2000

Aging
Geriatric Depression and Health Care Cost
Signs of Parkinson's Disease

Children
Books and Babies

Chronic Disease
Managing Cholesterol
Reexamining HIV Therapy
Improving Diabetes Care

Critical Care
Exploratory Surgery for Digital Nerve Injuries
Effects of Feeding Solutions on Antibiotics
Difficult Patients in the Emergency Room
The Risks of Mechanical Ventilation

Medication
Just a Spoonful of Medicine

Prevention
The Health Cost of Unhealthy Behaviors
Hazards of Smokeless Tobacco
When Doctors Advise Smokers to Quit
Immunization Saves Lives
Setting Priorities for Prevention

Research Update
A New Method for Steroid Separation

Women
Screening for Chlamydia
Preventing Osteoporosis

While only 1% to 2% of elderly patients are diagnosed with major depression, minor depression is common - about a fifth to a quarter of geriatric patients with appointments at primary care clinics have clinically significant depressive symptoms. Elderly patients frequently experience symptoms of depression along with chronic medical problems such as heart disease and diabetes. However, physicians often fail to diagnose depression in elderly patients, and elderly patients tend to be reluctant to report symptoms of depression. Potentially, older patients may over use the general medical system when their depression is not properly treated.

About 500 HealthPartners geriatric enrollees participated in the Seniors Quality of Life Study, a collaboration between HealthPartners Research Foundation and the University of Minnesota. As part of this study, researchers investigated the association between depressive symptoms and use of health care services.

The study found that elderly patients with depressive symptoms go to medical clinics more often than patients who are not depressed. Having depressive symptoms increases costs for clinic visits by about $500 to $1,200 a year depending on other chronic health problems.

These findings suggest that better treatment for depressed elderly patients could decrease unneeded visits to medical clinics. Thus, the cost of programs to improve depression care might be offset through reductions in outpatient expenditures.

Research Team
HealthPartners Research Foundation: Lucy Rose Fischer, PhD, Sharon J. Rolnick, PhD, Feifei Wei, PhD, Jody Jackson. University of Minnesota: Judith Garrard PhD (PI), Nicole Nitz, Lori Luepke

Funding
Agency for Health Care Policy and Research, Grant # 1R01 1BS 0772

Related Presentation and Publications
Fischer LR, Rolnick SJ, Wei W, Jackson J, Garrard J, Nitz N. Luepke L. Geriatric Depression, antidepressant treatment, and health care utilization in an HMO. Annual Meetings of the Gerontological Society of America, San Francisco, CA, November 1999.

Garrard J, Rolnick SJ, Nitz NM, Luepke L, Jackson J, Fischer LR, Leibson C, Bland P, Heinrich R, Waller L. Clinical detection of depression among community based elderly people with self reported symptoms of depression. J Gerontol A Biol Sci Med Sci 1998;53(2):M92-101.

Fischer LR, Rolnick SJ, Garrard JM, Jackson JM, Luepke L. The Geriatric Depression Scale: a content analysis of respondent comments. J Ment Health Aging 1996;2(2) Summer/Fall:125-135.

SEQOLS and other studies have documented that depressive symptoms diminish quality of life. For elderly patients with chronic medical problems, depression complicates diagnosis and treatment and can lead to a downhill spiral - a decline in physical and mental health.

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Parkinson's disease, a condition caused by the degeneration of nerve cells in the area of the brain that controls movement, affects over 1,000,000 people every year. Each year, 50,000 new cases are diagnosed, and the figure is expected to grow as the population ages.

No laboratory test exists to diagnose Parkinson's disease, so doctors must rely on the appearance of clinical symptoms such as tremors, slow movement, stiffness, shuffling gait, and stooped posture to detect the disease. The presence of microscopic structures in the brain, called Lewy bodies, typically mark the presence of the disease but can only be found through an autopsy. Parkinson's disease can eventually lead to dementia, the decline in mental abilities such as memory and judgement. There are many causes of dementia, so not all dementia patients have Parkinson's disease.

A retrospective study of dementia patients investigated the relationship between the appearance of clinical signs of Parkinson's disease in the last years of life and degeneration of substantia nigra, a part of the brain that controls movement. Tissue samples from the Alzheimer's Treatment and Research Center Brain Bank at Regions Hospital were examined for substantia nigra degeneration and the presence of Lewy bodies. These results were compared to patient records of dementia and Parkinson's disease.

Some dementia patients, although they showed signs of substantia nigra degeneration and the presence of Lewy bodies at autopsy, did not display clinical symptoms of Parkinson's disease during the course of their dementia. Researchers found no clear relationship between the clinical and pathological signs of Parkinson's disease. The study suggests that the cause of the abnormal movements seen in Parkinson's disease is more complex than was traditionally thought. Future studies of the treatment and pathological diagnosis of Parkinson's disease should consider the possibility of additional factors.

