Table of Contents

Best Practice: Washington Hospital Center's "Diabetes for Life" Campaign
Recent Literature on Asthma, Cardiovascular Disease, Diabetes and Nutrition
Managing Postpartum Depression
PANDA Helps Dentists Repond to Chid Abuse and Neglect
Do You Test for Chlamydia?
It's Not Too Late to Vaccinate Against Flu
Prevent Missed Opportunities To Immunize
2001 MHCC Report Cards Released
Targeting Teens for Hepatitis B Prevention
Malaria Prevention Advisory
Philosophy of Care

Washington Hospital Center's "Diabetes for Life" Public Service Campaign

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 Maryland, Virginia and Washington, D.C.,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.

In 1996, Washington Hospital Center (WHC) launched a public service campaign on women and heart disease. Physicians at the tertiary care hospital located in Washington, D.C., recognized a need for heightened awareness among women of their risk of cardiac problems. An advisory board was assembled to integrate physician concerns into effective consumer outreach, and NBC4, one of the area’s most respected television news stations, became the hospital’s partner in delivering important messages to women about cardiac health.

In the last year of the four-year campaign on women’s cardiac health, the need for an outreach program on diabetes became clear in two ways. One was that the WHC’s focus on cardiac patients put a spotlight on the 30 percent of discharged cardiac patients who had diabetes. Two, a diabetes team was forming within WHC as the hospital itself began to jell within the newly established MedStar Health hospital system. The MedStar Diabetes Institute was formed in 2000 with one particularly clear goal: to create system- wide standards of care for diabetes, which has a higher-than-average rate of incidence in the nation’s capital.

Diabetes, however, would pose a challenge in developing an effective consumer outreach program. “We have always found that it’s best to focus on very simple messages when educating a broad audience,” says Donna Arbogast, a public relations official for WHC. “Diabetes is a topic with numerous and complex messages. We established a large physician advisory board for this initiative due to the fact that diabetes impacts care in so many specialties. We needed input from practitioners in all specialties who see patients with diabetes, but then we needed to pick the most pmportant messages for greater diabetes awareness."

Because WHC specializes in caring for the sickest of patients, the campaign’s focus was built around reducing the risk of diabetes complications. “While prevention is certainly important, we decided to focus our efforts on our patient population and those in the Washington area who have the disease and need help managing it,” says Ms. Arbogast. WHC re-teamed with NBC4 for the three-year “Diabetes for Life” campaign.

Now approaching its second year, the campaign has spent one year promoting diabetic foot care and now will focus on heart disease and diabetes. In the first year, to help tackle the rate of amputation stemming from diabetes-related foot problems, WHC and NBC4 produced and aired foot-focused television awareness spots that advertised a free information kit (containing a comprehensive booklet, a “reduce-your-risk” poster, a healthy feet bookmark, diabetes-friendly recipe cards and a wallet card). WHC says the bulk of its Diabetes for Life budget goes to the NBC4 partnership, which includes ad production and air time, on-air promotions of the campaign’s community events, a presence on the NBC4 Web site and participation in the annual Health and Fitness Expo, which is attended by 60,000 area residents each year.

"We have found that the tremendous exposure generated by this partnership makes the investment well worth it,” says Ms. Arbogast. “As a result of our television ads, we receive thousands of calls not only from individuals, but also from community groups seeking speakers and more information on diabetes.”

A number of WHC physicians are part of the national effort to develop clear screening and treatment standards for diabetes. Within the Diabetes for Life campaign, WHC strives to promote the ABCs of diabetes — target levels and monitoring frequencies recommended by the National Diabetes Education Program and the American Diabetes Association for A1c, blood pressure and cholesterol. To ensure greater awareness of these new standards and goals, the hospital will launch a physician education initiative during the second year of the diabetes campaign.

An educational mailing about the ABCs of diabetes management, one of today’s hottest topics in diabetes care, will be sent to more than 5,000 physicians in the Washington metropolitan region. Follow-up visits with doctors and education days with WHC endocrinologists also will be part of this physician outreach effort.

Kicking off the second year of the campaign, CareFirst was proud to co-sponsor WHC’s Diabetes Day in November. This one-day seminar was free and open to the public and featured Robert Anderson, Ph.D., an author and diabetes educator from the University of Michigan, as keynote speaker. Also speaking at the event was William Regenold, M.D., a geropsychiatrist from the University of Maryland, who discussed diabetes and depression.

