Improving outpatient diabetes management through a collaboration of six competing, capitated Medicare managed care plans.

This report addresses diabetes care in the managed care setting and improvement in care brought about by collaboration between 6 Medicare managed care plans (MCPs) and a Peer Review Organization (PRO). The objective was to improve the quality of care of outpatient diabetes patients provided by primary care physicians through the mutual collaboration of 6 Medicare managed care plans and a Medicare Peer Review Organization. The design involved pre-post intervention trial based on 2 random samples, a baseline sample drawn in 1995 and a remeasurement sample drawn in 1996. Medical records of patients in both samples were reviewed by the PRO to determine provision of 14 quality indicator services over a 1-year period. The setting was 6 Arizona Medicare managed care plans comprising approximately 40% of the Arizona Medicare population. Two random samples were drawn from type 2 diabetes patients continuously enrolled in the same managed care plan for at least 1 year. The intervention was comparative feedback of baseline data by the PRO, enabling each plan to compare itself to any other plan on any or all indicators. Each plan developed and implemented its own intervention in response to the 1995 baseline results. The main outcome measures were mean HbA1c, the proportion of HbA1c values below 8%, and positive change in provision of 14 quality indicator services. At postintervention remeasurement, mean HbA1c values fell from 8.9 +/- 2.2 to 7.9% +/- 2.1, and the proportion of patients with HbA1c values below 8.0% rose from 40% to 61.6%. The proportion of the 14 indicator services provided to patients rose from 35% to 55%. The mean number of physician office visits fell 13% and the number of services provided per visit doubled. We conclude that improving the process of care improves glycemic control. Better outpatient diabetes management in competing, capitated managed care plans is an attainable goal when mediated through a neutral third party such as a PRO.

Friction in perspective.

In the past, most frictional resistance studies have been conducted in a steady state condition that does not simulate the dynamics of the oral environment. Various oral functions as chewing, swallowing, speaking, etc, as well as the oral tissues contacting any orthodontic appliances, result in periodic, repetitive, minute relative motion at the bracket/arch wire interfaces several thousand times each day. This in turn affects the normal forces at the interfaces, and because frictional resistance is directly proportional to the normal force, a pilot study was undertaken to emulate the dynamic environment of the oral cavity and its effect on frictional resistance. Tests of a limited sample of stainless steel arch wires and brackets typically used in sliding mechanics revealed that frictional resistance was effectively reduced to zero each time minute relative movements occurred at the bracket/arch wire interfaces. Factors such as the degree of dental tipping, relative arch wire/slot clearances, and method of tying, did not have a measurable effect on frictional resistance in the simulated dynamics of the oral environment.

An evaluation of the wind chill factor: its development and applicability.

The wind chill factor has become a standard meteorologic term in cold climates. Meteorologic charts provide wind chill temperatures meant to represent the hypothetical air temperature that would, under conditions of no wind, effect the same heat loss from unclothed human skin as does the actual combination of air temperature and wind velocity. As this wind chill factor has social and economic significance, an investigation was conducted on the development of this factor and its applicability based on modern heat transfer principles. The currently used wind chill factor was found to be based on a primitive study conducted by the U.S. Antarctic Service over 50 years ago. The resultant equation for the wind chill temperature assumes an unrealistic constant skin temperature and utilizes heat transfer coefficients that differ markedly from those obtained from equations of modern convective heat transfer methods. The combined effect of these two factors is to overestimate the effect of a given wind velocity and to predict a wind chill temperature that is too low.

A new concept: impulse in orthodontics.

One of the important uses of extraoral appliances is to counterbalance force systems placed on the reactive, anchor teeth by intraoral appliances such as space closure springs. Extraoral appliances are often worn less than full time, whereas intraoral springs act full time. Anecdotal evidence indicates that sufficient part-time extraoral appliance wear with appropriate force level is sufficient to balance intraoral appliance activity while preserving anchorage. A rational explanation is presented to substantiate this clinical evidence through equating extraoral impulse (force x time and/or moment x time) to the impulse conveyed to the teeth by the intraoral appliance. By adjusting force and/or moment magnitude in combination with the correct time of application, the clinician can achieve appropriate energy levels for anchorage in three dimensions.