Research Team
Tom Ala, MD, K.-H. Yang, MD, J.H. Sung, MD, William H. Frey, II, PhD

Funding
Regions Hospital Foundation, The Robert Wood Johnson 1962 Charitable Trust, The Extendicare Foundation, The National Association of Retired Federal Employees Grant from the State of Minnesota

Related Publication
Ala TA, Yang KH, Sung JH, Frey WH. Clincal parkinsonism in dementia patients with substantia nigra Lewy bodies. J Neural Transm 1999; 106(1):47-57.

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Reading to babies, even those only a few months old, helps in early brain development through exposure to rich language and interactive experiences. Health plans are in a unique position to encourage parents to read to their very young children when they come for visits to pediatric clinics.

Project Read, a program at HealthPartners since 1996, places volunteer readers in clinics, gives books to children, and educates new parents and clinical staff about the value of reading to small children. In 1997, HealthPartners clinics started giving new parents a video entitled "Food for Thought."

An evaluation of Project Read began in 1999 with three intervention clinics and three control clinics. The intervention included placing volunteer readers in clinics, giving books to children, setting out brochures and posters, and educating clinical staff about encouraging reading. Surveys were administered to parents with children under one year of age who had visited these six clinics.

About three-fourths of parents were actively involved in reading to their children. There was no difference between the intervention and control clinics. Giving the "Food for Thought" video to new parents may be sufficient and inexpensive tool to encourage parents to read to their babies. Even so, the clinic staff and volunteer readers reported that they enjoy Project Read. They felt that the project provides parents with quiet time, occupies siblings, and shows parents and children that the clinic is a friendly environment.

Research Team
HealthPartners: Kristine K. Fortman, PhD, Terese A. DeFor, MS, Brenna Walker, BA. University of Minnesota: Robert O. Fisch, MD, Margaret Y. Phinney EdD.

Funding
HealthPartners Research Foundation

Related Publication
Evaluating the efficacy of reading programs in a clinical environment. Currently under review.

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High levels of low-density lipoprotein (LDL) cholesterol, or "bad cholesterol," in the blood can lead to heart disease, hardening of the arteries, and strokes. A diet high in saturated fats, such as those found in animal products, can cause extra cholesterol to be stored in the arteries, increasing the risk of heart disease. Alternatively, high-density lipoprotein (HDL) cholesterol, or "good cholesterol," may protect against heart attacks, as it removes cholesterol from the blood stream.

Studies have shown that lowering LDL cholesterol levels can reduce the risks of heart attacks, chest pain, bypasses, and strokes. The benefit is especially significant in patients with coronary heart disease and patients with diabetes. The National Cholesterol Education Program outlines LDL-C goals for patients at various risk levels. Even though more and more patients are being educated about the importance of managing cholesterol levels, the attainment of cholesterol level goals has been less than optimal.

In a two-year study, HealthPartners researchers evaluated how well patients with chronic health problems manage their cholesterol levels. They found that about one-third of patients with coronary heart disease achieved their LDL-C goal and one-fourth of diabetes patients achieved their goal. While these results indicate an improvement over previous figures, there is much room for further improvement.

The under-use of cholesterol-lowering medications and the lack of follow-up may contribute to the low rate of patients achieving their cholesterol level goals. This study will provide a baseline for further studies and a comparison of cholesterol management strategies in the future.

Research Team
Robert Straka, PharmD, Reza Taheri, PharmD, Susan Cooper, RPH, Agnes W.H. Tan, PhD, James C. Smith, MD, Lori Amborn PharmD

Funding
Merck & Co.

Related Publication
Taheri R, Amborn L, Smith JC, Cooper S, Tan AWH, Straka RJ. Assessment of hypercholesterolemia in a managed care setting. Pharmacotherapy 2000;20(3):340, Abstract #15.

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Close to 16 million Americans have diabetes, a series of diseases in which the body does not produce or respond correctly to insulin. Because insulin is a hormone that converts sugars, starches, and food into energy, controlling blood glucose levels is essential in diabetes patients. The consequences of not properly controlling blood glucose levels can be severe, resulting in blindness, coma, or even death.

Patients with diabetes are especially at risk for developing cardiovascular disease. Therefore, managing blood pressure and cholesterol levels and quitting smoking, along with glycemic (blood glucose) control, are vital.
HealthPartners researchers have been examining the effectiveness of diabetes care programs, a primary focus in recent years at HealthPartners Medical Group.

In 1997, HealthPartners implemented a formal diabetes care improvement program in 18 local primary care clinics. The goals of this program included improving glycemic control and reducing the risk of cardiovascular disease by lowering cholesterol levels. Some of the interventions in the diabetes care improvement program included empowering patients in self-management, supporting care team decision making, redesigning office systems, and utilizing information technology.

New findings point to both better monitoring and improved outcomes for diabetes patients. Over the course of five years, the percent of patients in the population studied who received HBA1c tests (testing for glycosylated hemoglobin, a measure of glucose in the blood) and LDL ("bad") cholesterol level tests improved. At the same time, both average glycosolated hemoglobin level and average LDL cholesterol level improved substantially. These improvements, if sustained over time, could result in up to 50% decrease in cardiovascular events among diabetes patients.

