By Simeon Margolis, M.D., Professor of Medicine and Biological Chemistry, Johns Hopkins University School of Medicine.

There is no longer any question that intensive control can delay or prevent the long-term complications of chronically high blood glucose levels in both type 1 and type 2 diabetes. The Diabetes Control and Complications Trial (DCCT), published in The New England Journal of Medicine (1993; 329: 977-86), randomly assigned a total of 1,441 type 1 patients to either intensive or conventional insulin therapy and followed them for a mean of 6.5 years. The mean values for HbA1c and glucose in the conventional and intensive treatment groups were 9 percent vs. 7 percent and 231 mg/dL vs. 155 mg/dL, respectively. Compared with conventional treatment, complications in the intensive treatment group decreased as follows:

• Development of new retinopathy (by 76 percent).
• Progression to proliferative or severe nonproliferative retinopathy (by 47 percent).
• Occurrence of microalbuminuria (by 39 percent).
• Clinical neuropathy (by 60 percent).

The results of the United Kingdom Prospective Diabetes Study (UKPDS), published in The Lancet (1998; 352: 837-53), made it clear that improved glucose control also provides type 2 patients protection against some of the late complications of hyperglycemia. This study randomly assigned 3,867 patients with newly diagnosed type 2 diabetes to treatment with diet alone or to more intensive control with either sulfonylurea or insulin. After a median of 12 years of follow-up, the average differences between the HbA1c levels in the two groups was modest — 7.9 percent in the diet group and 7.0 percent in the intensive treatment group — and the benefits were less dramatic than those found in the DCCT. Compared to those on diet alone, the intensive treatment group:

• Had a 25 percent overall reduction in microvascular endpoints, mostly due to fewer cases of retinal photocoagulation.
• Lowered their progression of retinopathy by 21 percent.
• Decreased the occurrence of microalbuminuria by 33 percent.

However, the intensive treatment group showed no difference in clinical evidence of peripheral neuropathy.

Two other findings from UKPDS have important implications for management. The fasting glucose and HbA1c levels deteriorated over time in both groups of patients, showing that type 2 diabetes progressively worsens. Consequently, as type 2 patients grow older, they require an increase in the intensity of the measures used to control blood glucose: raising the dose of a single oral agent, combinations of several oral agents or insulin treatment. The authors also concluded that the improvement in glycemic control achieved in this study did not diminish the risk of macrovascular disease — coronary artery or cerebrovascular disease. In order to prevent these macrovascular complications, it is therefore essential to control risk factors for cardiovascular disease, such as hypertension, cigarette smoking and abnormal lipid values, in addition to controlling blood glucose levels.

More frequent and severe episodes of hypoglycemia were the major risks brought by intensive treatments in both the DCCT and UKPDS. Blood glucose measurements are recommended as often as four times a day in type 1 patients, and at least twice a day in type 2 patients who are taking sulfonylurea or insulin. At times, the HbA1c levels may seem inconsistently high when compared with a patient’s recorded home glucose measurements. It is important to remember that the HbA1c averages all blood glucose values, including the rises that occur after a meal; and most patients only measure their glucose levels before meals or at bedtime. Spot checks of postprandial glucose levels may explain the seeming inconsistency between HbA1c and home glucose levels, and can help the practitioner plan appropriate therapy.

The American Diabetes Association has recommended the following goals for glycemic control:

• Fasting/preprandial glucose, 80-120 mg/dL.
• Bedtime glucose, 100-140 mg/dL.
• HbA1c, less than 7.

Additional action is suggested when fasting/preprandial glucose > 140 mg/dL; bedtime glucose > 160 mg/dL; or HbA1c > 8 percent. These targets are, admittedly, difficult to achieve. However, the DCCT and other studies have shown that the greatest benefits result from reductions in especially high values of HbA1c, for example, when HbA1c is reduced from 10 percent to 8 percent as compared with a reduction from 8.5 percent to 6.5 percent.

That oral health is a critical component of general health and well-being is the main premise of the recently released Oral Health in America: A Report of the Surgeon General*, the first-ever report on the topic by a surgeon general. It’s alarming, then, that the report reveals a prevalence of dental decay (caries) in a significant number of America’s children. Among the surgeon general’s findings:

• Dental caries is the single most common chronic childhood disease — five times more common than asthma and seven times more common than hay fever.
• Over 50 percent of 5- to 9-year-old children have as least one cavity or filling, and that proportion increases to 78 percent among 17-year-olds.
• Poor children suffer twice as many dental caries as their more affluent peers. One out of every four children in the United States is born into poverty.

