Best Practice
CareFirst, Delmarva Foundation Team Up To Reduce Needless Deaths in Hospitals in Mid-Atlantic Region
CareFirst Committment
Braddock Medical Group Earns Bridges to Excellence Certification
CareFirst, Boat People SOS Forge Partnership
Corporate Update
CareFirst Introduces New Initiative - Providers Solutions
Technology
New and Emerging Technology
Disease Management
Recent Literature Related to CareFirst and CareFirst Disease Management Initiatives
Magellan Health Services Mid-Atlantic Care Management Center Launches a Child & Adolescent Depression Prevention Program
Current News
Medication Errors Detected Through Claims Analysis
Quality Improvement
HEDIS Results
MHCC Report Card
2005 MHCC HMO Report Cards Released
CareFirst, Delmarva Foundation Team Up To Reduce Needless Deaths in Hospitals in Mid-Atlantic Region
The following is presented in an effort to highlight hospital “best practice” in the CareFirst BlueCross BlueShield service area and to share with medical professionals throughout the region the innovative approaches hospitals are adopting in Maryland, Washington, D.C. and Northern Virginia. The “best practice” approach to patient care is not only improving the quality of care but also helps contain the rising cost of care.
Imagine 100,000 lives. It may be hard, but try it this way. Think of a big time football game – Michigan versus Ohio State, perhaps. There, all sitting in one stadium, you have 100,000 lives -- give or take a few thousand. The people sit, and stand, and talk and scream. They are alive, animated and enjoying themselves. Now, think how cold and quiet that stadium is without those people.
 The life-and-death significance of the “100K Lives and Beyond” campaign, a three-year hospital safety initiative to make hospitals in the Mid-Atlantic region as safe as possible, comes down to a focused, practical effort to keep 100K people alive. Research by the Institute of Medicine has shown that as many as 98,000 Americans die preventable deaths in hospitals each year due to medical errors.
In October, CareFirst BlueCross BlueShield partnered with the Delmarva Foundation of Easton, Md., to join the national “100K Lives and Beyond” campaign with the goal of saving 4,000 lives in Delaware, Maryland, the District of Columbia and Northern Virginia by June 2006. The Delmarva Foundation is a national, not-forprofit organization dedicated to improving health care quality in more than 30 states. Twenty-seven hospitals within the CareFirst Mid-Atlantic service region are being encouraged to develop and adopt procedures that promote cleanliness, avoid simple mistakes and improve responses to medical emergencies.
“Our purpose in providing support to the 100,000 Lives campaign is simple – to encourage adoption of procedures and standards that will improve care and save lives,”said David D. Wolf, CareFirst Executive Vice President, Medical Systems and Corporate Development.
Focusing initially on the intensive care units and operating rooms in the participating hospitals, the 100K initiative currently includes five specific procedures and practices that offer the greatest potential for saving lives in a hospital setting:
- Empower any hospital staff member – no matter what level -- to deploy a rapid response team at the first sign of a patient in distress.
- To prevent adverse drug events, require a review of medications to ensure proper dosage at admission, at discharge and before any transfers within the hospital.
- To prevent catheter-related bloodstream infections, consistently provide a five-part “bundle” of appropriate care, including measures to improve hand hygiene.
- Guard against surgical site infections by reliably dispensing the proper antibiotics, maintaining patient glucose levels and avoiding shaving hair in the vicinity of the surgery.
- Avoid the possibility of ventilator-associated pneumonia by taking specifi c preventive steps – including measures as simple as elevating the head of the hospital bed by 30 degrees.
A sixth procedure, relating to the treatment of heart attack victims and emergency room procedures, will be introduced as part of the Delmarva Foundation’s 100K Lives initiative later this year (2006).
“The strength of the initiative is that it is evidenced based and bundles together five basic practices that are very simple but very effective,” explained Ingrid Connerney, Director of Clinical Effectiveness at the University of Maryland Medical Center in Baltimore. Connerney adds that the involvement of IHI (Institute of Healthcare Improvement) and the Maryland Patient Safety Center Collaborative provide tools and ideas on how to optimize the 100K Lives initiative.
“To sustain the highest level of compliance, we revisit the evidencebased practices periodically, collect data on compliance, and monitor outcomes,” she said. “In the ICU, this has gotten us to 100 per cent compliance with practice related to the ‘ventilator-associated pneumonia’ bundle. (A practice that involves head-of-bed elevation at 30 degrees, peptic ulcer prevention, and deep-vein thrombosis prevention.)
Team leaders in the intensive care units and operating rooms of participating hospitals evaluate procedures, modify them when appropriate to improve results and, when necessary, introduce new procedures that further reduce the chances of a patient dying in the hospital.
 The Delmarva Foundation is leading the clinical integration of procedures developed in the 100K Lives campaign. CareFirst has contributed $450,000 that is being used by the Delmarva Foundation to fund a series of quarterly meetings where life-saving procedures are explored, discussed and evaluated. The meetings bring together the team leaders from all the participating hospitals and are led by foremost medical authorities who share their knowledge and experience on specific life saving procedures – what works and what doesn’t.
