Biomedical subjects

S J Rolnick

Publications and source records attributed to S J Rolnick.

At least 19 recordsLinked to original sources

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↗

PubMed2001

Conducting randomized, controlled trials. Experience with the dysfunctional uterine bleeding intervention trial.

OBJECTIVE: To conduct a randomized, controlled trial (RCT) to examine issues associated with therapeutic alternatives to standard hysterectomy for women with dysfunctional uterine bleeding. STUDY DESIGN: Participants were to be randomly assigned to one of three treatment groups: hysterectomy, endometrial ablation and medical management. Recruitment was targeted at 375 women. RESULTS: Despite multiple recruitment strategies, recruitment was weak, with only five women enrolled after six months. Providers and women screened for eligibility often expressed discomfort with randomization. The protocol was amended to an elective treatment cohort design with a randomization component. Recruitment improved, with 37 women enrolled after four months. CONCLUSION: The success of RCTs may be affected by multiple factors. Acceptance of the protocol by patients and providers is essential. The RCT may present providers with a conflict between the goals of research and of providing optimal individualized care. Thus, RCTs may not always be appropriate for studies designed to examine best treatments in clinical practice, and nonrandomized designs may provide appropriate alternatives in some cases.

Clinical Protocols↗

PubMed2000

Lessons from experienced guideline implementers: attend to many factors and use multiple strategies.

BACKGROUND: Studies of clinical guideline implementation have focused almost entirely on changing individual clinician behavior with single intervention strategies and without much attention to the situational context. The goal of this project was to learn from clinic leaders, seasoned in the guideline implementation process, what contextual variables they viewed as important and whether implementation success could be expected if only a single implementation strategy was used. METHODS: In 1998, 12 people with extensive experience in leading clinical guideline implementation were identified who were thought to have particularly keen insight into the process. They were interviewed to generate variables they considered important, as well as strategies they considered effective when used appropriately. A modified nominal group/Delphi process was then used for rating these variables and strategies, and the reactions of international experts were obtained to add perspective to this information. RESULTS: Eighty-seven variables and 25 strategies were identified, clustering in 6 categories (ranked in order of importance by the panel): organizational capabilities for change, infrastructure for implementation, implementation strategies, medical group characteristics, guideline characteristics, and external environment. All six categories were considered to be important, key, or essential by the experienced implementers, although variables within a medical group that directly affect its ability to undertake planned change were rated as much more important than either guideline characteristics or the external environment. DISCUSSION: Although the opinions of those experienced in the process of guideline implementation are primarily of value for generating hypotheses, panel members believe that implementation efforts focusing on the individual physician with a single strategy are unlikely to be successful. Rather, implementation efforts must use multiple strategies that take account of multiple characteristics of the guideline, practice organization, and external environment.

Delphi Technique↗

PubMed2000

The implementation of clinical guidelines in a managed care setting: implications for children with special health care needs.

OVERVIEW: The project tracked the development and implementation of a pediatric asthma guideline to determine its usefulness as a quality assurance mechanism for children with special health care needs. METHODS: Interviews were conducted with clinic staff to gather descriptive information about guideline implementation at owned clinics within a large HMO. RESULTS: Providers developed multiple implementation strategies emphasizing patient/family education. Service coordination within the health plan was well established, while coordination of services beyond the health plan was less clearly related to guideline implementation. CONCLUSION: Guideline implementation appeared to be a highly variable process. Clinical guidelines alone may not be sufficient tools of quality assurance for children with chronic or complex conditions.

Adolescent↗

PubMed2000

A successful collaboration between a private nonprofit health plan and a state health department.

This article describes the experience of a private, nonprofit health plan in establishing a collaborative relationship with a state health department. Through a federal grant project, efforts toward assuring quality care for children with special health care needs in managed care settings provided unique opportunities to form partnerships between multiple health plans, community groups, and other stakeholders. Collaborative activities included (1) formation of a pediatric asthma task force and a performance measurement and quality assurance committee; (2) planning and execution of a statewide conference; (3) development of a teaching manual for incorporating asthma education into elementary classroom curricula; and (4) publication of a parent resource manual for health plan members. Key ingredients and influencing factors for successful public-private partnerships are discussed.

Aged↗

PubMed2000

Impact of birthweight on healthcare charges within a managed care organization.

