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

Five years ago, many hospitals joined the trend of “re-engineering” their work processes to improve efficiency and service. For Howard County General Hospital, this included taking a close look at processes that impact patients directly. “It was during this time that we became focused on making a visit to our hospital a seamless process for patients and their families,” says Janet Ellis, Howard County General’s Director of Case Management. “Like any hospital, we also had some financial considerations in mind and knew we needed to reduce the length of stay at our facility and improve utilization.”

To achieve these goals, Howard County General introduced case management services in areas of the hospital that could benefit from greater coordination. Case managers are now in place to coordinate and facilitate efficient care in all inpatient units. They may confer with an on-site utilization reviewer and the attending physician when ordered care for an admitted patient falls outside of the clinical pathway — or when they believe that treatment not typically part of a particular pathway might be appropriate. “Both our case managers and CareFirst’s Utilization Review Nurse, Leanne Curley, have a lot of clinical knowledge and can communicate effectively with physicians. They work together,” says Ms. Ellis. She continues, “We found that the physicians were very receptive to working with our case managers given their clinical knowledge. Our case managers are cross-trained in all departments of the hospital.” Ms. Curley also applauds the case managers’ efforts. She says, “I feel I have developed a team relationship with Howard County’s case managers.”

Case management’s presence has contributed to significant improvements in two units in particular: Admissions and the Emergency Department. Before a patient is admitted, Howard County General’s case managers make sure the patient will be admitted to the appropriate unit, ensure the patient’s admission is communicated to the insurance company and consider alternatives to hospital admission, such as sub-acute care facilities and home care. “If admission is appropriate,” says Leslie Hope, R.N., Admitting Case Manager, “we discuss discharge with the patient and his family from the very beginning of their stay. We want them to understand that the patient may not be in the hospital a long time and that we can help them prepare for the next step.”

In fact, discharge planning often begins before the patient even arrives at Howard County General for admission — and it goes beyond simply arranging for the patient to leave the hospital on a given day. Says Ms. Hope, “We work closely with the on-site reviewers to facilitate safe discharges and are careful to ensure that the patient has the understanding and resources to obtain whatever follow-up care might be needed.”

Howard County’s Emergency Department short-stay unit opened in September of 1997 following the introduction of case management throughout the hospital. In the Emergency Department, case managers work an extended twelve-hour shift and are able to avert inappropriate admissions by routing patients with borderline conditions to the short-stay area for observation. Sometimes, instead of being admitted, these patients can have certain needs accommodated in the short-stay area and then move to a more appropriate non-hospital setting. For example, a patient who is prescribed a course of IV antibiotics might be given the first dose in the short-stay unit and then be allowed to go home for the remainder of treatment.

Howard County General has seen numerous benefits from case management’s efforts and the hospital’s short-stay Emergency unit, including a decrease in patients’ average length of stay. Says Ms. Hope, “Our case managers are here every day. This means that even discharges requiring complex coordination of resources can be accomplished on a daily basis, and that gives us an edge on reducing length of stay.” More importantly, says Ms. Ellis, “Our case management program provides an advocate for the patients — someone to look at the multiple issues affecting the patient’s situation, not simply the insurance benefits they have.” Howard County General Hospital’s comprehensive approach to case management not only heads off unnecessary admissions and lengthy stays, it also improves the service and care patients receive.

Availability of Physician Reviewers

CareFirst physician reviewers are available to discuss utilization management decisions during regular business hours. In the Maryland region, physicians may call 410-528-7041, and in the National Capital region, 202-479-7956, to speak with a physician reviewer.

Please Take Note

CareFirst affirms that all Care Management decision-making is based only on appropriateness of care and service. We do not compensate practitioners or other individuals conducting utilization review for denials of coverage or service. CareFirst is concerned about the potential for underutilization and therefore monitors for the underutilization of services on a quarterly basis. In addition, financial incentives for care management decision-makers do not encourage denials of coverage or service.

