|
Circulation 2004; 109 (5, 10 Feb): 573-579 |
| The authors of Trends in Self-Reported Multiple Cardiovascular Risk Factors among Adults in the US, 1991-1999 (from the CDC) state, “The substantial proportion of persons with known multiple risk factors (25% of the population [emphasis ours]) suggests that increased CVD prevention and risk factor reduction efforts should focus on comprehensive risk reduction strategies. Our results also demonstrate persistent disparities between blacks and whites, Hispanics and non-Hispanic whites, and those with low vs. higher educational attainment in the percentage of persons with multiple risk factors. An overarching goal of Healthy People 2010, the nation's health objectives, is to eliminate health disparities. If this goal is to be achieved for CVD, then interventions and prevention programs must also focus on reducing disparities in risk factors. These observations suggest that population-wide and individual high-risk approaches to prevention and risk reduction efforts must continue to reduce the burden of heart disease and stroke in the United States.” |
Archives of Internal Medicine 2004; 164 (2, 26 Jan):181-188 |
| High-Intensity Statin Treatment for Coronary Artery Disease is an editorial that discusses the REVERSAL study, also in this issue (pp1071-1080). The REVERSAL study compares pravastatin 40mg/day with atorvastatin 80mg/day. The author states that until the results of several large long-term trials comparing intensive and conventional statin therapy are available in the near future, it is prudent to continue to treat high-risk patients with guideline-defined statin doses to achieve goal LDL-C of <100mg/dl. At least as important are the effective modifications in diet and lifestyle capable of achieving major improvements in cardiovascular disease incidence. |
Journal of the American Medical Association 2004;
291 (9, 03 Mar): 1132-1134 |
| Intensive Statin Therapy- A Sea Change in Cardiovascular Prevention discusses the REVERSAL and the PROVE-IT studies' implications for lipid therapy. The latter is also in this issue in Intensive versus Moderate Lipid Lowering with Statins after Acute Coronary Syndromes. The Heart Protection Study in 2002 showed an overall reduction in coronary events by 25% if the LDL was lowered 40mg/dl, whether or not the pre treatment LDL was high (i.e., >100mg/dl). The REVERSAL study showed halting of progression, and some reversal, of plaque in patients with stable coronary disease based on intravascular ultrasound (IVUS) monitoring. The PROVE-IT study, using the same statin disease as REVERSAL, showed that patients with acute coronary events had a 28% reduction in mortality, beginning within 30 days of start of therapy with atorvastatin. This editorial concludes, “There will soon be a sea change in the prevention and management of atherosclerotic vascular disease. The proportional reduction in major clinical outcomes that results from aggressive statin therapy is of the same order of magnitude as that seen when statins were compared with placebo in controlled trials. Intensive therapy with statins, monitored by means of measurements of LDL cholesterol or biologic markers of inflammation, is likely to result in even greater steps toward actualizing the full benefit of this remarkable class of medicines.” |
New England Journal of Medicine 2004; 350 (15, 08 Apr) |
| Congestive Heart Failure |
| What's Available |
Where to Find It |
| “Patients with signs and symptoms of heart failure and a normal left ventricular ejection fraction are said to have diastolic heart failure. It has traditionally been thought that the pathophysiological cause of heart failure in these patients is an abnormality in the diastolic properties of the left ventricle; however, this hypothesis remains largely unproven.” Diastolic Heart Failure – Abnormalities in Active Relaxation and Passive Stiffness of the Left Ventricle finds that “…Patients with heart failure and a normal ejection fraction have significant abnormalities in active relaxation and passive stiffness. In these patients, the pathophysiological cause of elevated diastolic pressures and heart failure is abnormal diastolic function.” |
New England Journal of Medicine 2004; 350 (19, 06 May): 1953-1959 |
