Healthy Outcomes

1995

Reducing Risks
Partners for Better Health
Detecting Breast Cancer Early
Who Should Be Vaccinated Against Chicken Pox?
Whooping Cough
Helping Children with Chronic Illness

Women's Health
How Many Women Have a Pap Smear?

Better Health Services
CHESS: Using Computers for Better Health Care
Improving Obstetric Care

Health Care for Seniors
Frail Elderly and the Loss of the Social HMO

Diabetes Care
Project IDEAL
Improving Care for Patients with Diabetes

Prevention
Using CQI to Improve Prevention-Oriented Care: A Progress Report

Programs for Smokers
Helping Smokers Quit
Who Smokes After a Heart Attack?

1994 / 1995 / 1996 / 1998 / 1999 / 2000 / 2001 / 2002 / 2003 / 2004

REDUCING RISKS
Partners for Better Health

Group Health Foundation has begun an evaluation of the Partners for Better Health initiative at HealthPartners. This initiative is intended to change the focus of health care -- from cure to prevention. The program is designed to improve health and reduce chronic disease by encouraging more healthy life styles. An important part of the Partners for Better Health vision is to create a partnership among health care providers, employer groups, policy makers, and consumers.

Long-range goals include reducing heart disease, increasing rates of immunization against childhood diseases, improving the early detection of breast cancer, increasing the early detection of adult onset diabetes and reducing complications from diabetes, reducing infant and maternal complications, reducing new dental caries, and reducing injuries from domestic violence.

As part of the evaluation, Group Health Foundation is conducting a baseline survey of 8,000 HealthPartners members, age 40+. The sample is composed of five groups: patients diagnosed with one of four chronic conditions -- hypertension, diabetes, heart disease, or dyslipidemia -- and "healthy" persons who do not have a diagnosis for one of these conditions. Individuals responding to the survey will be followed for the next three years to measure progress toward meeting the Partners for Better Health goals.

Research Team
Patrick O'Connor, MD, MPH; Nico Pronk, PhD; Raymond Boyle, PhD; Cheri Rolnick, PhD, MPH; Andy Nelson, MPH; Cathy Wisner, PhD; Bill Rush, PhD; Linda Cherney, MPH; Carol Westrum, MA; Jody Jackson; Jon Burns; Shelly Annette

Funding
Center for Health Promotion, HealthPartners

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Are women who are screened routinely for breast cancer more likely to have their cancer detected early? Part of the Partners for Better Health evaluation will be to determine if there are differences in screening histories between women with early stage and late stage breast cancer. This assessment will be based on a review of medical charts for all women ages 50-74 diagnosed with breast cancer between 1990 and 1994. Each review will assess the stage at diagnosis and the history of mammography screening. In addition, women who have never, or only rarely had a mammogram will be interviewed in order to better understand the reasons some women do not have routine screening.

Research Team
Sharon Rolnick PhD, MPH, Linda Loes, MD; Shirlee Sherkow; Bill Rush, PhD; Diane Werhle; Jody Jackson: Coordinator.

Funding
Center for Health Promotion, HealthPartners

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The chickenpox vaccine was licensed in March of 1995. With licensure, the true population rate of immunity to chickenpox (varicella zoster virus) became an important issue. Until then, it was of interest primarily for hospital work staff.

Who should be vaccinated? Are older or younger people more likely to be immune to chickenpox? What is the most cost-effective approach to assure population immunity to varicella?

Two groups participated in the study: 599 subjects came to Group Health clinics for immunization and had no history of previous varicella infection. An additional 403 subjects were pregnant and either thought they had not had varicella or did not know. As a part of routine care, a blood sample was taken from each of the participants and tested for the presence of antibodies to varicella.

The study found that older people (over age 50) are almost always immune. Conversely, adolescents and younger adults are often not immune.

Therefore, the most cost effective strategy is as follows: Immunize all children less than age 13. Test all 13 to 50 year-olds and immunize those who need it. Assume that all patients over 50 years of age are immune.

Research Team
James Nordin, MD, MPH, Leslie Baken, MD, Richard Carlson, MS, John Hering, MD.

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The Centers for Disease Control and Prevention has funded a two-year study at HealthPartners to investigate the incidence of pertussis (whooping cough) infection in adolescents and adults, 10 to 49. It is believed that people in this age group may be transmitting pertussis to infants and young children. Because children are not fully immunized against pertussis, they are at risk of getting severe pertussis and its complications.

