Best Practice
CareFirst, Hospitals Team for Gold Card Care
CareFirst Commitment
Hair Stylists, CareFirst Unite to Improve Health of African
CareFirst Cares for the Community
Current News
CareFirst and CareFirst BlueChoice Launch Generic Drug Campaign
Technology
New and Emerging Technology
Disease Prevention and Disease Management
Recent Literature Related to: CareFirst and CareFirst BlueChoice Disease Prevention and Management Initiatives
Treating Depression through Collaborative Care
New Vendor to Administer Disease Management Programs
Quality Improvement
QI Program: Setting Goals for Improved Care and Service
CareFirst, Hospitals Team for Gold Card Care
The following is presented in an effort to highlight hospital “best practice” in the CareFirst and CareFirst BlueChoice service areas and to share with medical professionals throughout the region the innovative approaches hospitals are adopting in Maryland, Washington, D.C. and Northern Virginia. Their “best practice” approach to patient care is not only improving the quality of care but also helps contain the rising cost of care.
 Picture a golden approach to patient care. It’s when doctors and staff at hospitals provide attentive, immediate service. It’s when medical tests and exams are performed promptly. And it’s when patients are discharged without delay.
It’s what all hospitals strive for, but not all achieve. Call it gold medal health care. Better yet, call it Gold Card service. In January, CareFirst and CareFirst BlueChoice began its Gold Card initiative, an ambitious program that allows hospitals in the mid-Atlantic region more flexibility to monitor themselves in regards to denial rates and the length of patient stays.
For hospitals in the Gold Card plan, CareFirst and CareFirst BlueChoice will redeploy its Utilization Review Specialists – nurses who work with hospitals’ utilization review nurses and discharge planners to determine the length of patient stay and services covered by the insurer -- from facilities that have maintained a low denial rate and an appropriate length of patient stay for at least a year.
Simply put, the role of CareFirst Utilization Review Specialists changes to that of adviser for hospitals that do a good job in keeping the number of days a patient is hospitalized to within guidelines for appropriate hospital stays. Those hospitals are eligible for Gold Card status -- and the prestige that comes with it.
“This gives [hospitals] more autonomy, more control over their internal operations,” said Dr. Daniel Winn, MD, CareFirst Associate Vice President & Senior Medical Director. “It builds trust with hospitals. There’s less confrontation and more collaboration. Hospitals selected
to be in the Gold Card program will see extremely few, if any, denials.”
At Gold Card hospitals, the facility’s own utilization review nurses and physicians monitor themselves for patient efficiency to ensure that patient care is performed promptly and in the best interests of the patient, insurer and hospital. At Gold Card hospitals, prompt tests and diagnostic procedures are very important. “Ordered today, seen today,” said one CareFirst Utilization Review manager.
CareFirst Utilization Review Specialists are currently at most of the region’s hospitals or available by telephone to review each case, collaborating with hospital nurses to ensure that patients are given correct care in an expedient manner.
Although Utilization Review Specialists may not be at Gold Card facilities, they still will assist with proactive discharge planning in conjunction with the participating facility, be available in an advisory capacity to the facility regarding length-of-stay questions, enter discharge dates provided by the facility to expedite claims payment and work with the facility to maintain discharge planning responsibilities.
“This is a mutually agreed upon program,” Winn said. “We’re trusting the hospital to do a good job.”
How the Gold Card program works:
- CareFirst and CareFirst BlueChoice will review the average length of stay of the participating facility on a monthly basis and share the information with the facility
- Average length of stay must remain within a benchmark range
- If average length of stay shows an increase for two consecutive months subsequent to the initiation of the program, CareFirst's Utilization management team will meet with the facility to identify issues that resulted in increased length of stay and to formulate an action plan to reduce the length of stay
- If the average length of stay remains elevated for a third consecutive month, full utilization review activities will resume so that CareFirst and CareFirst BlueChoice can fulfil its fiduciary responsibilities to members and employer groups
So far, only the Anne Arundel Medical Center is a Gold Card hospital, but another suburban Baltimore facility is under consideration.
There are no limits to how many hospitals might be given CareFirst Gold Card status, and others will be added incrementally. “We intend to add hospitals that meet performance standards,” Winn said.
Dr. Mitchell Schwartz, clinical director of medical initiatives at the Anne Arundel Medical Center, said that his facility’s inclusion in the Gold Card program was natural because of the efficiency in which patient care there is performed.
“It allows us to review our care process without as much direction from CareFirst,” Schwartz said. “We take care of everybody the same way. We like the recognition that we’re known to be that type of hospital. We treat our patients well.”
 Schwartz also likes the program because if someone is very sick and needs additional time in the hospital, the patient is given as much time as necessary to recover.
Lon Steele, a manager in the CareFirst Utilization management department, said the insurer does not have to look at each case on a “micro level” for hospitals with Gold Card status. “The overall picture says their length of stay is more than acceptable,” he said.
By taking Utilization Review Specialists from hospitals, CareFirst and CareFirst BlueChoice will be able to redirect its resources toward other methods of improving health care for members.