| The author of Understanding “Diastolic” Heart Failure states, “…Despite great progress in our understanding of and therapeutic approach to heart failure associated with systolic dysfunction, or systolic heart failure, we are now realizing that basic research and clinical investigations have failed to address nearly half of the epidemic of heart failure.”Following the discussion of the pathophysiology of diastolic heart failure, the author states,“…Without a better understanding of these factors, no plausible therapeutic strategies can be advanced. Although some advocate testing the same strategies used in systolic heart failure, the rationale for this approach is based largely on assumptions, and many patients with diastolic heart failure are already being treated for hypertension with the standard therapies used for systolic heart failure. Most important, without a better understanding of the pathophysiology of diastolic heart failure, opportunities for new and potentially more effective strategies may be missed.” |
New England Journal of Medicine 2004; 350 (19, 06 May): 1930-1931
|
| Chronic Obstructive Pulmonary Disease |
| What's Available |
Where to Find It |
| In The Body-Mass Index, Airflow Obstruction, Dyspnea, and Exercise Capacity Index in Chronic Obstructive Pulmonary Disease, the authors explain, “Chronic obstructive pulmonary disease (COPD) is characterized by an incompletely reversible limitation in airflow. A physiological variable — the forced expiratory volume in one second (FEV1) — is often used to grade the severity of COPD. However, patients with COPD have systemic manifestations that are not reflected by the FEV1. We hypothesized that a multidimensional grading system that assessed the respiratory and systemic expressions of COPD would better categorize and predict outcome in these patients. We first evaluated 207 patients and found that four factors predicted the risk of death in this cohort: the body-mass index (B), the degree of airflow obstruction (O) and dyspnea (D), and exercise capacity (E), measured by the six-minute–walk test. We used these variables to construct the BODE index. The BODE index is better than the FEV1 at predicting the risk of death from any cause and from respiratory causes among patients with COPD.” |
New England Journal of Medicine 2004; 350 (10, 04 Mar):1005-1012 |
Looking at the Patient – Approaching the Problem of COPD is an editorial that reinforces the utility of the BODE index.
|
New England Journal of Medicine 2004; 350 (10, 04
Mar):965-966 |
| GOLD Workshop Report - Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease is from the National Heart, Lung and Blood Institute (NHLBI) and the World Health Organization (WHO). It includes excellent guidelines and patient materials. |
www.goldcopd.com |
| American Thoracic Society Statement: Guidelines for the Six-Minute Walk Test is a thorough discussion and description of this test. |
American Journal of Respiratory Critical Care Medicine 2002; 166:111-117
Available free |
|
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Disease Management Enhances Services
In February 2004, CareFirst and CareFirst BlueChoice added an additional service to the Disease Management programs for members with diabetes, coronary artery disease, congestive heart failure, asthma and chronic obstructive pulmonary disease. This new service helps improve members’ awareness of their conditions and helps encourage members to take a more active role in managing these conditions using claims analysis to identify members who might need certain tests. Specific tests may include:
- dilated eye exams
- lipid panel checks
- microalbumin tests
- A1c tests
Once identified, members receive a letter explaining the importance of the test in terms of their progress and/ or to detect complications. Members are encouraged to see their physician to inquire about identified tests. A nurse care manager may, in the course of her assessment, call or fax this information to your office to make you aware that this communication has taken place.
Click here to learn more about CareFirst and CareFirst BlueChoice’s Disease Management programs.
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Medication for Patients in Need
Senior Prescription Drug Program Benefit Increase
Many patients cannot comply with prescription regimes for financial reasons, which can compromise their care and be frustrating for the health care professionals who care for them. The Senior Prescription Drug Program and the Maryland Medbank Program both offer solutions for you and your patients.
Senior Prescription Drug Program
CareFirst administers the Senior Prescription Drug Program (SPDP), currently available to maximum of 37,000 Medicare beneficiaries. The SPDP is in its fifth year and has over 33,000 enrolled.
