2001
Aging
Keeping the Elderly Out of Nursing
Homes
Medications
Intranasal
Treatment for Stroke
A Warning on the Label
Antibiotics in Dentistry
Treating Heart Disease
Lifestyle
Smoking
and Other Unhealthy Behaviors
Exercise for Life
Improving Health Care
Treating
Genital Warts
Daily
Rhythms and Hormone Therapies
A Project to IMPROVE Health Care
Integrating Research and Practice
Mothers and Babies
Maternal
Hormone Regulation
Checking for Jaundice at Home
Low Birthweight Babies
Why do Physicians Induce Labor?
Critical Care
Using
the Emergency Department
Noninvasive Ventilation
X-rays of Jaw Fractures
New Studies
Health
Care for Survivors of Torture
The Vaccine Safety Datalink
Creating a Population Database on Cancer Patients
Using Simulations to Improve Diabetes Care
AGING
Keeping the Elderly Out of Nursing Homes
Most elderly people
prefer to stay in their own homes or apartments and avoid being placed
in a nursing home for the rest of their lives. Nursing homes are also
extraordinarily expensive--costing over $40,000 a year.
The national Social Health Maintenance Organization (Social HMO) demonstration
project, begun in 1985, used community-based services, such as case management,
home health care, and homemaking, in an effort to prevent or postpone
nursing home placement for at-risk elderly. The Social HMO experiment
added a "social" component to Medicare HMO services because
elderly patients often have functional problems affecting both their health
and ability to live independently.
Two of the original Social HMO sites were Kaiser Permanente in Oregon
and HealthPartners (formerly Group Health) in Minnesota. The Social HMO
at Kaiser Permanente continues to operate. Because of major financial
losses, HealthPartners reluctantly terminated its Social HMO at the end
of 1994.
Researchers from HealthPartners Research Foundation and the Center for
Health Research at Kaiser Permanente followed more than 18,000 elderly
enrollees from their two sites about five years after the closing of the
Social HMO in Minnesota. They wanted to determine if elderly enrollees
in the Social HMO were more likely to be placed in nursing homes after
their program was closed.
Most of the enrollees were in their mid-70s or older at the time the study
began. Over the next five years, about ten percent were placed in nursing
homes. Controlling for age, gender, chronic health conditions, and potential
site differences, the study found that former enrollees in the Minnesota
Social HMO were about 40 percent more likely to be placed in nursing homes
than similar enrollees in Oregon who continued to have access to services
through their Social HMO.
This research suggests that, consistent with its intended purpose, the
Social HMO served as a protective factor for at-risk elderly people by
substituting community-based long-term care services for institutional
placement.
Research Team
HealthPartners Research Foundation: Lucy
Rose Fischer, PhD, Michael
Goodman, PhD, Feifei
Wei, PhD, Gerald Amundson, BS, Nicholas Strub, BA, Mary Kelley, BA.
Kaiser Permanente Center for Health Research: Carla A. Green, PhD, MPH,
Mikel Aickin, PhD, Kathleen K. Brody, BSN, PHN, Linda W. Phelps, MA.
Brandeis University: Walter Leutz, PhD.
Funding
National Institute on Aging R01 AG16366
Related Publications
and Presentation
Fischer LR, Leutz
W, Miller A, von Sternberg TL, Ripley JM. The closing of a social HMO:
a case study. J Aging Soc Policy 1998;10(1):57-75.
Dowd B, Hillson S, von Sternberg TL, Fischer LR. S/HMO versus TEFRA HMO enrollees: analysis of expenditures. Health Care Financ Rev 1999 Summer;20(4):7-23.
Fischer LR, Goodman MJ, Green CA, Wei F, Aicken M, Brody KR, Phelps LW, Amundson G, Strub N, Leutz W, Kelley ME. Risk of institutionalization associated with the termination of a social HMO: preliminary findings. Presented at the Gerontological Society of America Annual Meeting, Washington, DC, November 2000.
MEDICATIONS
Intranasal Treatment for Stroke
Researchers at HealthPartners
are working on a method to deliver medication for stroke patients via
the nose. This non-invasive technique allows medication to reach the brain
directly and quickly, countering the negative effects of a stroke. The
protective blood-brain barrier, consisting of tightly woven cells in the
blood vessels around the brain, often blocks drugs that are injected into
the bloodstream. When delivered intranasally, these drugs can travel along
the olfactory and other nerve pathways to the brain, bypassing the blood-brain
barrier.
Previous studies have shown that nerve growth factors-natural proteins
that protect nerve cells from-can reach the brain within minutes using
this method. Nerve growth factors offer a promising treatment for Alzheimer's
disease. Insulin-like growth factor-1, a drug that improves neurological
deficits following a stroke, also appears to reach the brain when delivered
through the nose. Researchers administered insulin-like growth factor-1
to rats with strokes using this technique and found reduced cerebral swelling
and reduced brain damage compared to the control group. This nerve growth
factor may also be beneficial for Alzheimer's disease and for head injury.
Intranasal delivery of drugs has many advantages. Various drugs that could
not otherwise pass the blood-brain barrier now have potential use. Delivering
drugs through the nose also reduces certain side effects since the drugs
avoid traveling through the bloodstream. This new method of delivery offers
many possibilities for the treatment of a variety of neurological disorders,
including Parkinson's disease and Alzheimer's disease.
