11
Nutrition Services in Ambulatory Care Settings

In the past decade, significant changes have occurred in health care that have influenced where and how care is delivered. Medicare’s prospective payment system in acute care settings and the growth of managed care have contributed to a shift in provision of services to the ambulatory care setting. From 1987 to 1997 there was a 68 percent increase in outpatient visits (AHA, 1999). This shift in care has not been accompanied by a similar transfer of reimbursement monies, especially for nutrition and other self-management interventions.

In addition to the shift of health care to the ambulatory setting, there has also been an increased emphasis on primary, secondary, and tertiary prevention of disease. Primary prevention addresses the promotion of lifestyle changes when there are no risk factors and no apparent disease. Secondary prevention focuses on early identification and prompt treatment of disease, and promotes life-style changes that favorably affect known risk factors. Tertiary prevention emphasizes reduction in impairment or disability and prevention of disease progression following diagnosis (USPSTF, 1995). Nutrition services in ambulatory settings play a role in all three areas of prevention.

REIMBURSEMENT FOR NUTRITION THERAPY IN AMBULATORY CARE

At the present time, Medicare Part B covers medical and other health services which are incident to a primary care provider’s services. Incident



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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population 11 Nutrition Services in Ambulatory Care Settings In the past decade, significant changes have occurred in health care that have influenced where and how care is delivered. Medicare’s prospective payment system in acute care settings and the growth of managed care have contributed to a shift in provision of services to the ambulatory care setting. From 1987 to 1997 there was a 68 percent increase in outpatient visits (AHA, 1999). This shift in care has not been accompanied by a similar transfer of reimbursement monies, especially for nutrition and other self-management interventions. In addition to the shift of health care to the ambulatory setting, there has also been an increased emphasis on primary, secondary, and tertiary prevention of disease. Primary prevention addresses the promotion of lifestyle changes when there are no risk factors and no apparent disease. Secondary prevention focuses on early identification and prompt treatment of disease, and promotes life-style changes that favorably affect known risk factors. Tertiary prevention emphasizes reduction in impairment or disability and prevention of disease progression following diagnosis (USPSTF, 1995). Nutrition services in ambulatory settings play a role in all three areas of prevention. REIMBURSEMENT FOR NUTRITION THERAPY IN AMBULATORY CARE At the present time, Medicare Part B covers medical and other health services which are incident to a primary care provider’s services. Incident

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population to refers to services specifically related to the medical care that is being provided by the physician at the time of the encounter. While Medicare Part B does not specifically cover or exclude payment for nutrition services, because regional carriers have the discretion to reimburse for nutrition services which are deemed reasonable and medically necessary, there are widespread inconsistencies and reimbursement is frequently denied. For patients who are enrolled in Medicare Part C (Medicare + Choice) it is up to the individual plan as to whether or not nutrition service is a covered benefit. Under Medicare Part B, in order to be covered as an incident to service, the service must be provided by the physician or an employee of the physician, physician group practice, ambulatory surgical clinic, ambulatory clinic, or rural health clinic. If the service is provided by an employee of the above providers, it must be directly supervised by the billing physician. A nutrition professional, such as a dietitian, providing nutrition services is not authorized to submit requests for payment separately. Since dietitians are rarely employees of physician practices or ambulatory clinics, the lack of specific coverage for outpatient nutrition services is a significant barrier to nutrition therapy. In 1996, the U.S. Preventive Services Task Force (USPSTF, 1996) recommended that “clinicians who lack the time or skills to perform a complete dietary history, to address potential barriers to changes in eating habits, and to offer specific guidance on meal planning and food selection and preparation, should either have patients seen by other trained providers in the office or clinic or should refer patients to a registered dietitian or qualified nutritionist for further counseling.” However, O’Keefe and colleagues (1991) reported that less than 25 percent of physicians routinely referred patients to a dietitian and only 10 percent had a dietitian available for dietary counseling. Most physicians or physician groups do not have sufficient funding in administrative budgets, office space, or enough patients requiring nutrition therapy to support hiring a dietitian as part of their office staff. As part of the Balanced Budget Act of 1997, reimbursement for diabetes self-management is now a covered benefit for Medicare beneficiaries (see chapter 6). Currently, the proposed regulations for diabetes self-management developed by the Health Care Financing Administration require that a registered dietitian and certified diabetes educator participate in the diabetes education program and that programs are accredited by the American Diabetes Association. Although the final regulations will not be released until early 2000, the proposed regulations include ten visits during the first year of diagnosis and one visit annually thereafter. Medicare reimbursement for ambulatory care moves to a prospective

