HealthInk: Your Connection to CareFirst

Industry Trends
More Doctors and Patients Get Online
Communicating With Patients Via E-mail
Treating Patients Who Are 'Wired'
Alternative Care Becomes More Conventional Choice
NIH Funds Research Into Complementary and Alternative Therapies
CareFirst Offers Complementary and Integrative Therapy Program

Inside CareFirst
Technology Assessment: Vital to Our Relationship With Providers
Recent Determinations

Quality Improvement
1999 HCACC Report Cards Released
Improved Care for Diabetics
New Preventive Services Guidelines

Care Management
Hospitalists: Changing the Face of Inpatient Care
Breast Cancer and Cervical Cancer Screening
Beneficial Care Management Programs for Your Patients
Case Management Enhances Quality of Care

Behavioral Health
Partnerships to Improve Behavioral Health
Do You Have SAD Patients?

Health Education
CME Credit Opportunities
Advance Directives Overview
Interactive Video Programs

What's Happening
Philosophy of Care
Influenza Vaccination: A Few Reminders




HealthInk: Your Connection to CareFirst

We are pleased to present the second issue of HealthInk, CareFirst's clinical newsletter for physicians and other health care professionals. HealthInk offers you a connection to CareFirst, and gives you insight into who we are and how we work. Through HealthInk, you can learn about valuable programs and services that are available for patients and practitioners. You can also find the results of our quality-improvement initiatives - both successes and opportunities for improvement.

This issue of HealthInk highlights interesting trends in the health care industry such as: the rapid growth in Internet use among physicians; the increased interest in alternative and complementary therapies; and the emergence of new "hospitalist" programs for care management. These are all exciting developments affecting the delivery of care as we approach the year 2000.

We hope you enjoy reading HealthInk and find it informative. Positive and open communication with you is vital to our continued mutual success.

-William A. Howard
Editor

Eighty-five percent of physicians are now using the Internet, a staggering increase of 875 percent since 1997. In addition, doctor-patient communication over e-mail has doubled in the past year.

Those are among the findings of a survey conducted by the Healtheon Corporation, which has been researching the computer needs and expectations of nearly 10,000 doctors for the past three years. Key findings of the research project were presented at this year's "Physicians on the Internet" conference in San Francisco. The survey also found that:

• More than 63 percent of the physicians surveyed use e-mail daily.
• E-mail for professional communication has increased 33 percent since last year.
• Approximately 30 percent of physicians and group practices surveyed have Web sites, while another 16 percent plan to develop a Web site for their practice within the year.

One of Healtheon's most notable discoveries was that doctors have dramatically increased their use of e-mail to keep in touch with their patients: One-third of the physicians surveyed have used e-mail to correspond with patients.

Obstacles Remain

Although Internet use is increasing rapidly, some doctors face obstacles in using online resources to their full potential. Perhaps not surprisingly, for many doctors the Internet does not fit into their busy schedules: Nearly half of those physicians who are not online say they do not have the time to use e-mail and other Internet services. Other stumbling blocks include concerns about:

• Security - 34 percent.
• Lack of content and services - 20 percent.
• Cost - 10 percent.

The growth of the Internet is opening up a new avenue for doctor-patient communication. According to a recent study in The Journal of the American Medical Association (JAMA), up to 40 percent of patients use e-mail to correspond with their health care providers.

It is quick and easy, but does e-mail benefit physicians and patients? Some say yes. The inconvenience and frustration of missing people by phone is virtually eliminated. Patients can write at their convenience and at length about a medical question. Doctors can follow up on questions raised during patient visits and respond to patients' inquiries when their schedules allow.

Managing Electronic Communication

Although e-mail can be a handy tool, it also can become a time-consuming part of the day. If you do decide to communicate with patients electronically, here are some tips to help you avoid an avalanche of e-mail that would be too time-consuming to answer:

• Consider whether or not you want to communicate with all patients or only those who meet certain criteria. For example, some physicians restrict their e-mail use to patients who are homebound or who have specific conditions.
• Ask patients to keep their communication brief.

Security Concerns

Confidentiality remains a major issue for both providers and patients. E-mail may be read by others, such as those who monitor e-mail traffic or someone who happens to view the message on the patient's or physician's screen.

Despite this concern, the JAMA study found that up to 90 percent of patients who communicate with their physician over e-mail discuss important and sensitive medical information. One way to address confidentiality concerns is by refusing to communicate specific information, such as test results, over e-mail.

The Future of E-mail

Some predict that in the not-so-distant future, e-mail may replace the automated voice-mail systems of many doctors' offices. Patients who have to call the office for directions or hours will be able to visit their doctor's Web site to find out that information. If they need to ask a question, there will be a form on the site for their convenience.

