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The INSURE Project on Lifecycle Preventive Health Services

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					The INSURE Project on Lifecycle
Preventive Health Services
DONALD N. LOGSDON, MD
MATTHEW A. ROSEN, PhD
MICHELE M. DEMAK, MPH




THE LIFECYCLE PREVENTIVE HEALTH Services (LPHS)                  Metropolitan Life Insurance Company in New York
study was recommended by an advisory group on health             City, consists of four full-time professionals.
education of the private life and health insurance com-
                                                                    The objectives of the project are as follows:
panies and was announced by the industry's Clearing-
house on Corporate Social Responsibility in July 1980               1. to define age-specific procedures and packages of
(1). The project is a 3-year feasibility study involving         preventive health services, including patient education,
the planning, implementation, and evaluation of pre-             for all age groups
ventive health services (including health education) in             2. to implement the LPHS packages at sites in dif-
primary medical care. The lifecycle health-monitoring            ferent areas of the United States
approach to be used includes specific preventive services           3. to recruit primary care physicians in group prac-
for 10 age groups. A quasi-experimental research de-             tices at each of the study sites
sign will be used in the LPHS study, whereby three                  4. to develop educational materials and protocols
study (experimental) sites are matched with three                for physicians and review with study physicians the
control sites. The sample size is 4,500 patients and ap-         LPHS approach
proximately 100 physicians. An analysis will be made of             5. to promote LPHS among patients at these study
the proximal impact of the preventive services on con-           sites
sumers, providers, and third-party payers, as well as               6. by using a quasi-experimental study design, to
of the costs.                                                    determine the short-term effects of the project on
   The project is being conducted by INSURE, a                   physicians and patients.
nonprofit organization whose board of directors in-                 Several group practice sites will be used for the
cludes members of the Advisory Council on Education
for Health and executives of life and health insurance           LPHS study. The packages of preventive services for
                                                                 the "well" population were reviewed in consultation
companies. The project staff, which is housed at the             with health professional groups, experts in preventive
Dr. Logsdon, assistant clinical professor, Department of Com-    medicine, and third-party payers. The costs of provid-
munity Medicine, Mt. Sinai School of Medicine of City Univer-    ing the recommended preventive services, including
sity of New York, is director of the INSURE Project on Life-     patient education, are based on the fee schedules of
cycle Preventive Health Services. Dr. Rosen, adjunct assistant   the participating group practice clinics, and they are
professor of public health, division of sociomedical sciences,
Columbia University, is associate director of the project. Ms.   estimated to be relatively low. The project will pay
Demak is a research associate for the project. This paper is     a negotiated amount to the provider of the services at
based on a presentation by Dr. Logsdon to the New York           the selected sites.
Academy of Medicine, section on occupational medicine, June
24, 1981.                                                           The impact of these preventive services on health
   Tearsheet requests to Donald N. Logsdon, MD, Director,
INSURE Project, 330 Park Ave. South, New York, N.Y. 10010.       knowledge, attitudes, and behavior and on the related
308 Public Health Reports
                                                                                                          PREVENTION




use of health care resources will be assessed. Data on        During this time, the Ad Hoc Advisory Group on
utilization, costs, services, and manpower requirements    Preventive Services of the Division of Health Promo-
will be collected. Recommendations will be made as to      tion and Disease Prevention of the Institute of Medi-
which specific preventive services should be part of       cine (IOM) was drawing up recommendations for
primary care as well as on ways to integrate these         preventive services for the well population. The IOM
services into various practice settings. The degree to     group prepared a summary report in April 1978 that
which the health insurance industry could improve          became part of the Surgeon General's report, "Healthy
health care by changes in benefit plans will also be       People" (3). The consensus IOM report further speci-
explored.                                                  fied what health history, physical examination proce-
                                                           dures, clinical laboratory tests, and patient counseling
Background                                                 should be included in preventive services for 10 age
                                                           groups. For example, the procedures listed for routine
In 1973, the National Institutes of Health, anticipat-     prenatal care, including health counseling, are similar
ing an emphasis on prevention at the Federal level,        to the recommended obstetrical services of the Ameri-
initiated a series of studies to review and evaluate the   can College of Obstetrics and Gynecology. Also, the
field of prevention. In these studies, problems in the     recommended preventive services for infants and chil-
application of preventive methods were defined and         dren incorporate most of the standards developed by
gaps in the knowledge base requiring further research      the American Academy of Pediatrics for well-baby and
were identified.                                           well-child care. The recommendations for adults, how-
   Among the recommendations generated by the sub-         ever, represent a departure from the annual checkup
sequent National Conference on Preventive Medicine,        that had been practiced in the past.