These findings place HealthPartners diabetes care among the best in the nation and indicate that well-organized primary care can be as effective or more effective than disease management programs.

Research Team
JoAnn Sperl-Hillen MD, Patrick J. O'Connor, MD, MPH, Bill Rush PhD, Rick Carlson MS, Teresa Bunkers-Lawson, MSN, CDE, Cindy Halstonsen CDE, Nico Pronk PhD, Terry Crowson, MD, Robin Whitebird PhD, Linda Cherney, RD, MPH, Cynthia Fay, MD, John Wheeler, MD, Jan Wuornma, RN

Funding
HealthPartners Research Foundation, HealthPartners Medical Group, Agency for Healthcare Research and Quality through Project QUEST, Grant # R01 HD09946-01

Related Publication
Sperl-Hillen J, O'Connor PJ, Carlson R, Bunkers Lawson T, Halstenson C, Crowson T, Worenma J. Improvement of diabetes care in 1999 in a large health care system: an enhanced primary care approach. J. Quality Improvement. 2000: in press.

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Currently, human immunodeficiency virus (HIV) treatment includes early and aggressive suppression of the virus in the blood through anti-retroviral therapy. However, because of drug side effects and possible resistance to therapy, researchers are beginning to question if this is the best method for preserving the long-term health of HIV-infected patients. Therapy-related side effects, such as metabolic problems and liver damage, are common. Many doctors worry about the development of drug-resistant strains of HIV. Furthermore, the majority of HIV-infected persons simply cannot afford the expensive drugs and treatments currently available.

Previously, researchers thought that damage to the immune system in advanced HIV infection was irreversible, and therefore concluded that beginning therapy as early as possible in the onset of disease would be the best treatment strategy. A recent study, however, found encouraging evidence that treatment, even at later stages, can reverse immune system damage.

In advanced stages of HIV, the virus destroys the network of follicular dendritic (virus-trapping) cells in the lymph nodes and spleen, contributing to the breakdown of the immune system. HealthPartners and University of Minnesota researchers found that anti-retroviral therapy, a common treatment for HIV infection, helped clear much of the virus from this network of cells. The return of the follicular dendritic cell network was key in restoring the immune system without needing to completely eradicate the virus and infected cells.

These findings demonstrate the innate healing power of the human body and fuel the debate over the best use of expensive but effective therapies for HIV infection. The irreversibility of immune damage was one of the main arguments for early, aggressive treatment, but the results of this study may change the approach to HIV therapy.

The focus of HIV therapy may be shifting towards an approach that is more closely tailored to the individual patient and his or her long-term health. Researchers hope that more conservative and patient-focused use of anti-retroviral therapy will allow HIV-patients to live relatively normal lives while diminishing the risk of side effects and resistance. A more conservative approach might prove to greatly reduce costs while still protecting patients from AIDS. Additionally, this strategy could more easily be exported to poor countries, allowing them to benefit from treatment advances.

Research Team
Regions Hospital: Keith Henry, MD
Hennepin County Medical Center: Holly Melroe, RN, NP, MSN, Ray Nelson, RN, Ellen Kane, RN, Bette Bordenave, RN, Marcia Meredith, RN
Park Nicollet: Renee St. Jacque, RN
St. Paul-Ramsey Department of Health: Jo-Ellen Nietzke, RN
HIV Program office staff: Jessica Kopaczdwski, BS, Jane Simpson, BS, Jenny Palmer, Betty Jarosch
Physician collaborators: Ron Schut, MD, Hal Martin, MD, Henry Balfour, MD, Ashley Haase, MD, Alejo Erice, MD, Winston Cavert, MD, Courtney Fletcher, PharmD, Leslie Baken, MD, Andrew Zalopa, MD, Pablo Tebas, MD

Funding
National Institutes of Health, Department of Human Services, the St. Paul-Ramsey Department of Health, and numerous pharmaceutical sponsors

Related Publications
Henry K. The Case for More Cautious, Patient-Focused Antiretroviral Therapy. Ann Intern Med 2000 Feb 15;132(4):306-11.

Zhang Z, Schuler T, Cavert W, Notermans D, Gebhard K, Henry K, Havlir D, Gunthard H, Wong J, Little S, Feinberg M, Polis M, Schranger L, Schacker T, Richman D, Corey L, Danner S, Haase A. Reversibility of the pathological changes in the follicular dendritic cell network with the treatment of HIV-1 infection. Proc Natl Acad Sci USA 1999 Apr 27;
96(9):5169-72.

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When a patient has a serious laceration or other injury that damages a digital nerve, surgeons must decide whether to perform exploratory surgery or to continue to follow a patient after the wound has been closed. Digital nerves conduct electrical impulses to and from the brain, providing sensation and movement to the hand and fingers. Most patients require surgery to repair the severed nerve, and delaying this surgery can make repairing the severed nerve more difficult and impair recovery.