OBJECTIVE: To determine the rate of low-birthweight (LBW) births and the association of LBW with utilization and healthcare charges in a managed care organization. DESIGN: Observational study of computerized and medical record data. PATIENTS AND METHODS: We assessed the rate of LBW (weight < 2500 g) for singleton infants born during 1993 and 1995 at 2 hospitals (1993, N = 3212; 1995, N = 3073). For a subset of infants born during 1995 (n = 1273), we examined differences in utilization and medical charges, by birthweight category (moderately LBW [MLBW; 1500 to 2499 g] vs normal birthweight [NBW]), at 1 year postdischarge. RESULTS: In both 1993 and 1995, 3% of singleton infants were LBW infants, and 2% to 3% were macrosomic (> or = 4500 g). Complete data for analyses of utilization and healthcare charges were available on 1273 infants who were enrolled for the entire postdischarge year. The use of outpatient, emergency department (ED), and subspecialty care by MLBW infants and by NBW infants was similar. However, MLBW was associated with an increased rate of rehospitalization during the first year of birth (P < .01). MLBW infants' medical care charges were 46% higher than those of NBW infants (P = .0125). CONCLUSIONS: MLBW infants and NBW infants had similar outpatient and ED service use during the first year after hospital discharge. Excess charges incurred by MLBW infants were primarily due to higher rates of rehospitalization. Of the 38 admissions, 21 were related to infection or fear of infection, and 4 were due to congenital malformations.

Adolescent↗

PubMed1999

A comparison of costs of universal versus targeted lead screening for young children.

The purposes of this study were to compare universal blood lead screening for young children versus targeting by a risk assessment questionnaire and to examine the cost implications of each approach. Costs reflect the total number of blood tests required and cost of specimen collection, handling, and testing per elevated case. The setting included the metropolitan areas of Minneapolis and St. Paul, Minnesota. Children (N=9603) from 17 community organizations had blood tests. In addition, each child's parent or guardian completed a questionnaire assessing potential risk for lead poisoning. Four different screening approaches are presented. Each screening approach is presented with associated costs of overall screening and cost per child identified at blood levels of >/=10 microg/dl (N=1140) and >/=15 microg/dl (N=317). Based on the screening strategy selected and an estimate of $17 per blood test, total screening costs ranged from $91,596 to $165,945. The cost per child identified with elevated lead levels ranged from $361 to $523 at >/=15 and $105 to $146 at >/=10. Nine to 13% of children would not have been detected by policies other than universal screening. A geographically based approach was able to detect 90% of children with elevated blood levels at two-thirds the cost of universal screening. Blood tests would be taken for all children living within city limits. Those residing elsewhere would be tested only if answers to questionnaire items pertaining to age of housing, prior history of lead poisoning, or eating paint chips indicated risk. The new CDC guidelines suggest that screening be based on an assessment of housing, population demographics, and community risk and resources. This paper presents such an assessment.

Child↗

PubMed1999

Impact of a new cervical pap smear screening guideline on member perceptions and comfort levels.

BACKGROUND: An evaluation was conducted to assess patient perceptions and comfort levels with a new triennial Pap smear screening guideline. METHODS: A random sample of women ages 20-69 (N = 673) was selected among members of three provider groups within a large health maintenance organization and mailed a survey. Questions pertained to Pap smear history and perceptions of the new guideline. RESULTS: The overall response rate was 63%. Over one-half of respondents had no recollection of being informed about the change in recommendation. Fourteen percent of subjects responded positively to the change, 16% were neutral, 20% were skeptical, and 50% made negative comments. Women significantly more likely to be negative or skeptical about the new guide line were those who reported more frequent prior Pap smears (P < 0.0001), those reporting a history of abnormal Pap smear (P < 0.01), and more educated women (P < 0.05). No statistical differences were found for those reporting a recent abnormal result, or based on provider group, age, or recollection of being informed. CONCLUSIONS: Regardless of patient knowledge and intellectual understanding of screening intervals, this new guideline raises patient concern about preventive care. More must be done to educate women regarding the change in recommended screening frequency and the reasons for it.

Adult↗

PubMed1999

The role of depression in the association between self-rated physical health and clinically defined illness.