Enrollment in the program is limited to Medicare beneficiaries who are Maryland residents, do not receive prescription drug benefits through Medicare Plus Choice or any other program or insurance plan and do not earn more than 300 percent of the Federal Poverty Level (FPL) (e.g., $27,930 for one person).
Effective August 1, 2004, the Maryland Health Insurance Plan Board, state agency that oversees the SPDP, authorized the prescription benefit to increase to $1,100. There is a $10 monthly fee from members, payable quarterly, plus copays.
A member of the SPDP with an income at or below 135% of FPL ($12,560 for one person) may also be eligible for the Medicare Approved Discount Card Transitional Assistance Program that provides a $600 credit toward prescription costs. For more information about the Senior Prescription Drug Program, call 800-972-4612.
Maryland Medbank Program
The Maryland Medbank Program is in its fifth year and has assisted over 27,000 patients. Medbank assists patients of all ages who cannot afford their medications by providing access to pharmaceutical industry patient assistance programs (PAPs), which offer brand name medications for free or at a low cost. To qualify, patients can earn no more than 300 percent of the FPL.
Within three days of being qualified, medications from Pfizer, AstraZeneca, Abbott and OrthoMcNeil are delivered to patients from the Medbank Pharmacy, Inc. Medications from other participating pharmaceutical companies require Medbank to send information to these companies and can take several weeks to fill.
Patients can self-refer to the Medbank Program by calling 877-435-7755. Medbank also advises qualified Medicare patients to apply for the $600 Medicare transitional assistance.
| If some of your patients take several medications, particularly branded medications, help them decide whether either of these programs meet their needs. The Senior Prescription Program is ideal for Medicare patients who take only a few medications and will not exceed the $1,100 benefit in 12 months. Please note that if a patient enrolls in the Senior Prescription Drug Program, he will be ineligible for most PAPs in the Medbank Program. |
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Member Access to Behavioral Health Care Practitioners
CareFirst BlueChoice and Magellan Health Services (Magellan) are committed to helping practitioners attend to the complex and chronic health care needs of their patients. CareFirst BlueChoice and Magellan recently conducted Primary Care Physician (PCP) Focus Groups to get feedback on PCP’s experiences accessing behavioral health care on behalf of members with depression. Based on this feedback, Magellan made the following improvements:
Access to care
- If a PCP or member is unable to get an appointment with a behavioral health practitioner, a Magellan specialist gathers the necessary information, contacts the behavioral health practitioner, arranges the appointment and notifies the PCP or member of the appointment date and time.
- Magellan continually monitors access to behavioral health care practitioners by reviewing geographical access and density information, second callback data and direct feedback from care managers and information from Magellan’s customer service representatives.
Elimination of referrals to providers not accepting new patients
- Behavioral health practitioners in Magellan’s network can minimize referrals when they cannot accept new patients by placing themselves “on hold” on Magellan’s Web site, www.magellanhealth.com. Awareness of Magellan’s access standards
- Magellan reminds practitioners that are not accepting new patients (identified by members or PCPs) of their access standards and the practitioner’s responsibility to place themselves “on hold” when their practice is full.
Newsletters
- Magellan regularly communicates to providers via medical journals and its own provider web-based newsletter.
Provider Recruitment
- Magellan actively encourages out-of-network providers, especially psychiatrists, who previously treated members to join the Magellan provider network.
Magellan, in collaboration with CareFirst BlueChoice, continually works to improve quality of care and addresses concerns identified by members and providers. Your feedback is always welcome; contact Magellan’s Quality Improvement Department at 800-720-7931.
Referring Patients with Depression to Behavioral Health Care Practitioners
Decisions to treat depression in the primary care setting or to refer the member to a behavioral health care practitioner should be made in collaboration with the patient. A referral for behavioral care is strongly suggested in the following situations:
- The patient is at risk of harming self or others;
- The patient has a behavioral health care issue and is pregnant or early postpartum;
- The patient does not respond adequately to evidence-based treatment for depression in the primary care setting or appears to have treatment-resistant depression;
- Potential co-existence of bipolar depression, dementia, psychosis, eating disorder, or another psychiatric or substance use disorder;
- Existence of severe and/or chronic co-existing medical disorder.