“If both entities can re-deploy to other areas of improving health care, it’s good for the member,” Winn said.
Steele called the Gold Card program a “win-win” situation for both CareFirst and eligible hospitals.
“It’s a program where both CareFirst and hospitals look to provide the best care for patients and make sure that they have all that they need. No one wants them to stay in the hospital any longer than they have to,” Steele said.
“It gives us flexibility to deploy those nurses to areas where they are needed more,” Steele said. “For the hospitals, it’s prestige. It’s a validation of their internal process.”
It’s also a plus for the Gold Card hospital because they can tout their efficiency to doctors and prospective patients. In addition, Steele said it is good public relations for the hospital to promote itself as a CareFirst Gold Card hospital.
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Hair Stylists, CareFirst Unite to Improve Health of African
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| Alicia Wilkinson (standing) and a customer look over a hairstyle at Wilkinson’s House of Masters barbershop and hair salon, where Wilkinson checks customers’ blood pressure in addition to styling hair. |
Precisely and confidently, Alicia Wilkinson snips hair and talks health care. Poised behind the first barber chair at the House of Masters barbershop and hair salon, she tells anyone who’ll listen of the health concerns of African Americans while shaping the latest “cut” or “do.”
“Blood pressure is the number one killing disease among African Americans. It’s the silent killer,” she says, briskly running her hand through a customer’s hair. “It's the number one killer – and something needs to be done about it.”
That’s also something Wilkinson handles with style. When not cutting hair – and often instead of cutting hair – Wilkinson checks the blood pressure of many of the men and women who frequent her shop on Liberty Road near the city/county line.
A recent graduate of the CareFirst-sponsored Hair, Heart and Health program that trains hair stylists to give blood pressure screenings, referrals and follow-up services to customers, Wilkinson is nearly as adept with a blood pressure cuff as she is with hair clippers.
“A lot of people won’t go to the doctor’s, but they will get their hair done,” says Wilkinson, a licensed hair stylist for more than 30 years who recently became a Master Barber.
“It’s a good idea to tell them about blood pressure and their health while I have them in the chair and maybe they’ll want to get their blood pressure checked. Customers always tell barbers what ails them anyhow.”
The Hair, Heart and Health initiative is a joint venture between CareFirst and the Community Health Awareness and Monitoring Program (CHAMP) – a health education and prevention program sponsored by the University of Maryland School of Medicine that serves inner city residents – to improve the health of the African American community.
The one-year program was introduced in a small number of Baltimore-area barbershops and hair salons last year. Hair stylists received free training and certification as Blood Pressure Measurement Specialists. To date, 216 clients have been screened for hypertension and 28 percent have been referred to their health care providers for elevated blood pressure.
Jon Shematek, MD, CareFirst Vice President for Quality and Medical Policy, believes that barbershops and hair salons are good settings for the program because research has shown that African Americans can improve their health through community-based programs that focus on health risks in casual locations.
“The health of the African American community is at risk,” Shematek says. “Statistics from the American Heart Association show that heart disease and stroke cause more deaths among African Americans than any other ethnic group.”
Dr. Elijah Saunders of the University of Maryland School of Medicine says that through barbers’ and hair stylists’ encouragement, their customers can take a greater responsibility for their health.
Although the hair stylist cannot give medical treatment, they can alert customers of the possibility of high blood pressure and advise them to seek medical attention.
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| Alicia Wilkinson puts the fi nal touches on a customer's hair. "It's a good idea to tell them about blood pressure and health while I have them in the chair.". |
Penny Walton, a hair stylist at Cut Up and Co. in downtown Baltimore, is also a recent graduate of the Hair, Heart and Health program that was held once a week at the Urban Medical Institute in West Baltimore for five weeks. Each class lasted about three hours.
She’s taken what she learned and passed it along to customers as she styles their hair.
“It’s good information that I can give my customers,” Walton says.
Walton says that she and some other stylists can tell what medicines customers use by the condition of their hair. Once she notices that, more conversation about their health and health care is sparked.
“Things affect their hair and the hair gets thin,” she says.
“I can tell if they’re taking medicines for high blood pressure because whatever you put in your body comes out in your hair.”
Upon receiving a certifi cate of completion from the Hair, Heart and Health program, Wilkinson also put her new skills to work.
“This is the black man’s social club,” she says of her barbershop. “So why not bring health into it. It makes no sense to make you look pretty if you’re going to drop dead tonight, does it?”
“I’m not trying to put any fear into the customers, but just saying that they should get checked by a doctor.”
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CareFirst Cares for the Community
Our CareFirst Commitment initiative is making health care more affordable, improving quality, and closing gaps that lead to health care disparities. CareFirst gives generously to organizations throughout the Mid-Atlantic region.
During the first six months of 2006, CareFirst and CareFirst BlueChoice gave more than $300,000 to support community causes.
Charitable giving highlights for the year to date include:
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The Maryland Society for Sight --- $25,000 donated to the organization’s adult screening program, which provides vision screenings and educational information to more than 4,500 adults annually in Central Maryland. CareFirst and CareFirst BlueChoice awarded a $5,000 grant last year to the Maryland Society for Sight.