CareFirst is proud to offer disease management programs for its HMO members with chronic illnesses such as diabetes and asthma. A critical component of these programs are CareFirst’s clinical practice guidelines. The guidelines are designed to assist physicians in making decisions based on reasonable medical evidence from nationally recognized experts, including the American Diabetes Association and the National Heart, Lung, and Blood Institute.

CareFirst recently consolidated the clinical practice guidelines for both asthma and diabetes previously used in Maryland and in the National Capital region. The two combined guidelines have been reviewed by a committee of community practitioners and will be re-evaluated at least every two years and updated as necessary. CareFirst measures physician performance annually against at least two of the recommendations within the guidelines. For diabetes, provision of HbA1c screenings and retinal eye exams is measured; for asthma, physician-patient communication and prescribing practices are evaluated. Specifically, physicians are asked to review asthmatics’ treatment plans every one to six months as needed and to ensure that patients with asthma are receiving the appropriate medications, such as anti-inflammatories for persistent asthma. The published clinical practice guidelines help direct decision-making at CareFirst in the areas of utilization management, member education and interpretation of covered benefits. Please note that inclusion of a particular service or treatment within the guidelines is not intended to imply comprehensive coverage under CareFirst member benefits. Also, please be sure to verify a member’s benefits prior to delivering a recommended service.

Look for Your Copy

In April, PCPs and applicable specialty practitioners received a disease management kit that included:

• A copy of CareFirst’s 2000 Clinical Practice Guidelines for Diabetes.*
• CareFirst’s Stepwise Approach for Managing Asthma in Adults and Children Older Than 5 Years of Age.†
• CareFirst’s Stepwise Approach for Managing Infants and Young Children
  (5 Years of Age and Younger) With Acute or Chronic Asthma Symptoms.†
• Samples of educational materials distributed to CareFirst patients enrolled in these programs.

We hope you will use these guidelines for treating patients with asthma and diabetes in your daily practice. If you have not received your disease management kit or would like additional copies of these materials, please call 800-228-8161 or 410-528-7103 in Maryland or 202-479-8102 in the National Capital region. Be sure to check out our feature article on “Asthma Action Plans” on the facing page.

*Adapted from 2000 Clinical Practice Guidelines published by the American Diabetes Association.

†Adapted from National Asthma Education and Prevention Program Expert Panel
Report 2: Guidelines for the Diagnosis and Management of Asthma, Office of Prevention, Education and Control, National Heart, Lung, and Blood Institute, National Institutes of Health, Pub. No. 97-4051, Bethesda, MD, 1997.

The following changes have been made to CareFirst’s 2000 Clinical Practice Guidelines for Diabetes:

• “Normal average fasting/preprandial glucose” has been changed from <110 to <100.
• “Normal average bedtime glucose” has been changed from <120 to <110.
• Yearly urinalysis for protein has been removed as a key test/exam.
• Microalbumin measurements are now recommended yearly unless an individual has been previously diagnosed with proteinuria or is on an ACE inhibitor angiotensin receptor blocker (ARB).
• A grid for “Prioritizing Treatment of Diabetic Dyslipidemia in Adults” has been added.
• Low-dose aspirin therapy is recommended as a primary prevention strategy in men and women with diabetes who are at
• high risk for cardiovascular events.

There are no proposed changes to CareFirst’s Stepwise Approach for Managing Asthma in Adults and Children Older Than 5 Years of Age or our Stepwise Approach for Managing Infants and Young Children (5 Years of Age and Younger) With Acute or Chronic Asthma Symptoms.

The following article was contributed by Philip R. Corsello, M.D., M.H.A., F.C.C.P., Medical Director, National Jewish Disease Management Programs.

With the ready availability of information about personal health, people are increasingly knowledgeable about their medical conditions and want to participate in their own health care. This is a healthy trend and most physicians encourage collaborative self-management — the assumption of responsibility by their patients. Asthma, a chronic respiratory disease with recurrent exacerbations of wheezing and shortness of breath, lends itself to this approach.