However, some patients with this type of injury may recover without surgery, as their nerves are sufficiently intact. This condition, called neurapraxia, is the temporary dysfunction of a nerve and usually subsides with time. Therefore, some patients who are scheduled for surgery may recover spontaneously and may not require nerve repair.

In a three-year study, researchers at HealthPartners found that 88% of the patients who were scheduled for exploration and digital nerve repair actually underwent surgical repair. Of the patients scheduled, 4% had spontaneous recovery and did not require surgery, and 8% had intact nerves, even though they showed a decrease in sensation before surgery. Therefore, 12% of the patients scheduled for surgery did not actually require surgical repair.

Researchers also found that patients who showed spontaneous recovery or intact nerves at the time of surgery were more likely to have nerve damage caused by a crush injury compared to those who underwent surgery.

This study underscores the need to standardize a treatment plan for identifying digital nerve neurapraxia and minimizing unnecessary exploratory surgery.

Research Team
Warren Schubert, MD, Aamir Siddiqui, MD, Charles Benjamin

Funding
Department of Plastic and Hand Surgery, Regions Hospital

Related Publications
Siddiqui A, Benjamin C, Schubert W. Incidence of neurapraxia in digital nerve injuries. J. Reconstr Microsurg 2000 Feb; 16(2):95-9.

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Acute and long-term care patients who are unable to feed themselves often receive their nutrition through enteral solutions such as Ensure. In enteral feeding, fluid is delivered directly into the gastrointestinal tract. Antibiotics are sometimes given at the same time as the feeding solutions or mixed with Ensure for ease of medication delivery. These feeding solutions, however, have been found to interact with a group of antibiotics frequently prescribed for both inpatients and outpatients.

Researchers investigated whether Ensure changed the amount of fluoroquinilone antibiotics, including ciprofloxacin, levofloxacin, and ofloxacin, available for use in the body. In a laboratory study, researchers combined antibiotics with different solutions, including water, salts mixed with water, and Ensure. They found that while the concentration of antibiotics stayed the same in the water and salt solutions, the concentration of all three separate antibiotics decreased substantially when mixed with Ensure.

The interaction between these antibiotics and Ensure may lead to treatment failure. Researchers recommend spacing administration of antibiotics and Ensure by at least two hours to avoid this drug interaction. This reaction could also occur with other brands of feeding solution as they are very similar in composition. In addition, these solutions are becoming popular among outpatients as dietary supplements. Therefore, consumers using these solutions along with oral fluoroquinolone antibiotics could experience the same type of interaction.

Research Team
John Rotschafer, PharmD, David Wright, PharmD, Sarah Pietz, Frank Konstantinides

Funding
Educational grant from Robert Wood Johnson Pharmaceutical Research Institute, Raritan, New Jersey.

Related Publications
Wright D, Pietz S, Konstantinides F, Rotshafer J. Decreased In Vitro Fluoroquinolone Concentrations After Admixture With an Enteral Feeding Formulation. J Parenter Enteral Nutr 2000 Jan-Feb; 24 (1):42-8.

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Intoxicated patients who arrive in the emergency room are often agitated and belligerent. Frequently these patients have been assaulted or injured and have a possible head injury. It is often difficult to tell if the agitated behavior is from alcohol intoxication or from a brain injury. A CT scan, a special technique that uses a computer to combine multiple X-ray images into a two-dimensional picture of soft tissue structures, can be used to see is there if brain injury. However, these patients are often unwilling or unable to cooperate to get a CT scan of their brain.

In a small-scale safety and observational study at Regions Hospital, the drug Propofol was tested to sedate a small number of agitated and intoxicated patients who required a CT scan. Propofol is usually used in operating rooms in low doses to obtain sedation without cessation of breathing.

Propofol seems to be an ideal drug for this type of situation because it can maintain adequate blood flow to the brain while sedating the patient. When the infusion is stopped, the clinical effects are usually gone in approximately five minutes, and neurological evaluation of the patient is still possible. This allows continuing physical and neurological evaluations to be done. Deterioration of the neurologic function in these patients can then be assessed and appropriate interventions performed.

Results from this small-scale study suggest that Propofol may be appropriate for patients such as these, when sedation is needed only for a CT scan. Using this drug could eliminate use of intubation and general anesthesia, which are more dangerous.

Research Team
Joel S. Holger, MD, David B. Hale, MD, PhD, Carson R. Harris, MD, Christine Solberg, PharmD, Frank Benfante, PA-C

Funding
Regions Hospital Emergency Medicine Department

Related Publication
Holger JS, Hale DB, Harris CR, Solberg C, Benfante F. Sedation of intoxicated, agitated patients requiring CT to evaluate head injury. Am J Emerg Med. 1999;17(3):321-3.

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Patients with trauma, severe pneumonia, systemic infection, extensive surgery, and severe burns frequently become unable to breathe on their own. Mechanical ventilation is often used to assist such critically ill patients, literally "pumping" air into and out of their lungs.

