From the ACA to Even Better Reform.

Because health policy decision makers have different economic and political interests as well as different ideological persuasions, those committed to fairer and more comprehensive reform must be prepared to compromise in order to make progress toward their goals. The primary purpose of this essay is to describe a more nearly ideal health care system and identify factors that affect how patients and providers make utilization decisions. Having a clear vision of the ultimate goals to achieve will help participants in the political process to make compromises that advance the effort and to avoid those which undermine it.

Subinhibitory concentrations of tedizolid potently inhibit extracellular toxin production by methicillin-sensitive and methicillin-resistant Staphylococcus aureus.

PURPOSE: Potent extracellular toxins including alpha-haemolysin, Panton-Valentine leukocidin (PVL) and toxic-shock syndrome toxin 1 (TSST-1) significantly contribute to Staphylococcus aureus pathogenesis, thus, toxin suppression is a primary focus in treatment of staphylococcal disease. S. aureus maintains complex strategies to regulate toxin expression and previous data have demonstrated that subinhibitory concentrations of beta-lactam antibiotics can adversely increase S. aureus exotoxin production. The current study evaluates the effects of subinhibitory concentrations of tedizolid, a second-generation oxazolidinone derivative, on expression of staphylococcal exotoxins in both methicillin-resistant and methicillin-sensitive S. aureus. METHODOLOGY: S. aureus exotoxin expression levels were compared at 12 and 24 h following treatment with tedizolid, linezolid, nafcillin or vehicle control. RESULTS: Our findings show that the level of antibiotic required to alter toxin production was strain-dependent and corresponds with the quantity of toxin produced, but both tedizolid and linezolid could effectively reduce expression of alpha-haemolysin, PVL and TSST-1 toxin at subinhibitory concentrations. In contrast, nafcillin showed less attenuation and, in some S. aureus strains, led to an increase in toxin expression. Tedizolid consistently inhibited toxin production at a lower overall drug concentration than comparator agents. CONCLUSION: Together, our data support that tedizolid has the potential to improve outcomes of infection due to its superior ability to inhibit S. aureus growth and attenuate exotoxin production.

Subinhibitory Dalbavancin Attenuates Exotoxin Production from Methicillin-Sensitive and Methicillin-Resistant Staphylococcus aureus In Vitro.

This study investigated the effects of subinhibitory doses of the lipoglycopeptide antibiotic dalbavancin on Staphylococcus aureus toxin production in vitroS. aureus toxin production levels were compared to those seen with the natural glycopeptide antibiotic vancomycin and with representative beta-lactam and oxazolidinone antibiotics. While neither dalbavancin nor vancomycin adversely affected toxin production, of these glycopeptide antibiotics, only dalbavancin significantly attenuated toxin production at subinhibitory concentrations. These findings support the recent success of dalbavancin for treatment of staphylococcal infections.

Open questions concerning influences on clinical decision making.

Efforts to influence utilization of services to bring down spending and to improve quality of care have largely failed. A critical reason is that most attention has focused on dysfunctional financial incentives without considering other factors that also influence physicians' utilization decisions. In this article, after providing a framework for ideal physician-patient interactions, questions are also raised about other influences, including physicians' impulse to help patients, professional codes of ethics, the threat of malpractice claims, and the leadership of health care organizations. An Appendix contains a summary of the literature on these factors.

The feasibility and value of new measures showing patterns of quality for patients with 3 chronic conditions.

The aim of this study was to create new measures of quality that combine individual service measures. Using an all-or-none approach, we identify 5 levels of care reflecting the extent to which optimal patterns of service were obtained by patients with asthma, diabetes, and heart failure. We also assess the feasibility of these levels-of-care measures and their potential value in quality improvement efforts. The study was designed to analyze claims data to reflect patterns of services used in a single metropolitan market of about 1 million residents in the northeastern United States. More than 80,000 patients insured over 4 years (1994-1997) had claims with 1 or more of 3 chronic conditions. The analysis showed that the measures discriminated effectively among groups of patients with the 3 chronic conditions and highlighted areas to target quality improvement efforts. Although the numbers vary by year, for two of the diagnoses, most patients were in the lowest categories (59%-75%), and for the third, 40% were in these categories. Few were in the highest category. Most patients were in the same category from one year to the next. The levels-of-care approach to quality measurement can help caregivers and policy makers find methods for avoiding unnecessary utilization and expenditures while raising--not lowering--the probability that utilization patterns will conform to condition-specific recommended care.