Few studies have been done to document the role of Bordetella pertussis as a cause of cough illness in adolescents and adults. HealthPartners study participants are being tested for pertussis using several testing methods. Improved knowledge about the incidence or prevalence of pertussis in adults will be important in determining future vaccination policy.

Research Team
James Nordin, MD, MPH; Sharon Rolnick, PhD, MPH; Sheila Burns, Sally Kvern, Sondra Otto

Funding
The Centers for Disease Control and Prevention

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Children with chronic conditions and disabilities require complex health and social services. How can an HMO work with other health and social service providers to best serve these children and their families?

Several organizations are collaborating on a project to create a new model of integrated services for helping children with chronic illness. The collaborators include Group Health Foundation/HealthPartners Inc., the Center for Children with Chronic Illness and Disability (a national training and research center based at the University of Minnesota), and PACER Center (a non-profit parent advocacy group). Chronic conditions common in young children include congenital cardiac disease, cystic fibrosis, cerebral palsy, spina bifida, autism, trisomy 21, diabetes, and muscular dystrophy.

This project is now in a planning stage and has three goals: (1) to analyze how children with chronic conditions and disabilities are presently served in the staff model clinics at HealthPartners, (2) to examine how health care, educational and social services interact in serving these children and their families, and (3) to develop a new model of integrated service delivery, based on research findings about the current system.

Information is being gathered from interviews with parents of 35 children with chronic conditions, as well as surveys of pediatricians and family practice physicians. This project will assess how well the present systems function in coordinating services for special needs families. Researchers also will analyze the financial costs of health care in a fiscal year. Project consultation is provided by a Parent Advisory Council, consisting of parents of children with a variety of conditions, and a Community Advisory Council, with national, state, and local representatives.

Implementation will involve putting the model of the integrated service delivery system to work. Social services, education, and health systems will work cooperatively to provide care that is driven by children and family needs, rather than the availability of programs.

Research Team
Barbara Staub, MD, Project Director; Brooks Donald, MD, Community Advisory Council Chair; Andrew Nelson, MPH; Robert Blum, MD (Univ. of Minnesota); Anne Kelly, MD (Univ. of Minnesota); Celia Shapland, RN, (PACER Center); Karen Mason, RN; Catherine Wisner, PhD; Kirsten Hase; Brita Hedblom

Funding
Robert Wood Johnson Foundation

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About five thousand women in the United States die from cancer of the cervix every year. Research has shown that routine screening markedly reduces morbidity and mortality because cancer of the cervix and its pre-cancerous lesions can be detected by cervical cytologic screening (Pap smear).

How many women in an HMO have an annual Pap smear? Are older or younger women more likely to have this procedure? How many women who are screened are found to have cancer or some kind of abnormality? Are women with cervical cancer less likely to have had a Pap smear than the other women in the population? A study to address these questions was conducted based on computerized records on 22,639 women enrolled in Group Health for five consecutive years, 1986-90. The Pap smears were interpreted by the University of Minnesota Cytology Laboratory. In addition, medical records were examined for 32 patients with a diagnosis of cervical cancer.

The study found that 85 percent of women had at least one Pap smear within the five year duration. Nearly half (47 percent) obtained four to five tests within this period; 14 percent were screened only once during the five years. Younger and older women were similar in their rates of screening.

The second issue addressed in the study related to the proportion of abnormal cytologic findings. The Bethesda System of classification, used by the cytopathology laboratory, has four major classifications: normal, low-grade squamous intra-epithelial lesions (LSIL), high-grade squamous intra-epithelial lesions (HSIL), and suspected malignancy. Table 1 shows the distribution over the five years.

Younger women were more likely to evidence low or high grade lesions, older women were somewhat more likely to have carcinoma.

The 32 women with an actual diagnosis of cervical cancer were signficantly less likely to have had a Pap smear.

Cervical cancer is not a homogeneous disease and progresses at different rates in different women. While screening has been shown to be efficacious, it will not detect all cancers. For patients with carcinoma, screening effectiveness varied by type. Those patients with squamous cell carcinoma might have been detected earlier had they come in for screening. Of the 25 women with this finding, seven (28 percent) had not been screened within three years. On the other hand, patients with adenocarcinoma were less likely to be detected. Of the seven women with this diagnosis, four had received a Pap test within one year and all but one within three years. This type of cancer, although less frequent, is less likely to be detected with current technology.