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D.C. Campaign to Prevent Teen Pregnancy --- $25,000 donated for a teen-friendly initiative to improve access to comprehensive health care for teens living in the District. CareFirst and CareFirst BlueChoice provided a $50,000 contribution last year.
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American Heart Association --- $85,000 donated for a stroke awareness effort that targets African Americans between ages 30 and 64. African Americans suffer higher death rates from stroke than other races in the United States, but in most cases strokes are preventable through education and adoption of a healthy lifestyle. CareFirst and CareFirst BlueChoice have funded many initiatives of the American Heart Association in past years.
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American Cancer Society --- $125,000 donated to create the Patient Resource Navigation System, to be located at Howard University in Washington, D.C., and provide a hospital-based staff coordinator to assist individuals and their families in accessing a range of support services including: transportation to treatment centers, bi-lingual services, support groups and oncology services.
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College of Southern Maryland --- $40,000 donated to The College of Southern Maryland Foundation to purchase two highly technical patient simulators to support the college’s Nursing, Emergency Medical Services and Allied Health programs. The “SimMan” patient simulators provide realistic training scenarios and more effectively teach students in the Southern Maryland region.
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CareFirst and CareFirst BlueChoice Launch Generic Drug Campaign
Beginning August 2006 through December 2006, CareFirst and CareFirst BlueChoice will launch a co-pay waiver program where members that switch from an eligible brand name drug to a generic alternative, will receive up to $10 off their co-pay at the pharmacy. The program aims to inform members of generic equivalents and therapeutic alternatives to expensive brand name drugs and the savings from their use. This waiver is a one-time offer on the member’s initial prescription fill. If a member changes from a brand name to a generic equivalent or a therapeutic alternative drug, they will see a long-term reduction in their out-of-pocket costs, as they will be paying for a tier 1 drug rather than a tier 3 drug.
Members are advised to ask their doctors if any of their current medications can be filled with a generic equivalent or a therapeutic alternative. In cases where a brand name drug has no generic, members are advised to ask if they might benefit from another drug in the same therapeutic class. As you are aware, generic drugs are made with the same active ingredients and produce the same clinical benefit as their brand-name equivalents, but sell for much less, thus saving patients’ money.
While we recognize that the decision to prescribe a generic medication is ultimately made between you and your patient, we hope that you consider prescribing a generic drug whenever possible which can reduce prescription drug costs while maintaining the same strength, dosage and quality as the brand-name drug. We will also be sending mail to the provider offices including the list of the brand name medications and their generic equivalents and therapeutic alternatives that are eligible for this co-pay waiver offer.
For the most current preferred drug list, prior authorization forms and pharmacuetical management procedures, please visit the Pharmacy section of our Web site at www.carefirst.com . For a paper copy of the formulary and pharmacuetical management procedures, call 877-800-3086.
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New and Emerging Technology
CareFirst and CareFirst BlueChoice’s Technology Assessment Committee – which includes CareFirst and CareFirst BlueChoice physicians, nurses and external consulting physicians – reviews new and developing technologies. The committee relies on current medical literature, local expert consultants and physicians to determine whether those technologies meet CareFirst and CareFirst BlueChoice’s criteria for coverage. Coverage policies applicable to national Blue Cross Blue Shield accounts and Federal Employees Benefi ts 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:
| Gastric electrical stimulation (“gastric pacemaker”) for treatment of morbid obesity |
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Gastric electrical stimulation systems have been approved under a Humanitarian Device Exemption as a treatment for gastroparesis in patients refractory to medical treatment. Some patients have reported a loss of appetite secondary to gastric electrical stimulation, and so the device is being investigated as a treatment for morbid obesity as an alternative to surgical intervention such as gastric bypass.
CareFirst and CareFirst BlueChoice determination:
No gastric electrical stimulation system has presently received approval from the FDA for labeling as a treatment of obesity. In the few published studies that are available, evidence is derived primarily from small, uncontrolled case series wherein electrical stimulation was used in conjunction with dietary treatment. In this context, it is not possible to isolate a treatment effect to the gastric stimulation, and possible placebo effects are unaccounted for. Where excess body weight loss was measured, in small study groups weight loss was reported on the order of 20 to 30 percent of excess body weight, but the weight loss occurred in a short follow-up period. Durability and effectiveness over time is therefore unclear, and it cannot be concluded from this level of evidence if the treatment improves outcomes for morbidly obese patients. There is no evidence whether the use of gastric electrical stimulation is at least as effective as any of the other, well-established interventions such as gastric bypass. CareFirst and CareFirst BlueChoice, therefore, consider gastric electrical stimulation experimental / investigational as a treatment for morbid obesity.
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| Total body photography for monitoring of patients at risk for melanoma |
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Total body photography is being promoted as a tool for the dermatologist to use in periodic skin care / cancer prevention for those at risk for melanoma, as a means to compare the appearance of existing benign skin lesions which may transform to malignant lesions over time, and to identify new lesions which have not appeared on previous examinations.
