Improving Services for Sex Partners of Chlamydia-infected Patients in an HMO

John P. Mullooly, PhD;Barbara Valanis, RN, DrPH;Julie E. Maher, PhD;Nancy A. Vuckovic, PhD;Jerry Slepack, MD;Susan G. Cooksey, PhD;Kathy Easter, BS;Nancy H. Stevens, PhD;Kathleen Irwin, MD, MP;

Publication

Article

October 1, 2005

The American Journal of Managed Care

October 2005

Volume11

Issue 10

Improving Services for Sex Partners of Chlamydia-infected Patients in an HMO

Author(s):

John P. Mullooly, PhD,Barbara Valanis, RN, DrPH

Objective: To improve services for sex partners of chlamydia-infectedpatients (ie, chlamydia partner services [CPS]) at an HMO.

Study Design: Assessment of current CPS policy, practices, andopinions in Kaiser Permanente Northwest Region (KPNW) and inlocal health departments, and design, implementation, and evaluationof 4 CPS interventions.

Methods: We reviewed KPNW policy documents, conductedfocus groups with KPNW clinicians, and did phone interviews withKPNW chlamydia-infected patients and health department diseaseintervention specialists. We then implemented 3 informationalinterventions: CPS information was added to the after-visit summarygiven to patients tested for chlamydia; information on how totest, treat, and counsel chlamydia-infected patients was added toKPNW's electronic clinical-decision tool; and CPS information anda direct link to KPNW's chlamydia screening and treatment guidelineswere added to KPNW's Web site. We also organized trainingfor KPNW clinicians to review the roles of CPS and disease interventionspecialists. We evaluated intervention uptake and impactby reviewing electronic medical charts, Web site "hits," and post-trainingevaluations.

Results: Clinicians and disease intervention specialists reportedthat KPNW's CPS policy and the roles of disease intervention specialistsregarding KPNW patients were unclear. Clinicians andpatients wanted more CPS information. Clinicians commonly usedthe after-visit summary and Web-based CPS information andreported that training improved CPS knowledge. However, noneused the clinical-decision tool.

Conclusions: Several simple, centralized informational interventionsto improve CPS were feasible and used by KPNW clinicians.These interventions could potentially be used in othersettings structured like KPNW.

(Am J Manag Care. 2005;11:609-618)

hlamydia trachomatis,

the most commonlyreported sexually transmitted disease (STD) inthe United States, affects about 3 million personsannually. Untreated infection may result in seriousand costly consequences, including pelvic inflammatorydisease, infertility, ectopic pregnancy, and chronicpelvic pain.^1,2Because up to 75% of infected women areasymptomatic, routine screening is critical.³Severalnational organizations recommend routine screeningfor all sexually active women under age 25 years, andfor high-risk women aged 26 and older.^3-7Services forsex partners, referred to as chlamydia partner services(CPS), could prevent disease transmission, encouragetreatment of infected partners, and prevent patientreinfection.⁸

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Public health departments usually provide CPS forpublic-sector patients. New screening guidelines haveincreased the number of -infectedwomen diagnosed in HMOs and strained the capacity ofhealth departments to notify exposed sex partners ofHMO patients.^9,10Partnerships between health departmentsand HMOs could improve both the effectivenessand efficiency of CPS. Enhancing CPS in HMOs requireslearning current CPS practice and then addressing thebarriers and facilitators to CPS as perceived by HMO clinicians,managers, patients, and health departments.

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Although many HMO clinicians counsel -infected patients to notify their sex partners, cliniciansmay not follow up on notification outcomes.¹¹Anevaluation of STD services¹²concluded that partnermanagement needed attention, particularly in the areasof legal responsibility, liability, and confidentiality. Itrecommended strengthening partnerships betweenHMOs and health departments, focusing on cost effectivenessand relevance to managed care, integration ofSTD care into existing activities, and education aboutthe importance of CPS for comprehensive chlamydiacontrol.

Our team partnered with local public health agenciesto assess CPS knowledge and practices, and localCPS barriers and facilitators. This paper describesthat assessment and the subsequent development,implementation, and evaluation of interventions toimprove CPS.