The Internet puts a wealth of information on nearly any topic at a user's fingertips, and many people are using electronic resources for immediate access to healthy-lifestyle information, as well as for comprehensive data on virtually every health topic imaginable.

Eighty-two percent of those who responded to one health Web site's online poll said they use the Internet for health information more this year than they did a year ago.

As a result, it is not unusual today for patients to visit their doctor armed with "facts" about a certain medical condition. If patients obtain credible information, their Web search may help your discussion about their condition. On the other hand, if they visit sites containing inaccurate information, you may have to help them decipher what is valid and what is incorrect or unproven.

Steering Patients in the Right Direction

You can help to prevent confusion by reminding patients that not all Web sites contain accurate information. Guide them in their search for health information by advising them to avoid sites that are posted anonymously, steering them toward reliable government and professional association sites, and developing your own list of recommended sites. You may want to consider passing along the following list of credible Web sites to your patients:

• American Medical Association: www.ama-assn.org
• U.S. Centers for Disease Control and Prevention: www.cdc.gov
• National Institutes of Health: www.nih.gov
• American Cancer Society: www.cancer.org
• American Heart Association: www.americanheart.org
• CareFirst BlueCross BlueShield: www.carefirst.com

The medical community, the public and government agencies are paying more attention to "alternative" or "complementary" therapies than ever before. In fact, a study published in The Journal of the American Medical Association estimated that millions of Americans are embracing some form of what were previously considered unconventional therapies. The study, conducted at Beth Israel Deaconess Medical Center and Harvard Medical School, found that four out of 10 Americans have used alternative therapies. Those most likely to seek out alternative medicine were college-educated, relatively affluent women between the ages of 35 and 49, and most treatments were for chronic conditions such as back and neck problems, arthritis and headaches.

The study was based on a telephone survey of more than 2,000 adults in 1997, questioning them on the use of 16 alternative therapies such as relaxation techniques, massage, chiropractic and acupuncture. By comparing their results with a similar survey conducted seven years earlier, researchers were able to track trends. For example:

• The number of Americans who use alternative therapies increased 25 percent between 1990 and 1997.
• From 1990 to 1997, visits to alternative practitioners increased by 47 percent, from an estimated 427 million in 1990 to 629 million in 1997.
• In 1997, Americans paid an estimated $21.2 billion for services provided by alternative medicine practitioners, an increase of 45 percent from 1990.

Helping Patients Who Use Alternative or Complementary Therapies

It is a good idea to talk with your patients about their use of alternative or complementary therapies. You can help guide them by suggesting that they:

• Set realistic goals. Ask if they are searching for pain relief or a "magic bullet."
• Talk with you first. Offer them solutions that they may have overlooked.
• Assess the therapy's safety and effectiveness. Counsel them to look at credible scientific data to make sure the benefits of any therapy outweigh the risks.
• Speak with people who have had the treatment. Remind them that while patient testimonials may be useful, they do not ensure safe, effective therapy.
• Consider both quality and cost. Ask if the potential benefit to them is worth the cost.
• Talk to the alternative practitioner. Advise them to discuss treatment advantages, disadvantages, risks, side effects, likely results and length of treatment.
• Keep you informed. Remind them that you are there to monitor their overall health and are interested in all therapies they use.

The federal government is now funding research to help physicians and the general public better understand the benefits and risks associated with various complementary and alternative therapies.

Following a congressional mandate, the Office of Alternative Medicine was established as part of the National Institutes of Health (NIH) in 1992. That office was expanded and renamed the National Center for Complementary and Alternative Medicine (NCCAM) in 1998. NCCAM funds research to evaluate the effectiveness of various complementary and alternative therapies for specific conditions such as cancer, asthma, immunological disorders, allergies, AIDS, addictions and pain.

"Research is vitally important," says Anita Greene, a spokesperson for NCCAM. "This is an important area for NIH to research so we can provide answers to those who are considering or using alternative therapies without the benefit of valid scientific results."

According to Ms. Greene, NCCAM expects to see results on some of the early research projects they funded some time next year. In the meantime, she says people should remember that some therapies may be unsafe or may adversely interact with their medication. She advises patients to gather as much information as they can about a particular therapy and, in all cases, to talk with their physician.

"The patient's physician knows the patient's medical condition and has worked with the patient over time," says Ms. Greene. "They can provide the best advice to help patients navigate through the research."

Beginning Jan. 1, 2000, CareFirst will offer its members CareFirst Options - the region's first complementary and integrative therapy network and discount program.