CareFirst and CareFirst BlueChoice determination:
The use of photography to record images of lesions is a convenient method of documenting and record keeping in patients with conditions such as dysplastic nevi or a history of a prior melanoma, or other patients who may be at increased risk for skin cancers. Documentation and record keeping is considered integral to the Evaluation and Management services described by CPT® codes. Therefore, total body photography is considered included in the benefit for evaluation and management.
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| Vagus nerve stimulation for chronic depression refractory to medical treatment |
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Electrical stimulation of the vagus nerve is an accepted treatment for certain types of seizures. It has also been proposed as a remedy for chronic severe depression that is not responding to antidepressant medications, as a result of observations of epilepsy patients who have reported mood elevation subsequent to vagus nerve stimulator implantation for their seizure disorders.
CareFirst and CareFirst BlueChoice determination:
Although there has been some preliminary evidence of a treatment effect on severe, refractory depression, these data have emerged primarily from studies with significant design flaws. In trials that have employed more rigorous designs, results are conflicting. One randomized, placebo-controlled study reported that using standardized measurements of depression severity, results obtained from the use of the vagus nerve stimulator were no better than placebo. Another reported essentially no observable treatment effect over a short term, i.e. six months. Still another study observed an improvement of depressive symptoms in only 30 percent of the study group, a rather small percentage, and one where it would be difficult to attribute the improvement to the treatment as opposed to the natural progression of chronic depression. Although the device received a premarketing approval (PMA) from the Food and Drug Administration, the approval was granted despite recommendation for rejection from an expert advisory panel. Considering the low-level of expert support for the device, and the conflicting nature of the results of studies published to date, CareFirst and CareFirst BlueChoice have determined that the treatment is experimental / investigational.
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| Selective internal radiation therapy (SIRT) for treatment of primary or metastatic cancers of the liver |
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Although surgical resection of malignant tumors of the liver is curative, many patients presenting with liver cancer are not candidates for surgery based on tumor size and location, or diminished hepatic reserve. SIRT is a proposed palliative treatment involving the use of yttrium-90 impregnated microspheres infused into the vessels of the liver via the hepatic artery.
CareFirst and CareFirst BlueChoice determination:
The need exists for a palliative treatment for primary or metastatic liver tumor that is well tolerated by patients. Although SIRT is generally well tolerated, the evidence that it prolongs survival is limited, and derives mainly from uncontrolled studies of small groups of patients. For a treatment to be effective for palliation, quality of life issues must also be addressed, and in this regard the evidence is even more limited. Expert reviewers have generally called for welldesigned, randomized studies to determine the effi caciousness of SIRT as a palliative treatment. Because the available evidence is too limited to permit conclusions regarding patient outcomes, CareFirst and CareFirst BlueChoice have determined that SIRT is experimental / investigational.
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| Automated percutaneous diskectomy for lower back pain |
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Herniated disk disease of the lumbar spine is a common condition that accounts for a significant impact on society in terms of health care utilization, disability and reduced quality of life. Although most patients recover with conservative therapy and medication, surgical intervention is offered to those who do not respond to conservative care. Minimally invasive, percutaneous approaches have been proposed that remove bulging intervertebral disk material and relieve pressure on nerve roots. These include the use of lasers, cutting-and-suction catheters (Dekompressor®) and thermal ablation (DISC Nucleoplasty™). These percutaneous procedures can often be performed in the outpatient setting, with minimal anesthesia and sedation, with a rapid recovery time, and so may be a very appealing alternative when proposed to patients in chronic pain.
CareFirst and CareFirst BlueChoice determination:
In chronic, painful conditions such as herniated lumbar disk, well-designed, controlled studies are necessary to account for anticipated placebo effects when new technologies are developed. In the case of automated percutaneous diskectomy, these technologies have not been evaluated in such studies. Evidence for safety and effectiveness derives primarily from small, uncontrolled case series studies that may best be described as preliminary in nature. Although the few such studies that are available are promising, the results are not reliable enough to permit conclusions on the effect on health outcomes. The available data to date report observations over the short term, thus the durability of any symptom relief over time is unclear. Most importantly, there is no available study that compares the percutaneous procedures to the gold standard laminectomy with diskectomy/microdiskectomy, a well-tolerated intervention with proven safety, efficacy, and durability. Several expert reviewers have commented on these observations. Automated percutaneous diskectomy procedures, therefore, do not meet the evidence-based criteria, and are considered experimental / investigational by CareFirst and CareFirst BlueChoice.
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| Intraspinous decompression implant for relief of pain from spinal stenosis |
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Spinal stenosis is a condition that may be brought on by arthritis, intervertebral disk degeneration or the consequences of the aging process, wherein the spinal canal becomes narrowed, impinging on nerves, leading to pain in the back and legs, with numbness, or cramping in the legs. Symptoms may be aggravated by prolonged standing or walking, and may vary in severity. Many patients with spinal stenosis have symptoms that are mild and intermittent. Physical therapy and analgesic and anti-inflammatory medications are used successfully as conservative treatment.