“We call these meetings collaborations,” said Ann Doyle, CareFirst’s Program Manager for Quality Control and Patient Safety, “because the team leaders work together, exchanging information among themselves in developing alternative solutions to particular problems or care situations.” She adds that all of the participating hospitals are free to determine for themselves and to adopt as they see best the recommended practices that produce the best results for them.
In addition to the 27 hospitals in the CareFirst service area that currently participate in the “100K Lives and Beyond” initiative, more than 2,800 hospitals throughout the United States are taking part in the campaign to reduce preventable deaths.
Jocelyn Fiedler, the clinical leader for the critical care unit at Atlantic General Hospital in Berlin, Maryland, said that the hospital began integrating the procedures of the 100K Lives initiative last January starting with the best practices for reducing ventilatorassociated pneumonia. New protocols for medication reconciliation and prevention of blood stream infections were recently phased in and in February of this year (2006) a rapid response team will be introduced.
“Atlantic General is a small hospital, so we have had to be creative in developing consistent procedures that work for us,” she said. “The key has been evidence-based protocols that produce results.”
Assessing the benefi ts for hospitals participating in the 100K Lives initiative, Ingrid Connerney at the University of Maryland Medical Center, said, “Having a bundle of best practices for a patient population helps us make sure we get it right every time. This initiative is pushing us to not accept average performance. Hospitals are reaching out to prevent mortality and are changing the perception of what can be prevented.”
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Braddock Medical Group Earns Bridges to Excellence Certification
As part of the CareFirst Commitment campaign promoting high quality care, CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (CareFirst BlueChoice) last year launched its Bridges to Excellence (BTE) initiative. The three-year pilot program will provide recognition and financial rewards to primary care physicians who take concrete steps that encourage and support optimum care and better outcomes for patients.
So far, 20 of the 22 physician practices selected for the program have completed a thorough certifi cation process administered through the National Committee for Quality Assurance – a leading national organization dedicated to improving and measuring health care quality.
Participating physicians in the CareFirst-BTE pilot can earn rewards of up to $50 per patient per year. Individual physicians can earn up to $20,000 in the first year and $50,000 over three years. The maximum annual award for any single practice site is $100,000. CareFirst estimates that nearly $1.4 million in rewards will have been paid out in 2005.
 The Braddock Medical Group, a seven-member medical practice in Cumberland, Md., is among the region’s first practices to implement steps designed to deliver safe, high quality health care and earn certification in the Bridges to Excellence program.
The Braddock Medical Group made substantial upgrades in technology to transition away from reliance on paper-based record keeping.
“The technology improvements we made as part of the BTE program – such as creating a full computer network and getting hand-held computers into the hands of our nurses – will allow us to do a better job of following up with patients, tracking their care and making sure patients get the tests and lab visits they need,” said Michael Burkey, Group Administrator.
Said Jon Shematek, MD, CareFirst’s Vice President for Quality and Medical Policy: “We are thrilled that Braddock Medical Group has taken the necessary steps to become a certified participant in our Bridges to Excellence program. Patients will benefit directly through this program. It’s evidence that physicians are looking for and willing to work at innovative, pragmatic and measurable ways to improve the care they provide their patients.”
| The Maryland, Delaware and District of Columbia physician practices certified for Bridges to Excellence so far are: |
| • Wyman Park Internal Medicine |
• Carrolltowne Medical Center |
| • Harford Primary Care |
• Washington Primary Care Physicians |
| • Associates in Family Practice |
• Don H. Yablonowitz, M.D. |
| • David J. Hartig, M.D. |
• Cameron Medical Group |
| • Columbia Medical Practice |
• Andrew S. Dobin, M.D. |
| • Bel Air Health Center |
• Drs. Mulhauser and Duke, LLP |
| • Braddock Medical Group |
• Kenneth M. Klebanow, M.D. & Associates |
| • Alice Tanner, M.D. |
• J. Richard Lilly, M.D. & Associates |
| • Dover Family Physicians |
• Pediatric and Adolescent Care of Silver Spring |
| • Chapel View Family Care |
• Pediatric and Adolescent Care, P.A. |
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CareFirst, Boat People SOS Forge Partnership
CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc., (CareFirst BlueChoice) are not only committed to improving the quality and safety of health care, but also to making it more accessible to all ethnic groups.
To address the specifi c needs of the Vietnamese community, CareFirst has forged a partnership with the Boat People SOS (BPSOS) and donated $585,000 to a three-year initiative aimed at raising cervical cancer screening rates among Vietnamese women in the Washington, D.C. area. BPSOS is a leading advocacy and service organization for Vietnamese immigrants.
The program began in September and focuses on Vietnamese women living in northern Virginia last year. It expands to Washington, D.C. this year, and Montgomery and Prince George’s counties next year. The program hopes to target about 10,000 women age 21 and older, many of whom are unaware of their risks.
 Vietnamese women have fi ve times the risk of developing cervical cancer as Caucasian women. Barriers such as limited English profi ciency, low literacy, cultural beliefs, and misconceptions and unfamiliarity with the American health care system prevent Vietnamese women from seeking early screening and preventive services.