Unfortunately, recent experimental and clinical evidence indicates that mechanical ventilation as traditionally applied to patients with respiratory failure can further damage the lungs, causing them to become "leaky," filled with fluid and stiff. Many of these patients develop Acute Respiratory Distress Syndrome, a serious and often progressive disorder that has an associated mortality of over 30%. A National Institutes of Health multicenter clinical trial demonstrated that using smaller breaths so ventilate critically ill patients dramatically improved their survival.

A recent study through HealthPartners and the University of Minnesota examined the effects of increased number of breaths per minute or decreasing the pressures within the lung blood vessels during mechanical ventilation on the severity of lung injury. The study demonstrated that decreasing the number of breaths delivered per minute or decreasing the pressure within the lung blood vessels markedly decreased lung injury.

Although further work is clearly needed, the ultimate goal is to demonstrate that appropriately lowering respiratory frequency and controlling the pressures within lung blood vessels can directly improve the survival of these patients.

Research Team
John J. Marini, MD, David J, Dries, MD, MSE, Avi Nahum, MD, PhD, John R. Hotchkiss, MD, Laurel A. Wright, MD, Doug A. Olson, MD, Christopher Carter, Research Fellow, Alexander B. Adams, RRT, MPH, Mary B, Stone, RRT, Terrie Grove, Teri Manz, Robert Varuska

Funding
National Institutes of Health SCOR grant #NIH/2P50-HL50152-06, American Heart Association Scientist Development Grant, Alliance Pharamaceuticals

Related Publications
Hotchkiss JR, Blanch L, Murias G, Adams A, Olson D, Wangensteen OD, Leo PH, Marini JJ. Effects of increased respiratory frequency on ventilator induced lung injury. Am J Resp Crit Care Med 2000; 161(2):463-468.

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Nearly 25 years ago, the American Academy of Pediatrics reported on the inaccuracies of administering liquid medication by household spoons. The volume of household teaspoons can range from 2 to 10 ml. Moreover, the same spoon, when used by different people, may deliver from 3 to 7 ml of medication. In response to this problem, a variety of liquid medication dosing devices have been developed, each of which has advantages and disadvantages. A HealthPartners study examined devices commonly used by families, how accurately people measure liquids with the devices, and their ability to correctly interpret dosing instructions.

Volunteers from the waiting areas of three HealthPartners clinics participated in the study. The study found that the household teaspoon is the most frequently used device for measuring liquid medications. Women and more educated respondents were more likely to measure the liquids accurately and to interpret dosing instructions correctly. Common errors included misinterpreting instructions about how long to wait between doses and confusing teaspoon and tablespoon measurements on a medicine cup.

The study concluded that health care providers need to be aware that many people continue to use inaccurate devices, such as household spoons, to measure liquid medication. Doctors should also advise patients to use more accurate devices, particularly an oral dosing syringe. Providers need to consider the possibility of a medication dosing error when a treatment fails to work as expected.

Research Team
Diane J. Madlon-Kay, MD, Frederick S. Mosch, MD

Funding
The American Academy of Family Physicians Foundation, The Minnesota Academy of Family Physicians Foundation

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Smoking, not exercising, and obesity are bad for health. Many studies have shown that these behaviors substantially increase the risk of heart disease, cancer, diabetes, emphysema and other serious health problems. The good news is that these unhealthy behaviors can be modified to improve health. Health plans can support programs that help patients stop smoking, lose weight, and participate in regular aerobic exercises. In the long run, such programs should help keep patients healthy and save money by preventing heart attacks, cancer, and so forth. But how do unhealthy behaviors affect the cost of health care in the short run?

A study at HealthPartners Research Foundation examined the relationship between modifiable health risks and short-term health care charges. Over 5,000 HealthPartners enrollees completed a questionnaire that asked about smoking, physical inactivity, and obesity. The data from the questionnaire were then matched with information on health care charges over a period of 18 months.

The study found that people who had never smoked, exercised three days a week and were not obese had health care charges almost 50% lower than physically inactive smokers who were obese. The conclusion was that adverse health risks translate directly into much higher health care charges within 18 months.

The study also showed that the relationship of smoking status to health care charges is complex; current smokers often have lower health care charges than former smokers. A probable explanation is that many former smokers had serious health problems that led them to quit smoking.

Overall, study findings suggest that primary prevention is an important strategy to improve population health and reduce charges. In fact, health plans that do not systematically support their members' efforts to adopt healthy behaviors may be incurring large short-term costs that could be prevented. Health plans and payers seeking to minimize health care charges should consider strategic investments in interventions that help their members adopt more healthy behaviors.

Research Team
Nicholaas P. Pronk, PhD, Michael J. Goodman, PhD, Patrick J. O'Connor, MD, MPH, Brian C. Martinson, PhD

Funding
HealthPartners Research Foundation

Related Publication
Pronk, NP, Goodman MJ, O'Connor PJ, Martinson BC. Relationship between modifiable health risks and short-term health care charges. JAMA 1999 Dec 15;282(23):2235-9.