ASSESSMENT

Methods

Kaiser Permanente Northwest Region (KPNW) is anonprofit, group-practice HMO that provides prepaidmedical care to 470 000 members in the Portland,Oregon and Vancouver, Washington areas. Cliniciansuse a systemwide electronic medical record system(EpicCare). EpicCare enables KPNW clinicians to accessmembers' medical records. It also integrates into themedical record clinical practice guidelines and clinicianreminders about needed services specific to eachmember (eg, overdue for a mammogram).

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To assess CPS knowledge, barriers, and facilitators,we reviewed HMO policies and database records, conducted4 focus groups with 22 clinicians, conductedopen-ended phone interviews with 7 disease interventionspecialists employed by 2 local health departments,and conducted phone interviews with 30 female and5 male KPNW members infected with from June to December 2000. All procedures for theassessment and intervention design, implementation,and evaluations were approved by the KPNW institutionalreview board and followed the procedures of theCenters for Disease Control and Prevention (CDC)regarding protection of human subjects.

Results

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KPNW guidelines recommend screening young, sexuallyactive female patients for , and testingfemale and male patients with -relatedsymptoms. According to laboratory databases, KPNWidentified 1223 adults with positive testsamong 54 929 tests conducted in 1998 and 1999. Most(84%) positive tests were in female patients; 88.2% ofthese patients were between the ages of 12 and 29years. Pharmacy data showed that 91% of patients withpositive tests received azithromycin ordoxycycline through the KPNW pharmacy. Fifteen percentof these -infected patients receivedmore than 1 of these prescriptions on the same day, andan additional 6% were dispensed repeat doses withinweeks of a positive test. KPNW's pharmacydatabase does not capture reasons for multipleprescriptions or doses, but the additional medicationmay have been for partners.

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KPNW's Infection Control Department reported 642positive lab tests to Oregon or Washingtoncounty health departments during 1998. Statehealth department records indicate that Oregon diseaseintervention specialists interviewed 58% of KPNWpatients with and Washington diseaseintervention specialists interviewed 17% of KPNWpatients with diagnosed in 1998.

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During the evaluation period, KPNW policy documentsrecommended that clinicians use CDC's 1998Guidelines for Treatment of Sexually TransmittedDiseases.⁵These guidelines state that "patients shouldbe instructed to refer their sex partners for evaluation,testing, and treatment." However, KPNW had no officialpolicies about partner services and no clinical practicesupports to promote guideline adherence. KPNW policydid not officially endorse services to nonmembers,although KPNW managers said this sometimesoccurred. An oral agreement between KPNW and someOregon health departments gave disease interventionspecialists blanket permission to contact KPNW's -infected members about CPS without askingclinicians.

Clinicians.

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In focus groups, most clinicians statedthey knew that reporting infections is requiredand that KPNW's Infection Control Departmentreported positive tests to local healthdepartments. However, only about half of the cliniciansreported telling patients with positive results about this health department reporting. Most cliniciansdid not know that disease intervention specialists,without informing them, routinely contact KPNWmembers diagnosed with to inquireabout sex partners and offer treatment help. Few cliniciansreported telling patients that health departmentstaff might contact them, and fewer than half talkedabout health department services available for help withpartner notification. None reported collecting informationabout sex partners or having their office notify thepartners.

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Consistent with treatment guidelines, almost all cliniciansreported talking to patients infected with about abstaining from sex during treatment,safer sex practices, and the need to notify partners.Although clinicians or their staff generallynotified patients of positive tests and the majorityadvised patients to notify partners of the need for testingand treatment, few reported discussing specificnotification strategies. About half reported givingpatients literature intended for their sexpartners, and about half said they had at least once prescribedmedications to an infected member for their sexpartners. About two thirds reported ever talking with aninfected member about their sex partners' possiblereactions to being notified, but only about half said theyalways did this.

Clinicians named a number of barriers and facilitatorsto providing CPS (see Table 1). To improve CPS,clinicians suggested explicit health plan policies aboutCPS and patient-delivered partner therapy, speciallytrained staff to notify and follow up with infected membersand partners, and better coordination betweenKPNW and local clinics. They also suggested clinicianeducation about KPNW policies, local regulations andlaws, and health department roles.

Disease Intervention Specialists.

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Of the 7 intervieweddisease intervention specialists, 4 said that in the pastyear they infrequently contacted KPNW clinicians forpermission to contact their -infectedpatients, 1 always tried to get permission, and 2 neverdid. Most reported contacting KPNW's medical recordsdepartment to verify information before contactinginfected KPNW members. Five indicated they werecomfortable with the oral agreement with KPNW thatprovides blanket permission to contact -infected members. Disease intervention specialistsreported never or rarely receiving partner information,such as names or locating information, from KPNW duringthe past year.