CareFirst also will cosponsor NBC4’s Health and Fitness Expo in January 2002 at which WHC and CareFirst will host a Diabetes Corner. The exhibit will offer screenings, results analyses by endocrinologists, and foot screenings by a podiatrist to the 60,000 members of the public expected to attend. The NBC4 Health and Fitness Expo will be held at the Washington Convention Center on Saturday, Jan. 19 and Sunday, Jan. 20, from 9 a.m. through 5 p.m.

The focus of the Diabetes for Life campaign’s third year will be determined in the near future. For more information on the campaign or for a free Diabetes for Life kit, call Washington Hospital Center at 202-877-DOCS (3627).

Recent Literature on Asthma, Cardiovascular Disease, Diabetes and Nutrition

By T.A. Dadisman, M.D., medical director, Preventive Medicine and Health Promotion

This article is intended to call your attention to recent information you may have missed on management of asthma, cardiovascular disease and diabetes, along with some recent literature on nutrition.

Diabetes

Nutrition

Asthma

Cardiovascular Disease

Clinicians Managing Postpartum Depression

More Than Just Baby Blues

Most women experience mood swings after the birth of their baby. Yet when feelings of depression overwhelm a new mother and she can’t function well by her second postpartum week, there is serious cause for concern.

Postpartum depression, which is a major depression and not “the blues,” affects more than 10 percent of postpartum women. Some risk factors for postpartum depression include a history of depression or anxiety, stressful life events and an unsupportive environment. The dramatic neuroendocrine changes that occur in women after delivery play an important etiological role in postpartum mood disorder. The presence of depression in a pregnant woman is still the strongest predictor of postpartum illness.

How Clinicians Can Assess for Postpartum Depression

When assessing risk for depression in new mothers, providers should listen for phrases like “It’s too much to handle,” “I feel so overwhelmed,” “I can’t stop crying” or “I’m not able to take care of my baby.” Other signs to watch for in a new mother are:

• Difficulty engaging with her baby and/or lack of interest
• Agitation, anxiety or panic attacks
• Fear of injuring her baby
• Feelings of guilt, hopelessness, sadness or fatigue
• Excessive worry, irritability or difficulty concentrating

If you’re unsure that a woman is exhibiting clear signs of depression, simply ask her the following questions:

• During the past month have you often felt down, depressed or hopeless?
• During the past month have you often been bothered by little interest or pleasure in doing things?
• Do you fear you might hurt your baby or yourself?
• Have you ever had medications prescribed for anxiety or depression?

A “yes” to any question above is indicative that a woman may need some help.

What Can Clinicians Do?

Women who experience their first episode of depression within the first four weeks postpartum respond well to antidepressants, combined with supportive therapy and education. Treatment for postpartum depression is safe and effective. Treatment is more successful when it’s initiated early and continues without interruption. Several treatment strategies are to:

• Educate the mother about postpartum depression, its treatment and the risks to the mother and child.
• Consider psychotherapy, pharmacotherapy or a combination of both. Titrate medications, starting with low doses. Closely monitor the mother’s response to therapy and be mindful of serum levels.
• Provide education and resources on infant care. Knowing what to expect can reduce anxiety.
• Involve the family in providing support and infant care, which includes midnight feedings to ensure Mom gets adequate sleep.
• Periodically review progress with Mom and reinforce signs of improvement.
• Encourage Mom to attend a local support group.
• Encourage healthy habits like eating well, exercising (walking, for example) several times a week and getting adequate sleep.
• Rule out thyroid disease, including Hashimoto’s thyroiditis, as well as anemia as the underlying cause of depressed mood or fatigue.
• Consider a psychiatric consultation for any of the following:
  — Suicidal ideations
  — Poor perinatal care, which poses risks for mother and child
  — Severe depression
  — Comorbid psychiatric condition
  — Complicating medical condition
  — Psychotherapy indication
  — Complex pharmocotherapy indication
  — Electroconvulsive therapy indication
  — Response to treatment that is not as anticipated

Remember that you play an important role in the life of a new mother facing unfamiliar experiences. She’ll look to you for knowledge and guidance. Recognizing women at risk for postpartum depression begins early in pregnancy and helps ensure a healthy mother and child. Stressing awareness and treatment of postpartum depression can help both new parents.

Ask your postpartum patients to complete the Edinburgh Postnatal Depression Scale while in your office. The Edinburgh Postnatal Depression Scale is a 10-item scale that can be selfadministered. For a copy of the scale in Spanish, call Provider Relations at 410-528-7103 or 800-228-8161.

Instructions for Using the Edinburgh Postnatal Depression Scale

The mother is asked to check the response which comes closest to how she has been feeling in the previous seven days. All 10 items must be completed. Care should be taken to avoid the possibility of the mother discussing her answers with others. The mother should complete the scale herself, unless she has limited English or has difficulty with reading.