Maryland’s Dental Decay Crisis

The prevalence of tooth decay in children living within CareFirst BlueCross BlueShield’s (CareFirst’s) Maryland service area is higher than nationally reported levels. This is due to both an inadequate comprehensive dental public health program and a lack of awareness in the general population of the importance of dental decay prevention measures.

The 1995 Survey of the Oral Health Status of Maryland’s School Children from the Dental School, University of Maryland, and the Office of Child Health, Maryland Department of Health and Mental Hygiene, concludes:

• 60 percent of the school-age population in the State of Maryland has experienced dental decay.
• 55 percent of teeth that have decay experience are left untreated.
• The decay experience among children in the lower socioeconomic groups is approximately 31 percent higher than the Maryland state average.

A particularly virulent form of dental decay is early childhood caries (ECC), which is epidemic in lower-income families. ECC prevalence in Maryland Head Start children may be as high as 90 percent in some subpopulations.

Your Role in Easing the Epidemic

There are not enough dentists in the region to treat decay, teach its prevention and administer public oral health programs as well. All health care providers can assist in the control of dental decay by reminding their patients that their overall wellness is contingent on good oral health.

• Primary care practitioners should make an examination of the mouth and teeth part of every physical examination, with referrals to a dentist made when decay is noted. Discuss the importance of conscientious brushing and flossing, good nutrition and the application of sealants (when practical) with your patients or their parents.
  
  
• Water fluoridation is the single most effective dental caries disease-preventing measure. Where fluoridated water is not available, consider fluoride supplements for your patients.
  
  
• Decay prevention should be part of health education efforts made by other health care providers, social workers and outreach personnel.

Children’s advocates can help build support for public dental health and treatment by including decay prevention in their agendas. A cooperative prevention effort among health care workers is needed to alleviate the children’s dental decay crisis in Maryland and nationwide.

For more information about this topic Contact:

The American Academy of Pediatric Dentistry at www.aapd.org or the American Association of Dental Public Health at www.pitt.edu/

Updates on Flu and Other Immunizations

This summer, the Food and Drug Administration and the Centers for Disease Control and Prevention (CDC) formally briefed the Advisory Committee on Immunization Practices (ACIP) on a potential shortfall in the influenza vaccine supply for the 2000-2001 flu season.

At this time, the ACIP recommends that health care providers delay their adult immunization efforts until the month of November (the usual recommendation being October) so as to proactively conserve supplies of the vaccine.

In addition, patients at highest risk — those over 65 and immunosuppressed individuals — should receive priority consideration for vaccination.

If a substantial shortage of the vaccine does occur, the ACIP and CDC will further modify their immunization recommendations for the 2000-2001 season. (You can access timely press releases on this situation and other health issues at the CDC’s Web site Media Relations page, www.cdc.gov/od/oc/media.) Until new information confirms a crisis, however, please continue to consider the following categories of patients for vaccination:

• Persons aged 65 and older.
• Residents of nursing homes and chronic care facilities.
• Adults and children with chronic disorders of the pulmonary or cardiovascular systems, including asthma.
• Adults and children who received treatment or were hospitalized during the preceding year because of diabetes, renal dysfunction, hemoglobinopathies or immunosuppression.
• Persons aged 6 months to 18 years who are receiving long-term aspirin therapy.
• Women who will be in the second or third trimester of pregnancy during the influenza season.
• Patients planning to travel to the tropics or the Southern Hemisphere from April through September, or who plan to travel with large organized tourist groups at any time of the year.
• Anyone who wishes to reduce his or her risk of becoming ill with influenza.

Control of the flu’s spread can be maximized by administering the vaccine during routine office visits and to hospitalized persons prior to the influenza season.

Although annual vaccination is recommended for health care workers, the 1997 National Health Interview Survey revealed that only 34 percent of health care workers reported having received the influenza vaccine. The following individuals can transmit the flu to persons in high-risk categories and should be vaccinated:

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

The 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. However, minor illnesses with or without fever should not contraindicate the use of influenza vaccine, particularly among children with mild respiratory tract infection or allergic rhinitis.