In an HMO, we might expect that patients would obtain more regular preventive screening of all types. Even so, as these findings show, some women at high risk fail to have a Pap smear. It would be useful to know why this happens. Are women embarrassed or uncomfortable with the test? Would patient education be useful? Do doctors and nurses forget to remind or inform patients about needed tests? Screening high risk patients represents the best opportunity to reduce morbidity, mortality, and expense from preventable cervical neoplasias.

Research Team
Sharon Rolnick, PhD, MPH, John J. LaFerla, MD, MPH, Diane Wehrle, BS, Eric Trygstad MD, Takashi Okagaki MD, PhD

Funding
Group Health Foundation

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CHESS (Comprehensive Health Education Enhancement Support System) is an interactive computer system that helps patients with breast cancer or HIV. The purpose of CHESS, which was developed by the University of Wisconsin, is to provide both information and support to people facing a medical or life crisis.

Group Health Foundation is collaborating with the University of Wisconsin to evaluate this new technology in health care. The CHESS study is assessing how patients with either breast cancer or HIV infection use the technology and whether or not patients find the system helpful. In the study, patients with breast cancer or HIV infection have been randomly assigned to receive either written information or the CHESS computer in their home for three months.

Breast cancer patients, who had the CHESS computer in their homes, used the system most often to discuss treatment options. HIV patients most frequently used CHESS to talk about daily happenings in their lives. The Question and Answer component and Instant Library were most used by the breast cancer patients. The Instant Library and Personal Stories were most used by the HIV patients.

The computer system was well-received by the patients, affording them privacy, accessibility and the ability to learn at their own pace. Comparative results from both groups should be available by early 1996.

Research Team
Cheri Rolnick PhD, MPH, Principal Investigator; Laurie Sathe, Co-Investigator; Leah Cooper, MPH, Educational Coordinator; Mary Kelley Project Coordinator; Robert Hawkins PhD; Betta Owens, MS; David Gustafson, PhD; Chris Defreitas: University of Wisconsin-Madison.

Funding
HealthPartners Center for Health Promotion/ University of Wisconsin-Madison

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The Institute for Clinical Systems Integration (ICSI) has created a Practice Guideline for improving obstetric care for women who are experiencing problems in labor. The goal of this guideline is to assist women in obstetrical labor to progress to vaginal birth. The guideline will define a critical path for assessing and treating failure to progress. An important outcome is to prevent inappropriate caesarean sections. Group Health Foundation will conduct a pre/post evaluation on 1000 women (500 pre-guideline and 500 post guideline) who gave birth to their first child in January through June of 1993 and 1995 at two hospitals.

Research Team
Cheri Rolnick, PhD, MPH, Principal Investigator; Barbara Hyer, MD, Co-Principal Investigator; William Rush, PhD; Patrick O'Connor, MD, MPH; Javid Malik, MD; Rick Carlson, Jody Jackson, Research Coordinator.

Funding
Institute for Clinical Systems Integration

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From 1985 to 1994, Group Health, Inc. was one of four national demonstration sites for the Social HMO experiment that offered innovative ways to integrate acute care with long-term care for the elderly. A study is now being conducted to examine how the loss of this program (known as Seniors Plus) has affected the frail elderly.

Seniors Plus offered elderly patients all the benefits provided by Medicare plans. In addition, about 500 frail elderly who were at risk of institutionalization received case management and long-term care services in their homes. These services included homemaking, personal care, nursing, therapy and adult day care, and were above and beyond home care benefits covered by Medicare.

Researchers at Group Health Foundation conducted a survey to examine in what ways and to what degree at-risk elderly have replaced the Seniors Plus home-care services with informal or formal services. Preliminary findings suggest that the loss of the Social HMO has been difficult for many but not all of the 500 enrollees. About a fifth indicated that they no longer need as much home help this year as the did last year. Of the remaining, just over half said they continue to receive as much or more help now than they had with the Social HMO.

Further analysis of the survey data, as well an in-depth interviews of a sample of former enrollees, will examine other questions such as: What types of community-based services are most likely to be replaced? How do at-risk elderly or their caregivers manage the process of replacing the Social HMO community-based services? How do the at-risk elderly or their caregivers perceive the loss of services on their quality of life, risk of institutionalization and out-of-pocket costs?