sponsored by the National Institutes of Health, were          "Healthy People, the Surgeon General's Report on
guidelines for age-specific preventive procedures for      Health Promotion and Disease Prevention," which ap-
patient care. In 1977, the lifetime health monitoring      peared in the fall of 1979, included the statements that
program of Breslow and Somers (2) provided visi-                .75 percent of all deaths in this country are due
bility to this concept of including "cost effective and    to degenerative diseases such as heart disease, stroke,
health effective preventive measures" in health care.      and cancer . . . accidents rank as the most frequent
The authors proposed a framework in which clinical         cause of death from age one until the early forties . . .
and epidemiologic criteria would be used to identify       environmental hazards and behavioral factors also exact
goals and services for 10 age groups, from prenatal        an unnecessarily high toll on the health of our people
care through geriatric care, and which would replace       (3)." The report called for a new commitment to pre-
the annual physical examination. The issue of insurance    ventive services through disease prevention and health
coverage for these preventive services was also raised.    promotion.
                                                                                      July-August 1982, Vol. 97, No. 4 309
   The report of the Canadian Task Force (CTF) on            to improve the health and lifestyle of employees by pro-
the Periodic Health Examination, published in 1979,          viding preventive services at the place of employment.
was the most detailed and comprehensive evaluation           Another aim of these worksite programs is to decrease
of screening and casefinding involving healthy persons       the rise in the costs of health benefits. To achieve this
to that date (4). The members of the task force began        aim, both business and labor have begun to establish
by setting the criteria to judge the scientific validity     health promotion or "wvellness" programs at the wvork-
of the diagnostic and therapeutic procedures that a          site.
physician might use in providing a periodic health ex-          Questions inevitably begin to arise regarding the de-
amination for a well person. T'he task force also re-        finition of health promotion, its future in clinical medi-
viewed the mortality, morbidity, and disability related      cine, and more particularly its role in primary medical
to 78 health conditions and evaluated the potential          care. Health promotion has been broadly defined as
effect of treatment. Finally, the recommended proce-         the sttudy and application of methods to augment phy-
dures were grouped into 18 health protection packages        sical and emotional well-being, increase longevity, and
to be performed at 35 specified times between preg-          enhance the quality of life (7). Unfortunately, health
nancy and old age.                                           promotion lacks a solid foundation of scientific knowl-
   Perhaps the most obvious feature of the CTF pack-         edge; the literature on the subject is filled with generali-
ages is the exclusion of a number of traditional diag-       ties and good intentions. Because of this disadvantage
nostic procedures performed on normal, healthy adults,       and the problem-oriented approach of most practicing
such as chest roentgenograms, electrocardiograms, and        physicians, clinicians have lacked interest in health pro-
sigmoidoscopy, as well as the annual checkup. As the         motion. A major disincentive to the clinical use of
CTF noted, most disease-detection procedures used in         health promotion and preventive health services in of-
periodic health examinations were included because           fice practice has been the lack of third-party coverage
they had been useful in the diagnosis of symptomatic         for these services. Medicare does not cover preventive
                                                             care except pneumococcal vaccine, and Blue Cross-Blue
patients. That does not necessarily mean, however,
that these procedures would be as useful in the early        Shield coverage is primarily limited to hospital-based
detection of presymptomatic disease or in the reduc-         inpatient health education. Private insurance compa-
tion of risk factors.                                        nies expect the patient to pay for nonillness-related
                                                             routine medical services.
   As a result of the renewved interest in the prevention       Cost effectiveness is a term frequently used in the
of illness, disability, and premature death, the concept     LPHS sttudy becatuse the technique has been applied
of reducinig risk factors, whether they arise from the       to certain preventive health programs with some suc-
environment or personal behavior, has come to be             cess. In cost-effectiveness analysis, an attempt is made
viewed as a necessary part of health care.                   to summarize all health priogram costs into one number
   Risk factors consist of p)ersonal habits or lifestyle     and the effectiveness or benefits into a second number
such as cigarette smoking, lack of exercise, and alcohol     and to base the rules for policy decisions on the re-
abuse, and stuch physical characteristics as high blood      lationslip between the twvo ntumbers. Put another way,
pressure and elevated serum cholesterol, as well as en-      cost-effectiv-eness analysis is a method to deteirmiine
vironmental risk factors. Progress has been made in          which health programs achiexve a given goal at the
identifying and quantifyinig these factors and controlled    minimtum cost. Effectiveness is expressed in descriptixe
trials are now beginniing to provide results in terms of     terms suich as added years of life; Ino attempt is made
lowering the risk factors for coronary heart disease.        to apply a dlollar valuLe to benefits as in cost-benefit
These data will be analyzed for the effect of risk factors   analysis (8).
on cardiovascular disease, as for example, in the Mul-          The LPHS stuLdy will not be able to directly
tiple Risk Factor Intervention Trial (5). The MRFIT          measure cost effectiveness, because in the initial phase
approach is an example of the medical model in risk          it wvill riot be possible to answer the question, Does the
factor reduction in which the individual patient at risk     intervention lead to better health otutcomes? A deter-
is identified and treated. The community model aims          mination wvill first be made of the feasibility of intro-
eduLcational and environmental measures at a whole           ducing the services and changing the attitudes and
community to improxve the health-related behavior of         behavior of providers and constumers. If the study shows
an entire population and reduce its risk factors, as for     that these objectixes are feasible, then morbidity and
example, inl the three-commuinity study conducted by         mortality data may be puirsued. The study design will
the Stanford Heart Disease Prevention Program (6).           incluide a strategy to determine cost effectiveness if the
In addition, in the worksite model attemrpts are made        sttudy continuLes beyond 3 years.