The disease intervention specialists estimated thatthey interviewed at least 75% of the private-sector patientsby phone. They estimated that 10% to 65% ofthese contacted patients did not know that a diseaseintervention specialist would be contacting them, andthat 1% to 25% were upset about being contacted.Disease intervention specialists estimated that from 0%to 20% of these contacted patients refused to talk withthem. Of those patients who did talk with disease interventionspecialists, about 5% to 40% refused to providepartner names. The ranges are wide because of variationin clinician practice and specialists' perceptions ofpatient reactions.

Disease intervention specialists named several barriersto providing CPS and suggested ways to improveCPS at HMOs (see Table 1). They noted that patient-deliveredtherapy might increase the proportion of partnerstreated, but patients who had already receivedmedication for their partner might not talk with diseaseintervention specialists, and so might not receiveprevention education. Nearly all disease interventionspecialists suggested that clinicians should more fullyeducate infected persons about the importance of partnernotification and treatment, coach patients abouthow to notify their partners, and inform patients that adisease intervention specialist might contact them. Afew disease intervention specialists suggested thatKPNW clinicians treat partners of infected members orinform partners about the health department and otherfacilities for STD evaluation, use noninvasive (ie, urine)tests, and prescribe single-dose medication regimens.Finally, some disease intervention specialists suggestedcloser CPS collaborations between KPNW and diseaseintervention specialists.

Patients With Positive

Tests.

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C trachomatis Beforeour interviews, KPNW had informed all 35 participantsof their positive test by telephone or letter.Although 25 participants reported that their KPNWclinician counseled them to prevent reinfection byusing condoms, only 14 remembered receiving preventionliterature. Twenty-four participants reported beingcounseled about some aspect of partner evaluation ortreatment. Nine participants reported that their KPNWclinician prescribed medication for partners. About onethird of participants recalled being told that the healthdepartment might contact them. Twenty said they werecontacted by the health department: 14 by telephone,5 by letter, and 1 by both letter and telephone. All but4 members reported that at least 1 partner had beennotified about their exposure, either bythemselves or by disease intervention specialists.

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Infected members identified several barriers totelling partners about infection (seeTable 1). Patients suggested improving CPS with accurateinformation about coaching abouthow to notify partners, nonjudgmental and supportiveservices, and joint patient-partner counseling.

INTERVENTION

Methods

Based on our assessment, we developed interventionsto help facilitate CPS at KPNW. We systematicallyreviewed KPNW patient care and clinical informationsystems to identify system-level interventions thatcould address the barriers to CPS cited by clinicians,disease intervention specialists, and patients. Potentialinterventions were required to be consistent with principlesof centralization, low resource requirements,simplicity, and minimal demand on clinician time.¹³Wethen consulted with KPNW clinicians and managers,disease intervention specialists, and health departmentclinicians and managers on the feasibility and acceptabilityof potential interventions.

Several proposed interventions were deemed infeasible:increased funding for health department diseaseintervention specialists to provide services to KPNWpatients, posting disease intervention specialists in KPNWclinics to notify partners, and using KPNW staff to elicitpartner contact information and provide this informationto health departments, and/or notify the partners themselves.Creating new KPNW policy and funding mechanisms to cover testing, treatment, and counseling fornonmember partners was deemed too complicated fromthe medicolegal perspective for rapid implementation.

Several interventions for educating clinicians andpatients and improving collaboration between KPNWclinicians and disease intervention specialists weredeemed feasible by KPNW clinicians and managersbecause they could be readily implemented with minimaleffort and cost, and they would promote consistenthealthcare delivery. Three computerized informationalinterventions and 1 educational intervention met ourcriteria, were acceptable to KPNW managers, and couldbe evaluated by using process outcome measures.Because the proposed interventions were expected tosave rather than demand clinician time, KPNW managementdid not require that efficacy be demonstratedbefore initial implementation.

Additional Information in After-

visit Summary.