CareFirst and CareFirst BlueChoice are excited about this collaboration with BPSOS and are committed to improving the health of the Vietnamese community through its support to promote health education and early detection of cervical cancer.
A media campaign aimed at local and national audiences will be used to reach different levels of literacy in the Vietnamese community. Vietnamese radio, television, public service announcements and BPSOS’s monthly publication will stress the urgency of cervical cancer and preventive health awareness.
Bilingual health advocates and trained volunteers will ensure that the women receive the necessary support to access participating health service providers offering free screenings.
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CareFirst Introduces New Initiative - Providers Solutions
To all CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. providers, we heard you.
You said that you wanted easier, more effi cient ways to interact with us, so during the past year we made several enhancements to provider service, technology products and case management.
For instance, we’ve extended our service hours, expanded electronic claims submission, added our no referral feature to BlueChoice and BlueChoice Opt-Out Plus products, expanded CareFirst Direct and launched an electronic proscribing program, top name just a few of our initiatives. Already, we have introduced several new processes and procedures, which we are pleased to say have contributed to higher levels of satisfaction on our most recent Provider Satisfaction Survey.
But we’re not done. We’ll soon begin a Unified Service System in which our associates can view screens easier and respond to your needs even faster; launch Provider Information and Credentialing Automation that will streamline the credentialing process and provider updates, as well as maintain all provider data in a single provider file; and expand the capabilities of FirstLine and BlueLine, our self-service, voice response units, to provide even higher levels of accurate eligibility, claims and benefi t information.
Our goals in creating these initiatives were to enhance our service and technology so you can spend more time practicing medicine and less time dealing with paperwork.
Throughout 2006, you will hear more about what CareFirst is doing to reduce the complexity of providing care to our members. Under the theme “Physician Solutions – Making Blue Work for You,” we are committing to delivering more responsive and effi cient service to the many health care professionals who serve CareFirst members.
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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:
| Growth hormone therapy for children born small for gestational age |
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Between 3 and 10 percent of live births have been described as small for their gestational age (SGA). While most of these children will have achieved catch-up growth by the age of two, a small subset of one in 10 will fail to achieve full catch-up growth and will maintain short stature, both as children and adults. Typically, such patients will demonstrate normal growth hormone levels in standard laboratory tests. Long-term use of human growth hormone (GH) in these children can result in growth gains through childhood to fi nal adult height, and the FDA has approved labeling of human growth hormone products for this indication.
CareFirst and CareFirst BlueChoice determination:
Having short stature secondary to being born small for gestational age does not indicate a functional impairment subject to treatment with growth hormone injections. While studies have shown that administration of GH is effective in adding to a child’s height and increasing the projected fi nal adult height, there is no evidence that this improves the health outcomes of the patient, either as a child or an adult. Although the case has been made that children with short stature suffer psychosocial impairments in greater proportion than the general population, there is inadequate scientifi c evidence to demonstrate that this is true. Conversely, there is no evidence that not providing GH to children with short stature results in adverse health outcomes. Therefore, CareFirst and CareFirst BlueChoice have determined that the use of GH in children who are small for gestational age is not medically necessary.
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| Gene expression profi le for breast cancer management, e.g. Oncotype DX® assay |
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Research has recently identifi ed panels of gene expression markers that appear to be predictive of breast cancer recurrence in populations of women with node-negative disease. These patients are currently treated with chemotherapy administered in follow-up to resective surgery. However, a large proportion of these women could experience 10-year disease-free survival without chemotherapy or with tamoxifen therapy alone. Thus, for these patients, there is no benefi t to the chemotherapy. A more precise alternative to the current decision algorithm for placing a patient on chemotherapy would therefore spare patients the adverse effects of chemotherapy without a reduction in disease-free survival, and those women who have been excluded from chemotherapy based on current algorithms could derive a health benefit.
It is believed that a microassay gene expression panel could be used to provide this kind of prognostic information and improve outcomes by determining whether a patient would or would not benefi t from adjuvant chemotherapy after primary surgery. Validation studies have focused on a narrowly-defi ned group of patients: those who are newly diagnosed, with node-negative stage I or II disease, are estrogen receptor positive and will be treated with tamoxifen.
CareFirst and CareFirst BlueChoice determination:
Assays of this type appear to be developing. The literature indicates that several gene panels have been identifi ed and analytic validation studies have been performed. Further, clinical validation studies are in progress to establish in relevant patient populations the association between the genetic markers and patient outcomes. However, there is no published evidence to indicate that the use of such genetic marker assays improves patient outcomes or disease free survival over currently used protocols, or that patients who would not benefi t from adjuvant chemotherapy without an adverse effect on disease free survival can be identifi ed. In other words, there is insuffi cient evidence to show that gene expression profi le assays for breast cancer infl uence disease management decisions. Therefore, CareFirst and CareFirst BlueChoice consider assays of this type to be experimental/investigational, as the evidence does not permit conclusions concerning the effect on health outcomes.