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Smokeless tobacco is used less often than cigarettes-about 6% of the general population compared to 25% -but is just as hazardous to health. Snuff and chewing tobacco cause cancers of the mouth, tongue and throat. Smokeless tobacco is highly addictive and users experience withdrawal symptoms that are similar to those for cigarette smoking. Because it is less common, there has been much less research on smokeless tobacco than on smoking.

In a series of studies, researchers at the University of Minnesota and HealthPartners Research Foundation have examined who uses smokeless tobacco, what behaviors are associated with its use, and what methods might be effective in helping users to quit. For a recent cessation trial, 400 smokeless tobacco users were recruited to participate. The project compared the use and effectiveness of nicotine patches and mint snuff, a non-nicotine mint-leaf product.

At the beginning of the study, all participants were surveyed about how they use smokeless tobacco products. On average, smokeless tobacco users have tobacco in their mouths about half of their waking hours! Moreover, almost three-quarters of users swallow the spit produced by smokeless tobacco products. Swallowing the spit increases bodily exposure to the carcinogens in tobacco.

Results from the randomized trial suggest that quitting is difficult. Younger users found it especially difficult to quit.

The nicotine patch reduced craving and other symptoms of withdrawal but did not appear to enhance long-term treatment success. The mint snuff, which provides a non-nicotine substitute for the behavior and sensory aspects associated with chewing tobacco, did not improve treatment outcome but was also not detrimental.

Another study, at HealthPartners Research Foundation, tested the effectiveness of telephone counseling. The project recruited 210 smokeless tobacco users and randomly assigned them to two groups: one group was given a self-help manual while the other received the manual and also participated in a telephone counseling program to help them quit. Preliminary findings suggest that the people in the counseling group were about twice as likely to quit.

Findings from the counseling study are encouraging; telephone counseling may be an effective method to help users end their addiction. As a follow-up to the use of telephone-based counseling for smokeless tobacco cessation, the HealthPartners research team is developing a new project to test the application of biomarker feedback combined with telephone counseling to help users quit.

Research Team
HealthPartners: Raymond Boyle, PhD, Chris Enstad. Tobacco Research Program, U of M School of Medicine: Dorothy K. Hatsukami, PhD, Joni Jensen, MPH

Funding
National Institutes of Health Grant R01DA0513 and R03 CA74025. SmithKline Beecham; Oregon Mint Snuff.

Related Publications
Hatsukami DK, Grillo M, Boyle RG, et al. Treatment of spit tobacco users with transdermal nicotine system and mint snuff. J Consult Clin Psychol. 2000;68(2):241-9.

Hatsukami DK, Jensen J, Boyle RG, Grillo M, Bliss R. Characteristics of smokeless tobacco users seeking treatment. Addict Behav. 1999;24(4):551-7.

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How do patients who smoke feel about getting advice from their doctors about quitting? Many studies have proven that smoking patients are likely to listen when doctors advise them to quit, but many physicians hesitate to give this advice very often. Physicians are often afraid of antagonizing patients and lowering patient satisfaction.

A recent collaborative study between HealthPartners and BlueCross BlueShield of Minnesota looked at how physician advice to quit affects patient satisfaction. Almost 3,000 smokers completed surveys regarding their satisfaction with their physicians and whether they were given advice on smoking.

The study found that smokers were more satisfied overall when they received advice about quitting. Even smokers who were not interested in quitting were more satisfied when their physician discussed cessation with them.
This study should encourage clinicians to increase interventions to help patients quit smoking. In fact, failure to offer such help could make patients less satisfied.

Research Team
HealthPartners: Leif I. Solberg, MD, Raymond G. Boyle, PhD. BlueCross BlueShield of Minnesota: Sanne J. Magnan, MD, PhD, Carolyn Link Carlson, RN, MPH. Consultant: Gestur Davidson, PhD,

Funding
The Robert Wood Johnson Foundation (program for Addressing Tobacco in Managed Care)

Related Publications
Solberg LI, Boyle RG, Davidson G, Magnan SJ, Carlson CL. Is patient satisfaction at risk if we discuss smoking during clinical visits? Presented at the Minnesota Health Services Research Conference, February 2000.

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Every year, influenza and pneumonia together cause over a half million hospitalizations and 40,000 deaths among elderly patients in the United States.

National health experts recommend that elderly and at-risk persons receive yearly vaccines. However, over one-third of elderly patients nationwide do not receive an influenza vaccination and over half do not receive a pneumonia vaccination.

A recent study through the Veterans Affairs Medical Center, the University of Minnesota, and HealthPartners found that vaccinated patients had much lower rates of hospitalization and death and had fewer outpatient visits. Medical care costs were also considerably lower in vaccinated patients.

Additionally, unvaccinated patients had influenza and pneumonia rates that were twice as high in influenza seasons as in non-influenza seasons, while the rates in vaccinated patients did not vary greatly between seasons.

These findings demonstrate that influenza and pneumonia vaccinations are cost effective and save lives.

