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Biomedical subjects

L R Fischer

Publications and source records attributed to L R Fischer.

At least 19 recordsLinked to original sources
PubMed2001

The failure of a controlled trial to improve depression care: a qualitative study.

BACKGROUND: The DIAMOND Project (Depression Is A MANageable Disorder), a nonrandomized controlled effectiveness trial, was intended to improve the long-term management of depression in primary care medical clinics. The project tested whether a quality improvement (QI) intervention could implement a systems approach-so that there would be more reliable and effective monitoring of patients with depression, leading to better outcomes. THE QUALITATIVE STUDY: A study was conducted in 1998-2000 to determine why a quality improvement intervention to improve depression care did not have a significant impact. Data consisted of detailed notes from observations of 12 project-related events (for example, team meetings and presentations) and open-ended interviews with a purposive sampling of 17 key informants. Thematic analytic methods were used to identify themes in the contextual data. PRINCIPAL FINDINGS: Overall, the project implementation was very limited. Five themes emerged: (1) The project received only lukewarm support from clinic and medical group leadership. (2) Clinicians did not perceive an urgent need for the new care system, and therefore there was a lack of impetus to change. (3) The improvement initiative was perceived as too complex by the physicians. (4) There was an inherent disconnect between the commitment of the improvement team and the unresponsiveness of most other clinic staff. (5) The doctor focus in clinic culture created a catch-22 dilemma-the involvement and noninvolvement of physicians were both problematic. CONCLUSION: Problems in both predisposing and enabling factors accounted for the ultimate failure of the DIAMOND quality improvement effort.

Case Management↗
PubMed2001

What is the impact of osteoporosis education and bone mineral density testing for postmenopausal women in a managed care setting?

OBJECTIVE: To assess whether osteoporosis education, with and without bone mineral density (BMD) testing, increases the initiation of lifestyle changes and pharmaceutical treatment to prevent osteoporosis. DESIGN: A total of 508 women, aged 54-65, from a large managed care organization who were not on osteoporosis prevention therapy participated in an intervention study. Participants were randomly assigned to either an education class on osteoporosis (n = 301) or education plus BMD (n = 207). A control group of 187 women receiving no intervention were also surveyed to serve as comparison. Group differences and differences based on BMD test result were compared 6 months after education regarding self-reported changes in health behaviors using chi2 tests and logistic regression analyses. RESULTS: Of the 508 intervention participants, 455 (90%) responded to the follow-up survey. Initiation of hormone replacement therapy was reported by 9%, with 5% reporting starting alendronate. More than half reported changes in diet, exercise, or calcium intake. Forty-three percent increased their vitamin D intake. There were no significant group differences in behavior except with regard to pharmaceutical therapy; subjects with education plus BMD were three times more likely than those receiving education only to report starting hormone replacement therapy (p = 0.004). Low BMD scores were associated with increasing vitamin D intake (p = 0.03) and starting medication (p = 0.001). Women in the intervention groups were significantly more likely to report modifying their diet (p < 0.001), calcium (p < 0.01), and vitamin D intake (p < 0.0001) than women in the control group, not exposed to education. CONCLUSION: Education regarding osteoporosis prevention seems to encourage women to make lifestyle changes. The inclusion of BMD testing enhances the likelihood that women will consider pharmaceutical therapy.

Aged↗
PubMed2000

Screening for hepatitis C virus in a health maintenance organization.

BACKGROUND: Chronic infection with hepatitis C virus (HCV) is a major public health problem and is associated with over 10,000 deaths a year in the United States. In its early stages, HCV tends to be asymptomatic and can be detected only through screening. OBJECTIVES: To develop and validate a database risk algorithm for HCV infection using electronic data at HealthPartners, a health maintenance organization (HMO) in Minnesota. A secondary objective was to evaluate the benefit of screening health care workers for HCV. METHODS: A database risk algorithm was developed using diagnostic and procedure codes in the administrative database to identify at-risk enrollees. One thousand three hundred eighty enrollees (an at-risk sample and a control sample) and 502 health care workers participated in anonymous screening. Both descriptive statistics and logistic regression were used to examine the frequency of HCV infection, associations with risk factors, self-selection factors in participation, and concordance between the database risk algorithm and the risk profile questionnaire. RESULTS: Eleven enrollees tested positive for HCV, 9 from the at-risk sample and 2 from the control sample. All health care workers tested negative for HCV. Both lifestyle and medical risk factors were associated with positive test results for HCV. Enrollees with alcohol-drug diagnoses were less likely to participate in screening. A substantial proportion of enrollees with risk factors was identified either by the database risk algorithm or the risk profile questionnaire, but not by both. CONCLUSION: While the frequency of HCV infection was lower than previous estimates for the US population, the strong correlation with risk factors suggests that using the database risk algorithm for screening is a useful approach. Managed care plans with suitable data on their enrollee populations are in a key position to serve an important public health role in detecting asymptomatic patients who are infected with HCV.