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| Palatal stiffening implants for obstructive sleep apnea (Pillar procedure) |
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Palatal stiffening surgery has been proposed as a treatment for obstructive sleep apnea where the airway obstruction originates in the tissues of the palate, as the muscles relax during sleep. The rationale is that the palatal tissue becomes flaccid so as to obstruct the airway by causing a dynamic flutter, and stiffening the palate therefore should relieve the condition. The PillarTM palatal implant system has been proposed as a remedy. The Pillar procedure is an office procedure, performed under local anesthesia, using polyester fibrous threads placed in the roof of the mouth with a special implantation tool.
CareFirst and CareFirst BlueChoice determination:
A search of MEDLINE using multiple search criteria failed to identify any citations in the peer reviewed literature pertaining to the Pillar procedure. Therefore, it is not possible to determine if this technology meets any of the evidence-based criteria for coverage. There is one unpublished study available from the Restore Medical web site that reports on the results of 16 patients who received the Pillar procedure and showed an improvement in the Apnea-Hypopnea Index (AHI) at 90 days. This study was non-randomized and non-controlled, and used very limited measurement criteria on which its conclusions were made. Furthermore, the study was sponsored by Restore Medical so the results could only be interpreted as a pilot study at best. Therefore, CareFirst and CareFirst BlueChoice have determined the Pillar procedure to be experimental/investigational.
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| CT angiography for coronary artery disease |
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CT angiographic imaging of the chest is considered a standard for such conditions as aortic aneurysm and pulmonary embolism, but has not been widely used until recently for coronary arteries due to the technical difficulties encountered in imaging the coronary vessels due to the movement of the heart and the relatively small vessel diameters. As CT apparatus has continued to become more technically accurate, image acquisition times have become shorter, and the machines are able to take thinner “slices” of the object for imaging, the technology is again under investigation. Computed tomographic angiographic (CTA) imaging of the coronary arteries is being proposed as a non-invasive alternative to established coronary angiography for evaluation of the coronary arteries. Possible applications for CT angiography include: 1) as an adjunct to other diagnostic tests such as stress ECG testing; 2) to rule out the necessity for invasive coronary angiography (CA) in patients with symptoms but with a low likelihood of coronary artery disease (CAD) in need of intervention.
CareFirst and CareFirst BlueChoice determination:
Studies published to date indicate that this is a rapidly developing technology with promising early results. However, there are weaknesses in at least some of the studies that would tend to skew the data in favor of the technology, such as elimination from the data of vessels that could not be evaluated due to heavy calcifi cation. Furthermore, the calculations of specifi city and negative predictive values tend to be considerably lower when the patient is used as the unit of analysis rather than vessel segments. For these reasons, most reviewers agree that the evidence is not robust enough to consider CTA to be at least equivalent to the current gold standard coronary angiography. There is insufficient evidence to permit conclusions regarding the effect of CTA on health outcomes, therefore, CareFirst and CareFirst BlueChoice consider the technology to be experimental/investigational.
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| Pulmonary vein ablation / isolation for atrial fibrillation |
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Because it is believed that a high percentage of atrial fi brillation (AF) cases originate in the myocardial tissue at the base of the pulmonary veins, this procedure was developed as a means of obliterating the focal points of the aberrant atrial beats by creating scar tissue in the area so as to isolate the pulmonary veins from the atrium. Both open and transcatheter techniques have been developed.
CareFirst and CareFirst BlueChoice determination:
The published evidence for this procedure reflects that of a technology still in development. For example, most of the outcomes data have been in the form of results of a few small series of patients, without controls or well-designed outcomes measures, performed on carefully selected patients. In January 1994, the FDA published a recommendation for design of a clinical study to address the safety and efficacy of pulmonary vein isolation, to include several well defined endpoints for efficaciousness, as well as safety. The primary endpoint of the current evidence seems to focus on the effect of the procedure on the characteristics of the arrhythmia alone. In early studies, pulmonary vein stenosis, a potentially serious complication, was observed in a significant number of cases; and in the most recent studies, while suggestive that improvement in technique may have addressed the problem, that issue has not been clearly documented. Results of the procedure have been observed over short to intermediate periods, and although these results are encouraging, there is still not a body of evidence pointing to a durable and safe procedure over time. The results also indicate that pulmonary vein isolation may not obviate the need for long term medication to control recurrent AF, and may not be effective in all cases. Finally, the current evidence does not clearly establish which patients may benefit from the intervention, although patients with the paroxysmal type of AF seem to show better results in terms of reduction or elimination of episodes of AF than patients with a persistent type.
It appears this procedure is being performed on a limited basis in a few specialized medical centers, and has not yet received widespread acceptance.
Therefore, CareFirst and CareFirst BlueChoice have determined the procedure to be experimental/investigational.
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| Magnetoencephalography and magnetic source imaging |
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Magnetoencephalography (MEG) is a non-invasive imaging modality based on sensing weak magnetic forces emanated by the electrical activity of the brain. The data obtained are modeled so as to localize areas of neuronal activity in the brain. Typically, MEG information is superimposed on an MRI structural image, in which case it is known as magnetic source imaging (MSI). The technique has been known and used in the research setting for about 30 years, but recently has begun to see greater application in the clinical setting, in the evaluation of surgical treatment for epilepsy and in presurgical evaluation for excision of intracranial lesions. In the fi rst scenario, MSI is proposed as a means for identifying the epileptic area for resection while avoiding more invasive testing. In the second, MSI would be used to identify functional anatomic regions of the brain that must be avoided during the resective surgery, again obviating the need for invasive cortical mapping.