Atthe end of medical visits, clinicians give patients a printedtreatment plan called an after-visit summary. Weadded CPS information to the after-visit summary givento patients tested for chlamydia. Project investigatorssought advice on CPS content from KPNW's RegionalPrevention Steering Committee and their ChlamydiaScreening Guidelines Subcommittee. Reviewers requestedlimiting the new material to 1/2 page. After muchdiscussion, reviewers decided that CPS information onthe after-visit summary would not risk breaching confidentialitybecause members are responsible for handlingthat information. CPS information intended toencourage patients to complete treatment and notifypartners was added on October 15, 2001.

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The new CPS information addressed how chlamydiaand gonorrhea are transmitted, the importance of treatmentif the test is positive, the need to abstain from sexduring treatment, the need to notify partners of infectionexposure, the health department's role in CPS, andrelevant telephone numbers and Internet Web sites. Wewere unable to target this after-visit summary informationonly to patients with positive testresults because most patients are notified of positivetest results by phone or letter days after the visit.

Computerized Decision Support Addition: Smart

Set.

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A computerized clinical decision support tool calledSmart Set enables clinicians to order medications andlab tests, and to document counseling services by clickingin a single location in EpicCare. We developed anew Smart Set component to help clinicians test for , treat , counsel about and CPS, and document these services inEpicCare. The pharmacy department reviewed the /CPS Smart Set material to ensure accuracyof treatment recommendations. After approval byEpicCare managers and piloting, the /CPSSmart Set was installed on EpicCare on December 20,2001, indexed as "Gonorrhea/Chlamydia." In January2002, it was additionally indexed as "Chlamydia/Gonorrhea"to make it easier for clinicians to locate.

Intranet Resources on

Screening and

CPS.

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C trachomatis We developed a new module for KPNW's internalWeb site on screening and CPS. The CPSmodule includes information on chlamydia reporting tolocal health departments, the role of disease interventionspecialists in CPS, and how to counsel patientsabout partner services. The module also advises cliniciansto counsel patients about safer sex, abstainingfrom sexual intercourse during treatment, telling theirsex partners to seek care, sex partners' possible reactions,possible contact by health department diseaseintervention specialists, and health department servicesfor notifying partners. KPNW's Regional PreventionSteering Committee approved the new CPS module andposted it on October 15, 2001. By October 22, 2001, theKPNW STD treatment guideline linked directly to thenew module.

Clinician Training.

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We developed a CPS trainingsession for KPNW clinicians. To reach as many traineesas possible, we e-mailed letters to chiefs of clinicaldepartments that treat -infected patients,explaining the project and reporting that clinician focusgroups identified interest in CPS training. We thenrequested 30-45 minutes for CPS training at continuingmedical education sessions or department meetings.

At the CPS training, a project clinician reviewed theCPS project. Then disease intervention specialists fromlocal health departments reviewed CPS procedures—specifically that the KPNW Infection Control Departmentreports positive chlamydia test results bypatient name to local health departments and that diseaseintervention specialists counsel patients, discussand plan partner notification, and notify and managetreatment of partners of some infected members. Next,the project clinician summarized key clinician behaviorsthat facilitate KPNW-health department coordination:counseling infected patients about STD riskreduction and abstinence from sex during treatment,how to tell sex partners to seek evaluation and treatment,and sex partners' possible reactions to beingnotified. Clinicians were advised to provide patientswith information about health department services andto tell them that KPNW reports positive tests to thehealth department. Clinicians also were encouraged tocontact disease intervention specialists for help in providingCPS. Presentation handouts included healthdepartment telephone numbers, the after-visit summarytext, the Smart Set, and the revised Web site information.The sessions ended with questions andanswers.

Evaluation

After-

visit Summary.

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We assessed how often cliniciansprinted the after-visit summary by monitoring EpicCarecharts of patients who had a positive test.EpicCare charts were reviewed for the 3.5-month periodbeginning with after-visit summary implementation onOctober 15, 2001, through January 31, 2002.

Smart Set.

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We ascertained clinician use of the SmartSet by reviewing provider notes in EpicCare charts of allpatients who had positive tests duringthe period from December 20, 2001, when the SmartSet was implemented, through January 31, 2002. Wealso abstracted documentation of CPS counseling fromthe Smart Set.

Screening and CPS Guidelines.

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C trachomatis Usinga standard Web Trend reporting system, we monitoreduse of the newly posted /CPS guidelines.The number of times the /CPS guidelinepages were accessed ("hits") were tracked weekly fromSeptember 1, 2001, through January 31, 2002. The screening guidelines and STD treatmentareas of the Intranet were operational during this entireobservation period. The CPS-specific module was postedand linked in mid-October. Data on Web page useincluded all KPNW computer users because KPNW confidentiallyregulations preclude tracking of Web usageby individual users. Project staff kept logs of their visitsto the /CPS Web pages to distinguishtheir usage from clinical usage.