Algorithms↗
PubMed2000

Educating health professionals: a hepatitis C educational program in a health maintenance organization.

OBJECTIVE: To describe the components of and staff reaction to an educational outreach program about hepatitis C (HCV) at a managed care organization in Minnesota. PROJECT PROTOCOL: Educational programs for primary care clinicians consisted of lunch-and-learn sessions conducted in 2 phases. In phase 1 (1997-1998), educational programs were offered in 4 clinics; in phase 2 (1999), these programs were offered to a larger number of clinics. There was a structured, 2-stage recruitment process, and the protocol included multiple contacts that involved sending educational materials to participants several weeks before the program. A development team, comprised of key health maintenance organization (HMO) stakeholders, provided consultation. EVALUATION: The initiative reached more than 1000 healthcare professionals, including 150 physicians. The educational programs received very high ratings, and pre- and posttests documented significant improvement in knowledge about HCV. CONCLUSIONS: This successful educational initiative had 5 key elements: (1) value to healthcare staff (i.e., importance of the topic and quality of the programs); (2) incentives (i.e., convenience, free lunch, and continuing medical education/continuing education unit credits); (3) repeated exposures (i.e., multiple opportunities for learning, both oral and written); (4) commitment by key stakeholders at the HMO and the clinics; and (5) an exceptionally well-organized implementation plan.

Attitude of Health Personnel↗
PubMed1999

The need for a system in the care of depression.

BACKGROUND: Many problems have been identified in the usual care of patients with depression, including lack of identification, overreliance on medications, and inadequate treatment and follow-up. Most of these problems can be attributed to an absence of depression care systems in primary care practice. We collected information from a group of practices to assess the need for and acceptability of such systems. METHODS: We conducted 4 focus groups with primary care physicians and their staffs to identify attitudes and perceived behaviors for depression problems and to determine the participants' level of acceptance of alternative systematic approaches. We also surveyed clinicians and a sample of patients who recently visited their practices. RESULTS: Systematic screening was viewed unfavorably, and many barriers were identified with collaborative care with mental health clinicians. Participants did support involvement of other office staff and more systematic follow-up for patients with depression. The patient survey suggested that some patients with depressive symptoms were unrecognized and undertreated, but the key finding was considerable variation in care among practices. CONCLUSIONS: These findings suggest that a more systematic approach could improve the problems associated with treatment of patients with depression in primary care and would be acceptable to physicians if introduced appropriately. There are at least 2 promising approaches to introducing such changes. One involves external feedback of data about their care to the practices, followed by offering a variety of systems concepts and tools. The other involves an internal change process in which a multiclinic improvement team collects its own data and develops its own systematic solutions using rapid-cycle testing.

Attitude of Health Personnel↗
PubMed1999

S/HMO versus TEFRA HMO enrollees: analysis of expenditures.

This study compares expenditures on health care services for enrollees in a social health maintenance organization (S/HMO) and a Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)-risk Medicare health maintenance organization (HMO). In addition to the traditional Medicare services covered by the TEFRA HMO, the S/HMO provided a long-term care (LTC) benefit and case management services for chronic illness. There do not appear to be any overall savings associated with S/HMO membership, including any savings from substitution of S/HMO-specific services for other, traditional services covered by both the S/HMO and the TEFRA HMO.

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PubMed1998

Quality improvement in primary care clinics.

BACKGROUND: Case studies from Project IMPROVE, the first randomized controlled trial to evaluate the effectiveness of continuous quality improvement (CQI) in primary care, were subjected to a qualitative analysis. Three questions were addressed: How does change in the health care environment affect a quality improvement (QI) process? How does clinic organization influence a QI process? and What is the impact of a QI process on clinic organization? METHOD: Case studies were conducted in 6 clinics that had been randomly selected from the 22 clinics participating in the IMPROVE intervention. The case study data consisted of observations of CQI team meetings, open-ended interviews with 30 informants (team members plus others in the clinics), interviews with IMPROVE consultants, and documentation from the project. The data were analyzed to identify themes and generate concepts, assess and compare the informants' experiences, and develop a conceptual framework stimulated by research and theory literature. RESULTS: Change and uncertainty in the health care environment both complicated the QI process and motivated participation in improvement. The smaller clinics appeared to have more difficulty with the QI process because of limited resources and lack of compatibility between the QI approach and their clinic organization. Project IMPROVE had two qualitative effects on clinics: increased awareness of preventive services and application of the CQI method to other problems and issues. CONCLUSION: QI initiatives can help clinics adapt to a changing health care environment and create functioning teams or groups that can address a variety of organization problems and tasks. The process should be flexible to accommodate varying organization structures and cultures.