MEG has both technical advantages and disadvantages. MEG measurements are less subject to distortion by tissues of the scalp, skull and brain, and by cerebrospinal fluid, which allows for better spatial localization of epileptic foci than those detected by surface EEG, which can produce distorted signals. However, lesions which lie at deeper levels in the brain tissue may not be detectable by MEG due to decay of the magnetic fi eld signal over distance.
CareFirst and CareFirst BlueChoice determination:
There have been several studies to compare MEG to invasive EEG and electrocortical testing. These studies have generally involved small groups of patients, and have been limited by such factors as non-blinding of reporting results and limited analysis of data. These limited data suggest that MEG and EEG results are in general agreement, but that it could not be concluded that MEG could be construed as a replacement for the current gold standard, which is the invasive intraoperative EEG. Some studies have reported that MEG was able to identify lesions that could not be identifi ed by other methods, such as MRI or invasive EEG. However, one study reported the presence of epileptogenic foci seen on MEG postoperatively in a patient that was seizure-free.
Overall, evidence from these small studies is variable from those which report a high correlation between MEG/MSI results and invasive EEG results, to those which report a signifi cantly lesser degree of correlation. Small sample groups, non-blinding of reported results, and mixed patient populations highly limit one’s ability to draw reliable conclusions as to the effect on health outcomes. A few reviewers have taken the position that MEG/MSI should be considered a “complementary” diagnostic procedure to the invasive EEG, as both tests have relative advantages and disadvantages in their designs. However, there is no direct evidence that the use of MEG/MSI has contributed to improved net outcomes.
For these reasons, CareFirst and CareFirst BlueChoice have determined that magnetoencephalography and magnetic source imaging to be experimental/investigational.
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| Actigraphy |
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Actigraphy is a means to measure a patient’s movements in the study of sleep/wake cycles and circadian rhythms by wearing a sensor on the wrist. Actigraphy has been proposed as a diagnostic tool for conditions such as sleep-related breathing disorders and insomnia.
CareFirst and CareFirst BlueChoice determination:
There is insuffi cient evidence in the literature to permit conclusions regarding the effect of the use of actigraphy on health outcomes of patients with sleep disorders. Furthermore, at least one published review indicates that a defined standard does not exist for such parameters as scoring and analysis of data, threshold settings and artifact defi nitions.
For these reasons, CareFirst and CareFirst BlueChoice consider actigraphy to be experimental/investigational.
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Recent Literature Related to CareFirst and CareFirst Disease Management Initiatives
By Richard S. Safeer, MD, Medical Director, Preventive Medicine
 CareEssentials: Disease Management
As part of the Disease Management component of CareEssentials, the CareFirst and CareFirst BlueChoice multi-faceted care management program that provides you with essential tools for patient care, this article is intended to call your attention to recent literature that may be of interest to you.
For more information on how to enroll your patients in one of our disease management programs, please call 800-783-4582.
| GESTATIONAL DIABETES MELLITUS • What's Available: |
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The American College of Obstetricians and Gynecologists recommends that pregnant women have a diabetes screening between their 24th and 28th weeks of pregnancy. Not every country, such as Australia, has a similar recommendation. The authors of Effect of Treatment of Gestational Diabetes Mellitus on Pregnancy Outcomes aimed to either support or refute the recommendation of screening for gestational diabetes. One thousand Australian women with gestational diabetes mellitus were randomly assigned to either the intervention group (dietary advice, blood glucose monitoring and insulin therapy) or routine care. The intervention resulted in reducing “the rate of serious perinatal outcomes (defined as death, shoulder dystocia, bone fracture and nerve palsy) from 4 percent to 1 percent…In our study, the rate of cesarean delivery was similar in the two groups.” Furthermore, researchers found that infants born to mothers receiving intensive therapy “were significantly less likely to be large for gestational age and to have macrosomia.” The positive clinical outcomes of this study support the practice of screening for Gestational Diabetes Mellitus.
Consider enrolling your pregnant patients in our Great Beginnings program by calling 888-264-8648. As a member of Great Beginnings, pregnant patients will receive educational information in the mail and over the phone. Our nurses can assist in helping to see that your patients attend their prenatal appointments, follow dietary advice and complete recommended laboratory testing. If the member has complications during pregnancy, the Case Manager will work closely with the member and doctor to coordinate the necessary services. Please don’t forget to see your patients three to eight weeks after delivery and ask about postpartum depression.
