Body mass index and outcomes following gastrointestinal cancer surgery in Japan.

BACKGROUND: Recent studies in the USA have shown a lower postoperative mortality rate in mildly obese patients, described as the 'obesity paradox'. The results from the relatively obese population in Western countries may not be generalizable to Asian countries, prompting the present study to investigate the relationship between body mass index (BMI) and outcomes after gastrointestinal surgery. METHODS: Patients who underwent gastrectomy or colorectal resection for stage I-III cancer between July and December 2010 were identified from a nationwide inpatient database in Japan. Multivariable logistic regression models for in-hospital mortality and postoperative complications, and a linear regression model for total costs were established, with adjustment for age, sex, co-morbidities, cancer stage and BMI. Restricted cubic spline functions were used to consider potential non-linear associations between BMI and the outcomes. RESULTS: Among 30 765 eligible patients, associations between BMI and the outcomes were U-shaped, with the lowest mortality, morbidity and total costs in patients with a BMI of around 23·0 kg/m(2) . A BMI of 18·5 kg/m(2) was associated with significantly greater mortality (odds ratio (OR) 2·04, 95 per cent confidence interval 1·64 to 2·55), postoperative complications (OR 1·10, 1·03 to 1·18) and total costs (difference €1389, 1139 to 1640) compared with a BMI of 23·0 kg/m(2) . Patients with a BMI exceeding 30·0 kg/m(2) had significantly higher rates of postoperative complications and total costs than those with a BMI of 23·0 kg/m(2) , but no significant association was evident between a BMI of more than 23·0 kg/m(2) and in-hospital death. CONCLUSION: Unlike previous studies in the USA, in the present national Japanese cohort of patients undergoing surgery for gastrointestinal cancer, those who were either underweight or overweight had more postoperative complications and greater perioperative costs than those of normal weight.

Minimally important differences were estimated for the Functional Assessment of Cancer Therapy-Colorectal (FACT-C) instrument using a combination of distribution- and anchor-based approaches.

OBJECTIVE: To estimate minimally important differences (MIDs) on the Functional Assessment of Cancer Therapy-Colorectal (FACT-C) instrument using anchor- and distribution-based methods. STUDY DESIGN AND SETTING: Preliminary MIDs were generated for FACT-C scores based on published results for two samples (n = 60 and n = 63) from the FACT-C validation study. Preliminary MIDs were confirmed using data from a Phase II randomized controlled clinical trial (n = 104) and a population-based observational study (n = 568). MIDs were estimated for the colorectal cancer subscale (CCS); the FACT-C Trial Outcome Index (TOI-C), which is the sum of the CCS, physical well-being, and functional well-being subscales; and the FACT-C total score. Both cross-sectional and longitudinal analyses were used. RESULTS: MIDs were stable across the different patient samples. The recommended MIDs ranged from 2 to 3 points for the CCS, 4 to 6 points for the TOI-C, and 5 to 8 points for the FACT-C total score. CONCLUSIONS: MIDs can enhance the interpretability of FACT-C scores, and they can be used to provide a basis for sample size estimation and to determine clinical benefit in combination with other measures of efficacy. General guidelines for estimating MIDs for other FACT instruments are suggested.

Quality of care for coronary heart disease in two countries.

Coronary heart disease is the leading cause of death in the United States and England, and each country devotes substantial resources to its prevention and treatment. We review recent strategies for improving quality of care for coronary heart disease in each country, including clinical guidelines; national standards; performance reports; benchmarking, feedback, and professional leadership; and market-oriented approaches. These strategies highlight the importance of information systems, organizational culture, and incentives to improve the quality of care in both the decentralized health care system of the United States and England's more centralized system.

Supplemental insurance and use of effective cardiovascular drugs among elderly medicare beneficiaries with coronary heart disease.