Other Immunization Updates

Pneumococcal Vaccine

Pneumococcal vaccine can be given at any time during the year, so consider administering it at the same time you give the influenza immunization. The pneumococcal vaccine is recommended for patients over 65 and for others exhibiting appropriate risk factors. Revaccination intervals continue to be studied, but current recommendations are once in a lifetime or a one-time revaccination for individuals at risk for morbidity or mortality from pneumococcal disease and who were vaccinated more than five years before.

Meningococcal Vaccine

At least 3,000 cases of meningococcal disease occur each year in the United States, and 10-15 percent of these patients die despite having received antibiotics early in the illness. Of those who survive, an additional 10 percent suffer severe after-effects, including mental retardation, hearing loss and arterial thrombi leading to gangrene and a potential loss of limbs. The ACIP has modified its guidelines for use of the polysaccharide meningococcal vaccine to prevent bacterial meningitis for college freshmen who live in on-campus dormitories (a group at increased risk of meningococcal disease). Vaccination should be provided or made easily available to those freshmen who wish to reduce their risk of disease. Other undergraduate students wishing to reduce their risk of meningococcal disease also can choose to be vaccinated.

Effective June 1, 2000, Maryland requires that all college students housed on-campus be vaccinated against meningococcal disease. Individuals may be exempted, if they wish, once they have been provided with detailed information on the disease and the vaccine’s effectiveness, and the student’s parent, guardian or the adult student himself has signed a waiver. For more information on the new Maryland requirement and meningococcal meningitis, call the Center for Immunizations at 410-767-6679 or visit their Web site at www.edcp.org. The Maryland Department of Health and Mental Hygiene also plans to make a fact sheet available.

For more information on meningococcal disease, its symptoms and the vaccine, visit the CDC’s Web site at www.cdc.gov/ncidod/dbmd/diseaseinfo or the American College Health Association’s site at www.acha.org.

The Hepatitis B Vaccine and Adolescents

According to the CDC, 90 percent of all cases of hepatitis B reported to the government occur in adolescents and young adults. Routine immunization against the disease in infants began in 1991, but the adolescent population born prior to that year remains a high-risk group — particularly because adolescents’ visits to the doctor are typically not for preventive services (such as immunizations) but for relief from symptoms of illness. According to a recent study, approximately 50 percent of persons age 11 to 12 have not been vaccinated against hepatitis B. Remember to vaccinate your preteen and adolescent patients with the hepatitis B series — and don’t forget to screen for a history of chickenpox disease. If no history is found, the varicella vaccine should be administered.

For more information on hepatitis B, contact the Centers for Disease Control and Prevention at 888-4-HEP-CDC or visit www.cdc.gov.

Back-to-School Immunization Requirements Updated Across Region

As of the 2000-2001 school year, hepatitis B and varicella vaccines are required for children entering preschool and day-care programs in the District of Columbia*, Maryland and Virginia**. These immunizations are required in addition to the DTaP, Hib, IPV and MMR vaccines, which were already required by law for children in preschool and day care in the District of Columbia, Maryland and Virginia.

Children should receive a complete three-dose series of the hepatitis B vaccine. The varicella vaccine should be given no earlier than the child’s first birthday unless proof of varicella immunity by medical diagnosis or positive blood test exists. Physicians may document a child’s disease history according to parental recall.

Should you have questions about the minimum vaccine requirements for children enrolling in preschool, day-care and school programs in your state, contact:

In Maryland
The Center for Immunizations, Maryland Department of Health and Mental Hygiene Epidemiology and Disease Control Program: 410-767-6679.

In the District of Columbia
The District of Columbia Immunization Program: 202-576-7130.

In Virginia
The Virginia Department of Immunizations: 800-568-1929 or 804-786-6246.

* In the District of Columbia, varicella and hepatitis B vaccination is required for entry into kindergarten through 12th grades as well as for preschool entry.
** In Virginia, beginning July 1, 2001, hepatitis B vaccination will be required prior to entry into the sixth grade.

The following is presented in an effort to highlight hospital “best practice” around the region. 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.

A reorganization of Children’s National Medical Center’s Clinical Resource Management Program was implemented 18 months ago as part of the hospital’s strategic plan to improve quality of care while addressing cost concerns. Are the two at odds? Kathy Chavanu, R.N., M.S.N., Director of Clinical Resource Management and Kurt Newman, M.D., Medical Director of Clinical Resource Management and an attending surgeon at Children’s, can now share evidence that an integrated pathways program can lead to improved patient outcomes and reductions in length of stay, balancing both quality and cost.