Where to Find it: New England Journal of Medicine 2005; 352:2477-86
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| CHRONIC OBSTRUCTIVE PULMONARY DISEASE • What's Available: |
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Once a COPD exacerbation begins, controlling it can be diffi cult. Investigators of Prevention of Exacerbations of Chronic Obstructive Pulmonary Disease with Tiotropium, a Once-Daily Inhaled Anticholinergic Bronchodilator were looking for a way to prevent aggravation of the disease. In a randomized, double-blind study of nearly 2,000 predominantly male, caucasian patients with moderate to severe COPD, half the patients inhaled tiotropium once a day, and the other half inhaled placebo. After six months, “tiotropium signifi cantly reduced the percentage of patients who experienced at least one COPD exacerbation” and “tiotropium also reduced the percentage of patients who experienced one or more hospitalizations due to COPD exacerbations during the same period.” As shown in previous studies, inhaled Beta-agonists and inhaled corticosteroids also reduce COPD exacerbation rates. Nurses in our COPD disease management program can help improve your patient’s compliance with the medication you prescribe.
Where to Find it: Annals of Internal Medicine 2005; 143(5):317- 326
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| ASTHMA • What's Available: |
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Compliance with medications is a challenge. When compliance with asthma medications is successful, it helps avoid emergency room visits and hospitalizations. The authors of “Daily versus As-Needed Corticosteroids for Mild Persistent Asthma” wanted to know whether daily treatment with either inhaled budesonide or oral zafi rlukast produced better clinical outcomes in patients with mild persistent asthma compared to intermittent short-course corticosteroid treatment guided by symptoms. Mild persistent asthma is defi ned as the presence of one or more of the following clinical features: symptoms requiring treatment more than two times per week, awakening at night from asthma symptoms more than two times a month or variability of the patients P.E.F. by 20 to 30 percent.
Patients in the Improving Asthma Control Trial (IMPACT) were randomly assigned to one of three groups; inhaled budesonide plus oral placebo b.i.d., zafirlukast plus inhaled placebo b.i.d. or both oral and inhaled placebo b.i.d. All three groups were instructed to use inhaled budesonide during exacerbations. The authors concluded that there was “no clinically significant difference among the three treatment groups with respect to morning PEF.” Although other objective measures of lung function and airway biology were improved and patients reported 26 more days free from symptoms of asthma per year when treated with budesonide on a daily basis than with the other treatments, the frequency of asthma exacerbations did not differ significantly among the groups. Although these results are interesting and challenge the current N.I.H. guidelines, the sample (n=199) was small. The results of this study support the execution of a similar study with a larger sample size.
The nurses in our asthma disease management program will help your patients understand the asthma action plan you provide and ultimately help your patients avoid an exacerbation.
Where to Find it: The New England Journal of Medicine 2005; 352(15):1519-28
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| CONGESTIVE HEART FAILURE • What's Available: |
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Several medications, including angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs) and Beta adrenoreceptor antagonists, have been shown to decrease morbidity and mortality from congestive heart failure (CHF). Investigators in “Risk –Treatment Mismatch in the Pharmacotherapy of Heart Failure” hypothesized that those CHF patients at highest risk for death were the least likely to receive appropriate medications.
The subjects of the study were patients admitted to a hospital for the primary diagnosis of CHF (with a left ventricular ejection fraction of less than 40 percent). The patients were classifi ed in to one of three groups based on their predicted one year mortality rate; low, average and high-risk. The prescription rates at discharge and 90 days later were elicited and compared among the groups. “With increasing mortality risk, discharge prescription rates of ACE inhibitors, ACE inhibitors or ARBs, and Beta-adrenoreceptor antagonists decreased… Even after eliminating perceived contraindications and life-limiting comorbidities that could potentially confound the risk-treatment relationship, the mismatch remained…Several studies have found that there are equivalent or greater benefi ts of heart failure therapy in patients at highest risk of death.” These fi ndings give the medical community reason to pause and ask, what is keeping us from treating our sickest patients with the recommended interventions?
Where to Find it: The Journal of the American Medical Association 2005; 294(10):1240-7
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| CORONARY ARTERY DISEASE • What's Available: |
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Like many other areas of our society, the way a person is treated within the medical community often depends on their race, gender and socioeconomic status. The authors of Sex and Racial Differences in the Management of Acute Myocardial Infarction, 1994 through 2002, explores the progress in achieving parity throughout a diverse population. Investigators looked at the medical records of 598,911 patients entered in the National Registry of Myocardial Infarction. The treatment these patients received for their myocardial infarction was compared to the treatment recommended by the American College of Cardiology and American Heart Association (ACC-AHA) since the beginning of the study period. Barring any contraindications, the ACC-AHA recommendations included reperfusion therapy (within 24 hours) for patients with ST-segment elevation, administration of beta-blocker and aspirin within 24 hours of admission and coronary angiography prior to discharge.
Investigators found that “compared with white men, fewer black men and black women received reperfusion therapy and coronary angiography, whereas black women had the highest adjusted mortality rate among all sex and racial groups.” There were only small differences in the use of beta-blockers and aspirin between race and gender. “Management differences were greater when patients were compared according to race within each sex (black men vs. white men and black women vs. white women) than when compared according to sex within each race (black men vs. black women and white men vs. white women), suggesting that disparities according to race may be more important than disparities according to sex.” The authors admit that a potential weakness of their study is that they were unable to control the potentially confounding variable of socioeconomic status. Of equal or greater concern than the differences in health care delivered based on race and gender is that although it has been 15 years since the fi rst reports of health care disparities, the authors found that “racial and sex differences were essentially unchanged between 1994 and 2002.”