CareFirst is working with OneBody, a leader in the field of credentialed integrative medicine programs, to offer CareFirst members discounts of 15 to 25 percent on certain complementary treatments and therapies, including acupuncture, chiropractic, massage therapy and fitness center memberships.

CareFirst Options is a discount program. It neither replaces nor is a part of a member's CareFirst benefits. There are no claim forms, and CareFirst does not reimburse members or practitioners.

Although members do not need a physician referral to take advantage of these discounts, we are encouraging them to keep their physicians informed about any complementary care they may receive.

OneBody is now developing the CareFirst Options provider network in our service area. To participate in the program, practitioners must follow OneBody's rigorous credentialing process, which carefully evaluates practitioners' training, licensing and experience. In addition to credentialing providers, OneBody also will handle quality review and inquiries from our members.

For more information about this new discount program, call OneBody toll-free at 888-922-9452.

New technologies are constantly emerging in the rapidly-changing health care field, and CareFirst makes a consistent effort to stay on top of groundbreaking and beneficial treatments. Our Technology Assessment Unit continually evaluates new and existing technologies for application to our indemnity and managed care benefit plans.

"Technology," broadly considered, encompasses not only new equipment, but also novel applications of currently available devices and innovative procedures. Technology assessment is therefore one of CareFirst's most important tasks. It is also a key component of our relationship with our providers and the wider health care community.

One of the main ways we become aware of new technologies is through requests for preauthorization from physicians. Our technology assessors - doctors, nurses and consultants from outside medical groups or universities - also stay abreast of the latest techniques by reviewing medical newsletters and Internet databases such as Medscape and by keeping in close contact with representatives from medical device manufacturers. Universities also play an important role in informing us of cutting-edge developments, and we actively work to develop and maintain solid relationships with the leading medical universities in our region.

Once we have identified which technologies require evaluation, our technology assessors research the latest outcome studies for a particular technology and evaluate if, and in what circumstances, CareFirst should provide coverage. "If the technology is safe, dependable, reliable and at least as effective as other treatments, we decide if it should be covered," says Russ Wilbar, R.N., CareFirst's Coordinator of Technology Assessment. Although the unit conducts and considers the research as a group, Mr. Wilbar - who has degrees in nursing and microbiology as well as 15 years' experience with technology evaluation - coordinates their decisions. He continues, "If data on new procedures is lacking or inconclusive, it's still too early" for CareFirst to provide coverage. The assessors meet every other month and evaluate at least four different procedures at each meeting. They present medical data, discuss the implications of new technologies for our providers and CareFirst, and consider trends in health care practice.

Mr. Wilbar believes that our technology assessment procedures keep CareFirst on top of a constantly changing health care delivery environment, and notes that "if we cover something, we know it's safe, we know it's effective and we know it works better than the previously-used treatment."

Listed below are some determinations recently made by CareFirst's Technology Assessment Unit on new procedures.

All determinations are reported on a regular basis in BlueLink, our bimonthly administrative newsletter for practitioners.

The Maryland Health Care Access and Cost Commission (HCACC) recently released its third annual guide for consumers on the performance of 15 Maryland HMOs. The HCACC report card rates each Maryland HMO on how frequently members obtain preventive and wellness services, whether members are satisfied with the health care they receive, and how customers feel about their health plan.

Report card results are based on the Consumer Assessment of Health Plans Study (CAHPS) and clinical data from HEDIS audits. Highlights from the HCACC report card are shown below. Higher than average scores indicate significantly better performance than the Maryland HMO average.

1999 HCACC Report Card

Measures of Clinical Performance	CapitalCare	FreeState	Delmarva
Childhood immunizations
Adolescent immunizations
Screening for breast cancer
Screening for cervical cancer
Eye exams for adults with diabetes
Measures of Customer Satisfaction	CapitalCare	FreeState	Delmarva
Overall satisfaction with health plan
Overall satisfaction with health care
Getting needed care was not a problem
Getting care quickly was not a problem
How often doctors communicated well
Satisfaction with health plan customer service
Helpfulness of coverage information
Few customer complaints

Above Average     Average     Below Average

As our Quality Improvement programs mature and expand, we expect to see continued progress and improvement. At this time, we are focusing our efforts towards improvement in health plan services and preventive health services, especially in the areas of women's health and diabetes care. For more information about the HCACC report card, go to the Web site: www.mhcc.state.md.us.

We recently reviewed data on the care of FreeState members with diabetes and are pleased to report improvement. Between 1998 and 1999, the rate at which diabetics in FreeState received recommended testing and services increased for the following services: HbA1c testing, foot exams, dilated retinal exams, LDL screening and smoking-cessation advice. While rates have improved, there is still work to be done.