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population payment system (PPS) with the Ambulatory Payment Classification system beginning in January 2000. This system provides hospital outpatient departments both opportunities and risks similar to those experienced when the PPS was implemented in acute care, short-stay hospitals (Duncan, 1999). It is unclear how this will impact services in the ambulatory setting (Lake, 1998). In the acute care setting there was adequate support for nutrition professionals prior to implementation of the PPS. However, support for the nutrition professional in the ambulatory setting is presently inconsistent and inadequate. ACCREDITATION STANDARDS FOR THE AMBULATORY SETTING The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accredits ambulatory facilities (free-standing ambulatory clinics) under separate guidelines from those used in hospital-based outpatient services. Hospital-based outpatient services are surveyed using hospital standards that include requirements for nutrition screening, assessment, and therapy provided by a qualified dietitian (JCAHO, 1999a). For ambulatory facilities, requirements specify that nutritional status must be assessed when warranted and dietary needs, including the provision of nutrition therapy, must be met when appropriate (JCAHO, 1999b). These standards state that a “nutritionist or other qualified individual” is to be involved in the assessment and documentation of patient needs (JCAHO, 1999b). JCAHO identifies the “dietitian or nutritionist” as the primary provider of specific nutrition services. The National Committee for Quality Assurance (NCQA) surveys and ranks managed care organizations, including those who provide services under Medicare Part C. NCQA uses the Health Plan Employer Data and Information Set in its evaluation process. The key systems and processes that make up the health plan are evaluated, including how well the plan provides services to keep its members healthy or manage chronic disease. Current outcome measures related to nutrition therapy include lipid levels, HbA1c levels, and the provision of education for individuals with diabetes. Outcome measures selected for further development include documentation of calcium intake in women and the provision of benefits for individuals who are overweight. Access to health care providers is also measured. While a nutrition professional is currently not included in the “access to health care provider” measure as mentioned above, several outcome measures in which nutrition intervention can have an impact are tracked and measured (NCQA, 1999).

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population NUTRITION SERVICES IN AMBULATORY SETTINGS Primary Prevention The U.S. Dietary Guidelines suggest numerous dietary goals to aid in the prevention of chronic disease. Several studies have evaluated the impact of resulting dietary changes. The San Diego Medicare Preventive Health Project evaluated health behavior change 1 year after an intervention that included a nutrition component. The study found significant positive changes in the participants’ nutrition-related behaviors, most notably in the reduction of fat consumption (e.g., red meat, gravy, butter, fried foods) and increased fiber intake (Mayer et al., 1994). In addition, the Women’s Health Initiative, which includes women ages 49 to 79, is an ongoing study that focuses on assisting participants in following a low-fat diet with increased fruits, vegetables, and grains. Overall, research that links general preventive counseling to health habit change and its corresponding alterations in the development of chronic disease is limited. Nutrition services in ambulatory settings should include screening to identify individuals who need nutrition intervention and triaging to the most appropriate professional for care. Intervention can include basic nutrition education for disease prevention or more complex nutrition therapy. Nutrition services may be provided in physicians’ offices, health maintenance organizations, outpatient departments, primary care centers, health clinics, or the private offices of a nutrition professional. The format for the encounter can be individual or group. It may occur as part of the routine medical visit or as an in-depth assessment and intervention by a nutrition professional. Information may also be provided using written materials, videoconferencing, or computer and Internet programs. There are several major trends related to the role of nutrition and prevention in the ambulatory care setting: the increased use of dietary supplements among older individuals, changes in knowledge about how properties of foods enhance health, technological advances in communication (e.g., television and the Internet), a growing interest in complementary and alternative therapies, and the related burgeoning market for nutritional and botanical products. The older person can be particularly vulnerable to claims made about health and nutrition. Elders are often coping with the effects of chronic disease and its treatment. They may also be living on limited incomes, be socially isolated, and be unable to evaluate the accuracy of information provided by marketing materials, television advertising, and the Internet. These problems are compounded by the lack, in many cases, of strong evidence to support effectiveness, safety, potential interaction of supplements with medications, and cost-effectiveness of alternative medicine therapies.