310 Public Health Reports
                                                                                                              PREVENTION
   The term lifecycle is used in this study to describe       have begun to lead health professionals into an ex-
the lifestyles of people as they mature and grow older        ploration and demonstration of the role that practicing
and, in particular, to describe how the attitudes and         physicians can play in health promotion and disease
behavior of "well" patients change over time. Social          prevention. It has been shown that after exposure of
scientists, using the concept of a "family life cycle,"       physicians to a single teaching session, they spend more
have demonstrated that a combination of age, marital          time teaching hypertensive patients (13), and these
status, and parental condition explains a broad range         patients adhere better to drug regimens and achieve
of economic behavior better than age alone, as well           better control of their blood pressure. With regard to
as providing an explanation of the etiology of some           smoking, those patients of general practitioners, in a
mental disorders, patterns of work and leisure time,          British experimental study, whose physicians gave them
and adult socialization and morale (9,10). A question         simple but firm advice to stop smoking, in the phy-
for the LPHS study is the extent of the relationship          sician's own style and in 1 or 2 minutes, were sig-
between lifecycle (defined in terms of age and marital        nificantly more likely to stop than control patients
and parental status) to patterns of health behavior           (14).
among asymptomatic, healthy people. This health be-              The orientation of physicians to the LPHS protocols
havior contrasts with illness behavior, which is the way      and their education in the preventive health behaviors
that people respond to symptoms of disease.                   that they are subsequently to teach their patients are
                                                              part of the same process; together they comprise the
The Intervention                                              LPHS intervention. Both the LPHS medical proce-
Primary care providers are the source of regular medi-        dures and patient education will be provided by, or
cal care for most of the U.S. population (11), and the        under the supervision of, physicians in primary care
incorporation of preventive services, including patient       practice.
education and counseling, into the existing system of            The recommended LPHS protocols are based on the
medical care is a logical and appropriate step. Support       work of Breslow and Somers (2), the Institute of
for the potential effectiveness of this approach is illu-     Medicine Ad Hoc Advisory Group (15), and the Ca-
strated by the responses to a national poll conducted         nadian Task Force's report on the periodic health ex-
by Louis Harris and Associates (12). Fifty-seven per-         amination (4). The protocols represent a merger of
cent of the respondents in the poll stated that they          these three reports. The current LPHS version is a
would be greatly helped in achieving a healthy diet if        guide to the minimum procedures that a physician will
they received recommendations from their doctor, and          use during an LPHS patient visit. Physicians will want
a majority of smokers believed that medical advice            to use their clinical judgment and add or delete pro-
would be effective in helping people to stop smoking.         cedures according to the patient's history and phy-
Yet the current practice of medicine does not reflect         sical examination. For example, a heavy smoker with
this potential-according to the Harris poll, only 16          a chronic, productive cough may require a chest X-ray
percent of the people who have gone on a diet at all          even though chest X-rays are not included in the re-
say they were prompted to do so by their doctor's ad-         commended LPHS guidelines.
vice. In contrast, 47 percent of the public say they             Patients will receive the LPHS examination and
currently get a great deal of information about health        eduication from their own primary care physician. It
and medical care from their doctors. This is a much           is fundamental to the LPHS approach that preventive
smaller proportion than the 70 percent wvho express           services be delivered in primary care settings by the
the belief that information from their doctors would          patient's own physician. Any patient education pro-
be very useful and reliable. This discrepancy between         vided directly by another health professional already
the potential and actual roles of the physician in pre-       employed in the office practice (for example, a nurse
vention, and in patient education in particular, pro-         or health educator) will be done with the expressed
bably has complex and structurally perpetuated origins.       support and direction of the physician; the importance
Medical practice patterns are well established, and the       of communicating to the patient the physician's sup-
demands that illness care makes on the physician's            port of these other professionals' efforts will be stressed
time and skills are substantial. For the practicing phy-      in orientation sessions with the physicians.