CONTEXT: Cost-sharing in US prescription drug coverage plans for elderly persons varies widely. Evaluation of prescription drug use among elderly persons by type of health insurance could provide useful information for designing a Medicare drug program. OBJECTIVE: To determine use of effective cardiovascular drugs among elderly persons with coronary heart disease (CHD) by type of health insurance. DESIGN, SETTING, AND PATIENTS: Cross-sectional evaluation of 1908 community-dwelling adults, aged 66 years or older, with a history of CHD or myocardial infarction from the 1997 Medicare Current Beneficiary Survey, a nationally representative sample of Medicare beneficiaries. MAIN OUTCOME MEASURES: Use of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins), beta-blockers, and nitrates, and out-of-pocket expenditures for prescription drugs, stratified by type of health insurance: Medicare without drug coverage (Medicare only or self-purchased supplemental insurance) or with drug coverage (Medicaid, other public program, Medigap, health maintenance organization, or employer-sponsored plan). RESULTS: Statin use ranged from 4.1% in Medicare patients with no drug coverage to 27.4% in patients with employer-sponsored drug coverage (P<.001). Less variation between these 2 types occurred for beta-blockers (20.7% vs 36.1%; P =.003) and nitrates (20.4% vs 38.0%; P =.005). In multivariate analyses, statin use remained significantly lower for patients with Medicare only (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.05-0.49) and beta-blocker use was lower for Medicaid patients (OR, 0.55; 95% CI, 0.34-0.88) vs those with employer-sponsored coverage. Nitrate use occurred less frequently in persons lacking drug coverage (patients with Medicare only, P =.049; patients with supplemental insurance without drug coverage, P =.03). Patients with Medicare only spent a much larger fraction of income on prescription drugs compared with those with employer-sponsored drug coverage (7.9% vs 1.7%; adjusted P<.001). CONCLUSION: Elderly Medicare beneficiaries with CHD who lack drug coverage have disproportionately large drug expenditures and lower use rates of statins, a class of relatively expensive drugs that improve survival.

Quality of ambulatory care after myocardial infarction among Medicare patients by type of insurance and region.

PURPOSE: To evaluate use of effective cardiac medications and rehabilitation after myocardial infarction in the ambulatory setting in health maintenance organizations (HMOs) and fee-for-service care, and by region. SUBJECTS AND METHODS: We surveyed elderly Medicare patients during 1996 and 1997 in California (n = 516), Florida (n = 304), and the Northeast (n = 220; Massachusetts, New York, and Pennsylvania) approximately 18 months after myocardial infarction. We assessed use of cardiac medications and rehabilitation for HMO (n = 520) and fee-for-service (n = 520) patients matched by age, sex, month of infarct, and region. RESULTS: Across all regions, similar proportions of HMO and fee-for-service patients were using aspirin (72%, n = 374 vs. 74%, n = 387), beta-blockers (38%, n = 195 vs. 32%, n = 168), angiotensin-converting enzyme inhibitors (31%, n = 159 vs. 29%, n = 148), cholesterol-lowering agents (28%, n = 146 vs. 30%, n = 157), and calcium channel blockers (31%, n = 162 vs. 31%, n = 159; all P >0.07), except in California where more HMO patients received beta-blockers (36%, n = 93 vs. 26%, n = 66, P = 0.01). In adjusted analyses, use of these drugs did not differ significantly between HMO and fee-for-service patients. Substantial regional differences were evident in the use of beta-blockers (Northeast 46%, n = 102; Florida 34%, n = 102; California 31%, n = 159) and cholesterol-lowering agents (California 35%, n = 182; Florida 24%, n = 73; Northeast 22%, n = 48; each P <0.001). Fee-for-service patients were more likely than HMO patients to receive cardiac rehabilitation in unadjusted (32%, n = 167, vs. 22%, n = 141, P = 0.001) and adjusted analyses. CONCLUSIONS: Both HMO and fee-for-service patients would likely benefit from greater use of beta-blockers and cholesterol-lowering agents. Professional fees for cardiac rehabilitation may promote increased use among fee-for-service patients. Future studies should assess the quality of ambulatory cardiac care in different types of HMOs and the reasons for geographic variations in cardiac drug use.

Impact of patient and provider characteristics on the treatment and outcomes of colorectal cancer.