Clinician Training Sessions.

At the end of the session,attendees evaluated the relevance and value of thepresentations, what they learned, and their likelihood ofadopting the various clinician CPS behaviors, includingcalling disease intervention specialists for help in providingCPS. We compared department responses totraining session evaluation questions using chi-squaretests with a 2-tailed significance level of .05.

Results

Use of After-

visit Summary.

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Of the 183 abstractedcharts, 95% contained documentation that the after-visitsummary was printed when the test was ordered. Most encounters that lacked documentationof printing the after-visit summary occurredin emergency departments. Whenever an after-visitsummary was printed, it contained the CPS information,indicating that clinicians did not avoid the CPSaddition by printing the after-visit summary beforeordering the test.

Use of Smart Set.

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In the 75 abstracted charts ofpatients with -positive tests when theSmart Set was available, we found no evidence of SmartSet use at initial encounters when testswere ordered, nor at follow-up encounters whenpatients were informed of their positive test results.

Use of Guidelines.

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The /CPS guidelinepages had 180 hits from September 2001 throughJanuary 2002, 6 of which were made by CPS projectstaff. The weekly number of hits ranged from 3 to 16(Figure). The /CPS Web pages wereaccessed most frequently after initial posting and afterclinician training sessions; hits declined over time.Average Web site session time increased during the 5-month observation period (September 2001-January2002) from less than 30 seconds during September toabout 1 minute after the first department presentationon October 9, 2001, then to a maximum of 3.5minutes during the second week in December. Briefvisits by project staff to verify site content and operationscontributed to the low average session time inSeptember.

Clinician Training Sessions.

A total of 127 cliniciansattended the educational presentations: 37 frompediatrics, 45 from internal medicine, 20 from obstetrics/gynecology, and 25 from family practice. A total of72 (57%) participants completed evaluation forms.

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Most participants thought the presentations werevaluable and relevant (Table 2). Most also indicated thatthe presentations made it more likely that they wouldcounsel infected patients to notify their partners, wouldtalk with patients about partner reactions, and wouldnotify them about health department services. Eightypercent were more likely to call disease intervention specialistsif patients needed help notifying sex partners.Fifty-four percent reported learning something new fromthe training sessions (Table 3). This percentage was highestfor pediatrics (65%) and lowest for obstetrics/gynecology(31%). Respondents most frequently cited learningsomething new about disease intervention specialists,including their existence and role in CPS, followed bytesting procedures. Departmental differenceswere not statistically significant.

DISCUSSION

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We found that KPNW has many strengths in the areaof CPS and treatment. For 90% of infectedpatients, drug prescriptions followed the CDC treatmentguidelines, which is consistent with otherstudies.^14,15Appropriate treatment of a patient makesuninfected partners less likely to become infected. Mostclinicians reported talking to patients about abstainingfrom sex during treatment, STD riskreduction, and notifying sex partners so that they canseek evaluation. Similarly, most interviewed patientsrecalled receiving such counseling. Clinicians may haveprovided these services because they were recommendedby CDC and KPNW treatment guidelines, were consideredto be a routine clinical function, or tookminimal time. Reporting of positive teststo the health department by KPNW's infection controlstaff was consistent with other studies showing fairlycomplete reporting in health plans with centralizedreporting.¹⁶Like clinicians in other studies, most KPNWclinicians were aware that -infectedpatients were reported to the health department.¹⁰

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We also found several policy-, clinical-, and patient-levelbarriers to CPS, consistent with studies of private-sectorsettings, which confirm that partner servicesare challenging¹⁷or inadequate.¹⁰KPNW had no writtenpolicy on partner treatment, including patient-deliveredpartner therapy, for . Pharmacy data andmember reports suggest some patient-delivered partnertherapy occurs. As a result of this evaluation, KPNW iscurrently reviewing their nonmember policy to determinewhether treating nonmember partners mayreduce risk of reinfection for KPNW members. Healthdepartment records and patient interviews suggestthat the disease intervention specialists interviewedonly a small portion of KPNW -infectedpatients, increasing the importance of clinicians andstaff discussing partner notification and treatment aswell as prevention with patients.