Research Team
Alzheimer's Research Center of the HealthPartners Research Foundation:
Xin-Feng Liu, MD, John R. Fawcett, BS, Robert G. Thorne, BS, William
H. Frey II, PhD.
Funding
Leroy Stutzman- Stroke Fund, Chiron Corporation
Related Publications
Liu XF, Fawcett JR, Thorne RG, Frey
WH 2nd. Intranasal IGF-1 protects against transient focal cerebral
ischemia in rats following middle cerebral artery occlusion (MCAO). Stroke
2001; Jan32(1):352.
Liu XF, Fawcett JR, Thorne RG, Defor TA, Frey WH 2nd. Intranasal administration of insulin-like growth factor-I bypasses the blood-brain barrier and protects against focal cerebral ischemic damage. J Neurol Sci, 2001 Jun 15;187(1-2):91-7.
Liu XF, Fawcett JR, Thorne RG, Frey WH 2nd. Noninvasive intranasal insulin-like growth factor-I reduces infarct volume and improves neurologic functions in rats following middle cerebral artery occlusion. Neurosci Lett 2001 Aug;308(2):91-4.
Thorne RG, Frey WH 2nd. Delivery of neurotrophic factors to the central nervous system: phamacokinetic considerations. Clinical Pharmacokinetics 2001 (in press).
A Warning on the Label
In 1993, a prescription
treatment for nocturnal heartburn, cisapride, with the trade name Propulsid,
entered the drug market in the United States. Within two years, 47 cases
of cardiac arrhythmia had been reported to the Food and Drug Administration
(FDA), four of which had resulted in death. The FDA intervened by way
of a "black box" warning placed on the cisapride label describing
the hazardous effects posed to patients already taking specific prescription
drugs and those with pre-existing heart conditions. Beginning in 1998,
the FDA also required the manufacturer of cisapride to send a letter to
all health care providers cautioning about the potential adverse effects
associated with this drug.
Researchers at HealthPartners collaborated on a multi-site study to evaluate
the effectiveness of the FDA approach. This study used electronic medical
information to identify patients who had filled new cisapride prescriptions
both before and after the 1998 regulations. The researchers also used
medical records to determine which patients had pre-existing heart conditions
or were taking contraindicated medications.
The study revealed that the FDA approach was ineffective-there was almost
no decrease in contraindicated use of cisapride despite the warning labels
and letters to physicians. Thus, many patients continued to be exposed
to the risk of an inappropriate medication.
Cisapride was removed from the drug market in the United States in July
2000. Nonetheless, the risk of inappropriate prescribing is a persistent
problem for many types of medications. This research illustrates the FDA's
predicament: even a substantial effort to warn health care providers may
fail to prevent serious medical errors.
Research Team
Vanderbilt University School of Medicine: Walter Smalley, MD, MPH, Wayne
A. Ray, PhD.
HealthPartners Research Foundation: Michael
Goodman, PhD, Terese DeFor, MS, Kristi Paulsen, BA.
Food and Drug Administration: Diane K. Wysowski, PhD.
United Health Group: Deborah Shatin, PhD, Stephanie D. Schech, MPH.
Fallon Healthcare System: Jerry Gurwitz, MD.
University of Rhode Island: Susan E. Andrade, DSc.
Harvard Medical School: K.Arnold Chan, MD, DSc.
Harvard Pilgrim Health Care: Richard Platt, MD, MS.
Funding
The Food and Drug Administration: FD-U-001641, FD-U-001643, and FD-U-
001646.
Related Publication
Smalley W, Shatin D, Wysowski DK, Gurwitz J, Andrade SE, Goodman
M, Chan KA, Platt R, Schech SD, Ray WA. Contraindicated use of cisapride:
impact of Food and Drug Administration regulatory action. JAMA 2000;284(23):3036-3039.
Antibiotics in Dentistry
Millions of antibiotic
prescriptions are written annually, and dentists contribute a small but
significant percentage of all antibiotics prescribed by health care providers.
Currently, not much is known about how often or why dentists prescribe
antibiotics. With new and increasing microbial resistance to antibiotics,
there is an urgent need to control antibiotic prescribing by all providers,
including dentists.
HealthPartners in Minnesota and Kaiser Permanente Northwest in Oregon
offer both medical and dental services and have databases on these services.
A recent project, utilizing electronic data on antibiotic prescriptions
and a random sample of 200 medical and dental charts at each site, investigated
the number and types of antibiotics prescribed by dentists, physicians
and nurse practitioners and the reasons for antibiotic prescriptions.
The two sites did not differ in terms of the types of antibiotics; penicillin
comprises 77 percent of all the antibiotics prescribed by dentists. However,
the reasons for prescribing them appear to vary by geographic location.
These variations suggest that some dentists may be prescribing antibiotics
more frequently than is medically necessary.
Research Team
HealthPartners: Donald
B. Rindal, DDS, Bill
A. Rush, PhD, Michael
J. Goodman, PhD, Stephanie J. Klohs, RDH
Kaiser Permanente, Portland, Oregon: B. Alex White, DDS, DrPH
Funding
The Center for Disease Control 200-95-0953-039
Related Presentations
Rindal DB, White
BA, Goodman MJ.
Evaluation of prescribing practices for antibiotics among dentists. J
Den Res 2001 Jan;80(Spec Issue):209.
Rindal DB, Goodman MJ, White BA. Evaluation of prescribing practices for fluoride supplements among dentists and physicians. Presented at the American Association of Public Health Dentistry Annual Meeting, Portland, OR, April 30-May 2, 2001.
Treating Heart Disease
Diet, exercise, and
managing stress are important for preventing heart disease-the number
one cause of death in the United States. New cholesterol-lowering medications,
called statins, also have become an essential part of treatment.