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Vitamin and Mineral Supplementation Estimates of the numbers of elderly individuals taking vitamin and mineral supplements are as high as 55 percent (Ervin et al., 1999). With the increased marketing and varying potency of supplements on the market, elders need assistance to evaluate their current and prospective supplementation needs. As the new dietary reference intakes are being developed (IOM, 1997), tolerable upper intake levels are also being defined. This information should help consumers and professionals interpret safe levels of intake. While vitamin and mineral supplementation can help round out nutrient intake, it is recommended that health professionals continue to stress the importance of a well-balanced diet. Functional Foods, Botanicals, and Alternative Medicine More than 30 percent of Americans sought treatment from complementary and alternative providers in 1992 (Eisenberg et al., 1993). Many of the complementary and alternative medicine regimens include botanicals or nutrient supplements. In 1997, U.S. sales of botanicals and related remedies reached $3.24 billion (Johnston, 1997), which represents a growing share of the sale of dietary supplements. Eisenberg and coworkers (1998) estimated that 15 million adults took prescription medications concurrently with botanicals or related remedies. Data pertaining to the adverse effects of botanicals and related remedies alone or in combination with prescription medications are either limited or nonexistent. Since many individuals view botanicals and dietary supplements as food items, their use is often identified in the course of a comprehensive nutrition assessment. The role of food in enhancing health has also emerged with the concept of “functional foods” and “functional food components.” Functional foods have been defined as foods that may provide a benefit beyond basic nutrition. Functional food components have similarly been defined as nutritive and non-nutritive compounds found in food that are thought to reduce the risk of disease or promote health (IFIC, 1998). Another popular term that is emerging is “nutraceutical.” It has been defined as a substance that provides medical or health benefits, including the prevention and treatment of disease, and may be considered a food or part of food (Mahan and Escott-Stump, 1996). Consumers need assistance in interpreting these new terms and their claims, as well as determining the value in relation to their own nutritional needs. Limited research is available that evaluates the potential health benefits of nutrition-related complementary and alternative medicine for conditions such as Alzheimer’s disease (Le Bars et al., 1997; Oken et al., 1998;

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Sano et al., 1997; Zaman et al., 1992), osteoarthritis (Morreale et al., 1996; Pujalte et al., 1980), atherosclerotic vascular disease (Silagy and Neil, 1994; Tyler, 1993; Warshafsky et al., 1993), and cancer (Lersch et al., 1992). Further research is needed to determine efficacy for health benefits. Also, elderly consumers need assistance in translating research findings into meaningful lifestyle change. Basic Nutrition Education Almost all members of the health care team can and should play a role in providing various components of nutrition care. Table 11.1 summarizes the roles of many health care providers in the provision of nutrition services. Traditionally, primary care physicians and nurses have screened patients and provided basic nutrition information. Basic nutrition education is characterized as either a group or an individual interaction based on sound nutrition principles and is generally considered primary prevention. However, reinforcement of dietary changes required for secondary and tertiary prevention in certain conditions may also be accomplished through basic nutrition education. The education may consist of information about the importance of nutrition in relation to risk factors or known disease conditions. The role of each provider can be enhanced by using evidence-based practice guidelines and protocols to help identify patients who need nutrition care and provide information that improves quality-of-life outcomes (Wagner et al., 1996). Nutrition Therapy Nutrition therapy is characterized by an in-depth assessment of pertinent medical, dietary, anthropometric, and lifestyle data and is provided following a referral from a physician. The therapy is relevant to specific disease states or conditions and includes an individualized diet prescription. Nutrition therapy usually involves in-depth counseling that takes 30 to 60 minutes, depending on the number of conditions and the complexity of the diet prescription. It also includes some form of follow-up care to monitor changes, reinforce new food choices and eating behaviors, adapt to social and cultural norms, and provide feedback to the patient regarding clinical outcomes. Nutrition therapy has been shown to be effective in the management and treatment of many chronic conditions that affect Medicare beneficiaries, including dyslipidemia, hypertension, heart failure, diabetes, and chronic renal insufficiency (see chapters 5–7). As such, nutrition therapy usually focuses on secondary or tertiary prevention. Medicare beneficiaries undergoing cancer treatment (chemotherapy,