Chavanu and Dr. Newman lead the administrative and clinical centers within Children’s that partnered to revamp the Clinical Resource Management (CRM) Program. They report to the hospital’s senior officers and executives, including Nellie C. Robinson, Vice President of Patient Care Services, and Peter Holbrook, M.D., Chief Medical Officer, regarding the CRM Program’s denial management and pathway components. The denial management program works with the hospital’s payors and providers to discuss how cases can be better managed, especially via the care coordination performed by Children’s case managers. For example, if payors continually deny admissions or inpatient days related to a certain diagnosis, the payors might be polled on whether they believe a care pathway not involving admission could be utilized. Alternate pathways might then be considered. In addition, Dr. Newman and the manager of CRM, Mary Sasser, head a Complex Case Review Board that brings together payors, families of patients and medical staff to meet and discuss all aspects of Children’s most high-maintenance patient cases.

Chavanu recognizes Pat Johnson, Ph.D., Practice Facilitator, for overseeing development of the pathway portion of the CRM Program. Dr. Johnson brings together multidisciplinary teams to look at best evidence for various diagnoses and then orchestrates the most effective components into complete pathways of care. Key physicians and nurse leaders guide pathway development. Pathways are fully integrated into the seven Centers of Excellence at Children’s Hospital. “Before we instituted the Pathway Program,” says Dr. Newman, “a multidisciplinary approach to pathways didn’t exist. From a clinical perspective, we had to decide how to energize a full-on approach to the concept of care quality. We chose to place accountability on the Centers to force a service-line approach. It’s an improvement because each Center is an integrated package of researchers, nurses, case managers, physicians, etc.” Each of Children’s Centers of Excellence has been assigned the management of three major diagnoses (with 17 pathways implemented to date). The hospital compiles review data for each Center to help evaluate its success — for example, the number of admissions, total charges, and denials received for a certain diagnosis. (To ensure compatible data, all benchmarking is performed with data pulled from patients with conditions of matching severity levels.)

The multidisciplinary goals of all Children’s CRM Program Pathways are to:

• Improve patient-family education.
• Reduce length of stay (Children’s National has traditionally been above the national standards set by other children’s hospitals for a number of diagnoses).
• Address chronic denials.
• Enhance coordination of care.
• Improve efficiency of patient discharge.

One example of how Children’s is meeting these goals comes courtesy of the Diabetes Pathway Program, championed by Audrey Austin, M.D., the Children’s Chair of Endocrinology in the Center for Complex Diseases. Diabetes discharges were once less timely — with 10 to 12 discharge delays per quarter — often due to the fact that there were no nurses available on weekends to teach skill sets to patients who were otherwise ready for discharge. Since allocating the needed weekend staff, Children’s diabetes-related discharge delays have been reduced to only one to three per quarter. Overall, Children’s National has reduced its average diabetes length of stay from 3.75 days to less than 2, and has maintained an average length of stay below national benchmarks (an average of 2.8 days) for the last seven consecutive quarters.

Children’s National Medical Center has one of the largest pediatric sickle cell programs in the country. Catherine Driscoll, M.D., Medical Director of the Sickle Cell Program, is also the leader of the Sickle Cell Path Team. Dr. Driscoll guided the interdisciplinary team to improve quality of care via efforts to reduce re-admissions and improve pain management for children and adolescents in sickle cell crisis. Many of these children are heavy hospital users and are prone to pain crises. The Sickle Cell Pathway was implemented in September 1998 with the goal of reducing the number and length of admissions for so-called “frequent flyers” and of alleviating the social detriment they experience by spending many of their childhood days in the hospital.

One issue the pathway team addressed was the use of Demerol for pain management. To manage ED interventions more effectively, intravenous morphine is now used instead of Demerol. Further improving this change was the introduction of PCA (patient controlled analgesia) pumps for patients age 8 and older. The PCA pumps were found to control pain more quickly and have reduced admissions from 70 percent pre-pathway implementation to 30 percent post-implementation.

For those patients who must be admitted, a Behavioral Contracting System has been introduced to improve inpatients’ management of their own care. Children 8 and up sign a “contract” with their nurse, psychologist and parents that establishes an honor system by which, for example, a school-age child might agree to accomplish 30 minutes of homework when experiencing pain perceived as less than an “8” on a scale of 1 to 10, or when the child has needed his or her PCA pump less often than when first admitted. Younger children also are encouraged to distinguish between needed intervals of rest and less painful periods to take on more social or artistic activities. “By building stimulation and responsibility into their care management, our sickle cell patients gain a sense of control over their illness. Our clinical staff maintain that patients recover and assimilate back into their daily routines more quickly as well,” states Pat Johnson, Ph.D.