sician, a complete reorientation toward preventive care
is unlikely, given his or her current interests and skills.      The physician orientation sessions are the major
                                                              focus of the LPHS orientation process. As a first step
   Despite the difficulties of incorporating prevention       (see chart) the project staff and consultants will con-
into the practice of primary care, the potential benefits     duct a walkthrough of the clinic site to gain an ap-
                                                                                          July-August 1982, Vol. 97, No. 4 311
preciation of the procedures and dynamics of the group        * a lecture on tlle physician's role in risk reduction in
practice. In addition, a focused interview will be con-       coronary heart disease
ducted at this time, in which several participating phy-      * r1evliew and discussion of LPHS gtuidelines and en-
sicians will discuss with the project staff the issues        counter forms for 10 patient groups
related to the implementation of LPHS in their prac-          * role-playing session of a physician-patient interaction
tice, including the physicians' cturrent practice patterns    * stummary of the principles of physician-patient com-
and feelings about their role in healtlh promotion and        munication
disease prevention. The impressions gained from the
walkthrotugh and the fiIrst focused interview, as wvell       * review of LPHS physician's manual and patient's
as from data obtained in physician interviews at time         gutlicle (detailed in the next paragraph)
1 (see under "Sttudy Design," page 314), will be used         * data collection and administrative proceduLres.
in neecls assessment to determine the appropriate tone
and emphases for the orientation sessions.                    These sessionis will have a varied format emphasizinr
   The recommended packages of LPHS services (in-             small group discussion; patient case histories wsill be
cluding patient education) and a means for incorpo-           used to illustrate the material discussed. The orienta-
rating them into office practice w ill be discussed at        tion sessions, as well as the wvritten materials that will
the physician orientation sessions. At these sessions not     be uised, are being prepared by the project staff
only will the preventive serxices that physiciains will be    in coInjuinction with the DartmouLth Medical School
providing uinder LPHS be introduced, but physicians           Department of Commnn-tiity and Family Mledicine.
also will be oriented as to how to implement patient             A LPHS physician manual has been prepared, wshich
counseling in a typical office visit. Since phlysiciain-      sulpplements the orieintation sessions and provides a re-
patienit commtunicatioin affects patients' attittudes and     ference for the physicians throtlghout their participa-
health otutcomes (16-19), the LPHS physician orienta-         tion in the project. Each physician will receixe a copy
tion sessions xvill incorporate soImle of the practical in-   of this manutal, which has tabs to facilitate reference
plications of this association, suLch as how to assess the    to (a) the LPH.S quidelines, (b) the encounter forms
patient's cturrent knowledge and health-related behavior      and instructions for their use, (c) study procedtures, (d)
 (including his concerns abouit lifestyle problems of         references to the literatuire, and (e) the detailed sec-
smoking, alcohol, and exercise). The sessions, however,       tion oIn patient commutnication and strategies for pa-
are not inteinded to radically alter the practice styles      tient education in each of the risk areas addressed in
of the participating physicians; they are intended to         the LPHS guIidelines. The LPHS encotunter forms
increase physicians' awvareness of the process involved       were plrepared so as to reflect the age-specific guide-
in patient interactions and the extent to which the           lines and to remind the physician dturing a patieint's
level of a patient's motivation and skill determines          office visit of the medical procedtures and edtucational
that patient's compliance with the physician's recom-         topics appropriate for the patient's age group. Besides
mnendations. The sessions are not designed to intro-          serving as a reminder and instrument for medical data
duce structtural change, to turn physicians completely        collection, the encotunter form has space to note the
away from curatixve medicine, or to require them to           primary risk areas for each patient and the physician's
arrive at skills in communlicatioin that are more ap-         perception of the degree of motivation the patieint has
propriately a function of indixidual style anid years of      to chanae his or her health-ielated behavior.
practice. Instead, the sessions are designed to stimulate        The encouinter form also includes a prevention pre-
thoug>ht and discussion in these areas and to instill         scription form on which physicians will make specific
an appreciation of those kiinds of improvements in            recommendatioins to the patient for behavioral change.
patients' health that occur slowly and have broad-            Copies of this prevention prescription will be kept in
rather than dramatic individual and clinical impacts          the patient's medical records for stubsequient followup.
on health outcomes.                                           and copies will be retained by the project staff for data
   Two sessionis w'ill be held, each schedtuled as a dinner   collection pUrIposes. A copy also will be oiven to the
meeting and planned to last 3'2 hours. Physicians will        patient to take home as a reminder of the discuissioni
receive Category I Continuiing Medical Education              and the recominendations made during the v-isit. By
credit for participation. A consultant to the project         capitalizinr on the stimtlulIs for change that has de-
who has had stuccess in orieinting physicians to their        xveloped dturingy the physician-patient interaction, this
role in cardioxascular risk reduction will present much       techniuclte is expected to aid in motivating the patieIlt
of the material on physician-patient communication.           to iiitiate behavioral change. The prevention prescrip-
The ag,enda for the two sessions includes:                    tion represents an approach that does not substantially
312 Public Health Reports
                                                                                                                   PREVENTION

                                 Study design for lifecycle preventive health services study




deviate from normal medical practice patterns and,               amination, and other data on their attitudes will be
thus, is not expected to seem strange or inappropriate           discussed.