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population TABLE 11.1 Roles of Various Providers in Nutrition Care in Ambulatory Settings Provider Role Primary care physician or nurse practitioner or certified nurse midwife   Screens, initial assessment of nutritional status Comprehensive physical assessment Orders appropriate lab tests Diagnosis, basic nutrition information Provides needed biochemical and physical assessment and other data to registered dietitian on referral as defined in nutrition therapy protocols Limits or restricts activity of patients or modifies target ranges in protocols as needed Educates patients on food–drug interaction Registered nurse   Screens, requests nutrition consult per screening protocol Provides basic nutrition information Educates patient on food–drug interactions Reinforces nutrition therapy principles in collaboration with registered dietitian Registered dietitian   Develops or implements nutrition screening tools Provides in-service education to non-nutrition staff regarding screening, assessment, and nutrition therapy Provides comprehensive nutrition assessment Provides nutrition therapy and self-management training in food and nutrient modification to treat medical conditions or diagnosis Educates patients on food–drug interactions Makes evidence-based recommendations to patients about use of nutrient supplements, liquid dietary supplements, botanicals, etc. Refers patients to community services, food resources (e.g., food stamps, food pantries, home delivered meals) Collaborates or coordinates services with inpatient, long-term care, home care, and referring providers Social worker   Identifies patients in need of nutrition information or intervention Collaborates with registered dietitian to plan for care in the continuum Assists patients in obtaining needed food resources (e.g., food stamps, food pantries, home-delivered meals, Medicaid prior approval for nutritional supplements) Psychologist or LCSW   Identifies patients in need of nutrition information or intervention Collaborates in behavioral group interventions   SOURCE: Adapted from Cambridge Health Alliance (1999).

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population radiation, or surgical intervention) may also benefit from nutrition therapy aimed at controlling side effects or improving food intake. During nutrition therapy sessions, other nutrition concerns of interest to the patient can be addressed. This may be particularly important for the older individual who is undernourished or who has questions related to vitamin and mineral supplements, liquid dietary supplements, botanicals, functional foods, or other alternative forms of care. EFFECTIVENESS OF NUTRITION THERAPY IN AMBULATORY SETTINGS Decreased length of stay and increased acuity levels in acute care settings have strengthened the argument that nutrition counseling is best conducted outside the hospital setting (Laramee, 1996). For education to be effective, patients must be “ready to learn.” Hospitalized patients are generally too ill to participate in self-management education. Dietary behavior changes have been identified as the most difficult component of diabetes and other chronic disease self-management programs (Lockwood et al., 1986). Food practices are an important aspect of culture and lifestyle, and unlike cigarette smoking, alcohol, or other drugs, individuals with food addictions cannot opt for avoidance. Food options are an unavoidable choice to be made multiple times each day. To effect long-term changes in food-related behaviors, adequate time and conditions conducive to the counseling process are needed. The ambulatory setting affords the clinician time to build a relationship with the patient, which can be an essential component of guiding patients to make long-term behavior changes. Several authors have explored the skills and techniques needed for optimal self-management. Successful educational programs go beyond just providing information. They use frequent positive reinforcement, a combination of group and individual interactions, practical demonstrations and participant practice, and active participation in decision making by patients (Beck et al., 1997; Lorig et al., 1999; Prohaska, 1998). Elders are often avid learners and able to make lifestyle changes, especially when there is peer or spouse support (Clement, 1995). Appropriate self-management activities are often most effective when the older person can link symptoms of the disease with health behaviors such as diet (Prohaska and Glasser, 1994). Some studies have looked at the effectiveness of the dietitian’s counseling skills. Stetson and colleagues (1992) videotaped sessions with dietitians and concluded that interpersonal skills were good but dietitians needed supplemental training to improve teaching and adherence promotion skills. The skills identified for improvement were presentation skills, active patient involvement, assessment evaluation, feedback, for-