Children’s has seen remarkable results since implementing the Sickle Cell Pathway Program. Over the last four quarters, Children’s (which started out with a 7-day average length of stay for patients 8 and older) has been able to claim a 3.3 to 4-day average for sickle cell patients on PCA, well under the national 4.5 day benchmark.

Initially, investing in things such as weekend staff and PCA pumps can impact a hospital’s bottom line. Says Dr. Newman, “Changing our old patterns of care management may hurt us financially at first. But we know that we’re making expensive investments in order to effect a long-term reduction in care costs.” Already, Children’s National Medical Center has seen an overall reduction in length of stay. Although it’s hard to capture all aspects quantitatively, Dr. Newman and Kathy Chavanu are confident that “overall patient care at Children’s has improved through Clinical Resource Management.”

The Balanced Budget Act of 1997 mandated that health plans develop a process for identifying and implementing a care plan for patients with serious medical conditions within 90 days of enrollment in a Medicaid or Medicare Managed Care Organization (MCO). A Health Risk Assessment (HRA) or Appraisal (the term used by Medicare) is a tool designed to identify individuals at risk for poor health outcomes and high utilization of services. FreeState Health Plan believes in proactive and appropriate health care for its at-risk members and has implemented the completion of HRAs for all FreeState Medicaid MCO and Medi-CareFirst members upon their enrollment.* If you are a primary care practitioner in either the Medicaid MCO or Medi-CareFirst networks, FreeState wants you to understand how HRAs and our Case Management Team can help you respond quickly to the special needs of a high-risk patient.

Upon enrollment, an HRA questionnaire is mailed to each new FreeState Medicaid or Medi-CareFirst member. The questionnaire asks the individual approximately 25 questions regarding his or her current state of health and related issues. All HRAs for new FreeState Health Plan Medicaid MCO members are facilitated by the State of Maryland’s contracted enrollment broker, Benova, that regularly downloads all HRA results into our computer system. The HRA utilized for screening of FreeState’s Medi-CareFirst members is based upon the Pra-Plus®, a validated tool that assigns a numeric score to a participant based upon his or her likelihood for adverse events. In both cases, the HRA is used to identify a confluence of factors that put that patient at risk for poor health outcomes and high utilization.

Members with a “positive” HRA are referred to the appropriate case management department for assessment. Case management assessments for FreeState Health Plan Medicaid MCO members are performed by the Medicaid Case Management Team or by the member’s case management-delegated medical management group. Case management assessments for FreeState’s Medi-CareFirst members are facilitated by the Case Management Department or by the member’s delegated medical management group. Case managers are either registered nurses or licensed clinical social workers, and contact the member via telephone (or by any other means necessary) to conduct a one-on-one review of his or her HRA questionnaire. This follow-up ensures that referral of a patient for case management services is still appropriate. For example, respondants within the geriatric population are prone to situational and temporary feelings of sadness or depression. Case management assessments often reveal that the patient’s situation has changed and his or her emotions have lifted since completing the HRA survey (which may indicate that case management of that individual on the basis of depression alone may not be necessary).

After assessment is complete, the case manager seeks both the member’s and his or her PCP’s consent to participate in the case management program. The case manager then takes on an active role in developing a plan of care with the member’s PCP, designed to provide the member with appropriate and timely care. The case manager is the lead coordinator on that plan of care until the patient’s identified health risks have been resolved.

Case management is a benefit of no cost to the member under both the FreeState Medicaid MCO and Medi-CareFirst products. If you have any questions about HRAs or our Case Management program, please call 410-605-2413 or 888-264-8648.

*Please note that FreeState has frozen new Medi-CareFirst enrollment in all Maryland counties effective July 3, 2000 and has informed HCFA that it will no longer offer a Medicare HMO product after December 31, 2000. HCFA requires that FreeState accept applications from Medicare eligibles who turn 65 during the closed enrollment period.

Assessing Patients’ Needs

What does a case management assessment evaluate? How is it customized for the Medi-CareFirst and Medicaid populations’ particular needs?

The Medi-CareFirst Case Management Assessment includes an evaluation of an individual’s:

• Physical functioning abilities.
• Cognitive status.
• Health history.
• Environment and current living arrangements.
• Family/caregiver support system.