We will continue to educate members about ways to avoid preventable complications and support physicians in providing quality diabetes care. For a copy of our treatment guidelines, or if you have any questions, please contact the Health Education Department at 410-528-7997 or 800-323-4472.

Recently, we mailed primary care practitioners our new consolidated Preventive Services Guidelines. These new guidelines were created from the ones that were previously in use in our Maryland and National Capital regions. They are based on scientific findings from sources including regulatory, professional and specialty societies. By sending out these guidelines, we hope to encourage optimal preventive health care. If you are interested in receiving a copy, please call Sally Rickenbach, R.N., at 202-479-8221.

In recent years, an important new health care specialty, known as hospitalist, has grown in popularity. Simply put, a hospitalist is a doctor who specializes in inpatient treatment. When a patient requires hospitalization, the primary care provider (PCP) transfers inpatient oversight to the hospitalist, who supervises and coordinates all of the patient's health care needs. A hospitalist's duties include:

• Coordinating the patient's tests and specialty care.
• Communicating with the patient's PCP and insurance providers.
• Planning the patient's discharge, home care, hospice or assisted living.
• Ensuring that all interactions with the patient and family members are done in a timely and sensitive manner.

While they are hospitalized, patients depend on the hospitalist to manage all of their health care needs. The PCP remains informed of the patient's progress and treatment and may consult with the hospitalist or visit hospitalized patients if he or she chooses.

Recent trends have supported the growth of hospitalist programs. PCPs are spending more of their time dealing with outpatients, and only a small percentage of their patients at any one time will be hospitalized. There are now more health care problems that can be effectively treated outside a hospital environment, and the remaining inpatient population tends to be sicker and require greater attention and care. The combination of increased outpatient demands on PCPs and a more fragile inpatient population has brought about the need for specialized inpatient care.

Well-run hospitalist programs fill this need and provide potential benefits for all of the various groups involved in patient care. CareFirst is committed to working with hospitalist programs, says Daniel Winn, M.D., Senior Medical Director at CareFirst, since "we are always looking for innovative ways to improve care."

For patients, the primary benefit of working with a hospitalist is continuity of care during the hospital stay. Whereas a PCP can see hospitalized patients only briefly when he or she is able to get away from the office, the hospitalist is continually available to answer questions, discuss treatment options and quickly react to changes in medical data or the patient's condition. Jim P. Sinnott, Director of Managed Care Business Development at Anne Arundel Medical Center - where a hospitalist program has been in place for approximately 18 months - says that the new system has proven superior because the hospitalist can manage care levels throughout the day. "In the old system," he notes, "the physician would call in during the morning or evening, which was not always the best time for important decisions to be made." Hospitalists manage a patient's care from admission to discharge and are a consistent presence during the period of hospitalization, with the result that "it has improved the timeliness and efficiency of care." Deneen Pieri, M.D., a PCP at Potomac Physicians in Glen Burnie, has a similar evaluation of hospitalist programs. She works primarily with the hospitalist program at Mercy Medical Center, and this association "has benefited the patients: you have someone there who can react immediately."

Some patients might initially find it discomforting to work with a new doctor. In Dr. Pieri's experience, "It can initially be difficult for patients not to see their primary care physician at the hospital." This patient reaction is typically short-lived and ends when they realize that a hospitalist can give them consistent and effective care while hospitalized. Karen Trent-Mims, M.D., a PCP at the Inner Harbor Health Center in Baltimore, says that her patients have reacted positively. "They're completely satisfied with it," she adds.

A comprehensive national study has yet to be done; however, initial statistics back up these doctors' experiences. A recent CareFirst survey found 94 percent of members were satisfied with their experiences in a hospitalist program. Similarly, a survey conducted at Anne Arundel Medical Center found greater than 95 percent patient satisfaction with physician politeness, physician care and nursing care in responses tracked over one year. "Most importantly, these programs provide state-of-the-art care," says Dr. Winn.

PCPs benefit from hospitalist programs as well: They allow the physicians to focus on the increasing demands of outpatient care. PCPs can devote more attention to office practice and make fewer time-consuming and schedule-tightening trips to the hospital to coordinate care for only a few patients. When asked if working with hospitalists had freed up her office schedule, improved outpatient access and made her on-call duties less onerous, Dr. Trent-Mims responded, "Absolutely." Dr. Pieri said that she now found it "easier to focus on outpatient care" and noted that she could perform more of her on-call duties from home. Furthermore, PCPs can gain these benefits without losing track of what is happening to their patients, since they are kept fully informed of inpatient care. When the patient is "handed back" after hospitalization, the PCP should receive a report of all treatments provided to the patient.