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population mulation of a behavioral plan, negotiation and accountability, and behavioral techniques (Stetson et al., 1992). Gilboy (1994) reported a survey of 508 dietitians and found that those in outpatient or ambulatory settings used more compliance-enhancing skills, had greater self-efficacy, and had higher levels of outcome efficacy than did inpatient dietitians. For dietitians working in the outpatient setting, a greater number of counseling and follow-up sessions correlated with the best compliance-enhancing practices (Gilboy, 1994). FUTURE AREAS OF RESEARCH The committee found limited research documenting the efficacy of nutrition therapy focused solely on primary prevention. Further research is needed to evaluate effectiveness of nutrition therapy in assisting the consumer to appropriately select food, dietary supplements, fortified or functional foods, and nutrition-related complementary and alternative medicine therapies that are consistent with the U.S. Dietary Guidelines. In addition, research comparing the effectiveness of nutrition therapy in the acute care versus ambulatory settings in producing lasting and meaningful behavior change is lacking. Research is also needed to evaluate the effectiveness of various methods of delivering nutrition therapy and contributions of various healthcare team members. SUMMARY Health care trends, such as a shortened length of stay in acute care facilities, have appropriately shifted the bulk of nutrition education and nutrition therapy to the ambulatory setting. Nutrition therapy provided in the ambulatory setting is thought to better meet patients’ learning needs and produce meaningful long-term, nutrition-related behavior change. Currently, Medicare coverage for nutrition therapy in ambulatory settings is at best inconsistent, but most often, nonexistent. Consumers’ interest in and the availability of dietary supplements, botanicals, alternative medicine, and functional foods have increased and a myriad of marketing mechanisms have been aimed at the consumer. Individuals evaluating products need guidance from trained nutrition professionals in interpreting the complexity of mixed messages and scientific findings. Elderly individuals in particular may need advice on the efficacy of products as well as the safety of integrating them with medications. Basic nutrition education for the primary prevention of chronic disease in the elderly should continue to be provided by a variety of health care professionals within the context of routine preventive health. There

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population is little evidence to support replacing such basic nutrition education by nutrition therapy focused solely on primary prevention or that the basic nutrition education should be provided by a nutrition professional. Prevention topics are routinely included in all sessions of nutrition therapy regardless of the diagnoses leading to the referral. In contrast, there is reasonable evidence documenting the efficacy of nutrition therapy for the treatment and management (secondary and tertiary prevention) of many conditions that are common among Medicare beneficiaries. Since a majority of Medicare beneficiaries 65 years of age or older will have a diagnosis supporting a referral of nutrition therapy, the primary prevention issues would likely be addressed as part of the nutrition therapy for those diagnoses. RECOMMENDATIONS For dyslipidemia, hypertension, heart failure, diabetes, and renal disease, available evidence (reviewed in chapters 5–7) supports a role for nutrition therapy in the routine management of these conditions for the Medicare population. For this reason it is recommended that nutrition therapy be considered a covered benefit for Medicare beneficiaries in the ambulatory setting. Nutrition education is also important in the primary prevention of chronic disease. However, a variety of health care professionals such as physicians, nurses, and pharmacists should and do provide nutrition education in the context of routine preventive health visits or patient encounters. These encounters, however, should not constitute a separate covered visit, but rather be considered incident to medical care or the nutrition therapy being provided. In order to eliminate a barrier to access for nutrition therapy, nutrition professionals should be considered eligible as qualified providers who receive direct Medicare reimbursement. REFERENCES AHA (American Hospital Association). 1999. Hospital Statistics: The AHA Profile of United States Hospitals. Historical Trends. Chicago, Ill.: AHA. Beck A, Scott J, Williams P, Robertson B, Jackson D, Gade G, Cowan P. 1997. A randomized trial of group outpatient visits for chronically ill older HMO members: The cooperative health care clinic. J Am Geriatr Soc 45:543–549. Cambridge Health Alliance. 1999. Ambulatory Nutrition, Policy and Procedures—Practice Guidelines. Cambridge, Mass.: Cambridge Health Alliance. Clement S. 1995. Diabetes self-management education. Diabetes Care 18:1204–1214. Duncan D. 1999. Preparing for Medicare’s APC System. Healthcare Finan Mgmt 53:40–45.

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