While the management and prognosis of colorectal cancer are largely dependent on clinical features such as tumor stage, there is considerable variation in treatment and outcome not explained by traditional prognostic factors. To guide efforts by researchers and health-care providers to improve quality of care, we review studies of variation in treatment and outcome by patient and provider characteristics. Surgeon expertise and case volume are associated with improved tumor control, although surgeon and hospital factors are not associated consistently with perioperative mortality or long-term survival. Some studies indicate that patients are less likely to undergo permanent colostomy if they are treated by high-volume surgeons and hospitals. Differences in treatment and outcome of patients managed by health maintenance organizations or fee-for-service providers have not generally been found. Older patients are less likely to receive adjuvant therapy after surgery, even after adjustment for comorbid illness. In the United States, black patients with colorectal cancer receive less aggressive therapy and are more likely to die of this disease than white patients, but cancer-specific survival differences are reduced or eliminated when black patients receive comparable treatment. Patients of low socioeconomic status (SES) have worse survival than those of higher SES, although the reasons for this discrepancy are not well understood. Variations in treatment may arise from inadequate physician knowledge of practice guidelines, treatment decisions based on unmeasured clinical factors, or patient preferences. To improve quality of care for colorectal cancer, a better understanding of mechanisms underlying associations between patient and provider characteristics and outcomes is required.

Impact of underuse, overuse, and discretionary use on geographic variation in the use of coronary angiography after acute myocardial infarction.

BACKGROUND: Geographic variation in the use of medical procedures has been well documented. However, it is not known whether this variation is due to differences in use when procedures are indicated, discretionary, or contraindicated. OBJECTIVES: To examine whether use of coronary angiography after acute myocardial infarction (AMI) according to appropriateness criteria varied across geographic regions and whether underuse, overuse, or discretionary use accounted for variation in overall use. DESIGN: Retrospective cohort study using data from the Cooperative Cardiovascular Project. SETTING: Ninety-five hospital referral regions. PATIENTS: There were 44,294 Medicare patients hospitalized with AMI during 1994 or 1995, classified according to appropriateness for angiography. MAIN OUTCOME MEASURE: Variation in use of angiography, as measured by the difference between high and low rates of use across regions. RESULTS: Across regions, variation in the use of angiography was similar for indications judged necessary; appropriate, but not necessary; or uncertain. Variation was lowest for indications judged unsuitable (difference between high rate and low rate across regions = 16.3%; 95% CI = 12.6%; 20.6%). The primary cause of variation in the overall rate of angiography was due to use for indications judged appropriate, but not necessary or uncertain. When variation associated with these indications was accounted for, the difference between the resulting high and low overall rates was 10.8% (9.4%, 12.4%). In contrast, variation in the overall rate remained high when underuse in necessary situations or overuse in unsuitable situations was accounted for. CONCLUSIONS: Across regions, practice was more similar for patients categorized unsuitable for angiography than for patients with other indications. Variation in overall use of angiography appeared to be driven by utilization for discretionary indications rather than by underuse or overuse. If equivalent rates across geographic areas are judged desirable, then greater effort must be directed toward defining care for patients with discretionary indications.

Validating recommendations for coronary angiography following acute myocardial infarction in the elderly: a matched analysis using propensity scores.

We determined whether adherence to recommendations for coronary angiography more than 12 h after symptom onset but prior to hospital discharge after acute myocardial infarction (AMI) resulted in better survival. Using propensity scores, we created a matched retrospective sample of 19,568 Medicare patients hospitalized with AMI during 1994-1995 in the United States. Twenty-nine percent, 36%, and 34% of patients were judged necessary, appropriate, or uncertain, respectively, for angiography while 60% of those judged necessary received the procedure during the hospitalization. The 3-year survival benefit was largest for patients rated necessary [mean survival difference (95% CI): 17.6% (15.1, 20.1)] and smallest for those rated uncertain [8.8% (6.8, 10.7)]. Angiography recommendations appear to select patients who are likely to benefit from the procedure and the consequent interventions. Because of the magnitude of the benefit and of the number of patients involved, steps should be taken to replicate these findings.

Patient-centered processes of care and long-term outcomes of myocardial infarction.