We enrolled 543 elderly participants of a managed care organization in a cross-sectional study to test whether the association between self-rated physical health and clinically defined illness differs for persons who are not depressed compared with persons with minor or serious depression. Depression was measured with the Diagnostic Interview Schedule (DIS). Clinically defined illness was measured with the Chronic Disease Score (CDS), a pharmacy-based measure. Additional variables included age, sex, and self-reported pain and physical function. Self-rated physical health was associated with both minor and serious depression, independent of clinically defined illness; minor depression was no longer significant when self-reported pain and physical function were added to the model. A significant negative correlation between self-rated physical health and clinically defined illness was observed for minor and no depression, but no correlation was seen for serious depression. These results confirm the association between depression and self-rated physical health and emphasize that, for persons with serious depression, self-rated health provides a less accurate picture of clinically defined illness at both ends of the spectrum. Also, a diagnosis of minor depression should not forestall investigation of inconsistencies between patient report and clinical evidence.

Aged↗

PubMed1999

Provider attitudes and self-reported behaviors related to hormone replacement therapy.

OBJECTIVE: The purpose of this study was to survey providers within a large health maintenance organization regarding their attitudes and practice patterns related to counseling women about hormone replacement therapy (HRT). DESIGN: A total of 260 providers from gynecology (n = 81), family practice (n = 96), and internal medicine (n = 83) from owned and contracted clinics were surveyed. Each was asked about prescribing philosophies, behaviors, and barriers to providing counseling regarding HRT. RESULTS: Respondents reported HRT's greatest benefit to be in the prevention of osteoporosis (99%) and cardiovascular conditions (96%). Gynecologists were more likely to report the benefits of HRT for Alzheimer's than were clinicians in internal medicine or family practice (p < 0.05), and women providers were more likely than men to report this (p < 0.01). There was no statistical difference based on years in practice. Providers did not vary significantly by specialty or sex in their concerns of risk for breast cancer of endometrial cancer. However, those in family practice and internal medicine were significantly more likely to report concern about thromboembolism (p < 0.01). Only 42% of physicians claimed to initiate discussion with their patients more than 75% of the time. The two factors most often mentioned as barriers to counseling were time and lack of adequate knowledge. CONCLUSIONS: Providers want to be an integral part of their patient's education regarding HRT; however, time constrains and a need for adequate information make this difficult. Now health systems must examine models of education for both providers and patients to ensure that women have access to current information with which to make informed decisions.

Aged↗

PubMed1999

Interventions to implement a clinic-based smoking cessation guideline within a staff model HMO.

Smoking cessation guideline development has become widespread, outpacing guideline implementation efforts. To address this problem, HealthPartners undertook a randomized trial of strategies to enhance compliance of a smoking cessation guideline. The intervention aimed at clinic leadership resulted in significantly more compliance, as measured by physicians coding "tobacco use" on a billing form. The intervention aimed at all clinic physicians had no significant effect. The study suggests that smoking cessation guideline efforts should focus on clinic leadership and system changes rather than on all staff physicians.

Follow-Up Studies↗

PubMed1999

Exemplary programs on midlife women's health issues in managed care settings.

OBJECTIVE: To identify exemplary programs on midlife women's health issues that have been developed and implemented in managed care settings. METHODS: Members of The American Association of Health Plans (AAHP) were invited by mail to submit information on their exemplary programs on midlife women's health issues. AAHP and HealthPartners Research Foundation established 12 criteria by which to evaluate the programs submitted. Following telephone interviews with representatives of eligible programs, they were asked to complete an extensive survey about their successful practices. The Women's Health Task Force of AAHP then reviewed and evaluated every program submission and selected 4 model programs on midlife issues for women. RESULTS: The 4 model programs included the use of health assessment questionnaires to assist providers in identifying risk areas and patients' needs for information; group educational sessions focusing on midlife issues related to lifestyle and hormone replacement therapy; a module-based curriculum syllabus; and an osteoporosis disease management program. All groups utilize multidisciplinary teams to develop and promote educational programs. CONCLUSIONS: As study findings add to our knowledge of menopause treatment approaches and as new information and products become available, some managed care plans are using innovative channels of communication to keep women informed.

Female↗

PubMed1998

Management of shoulder impingement syndrome and rotator cuff tears.