Recent studies have suggested that many patients who should be receiving
statin therapy, such as Zocor and Lipitor, but are not. There may be too
few prescriptions written by physicians and poor drug compliance on the
part of patients.
A study at HealthPartners, however, has documented a dramatic increase
in the use of statins for heart patients. Nearly 3000 HealthPartners members
with a history of heart disease were studied. Cholesterol levels and statin
use were analyzed for 788 of these members who had prescription drug coverage
and 2 LDL measurements 12 or more months apart over a 4-year period.
Between the two LDL test dates, statin therapy tripled from 24 percent
to 73 percent among these 788 members. At the same time, their LDL levels
decreased by 21 percent.
This research confirms that physicians at HealthPartners are increasingly
using the most effective therapy currently available to combat heart disease.
Large decreases in LDL levels are expected to substantially reduce the
risk of recurrent heart disease. Analysis is currently underway to determine
whether or not the large decreases in LDL do indeed lead to less heart
disease.
Research Team
Richard J. Gray, MD,
Patrick J. O'Connor,
MD, MPH, Michael
V. Maciosek, PhD, Kelly Fillbrandt, MS
Funding
Merck and Co.
LIFESTYLE
Smoking and Other Unhealthy Behaviors
Smoking is a serious
health hazard that causes or exacerbates a number of chronic health problems.
Because nicotine is highly addictive, many smokers have little motivation
to quit.
Previous studies have shown that smokers are also at risk from other unhealthy
behaviors-they tend to exercise less and have less healthy diets compared
to non-smokers.
Researchers at HealthPartners Research Foundation have investigated whether
smokers who are thinking about quitting are more likely to engage in related
healthy behaviors compared to smokers with no interest in quitting.
Almost 6,000 HealthPartners members responded to a survey that assessed
diet, exercise and other health-related practices, including smoking.
About 900 respondents were current or recent smokers and answered questions
about their interest in quitting.
The study found smokers with the least interest in quitting consistently
reported worse health practices than either former smokers or smokers
who were trying to quit.
Potentially, clinicians could try an indirect approach to help unmotivated
patients quit smoking. That is, they might focus on their other unhealthy
behaviors-encouraging them to get a little more exercise and/or improve
their diet. Success in making other lifestyle changes might stimulate
these patients to launch a serious effort to confront their addiction
and give up smoking.
This study was a collaboration between HPRF and the Center for Health Promotion as a part of the Partners for Better Health Initiative.
Research Team
Raymond G. Boyle,
PhD, Patrick
O'Connor, MD, MPH, Nico
Pronk, PhD, Agnes Tan, PhD
Funding
HealthPartners' Center for Health Promotion
Related Publications
Boyle RG, O'Connor
PJ, Pronk NP,
Tan AWH. Health behaviors of smokers, ex-smokers, and never smokers in
an HMO. Prev Med 2000 Aug;31(2Pt 1):177-82.
Boyle RG, O'Connor
PJ, Pronk NP,
Tan AWH. Stages of change for physical activity, diet, and smoking among
HMO members with chronic conditions. Am J Health Promot 1998 Jan-Feb;
12(3):170-5.
Exercise for Life
Regular exercise keeps
people healthy. But, does exercise help people who already have chronic
health problems-such as diabetes, heart disease, hypertension or high
cholesterol? Sometimes patients with these diseases are afraid to be physically
active.
In 1995, about 1,800 HealthPartners members with at least two chronic
conditions participated in a survey concerning their level of physical
activity. Over the next three and a half years, 197 of the respondents
died. Chronically ill patients who were inactive had twice the rate of
mortality compared with those who exercised at least thirty minutes a
week, taking into account physical limitations. While it is possible that
unmeasured severity of the diseases contributed to some of the inactivity,
this study strongly suggests that lack of exercise increases the risk
of dying.
An important implication of this research is that physicians and other
medical providers need to counsel their chronically ill patients about
the importance of maintaining physical activity-even mild exercise like
daily walks with the dog or around the neighborhood can improve health.
Physical activity decreases insulin resistance and lowers blood pressure-especially
beneficial to patients with hypertension, lipid disorders, diabetes and
heart disease.
Research Team
Brian C. Martinson,
PhD, Patrick
J. O'Connor, MD, MPH, Nicolaas
P. Pronk, PhD
Funding
HealthPartners Research Foundation, HealthPartners Center for Health Promotion
Related Publications
Martinson BC,
O'Connor PJ,
Pronk NP. Physical
inactivity and short-term all-cause mortality in adults with chronic disease.
Arch Intern Med 2001 May 14;161(9):1173-80.
Pronk NP, Goodman MJ, O'Connor PJ, Martinson BC. Relationship between modifiable health risks and short-term health care charges. JAMA 1999 Dec 15;285(23):2235-9.
Pronk NP, O'Connor PJ, Martinson BC. Population health and active living: economic potential of physical activity promotion. Am J Sports Med 2001 (in press).
Pronk NP, O'Connor PJ, Martinson BC. Population health and active living: economic potential of physical activity promotion. Am J Med Sports 2001. (In press)
This study was a collaboration between HPRF and the Center for Health Promotion as a part of the Partners for Better Health Initiative.
IMPROVING
HEALTH CARE
Treating
Genital Warts
Human papillomavirus,
the virus that causes genital warts, is one of the most common sexually
transmitted diseases. Researchers at HealthPartners and Kaiser Permanente
in Colorado examined the treatment of genital warts in these health maintenance
organizations to determine if clinicians understand and follow appropriate
care guidelines.