Outpatient management of diabetes mellitus in five Arizona Medicare managed care plans.

We report findings on the outpatient management of diabetes mellitus in Medicare beneficiaries enrolled in five Arizona Medicare-managed care plans. These findings are the baseline of an ongoing collaboration between the Health Services Advisory Group, Inc., Arizona's Peer Review Organization (PRO), and the five plans whose object is improved care of diabetes patients. The purpose of the study was to determine congruity between quality indicators identified by the five plans and the care actually received by diabetes patients enrolled in the five plans. The five plans agreed on a common set of quality indicators, including 10 services and 10 measures of patient status. Each plan has identified its diabetic population, 75 of whom are randomly selected each quarter by the PRO for chart review and inclusion in the study. The findings in this report cover two quarters of data. Data from chart review were examined to determine the extent to which actual practice reflected the indicators. The mean patient age was 71.8, and for most patients onset occurred between 55 and 69 years of age. About 25% had a positive family history, and we estimate the annual incidence of diabetes in this population to be about 1.1%. Mean hemoglobin A1c (HbA1c) was 8.9 +/- 2.1%; 46% were hypertensive; 42% continued to smoke cigarettes; 36% had retinopathy; 20% had proteinuria; and only 22% were on some kind of exercise program. Thirty-two percent were hospitalized during the 1-year baseline period, and the average number of outpatient visits per patient was 11.1 +/- 7.4. When care provided to diabetes patients enrolled in the plans was compared with the 10 quality standards identified by the plans themselves, only two of these standards was attained in more than 60% of patients: blood pressure, 98.7%; and foot examination, 62.7%. Two standards were achieved less than one-third of the time: urine dipstick, 10.4%, and appropriate use of angiotensin-converting enzyme (ACE) inhibitors, 31.25%. The others were all between 40 and 55%. Of the 10 service standards, about one-third received 1-4, one-third received 5-6, and one-third received 7-10. Only 5% of patients received 9 or 10 services. Outpatient management of diabetes patients in managed-care plans is similar to that in fee-for-service. When compared with fee-for-service or another HMO, a higher proportion of Arizona-managed care patients had HbA1c, and a much lower proportion had a dipstick test for urine protein. Values for other variables were usually within 10 percentage points of each other. Regardless of payment scheme, diabetes care is characterized by inconsistencies, omissions, and a lower than desirable level of services. Although few patients received most of the indicator services, diabetes patients are nevertheless high utilizers of medical care, both in and out of the hospital. The hospitalization rate is twice that of Arizona Medicare beneficiaries as a whole, and the number of office visits is three or four times that reported in other studies. Further, it seems that many visits are required to achieve even these modest service levels. Had the average number of visits been six or less, HbA1c rates, for example, would have fallen to less than one-third in three of the five plans. We believe that these data are conservative because it is likely that some and perhaps most of these indicators are underreported. It should be emphasized that these are baseline data whose purpose is to provide a basis against which subsequent improvements many be measured.

The health and symptom care of widows.

This paper compares the ways in which Anglo and Mexican American widows perceive, interpret and respond to problems of illness. It reports on a study which followed a sample of older, low income recent widows for 15 months after their bereavement. In this account Mexican American widows were found to differ from Anglo widows in aspects affecting their health: socioeconomic background, previous histories of health, health care resources and symptom care practices.

Pulmonary toxicity associated with fludarabine monophosphate.

Fludarabine monophosphate (FAMP), the 2-fluoro, 5' phosphate derivative of 9-beta-D-arabinofuranosyl adenine (ara-A), is a purine nucleoside antimetabolite presently undergoing clinical testing for the treatment of a variety of malignancies including lymphoproliferative disorders and acute leukemia. We report a case of diffuse interstitial pneumonitis during treatment of chronic lymphocytic leukemia with FAMP. This resolved quickly with high dose steroids, recurred with steroid withdrawal, and abated with further steroid therapy. To our knowledge, this is the first reported case of fludarabine monophosphate associated pulmonary toxicity.