The Medicaid case management assessment includes a review of the patient’s:

• Current health care needs.
• Medical history.
• Psychosocial needs.
• Language skills.
• Environment, housing and living arrangements.
• Cognition and education.
• Nutritional status.
• Personal support system.
• Health education.

Medical management groups delegated to perform case management assessments are required to include these elements in their evaluations.

The University of Maryland School of Medicine’s Complementary Medicine Program is conducting a groundbreaking study on the effects of complementary therapies for patients with osteoarthritis (OA) and fibromyalgia. As the first health insurer in the mid-Atlantic region to offer alternative and complementary therapy discounts to its members*, CareFirst encourages providers to tell osteoarthritis and fibromyalgia sufferers about the opportunity to participate. These are the largest randomized clinical trials ever conducted on the benefits of complementary therapies for OA and fibromyalgia, and the results are anticipated to be extremely significant.

The study on osteoarthritis will examine the effectiveness of acupuncture on OA of the knee. Participants must be over 50 years old, have mild knee pain on most days, have been diagnosed with OA of the knee at least six months before by their physicians, and never have had acupuncture treatment before. Participants will be randomly placed into three groups and may undergo real acupuncture, placebo acupuncture, or group arthritis education and self-help training (developed by the Arthritis Foundation). Those interested in participating should call 410-448-6279 or visit http://medschool.umaryland.edu/ for more information.

The limited efficacy of pharmacological treatments for fibromyalgia (FM) has led to the consideration of mind/body therapy for its management, the benefits of which have been reported for patients with other chronic pain syndromes. The University of Maryland Complementary Medicine Program’s FM study will evaluate the benefits of Multiple Component Mind/Body (MCMB) Intervention, including mindfulness and relaxation response techniques and Qi Gong movement therapy. Participants will be randomly grouped into the MCMB Intervention or a fibromyalgia self-help course developed by the Arthritis Foundation. Participants in this study must be at least 18 years of age. Exclusion criteria includes pregnancy, substance abuse, major psychiatric disorder or involvement in impending litigation or judgement for disability workers’ compensation. Those interested in participating should call 800-325-7096.

All participants should maintain their regular medical regimen under the care of their physicians. Physicians and health care providers are welcome to call the University of Maryland’s Research Supervisor and Osteoarthritis Project Director, Katherine Wright, Ph.D., or Recruitment Specialist, Jean Box, at 410-448-6448 for more information.

* Via CareFirst Options, a complementary therapies and wellness services discount program automatically available to members of any insurance plan bearing the CareFirst BlueCross BlueShield logo on the ID card.

Do You Test for HIV

That’s the question being asked of providers throughout Baltimore City as part of a new mass media HIV testing campaign sponsored by the Maryland AIDS Administration.

The Johns Hopkins University Center for Communications Programs, in conjunction with Eisner Communications, developed the Red Ribbon Question Mark Campaign to promote the message “Live Long. Live Strong. Get Tested for HIV.” This slogan and the familiar red AIDS advocacy ribbon shaped as a question mark appear in television, radio, and print ads throughout Baltimore that are designed to arouse curiosity and stimulate dialogue about HIV testing between practitioners and their patients. One ad asks, “What kind of mother could give her baby HIV?” The answer? “An untested one.” Although testing is one of the most effective ways to fight the spread of HIV/AIDS, it is estimated that 50 percent of perinatal HIV transmissions go undetected due to flawed screenings and a lack of testing.

Practitioners in the Baltimore area have a unique opportunity to take advantage of the HIV testing awareness generated by this campaign. CareFirst urges practitioners throughout the Maryland and National Capital service regions to talk with patients about HIV/AIDS testing.

For more information about the Red Ribbon Question Mark campaign, call the Program Coordinator at 410-659-6273.

The National Committee for Quality Assurance (NCQA) will highlight FreeState Health Plan’s Quality Improvement (QI) efforts in its first edition book, Quality Profiles^TM: In Pursuit of Excellence in Managed Care. FreeState was selected for inclusion by an advisory board of quality improvement experts by virtue of the impact our QI efforts have had on the health of, or services provided to, a certain patient population and retention of this impact over time. Some of the QI interventions highlighted are improving diabetes management through practitioner and member education and improving lipid management through targeted interventions. For more information, please contact NCQA Customer Support at 202-955-5697. Quality Profiles™ is a trademark of NCQA and is funded by Pfizer, Inc.