Where to Find it: The New England Journal of Medicine 2005; 353(7):671-682.
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| WHAT’S NEW IN PREVENTION? • What's Available: |
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The use of aspirin to prevent various diseases is an ongoing question raised concerning colon cancer. There have been favorable studies on patients with a history of colorectal adenoma or colorectal cancer. Studies of the population, without a previous history or colorectal neoplasia, show aspirin’s benefi t in preventing the development of adenomas, but they have not proved a reduction in colorectal cancer. In Long-term Use of Aspirin and Nonsteroidal Anti-infl ammatory Drugs and Risk of Colorectal Cancer, the authors looked at almost 83,000 women in the Nurses’ Health Study. The participants were mailed a questionnaire biennially to ascertain information about the consumption of aspirin (standard 325 mg dose) and non-steroidal analgesics. Data was collected for more than 20 years. The authors concluded, “Regular, long-term aspirin use reduces risk of colorectal cancer. Non-aspirin NSAIDS appear to have a similar effect. However, a signifi cant benefi t of aspirin is not apparent until more than a decade of use, with maximal risk reduction at doses greater than 14 tablets per week. These results suggest that optimal chemoprevention for colorectal cancer requires long-term use of aspirin doses substantially higher than those recommended for prevention of cardiovascular disease, but the dose-related risk of gastrointestinal bleeding must also be considered.” While the medical community continues to evaluate aspirin’s role in preventing colon cancer, it is very important to remember to screen for the cancer. Please be sure to screen your average-risk patients starting at age 50.
Where to Find it: Journal of the American Medical Association 2005;294(8):914-923.
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Magellan Health Services Mid-Atlantic Care Management Center Launches a Child & Adolescent Depression Prevention Program
Magellan Health Services Mid-Atlantic Care Management Center and CareFirst BlueChoice are excited about their new preventive health initiative, “Depression in the Children of Parents with a Depressive Disorder: Screening and Referral for Children, and Education for Parents and Providers.”
 Studies indicate that depression tends to run in families and the incidence of Major Depressive Disorder among children of parents diagnosed with depression has been found to be as high as 45 percent. Our program targets youngsters between ages nine and 17 whose parents have been diagnosed with depression to increase the rate of detection of depressive disorders in these children and to increase their rate of referral and care. An additional goal is to help parents of at-risk children foster resilience in their children as a protective factor against the development of depression.
We are sending information packets on depression in children to members who have accessed behavioral health services and have children in the targeted age group. The packets include brochures about depression in families and child and teen depression, a fact sheet on how to increase resiliency in children and a depression screening tool, the Brief Screen for Adolescent Depression—Youth Version.
As a primary care provider, you may receive questions regarding this program. The member’s child (or children) may be referred to you to evaluate and possibly treat any depressive symptoms. We hope that you will encourage your patient to take advantage of this program and to watch for signs and symptoms of depression in their children.
If you have any questions about the program, please contact Magellan Health Services Mid-Atlantic Care Management Center Quality Improvement Department at 1-800-720-7931 or online at www.MagellanHealth.com
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Medication Errors Detected Through Claims Analysis
Drugs used to treat erectile dysfunction (ED) should not be prescribed to patients who also take nitrate medications ecause of the known potentiated hypotensive effect of the combination. Deaths from taking this combination of drugs have been known to occur since at least 1998. Adverse reactions to this drug combination continue to be reported in the media.
Claims from January 2004 to June 2005 were analyzed by CareFirst BlueCross BlueShield’s Healthcare informaties Department to determine if this drug combination was prescribed simultaneously, defi ned as overlapping periods of drug days supply for each medication and to identify potential adverse reactions that may have resulted. The analysis confi rmed that the drug combination had been prescribed simultaneously and that members had been hospitalized within the prescription overlap period. Although a direct link between prescription and hospitalization could not be established, members were hospitalized for conditions including: extremity claudication, acute renal failure, mediastinal artery aneurysm, atheroselerosis of a native coronary artery and an autologous vein graft, and paroxysmal ventricular tachycardia.
In an effort to decrease the potential for adverse reactions and possible hospitalization of members, we are encouraging physicians and pharmacists to have a heightened awareness when patients are receiving this drug combination. Continuation of this practice suggests that additional education of pharmacists and physicians may be needed, as well as development of a systems approach to alert practitioners about this potentially dangerous drug ombination.
There are a number of patient-specific variables that must be taken into account. The physician is best qualified to balance quality and care considerations in choosing the most appropriate medications for the patient. It is recommended that before prescribing ED drugs, physicians should confi rm that their patients are not taking nitrates and educate their patients of the risks associated with taking mediations altogether.
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HEDIS Results
Every year, CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (CareFirst BlueChoice) participate in the Health Plan Employer Data and Information Set (HEDIS) initiative. HEDIS measures the quality of select aspects of care and services provided to HMO members, and participation in this study is mandated for HMO plans in our service area. We are sharing the results of information collected for the 2004 measurement year to inform you of where your strengths lie and offer suggestions where you can make a difference to improve services to our members.
What Improved?