When symptoms become severe and debilitating, and the patient is not responding adequately to conservative treatments, a decompression laminectomy can be performed to widen the spinal canal in the affected area and relieve pressure on the nerves. Where the vertebrae have actually shifted position and become mechanically unstable (spondylolisthesis) a fusion may be necessary to restore stability.
A less invasive procedure has emerged and is being considered as an alternative to decompression laminectomy with or without fusion, known as intraspinous process decompression (IPD), using an implanted titanium distraction device. The procedure involves only local anesthesia with sedation, and can be done in the outpatient setting, wherein the device is placed between the spinous processes using a special surgical tool. The device is designed to prevent extension of the symptomatic areas of the spine while allowing flexion, rotation, and lateral bending motions, and thus allow the spinal canal to maintain its maximum diameter. One such device, known as X-Stop®, has been approved for marketing by the FDA.
CareFirst and CareFirst BlueChoice determination:
The FDA approval letter issued to the manufacturer of X-Stop mandates a study to evaluate long term safety and effectiveness of the X-Stop in patients who received the device under an Investigational Device Exemption, and gives details of the framework of the required study. A separate study is to be conducted to determine whether patient selection criteria based on the language of the approval indication is adequate. This would suggest that although X-Stop met the statutory requirements sufficiently for the FDA to grant a PMA, the approval for marketing was conditional, as safety, efficaciousness and patient selection criteria for labeling purposes have not been clearly established. The one significant study on the treatment effect of the X-Stop randomized 191 patients to treatment with the X-Stop versus conservative treatment. During a one-year follow-up, success rates were described as 59 percent for the treatment group and 12 percent for the control group. In the same population followed over a two-year period, successful treatment was observed in 45 percent of the X-Stop group, but only in 7.4 percent of the controls, as determined by comparing baseline symptom severity scores. The study contained design flaws, such as lack of a placebo control group and blinding of subjects and observers, that could introduce bias favoring the treatment group. The gold standard surgical intervention is a decompression laminectomy, a technique well proven for efficacy and one that is well tolerated by even elderly patients. Success rates over the long term for decompression laminectomy are reported to be significantly higher than those for X-Stop, as reported from the above study. In view of these observations, intraspinous decompression implants for spinal stenosis do not yet meet the evidence-based criteria, and are considered experimental / investigational by CareFirst and CareFirst Blue Choice.
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Recent Literature Related to: CareFirst and CareFirst BlueChoice Disease Prevention and Management Initiatives
By Richard S. Safeer, MD, Medical Director, Preventive Medicine
 CareEssentials: As part of the Disease Management component of CareEssentials, the CareFirst and CareFirst BlueChoice multi-faceted care management program provides you with essential tools for patient care. Here is some recent literature of interest. For more information on how to enroll your patients in one of our disease management programs, please call 800-783-4582.
| DIABETES |
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It is well established that good control of serum glucose in diabetics decreases the risk of microvascular diseases, such as retinopathy, neuropathy and nephropathy. Epidemiologic studies indicate that diabetics are more likely to suffer and die from cardiovascular disease. However, it is unknown whether controlling glucose levels will help decrease the risk of cardiovascular disease, as has been seen with microvascular disease. Bear in mind that diabetics are prone to dyslipidemia, potentially accounting for the increased risk of heart disease in diabetics.
The Diabetes Control and Complications Trial (DCCT) was a randomized, controlled trial that continued after the initial phase as the Epidemiology of Diabetes Interventions and Complications (EDIC) study. Type I patients were studied for an average of 17 years. The intensive therapy group had serum glucose goals of 70 to 120 mg/dL before meals and less than 180 mg/dL after meals. The conventional therapy group had less concrete goals of avoiding hyperglycemia and hypoglycemia symptoms. As a result, the intensive therapy group had three or more insulin injections versus one to two daily insulin injections for the conventional treatment group. After the six and a half year duration of the DCCT, HbA1C levels in the intensive therapy group were two percentage points lower than the conventional group. Patients were released to their own physician and the prescribed intervention was no longer dictated by the investigators.
About 11 years later, after treatment differences between the two groups had dissipated to a point where HgA1C levels were not statistically different, clinical outcomes were compared between the two study groups. “As compared with conventional therapy, intensive diabetes therapy reduced the risk of a cardiovascular event by 42 percent and reduced the risk of severe clinical events, including nonfatal myocardial infarction, stroke, or death from cardiovascular disease, by 57 percent.” The authors concluded “a reduction in the glycosylated hemoglobin value might be expected to have beneficial
effects on cardiovascular disease.”
The American Diabetes Association recommends keeping HbA1C levels below seven percent.
Where to Find it: The New England Journal of Medicine 2005;353:2643-53.
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| ASTHMA |
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Inhaled corticosteroids have proven to be a valuable drug for treating asthma. Two studies questioning the effectiveness of inhaled corticosteroids in the prevention or delay of asthma development in children were recently published in the New England Journal of Medicine.