Scoring

Responses are scored 0, 1, 2 and 3 according to increased severity of the symptom. Items 3, 5, 6, 7, 8, 9 and 10 are reverse-scored (i.e., 3, 2, 1 and 0). The total score is calculated by adding together the scores for each of the 10 items. A score of 13 or above may indicate that the patient is experiencing symptoms of depression.

PANDA Helps Dentists Respond to Child Abuse and Neglect

Family violence is one of our society’s most tenacious and poorly controlled ills, often leaving its victims with physical trauma and lifelong emotional scars. Of particular concern is neglect and physical or sexual abuse of children, which often evolves from an established pattern of family violence.

According to U.S. Department of Health and Human Services data, the nation’s capital has the highest reported prevalence of maltreatment of children and the fourth highest rate of fatalities from abuse and neglect (see table). Child abuse and neglect has no socioeconomic, racial or ethnic boundaries, and its prevalence follows national norms in Maryland, Delaware and Virginia.

Dentists, dental hygienists and their staff are in a unique position to detect child abuse for the following reasons:

• As much as 75 percent of physical abuse involves injuries to the head or neck.
• Abusers often avoid the same physician but return to the same dental office.
• Children are more likely to receive regular preventive care in the dental office.

Nationally, only 0.32 percent of child abuse cases are reported by dentists with 87 percent of surveyed dentists saying they need more training in child maltreatment.With training, dentists are five times more likely to recognize and report child abuse.

CareFirst is sponsoring the formation of the Mid-Atlantic PANDA Coalition to build awareness of abuse and neglect in dentistry and other professional communities. PANDA (Prevent Abuse and Neglect Through Dental Awareness) is an international program that develops volunteer trainers to teach dentists and their staff how to detect and report child abuse and neglect. The desired result is the reduction of abuse and neglect through early identification and appropriate intervention.

The first PANDA program, introduced in Missouri, saw a 160 percent increase in dentists’ reports of suspected child abuse and neglect in the first year, with increased reporting every year since its inception. Oklahoma PANDA increased reporting by 400 percent in three years, while Illinois PANDA increased reporting by 800 percent.

The Mid-Atlantic PANDA Coalition has brought CareFirst together with several other organizations interested in child abuse intervention: University of Maryland Dental School, Howard University School of Dentistry, Freeman Dental Society, Children’s National Medical Center, Maryland State Dental Association,Maryland Dental Society, the Maryland Department of Health and Mental Hygiene, the Delaware Department of Health and the Delaware Dental Society.

On Aug. 8, the first Mid-Atlantic training session for PANDA trainers was held at Children’s National Medical Center. Currently, networks of trained dental personnel are being developed in each of the Mid-Atlantic’s participating jurisdictions (Maryland,Delaware and Washington, D.C.) with the goal of training 2,000 dentists, dental hygienists and other dental personnel by the end of 2002.

CareFirst is very proud to sponsor the Mid-Atlantic PANDA Coalition. Only through a cooperative endeavor involving organizations and individuals devoted to this difficult issue can child abuse and neglect be reduced.

Reported Child Abuse and Neglect

Source: U.S. Department of Health and Human Services state reported data for 1999

Do You Test for Chlamydia?

Chlamydia infection is one of the fastest growing communicable diseases in the country, especially among young adults and those who have multiple sexual partners. The Centers for Disease Control and Prevention estimates that there are 3 million new cases each year.

The National Committee on Quality Assurance tracks the chlamydia screening rate in women as reported in Health Plan Employer Data and Information Set (HEDIS) HMO reviews. HEDIS assesses how many sexually active* women between the ages of 16 and 26 years received a test for chlamydia during the measurement year.

In 2001, HEDIS reported the following chlamydia screening rates for CareFirst HMOs:

The Maryland Health Care Commission reports that across HMOs operating in the state (which includes CareFirst BlueChoice and FreeState), the average screening rate for women in both of these age groups is around 20 percent. Individually, Maryland HMO scores ranged as low as 1 percent and as high as 46 percent in the 16- to 20-year-old category; they ranged from 1 percent to 38 percent for those 21 to 26 years old.

In 75 percent of cases, chlamydia in women has no symptoms. Testing is imperative to detecting it in many of those afflicted. Be sure to consider the need for this screening when administering Pap tests.