Information sharing is the foundation of a successful hospitalist program. Dr. Trent-Mims asserts that clear communication between the hospitalists and the PCP "has to be there or the program doesn't work." Dr. Winn agrees that information sharing "is the highest priority."

What kind of information do PCPs receive? Dr. Pieri gets a complete history and physical report faxed to her office on the day one of her patients is admitted (or the following day if the patient is admitted late at night). When the patient is released from the hospital, she receives a detailed discharge summary within a day or two. Mr. Sinnott reported that in a survey of PCPs, over 85 percent believed the hospitalist program had improved communication between the hospital and the PCP. PCP satisfaction levels with the overall program were 93 percent. Community physicians "overwhelmingly support" the hospitalist program, according to Mr. Sinnott, and over half of all medical admissions fell under the voluntary hospitalist program.

CareFirst advocates the use of hospitalist programs and has begun trial associations with several programs in the Maryland and National Capital regions. In the Maryland region, we began working with St. Agnes Health Care, Mercy Medical Center and Greater Baltimore Medical Center (GBMC), where effective hospitalist programs were already in place. In the summer, CareFirst began an association with a successful hospitalist program at Anne Arundel Medical Center. In the National Capital region, we have contracted with MDxL, a network of physicians that specializes in inpatient care, to provide hospitalist services to members in the region who are admitted to certain participating hospitals through the emergency room. This pilot program, which began in August 1999, is currently offered at Holy Cross, Prince George's, Shady Grove and Washington Adventist. Data from the first two months of the program show improved efficiency and shortened lengths of stay.

Breast cancer and cervical cancer are the two most common cancers among American women. Mammograms and Pap tests allow early detection and are effective means to reduce the morbidity and mortality rates from these cancers.

Research has shown the physician plays an important role in improving mammography and Pap test screening rates. According to studies on the likelihood of women receiving regular mammography and Pap test screenings, physician recommendations and examination by a physician in the previous year are important determining factors. Most women who have not received regular screenings reported, "I would have it if it had been recommended by my doctor."

We encourage physicians, especially primary care physicians and gynecologists, to remind women during office visits if they are overdue for a regular mammogram or Pap test.

Congestive Heart Failure

CareFirst offers a special disease management program for its Maryland region members who suffer from congestive heart failure (CHF). This program provides case management services to NYHA class III and IV CHF patients - who often are the most difficult to manage for practitioners and the family. In this program, the patient receives home care visits and follow-up phone calls from cardiac nurses. To precertify patients for this program, please call 410-605-2661 for Maryland region indemnity members or 410-277-3900 for FreeState members.

Heparin-Coumadin Conversion Program

In the Maryland region, CareFirst offers a program that provides home-based anticoagulation services to:

• Convert coumadin-dependent patients who require invasive surgical or diagnostic procedures to heparin; and
• Convert patients back to coumadin after the procedure, administering heparin therapy in the home during the conversion process.
• Experienced cardiovascular nurses screen for selected criteria prior to the patient's acceptance into the program and conduct all patient management. We strongly recommend the use of this program for patients meeting the appropriate criteria.

Please precertify these services by calling the Precertification Department at 410-528-7029 or 800-338-3787 for FreeState patients and 800-443-5434 for Maryland region indemnity patients.

Front-loading Program for Orthopedics

The front-loading program for orthopedics is a mandatory presurgical assessment and educational program specifically for FreeState members who are candidates for total hip or knee replacement surgery.

For this program, the primary care physician's office must call 410-528-7029 or 800-338-3787 to precertify the patient at least two weeks prior to surgery.

Many CareFirst members benefit from case management, a program that offers extra support to patients with complex needs. Patients in case management are assigned a case manager, who acts as a liaison between the patient and the providers of care. Case management helps to ensure greater efficiency and quality in the delivery of care.

Many employer groups are beginning to recognize the value of case management in improving quality of care, and prospective employer groups are interested in reviewing data on quality outcomes. Recently, we reviewed a select number of cases to determine the most significant positive outcome for each case in terms of quality. The chart below summarizes our findings:

If you are interested in referring a patient for case management:

In the Maryland region, please call the Central Intake-High Risk Outreach Unit at 410-605-2413 or 888-264-8648 (888-CMI-UNIT) toll-free.

In the National Capital region, please call the number for precertification printed on the back of the member's ID card. An associate care coordinator will direct your call to the appropriate case manager.