The first, Long-Term Inhaled Corticosteroids in Preschool Children at High Risk for Asthma, aimed to alter the outcome of children at high risk for asthma. Children (age two to three) at high risk for asthma were randomly assigned to either the placebo or the inhaled corticosteroid group for two years. The children were followed for a year after discontinuing the treatment arm to study the difference in episode-free days (as reported by the parents). “Clinical improvement was observed while the children were treated with the inhaled corticosteroid but disappeared after treatment had discontinued.” The authors concluded that “inhaled corticosteroids can be used to control active disease but should not be used to prevent asthma in high-risk preschool children.”
In the second study, Intermittent Inhaled Corticosteroids in Infants with Episodic Wheezing, the subjects were enrolled at age one month and randomized after their first episode of wheezing. If the wheezing symptoms persisted for three days, the patients were treated with either Budesonide or placebo for a two-week period. Parents kept a journal of symptoms and medication use during the three-year trial. The authors found the “proportions of symptom-free days and days free of the need for rescue medication, as well as the numbers of episodes and treatments with add-on medication, were similar in the two groups.”
The accompanying editorial accepts the conclusions of both authors that “inhaled corticosteroids do not alter the natural history of the disease and that the risk of wheezing will persist beyond the first years of life.” The editorial cautions that “the long-term use of inhaled corticosteroids in early life may have adverse effects not only on height growth but also on alveolar growth, which, in contrast to airway development, occurs in the last months of gestation and the first few years of life.”
CareFirst asthma disease management nurses can help your patients understand your treatment plan, including the proper method of using inhaled medications. Consider enrolling your patients in our disease management program or having your patients call 800-783-4582 to begin receiving additional education and support.
Where to Find it: The New England Journal of Medicine 2006;354(19)
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| CHRONIC OBSTRUCTIVE PULMONARY DISEASE |
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With so much data to explain why smoking cigarettes is unhealthy, it is often baffling to non-smokers why anyone would engage in this behavior. Nowhere is it more puzzling than in the population of people who have Chronic Obstructive Pulmonary Disease (COPD) and still smoke. The authors of Cigarette Smoking and Smoking Cessation Among Persons With Chronic Obstructive Pulmonary Disease determined which variables among adults smokers with COPD were predictive of smoking cessation.
The authors looked at data from the National Health Interview Survey (conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention) with 175,631 adults over age 25. The data for those persons who self-reported a diagnosis of either emphysema or chronic bronchitis was analyzed to discern information about their smoking habit and any cessation activities.
Almost half of those with COPD who had smoked cigarettes at some point in their life had already quit. Of those who were still smoking, half tried to abstain for at least one day in the previous year. Fourteen percent were successful in quitting altogether. Feelings of helplessness and being poor were two predictors of not being able to quit. While most patients with COPD reported receiving counseling from their physician, 20 percent did not.
Despite increasing cigarette prices, overwhelming evidence of their ill effects and mounting laws that curb where smoking is allowed, people continue to smoke. Brief counseling can make a difference, even in those patients who have smoked most of their lives and now have activity limitations as a result. If your patients want more information on how to quit smoking, they can go to MyCareFirst.com and click on ‘smoking cessation’ under the wellness tab on the home page.
Where to Find it:American Journal of Health Promotion 2006;20[5]: 319-323.
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| CORONARY ARTERY DISEASE |
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Is there a way to increase the chance that our patients’ first presentation of heart disease is subdued? The research team of the ADVANCE Study investigated the relationship of Statin and Beta-blocker Therapy and the Initial Presentation of Coronary Heart Disease. The authors looked retrospectively at more than 1,300 patients who had presented with either acute myocardial infarction or stable exertional angina to compare potential predisposing characteristics. The patients in this study had no previous history of coronary heart disease prior to identification.
Characteristics more common in the acute myocardial infarction group included smoking, physically inactive, hypertensive and diabetic. “The most striking differences between these groups were the markedly lower previous use of statins and Beta-blockers in patients who presented with an acute myocardial infarction as their initial presentation of coronary heart disease,” according to the study.
For those in whom statins and Beta-blockers are appropriate, their use will have a beneficial affect on ameliorating the presentation of coronary artery disease. Should your patients have cardiovascular disease, let our disease management programs help keep your patients on track with your recommended treatment plan. Call 800-783-4582 to refer your patient into our coronary artery disease management program.
Where to Find it:Annals of Internal Medicine 2006;144:229-238.
Over the course of many years, a hypothesis of an association between elevated homocysteine levels and cardiovascular disease developed. As a result, folic acid supplementation became regularly recommended as it has a lowering effect on homocysteine. Two studies in the same edition of The New England Journal of Medicine explore the effectiveness of reducing cardiovascular morbidity and mortality by the use of folic acid and other B vitamins to lower homocysteine levels.