Even with mild asthma, symptoms may occur unexpectedly and with little warning in response to allergens and irritants. An Asthma Action Plan (AAP) allows patients to be prepared to respond quickly. A typical AAP lists regular and emergency medications, symptoms to watch for and the steps to be taken by the patient when asthma worsens. A good plan reflects physician knowledge of the patient’s coping skills as well as the severity of the individual’s disease. Peak flow measurements and attention to symptoms enable the patient to assess the severity of an asthma attack and take appropriate action. While a physician can prepare an AAP in just a few minutes, this approach can prevent hours of worsening asthma and even death. It is for this reason that the National Institutes of Health Expert Panel strongly recommends the use of an AAP in its Guidelines for the Diagnosis and Management of Asthma.

Philosophy of the Asthma Action Plan

• That a knowledgeable physician can anticipate problems and prescribe therapy and actions to be taken, in advance.
• That patients can accurately assess asthma worsening and, with the plan’s guidance, effectively and safely take immediate steps to combat it.
• That patients are able to make responsible decisions when provided with the information and guidance required.
• That the plan is a tool, helpful to both patient and physician, and not a substitute for emergency professional assistance when indicated.

The Internet is transforming the way we shop, manage our finances and communicate with each other. It’s also fast becoming a major source for obtaining all kinds of information — including the latest medical news.

For busy physicians, the Internet can make it easier to keep up with medical journals, research an unusual case, talk with other doctors, get practice management tips, etc.

“There’s been an explosion in the amount of information available, and it will continue,” says Herman Abromowitz, M.D., a member of the board of trustees for the American Medical Association. “The Internet is a great educational tool for physicians and patients.” But Dr. Abromowitz cautions that there is a downside to this growing trend. “There is a lot of great information out there, but physicians should be very cautious,” he says. “We’re concerned because of the questionable quality and accuracy of some of the information.”

Surfing for Quality Information

Navigating the countless health-related sites on the Internet can be challenging. Dr. Abromowitz says physicians may want to rely on peer-reviewed, credentialed sites that provide quality, accurate information.

To help you in your search for credible medical information, here are some popular Web sites that provide information for physicians:

• Medscape — www.medscape.com — Touted as the “on-line resource for better patient care,” this site offers multispecialty, peer-reviewed medical information for specialists, primary care physicians and other health professionals. Medscape offers: clinical management modules; next-day conference summaries; free, full-text, peer-reviewed clinical medical articles; textbooks; continuing medical education resources; job listings; tips to improve practice management skills and profitability; money management advice; a “humor and medicine” page, and more.
• National Institutes of Health (NIH) — www.nih.gov — This comprehensive government site offers a wide range of information on conditions under investigation at NIH, links to the many individual organizations that comprise NIH, research funding opportunities, scientific resources, etc.
• The National Library of Medicine (NLM) — www.nlm.nih.gov — This government site claims to be the world’s largest medical library. It offers information on specific health topics ranging from AIDS and bioethics to public health and toxicology. From here, you can reach another notable NLM Web site, MEDLINE, which offers access to the more than 11 million references and abstracts in its database as well as links to full-text articles from some 400 journals (some publishers require a subscription).
• Martindale’s Health Science Guide 2000 — www.martindalecenter.com/HSGuide.html — This site offers a comprehensive guide to health science resources available on the Internet. It also contains thousands of teaching files, medical cases, multimedia courses and textbooks, tutorials and more than 3,700 databases.
• Hardin Meta Directory — www.lib.uiowa.edu/hardin/md — This site provides “access to the best directory sites in health and medicine.” By clicking on a specific medical specialty, you can find key Web sites related to that specialty. The sites are also rated for ease of connection.
• Centers for Disease Control and Prevention — www.cdc.gov — This government site offers information on a wide range of topics including CDC data and statistics, current health news and CDC prevention guidelines. Physicians also may access the Emerging Infectious Disease Journal, a peer-reviewed journal that tracks trends and analyzes infectious disease issues worldwide, and the Morbidity and Mortality Weekly Report, a weekly scientific publication highlighting data and reports on specific health and safety topics.