By Dr. Andrew Rudo
Medical Director, Magellan Behavioral Health

The medical leadership of Magellan and CareFirst have collaboratively developed a number of quality improvement programs for the Maryland region of CareFirst. These programs, sensitive to the needs of primary care physicians, are part of Magellan's overall medical integration plan, which attempts to better coordinate medical and behavioral health services. This plan includes efforts to improve communication between behavioral health and medical providers, as well as preventive health activities, such as screening all new acute cardiac patients for depressive illness. Listed below are some of our joint efforts:

Improving Psychotropic Prescribing Practices and Decreasing Adverse Reactions

Working in collaboration with CareFirst's Pharmacy and Therapeutics Committee, we analyzed psychotropic prescription data for 1997 to identify priorities for education. Here are some of our findings:

• A small number of prescriptions for meprobamate, an anti-anxiety medicine long out of favor due to its addictive potential, danger in overdose and inferior efficacy when compared to the benzodiazepines.
• The occasional use of amoxapine and antidepressant-antipsychotic combination medications, such as Etrafon (amitriptyline and perphenazine). Amoxapine (Asendin) is an antidepressant that is chemically similar to loxapine (Loxitane), an antipsychotic medication. It can be appropriately used on a short-term basis for the management of a psychotic depression, but when used long-term as a maintenance drug, there is a significant risk of tardive dyskinesia. Similarly, the combination antidepressant-antipsychotic medications contain a phenothiazine and can induce tardive dyskinesia over time if used as maintenance medications.
• Instances of co-prescribing two medications likely to have significant adverse interactions. As a result of this finding, we began a medication use evaluation program in which we sent each prescribing physician patient-specific educational letters informing them of the co-prescribing in that patient and potential for adverse drug interaction.

Preventive Health Programs

• We are targeting patients who recently suffered an MI and/or have had a cardiac procedure (angiography, angioplasty and bypass surgery) in the context of acute cardiac disease. These patients are at much higher risk of developing clinical depression and face increased morbidity and mortality if depression goes untreated. Working together with the University of Maryland Cardiac Network, we are assisting patients who score positive on a depression screening tool to get a referral for evaluation.
• The second program is for diabetic patients, another group at high risk for depression. Studies show that the prevalence of major depression among diabetics is three times that of the general population. Approximately 5,300 known diabetic members were mailed educational information about depression and a depression screening tool. Over 300 members have returned the screening tool and of these, almost 30 percent scored positive for possible clinical depression. Our intervention has involved targeted mailings to the member's PCP and the member about the need for evaluation for depression.
• The third program targets geriatric HMO members who attend senior health fairs conducted by CareFirst. A clinician from Magellan's Speaker's Bureau delivers an educational talk on depression and then screens the attendees using the Geriatric Depression Scale. Positive scorers are then assisted with a behavioral health referral, if they wish.
• The fourth program is in the primary prevention arena. We began a Parent Skills Training Program in March of this year, working in collaboration with CareFirst and the Maryland Psychological Association. This excellent six-week course is for parents of children ages 2 to 12, and teaches parenting techniques for normal and at-risk children. Better parenting can enhance a child's self-esteem and thereby reduce the risk of adolescent mental and substance-use disorders. We plan to offer this program in the fall and spring of each year. If you know of parents who may be interested, please refer them to CareFirst's Health Education Department at 410-528-7997 or 800-323-4472.

Over the past 20 years, mental health research has shown that many patients experience depressive symptoms during the winter months. This condition is called seasonal affective disorder (SAD) and is a variant of major depression. Like other kinds of depression, the symptoms of SAD can range from mild to severe; however, the symptoms of SAD differ from those of classical depression, in which one usually finds insomnia, weight loss and feelings of hopelessness. Typical SAD symptoms include:

• Feelings of sadness, depression or irritability.
• Fatigue.
• Carbohydrate cravings.
• Difficulty waking in the morning.
• Social withdrawal.
• Reduced productivity.

The onset of SAD is thought to be triggered by a decreased exposure to daylight and may affect up to 20 percent of the population in northern regions of America. The prevalence of SAD increases the further north one travels. Symptoms usually begin in the fall but become most pronounced during the months of January and February. Cases of SAD have been reported in all ages, including children.

Research suggests there is a possible chemical basis for SAD. Due to shortened fall and winter days, we experience a decline in ambient natural light. When light strikes the retina, it signals the brain to produce more serotonin and to reduce the production of melatonin from the pineal gland. Serotonin has an important role in mood regulation, and melatonin affects sleep. When there is less sunlight, serotonin levels decline, possibly causing depression, while melatonin levels rise, causing sluggishness.