Accessing Referrals for Behavioral Health Care Magellan is available to help you obtain referrals to behavioral health providers 24 hours a day, seven days a week online, or by phone at (800) 640-9558.
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New and Emerging Technologies
CareFirst and CareFirst BlueChoice’s Technology Assessment Committee-- which includes CareFirst and CareFirst BlueChoice physicians and nurses and consulting physicians outside of CareFirst and CareFirst BlueChoice-- 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.
| New Technology |
Description |
CareFirst and CareFirst BlueChoice Determination |
Gastric
electrical
pacing /
stimulation
for refractory
gastroparesis |
Chronic gastroparesis is a complication of diabetes, previous abdominal surgery or neurological disorders. It may also be idiopathic. Although many patients respond well to medical treatment with metoclopramide, some do not respond favorably to conservative management. For these patients, an electrical stimulation unit has been proposed, which attempts to restore the “wave” of smooth muscle stimulation along the stomach to improve gastric emptying (in a manner similar to a cardiac pacemaker).
|
One stimulation system, the Enterra® by Medtronic, Inc., received a Humanitarian Device Exemption (HDE) designation from the FDA. The published studies to date involved small groups of patients and incorporated methodological flaws, which limit the ability to draw conclusions regarding the effect of gastric pacing on health outcomes, mostly due to the possibility of a placebo effect in patients’ subjective reporting of improvement in symptoms. There is limited evidence that gastric pacing helps alleviate symptoms of nausea and
bloating and very little evidence that it improves gastric emptying.
We have determined that since the Enterra system is a humanitarian device, patients determined to be candidates for gastric stimulation will receive individual case consideration for benefit coverage.
|
Ovacheck™ screening
test for ovarian cancer in at risk patients |
Ovacheck uses proteomic pattern analysis to identify the characteristic pattern in the protein structure of the blood left by ovarian cancer. A reliable screening test for ovarian cancer is highly desirable, but to date no tests have been proven sensitive and
specific enough for screening purposes. However, the proteomic-pattern type test may eventually become clinically accepted for ovarian cancer screening.
|
Early validation studies for this test have shown promise. Reported values for sensitivity and specificity for proteomic pattern analysis are extraordinarily high when tested in a patient population whose presence or absence of ovarian cancer was known. Before the test can be considered a reliable disease screening tool, it needs to be tested in a screening population, where it is unknown beforehand whether the patients in the study have the disease. The Society of Gynecologic Oncologists in a statement published in February 2004 cautioned that more research is needed to validate the test’s effectiveness before offering it to the general public. However, at least two major commercial laboratories plan to offer the tests this year. We consider Ovacheck to be experimental/ investigational.
|
Fusionless surgery
techniques for idiopathic scoliosis |
Depending on the severity of the curvature, most patients with idiopathic scoliosis can be treated conservatively. For relatively few patients for whom surgery is indicated to stabilize the spine and/or reduce the lateral curvature, a diskectomy and fusion is the established technique. Recently, new, less invasive techniques have been proposed eliminate the fusion of the vertebral segments and allow for greater spinal mobility. |
Two new techniques are being tried on an experimental basis. The vertebral stapling technique is designed for patients who have not reached skeletal maturity, and involves endoscopic placement of titanium alloy staples along the spinal curvature in an attempt to retard progression of the scoliosis as the patient matures. Early published results show that the technique is feasible and relatively safe, but the data is insufficient to permit conclusions as to whether the technique improves health outcomes. The second technique is for skeletally mature patients and uses a vertebral wedge osteotomy technique on the concave side of the lateral curvature to allow for straightening of the curve. The goal is to maintain flexibility of the spine while relieving pain and reducing the degree of associated disability. This procedure is still in the experimental stages. There are insufficient outcomes data to discern whether this approach represents a viable alternative to spinal fusion.