The study, which was based on almost 1000 clinician surveys and reviews
of the medical records for 180 patients, found that clinicians understood
and adhered to the 1998 Guidelines for Treatment of Sexually Transmitted
Diseases developed by the Center for Disease Control and Prevention (CDC).
When presented with three medical scenarios involving genital warts, the
majority of clinicians followed the recommended treatments. Fewer than
2% reported recommending a non-adherent treatment.
Managed care organizations perform an increasing role in the treatment
of genital warts and other sexually transmitted diseases. This study confirms
that, at least in these managed care organizations, patients with genital
warts are receiving care in accordance with the national guidelines established
by the CDC.
Research Team
HealthPartners: Michael Stiffman, MD, MSPH, Terese Defor, MS, A.
Lauren Crain, PhD, Linda Cherney, MA, Carol Westrum, MA.
Kaiser Permanente: David Magid, MD, MPH, Ella Lyons, MA.
Division of STD Prevention, Center for Disease Control and Prevention:
Kathleen Irwin, MD, MPH, Lynda A. Anderson, PhD.
Funding
Center for Disease Prevention and Control (CDC) 200-95-0953-026
Related Presentation
Stiffman MN, Magid DJ, Irwin KL, Anderson LA, Cherney LC, Defor T, Westrum
CA, Lyons E, Strub N. Use of and adherence to CDC-recommended treatment
guidelines for chlamydia and genital warts: a survey of managed care providers.
Presented at the National STD Prevention Conference, Milwaukee, WI, December
2000.
Daily Rhythms and Hormone Therapies
The human body functions
rhythmically. The most prominent rhythms are circadian, which occur over
a 24-hour period. Although circadian rhythms can adjust to differences
in exposure to day-night periods, they can persist under constant environmental
conditions, such as space flight.
HealthPartners researchers, in collaboration with researchers in other
countries, are conducting a series of studies to examine how the timing
of circadian rhythms for hormonal and biochemical functions vary by gender
and age. Their studies to date show that boys and men tend to have different
timing than girls and women. Moreover, while circadian rhythms persist
in healthy people into very old age, the amounts of certain hormones released
by the body tend to decrease with age.
For a variety of reasons, people commonly take doses of hormones-such
as growth hormone, melatonin, or sex hormones. Hormone replacement therapy,
for example, is commonly prescribed for post-menopausal women to prevent
osteoporosis and possibly other conditions. Hormones are typically taken
with little attention to the timing. This research will help to adjust
the timing of treatment to conform to natural circadian rhythms and avoid
disrupting rhythmic functions.
Research Team
HealthPartners: Erhard
Haus, MD, PhD, David
Lakatua, MD, Linda Sackett-Lundeen, MT (ASCP).
Romanian Academy of Medical Sciences: Grazziela Y. Nicolau, PhD, Leonard
Dumitriu, MD.
University of
Paris: Yvan Touitou, PhD.
Tel Aviv University: Israel Ashkenazi, PhD, Aharon Ticher, PhD.
Funding
Department of Pathology-Regions Hospital, Romanian Academy Sciences, Department
of Human Genetics-Tel Aviv University, Ramsey Foundation
Related Publications
Touitou Y, Haus E.
Alterations with aging of the endocrine and neuroendocrine circadian system
in humans. Chronobio Int 2000 May 17(3):369-390.
Haus E, Touitou Y. Chronobiology of development and aging. In: Redfern P, Lemmer B, eds. Handbook of experimental pharmacology: physiology and pharmacology of biologic rhythms. Berlin: Springer-Verlag, 1997; 125:94-134.
A Project to IMPROVE Health Care
Continuous quality
improvement (CQI) techniques have been used in many types of industries
to improve the quality of products and services and to promote cost-efficiency.
These techniques also have been adapted for health care settings.
Project IMPROVE (IMproving PRevention through Organization,
Vision & Empowerment) was the first large randomized
controlled trial to test the effectiveness of CQI in health care. The
purpose of IMPROVE was to test whether CQI training might help
to enhance rates of eight preventive services: blood pressure monitoring,
Pap smears, cholesterol monitoring, tobacco cessation, breast examination,
mammography, influenza vaccine, and pneumococcal vaccine.
Forty-four primary care clinics volunteered to participate in this four-year
collaborative project between HealthPartners and Blue Cross and were randomly
assigned to intervention and control groups. The intervention involved
training in a seven-step CQI process and in how to construct a system
for prevention. Researchers surveyed 12,000 patients and examined a large
number of medical charts to determine if the intervention was associated
with an increase in the eight preventive services.
The trial failed to show an improvement in preventive services. Many of
the clinics had high rates of preventive services before the project began,
limiting the potential for improvement. Furthermore, many of the teams
found the particular CQI approach being taught to be too time consuming
and did not complete the process.
Although this scientific trial did not demonstrate the desired effect,
most of the clinics and medical groups throughout Minnesota that participated
in the project felt it had been a valuable experience. They had acquired
skills and knowledge that allowed them to make many subsequent improvements
in patient care. The project also led to the publication of over 30 articles
and book chapters about the many lessons learned.
Research Team
HealthPartners: Leif
I. Solberg, MD, Gail M. Amundson, MD, Gerald Amundson, BA, Ann Book,
BS, Carolyn Calomeni, RN, MPA, Marty Campbell, Kathleen Conboy, RN, Katherine
Giles, BSN, MBA, Andrew Nelson, MPH, Kathy Schaivone, MPA, Ann Sisel,
BA, Charlotte Straw, BS, Carol Westrum, MA, Lynne Dancha, BS, FLMI, Chris
Judge, RN, BSN, John Wheeler, MD
Mayo Clinic and Foundation: Thomas E. Kottke, MD, Greg Angstman, MD.