Ambulatory Care Facilities↗
PubMed1998

Clinical detection of depression among community-based elderly people with self-reported symptoms of depression.

BACKGROUND: Depression is under-diagnosed and under-treated in the primary care sector. The purpose of this study was to determine the association between self-reported indications of depression by community-dwelling elderly enrollees in a managed care organization and clinical detection of depression by primary care clinicians. METHODS: This was a 2-year cohort study of elderly people (n = 3410) who responded to the Geriatric Depression Scale (GDS) at the midpoint of the study period. A broad measure of clinical detection was used consisting of one or more of three indicators: diagnosis of depression, visit to a mental health specialist, or antidepressant medication treatment. RESULTS: Approximately half of the community-based elderly people with self-reported indications of depression (GDS > or = 11) did not have documentation of clinical detection of depression by health providers. Physician recognition of depression tended to increase with the severity of enrollees' self-reported feelings of depression. Men 65-74 years old and those > or = 85 years old were at highest risk for under-detection of depression by primary care providers. CONCLUSIONS: Clinical detection of depression of elderly people living in the community continues to be a problem. The implications of failure to recognize the possibility of depression among elderly White men suggest a serious public health problem.

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PubMed1998

The closing of a social HMO: a case study.

A social health maintenance organization (SHMO) integrates acute and long-term care and provides an extended-care benefit for elderly who are at risk of institutionalization. This article reports findings from a case study of the termination of the Group Health SHMO in Minnesota. Interviews were conducted with social workers and at-risk elderly who had been receiving long-term care through the SHMO. The case study examines the post-SHMO transition and the process of replacing SHMO care coordination and longterm care services. Most of the elderly and their caregivers indicated they were "losing ground"--that is, they were paying more or getting less care. Some were paying more for less care. Because they tended to switch to private-pay arrangements and to rely more on informal care, it appears that their care system became much less stable after the closing of the SHMO.

Aged↗
PubMed1997

A process IMPROVEment approach to preventive services: case studies of CQI demonstration projects in two primary care clinics.

The IMPROVE Project is a 4-year randomized controlled trial to test the hypothesis that HMOs can improve preventive services in their contracted primary clinics by assisting clinics to implement continuous quality improvement (CQI) and an organized system for preventive services. This paper describes findings from case studies of CQI teams in two demonstration sites where the CQI approach was tested. The case study analysis is based on interviews and observations conducted about 10 to 12 months after the CQI teams began. Initial responses of clinic staff to the IMPROVE Project included a mixture of interest in CQI, enthusiasm for prevention-oriented care, concern about the burden the project might impose, and skepticism. There were two formidable barriers to change: time and inertia. Environmental changes in the parent organizations also complicated and impeded the CQI process within the clinics. The thematic analysis identified four factors that appear to be important in implementing a CQI process in a clinic setting: awareness, momentum, ownership, and communication.

Awareness↗
PubMed1994

What is an emergency? The judgments of two physicians.

How an "emergency" is defined by an internist and an emergency physician is the focus of this paper, which originated in a study of nonemergency use of two urban hospital emergency departments by Medicaid, uninsured, and commercially insured patients. Retrospective medical record reviews of 219 patients conducted independently by these two physicians revealed agreement on clinical impressions but dramatic divergence regarding the designation of visits as "emergencies" and the appropriate treatment location. Subsequent interviews with each physician suggested that the divergence of opinion regarding the definition of a true emergency is ideologically motivated and specialty related. Considered in the context of ED studies, which show enormous variations in the percentage of cases judged to be "emergencies," defining an "emergency" may be more a matter of physician training, specialty, and beliefs than of science. Further analysis revealed no correlation between patients' perceptions and either physician's judgments concerning what constitutes an "emergency," suggesting that neither specialty's assumptions are sensitive to patients' experience of the physical pain and anxiety that frequently lead them to present to the ED.