We consider these techniques to be experimental/ investigational.
|
Lysis of epidural
adhesions in patients with chronic low back pain |
Following surgery to the lower back, a significant number of patients continue to experience pain and disability, originating from the growth of fibrotic tissue impinging on nerves. Lysis of these epidural adhesions using a percutaneous approach has been performed for several years, but published studies are generally of low quality, involving small groups of patients in a case series design with no controls and limited follow-up. Nonetheless, various clinical specialists routinely perform the procedure.
|
The first randomized, controlled study was recently published. Although it is somewhat flawed methodologically, it tends to show that in patients whose back surgery failed, there is a positive treatment effect that is likely not attributable to placebo effect.We made the decision to consider percutaneous lysis of epidural adhesions medically necessary in patients who meet certain well-defined criteria regarding chronicity and severity of symptoms, and whose nerve impingement by fibrous tissue growth is clearly demonstrated.
|
Thoracic electrical
bioimpendance
as a measurement of cardiac output |
Assessing patients' hemodynamic status is desirable if they have conditions such as pulmonary hypertension, congestive heart failure, sepsis or rejection of a transplanted heart. The standard for such measurement has been the use of a thermodilution catheter placed in the pulmonary artery. Thoracic bioimpedance was developed as a non-invasive assessment tool for cardiac output. By using plethysmography, cardiac output can be assessed without the risk posed by threading a thermodilution catheter. |
A body of evidence exists in validation studies that indicate a reliable correlation between groups of patients assessed for cardiac output using thoracic electrical bioimpedance versus the standard thermodilution method. Its noninvasive nature can allow reliable assessment of a patient’s hemodynamic status outside of critical care units. We consider thoracic electrical bioimpedance assessment of cardiac output to be medically necessary for patients who would otherwise be considered for hemodynamic studies by thermodilution (i.e. patients with pulmonary hypertension, sepsis, transplant rejection or severe congestive heart failure). We consider thoracic bioimpedance measurement not medically necessary in routine follow-up of patients with high blood pressure or coronary artery disease. |
Immunologic
testing for recurrent pregnancy loss |
Recurrent pregnancy loss is determined when first- or early second-trimester miscarriage occurs in three consecutive pregnancies. Situations that may lead to recurrent pregnancy loss may be anatomical, chromosomal or hormonal. Research is also being conducted in association with a possible immune mechanism as well, in which the woman’s immune system attacks the conceptus by autoimmune or alloimmune mechanisms. |
Experts in the area of recurrent pregnancy loss have made recommendations as to the standard investigation into the cause of the repetitive pregnancy terminations. At this time, an immune system origin is an area of clinical research. To date, investigations are still theoretical in nature, and treatments directed at unproven immunologic responses have not been proven beneficial in the investigational settings. Therefore, we
consider immunologic testing for recurrent pregnancy loss to be experimental/ investigational. |
Nerve-sparing
surgical technique and sural nerve
grafting to the cavernous nerves to
maintain or restore sexual function
following radical
prostatectomy |
Although radical prostatectomy has a record of success as a prostate cancer treatment, the operation carries a high probability of loss of sexual function. The use of nerve-sparing technique attempts to preserve sexual potency. Where the nerve-sparing technique is not feasible due to extension of the tumor outside of the capsule (for example), sural nerve grafting to the cavernous nerves has been attempted in an effort to restore innervation and normal sexual functioning. Nerve sparing technique, where feasible, has been shown to preserve sexual functioning in a significant percentage of patients. An intraoperative monitoring device known as Cavermap™ is used during surgery to assist in the technique by helping identify the neurovascular bundles. |
There is little evidence that the use of the Cavermap device improves outcomes significantly, and some surgeons have reported that it is not a useful tool. Sural nerve grafting technique is being performed in certain specialty centers. Published results are being characterized as “preliminary” in nature, with endpoints not clearly defined, which limit the ability to draw conclusions regarding the effect on patient outcomes.