We successfully developed and implemented informationalinterventions to improve CPS in an HMO.Interventions were based on identified barriers andfacilitators, the criteria of feasibility and acceptabilityto KPNW management and clinicians, and past interventionexperience.^18,19

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Of the 4 interventions, 3 were commonly used andsustainable. Almost all clinicians printed the CPS componentof the after-visit summary when they ordered atest. We can only assume that patientsreceived the after-visit summary because clinic protocolsrequired that a medical assistant give the after-visitsummary to the patient and explain its content, andKPNW staff indicated that patients generally likereceiving the after-visit summary. Clinicians who wereconcerned that the CPS information would offendpatients could have printed the after-visit summarybefore ordering the tests, but nonechose this option. KPNW is discussing the feasibility of2 different CPS components: 1 for patients who receivea test (about disease prevention, transmission,and treatment) and 1 for patients with positivetests (with information about partnernotification and the health department's role).

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No clinicians used the Smart Set to documentcounseling when it was indexed either under "Gonorrhea/Chlamydia" or the easier-to-find "Chlamydia/Gonorrhea."In theory, use of the Smart Setcan save considerable time by guiding cliniciansthrough treatment protocols and documentationfrom a single EpicCare location. Clinicians' past experiences with slow computer response timesfor other Smart Sets might have discouraged use of themodule. This prompted EpicCare staff tomake presentations to clinicians on the newer, fasterSmart Sets after the project period. KPNW will maintainthe Smart Set on EpicCare and promoteSmart Set use.

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Many clinicians attended the training sessions andreported that they learned more about and CPS, and that the training might influence futureCPS behaviors. Clinician comments about the Web-based/CPS guidelines were positive.The pattern of weekly hits on /CPSWeb pages—with use peaking just after training sessions—suggests that Web visitors obtain neededinformation at their initial visits. We expect therevised /CPS guidelines to be maintainedas standard information resources on KPNW'sinternal Web site.

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The quality of CPS at commercial health plans likeKPNW is increasingly important because more infections may be detected as a result of newscreening guidelines,⁵a Health Employer Data andInformation Set (HEDIS) measure to monitor the screening performance of health plans,²⁰andmore sensitive tests.²¹This project demonstrated thefeasibility of introducing centralized, low-cost, sustainableinformational interventions that address identifiedbarriers and facilitators to CPS. These informationalinterventions offer the potential for use in other settingswith centralized resources similar to KPNW. Futureresearch should address whether these interventionsaffect clinician and patient behaviors, notification andreferral of sex partners for evaluation and treatment, orrisk of reinfection in patients.

Acknowledgments

The contributions of the following KPNW staff are gratefully acknowledged:Linda Phelps, MA, and Mina Monroe, MPH, for technical assistance,Jill Mesa for administrative assistance, and Gary Miranda, MA, and JenniferCoury, MA, for editorial assistance.

CPS Workgroup collaborators include Silvia Teran, MD (Centers forDisease Control and Prevention, Atlanta, Ga); Lila Duncan, Jan Karius,Doug Harger (Oregon Departments of Human Services and Health Services);Mark Aubin (Washington State Department of Health, Olympia, Wash);Mary Ann Ware, MD, and Julie Castle (Multnomah County Health Department,Ore); Alan Melnick, MD (Clackamas County Health Department,Ore); and Karen Steingart, MD, and Marnie Marvin (Clark County HealthDepartment, Ore).

From the Center for Health Research, Kaiser Permanente, Portland, Ore (JPM, BV,NAV, SGC, KE); Program Design and Evaluation Services, Multnomah County HealthDepartment and Oregon Department of Human Services, Portland, Ore (JEM); NorthwestPermanente, Physicians and Surgeons PC, Portland, Ore (JS); Prevention Systems andHealth Systems, Kaiser Permanente Northwest Region, Portland, Ore (NHS); and theCenters for Disease Control and Prevention, Atlanta, Ga (KI, JD, LAA). A list of CPSWorkgroup collaborators is given in the Acknowledgments section at the end of this article.

This work was funded by the Centers for Disease Control and Prevention through theAmerican Association of Health Plans (Task Order #0957-031).

Address correspondence to: John P. Mullooly, PhD, Center for Health Research, KaiserPermanente, 3800 N Interstate Ave, Portland, OR 97227. E-mail: john.mullooly@kp.org.

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