The American medical care system falls to provide effective prevention services even though some prevention services are among the most cost-effective medical procedures available. Many prevention services are routinely delivered in inefficient or ineffective ways, and new technologies may be widely and aggressively implemented despite serious doubts about their efficacy and cost-effectiveness. The barriers to effective prevention services result from conceptual limitations in our model of medical care systems, particularly the lack of a population-based perspective. A change in paradigm is needed before reforms in our health care system can improve health without bankrupting the nation.
OBJECTIVE:To describe and assess the perceived impact of an innovative patient health informatics tool among members of a managed care organization.SETTING:Mixed-model HMO in Connecticut.DESIGN:Intervention group only, post-test only (telephone interview using structured protocol).PARTICIPANTS:Members of a Connecticut HMO who responded to a free video offer and met study eligibility requirements.INTERVENTION:Patient education videos from the entire Time Life Medical At Time of Diagnosis series.MAIN OUTCOME MEASURES:Knowledge of condition and treatment options, attitude and outlook towards condition, patient-provider communication, behavior change, physician contacts for condition.RESULTS:Study participants reported that the video improved their understanding and knowledge of treatment options for their condition. They also reported a positive impact of the videos on a range of attitudes and behaviors pertinent to their condition. Participants endorsed the involvement of their HMO in distributing the videos, and few adverse effects from use of the videos were observed.CONCLUSIONS:This study provides preliminary evidence for a positive impact of health informatics tools on patient attitudes, including expectancies for care, quality of patient-physician communication, and satisfaction with health plan. The fact that most persons responding to the video offer had their condition for several years suggests that distribution of health informatics tools should not be limited to the newly-diagnosed.
Uninsured Americans often face barriers to or lack continuity of care. Care for this population is often fragmented, expensive and undercompensated. University Hospital in Denver, in partnership with Kaiser Permanente of Colorado, sought to address this problem by developing CU CARE, a managed care demonstration program for the medically uninsured within the University of Colorado Health Sciences Center. This paper describes the evolution and preliminary experience of the CU CARE program. Policy implications for the future of health care delivery to this population are also briefly discussed.
Although there is now solid evidence to support the efficacy of colorectal cancer screening, few health care systems have developed comprehensive screening programs. This report describes the scientific rationale, development and implementation strategies, and preliminary results of the Colon Cancer Prevention Program (CoCaP) of the Northern California Region of the Kaiser Permanente Medical Care Program. CoCaP is a sigmoidoscopy-based screening program that aims to provide screening to all average-risk program members once every 10 years beginning at age 50. During the first 2 years of the program, more than 100,000 sigmoidoscopies were performed in age-eligible members (age 50 years and above). Seventy-five percent of these were screening examinations. Participating endoscopists include gastroenterologists, generalist physicians, and a growing number of non-physicians, primarily nurses, nurse-practitioners or physicians' assistants. Data on depth of insertion and polyp yield suggest that non-physicians quickly become as proficient as physician endoscopists. The long-term goals of the CoCaP program are to reduce the incidence of and mortality from colorectal cancer. Collection and analysis of data from the screening examinations and follow-up colonoscopies will enable CoCaP to refine its screening algorithm and to quantify program effectiveness.
This paper describes the efforts of an HMO to improve its delivery of occupational health services. Customer needs identification, occupational health structure, data systems, case management, clinical guidelines, and quality management are outlined. Our experience suggests that high-quality occupational health services can be integrated into managed care systems thereby offering cost-effective care to large numbers of workers. Comparing 1991 to 1995, physician authorization of total disability days was reduced 17.9% per disability case (p < .0001). Based on July 1994 to June 1995 Oregon State Accident Insurance Fund (SAIF Corporation) data, HMO average total claim cost was $916/claim representing respectively, a 21% and a 20% reduced cost compared to two PPO model programs (MCO 00 and MCO 01). Patient satisfaction data indicated that 90% of patients were satisfied or very satisfied with the physician they saw. The savings appear to be due to cost-effective treatment and rapid return to work.
This paper describes the development and successful implementation of an evidence-based clinical practice guideline dealing with uncomplicated urinary tract infection in adult women (acute dysuria guideline). This guideline was based on an evaluation and synthesis of the medical literature using the best available evidence. Following guideline implementation, clinical practice changes recommended by the guideline were observed, including a significant decrease in laboratory testing and clinic visits for acute dysuria. Successful implementation of this guideline is attributed to the use of an explicit, evidence-based guideline development process, a combination of implementation strategies including decision support for providers, and a change in the roles of registered nurses.