Research Team
Lucy Rose Fischer, PhD; Annice Miller, MBA; William Rush, PhD; Walter Leutz, PhD (Brandeis); Jeanne Ripley; Carol Westrum, MA; Catherine Wisner, PhD

Funding
Group Health Foundation

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Project IDEAL (Improve Diabetes Care Through Empowerment, Active Collaboration, and Leadership) is a collaboration between the Minnesota Department of Health and HealthPartners. This project is intended to improve care and outcomes for people with diabetes. A major focus of the project is to use CQI (Continuous Quality Improvement) to help clinics improve the process of care and ultimately the outcomes of care for their patients with diabetes. The project IDEAL model will be disseminated to the Centers for Disease Control and Prevention, state health departments, HMOs, and other health care organizations.

The first year of the five year study has been spent developing collaborative relationships and organizing teams to work on the goals of the project. The Data Team is completing an assessment of the current state of diabetes care in HealthPartners. The Intervention Team has been developing a CQI-based training program to improve care for patients with diabetes.

One of the key goals of Project IDEAL is to develop an effective public-private partnership so that a state health department, an HMO, and employer groups can work together to improve health care. The staff from HealthPartners and the Minnesota Department of Health share a strong commitment to provide a better system of diabetes care.

Research Team
Patrick O'Connor, MD; Dace Trence, MD; Leif Solberg, MD; Andy Nelson, MPH; Sue Freeman, MD; Laura Ellis, RN; Linda Cherney, RD, MPH; Bill Rush, PhD; Lucy Rose Fischer, PhD; Teresa Pearson, MS, CDE; Minnesota Department of Health Team Members: Don Bishop, PhD; Janel Harris, PhD; Cindy Clark, MA; Jim Bluhm, MPH; Sue Lasch, RN, NP-C; Laurel Reger, MBA; Jay Desai

Funding
Centers for Disease Control and Prevention

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In 1994, a HealthPartners clinic, using methodology developed and tested by the Minnesota Department of Health in conjunction with the Centers for Disease Control and Prevention, implemented a Continuous Quality Improvement (CQI) process designed to improve the way care is provided to patients with diabetes.

Data on patient outcomes and costs from the experimental clinic that used CQI were compared to data from a comparison HealthPartners clinic that had not applied CQI. The comparison clinic had identical staffing and patient care systems and similar patients. Glycosylated hemoglobin (HBA1c) values for patients with diabetes at both clinics were compared for the one-year period before CQI intervention and for the one-year period following initiation of CQI intervention.

Project results indicate there were improvements in the clinic with the CQI process. In the year following CQI initiation, diabetic patients in the experimental clinic were more likely to have improved glycemic control than patients in the comparison clinic-that is, in the second year, the mean HBA1c values had improved for patients in the experimental clinic. This study suggests that a CQI process can effectively improve clinical outcomes in a population of patients with a challenging chronic disease.

Research Team
Patrick O'Connor, MD, MPH; Jackie Peterson, RN; Cheryl Keogh, RN; Pamela Morben, RN; Blanche Rohr, LPN; Carole Mensing, CDE; Linda Cherney, RD, MPH; William Rush, PhD; Susan Lasch, RN, NP-C (Minnesota Dept of Health); Cynthia Clark, MA (Minnesota Dept of Health).

Funding
Group Health Foundation

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Medical care today is oriented toward the treatment of and not the prevention of disease. We spend hundreds of billions of dollars for curing, almost nothing for preventing the costs of curing. Recommendations for preventive services are established but are not consistently addressed in primary settings.

IMPROVE -- IMproving PRevention through Organization, Vision & Empowerment -- is a collaborative effort involving HealthPartners, Blue Plus and Mayo Clinic. The research study is designed to test whether clinics are able to improve the quantity and quality of eight preventive services through the use of CQI. These services include breast exams, mammography, Pap smears, screening and management of hypertension and hypercholesterolemia, smoking cessation, and immunization for influenza and pneumococcus for patients 65 and older.

The IMPROVE Project is a four year randomized controlled trial, in which 44 primary care clinics, that have volunteered to participate. The participating clinics were randomly assigned to either intervention or control groups. The 22 random clinics have been trained in a seven-step process improvement model and are working toward implementing their "improved" systems and processes.

The CQI process being taught by the IMPROVE Project uses the HealthPartners seven-step model: (1) identifying the problem, (2) collecting data from "customers," (3) analyzing data, (4) developing alternatives, (5) generating recommendations, (6) implementing a plan, and (7) evaluation. One year after training, most of the clinics have progressed to at least Step 5. Step 5 entails piloting the changes that the teams have developed. The majority of the IMPROVE clinic teams meet every other week for an hour, with an average of five hours per team member a month.