Brekke Associates, Inc.: Milo L. Brekke, PhD.
Blue Cross and Blue Shield of Minnesota: Sanne Magnan, MD, PhD, Shirley
A. Conn, RN, MSN, Candace Moody, BS, MPA.
Consultants: Arnold Kaluzny, Eugene Nelson, ScD, Robert Steel, PhD, Gestur
Davidson, PhD, Brian Harmon, BA.
Funding
Agency for Health Care Policy and Research R01HS08091
Selected Publications
Solberg LI, Kottke
TE, Brekke ML, Magnan SJ, Davidson G, Calomeni CA, Conn SA, Amundson GM,
Nelson AF. Failure of a continuous quality improvement intervention to
increase the delivery of clinical preventive services: a randomized trial.
Eff Clin Pract 2000 May-June; 3(3):105-115.
Solberg LI, Kottke TE, Brekke ML, Magnan SJ. Improving preventive services is difficult. [commentary]. Eff Clin Pract 2000 May-June;3(3):153-5.
Kottke TE, Solberg LI, Brekke ML, Cabrera A, Marquez MA. Delivery rates for preventive services rates in 44 midwestern clinics. Mayo Clin Proc 1997 Jun;72(6):515-23.
Integrating Research and Practice
Because HealthPartners Research Foundation is affiliated with a health plan and a multi-specialty medical group, it is in a unique position to integrate research and medical practice. The research questions and ideas for projects frequently originate in problems or issues that occur in patient care. Most research projects conducted at HealthPartners Research Foundation involve practicing clinicians as principal investigators, collaborators, or consultants. Ideally, results and practical lessons from the research have a direct impact on improving patient care.
The following are just a few examples of partnerships between research and practice:
Treating Lung Injury. Pulmonologists at HealthPartners Regions Hospital noticed that intense artificial respiration for many patients with a critical lung injury did not raise their blood oxygen level sufficiently for survival. Their research has shown that simply turning a patient over improves dramatically his or her ability to breathe by preventing fluid from being pooled at the base of the lung due to gravity. This is now changing intensive care practice.
Preventing Osteoporosis. A good example of research integrated with practice is the relationship between researchers at the Research Foundation and the Obstetrics-Gynecology (OB/GYN) Department of HealthPartners Medical Group. A recent study showed that if women are given the results of bone mineral density tests and are found to have indications of osteoporosis, they are three times more likely to start hormone replacement therapy compared to those who only receive education about osteoporosis. This finding led the OB/GYN Department to obtain three bone density scanners and to visit each HealthPartners Medical Group primary care clinic to teach about this technology.
Clinical Guidelines. Researchers at the Foundation have worked closely with the Institute for Clinical Systems Improvement in Minnesota to develop clinical guidelines and evaluate their impact. Clinical guidelines provide the latest research-based evidence for incorporation into clinical practice. The evaluations have provided useful data on how to effectively implement guidelines into clinical practice. An evaluation of the female bladder infection guideline, for example, demonstrated how redesigning office systems could substantially improve medical practice.
Improving Chronic Care. One of the closest working relationships between research and practice is a project that is just starting. Project CHANGE (CHronic care and Access changes Need Good Evaluation), with funding from the Robert Wood Johnson Foundation, will evaluate two initiatives at HealthPartners Medical Group: a program to provide rapid access to clinical appointments and a new system of care for patients with chronic conditions.
The 2001 report from the Institute of Medicine expressed alarm about the "chasm" separating usual care from evidence-based practice. HealthPartners, through its support and sponsorship of the Research Foundation, offers an important model for integrating research and practice.
Principal Investigators:
Treating Lung Injury: John
Marini, MD
Preventing Osteoporosis: Sharon
J. Rolnick, PhD, MPH
Clinical Guidelines: Patrick
J. O'Connor, MD, MPH
Improving Chronic Care: Leif
I. Solberg, MD
MOTHERS
AND BABIES
Maternal
Hormone Regulation
A woman's steroid
hormones, estrogen and progesterone, direct growth and development of
the fetus during pregnancy. The two hormones serve as signals to initiate
different stages in fetal development as well as contractions of the uterus
during labor and delivery. Therefore, an internal control mechanism of
progesterone and estrogen is important for development and normal delivery
time.
One enzyme that plays a role in the synthesis of the steroid hormones
is 17b-hydroxysteroid dehydrogenase type 2. HealthPartners collaborated
with Canadian scientists on a study that examined the gene expression
of this enzyme in order to locate its primary area of production. The
researchers studied human placentas, after obtaining informed consent
from the new mothers. They divided the placentas into component parts
and assayed for the enzyme activity. The parts displaying enzyme activity
were then further examined to identify which cells were expressing the
gene.
The study determined that 17b-hydroxysteroid dehydrogenase type 2 is synthesized
exclusively in the cells along the inner walls of arteries where nutrients
are exchanged between the mother and the fetus. These results suggest
a regulatory role for these arterial cells and provide fundamental information
necessary for understanding maternal hormone regulation.
Research Team
HealthPartners Regions Hospital: Charles
H. Blomquist, PhD, Peter D'Ascoli, MD
Laboratory of Ontogeny and Reproduction, Laval Medical Center, Québec,
Canada:
Martin Bonefant, BS, Pierre R. Provost, PhD, Renee Drolet, BS, Yves Tremblay,
PhD.