Adult↗
PubMed1993

Home care quality and the home care worker: beyond quality assurance as usual.

Using data from diverse sources, we conclude that the jobs of paraprofessional home care workers who provide ongoing care for older clients would be more intrinsically rewarding and offer better conditions for high-quality care if workers had more contact with supervisors and peers, more information about clients and care plans, clearer accountability, and more authority. The home care worker's relationship with clients, which also affects quality of care, can be improved by addressing such issues as adequate compatibility, communication, boundary maintenance, balance of power, commitment, and flexibility.

Caregivers↗
PubMed1991

Older volunteers: a discussion of the Minnesota Senior Study.

We used findings from the Minnesota Senior Study to examine the theoretical and methodological difficulties of defining, coding, and analyzing data on older volunteers. This study, the first statewide survey of the needs and resources of the elderly in Minnesota in almost 20 years, found that over half (52%) of older Minnesotans do volunteer work for organizations--considerably higher than has been found in national surveys. Problems in definition and methodology, however, have confounded analyses. This paper proposes a new conceptual model for classifying volunteer roles, based on three dimensions: whether the voluntary service is "formal" or "informal"; whether the activity entails a regular or an occasional time commitment; and the nature of the service activity (person-to-community, person-to-object, or person-to-person).

Aged↗
PubMed1991

Relationships between home care clients and their workers: implications for quality of care.

In-depth interviews were conducted with 54 home care clients and their home health aides and personal care attendants. The interview data reveal that home care relationships tend to be both formal and informal, in that job responsibilities tend to be diffusely defined and home care workers often become involved in the "backstage" world of their clients. The study also suggests, however, that personal bonds may be problematic for both workers and clients. For workers there is the risk of exploitation; for clients, there is the potential for loss of control over their own care. The quality of relationships also affects quality of care.

Adult↗
PubMed1990

The provision of home health services through health maintenance organizations: the role of the physician.

The authors report the results of a comprehensive national study of the provision of home health care (HHC) through health maintenance organizations (HMOs), funded by a 1987 grant from the National Center for Health Services Research. The initial study included a literature review, interviews of 125 HHC providers and researchers, case studies of 6 HMOs, and a survey of 103 HMOs with Medicare contracts (as of March 1988). Upon discovery of controversy over the role of the HMO physician, the authors conducted an additional substudy of 30 primary care physicians. The article focuses on findings concerning the HMO physician in HHC and the implications for physicians generally, in light of what the larger study and additional data (January 1989-January 1990) show about HMO development and home health care.

Attitude of Health Personnel↗
PubMed1989

The provision of home health care services through health maintenance organizations.

The vast majority of the HMOs responding to the survey in this study use home health care as a substitute for acute inpatient hospitalization, contract out for services with community-based home health agencies, reimburse on a discounted fee-for-service basis, and use prior authorization and concurrent review as the primary methods to control the use of home health care. These findings suggest that HMO home health care services mirror the inadequacies of Medicare home health care in that they are acute care-focused and not intended to fill the supportive and maintenance care needs of the chronically ill elderly. HMOs, however, are typically more flexible in their service provision than is Medicare. Need for home health care is determined primarily on prospective, case-by-case evaluations of cost effectiveness, not on retrospective determinations based on strict, and sometimes arbitrary, guidelines and limitations. This, however, does raise some important issues for access and quality and for the relationship between HMOs and home health agencies. Is cost containment the only legitimate reason for providing home health care? Should home health care be used solely as a substitute for acute inpatient hospitalization? Where does the locus of authority lie for deciding coverage of home health care services? This study uncovered several issues related to the provision of home health care in HMOs that created conflict and uncertainty for all parties. These issues included: conflicting roles for HMOs, whether to provide services internally or externally, contracting between HMOs and home health agencies, the locus of authority for utilization review, the role of physicians, quality assurance, and perceived problems with the Health Care Financing Administration. HMOs are often perceived as failing to do an adequate job of providing home health care services because of the difficulty in satisfying conflicting considerations in three key areas: whether home health care should be focused on cost containment or meeting unmet needs, whether home health care should be focused on acute or long term care, and the unrealistic expectations patients and providers have of HMOs. HMOs primarily provide home health care in an effort to contain costs, particularly by using home health care to substitute for inpatient hospitalization. While HMO representatives acknowledge the importance of home health care in improving the patient's and family's quality of life by providing supportive or chronic maintenance care, the use of home health care for this purpose is generally not allowed by HMOs.(ABSTRACT TRUNCATED AT 400 WORDS)

Acute Disease↗