A major challenge for these clinics has been to maintain their participation in the IMPROVE Project and at the same time adjust to the incredible changes that have become a part of this area's primary care environment. Many of the clinics have gone through either a merger, a buy-out, or multiple combinations of these. Almost all clinics in the study have experienced changes in key staff.

In spite of the turmoil in the primary care environment, the intervention clinics have made substantial progress. They have done so because of the commitment of the teams to improve their clinics.

Research Team
Leif Solberg, MD, Principal Investigator; Thomas Kottke, MD, Co-Principal Investigator (Mayo); Steven Richards, MD (Blue Plus); Milo Brekke, PhD (Brekke Associates); Andrew Nelson, MPH; Lucy Rose Fischer, PhD; Caroline Calomeni, MPA; Shirley Conn, RN, MSN; Gail Amundson, MD; Jerry Amundson; Greg Angstman, MD; Lark Arrichiello; Matt Bernard, MD; Kathy Conboy, RN; Gestur Davidson, PhD; Katherine Giles, BSN, MBA; Arnold Kaluzny, PhD; Sanne Magnan, MD; Sue Majerus, RN; Eugene Nelson, ScD; Mike O'Fallon, PhD; Ann Sisel, BA; Charlie Straw, BS; Henry Tufo, MD; Carol Westrum, MA; John Wheeler, MD

Funding
Agency for Health Care Policy Research

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Three adult primary care clinics have experimented with different types of smoking interventions to encourage patients to quit smoking. The goal has been to follow the National Cancer Institute program - "ask, advise, assist, arrange" - in a manner that considers each patient's stage of change.

In one clinic, each nurse and doctor team is asked to distribute stage-based pamphlets to patients who smoke. Pamphlets are prominently placed in each exam room and nicotine dependence classes are offered twice a month for patients who wish to try nicotine replacement. During the first six months, 55 patients attended these classes.

In a second clinic, physicians refer patients to a nurse who provides counseling and follow-up telephone calls for nicotine dependence. After the initial consult, patients are called at 2 days, 2-4 weeks and at 3, 6, and 12 months after their "quit date." Approximately 100 patients have received an initial consult. Those who remained smoke-free at three months appear more likely to sustain cessation. Three-month success to date is 47 percent. The eight-session program of "Freshstart 2" is also offered.

A third clinic offers a brief 15 minute counseling visit by a nurse at the time of the patient visit. Also, ten patients per month are seen for an extended 30 minute nurse appointment. Recently, Freshstart 2 classes have been offered as six-session programs.

These pilot efforts are low cost and reach relatively large numbers of patients. To date, these programs have been well-received and may serve as models for other clinics.

Research Team
Donna Feucht, RN, David Klevan MD, Cheri Rolnick PhD, MPH

Funding
Como Clinic, Group Health Foundation

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Smokers who have been hospitalized for a cardiac episode are often motivated to quit smoking. Telephone follow-up interviews were conducted with 30 patients who were identified as smokers and who had been hospitalized with a cardiac episode. About 75 percent of the patients in the sample were men, with an average age of 58.

The interviews were conducted approximately one year after patients had been hospitalized (January - April 1994) to assess current smoking status. Patients who were still smoking were asked if they were interested in a program to help them stop smoking.

The study found that 16 of the 30 patients had completely stopped smoking. The remaining 14 current smokers reported a decrease in their smoking by nearly 50 percent. The mean cigarette consumption prior to admission was 1.4 packs per day, compared to .8 pack at the follow-up phone call.

For the 14 patients who continued to smoke, the study examined their readiness to change. Three patients were identified as "precontemplators" - they have little intention of quitting. Nine were "contemplators;" these patients have given some thought to quitting. Two described themselves as "in preparation" to quit smoking. The contemplators mentioned that stress, addiction and the pleasure of smoking made cessation difficult. Some of the contemplators thought that it was their own responsibility to stop smoking; others thought that programs that emphasized motivation, encouragement and physical activity would be helpful. Those "in preparation" did not express an interest in a quit-smoking program from their health care provider.

Cardiac rehab patients who smoke remain a challenge. These patients are a key focus for future smoking prevention programs.

Research Team
David Klevan MD, Cheri Rolnick PhD, MPH

Funding
Como Clinic, Group Health Foundation

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