If you have a patient with SAD, there are several methods that might help alleviate this condition. The fundamental process is to increase light exposure or to raise serotonin levels by other means. Suggest that patients maximize their exposure to light by:

• Spending a part of each day outside, when possible.
• Sitting or working near windows.
• Avoiding sunglasses during the months that they are symptomatic.
• Vacationing in a sunny area, if this is possible.

In addition, studies show a benefit from short-term prescription of a selective serotonin reuptake inhibitor (SSRI) antidepressant at the same dosage prescribed for major depressive symptoms. Dosage can often be tapered and discontinued with the onset of longer daylight hours.

It is important to consider SAD as a possible diagnosis for patients complaining of the above symptoms during the winter months. Ask about previous years because SAD usually cycles annually. When there is a recurrent pattern of winter depression, and the patient is well the remainder of the year, you may be dealing with a case of SAD. Additional information is available on the Internet at: http://www.psycom.net/depression.central.seasonal.html.

This information was provided in collaboration with Health Management Strategies Inc.

The Health Education Department makes available a variety of self-study programs that can be completed to earn CME credit hours. Details of these courses are outlined below. To order copies of the program materials, please call the Health Education Department at 410-528-7997 or 800-323-4472.

New CME Audio Conference Series

Each of the three programs in this new series can be taken for 1 credit hour in Category I of the Physicians Recognition Award of the American Medical Association, 1.25 contact hours of nursing and 1 contact hour of pharmacy credit.

New Thoughts on Ovarian Androgens and Applying This Information to Clinical Practice

Describes the androgens produced in the ovary and changes in serum levels at menopause; lists target organs for androgens and cellular actions that androgen affects; describes studies of estrogen /androgen vs. estrogen only and estrogen/progestin treatment with respect to bone protection, sexual dysfunction and symptoms of menopause; identifies patients most likely to benefit from the addition of androgens to HRT; and explains how to prescribe androgen therapy and monitor its effects.

Postmenopausal Estrogen and Progesterone Replacement Therapy:
A Balancing Act

Summarizes differences between synthetic progesterones and natural progesterone; discusses the primary cardiovascular and endometrial risk factors affected by hormone replacement therapy; analyzes the PEPI data; discusses the importance of adding progesterone to estrogen therapy and the effects of cyclical and combined treatment.

Helping Women Function Sexually After Menopause

Discusses how ovarian hormone changes resulting from both natural and surgical menopause relate to sexual physiology; explains the impact and symptoms related to estrogen and androgen loss in menopause; describes the efficacy and safety of estrogen/androgen therapy; describes the role of physician or nurse in evaluation and treatment of sexual dysfunction; describes three sexual counseling concepts; and identifies women who have serious mental disorders that call for referral to a mental health professional.

Other CME Credit Opportunities

Geriatrics Self-Study Program

This is a great opportunity for you to improve care for your senior patients while earning 50 CME credits! This program was developed jointly by the American Geriatrics Society and the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. It offers physicians the latest clinical information in geriatrics through six self-study modules. Participants will study general principles of aging and approaches to older patients, geriatric psychiatry, and conditions such as malnutrition, dementia, falls, pain management, sleep disorders, osteoporosis and incontinence. The growing elderly population makes this educational opportunity advantageous for all health care practitioners.

For a minimal cost of $90 (includes shipping and handling), physicians will benefit by expanding their knowledge of the clinical and behavioral aspects of aging and by earning 50 CME credits.

Elder/Vulnerable Adult Abuse and Neglect

We realize that physicians treat victims of family violence every day, yet often it is difficult to recognize the signs and symptoms of abuse. To give you the practical tools you need to help your patients, we are offering the following self-study program, sponsored by the Maryland Physicians' Campaign Against Family Violence: Elder/Vulnerable Adult Abuse and Neglect ($10 charge). Successful completion of this program awards up to 4 credit hours in Category I of the Physicians Recognition Award of the American Medical Association.

Working with Older Patients

To assist you in treating older patients, we offer a self-study program from the National Institutes of Health entitled "Working With Your Older Patients: A Clinician's Handbook." This free study program describes and explains issues pertinent to older patients, and offers practical and effective techniques for treating the extremely diverse elderly population. The National Institutes of Health designates this continuing medical education activity for 2 credit hours in Category I of the Physicians Recognition Award of the American Medical Association.

Advance directives are a patient's written instructions regarding medical care choices in the event that he or she becomes incapacitated and is unable to communicate. The Health Education Department offers a workshop that presents the law and our policy regarding advance directives. The workshop is currently offered in the Maryland region, but can be made available in the National Capital region upon request.

