Summer 1999 - Volume 3 Number 2

Original Research

Oncology Patients' Experience with Complementary and Alternative Forms of Therapy: A Preliminary Report.
Nancy Vuckovic, PhD; Judy Wick, RN, MA

Most participants use CAM treatments in conjunction with, rather than as replacement for, allopathic treatments for cancer. They characterize CAM as holistic, devoid of side effects, and focused on health promotion. According to these participants, providers accepted, but did not endorse, use of CAM treatments. Participants indicated a desire for additional information and guidance about CAM treatments from their medical providers and health plan.
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Use of and Interest in Alternative Types of Therapy Among Clinicians and Adult Members of the Kaiser Permanente Northern California Region: Results of a 1996 Survey.
Nancy P. Gordon, ScD; David S. Sobel, MD, MPH

Nearly 90% of the clinicians reported recommending at least one alternative therapy in the previous 12 months. Chiropractic, acupuncture, massage, and relaxation training/meditation were the methods of use most often cited by members and clinicians, and pain or stress management were the most frequently cited reasons for use. Two thirds of adult primary care physicians and three fourths of obstetrics/gynecology clinicians were at least moderately interested in using alternative therapies with patients.
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A Young Internist Seeing Part of Our History.
Oliver Goldsmith, MD
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Clinical Contributions

Introduction to The James A. Vohs Award for Quality
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The Comprehensive Computer-Based Patient Record (CPR) Project.
Northwest Division

In 1992 KPNW adopted an automated data collection system, creating a single repository which tied together data from 24 separate departmental systems. This system is now used by KPNW's entire care delivery staff and is available in every location. The impact, as assessed by multiple instruments, shows a pattern of significant improvement in many aspects of care, with increasingly positive clinician attitudes. Specific examples of improved care include outcomes data and cost control benefits. National recognition has ensued.
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Clinical Pharmacy Anticoagulation Service.
Colorado Region

The anticoagulant warfarin requires meticulous laboratory monitoring and is frequently associated with drug-induced hospitalization. Originated in 1991, CPAS assists physicians and patients in management of warfarin therapy, and was later enlarged to include low molecular weight heparin therapy for deep venous thrombosis. Most management is by clinical pharmacists. Data regarding thromboembolism and bleeding episodes related to warfarin before and after CPAS show substantial benefits, and use of low molecular weight heparin reduced hospitalizations. There is improved quality of anticoagulation therapy with reduced rates of bleeding, thromboembolism, hospitalization, and death.
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The Diabetes Prevention Care Program.
North Carolina Region

Diabetes is responsible for much increased morbidity and mortality, from many complications. In 1995, a multidisciplinary team approach to adult diabetes care was launched which emphasized a primary-care team approach and use of care managers. Since the program's inception, statistically significant improvements have been seen in multiple clinical measurements. This effective program is easily transferable to other facilities.
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Kaiser Permanente Medicine 50 Years Ago: A Review of Our Experience with Hernioplastic Procedures.
A. La Mont Baritell, MD, BA; Commentary by Richard A. Dorazio, MD, FACS

This 1944 article reports data about 623 hernioplastic procedures performed in a 21-month period at the Oakland, CA, Permanente Foundation Hospital. There was no mortality and almost no surgical complications, but 23% suffered minor or major pulmonary complications, not reduced by sulfadiazine prophylaxis. Of note is the fact there were no pulmonary complications in a small subset of persons ambulated on the first or second postoperative day.
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A Review of Advances in Treating Fibromyalgia Syndrome (FMS) Using a Multidisciplinary Approach.
Elizabeth Oyekan, PharmD, FCSHP; Jimmie S. Kung, MD, PhD, FABPM

This review describes the fibromyalgia syndrome, which is of unknown etiology and affects 3-6 million people in the US. The article describes the characteristics of fibromyalgia rheumatica, including the specifics of how to establish a diagnosis. A multidisciplinary management approach is described and advised with an algorithm detailing specific nonpharmacological and pharmacological treatment options. A table with addresses and phone numbers of potential support groups and services is included.
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Health Systems

A Stress Awareness Program for Physicians: "Care for the Caregiver"A Review.
Lee Jacobs, MD, Associate Editor

The Southern California Permanente Medical Group's "Care for the Caregiver" training program for clinicians is reviewed. This program was conceived in 1996 by "grass roots" physicians as a way to provide skills on dealing with their stressful work life. This three-hour educational session consists of minimal didactic instruction and entertaining and effective dramatic vignettes. An impressive program that other Permanente Groups should consider importing.
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Editors' Comments

Tom Janisse, MD, Editor-in-Chief
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A Word from the Medical Directors

Pursuing High Performance (An "Inside" Game)
Ronald L. Copeland, MD, FACS
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External Affairs

Optimal Renal Care. Interview with Ramon Hannah, MD & Joe Carlucci.
Scott Rasgon, MD, Associate Editor

This is the first "medical services" or "management services" product developed by a Permanente Medical Group (SCPMG) for the marketplace. ORC gives Permanente physicians opportunities to improve treatment outcomes, improve cost structures, and implement new technology and methods of dialysis care. Looking at the longitudinal costs of care, investing in programs and people to make patients better will result in healthier patients at time of dialysis, keep patients healthy during the dialysis years, and enable patients to receive a transplant. A healthy patient consumes fewer resources, creating resources for treatment of other conditions.
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A Bill or Not a Bill?
Donald W. Parsons, MD

"The water is building behind the dam," because despite high levels of members' overall satisfaction with their health plans, the American public has heard managed care horror stories and are looking for comprehensive patient protection. The dilemma is that the comprehensive approach in legislation "invites death by a thousand nibbles." If managed care reform is passed by Congress this year, look for single-issue, less complex bills, such as a definition of "medical necessity."
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Abstracts of articles authored or coauthored by Permanente clinicians
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Book Reviews

"The Water We Drink"
Joshua Barzilay, MD; Winkler G. Weinberg, MD; J. William Eley, MD, MPH
Review by Vincent J. Felitti, MD, Associate Editor
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"House Officer's Guide to Arthrocentesis and Soft Tissue Injection"
Bruce Carl Anderson, MD
Review by Vincent J. Felitti, MD, Associate Editor
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Soul of the Healer

Douglas P. Grey, MD

"A Woman."
Terry Laskiewicz, MD

"A Man."
Terry Laskiewicz, MD

"Winter Scene."
Marian Savige

The Lighter Side of Medicine


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