OBJECTIVE: To examine whether patients' experiences with nontechnical aspects of care such as patient education and discharge planning are associated with long-term outcomes. DESIGN: Observational cohort study. SETTING: Twenty-three New Hampshire hospitals during 1996 and 1997. PARTICIPANTS: Acute myocardial infarction (AMI) patients (N=2,272) enrolled prior to discharge. MEASUREMENTS: Surveys asking about problems with care and health were mailed to patients 1, 3, and 12 months after discharge. Patients were stratified into "worse" or "better" care groups on the basis of their hospital care problem score. Outcomes included self-reported overall health, physical health, mental health, chest pain, and shortness of breath. Other clinical measures were obtained from hospital discharge abstracts. MAIN RESULTS: The 1-, 3-, and 12-month surveys were returned by 1,346 (59.2%), 1,046 (46%), and 964 (42.4%) enrolled patients, respectively. The primary analytic cohort consisted of the 762 patients who completed both the 1- and 12-month surveys. After adjustment for postdischarge health status and other clinical factors, patients experiencing worse hospital care had lower ratings of overall health (48.4 vs 52.5 on 100-point scale; P=.02) and physical health (59.7 vs 68.4; P <.001), and were more likely to have chest pain (odds ratio [OR], 1.6; confidence interval [CI], 1.0 to 2.4; P=.04) 12 months after their AMI than other patients. However, differences in reports of chest pain were reduced if patients reporting worse hospital care had better experiences with subsequent ambulatory care. CONCLUSIONS: Patients' experiences with nontechnical processes of AMI hospital care are associated with long-term outcomes; however the association between a negative hospital experience and subsequent chest pain may be offset by more positive outpatient experiences.

Measuring population health risks using inpatient diagnoses and outpatient pharmacy data.

OBJECTIVE: To examine and evaluate models that use inpatient encounter data and outpatient pharmacy claims data to predict future health care expenditures. DATA SOURCES/STUDY DESIGN: The study group was the privately insured under-65 population in the 1997 and 1998 MEDSTAT Market Scan (R) Research Database. Pharmacy and disease profiles, created from pharmacy claims and inpatient encounter data, respectively, were used separately and in combination to predict each individual's subsequent-year health care expenditures. PRINCIPAL FINDINGS: The inpatient-diagnosis model predicts well for the low-hospitalization under-65 populations, explaining 8.4 percent of future individual total cost variation. The pharmacy-based and in patient-diagnosis models perform comparably overall, with pharmacy data better able to split off a group of truly low-cost people and inpatient diagnoses better able to find a small group with extremely high future costs. The model th at uses both kinds of data performed significantly better than either model alone, with an R2 value of 11.8 percent . CONCLUSIONS: Comprehensive pharmacy and inpatient diagnosis classification systems are each helpful for discriminating among people according to their expected costs. Properly organized and in combination these data are promising predictors of future costs.

Racial disparities in access to renal transplantation--clinically appropriate or due to underuse or overuse?

BACKGROUND: Despite abundant evidence of racial disparities in the use of surgical procedures, it is uncertain whether these disparities reflect racial differences in clinical appropriateness or overuse or underuse of inappropriate care. METHODS: We performed a literature review and used an expert panel to develop criteria for determining the appropriateness of renal transplantation for patients with end-stage renal disease. Using data from five states and the District of Columbia on patients who had started to undergo dialysis in 1996 or 1997, we selected a random sample of 1518 patients (age range, 18 to 54 years), stratified according to race and sex. We classified the appropriateness of patients as data on candidates for transplantation and analyzed rates of referral to a transplantation center for evaluation, placement on a waiting list, and receipt of a transplant according to race. RESULTS: Black patients were less likely than white patients to be rated as appropriate candidates for transplantation according to appropriateness criteria based on expert opinion (71 blacks [9.0 percent] vs. 152 whites [20.9 percent]) and were more likely to have had incomplete evaluations (368 [46.5 percent] vs. 282 [38.8 percent], P<0.001 for the overall chi-square). Among patients considered to be appropriate candidates for transplantation, blacks were less likely than whites to be referred for evaluation, according to the chart review (90.1 percent vs. 98.0 percent, P=0.008), to be placed on a waiting list (71.0 percent vs. 86.7 percent, P=0.007), or to undergo transplantation (16.9 percent vs. 52.0 percent, P<0.001). Among patients classified as inappropriate candidates, whites were more likely than blacks to be referred for evaluation (57.8 percent vs. 38.4 percent), to be placed on a waiting list (30.9 percent vs. 17.4 percent), and to undergo transplantation (10.3 percent vs. 2.2 percent, P<0.001 for all three comparisons). CONCLUSIONS: Racial disparities in rates of renal transplantation stem from differences in clinical characteristics that affect appropriateness as well as from underuse of transplantation among blacks and overuse among whites. Reducing racial disparities will require efforts to distinguish their specific causes and the development of interventions tailored to address them.

