Generalist care managers for the treatment of depressed medicaid patients in North Carolina: A pilot study

BACKGROUND: In most states, mental illness costs are an increasing share of Medicaid expenditures. Specialized depression care managers (CM) have consistently demonstrated improvements in patient outcomes relative to usual primary care (UC), but are costly and may not be fully utilized in smaller practices. A generalist care manager (GCM) could manage multiple chronic conditions and be more accepted and cost-effective than the specialist depression CM. We designed a pilot program to demonstrate the feasibility of training/deploying GCMs into primary care settings. METHODS: We randomized depressed adult Medicaid patients in 2 primary care practices in Western North Carolina to a GCM intervention or to UC. GCMs, already providing services in diabetes and asthma in both study arms, were further trained to provide depression services including self-management, decision support, use of information systems, and care management. The following data were analyzed: baseline, 3- and 6-month Patient Health Questionnaire (PHQ9) scores; baseline and 6-month Short Form (SF) 12 scores; Medicaid claims data; questionnaire on patients' perceptions of treatment; GCM case notes; physician and office staff time study; and physician and office staff focus group discussions. RESULTS: Forty-five patients were enrolled, the majority with preexisting depression. Both groups improved; the GCM group did not demonstrate better clinical and functional outcomes than the UC group. Patients in the GCM group were more likely to have prescriptions of correct dosing by chart data. GCMs most often addressed comorbid conditions (36%), then social issues (27%) and appointment reminders (14%). GCMs recorded an average of 46 interactions per patient in the GCM arm. Focus group data demonstrated that physicians valued using GCMs. A time study documented that staff required no more time interacting with GCMs, whereas physicians spent an average of 4 minutes more per week. CONCLUSION: GCMs can be trained in care of depression and other chronic illnesses, are acceptable to practices and patients, and result in physicians prescribing guideline concordant care. GCMs appear to be a feasible intervention for community medical practices and to warrant a larger scale trial to test their appropriateness for Medicaid programs nationally

Foraging behavior of egg parasitoids exploiting chemical information

Female parasitic wasps seek hosts for their offspring often in a dynamic environment. Foraging egg parasitoids rely on a variety of chemical cues originating from the adult host, host products, or the host plant rather than from the attacked host stage--the insect egg itself. Besides pupae, insect eggs are the most inconspicuous host stage attacked by parasitic wasps. To overcome the problem of low detectability of host eggs, egg parasitoids have evolved several strategies such as exploiting long-range kairomones of the adult hosts, for example, host aggregation and sex pheromones, plant synomones induced by egg deposition or host feeding, or short-range contact cues derived from the adult host or the host plant. Moreover, egg parasitoids have evolved the ability to use chemical espionage in combination with hitchhiking on the adult host (phoresy) to compensate their limited flight capability and to gain access to freshly laid host eggs. Here, we provide a comprehensive overview on the variety of host-foraging strategies of egg parasitoids exploiting chemical signals. Furthermore, the use of such infochemicals is discussed with respect to the wasps' dietary breadth and their ability to learn. Copyright 2008, Oxford University Press.