We therefore consider the Cavermap device and sural nerve grafting to the cavernous nerves to be experimental /
investigational.
|
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The Internet— An Important Tool for Providers
The Internet can make it easier to keep up with medical journals, research an unusual case, interact with other doctors and get practice management tips.
Since the reliability of some information on the Internet is questionable, physicians should trust only those Web sites with peer-reviewed credentialed information. Here are some respected Web sites that provide credible information for physicians:
- Medscape offers multispecialty, peer-reviewed medical information for specialists, primary care physicians and other health professionals.
- National Institutes of Health (NIH) offers information on conditions under investigation at NIH, links to the many individual organizations that comprise NIH, research funding opportunities and scientific resources.
- The National Library of Medicine (NLM) contains a large medical library. From here, there is a link to NLM’s MEDLINE, which offers access to the more than 11 million references and abstracts in its database as well as links to full text articles from some 400 journals (some publishers require a subscription).
- Martindale’s Health Science Guide 2000 offers a guide to health science resources on the Internet. It also contains thousands of teaching files, medical cases, multimedia courses and textbooks, tutorials and more than 4,400 databases.
- Hardin Meta Directory provides access to the directory sites in health and medicine.
- Centers for Disease Control and Prevention offers information on a wide range of topics including CDC data and statistics, current health news and CDC prevention guidelines. Providers may also access the Emerging Infectious Disease Journal and the Morbidity and Mortality Weekly Report. CDC Travelers Health site is a good source for vaccination and prophylactic medication needs, travel advice and information about disease outbreaks.
These sites are provided for your convenience and review only. CareFirst and CareFirst BlueChoice do not endorse the content of external Web sites.
You can now sign up to receive updates from CareFirst via email and access Medical Policies and forms on www.carefirst.com.
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Patient Safety— Increasing Awareness
The 1999 Institute of Medicine (IOM) of the National Academies’ report, To Err is Human: Building a Safer Health System, reported that up to 98,000 Americans die every year from preventable medical errors in hospitals. According to the IOM, most errors are due to “faulty systems, processes or conditions that lead people to make mistakes….” In 2002, another IOM report confirmed this and urged greater focus, research, leadership and expectations regarding health care quality and patient safety.
These reports have fostered a greater awareness of patient safety issues. It is clear that in order to effect a change, federal and state agencies, public and private purchasers, health care organizations, clinicians and patients must work together to redesign safe health care processes. Some approaches to reach this goal are raising performance standards, implementing safe practices at the service level and establishing a public reporting system.
The Leapfrog Group (Leapfrog), comprised of more that 150 public and private organizations that provide health care benefits, developed a series of performance indicators for urban hospitals including the use of a computer-based physician order entry (CPOE) system, the referral patterns to hospitals with high performance scores for complex medical procedures and the level of ICU staffing. Visit Leapfrog’s Web site to view hospital compliance status to Leapfrog Standards. (In CareFirst and CareFirst BlueChoice’s service area, completion of the survey is voluntary. Five hospitals that participate with CareFirst and CareFirst BlueChoice have reported as of May 2004.)
Obtain additional hospital quality/safety information from the following Web sites:
- Maryland Health Care Commission’s hospital performance guide includes facility profile, hospital report by Diagnosis Related Group (DRG), utilization by hospital for high volume DRGs (i.e., volume , length of stay, risk adjusted re-admissions) and hospital report by quality measures for hospitals in Maryland.
- HealthGrades includes Medicare data (i.e., MedPAR file) from Centers for Medicare and Medicaid Services, which was used for all of the HealthGrades ratings, except obstetrics. Hospital ratings include mortality by diagnosis and Leapfrog status.
- The Agency for Healthcare Research & Quality (AHRQ) offers CME credits related to patient safety through its online
journal and forum on patient safety and health care quality. The Web site also features Spotlight Cases, which readers anonymously submit and are followed by expert analysis.