The Norwegian Vitamin Trial (as reported in “Homocysteine Lowering and Cardiovascular Events after Acute Myocardial Infarction”) assigned patients with recent (less than seven days) myocardial infarction to either the intervention group (various combinations of folic acid, vitamin B12 and vitamin B6) or placebo. Although there was a 27 percent reduction in serum homocysteine levels, there was no clinically significant difference in outcomes.
Contrary to expectations, the group taking folic acid and both vitamins B6 and B12 had an increased risk of having another heart attack when compared to the other groups in the study. The other study reported in the same edition, “Homocysteine Lowering with Folic Acid and B Vitamins in Vascular Disease,” shares the results of The Heart Outcomes Prevention Evaluation (HOPE) 2 Investigators. They too combined folic acid, vitamins B6 and B12 to find that despite lowering homocysteine levels, this supplemental regimen did not lower the risk of death from cardiovascular disease in patients with vascular disease.
As seen with vitamin E and now folic acid, the effectiveness of vitamin supplementation suggested in observational studies is not always supported in randomized controlled trials. Many of our patients take vitamin supplements and alternative medicines. It is important to specifically ask our patients which non-prescription medicines and alternative treatments they take, as they may be doing more harm than good.
Where to Find it: The New England Journal of Medicine 2006;354(15):
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 Prevention
| WHAT’S NEW IN PREVENTION? |
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Until recently, skeptics of the role obesity played in the risk of cardiovascular morbidity and mortality would point toward the association between obesity and cardiovascular risk factors (i.e., hypertension and dyslipidemia) as the link to cardiovascular disease. The authors of Midlife Body Mass Index and Hospitalization and Mortality in Older Age consider the role of obesity as a risk factor independent of other, more established cardiovascular risk factors.
More than 17,600 men and women were studied over an average of 32 years. The participants were categorized into five groups: low risk, moderate risk, intermediate risk, elevated risk and highest risk. Patients with a medical history (or EKG indicating such) including cardiovascular disease or diabetes were eliminated from the study group. The ‘low risk’ participants had a systolic blood pressure of 120 mm Hg or lower and diastolic blood pressure of 80 mm Hg or lower, without the use of antihypertensives. ‘Low risk’ participants also were not currently cigarette smokers or receiving treatment for hypercholesterolemia. The other participant groups had increasing amounts of risk in the three areas of blood pressure, cholesterol and smoking status. The participants in the highest risk group smoked, had elevated blood pressure (or were taking medication to treat high blood pressure) and an elevated total cholesterol (or were taking medication to lower cholesterol). These groups (as defined by their risk level) were then stratified by BMI (normal weight, overweight and obese).
The authors concluded that “Overweight and obese persons had higher risks of having a CVD-related death or hospitalization than did individuals of normal weight with similar baseline risk profile.” The authors added that “Most previous research did not directly address the issue of whether BMI had an independent impact on cardiovascular outcomes apart from its associations with established risk factors such as blood pressure, serum total cholesterol level, and diabetes…The Framingham Risk Score does not include obesity, based on the argument that its effects are “to a large extent through the major risk factors,” and its “unique contribution to CHD prediction can be difficult to quantify.” We now know that all of our obese patients (those with and without HTN, dyslipidemia and/or smoking) will benefit from weight loss via decreased cardiovascular morbidity and mortality. Your patients have a resource for losing weight at their fingertips by visiting http://carefirst.staywellsolutionsonline.com/Wellness/Weight/
Where to Find it: Journal of the American Medical Association 2005;294(8):914-923
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Treating Depression through Collaborative Care
No longer seen as just ‘the blues,’ depression is a chronic disease with a high rate of recurrence. More than two thirds of adults with a depressive disorder are being treated in primary care practices. Behavioral health providers may also treat these members at the same time, thereby creating greater potential risks of dual treatment, including drug interactions and side effects. Magellan Health Services and CareFirst jointly support communication between primary care physicians and behavioral health care providers to enhance the safety and quality of member care. To assist you, Magellan and CareFirst have made available evidence based guidance on effective and collaborative care models for this complex disorder.
Treating Depression in Primary Care
CareFirst and Magellan advocate aggressive, early treatment with at least three visits during the first 12 weeks of diagnosis, and a follow-up visit within one to four weeks after the initial prescription of medication. Early follow-up allows the provider to assess response to antidepressant medications and make adjustments to the treatment plan, answer questions and address side effects or drug interactions that may cause a member to discontinue treatment.
Once symptoms are under control, long-term medication management is important to maintain improvements and reduce the likelihood of recurrence. This portion of treatment requires the member to remain on an antidepressant medication continuously for at least 12 months after the initial prescription.
While most members can be successfully treated in the primary care setting, some moderate to severe cases, and especially those at risk of endangering their own or someone else’s life, should be referred to a behavioral care specialist as soon as possible.