Funding
The Ramsey Foundation and the Medical Research Council of Canada
Related Publications
and Presentations
Bonenfant M, Blomquist
CH, Provost PR, Drolet R, D'Ascoli PT, Tremblay Y. Tissue- and site-specific
gene expression of type 2 17b-hydroxysteroid dehydrogenase: in situ hybridization
and specific enzymatic activity studies in human placental endothelial
cells of the arterial system. J Clin Endocrinol Metab 2000;85(12):4841-4850.
Checking for Jaundice at Home
Jaundice is a yellowing
of the skin caused by improper or immature functioning of the liver. Approximately
sixty percent of newborns in the United States develop jaundice. The condition
is usually not serious, but if left untreated, it can lead to severe brain
injury.
Typically, infants are released from the hospital before jaundice reaches
its peak at three to five days of life. Returning to a clinic soon after
childbirth is inconvenient.
A recent study at HealthPartners found that nurses checking for jaundice
in a home setting were an adequate substitute for clinic visits. Nurses
accurately identified newborns with the most severe jaundice. Thus, home
visit nurses provide new mothers with a convenient and dependable alternative
to clinic examinations.
Research Team
Diane
J. Madlon-Kay, MD, Laura Lantz, Pamela Ristau, Kim Stone, Annette
Swain, Mary Jo Feely.
Funding
Ramsey Foundation
Related Publications
Madlon-Kay
DJ. Home health nurse clinical assessment of neonatal jaundice: comparison
of 3 methods. Arch Pediatr Adolesc Med 2001 May;155(5):583-6.
Madlon-Kay DJ. Neonatal jaundice. In: Lipsky MS, ed. Gastrointestinal problems (AAFP). Philadelphia: Lippincott Williams and Wilkins, 2000:39-47.
Madlon-Kay DJ. Evaluation and management of newborn jaundice by midwest family physicians. J Fam Pract 1998 Dec;47(6):461-4.
Low Birthweight Babies
Very low or extremely
low birth weight infants-less than 1500 grams at birth-have extensive
medical problems that persist throughout childhood. But these babies comprise
fewer than one percent of newborns each year. Are infants with moderately-low
birth weight, those just below 2500 grams, also at risk?
Researchers at HealthPartners, using electronic birth and medical records
during 1993-1995, compared the general health of moderately low birth
weight babies with that of normal birth weight babies over the first year
of life.
The study discovered that even slightly underweight babies are at higher
risk for health problems. Even though problems were not detected immediately
following delivery, infants of low birth weight were three times more
likely than normal birth weight infants to be hospitalized within the
first year. The average health care cost for low birth weight infants
was about 46 percent higher compared to normal weight infants.
Given the high risk of re-hospitalization in low birthweight infants,
health plans may wish to be proactive to reduce the rates of premature
birth. For example, physicians should test for and treat vaginitis, a
vaginal bacterial infection that is common in pregnant women and has been
linked to low birth weight. Physicians could also counsel their patients
and encourage longer intervals between pregnancies and ensure care coordination
where there is suspicion or evidence of limited social support.
Research Team
Sharon J. Rolnick,
PhD, MPH, Jody M. Jackson, BA, Patrick
O'Connor, MD, MPH, Terese DeFor, MS, Diane Eggen, Michael
V. Maciosek, PhD, William
Rush, PhD, Nicolaas
P. Pronk, PhD.
Funding
Center for Health Promotion
Related Publications
and Presentations:
Rolnick SJ, Jackson
JM, O'Connor PJ,
DeFor TA. Impact of birthweight on healthcare charges within a managed
care organization. Am J Manag Care 2000 Dec;6(12):1289-96.
Rolnick SJ, Jackson JM, O'Connor PJ, DeFor TA. Impact of birthweight on healthcare charges within a managed care organization. Presented at the American Public Health Association Annual Meeting, Boston, MA, November, 2000.
Why Do Physicians Induce Labor?
Sometimes obstetricians
induce labor by using hormones to trigger contractions and hasten the
progress of childbirth. Over the past ten years, the rate of induced labor
has increased nationally from approximately 9 percent of all pregnancies
to over 19 percent. What has caused this large increase?
One explanation is that more women request inducement to allow them more
control and convenience during childbirth. Another is that more effective
labor-inducing agents have become available.
Several recent studies have also suggested that monetary factors may influence
clinicians' decisions about inducing labor. For example, one study found
that induction is more common when physicians are paid on a fee-for-service
basis compared to those whose salary is paid through a group health plan
or health maintenance organization.
A new Minnesota study compared rates of labor induction for salaried physicians
versus those reimbursed on a fee-for-service basis. The HealthPartners
study found no difference in the rate of induction based on how obstetricians
are reimbursed for their services. Nonetheless, the reasons tended to
be somewhat different-salaried physicians were more likely to induce labor
because of medical necessity whereas fee-for-service physicians were more
likely to describe the labor induction as elective.
Research Team
Department of Research, Olmstead Medical Center, Rochester, MN: P. Yawn,
MD MSc, Peter Wollan, PhD, Margary Kurland, RN.
HealthPartners: Sharon
Rolnick, PhD, Kristine
Fortman, PhD.
Funding
Grants from HealthPartners Foundation and the Olmstead Medical Center
Foundation
Related Publications
Bloom FB, Fortman KK,
Rolnick SJ, Lardy
BD. Monograph: Advancing women's health: health plans' innovative programs
in obstetrics and pregnancy care. The Commonwealth Fun and the American
Association of Health Plans (AAHP), 1998
Rolnick SJ, Hyer B, Jackson JM, Loes LM. Impact and implementation of an active management of labor guideline in a managed care setting. Qual Manag Health Care 1998 Spring;6(3):35-42.