either to physicians or patients.                                   2. Obtain physicians' reactions to the use of LPHS
   Two reinforcement-feedback sessions will be held              and to any problems that have arisen. Their reactions
with physicians during the period in which they are              will provide some qualitatixe measuire of the programi's
providing LPHS examinations. The first will occur                effect and will also be helpftul in implementing LPHS
4 to 6 weeks after the orientation sessions and the              at other sites.
second, 10 to 12 weeks after them. At these feedback                3. Reinforce the motivation of the physicians to use
sessions the project staff will carry out the following          the LPHS protocol and discuss their qtuestions and
actions.                                                         problems. There will be a final wrap-up session to
                                                                 summarize the experience.
   1. Provide physicians with feedback on a subsample
of 25 patients who were among the first to receive an            Patient Education Materials
LPHS examination. These data will be obtained in                 The prevention prescription given by the physician to
telephone interviews with this subsample of patients             each patient is a major source of direction for the
shortly after their LPHS examinations. Patients' be-             patient. In addition to the prescription, all patients
havioral change data, satisfaction with the LPHS ex-             will receive the "Patient's Guiide to LPHS ' when they
                                                                                               July-August 1982, Vol. 97, No. 4 313
arrive at the clinic. This guide includes a brief intro-      A pre-test and post-test assessment will be done (see
duction to the LPHS examination and space for the           chart). All physicians and patients will be surveyed at
patient to write in the answers to specific questions in    time 1 for baseline data on health attitudes, orientation
each of several risk areas. If the answer to any given      to prevention, and self-reported preventive health be-
question indicates that the patient may be at risk in a     haviors, among other items. Study physicians attend the
particular area, the response is shown on a tab that is     LPHS orientation sessions, and study patients are then
clearly visible to the physician. The physician can then    scheduled for their LPHS examination with their phy-
easily identify areas of risk for each patient and use      sician, which is paid for by INSURE. All physicians
the guide as a focus for discussion during the visit. The   and patients are then surveyed 10 months later to
patient is given the guide to use at home for identi-       assess changes in the outcome measures.
fying the benefits of, and personal barriers to, health        The sample size for the study is 4,500 patients:
behavior change.                                            2,250 study subjects .and 2,250 controls, or about 750
   The project staff reviewed the patient education         people at each of the 6 sites. The sample is stratified
materials currently available from a variety of sources,    by age and sex into the 10 age groups of the LPHS
including medical professional organizations and public     guidelines. Since stratification of the sample into 10
information agencies. The pamphlets selected in this        subgroups presents difficulties for statistical power,
review in each of the prevention areas in the LPHS          wherever possible data will be pooled across age groups
guidelines will be provided in quantity to the physicians   and sites to improve statistical power.
for distribution to LPHS patients during their office          The study design requires that the patient and phy-
visits.                                                     sician samples be linked; for each patient selected, his
   In any intervention of this type, an effective system    or her primary care physician must be participating
of patient followup is essential. Unless an illness oc-     in the study. The sampling frame, therefore, is the pa-
curs, patients will not return for an office visit during   tient roster of the participating primary care physicians
the course of the project; thus, a systematized followup    at the study and control sites. A random sample will
will be needed to maintain the motivation of the pa-        be drawn from the roster of each of the participating
tient who is attempting to change his or her behavior.      physicians.
Letters will be sent to the patients by the clinic on          The six sites participating are traditional, fee-for-
behalf of the patient's physician at 3 weeks and 12         service group practices in different areas of the United
weeks after their examinations. These letters will be as    States. They were selected from a purposive sample
personalized as possible and will refer to recommenda-      (N=28) generated from the Directory of the American
tions made during the patient's visit which were in-        Group Practice Association and the recommendations
cluded in the prevention prescription. This limited         of several experts in the group practice field. Three
followup is primarily designed to reinforce any be-         study sites were selected from this list: one in the upper
havioral change initiated by the patient after the exam-    Midwest, a second in the Southwest, and the third in
ination. It requires none of the major system changes       the Southeast. Control sites were then selected from
in a group practice that might be necessary for the         the list, which matched the study locations as closely
administration of a more elaborate followup system.         as possible in terms of the following criteria: size (num-
The cost of this limited followup will be considered        ber of physicians), specialty mix, and community
part of the LPHS examination and will be paid by the        served.