Unmet health needs of uninsured adults in the United States.

CONTEXT: In 1998, 33 million US adults aged 18 to 64 years lacked health insurance. Determining the unmet health needs of this population may aid efforts to improve access to care. OBJECTIVE: To compare nationally representative estimates of the unmet health needs of uninsured and insured adults, particularly among persons with major health risks. DESIGN AND SETTING: Random household telephone survey conducted in all 50 states and the District of Columbia through the Behavioral Risk Factor Surveillance System. PARTICIPANTS: A total of 105,764 adults aged 18 to 64 years in 1997 and 117,364 in 1998, classified as long-term (>/=1 year) uninsured (9.7%), short-term (<1 year) uninsured (4.3%), or insured (86.0%). MAIN OUTCOME MEASURES: Adjusted proportions of participants who could not see a physician when needed due to cost in the past year, had not had a routine checkup within 2 years, and had not received clinically indicated preventive services, compared by insurance status. RESULTS: Long-term- and short-term-uninsured adults were more likely than insured adults to report that they could not see a physician when needed due to cost (26.8%, 21.7%, and 8.2%, respectively), especially among those in poor health (69.1%, 51.9%, and 21.8%) or fair health (48.8%, 42.4%, and 15.7%) (P<.001). Long-term-uninsured adults in general were much more likely than short-term-uninsured and insured adults not to have had a routine checkup in the last 2 years (42.8%, 22.3%, and 17.8%, respectively) and among smokers, obese individuals, binge drinkers, and people with hypertension, elevated cholesterol, diabetes, or human immunodeficiency virus risk factors (P<.001). Deficits in cancer screening, cardiovascular risk reduction, and diabetes care were most pronounced among long-term-uninsured adults. CONCLUSIONS: In our study, long-term-uninsured adults reported much greater unmet health needs than insured adults. Providing insurance to improve access to care for long-term-uninsured adults, particularly those with major health risks, could have substantial clinical benefits. JAMA. 2000;284:2061-2069

Physicians' reports of focused expertise in clinical practice.

Little is known about the prevalence of focused expertise (special areas of expertise within a clinical field) among physicians, yet such expertise may influence how care is delivered. We surveyed general internists, pediatricians, cardiologists, infectious disease specialists, and orthopedic surgeons to describe the prevalence of focused expertise and identify associated physician and practice characteristics. About one quarter of generalists and three quarters of specialists reported a focused expertise within their primary specialty. Hospital-based physicians more often reported such expertise, and physicians reimbursed by capitation less often reported expertise. Learning how focused expertise affects processes and outcomes of care will contribute to decisions about physician training and staffing of medical groups.

Physician perceptions of HMO care for older persons. Health Maintenance Organization.

OBJECTIVE: Physician attitudes may be a key factor in effective managed care for older patients. We sought to explore physicians' views of the influence of health maintenance organization (HMO) policies on the care of their older patients. DESIGN: A self-administered one-page questionnaire consisting of questions about physician demographics, the impact of HMOs on physician practice, patient care, HMO policies, and respondents' personal use of managed health care plans. PARTICIPANTS: The survey was mailed to 838 randomly selected primary care physicians affiliated with two large, nonprofit, academically-oriented, Medicare HMOs in Massachusetts. RESULTS: Completed surveys were received from 516 of 797 eligible primary care physicians, affiliated with either Secure Horizons (Tufts Associated Health Plan) or First Seniority (Harvard Pilgrim Health Care). About half (55%) of the physician respondents reported they had sufficient time to spend with their older patients. Most (81%) respondents indicated that overall, patients aged 65 and older received either better care or no change in care after joining an HMO. The majority of physicians reported that HMO affiliation had increased the frequency with which they addressed geriatric issues with their older patients. There were several patterns of response that emerged with respect to beliefs about key HMO policies. CONCLUSIONS: The majority of physicians working in two nonprofit, academically oriented Medicare HMOs in Massachusetts believed that the overall quality of care that older patients received after joining an HMO either did not change or improved.