Rotator cuff impingement syndrome and associated rotator cuff tears are commonly encountered shoulder problems. Symptoms include pain, weakness and loss of motion. Causes of impingement include acromioclavicular joint arthritis, calcified coracoacromial ligament, structural abnormalities of the acromion and weakness of the rotator cuff muscles. Conservative treatment (rest, ice packs, nonsteroidal anti-inflammatory drugs and physical therapy) is usually sufficient. Some patients benefit from steroid injection, and a few require surgery.

Diagnosis, Differential↗

PubMed1998

Early- and late-stage breast cancer in a managed care setting in relation to mammography screening.

A case-control study was conducted to ascertain occurrence of advanced- and early-stage breast cancer, use of mammography, and the relationship between the two. All women with stage III/IV breast cancer (N = 46) were matched to two controls (stage 0/I and stage II) by year of diagnosis and age. Matched-pair analyses assessed antecedent use of screening mammography. Results indicated that advanced-stage patients were significantly less likely than their stage 0/I counterparts to have had antecedent screening within 13 months of diagnosis [chi2: 5.78; OR: 6.0; p < 0.05]. Cases compared with stage II controls did not differ statistically. Efforts should focus on increasing mammography in currently targeted age groups. Considerations might be toward extending regular screening for women 40 to 49 and over 75.

Adult↗

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.

Aged↗

PubMed1998

Implementation of an active management of labor guideline in a managed care setting.

This article reports on a study assessing the impact of a clinical guideline for the active management of labor. Modest changes were noted in the process of care with minimal impact on outcomes. Results might have been enhanced if more systems had been in place and if provider training had involved more comprehensive discussion and feedback on each of the components.

Adult↗

PubMed1997

Assessing the impact of clinical guidelines: research lessons learned.

Clinical guidelines are proliferating. Here, a theoretical and practical perspective is presented on how to evaluate the effectiveness of guidelines and lessons learned from impact studies conducted. A nosology of guidelines is presented, along with the rationale for evaluating key dimensions, including degree of implementation, impact on process, outcomes, and cost of care, as well as provider and patient satisfaction. Key methodologic problems in evaluation and some possible ways to address them are addressed. Rapid and practical evaluation of clinical guidelines is a critical step that can both confirm their usefulness and direct their revision and improvement.

Acute Disease↗

PubMed1997

Effects of brain injury on college academic performance.

Brain injury, a leading cause of mortality, morbidity and disability in the United States, has serious consequences and substantial costs. Although previous studies have assessed a variety of outcomes subsequent to brain injury, documentation of performance prior to brain injury using a case-control approach has not been included; preinjury performance differences may confound the estimate of the effects of brain injury on performance. The primary objective of this study was to compare academic performance before and after brain injury in a population of university undergraduate students to determine the extent to which the academic career of the brain-injured person was altered from what would have been expected in the absence of such an injury. Cases included all undergraduate students in a major university, between the ages of 17 and 27, who incurred a brain injury requiring hospitalization between 1980 and 1984 (n = 99). Two comparison groups were used to determine whether changes in academic performance were specifically related to brain injuries or injuries in general: (1) injured controls, i.e. 121 students between the ages of 17 and 27 years, hospitalized for injuries other than to the central nervous system, and (2) uninjured academic controls, i.e. 198 students with out injuries requiring hospitalization during the study period, matched 2:1 to the brain-injured students by age, gender, and completed course credits categorized as < 90, > or = 90. Although there were no differences when the total groups, including both males and females, were compared, there was a significant pre- to postinjury decrease in the grade point average for female cases when compared to their uninjured academic controls (p < 0.02). This difference was related to the effects of brain injury, and not to the effects of injury in general. No such difference was observed for the males. There were also no differences when the total groups, including males and females, were compared relevant to return to school. However, a significantly higher proportion of the female cases, compared with their uninjured academic controls, did not return to school after their injury; similar findings were identified for the injured controls as well. Thus, these differences were not specific to brain injury but rather to injury in general. In spite of this observation, the difference between female cases who returned and those who did not return was associated with neurological deficits, especially upper left limb motor deficits, as the time of hospital discharge. The findings from this effort are suggestive of gender differences in the consequences of brain injury and serve as a basis for further studies to evaluate the magnitude of this problem.

Adolescent↗