It is recommended that medical sites have someone trained to answer patient inquiries about advance directives. The next workshops will be held on:

January 27, 2000 9:30-11:30 a.m. Location: CareFirst's Corporate Offices, Owings Mills, MD

March 30, 2000 9:30-11:30 a.m. Location: CareFirst's Corporate Offices, Owings Mills, MD

To register, or to receive a copy of the advance directives packet, please call the Health Education Department at 410-528-7997 or 800-323-4472.

Please note: When a patient completes advance directives, please clearly document this fact in the patient's medical chart. Additionally, please display the sign stating that advance directives documents are available at your site. To obtain this sign, please call the Health Education Department at 410-528-7997 or 800-323-4472.

Topics:
Low Back Pain; Breast Cancer - the Surgery Decision; Benign Prostatic Hyperplasia.

These free, 60-minute, interactive educational programs help patients make more informed decisions about surgery and other treatment options they may be facing. Interactive videos are available for viewing at the following locations: Beltway Crossing Medical Center (Glen Burnie, MD), Bel Air Health Center (Belair, MD), and the Delmarva Health Plan office (Easton, MD). To view an interactive video at the Beltway Crossing Medical Center or at Bel Air, the patient may contact Sue Wingard at 410-528-7997 or 800-323-4472. To view a video at the Easton location, a patient can call Maryam Tabrizi at 410-763-6382 or 800-334-3427, ext. 6382.

We represent a philosophy of health care that emphasizes active partnerships between patients and their physicians. We believe that comprehensive health care is best provided by networks of health care professionals who are willing to be held accountable for the quality of their services and the satisfaction of their patients. We are committed to high standards of quality and professional ethics and to the principle that patients come first.

We believe that patients should have the right care, at the right time and in the right setting. This includes comprehensive care for acute and chronic illness, as well as preventive care - in the hospital, at the doctor's office and at home.

We believe that all health care professionals should be held accountable for the quality of the services they provide and for the satisfaction of their patients.

We believe that patients should have a choice within their health plans of physicians who meet high standards of professional training and experience, and that informed choice and the freedom to change physicians are essential to building active partnerships between patients and doctors.

We believe that health care decisions should be the shared responsibility of patients, their families and health care professionals, and we encourage physicians to share information with patients on their health status, medical conditions and treatment options.

We believe that consumers have a right to information about health plans and how they work. We believe that working with people to keep them healthy is as important as making them well.

We value prevention as a key component of comprehensive care, reducing the risks of illness and helping to treat small problems before they can become more severe.

We believe that access to affordable, comprehensive care gives consumers the value they expect and contributes to the peace of mind that is essential to good health.

Adapted from the American Association of Health Plans (AAHP).

CareFirst shall be the leading regional health care company recognized for a comprehensive portfolio of high-quality, innovative products and administrative services. Our purpose is to provide the best value to our customers in partnership with the health care community and in an environment which promotes respect, fairness and opportunity for our associates.

With flu season upon us, we would like to share some information and offer a few recommendations to practitioners. First, according to a recent survey of members ages 65 and older, the most common reason for members not getting a flu shot is the fear of an adverse reaction. We hope you will address this concern in your discussions with patients and remind them of the vaccination's benefits.

In deciding who should be vaccinated, the following categories of patients are key:

1. Persons ages 65 and older.
2. Residents of nursing homes and chronic care facilities.
3. Adults and children with chronic disorders of the pulmonary or cardiovascular systems, including children with asthma.
4. Adults and children who received treatment or were hospitalized during the preceding year because of chronic metabolic diseases, including diabetes, renal dysfunction, hemoglobinopathies or immunosuppression (including immunosuppression caused by medications).
5. Children and teenagers (6 months to 18 years) who are receiving long-term aspirin therapy and may be at risk for developing Reye's Syndrome after influenza.

Also, remember that the following groups of individuals can transmit influenza to persons in high-risk categories and should be vaccinated:

1. Practitioners, nurses and other personnel in hospital and outpatient care settings.
2. Employees of nursing homes and chronic care facilities who have contact with patients or residents.
3. Providers of home care to persons at high risk (e.g., visiting nurses and volunteer workers).
4. Household members (including children) of persons in high-risk groups.

Influenza vaccination is not recommended for persons with known anaphylactic hypersensitivity to eggs or other components of the influenza vaccine. Also, patients experiencing an acute febrile illness usually should not be vaccinated until their symptoms have abated.

Pneumococcal Vaccine

Pneumococcal vaccine can be given any time during the year; however, it may be convenient for the patient to receive it at the same time as the influenza immunization. Pneumococcal vaccination is recommended in patients over 65 and for others who have appropriate risk factors. The interval for re-vaccination continues to be studied. Current recommendations vary from once in a lifetime to every seven to 10 years.