Research team
Kristin L. Nichol, MD, MPH, Leslie Baken, MD, Andrew Nelson, MPH, Bill Rush, PhD

Funding
HealthPartners Research Foundation

Related Publications
Nichol KL, Goodman M. The health and economic benefits of influenza vaccination for healthy and at-risk persons aged 65 to 74 years. Pharmacoeconomics 1999;16 Suppl 1:63-71.

Nichol KL, Baken L, Nelson A. Relation between Influenza Vaccination and Outpatient Visits, Hospitalization, and Mortality in Elderly Persons with Chronic Lung Disease. Ann Intern Med. 1999; 130:397-403.

Nichol KL, Baken L, Wuorenma J, Nelson A. The Health and Economic Benefits Associated With Pneumococcal Vaccination of Elderly Persons with Chronic Lung Disease. Arch Intern Med, 1999; 159: 2437-2442

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The best cure for a disease is never as good as prevention. There are many types of health care services that can prevent illness. Busy patients and clinicians, however, have too little time for all possible preventive services. Of the may effective preventive services, including screening tests, counseling, and immunizations, which ones are the most valuable? Ranking clinical preventive services could provide guidance to individuals, health care providers and policy planners who must choose among competing demands for finite resources.

The nonprofit organization Partnership for Prevention, with guidance from the Committee on Clinical Preventive Service Priorities, assembled a team of medical researchers to rank over 30 clinical preventive services. The services were rank-ordered on two factors: clinically preventable burden and cost effectiveness. Clinically preventable burden represents the health benefit gained from each preventive service, as measured in quality adjusted life years (QALYs) saved. Cost effectiveness refers to the net cost of the preventive service per QALY saved.

Providing tobacco cessation counseling to adults and providing adolescents with an anti-tobacco message or advice to quit smoking ranked highest among counseling priorities, since both services address substantial burden of disease. Most of the services ranked highly effective are aimed at adults. Incidence of disease is greater among older people, thereby providing more opportunities for prevention.

Several of the most important and effective preventive services on the list are currently delivered to fewer than 50% of their target populations nationally. These high priority/low delivery clinical preventive services include: assessing adolescents and adults for tobacco use and advising smokers to quit smoking, immunizing patients over 65 against pneumonia, screening young women for chlamydia, screening people over 50 for colorectal cancer, and screening people over 65 for vision impairment. These services are all missed opportunities for preventing disease and promoting health.

The rankings will help decision-makers determine how to allocate resources for clinical preventive services.

Research Team
Partnership for Prevention: Ashley B. Coffield, MPA. HealthPartners Research Foundation: Michael V. Maciosek, PhD. The Robert Wood Johnson Foundation: J. Michael McGinnis, MD, MPP. Centers for Disease Control and Prevention: Jeffrey R. Harris, MD, MPH, M. Blake Caldwell, MD. Merck : Steven M. Teutsch, MD, MPH. Agency for Healthcare Research and Quality: David Atkins, MD, MPH. American College of Preventive Medicine: Jordan H. Richland, MPP, MPH. Emory University: Anne Haddix, PhD.

Funding
Alliance of Community Health Plans contract #200-95-0953 with Partnership for Prevention, funded by Center for Disease Control and Prevention and the Health Care Financing Administration.

Related Publication
Coffield A., Maciosek MV, Caldwell MB. Setting priorities among clinical preventive services. Presentation at the Building BridgesVI: The Road to Quality Care: Using Research to Drive Quality Improvement. American Association of Health Plans (AAHP); Agency for Healthcare Research and Quality (AHRQ); Centers for Disease Control and Prevention (CDC); Blue Cross and Blue Shield Association; 2000.

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Steroids, a group of hormones produced naturally in the body, support a variety of essential bodily functions. They help control metabolism and inflammation and have a key role in the development of sexual characteristics. Many steroid hormones are used in medicine, including birth control pills, estrogen replacement, and inflammation-suppressing corticosteroids. Steroid medications are similar to the steroids produced by the body and carry out many of the same tasks.

Steroid hormones also regulate the growth of tumors. An important area of research is analyzing how tumor cells metabolize steroids. When steroid hormones interact with tumor cells, various steroid products, such as testosterone, are formed. In order to identify these products of metabolism, they must be separated from each other, a process that has been time consuming and expensive.

HealthPartners researchers, collaborating with researchers in Canada, have developed a simple and efficient method of separating and identifying closely related steroid hormones. The technique involves thin-layer chromatography (TLC), which is used to separate one or more compounds in a mixture. TLC can also be used in analyzing serum and biological fluids as well as culture media from laboratory studies of hormone metabolism by cells and tissue.
Researchers are now using this technique to study the metabolism of androgen by lung tumor cells and the metabolism of androgen and estrogen by ovarian tumor cells. This more efficient method of separation will help researchers understand how steroids act on tumors, leading to improved treatments.

Research Team
Charles H. Blomquist, PhD, Yves Tremblay, PhD, Paul Lima, MS, Denise Ramsey, MLT, Donald Poirier, PhD, Chantal Godin

Funding
HealthPartners Research Foundation, the Ob/Gyn Cancer Research Fund of Regions Hospital Foundation, the Department of Ob/Gyn research fund, and The Medical Research Council of Canada and the National Sciences and Engineering Research Council of Canada.