CRITICAL CARE
Using the Emergency Department
When is an accident
or medical condition serious enough to justify an emergency room (ER)
visit? In a survey conducted at HealthPartners, emergency physicians,
primary care physicians, and laypersons, from diverse socio-economic backgrounds,
rated the appropriateness of several ER case examples.
Laypersons were somewhat more likely to use convenience as a factor in
assessing the role of the emergency room, whereas physicians were more
likely to use more restrictive biomedical criteria. For example, almost
a fifth of laypersons but none of the physicians thought it might be okay
for a young man without health insurance to go to the ER for a physical
in order to qualify for his first job. Laypersons who thought this was
appropriate cited the importance of obtaining a job as justification for
their ratings.
This study reflects the disparities in access of our health care system.
Unless these issues are addressed, controversy over the role of the ER
is likely to continue.
Research Team
HealthPartners Research Foundation and Regions Hospital Department of
Emergency Medicine: Brent
R. Asplin, MD, MPH, Mary Kelley, BA, Terese DeFor, MS.
University of Michigan: Rodney A. Hayward, MD, Steven J. Berstein, MD,
MPH, Susan D. Goold, MD, MHSA, MA, Toan Leung, MD.
University of Minnesota: Steve Copps, MD.
Funding
HealthPartners Research Foundation
Related Presentations
Asplin BR, Goold
SD, Leung T, Bernstein SJ, Hayward RA. Layperson perceptions of the appropriateness
of emergency department utilization. Presented at the Society for Academic
Emergency Medicine, San Francisco, CA. May 2000.
Noninvasive Ventilation
When patients require
assistance in breathing, mechanical ventilation can be life-saving. It
is most often applied using a breathing tube placed deep in the patient's
windpipe. Unfortunately, this breathing tube is uncomfortable, and it
increases the patient's risk of developing serious infections, such as
pneumonia.
Noninvasive ventilation uses a mask without an inserted tube. Researchers
at HealthPartners, the University of Minnesota and Vanderbilt University
in Tennessee investigated reasons why many patients (about 30 percent)
do not tolerate noninvasive ventilation.
This study focused on the effects of unavoidable air-leaks between the
patient's face and the breathing mask. The presence of such leaks leads
to marked variation in the size of the breaths given to the patient, the
effort required for the patient to "start" a breath, and the
timing of the breaths. Because such variation could seriously affect patient
comfort and tolerance of noninvasive ventilation, the researchers are
currently developing methods to decrease these unstable behaviors.
Research Team
HealthPartners Regions Hospital and University of Minnesota: John
R. Hotchkiss, MD, Alexander B. Adams, MPH, RRT, David J. Dries, MSE,
MD, John J. Marini,
MD.
Vanderbilt University: Philip S. Crooke, PhD
University of Minnesota: Perry H. Leo, PhD
Valley Inspired Products: Peter G. Bliss, MSE
External Funding
NIH SCOR HL 50152
American Heart Association
Related Publications
Hotchkiss JR,
Adams AB, Dries DJ, Marini
JJ, Crooke PS. Dynamical behavior during noninvasive ventilation:
chaotic support? Am J Respir Crit Care Med 2001 Feb;163(2):374-8.
Hotchkiss JR, Adams AB, Dries DJ, Marini JJ, Crooke PS. Variable ventilatory support in a model of invasive pressure support ventilation. Am J Respir Crit Care Med 2001 May;163(5):A483.
Crooke PS, Hotchkiss JR, Marini JJ. Linear and nonlinear mathematical models for non-invasive, passive ventilation. Math Comput Modeling 2001 ( in press).
X-rays of Jaw Fractures
Locating the precise
location and type of a jaw fracture is important for determining how to
surgically repair the fracture. The standard type of x-ray for examining
jaw fractures in preparation for surgery is called panoramic tomography.
This specialized x-ray projects the entire jaw on a single film. Another
type of examination, called computed tomography or CT scanning, has been
increasingly used to analyze fractures. Helical computed tomography incorporates
new technology that provides three-dimensional views of the jaw.
Researchers at the HealthPartners Regions Hospital and the University
of Minnesota compared these two forms of tomography to determine which
one was superior in identifying jaw fractures. The study involved 42 patients
with a total of 73 jaw fractures. The type and locations of the actual
fractures were confirmed during surgery. The attending surgeons also answered
questions regarding which examination they considered most accurate and
helpful in locating fractures.
The results showed that helical computed tomography accurately identified
more fractures than the commonly preferred panoramic tomography, which
missed seven fractures. Helical computed tomography also provided additional
information on the nature of the fractures that were correctly identified
by panoramic tomography.
Although panoramic tomography still gives a better assessment of fractures
involving tooth roots, the attending surgeons reported that helical computed
tomography alone would have provided sufficient information on the jaw
fractures for almost all their patients.
Past studies that documented poor performance of computed tomography were
conducted using old technology with lower sensitivity. The newer helical
computed tomography used in this study provided better resolution.
One of the advantages of helical computed tomography is that it can take
an image of an injured patient who is lying down. This research shows
that a surgeon in any hospital with a CT scan can adequately assess jaw
fractures in patients who are unable to sit up for a standard x-ray.
Research Teams
HealthPartners Regions Hospital: Charles I. Benjamin, MD, Peter A. Hilger,
MD, David D. Hamlar, MD, Frank G. Ondrey, MD, Joesph H. Tashjian, MD,
Warren Schubert,
MD.
University of Minnesota: Ian F. Wilson, MD, MPH, Adam Lokeh, MD, William
Thomas, PhD.