Dr. Abromowitz suggests that physicians verify the information they find on the Web by doing a literature search and checking with other physicians and medical entities.

“Physicians should use the Internet as one component of their armamentarium to obtain information for their patients or for their own education,” says Dr. Abromowitz.

These sites are provided for your convenience and review only. CareFirst does not endorse the content of external Web sites.

CareFirst is committed to providing the highest quality of care and service to its members. The Plan’s Quality Improvement (QI) Program strives to improve clinical care and administrative services in all areas of the delivery system.

Our QI Committees, working closely with community physicians, develop and implement the QI Program in a coordinated effort to promote preventive health care, manage chronic illnesses and continuously improve the care and services our members receive.

Annually, CareFirst implements a QI work plan that outlines specific clinical and service-related improvement activities using the National Committee for Quality Assurance (NCQA) Standards for Performance as a framework. Data is collected and analyzed for each activity throughout the year. Work groups then study barriers to improvement and develop targeted interventions to help us achieve our established goals. For example, in order to improve childhood immunization rates, a series of age-specific letters were developed to educate parents and remind them about the immunizations due for their child.

Categories of measures included in CareFirst’s quality improvement plan for 2000 include:

• Use of preventive services.
• Compliance with clinical practice guidelines.
• Continuity and coordination of care.
• Effectiveness of disease management programs.
• Availability of practitioners and access to care.
• Potential overutilization or underutilization.
• Member and provider satisfaction.

If you would like more information about the QI Program and how we’re meeting our established QI Program goals, please call 410-528-7103 or 800-228-8161 in the Maryland region and 202-479-3516 in the National Capital region.

In March, CareFirst distributed to all its participating physicians our 2000 Formulary. National drug costs rose 17 to 22 percent in 1999, and CareFirst believes that a formulary prescription program helps to minimize escalating drug expenditures. Winston Wong, Pharm.D., CareFirst’s Director of Pharmacy Management, explains, “Members are being persuaded by drug manufacturers’ direct advertising campaigns to request prescriptions for top-dollar brand name drugs. We want to encourage them to help curb the overall cost of their health care by opting for more cost-effective medication. Our formulary includes all generics and those brands which we have determined to be most cost-effective.”

CareFirst’s 2000 Formulary was developed by its Pharmacy & Therapeutics (P&T) Committee, which is comprised of physicians and pharmacists from the community as well as CareFirst’s medical management. The P&T Committee regularly reviews the drugs on the formulary to ensure they reflect current medical practice. Says Dr. Wong, “Our P&T Committee works to first identify the most effective drugs. If two drugs are found to be comparable in everything but cost, we select the less costly of the two for our formulary. For example, Prevacid and Prilosec are GI drugs that do exactly the same thing. You’ll find Prevacid on our formulary because it costs 10 percent less.”

CareFirst’s prescribing physicians are encouraged to refer to the formulary whenever preparing a prescription. If you did not receive the formulary, or if you would like extra copies, please call 410-528-7103 or 800-228-8161 in the Maryland region, or 202-479-8102 in the National Capital region.

This contribution was edited from Oral Cancer Prevention: The Role of Family Practitioners by Harold S. Goodman, D.M.D., M.P.H.; Janet A. Yellowitz, D.M.D., M.P.H.; and Alice M. Horowitz, Ph.D., in the Archives of Family Medicine, Volume 4, July 1995, by Gary A. Colangelo, D.D.S., M.G.A., Dental Director, CareFirst BlueCross BlueShield.