*defined as having been dispensed a prescription for contraceptives

It’s Not Too Late to Vaccinate Against Flu

It’s not too late to vaccinate against flu, especially in patients at high risk. The Advisory Committee on Immunization Practices advises practitioners to continue administering flu shots in December and to “continue as long as there is influenza activity and vaccine is available.” Information and recommendations can be found at the Centers for Disease Control and Prevention’s influenza vaccine Web site.

Prevent Missed Opportunities To Immunize!

• Use medical record immunization history schedules in charts. Review the histories at each visit to keep the information current and up-to-date.
• Screen for contraindications (which may not include mild acute illnesses) and recommend needed vaccines. If a parent asks to delay a child’s immunization and there’s no medical reason to do so, encourage them to follow the recommended vaccine schedule.
• Educate parents on the importance of keeping children up-to-date on their immunizations.Encourage them to keep their own current record of their child’s immunizations in a safe place, and ask them to bring the record to each office visit.
• Remind parents, in advance, of each scheduled appointment and the importance of rescheduling missed appointments, including well-child visits.

2001 MHCC Report Cards Released

The Maryland Health Care Commission (MHCC) recently released its annual guide for consumers on the performance of 12 Maryland HMOs. The MHCC 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 Survey (CAHPS) and clinical data from Health Plan Employer Data and Information Set (HEDIS) audits. Results for FreeState Health Plan, Inc. and CareFirst BlueChoice, Inc., CareFirst BlueCross BlueShield’s subsidiary HMOs, are shown here. The entire report card is published by the MHCC in Comparing the Quality of Maryland HMOs 2001: Consumer Guide to Commercial HMOs (also available by calling the Commission at 877-245-1762).

Overall, the results reflect that members continue to be satisfied with the services provided by FreeState Health Plan, Inc. (FreeState) and CareFirst BlueChoice, Inc. (BlueChoice). FreeState demonstrated above average performance in the categories of childhood immunizations, comprehensive diabetes care, beta blocker treatment after a heart attack, medications used for asthma and few customer complaints. The health plan was named “Star Performer” in the MHCC’s 2001 report for better-than-average performance over several years in the delivery of childhood immunizations. BlueChoice’s performance was rated above average in comprehensive diabetes care, breast cancer screening, well-child visits for infants and children, prenatal care, medications used for asthma and follow-up after hospitalization for mental illness.

FreeState’s HbA1c results for members with diabetes demonstrated an improvement in members who are in control. The results increased from 68 to 74 percent. FreeState’s members who have asthma showed an improvement in appropriate medication use from 58 to 65 percent.

BlueChoice also demonstrated a steady improvement in the areas of diabetic and asthma care. BlueChoice’s HbA1c results for our diabetic population increased from 46 to 71 percent. Our members who have asthma showed an improvement in appropriate medication use from 44 to 71 percent.

We attribute these successes to your ongoing attention to preventive care and to FreeState’s and BlueChoice’s diabetes and asthma disease management programs.

The National Committee for Quality Assurance (NCQA) also publishes HEDIS results and compares many HMOs on a national and regional basis in The State of Managed Care Quality 2001.

HEDIS 2001 PERFORMANCE

Targeting Teens for Hepatitis B Prevention

In the United States, most persons with hepatitis B virus (HBV) acquire the infection as adolescents or young adults. Immunization with hepatitis B vaccine is the most effective means of preventing HBV infection and its consequences.

Well-care visits, or any office visit, can be used to target adolescents for hepatitis B prevention. Don’t miss the opportunity to educate and vaccinate. Hepatitis B is preventable.

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

Malaria Prevention Advisory

CareFirst’s Department of Preventive Medicine and Health Promotion and the Centers for Disease Control and Prevention (CDC) want health care providers to be aware of appropriate malaria prevention regimens.

Health care workers who provide medical advice to travelers should be aware that chloroquine, once a readily recommended mode of prevention, is effective for malaria prevention only in a few areas of the world. Recommending and prescribing inappropriate drug prevention regimens can result in travelers becoming ill or dying from malaria.

The CDC recommends Malarone, mefloquine or doxycycline as options for malaria prevention in areas with chloroquine-resistant malaria; chloroquine combined with proguanil is no longer recommended. For detailed disease prevention recommendations, visit www.cdc.gov/travel or call 877-FYI-TRIP (394-8747).

Philosophy of Care

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 satisfaction of their patients and the quality of their services. 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 preventive care, as well as comprehensive care for acute and chronic illness — at home, at the doctor’s office and in the hospital.

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 treatment options, medical conditions and health status.

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 comprehensive, affordable 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

CareFirst’s Mission

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 that promotes respect, fairness and opportunity for our associates.

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