Funding
Regions Hospital Plastic Surgery Department
Related Publications
Wilson IF, Lokeh A, Benjamin CI, Hilger PA, Hamlar DD, Ondrey FG, Tashjian
JH, Thomas W, Schubert
W. Prospective comparison of panoramic tomography (zonography) and
helical computed tomography in the diagnosis and operative management
of mandibular fractures. Plast Reconstr Surg 2001 May;107(6):1369-75.
Wilson IF, Lokeh A, Benjamin CI, Hilger PA, Hamlar DD, Ondrey FG, Tashjian JH, Thomas W, Schubert W. Contribution of conventional computed tomography axial CT (non-helical), in conjunction with panoramic tomography (zonography), in evaluating mandibular fractures. Ann Plast Surg 2000 Oct:45(4);415-21.
NEW
STUDIES
Health Care for Survivors of Torture
Minnesota has a large
population of refugees, many of whom were victims of government-sponsored
torture in their countries of origin. As many as 14,000 torture survivors
currently live in the Twin Cities and Greater Minnesota. Survivors often
experience post-traumatic stress disorder- persistent physical and mental
health problems-as a consequence of the horror they suffered. Unfortunately,
many refugees and torture survivors lack adequate health care to meet
their special needs.
Researchers at the University of Minnesota and HealthPartners are in the
process of conducting a five-year Refugee Population Study to examine
the effects of torture and violence among Somalis and Ethiopians in the
Twin Cities. The purpose of the study is to identify the physical, social,
and mental health problems associated with torture, in order to define
the full spectrum of survivors' health needs.
About 1,000 refugees are participating in surveys, answering questions
about their health and post-traumatic stress conditions. The sample will
be divided into three groups: people who have experienced torture, those
who have gone through war-related trauma, and those with neither experience.
The project will compare physical and mental health symptoms and sources
of social support among these groups. In a later phase of the study, the
research team will select a sub-sample of torture survivors to investigate
mental health impairments associated with torture.
This project presents many challenges. The different ethnic groups and
languages involved in the study require careful staff selection and translation
services. Since torture is often set in a political context, many survivors
are reluctant to tell their stories or seek help, despite their need.
Findings from this research will provide critical information for better
serving the population of refugees suffering from post-traumatic stress
disorder.
Research Team
HealthPartners: James
Jaranson, MD, MA, MPH.
University of Minnesota: Joseph Westermeyer, MD, MPH, PhD, David Johnson,
MD, MPH, Cheryl Robertson, RN, MPH, PhD, James Butcher, PhD, Linda Halcon,
PhD, MPH, RN.
Funding
National Institute of Mental Health R01-MH59579 and HealthPartners Research
Foundation
Related Presentations
Jaranson JM.
Identifying torture and violence among resettled refugee populations.
Presented to the International Congress on Law and Mental Health (IALMH),
Siena, Italy, July 13, 2000.
Jaranson JM. The refugee population study: political, ethical, and methodological implications of studying torture and violence in Somali and Ethiopian communities in Minnesota, USA. Presented to the Conjoint Colloquium of L'Evolution Psychiatrique and the Society for the Study of Psychiatry and Culture, Paris, France, October 21, 2000.
The Vaccine Safety Datalink
HealthPartners Research
Foundation is collaborating with seven other research centers on a new
Vaccine Safety Datalink project. The purpose is to link vaccination information
with subsequent adverse events recorded in health plan databases.
Over the past two centuries, the development of vaccines to combat infectious
diseases has saved many lives. Despite this success, rare but life-threatening
adverse effects tend to be widely publicized and erode public confidence
in immunization programs.
Health plan databases offer a valuable resource evaluating vaccine safety.
They link detailed vaccination data with medical events, including hospitalizations
and emergency room visits. The new project is one of a number datalink
projects funded by the Center for Disease Control and Prevention (CDC)
to identify and prevent adverse events associated with common vaccines.
Principal Investigator
Feifei Wei, PhD
Funding
Center for Disease Control and Prevention, in conjunction with the American
Association of Health Plans, #200-95-0957-057
Creating a Population Database on Cancer Patients
Researchers at HealthPartners
Research Foundation, Meyers Primary Care Institute, Kaiser Permanente
Northern California, Henry Ford Health System, and Boston University are
collaborating on a project to create a large population database of cancer
patients who are enrolled in health maintenance organizations (HMOs) located
in four states.
Much of the data currently available on cancer treatment comes from cancer
registries. Using existing databases of HMO enrollees will expand opportunities
for research on cancer patients in community populations. The goal of
the current project is to determine the completeness and accuracy of HMO
electronic data for identifying treatments and outcomes for breast and
cervical cancer patients. HMO electronic data will be compared with information
contained in medical records. The researchers also plan to examine variations
in the completeness of electronic data among the HMOs.
Principal Investigator:
Feifei Wei, PhD
Funding
National Cancer Institute, #R01-CA87944
Using Simulations to Improve Diabetes Care
Researchers at HealthPartners
are in the process of testing two interventions for diabetes care. In
one intervention, physicians "treat" simulated clinical cases
and receive feedback on their care provided. In the other intervention,
an influential physician discusses diabetes care with the participating
physician. Diabetes care provided by participating physicians will be
compared to assess whether the interventions lead to better care for diabetes
patients.
The study involves 880 primary care physicians and an estimated 3,360
diabetes patients. HealthPartners Medical Group already provides some
of the best diabetes care in the country, and this project aims to improve
diabetes care even more.
Principal Investigator
Patrick J. O' Connor,
MD, MPH
Funding
Agency for Healthcare Research & Quality R01-HS10639
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