Referring for Behavioral Care
Behavioral care is warranted when these conditions arise:
- The member is at risk for harm to self or others
- There is presence of possible co-existing bipolar disorder, dementia, psychosis, eating disorder, or another psychiatric or substance use disorder
- There is presence of a severe and/or chronic co-existing medical condition
- The member is either pregnant or early postpartum
- The member does not respond adequately to evidence based treatment for depression in the primary care setting, or appears to have treatment-resistant depression
Medication and Therapy Best Treatment for Depression Research shows that the combined treatment of medication and behavioral therapy has the greatest success rate for treating depression. Below are recommendations based upon available research:
Mild to moderate depression
Two kinds of psychotherapy – cognitive-behavioral and interpersonal – have emerged as effective for treating mild to moderate depression. Psychotherapy may be an alternative when a member refuses treatment with antidepressant medications, or used as an adjunct to treatment with antidepressants for members with complicating situational concerns.
Cognitive-behavioral therapy targets irrational beliefs and distorted attitudes about the self, the environment and the future that can perpetuate depression.
Interpersonal therapy focuses on losses, role transitions, social isolation, deficits in social skills and other factors that may impact depression.
Severe depression
For severe depression, psychotherapy alone is not generally supported as an efficacious treatment strategy. However, several studies have shown that the combination of psychotherapy and pharmacotherapy is superior to treatment with a single modality for both severely depressed members and those with recurrent episodes of the disorder.
Accessing Behavioral Referrals
CareFirst and Magellan support members with their primary care providers in determining when referral to a behavioral health care provider should be a part of the treatment plan. For referral assistance, please contact Magellan Health Services at 1-800-640-9558 or visit www.MagellanHealth.com.
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New Vendor to Administer Disease Management Programs
Healthways, Inc. began administering CareFirst’s and CareFirst BlueChoice’s CareEssentials disease management programs for diabetes, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease and asthma on July 1, 2006.
Led by a team of nurses, the CareEssentials Disease Management Program Team encourages patients to be proactive in managing of their overall health. Participation is free and voluntary for all eligible CareFirst and CareFirst BlueChoice members. This covered service does not require a written referral for patients to participate.
Healthways has more than 20 years’ experience in providing specialized programs and services in disease management. Below are some of the resources that Healthways will provide:
Physician Resources:
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Registered nurse care managers work with patients to reinforce the physician’s treatment plan, increase patient compliance and improve clinical outcomes
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Physician support and educational materials, including quarterly newsletters and care guides
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Access to the program’s nurses through its toll-free number, 24 hours a day, seven days a week
Patient Resources:
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Regular telephone contact from registered nurse care managers to evaluate their health status, suggest possible lifestyle changes and encourage compliance with their physcian’s treatment plan
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Educational mailings, such as workbooks and quarterly newsletters, to help patients better understand and manage their condition
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Periodic reminders encouraging patients to obtain recommended laboratory tests and exams
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Periodic assessment of the patient’s success following a prescribed treatment plan
Doctors or their medical staff may refer patients to these programs by calling 800-783-4582. Information used to administer the program is confidential and will be used to administer the program in compliance with HIPAA regulations.
Doctors will continue to direct the patient’s treatment plan with the added support of the program’s team of registered nurses, who will reinforce the efforts to help enhance clinical outcomes and patient satisfaction.
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QI Program: Setting Goals for Improved Care and Service
CareFirst and CareFirst BlueChoice are committed to providing high quality care and service to members. The Quality Improvement (QI) Council works with community physicians to develop and implement the QI Program to help improve the quality and safety of clinical care in all areas of the health care delivery system. As part of this effort, QI supports the six guiding principles identified in the Institute of Medicine 2001 report, “Crossing the Quality Chasm: A New Health System by the 21st Century”:
- Safe: Avoid injuries from care intended to help
- Timely: No unnecessary waits
- Effective: Evidence-based treatments and technology
- Efficient: Not wasteful
- Equitable: Same care for everyone regardless of gender, race, ethnicity, age
- Patient-centered: Responsive to preferences, needs and values
CareFirst and CareFirst BlueChoice annually implement a QI work plan that outlines specific clinical and service-related improvement activities using the National Committee for Quality Assurance (NCQA) Standards and Guidelines as a framework. Data are collected and analyzed for each clinical and service-related improvement activity throughout the year. Work groups then study improvement barriers and develop targeted interventions to help us achieve our established goals. Here are some examples of our interventions:
- To improve childhood immunization rates, we mailed a series of age-specific letters to educate parents and remind them about the immunizations due for their child.
- To improve breast and cervical cancer screening in women, we mailed age-appropriate birthday cards to women that encourage appropriate screenings for women’s health.
- To promote preventive services among adult male members, we mail age-appropriate brochures to men promoting blood pressure testing and control, cholesterol testing and control, colon cancer screening (50 years and older) and pneumonia vaccine (50 years and older).
Categories of measures our QI plan used to analyze data are:
- Use of preventive services
- Compliance with clinical practice guidelines
- Continuity and coordination of care between medical and behavioral health care
- Effectiveness of disease management programs
- Patient safety in all aspects of clinical care
- Response to increasingly diverse populations’ health care needs
- Availability of practitioners and access to care
- Potential over- and under-utilization of care
- Member and provider satisfaction
For more information or a paper copy summary about the program results and how we meet our goals, call 410-528-7997 or 800-323-4472.
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