We are pleased to inform you that we have adopted uniform standards for medical record documentation across all sites and lines of business within CareFirst and its subsidiary HMOs. CareFirst’s medical record documentation standards include the following:

Documentation Fundamentals

• Elements of the medical record are organized in a consistent manner.
• The patient’s name or ID number appears on each page of the record.
• Entries are legible.
• All entries are dated.
• All entries are initialed or signed by the author.

• Personal and biographical data are included in the record.
• Current and past medical history and age-appropriate physical exams are documented and include serious accidents, operations and illnesses.
• Allergies and adverse reactions are prominently listed, or noted as “none” or “NKA.”
• Information regarding personal habits such as smoking and history of alcohol use and substance abuse (or lack thereof) is recorded when pertinent to proposed care and/or risk screening.
• An updated problem list is maintained.

• The patient’s chief complaint or purpose for visit is clearly documented.
• Clinical assessment and/or physical findings are recorded. Appropriate working diagnoses or medical impressions are recorded.
• Plans of action/treatment are consistent with diagnosis(es).
• Unresolved problems from previous visits are addressed in subsequent visits.
• Follow-up instructions and time frame for follow-up or the next visit are recorded as appropriate.
• Current medications are documented in the record, and notes reflect that long-term medications are reviewed at least annually by the practitioner and updated as needed.

Health care education provided to patients, family members or designated caregivers is noted in the record and periodically updated as appropriate.

• Screening and preventive care practices are in accordance with CareFirst BlueCross BlueShield’s Preventive Services Guidelines.
• An immunization record is completed for members 18 years and younger.

Requests for consultation are consistent with clinical assessment/physical findings.

• Laboratory and diagnostic reports reflect practitioner review.
• Patient notification of laboratory and diagnostic test results and instruction regarding follow-up, when indicated, are documented.

• There is evidence of continuity and coordination of care between primary and specialty care practitioners or other providers.

More information on these standards and performance measures for meeting them can be found in your Provider Manual. Compliance with these standards is monitored as part of our Quality Improvement program via a member records sampling review. Individual results of these reviews are shared with the practitioner, and aggregate results are reported periodically in BlueLink, CareFirst’s bi-monthly practitioner newsletter.

My Care First Offers Web Users Customized Health Information

CareFirst BlueCross BlueShield has launched a new health and wellness section called My Care First on our corporate Web site. Available to members and the general public, My Care First offers useful health and wellness information reviewed by CareFirst medical directors to help ensure its accuracy and safety.

Visitors to My Care First will find a library of health information, health polls and quizzes, and calculators to determine the user’s Body Mass Index, ideal weight, target heart rate and calorie burn rate. Other features of My Care First include:

• Assess My Health, a personalized health risk assessment.
• My Health Goals, which helps the user set health goals and monitor progress.
• My Health News, which presents news and information on topics of the visitor’s choosing at each visit.
• My Reminders, a free service that sends self-designed e-mail reminders regarding everything from blood sugar checks to exercise motivation.

Says Tad Dadisman, M.D., Medical Director, Health Education and Preventive Medicine, “We hope people will use the information offered on My Care First in conjunction with their physicians’ guidance to better manage and improve their own health.”

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 Credit events. Details can be obtained by calling the Health Education Department at 410-528-7997 or 800-323-4472. You may register directly by e-mailing Sue Wingard, Health Education Coordinator, at wingard@annapolis.net.

Congestive Heart Failure — Best Practices

This dinner/seminar 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 will include managing non-compliant and difficult-to-manage patients with heart failure. Pharmacology and the use of medications to treat heart failure will be covered with emphasis on angiotensin enzyme inhibitors, combination therapy and third generation beta-blockers. This seminar will be offered:

November 30, 2000 - Rockville, Md.

Depression in Chronic Disease

This dinner/seminar covers diagnosing depression in the primary care setting as well as recognizing comorbid 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 seminar will be offered:

October 12, 2000 - Rockville, Md.
October 26, 2000 - Timonium, Md.
November 9, 2000 - Northern Virginia/Washington, D.C. area

Diabetes and Heart Disease

This dinner/seminar will cover the scientific evidence supporting careful glucose control and monitoring methods, and will emphasize the necessity for control of concomitant hypertension and dyslipidemias. This seminar will be offered:

October 4, 2000 - Washington, D.C.
October 5, 2000 - Tyson’s Corner, Va.