INSURE project.                                                For feasibility purposes, group practice represents
                                                            the most appropriate practice type in which to initially
Study Design                                                test the LPHS approach. The presence of an admini-
The LPHS study and evaluation is being conducted            strative structure with similar procedures for a group
among patients and physicians at six group practices        of physicians simplifies some of the methodological pro-
in different areas of the United States. A quasi-experi-    blems of sampling as well as physician participation
mental research design is used; three group practices       and involvement. Group practice represents a signifi-
that have been designated as study sites will receive       cant and growing part of ambulatory medical care.
the intervention program, and three matched control         More than two-fifths of ambulatory services are pro-
sites will not. Although random assignment within one       vided in group practice (20). Although it is recognized
site would be preferable, the problem of possible con-      that another feasibility question is the impact of the
tamination of control subjects requires that they be        practice type, the study will be limited to one practice
drawn from a different and geographically separate          type for this phase of the investigation. A subsequent
population.                                                 larger study, should it be conducted, would implement
314 Public Health Reports
                                                                                                             PREVENTION
LPHS in a range of practice types, including solo               1. changes in patients' preventive health behavior
practice, HMOs (health maintenance organizations),           and attitudes toward prevention
neighborhood health centers, and hospital-based prac-           2. physicians' use of and adherence to LPHS guide-
tices.                                                       lines
   The study has been designed to evaluate the effects of       3. patient's utilization and adherence to LPHS
the LPIIS program as an intervention. T'his evaluation       guidelines
has twin foci: (a) feasibility and (b) the effects of           4. physicians' professional evaluation of LPHS
the program, taken as a whole, on physicians and pa-            5. levels of patients' satisfaction with LPHS.
tients. Because the program has not been tested, the
feasibility focus is important. Among the feasibility           Site selection is an important part of the study de-
questions the study addresses are: Can age-specific          sign. Although the element of self-selection of sites
protocols of preventive services, including patient ed-      cannot be completely eliminated in a feasibility study
ucation, be developed? Can these be implemented?              (the physicians and group practice administrators ac-
Will physicians agree to participate in such a program?      cepted our invitation to participate in the project),
Will they be willing and able to attend orientation          none were volunteers in the strict sense of the word.
sessions on a lifecycle approach to prevention? Will         Announcement of the INSURE project brought forth
they use the protocols with their study patients? Will       many offers from clinics and facilities to serve as study
they change their practice pattern to incorporate the        sites. It was believed, however, that the self-selection
LPHS recommendations? Can administrative proced-             bias among volunteers would be too great, and all six
ures for the study be devised that will facilitate the       sites in the study were first approached by INSURE.
introduction of this program into primary care set-             At each of the selected group practices, all primarv
tings and be congruent with the usual way patients'          care physicians are invited to participate in the study.
appointments are made, examinations are performed,           Four primary care specialties are included: family
and patients' charges are recorded?                          practice and general practice, pediatrics, obstetrics, and
   There are also feasibility questions concerning in-       general internal medicine. Physicians at the study sites
surance reimbursement issues. Among these are pro-           receive information and attend the orientation ses-
blems of cost, utilization, and reimbursement. There         sions in LPHS; control physicians do not. The assump-
are a range of feasibility questions concerning patients,    tion is that control physicians will continue to practice
such as: When offered a reimbursed preventive ex-            in their usual fashion. One hundred primary care
amination, what proportion of patients will actually         physicians are included in the study.
make use of it? Will participation-utilization be uniform       Patients are selected for the study from the billing
across age groups, or will it vary by age group? Finding     roster of the group practices. The samples are drawn
answers to these questions is vital for the success of the   by the group practice according to criteria specified
intervention, both in the project itself and for its         by study staff. Only active established patients of par-
widescale adoption.                                          ticipating physicians are eligible for selection. Patients
   The second focus of the evaluation is on the effects      must have visited their physician at least once in the
of the intervention on patients and physicians. The          last 2 years. In addition, patients with chronic and dis-
best measures with which to assess the impact of an          abling conditions vill be excluded from this study,
intervention aimed at health promotion and disease           which focuses on services for the asymptomatic patient.
prevention would be mortality and morbidity. How-            The same criteria are used to select patients at the
ever, given the constraint of time (the interval between     study and control sites. Selection of only active estab-
time 1 and time 2 data collection is 10 months), these       lished patients will limit the generalizability of any
data will simply not be available. The impact of the         conclusions to an active patient population. Included
program, therefore, will be measured by assessing short-     in the sample is a subgroup of male patients aged
run attitudinal and self-reported behavioral changes.        40-59 who are at high risk for coronary heart disease.
Evidence has accumulated linking personal behavior           An extra sample of 75 men aged 40-59 is selected at
and lifestyle with morbidity and premature mortality         each study site. It is expected that there will be ap-
(5,21,22). Because of the breadth of the issues ad-          proximately 112 men aged 40-59 at each study site,
dressed in the study design, which necessitate a strati-     of whom roughly 15 percent (or 17 men), will have
fied sample at multiple sites, the impact of the total       multiple risk factors for coronary heart disease. A special
program on different outcome measures is examined.           intensive intervention program will be conducted for
   In summary, the following short-term impact mea-          these approximately 50 (17 X 3 sites) men.