Related Publications and Presentations
Godin C, Blomquist C, Provost P, Tremblay Y. Steroidgenesis by a lung carcinoma cell line. The Endocrine Society, 80th Annual Meeting, New Orleans, LA, June 24-28, 1998, Abstract #P3-487.

Godin C, Blomquist C, Tremblay Y. Separation by Thin-layer Chromatography of the most Common Androgen-derived C19 Steroids Formed by Mammalian Cells. Steroids 64 (1999) 767-769.

Provost P.R., Blomquist C, Godin C, Huange, X-F, Flammand N, Luu-The, V, Nadeau D, Tremblay Y. Androgen formation and metabolism in the pulmonary type II-like epithelial cell line A549: Expression of 17b-hydroxysteroid dehydrogenase type 5 and 3 a-hydroxysteroid dehydrogenase type 3. Endocrinology, August (2000), in press.

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Chlamydia is the most common bacterial sexually transmitted disease (STD) in the United States, striking approximately three million Americans each year. At least 1 in 10 women under the age of 20 years and more than 1 in 20 women ages 20 to 24 years are infected with chlamydia. If left undetected, chlamydia can lead to serious complications, such as pelvic inflammatory disease, or even render a woman infertile. Once detected, chlamydia is easily cured by antibiotics, but because symptoms can be nonexistent, a woman with the condition may not know she has it until serious complications occur.

For these reasons, in the year 2000, the National Committee for Quality Assurance (NCQA) will require that all sexually active women ages 15-25 be tested annually for chlamydia. The NCQA maintains a set of standards that allows consumers to compare quality and performance of different managed health care plans. These standards, called the Health Plan Employer Data and Information Set (HEDIS), measure how health care plans perform on a number of high priority health care issues such as cancer, heart disease, and sexually transmitted diseases. HealthPartners researchers are currently testing methods of data collection for the HEDIS measure of chlamydia screening. This will help prepare managed care organizations for the NCQA HEDIS requirements.

The aim of the study is to find an accurate means of calculating the percentage of sexually active women of a specific age who were tested for chlamydia in 1998. The researchers developed a method of data collection using computerized codes for claims, and laboratory and pharmacy data. Researchers found specific codes that enhanced the accuracy of the measure. By improving ways in which sexually active women can be identified, this research will lead to a clearer target population for chlamydia screening and hopefully identify the disease earlier, before permanent damage occurs.

Research Team
HealthPartners: Feifei Wei, PhD, Michael Stiffman, MD, Mitch Arnhold, BA, Stacie Bigelow, MA. Centers for Disease Control and Prevention: Cathleen M. Walsh, DrPH, MSPH

Funding
Centers for Disease Control and Prevention, Division of STD Prevention, through the American Association of Health Plans

Related Presentation
Wei F, Walsh CM. Validation of data collection feasibility for HEDIS on chlamydia screening. Presented at Building Bridges VI Research Conference, Atlanta, GA. April 2000.

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Osteoporosis causes over a quarter of a million hip fractures and over half a million vertebral fractures every year. Over 80% of those afflicted by the disease are women, especially post-menopausal women, whose bodies produce much less estrogen. About 40% of women over 50 have a lifetime risk of some sort of fracture.

A recent HealthPartners study involving 500 post-menopausal women examined the impact of osteoporosis education and bone mineral density (BMD) screening. All of the participants attended a workshop on prevention of osteoporosis. Half of the women also received a peripheral BMD, which estimated the extent of bone loss. This study assessed if osteoporosis education with or without BMD testing encourages women to make lifestyle changes and/or start pharmaceutical treatments.

Most of the women participating in the study were already knowledgeable about osteoporosis. A high percentage correctly identified that both men and women can develop osteoporosis, that estrogen can protect against bone loss, that having a mother or grandmother who experienced loss of height has implications for their future bone health, and that active women tend to have higher bone density.

In a follow-up survey conducted six months after the education and BMD testing, over half of the women had modified their diet, increased exercise and increased calcium intake. Those whose BMD test indicated that they were at risk for osteoporosis were significantly more likely to begin pharmaceutical therapy, such as hormone replacement therapy (HRT), and newer drugs such as alendronate and raloxifene.

The study emphasizes the importance of osteoporosis education and the potential benefit of BMD testing for female patients.

Research Team
Sharon J. Rolnick, PhD, Lucy Rose Fischer, PhD, MPH, Richard Kopher, MD, Jody Jackson, BA, Renee Compo, WHNP Merck: Tom Abbott, PhD

Funding
Merck & Co.

Related Publications
Rolnick SJ, Kopher R, Jackson J, Fischer LR, Compo R, Abbott T. What is the impact of osteoporosis education and BMD testing for post-menopausal women in a managed care setting? Presented at the National American Menopause Society and the Society for Women's Health Research, New York. September 1999.

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