Oral cancer is responsible for over 8,000 deaths in the United States each year, making it more lethal than cervical cancer, malignant melanoma or Hodgkin’s disease. Approximately 30,000 people in the United States are diagnosed with oral cancer annually. While oral and pharyngeal cancer account for just 4 percent of all cancer cases, other aerodigestive tract cancers that share the same epidemiology, such as cancer of the larynx, esophagus and lung, account for a whopping 182,000 cases per year. Advanced oral cancer causes chronic pain, loss of function and socially-disfiguring impairment. The majority of oral carcinomas are found on the tongue and floor of the mouth, but lesions also may be found on the lips, soft palate, tonsils, salivary glands and oropharynx.

Risk Factors

The primary risk factors for oral cancer include past and present use of alcohol and tobacco, exposure to sun (lip cancer) and exposure to carcinogens in the workplace. Smokers have a two- to 18-fold increased risk of developing oral cancer, and alcohol and tobacco use accounts for 75 percent of all oral and pharyngeal cancers. Heavy drinkers who smoke more than one pack of cigarettes per day are 24 times more likely to develop oral cancer. Older adults also are at higher risk for oral cancer, with more than 90 percent of oral and pharyngeal cancers occurring in individuals over 45 years of age. American males are twice as likely as females to have oral cancer.

Screening for Oral Cancer

Of all treatments available for cancer, none has affected survival rates as much as early detection. Case findings and targeting are viable and cost-effective interventions for oral cancer screening when they are part of the routine practice of primary care practitioners. The oral cavity is easily accessible and oral cancer screening causes less discomfort and embarrassment than do other screening procedures.

Early suspicious lesions usually present with subtle changes in surface color and texture, ranging in appearance from non-elevated erythematous areas to velvety or granular patches. The lesions usually are less than 1.0 cm in diameter, ill-defined, asymptomatic and not easily noticeable by palpation.

With the patient seated, eyeglasses and any removable full or partial dentures removed, a visual inspection of the palate, cheeks, gums, tongue and lips can be accomplished using a suitable source of light. The under-surface of the tongue can be visualized by pulling the tongue laterally, and to each side, with a piece of gauze. Palpation of the lips, cheeks, submandibular regions and lymph nodes of the head and neck can be done with gloved hands. Patients with suspicious oral lesions should undergo biopsy for a definitive diagnosis. Many primary care practitioners refer patients to oral surgeons for biopsy.

Primary care providers can easily be trained through qualified continuing education programs to incorporate oral cancer screening into their practice. Patients also need knowledge of basic oral cancer prevention and early detection. Most oral cancer patients have delayed seeking professional advice for more than three months after first becoming aware of an oral sign or symptom.

Current Provider Practices

Several studies suggest that physicians’ and dentists’ prior knowledge and attitudes may cause them to miss early-stage oral lesions. Physicians may believe that dentists are primarily responsible for detecting oral cancer. They also may delay diagnosis because they confuse oral cancers with traumatic, inflammatory and infectious lesions. In one study, over half of dentists and physicians surveyed were unable to identify the most frequent patient complaint associated with oral cancer. Considering the heavy use of the medical care system by patients at risk for oral cancer, an opportunity now exists to reduce the morbidity, mortality and costs associated with oral cancer. The American Cancer Society recommends that an examination for cancer of the oral regions be part of all routine examinations by dentists and physicians. They also encourage all men and women over age 40 to be screened for oral cancer once a year.

Health care providers have an opportunity to decrease the devastating and costly effects of oral cancer through awareness of the causes, means of prevention, and early detection and referral of oral lesions. For more information on oral cancer, contact the American Cancer Society at 800-ACS-2345 or visit them on-line at www.cancer.org.

This article was contributed by Alan D. Fix, M.D., M.S., Assistant Professor, Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine.

Lyme disease was first described in the United States just over two decades ago. In the relatively short time since, much progress has been made in understanding its pathogenesis and risk factors as well as in identifying measures that may protect against the disease. Progress in recent years also has included the successful sequencing of the bacterium that causes Lyme disease (Borrelia burgdorferi), advances in the study of the factors involved in late manifestations and the introduction of a vaccine against the disease.