The following areas of care improved:
CareFirst and CareFirst BlueChoice strive to provide quality services to members and look for improvement in all aspects of care.
Where Do We Need to Improve?
The following areas of care need your attention:
Adolescent Immunizations:
Vaccinations are one of the best ways to put an end to the serious effects of certain diseases.
Hep B
Each year, it is estimated that more than 80,000 people, mostly young adults, are infected with Hepatitis B. About a third of those infected by Hepatitis B do not know how they contracted it. Hepatitis B is a three-dose series, ideally given during a six month course.
Varivax (Chicken pox)
If your adolescents did not receive a dose of Varivax prior to age 13 and has not yet had the infection, then they need two doses of the vaccine separated by at least four weeks.
Codes to Identify Adolescent Immunizations:
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Immunization
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CPT® Codes*
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ICD-9-CM Codes
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MMR
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90707, 90710
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V99.48
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Measles
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90705, 90708
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055**, V99.45
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Mumps
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90704
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072**, V99.46
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Rubella
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90706, 90708, 90709
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056**, V99.47
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Hepatitis B
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90723, 90740, 90743***, 90744,
90746, 90747, 90748
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V02.61**, 070.2**, 070.3**
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VZV (Varicella)
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90710, 90716
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052**, 053**
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*Note: Current Procedural Terminology (CPT) codes and descriptions are copyright of the 1966 American Medical Association. All rights reserved.
** Indicates evidence of disease. A member who has evidence of disease during is compliant for the antigen.
*** This CPT code identifi es the two-dose regimen for hepatitis B. The two-dose hepatitis B antigen Recombivax is only recommended for children between 11 and 14 years of age.
Share this information with your billing service.
Office Hints:
Document serology testing or the age of the child when there is history of the illness. Keeping this in a central place such as the immunization fl ow sheet ensures completeness. Discuss immunization importance with parents. The Center for Disease Control has printable information for patients and parents.
Post Partum Care
The goal for postpartum care is to optimize the health of the mother as well as that of the newborn. A postpartum visit is STRONGLY encouraged 21 to 56 days after delivery and includes details of the delivery, physical exam, laboratory tests and counseling. Counseling should include, but is not limited to, breast feeding, postpartum depression, contraceptive methods and future health and pregnancies.
Antidepressant Medication Management The fi rst step to treatment for depression is a physical examination by a physician. Certain medications, as well as some medical conditions such as a viral infection, can cause the same symptoms as depression, and the physician should rule out these possibilities through examination, interview and lab tests. If a physical cause for the depression is ruled out, a psychological evaluation should be done by the physician or by referral to a psychiatrist or psychologist.
A good diagnostic evaluation will include a complete history of symptoms, i.e., when they started, how long they have lasted, their severity, whether the patient had them before and, if so, whether the symptoms were treated and what treatment was given. The doctor should ask about alcohol and drug use, and if the patient has thoughts about death or suicide. Further, a history should include questions about whether other family members have had a depressive illness and, if treated, what treatments they may have received and which were effective.
Office Hints:
To meet the state regulatory and accreditation requirements, it is important for practitioners to include the appropriate ICD diagnosis code along with the Evaluation and Management CPT® Code. Coding is essential to identify your excellence in patient care.
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2005 MHCC HMO Report Cards Released
The Maryland Health Care Commission (MHCC) recently released its annual guide for consumers on the performance of seven Maryland Health Maintenance Organizations (HMOs). Th e MHCC report card rates each of the Maryland HMOs on:
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Frequency that members obtain preventive and wellness services
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Members’ level of access to health care delivery systems
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Member satisfaction with the health care they received
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How members feel about their health plan
Report card results are based on the Consumer Assessment of Healthcare Providers and Systems (CAHPS® 3.0H) and clinical data from the Health Plan Employer Data and Information Set (HEDIS) audits. Th e report card, Th e 2005 Consumer Guide to Maryland HMOs and POS Plans, is published by MHCC and is available at http://mhcc.maryland.gov/hmo/ or by calling MHCC at 877-245-1762.
CareFirst BlueChoice demonstrated above-average performance in five Effectiveness of Care measures, namely:
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Appropriate testing for children with pharyngitis
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Appropriate treatment for children with upper respiratory infection
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Use of appropriate medications for people with asthma ages 5 to 17 years
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Use of appropriate medications for people with asthma ages 18 to 56 years
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Colorectal cancer screening
And in five Access/Availability of Care measures as follows:
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Adolescents’ access to Primary Care Practitioners (12 to19 years)
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Children’s access to Primary Care Practitioners (7 to 11 years)
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Well-child visits for infants and children
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Adolescent well-care visits
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Prenatal care
In addition, the health plan showed statistically significant improvement from 2003 to 2005 in its rates for childhood immunization, adolescent immunization, controlling high blood pressure and use of appropriate medication for people with asthma in the 5 to 17 years age group.
BlueChoice continues to assess and implement new processes and programs as a method to improve the care and services provided to its members and to increase members’ level of satisfaction.
The National Committee for Quality Assurance (NCQA) also publishes HEDIS results and compares many HMOs on a national and regional basis in The State of Health Care Quality 2005. This report is available at http://www.ncqa.org/.
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