sures are examined:                                             Patients are notified of their selection for the study
                                                                                         July-August 1982, Vol. 97, No. 4 315
in an advance letter describing it. The letter is signed     sites, following their LPHS examination, to assess their
by the administrative and clinical leadership of the         reactions to the examination as well as short-term
group practice and by the director of the INSURE             behavioral changes. These interviews will provide data
Project.                                                     for presentation to physicians at the scheduled feed-
                                                             back sessions. In addition, patient recollection of which
Data Collection                                              services were provided-especially the areas in which
Survey data will be collected by mail and telephone          counseling was provided-serves as one means of vali-
questionnaires; medical data for study subjects will be      dating the information that physicians provide on the
collected from the LPHS encounter form that is               encounter form.
completed by the physician during a patient's LPHS              The data analysis plan calls for careful analysis of
examination. Patients will be surveyed at times 1 and        the feasibility issues by using both the quantitative
2 by mail questionnaire. Children under 12 years of          survey data and the. qualitative data from the focused
age will be sent a proxy questionnaire to be completed       interviews that were conducted with a subsample of
by their parents. Adolescents (ages 12-17) will be           the physicians. Patient change data will be studied in a
interviewed by telephone. The patient survey instru-         series of panel analyses that will range from a com-
ment is designed to assess self-reported preventive          parison of the mean change scores between the study
health behaviors in addition to measuring health             and control groups to complex multivariate analyses
attitudes and orientation toward prevention; perceived       in which the independent and interaction effects of dif-
health status; health knowledge; utilization behavior;       ferent groups of variables on change scores will be
attitudes toward the physician; and satisfaction with        examined.
medical care.
   Among the preventive health behaviors to be mea-          Present Status of Project
sured are cigarette smoking, alcohol use, weight re-
duction, diet and cholesterol intake, exercise, seat-belt    At this point (May 1982), the LPHS program has
use, breast self-examination for women, and manage-          been implemented at the first study site, a small fee-
ment of blood pressure-hypertension. In addition, the        for-service group practice in the upper Midwest. In the
instrument includes sociodemographic variables and           surveys conducted there, a 60 percent response rate
measures of aspects of patients' health insurance cover-     was achieved for the patient questionnaire, and a 100
age with regard to preventive services. A standard in-       percent response rate for the physician instrument.
strument will be used for adults, which has special          Orientation sessions have been held with participating
supplements for pregnant women and the elderly. In           physicians, and 300 LPHS examinations have been
order to begin to assess the degree of self-selection        performed. In a followup survey of a subsample of
among respondents to the questionnaire, a random             25 patients at this site, the response to the LPHS ex-
sample of 225 nonrespondents will be interviewed by          amination was positive, especially to the patient edu-
telephone with a shortened survey instrument.                cation. A substantial number reported that they had
   The physicians will be interviewed by telephone.          already begun to initiate the behavioral changes sug-
The physician survey instrument measures professional        gested by their physician at the time of the LPHS
characteristics, including background and training; cur-     examination.
rent practice characteristics, with an emphasis on pre-
ventive care; and attitudes toward prevention and            Funding of INSURE Project
preventive services in the physician's practice, includ-     The INSURE project established by the private insur-
ing patient education about lifestyle and health be-         ance industry in 1980 was originally funded by nine
haviors. The physician instrument also measures aspects      insurance companies. Twelve more companies have
of the physician's personal preventive health behavior.      since joined in its support. To supplement the funding
A self-administered checklist of preventive services         for research activities of the project and to provide
will be sent to each physician, on which he is to indicate   adequate evaluation, the project staff applied for and
which services he routinely provides in a preventive         received additional funding from the Robert Wood
checkup for patients in each of the 10 LPHS age              Johnson Foundation and the John D. and Catherine
groups. This checklist will be completed again at time       T. MacArthur Foundation. The project represents a
2 to assess change in the physician's preventive prac-       significant joint effort by the insurance industry and
tice pattern.                                                philanthropic foundations to support ,research in the
   A 10-minute telephone interview will be conducted         health sciences. Insurance company funds represent
with a random subsample of 150 patients at the study         approximately two-thirds of the total 1.2 million dollar
316 Public Health Reports
                                                                                                                    PREVENTION
budget, and foundation support accounts for approxi-              12. Pacific Mutual Life Insurance Company: Health mainte-
mately one-third. If the initial phase of the project is              nance: a nationwide survey of the barriers toward better
successful, funding for a longitudinal study will be                  health and ways of overcoming them. Newport Beach,
                                                                      Calif., November 1979.
sought.                                                           13. Inui, T. S., Yourtee, E. L., and Williamson, J. W.: Im-
                                                                      proved outcomes in hypertension after physician tutorials:
References                                                            a controlled trial. Ann Intern Med 84: 646-651 (1976).
1. Clearinghouse for Corporate Social Responsibility:             14. Russell, M. A. H., Wilson, C., Taylor, C., and Baker, C. D.:
   INSURE board meets in Washington; advances Lifecycle               Effect of general practitioners' advice against smoking. Br
   Preventive Health Services Study. Response 6: 11 (1980).           Med J 2: 231-235 (1979).