The key factor in development of Lyme disease is exposure to infected ticks. The presence of infected ticks depends on numerous ecologic factors and varies geographically with noted focal differences. Maryland is among those states with a relatively high incidence, and reported cases continue to increase. The Upper Eastern Shore has the highest incidence of Lyme disease in the state, but geographic spread continues, with increasing incidence in other parts of Maryland.

The clinical management of tick bites has proven to be a source of confusion.

In general, only a small percentage of tick bites will result in infection in endemic areas, and there is ample evidence that prolonged attachment (no fewer than 24 hours) is necessary for infection, although rare exceptions exist. The general recommendation for tick bite management is to carefully observe the patient for signs and symptoms of infection rather than to treat with antibiotics. However, consideration of prophylactic antibiotic therapy may not be unreasonable for those individuals in endemic areas who have had prolonged tick attachment. There is almost no place for serologic testing of patients presenting with tick bites who do not exhibit symptoms of Lyme disease.

It is important to keep in mind that an episode of Lyme disease does not necessarily confer immunity; in fact, there have been clear reports of reinfection. Last year, a Lyme disease vaccine was approved for those between 15 and 70 years of age and it is hoped that the vaccine will have a positive impact in endemic areas. Nevertheless, there are a number of cautionary notes. The vaccine is in no way fully protective, and Lyme disease must still be considered for illnesses of compatible clinical presentation. In these instances, the currently available ELISA tests will not be helpful, and when serologic testing is indicated, Western immunoblotting must be used. In addition, concern has been voiced about the theoretical possibility of late adverse effects among vaccine recipients who have previously been infected (although there has been no published evidence for this so far), and the vaccine is not indicated for those with active late manifestations. Given the incomplete protection by the vaccine, it must be emphasized to patients that they remain at risk and must employ the standard personal protective measures to avoid exposure to and attachment by ticks, especially since there are other infections transmitted by ticks in this area to which these patients remain fully susceptible.

CareFirst’s ongoing quality improvement efforts include the annual release of our preventive services guidelines. Last fall, CareFirst combined these guidelines across its Maryland and National Capital regions and, recently, we were pleased to introduce and mail to you our 2000 Preventive Services Guidelines. These guidelines are intended to encourage optimal preventive health care. They outline “best practice” preventive care for children, adults and pregnant women as defined by scientific findings from regulatory, professional and specialty societies.

Our Physician Advisory Committees have reviewed and endorsed these guidelines as sound clinical advice. We strive to present this information in an organized, concise format that’s easy to reference. This makes the guidelines an effective tool that we hope you will incorporate into your everyday practice.

The guidelines set forth preventive health care recommendations with the understanding that, depending on the individual patient, variations in care may be appropriate. Please familiarize yourself with them and insert them into your Administrative Manual for future reference. They also are accessible on our Web site, www.carefirst.com. If you would like additional copies of the guidelines or more information on them, please call 410-528-7103 or 800-228-8161 in the Maryland region and 202-479-8102 in the National Capital region.

New Additions and Revisions

CareFirst updates the guidelines periodically to reflect new clinical findings and recommendations. The following additions and revisions have been made to CareFirst’s preventive services guidelines for 2000:

• All newborns should be screened objectively for hearing loss prior to discharge from the hospital.
• All sexually active female adolescents and other asymptomatic persons at high risk for sexually transmitted infection should be routinely screened for sexually transmitted diseases, including chlamydia and gonorrhea.
• The hepatitis C virus test is recommended as a routine lab test for high-risk groups, including those with a history of injecting illegal drugs or those who received blood transfusions or organ transplants before July 1992, as well as children born to HCV-positive women.
• HIV testing should be offered to all women seeking preconception care and to all high-risk individuals, including: infants born to high-risk mothers whose HIV status is unknown; past or present injection drug users; persons seeking treatment for STDs or persons whose partner is HIV-positive; and persons with multiple sex partners.
• The hepatitis A vaccine is recommended in selected states and/or regions (consult your local public health department) and for groups at high risk for the disease, including international travelers, illegal drug users and workers in the food service, health care or day care industries.
• The routine patient history taken by physicians should include questions on the use of complementary and alternative medicines.
• The rotavirus vaccine has been removed.
• The polio recommendation has been changed to an all-injectable vaccine (IPV) schedule.
• The influenza vaccine recommendation has been revised to include anyone who wishes to reduce the likelihood of becoming ill with influenza.
• Acellular pertussis is the only recommended pertussis vaccine for all doses due to decreased adverse reactions. Whole-cell pertussis is no longer recommended.
• The Lyme disease vaccine recommendation has been revised to include high-risk individuals ages 15 to 70 who reside in, work in or visit areas where the disease is prevalent.
• The meningococcal vaccination should be provided or made easily available to those college freshmen living in dormitories who wish to reduce their risk of disease. Other undergraduate students wishing to reduce their risk of meningococcal disease can also choose to be vaccinated.
• Women who are perimenopausal should be counseled regarding menopause treatment and lifestyle modifications that may be available.
• The pneumococcal vaccine recommendation has been revised to state that a one-time revaccination may be appropriate for individuals at high risk who were last vaccinated more than five years ago.
• Diabetes, hepatitis C and hepatitis A have been added to high-risk identification during the initial prenatal visit.
• Screening for depression and domestic violence should take place during periodic primary care physician visits.

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.

CareFirst’s Health Education Department is pleased to offer the following CME courses. Details may be obtained by calling the Health Education Department at 410-528-7997 or 800-323-4472. You also may register directly by e-mailing Sue Wingard, Health Education Coordinator, at wingard@annapolis.net.

Congestive Heart Failure — Best Practices

This program covers the underlying pathophysiology of heart failure and the significance of identifying and treating a reversible etiology, e.g., ischemia. You will learn to risk-stratify patients with heart failure based on clinical and laboratory findings. Discussion includes managing noncompliant and difficult-to-manage patients with heart failure. The program also covers pharmacology and the use of medications to treat heart failure, with emphasis on angiotensin enzyme inhibitors, combination therapy and third generation beta-blockers. This course will be offered:

• September 14, 2000 — Northern Virginia/Washington, D.C. area
• November 30, 2000 — Rockville, Md.

Depression in Chronic Disease

This program covers diagnosing depression in the primary care setting as well as recognizing co-morbid psychiatric disorders. Participants will be able to utilize a practical screen for uncovering depression or other co-morbid disorders. Treatment options for depression and anxiety will be discussed along with methods to improve patient compliance. This course will be offered:

• June 22, 2000 — Pikesville, Md.
• October 12, 2000 — Rockville, Md.
• October 26, 2000 — Timonium, Md.
• November 9, 2000 — Northern Virginia/Washington, D.C. area

Diabetes — Best Practices

This program covers the physiologic mechanisms controlling insulin production, insulin action and glucose homeostasis and how these mechanisms are disturbed in patients with Type II diabetes. Treatment options are discussed, including the differences among available classes of oral hypoglycemic agents. Combination therapy also will be discussed. This course will be offered:

• May 25, 2000 — Northern Virginia/Washington D.C. area
• June 8, 2000 — Prince George’s County, Md.
• August 3, 2000 — Columbia, Md.
• September 28, 2000 — Annapolis, Md.

Be sure to call Myriad Genetic Labs at 800-469-7423 for your free copy of the AMA-produced monograph, “The Role of Genetic Susceptibility Testing for Breast and Ovarian Cancer.” This educational program will provide you with useful information about BRCA testing for breast and ovarian cancer, appropriate criteria to identify patients for whom testing would be helpful, appropriate referral of individuals for genetic counseling and/or testing, interpretation of test results and strategies for management of patients found to have BRCA mutations. Completion of this program awards two credit hours of Category I Continuing Medical Education credits.