- Patient Fact-Sheets , which offer tips on what patients can do to reduce problems exacerbated by today’s health care system, are available. Topics include: 5 Steps to Better Health Care, 20 Tips to Help Prevent Medical Errors and 20 Tips to Prevent Medical Errors in Children. You may find these helpful when addressing safety concerns with your patients.
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CareEssentials: Essential Tools for Patient Care
CareEssentials, CareFirst BlueCross BlueShield’s Care Management program, provides the tools that help support your care of CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice members. CareEssentials ensures access to quality care and an array of medical resources and information that help members stay as healthy as possible.
CareFirst and CareFirst BlueChoice have a team of highly qualified medical professionals, including 10 board-certified Medical Directors and more than 300 trained RNs who help make our programs successful.
The CareEssentials are:
Prevention: Keeping the healthy healthy.
Prevention provides educational resources that encourage members to take a more active role in managing their health to avoid illness through early detection. Our resources, including Vitality, our member newsletter, help increase member satisfaction.
Utilization Management: Right care. Right time. Right place.
Utilization Management coordinates medical services to ensure care is provided at the right time in the most appropriate setting. Utilization Management helps reduce duplication of services and includes drug utilization review and discharge planning.
Disease Management: Smart choices for healthy living.
Disease Management provides members with educational resources and reminders necessary for managing their chronic conditions in conjunction with their provider’s plan of care, reducing the disease’s effect through lifestyle changes and treatment compliance. In 2003, 55% of members reported improved physical status as a result of the programs, and 69% of members reported improved mental health. To refer a member, call 800-783 4582.
Case Management: When care is needed most.
Case Management guides members with catastrophic conditions or chronic illnesses through the health care system and improves the quality of life for these members and their families. Case managers develop individual care plans that coordinate medical and community resources. To refer a member, call 800-783-4582.
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Philosophy of Care
We represent a philosophy of health care that emphasizes active partnerships between patients and their physicians. We believe that comprehensive health care is best provided by networks of health care professionals who are willing to be held accountable for the satisfaction of their patients and the quality of their services. We are committed to high standards of quality and professional ethics and to the principle that patients come first.
We believe that patients should have the right care, at the right time and in the right setting. This includes preventive care, as well as comprehensive care for acute and chronic illness— at home, at the doctor’s office and in the hospital.
We believe that all health care professionals should be held accountable for the quality of the services they provide and for the satisfaction of their patients.
We believe that patients should have a choice within their health plans of physicians who meet high standards of professional training and experience, and that informed choice and the freedom to change physicians are essential to building active partnerships between patients and doctors.
We believe that health care decisions should be the shared responsibility of patients, their families and health care professionals, and we encourage physicians to share information with patients on their treatment options, medical conditions and health status.
We believe that consumers have a right to information about health plans and how they work. We believe that working with people to keep them healthy is as important as making them well.
We value prevention as a key component of comprehensive care, reducing the risks of illness and helping to treat small problems before they can become more severe.
We believe that access to comprehensive, affordable care gives consumers the value they expect and contributes to the peace of mind that is essential to good health.
Adapted from the American Association of Health Plans
CareFirst’s Mission
The mission of CareFirst BlueCross BlueShield is to provide health benefit services of value to customers across the region comprised of Maryland, Delaware, and the National Capital Area. To fulfill this mission, CareFirst BlueCross BlueShield commits to:
- Offer a broad array of quality, innovative insurance plans and administrative services that are affordable and accessible to our customers
- Fairly address the needs of customers in each jurisdiction in which we operate
- Conduct business responsibly as a non-profit health service plan, to ensure the plan’s long-term financial viability and growth
- Collaborate with the community to advance health care effectiveness and quality
- Support public and private efforts to meet needs of persons lacking health insurance
- Foster health systems integration and health care cost containment to benefit the people in areas we serve, and
- Promote respect, fairness and opportunity for our associates
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