2. Breslow, L., and Somers, A. R.: The lifetime health-           15. Fielding, J. E.: Preventive services for the well popula-
   monitoring program. N Engl J Med 296: 601-608 (1977).              tion. In Healthy people: the Surgeon General's report on
3. Department of Health, Education, and Welfare: Healthy              health promotion and disease prevention background
   people: the Surgeon General's report on health promotion           papers. DHEW Publication No. 79-55071A. Washington,
   and disease prevention. DHEW Publication No. 79-55071.             D.C., 1979, pp. 277-304.
   Washington, D.C., 1979.                                        16. DiMatteo, M. R:, Taranta, A., Friedman, H. S., and
4. Canadian Task Force on the Periodic Health Examina-                Prince, L. M.: Predicting patient satisfaction from physi-
   tion: Task force report. The periodic health examination.          cians' nonverbal communication skills. Med Care 18: 376-
   Can Med Assoc J 121: 1193-1235, Nov. 3, 1979.                      387 (1980).
5. Benfari, R. C., and Sherwin, R. (editors): The Multiple        17. Francis, V., Korsch, B. M., and Morris, M. J.: Gaps in
   Risk Factor Intervention Trial (MRFIT). Prev Med 10:               doctor-patient communication. N Engl J Med 280: 535
   387-553, July 1981.                                                 (1969).
6. Farquhar, J. W., et al.: Community education for cardio-      18. Korsch, B. M., and Negrete, V. F.: Doctor-patient com-
   vascular health. Lancet June 4: 1192-1195 (1977).                 munication. Sci Am 227: 66-74 (1972).
7. Taylor, R. B.: Editorial: Health promotion: can it suc-       19. Starfield, B., et al.: The influence of patient-practitioner
   ceed in the office? Prev Med 10: 258-262, March 1981.             agreement on outcome of care. Am J Public Health 71:
8. Shepard, D. S., and Thompson, M. S.: Cost-effectiveness           127-131 (1981).
   analyses in health. Group Pract J: 11-26, February 1981.      20. National Center for Health Statistics: National Ambula-
9. Riley, M. W., and Foner, A.: Aging and society. Vol. I.           tory Medical Care Survey 1979 summary. Advance Data
   An inventory of research findings. Russell Sage Founda-           66: 4 (1981).
    tion, N.Y., N.Y. (1968).                                     21. Belloc, N. B., and Breslow, L.: Relationship of physical
10. Estes, R. J., and Wilensky, H. L.: Lifecycle squeeze and         health status and health practices. Prev Med 1: 409-421
    the morale curve. Soc Prob 25: 277-292 (1978).                   (1972).
11. National Center for Health Statistics: National Ambula-      22. Breslow, L., and Enstrom, J.: Persistence of health habits
    tory Medical Care Survey 1977 summary. DHEW Publi-               and their relationship to mortality. Prev Med 9: 469-483
    cation No. (PHS) 80-1795. Hyattsville, Md., April 1980.          (1980).




                                                    I      (
  LOGSDON, DONALD N. (INSURE                   Preventive services, which will be      vention is conducted at the study
  Project, New York), ROSEN, MAT-           provided under a lifecycle approach        sites to assess their knowledge, atti-
  THEW, and DEMAK, MICHELE M.:              according to the age and sex of the        tudes, and behavior toward health
  The INSURE Project on Lifecycle Pre-      patient and include education of           behavior practices.
  ventive Health Services. Public Health    patients on health-related behavior,
  Reports, Vol. 97, July-August 1982,       will range from prenatal care through         The data from this study should
  pp. 308-317.                              geriatrics. A quasi-experimental de-       contribute to the discussion of several
     The INSURE Project on Lifecycle        sign will be used in which three study     policy questions regarding the deliv-
  Preventive Health Services is a 3-year    (experimental) group practice sites        ery of preventive services in primary
  study to determine the feasibility of     are matched with three control group       medical care as well as the discus-
  implementing preventive services in       practice sites. At the study sites, the    sion of cost-containment issues. The
  primary medical care as a health          primary care physicians will partici-      analyses to be conducted of physi-
  insurance benefit and to assess the       pate in orientation sessions on recom-     cians' practice patterns and of pa-
  short-term impact of this implementa-     mended preventive services and pa-         tients' attitudes and beliefs in respect
  tion on providers and consumers.          tient education procedures; they will      to behavioral change should add to
  Initiated by the life and health insur-   also examine and counsel the study         the growing literature in medical care
  ance companies, the project has re-       patients. The study and control physi-     and health education, particularly to
  ceived additional support from private    cians and patients will be surveyed        that regarding health-related be-
  philanthropic foundations.                before and after the program of inter-     havior.


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