Toward an effective strategy for the diffusion and use of clinical information systems.

The full impact of IT in health care has not been realized because of the failure to recognize that (1) the path from availability of applications to the anticipated benefits passes through a series of steps; and (2) progress can be stopped at any one of those steps. As a result, strategies for diffusion, adoption, and use have been incomplete and have produced disappointing results. In this paper, we present a comprehensive framework for identifying factors that affect the spread, use, and effects of IT in the U.S. health care sector. The framework can be used by researchers to focus their efforts on unanswered questions, by practitioners considering IT adoption, and by policymakers searching for ways to spread IT throughout the system.

Utilization of services by chronically ill people in managed care and indemnity plans: implications for quality.

Because incentives for managed care organizations favor cost containment, concerns have been raised that quality of care has suffered, especially for chronically ill people. This study compares utilization rates of managed care and indemnity patients with three chronic conditions, using five years of claims records (1993-97) from private plans and Medicare in one market. Findings show that for all three conditions, managed care patients were more likely to see both primary care physicians and specialists within a year, but less likely to use a hospital emergency department or to be an inpatient. Assuming that patients with these illnesses should see a physician annually and that good primary care reduces the need for emergency and inpatient services, it appears that the patterns of care used by chronically ill managed care patients in this market do not reflect lower quality than that received by similar indemnity patients.

Chronic disease medication use in managed care and indemnity insurance plans.

OBJECTIVE: To evaluate the impact of managed care on the use of chronic disease medications. DATA SOURCE: Claims data from 1997 from two indemnity and three independent practice association (IPA) model managed care insurance plans. RESEARCH DESIGN: Cross-sectional analysis of claims data. DATA COLLECTION: Adult patients with diabetes mellitus (DM, n = 26,444), congestive heart failure (CHF, n = 7,978), and asthma (n = 9,850) were identified by ICD-9 codes. Chronic disease medication use was defined through pharmacy claims for patients receiving one or more prescriptions for drugs used in treating these conditions. Using multiple logistic regression we adjusted for patient case mix and the number of primary care visits. PRINCIPAL FINDINGS: With few exceptions, managed care patients were more likely to use chronic disease medications than indemnity patients. In DM, managed care patients were more likely to use sulfonylureas (43 percent versus 39 percent for indemnity), metformin (26 percent versus 18 percent), and troglitazone (8.8 percent versus 6.4 percent), but not insulin. For CHF patients, managed care patients were more likely to use loop diuretics (45 percent versus 41 percent), ACE inhibitors or angiotensin receptor blockers (50 percent versus 41 percent), and beta-blockers (23 percent versus 16 percent), but we found no differences in digoxin use. In asthma, managed care patients were more likely to use inhaled corticosteroids (34 percent versus 30 percent), systemic corticosteroids (18 percent versus 16 percent), short-acting beta-agonists (42 percent versus 33 percent), long-acting beta-agonists (9.9 percent versus 8.6 percent), and leukotriene modifiers (5.4 percent versus 4.1 percent), but not cromolyn or methylxanthines. Statistically significant differences remained after multivariate analysis that controlled for age, gender, and severity. CONCLUSIONS: Chronic disease patients in these managed care plans are more likely to receive both inexpensive and expensive medications. Exceptions included older medications partly supplanted by newer therapies. Differences may be explained by the fact that patients in indemnity plans face higher out-of-pocket costs and managed care plans promote more aggressive medication use. The relatively low likelihood of condition-specific medications in both plan types is a matter of concern, however.

Management of cancer-related and noncancer-related chronic pain in Connecticut: successes and failures.

Findings are reported from a survey of Connecticut HMO patients who had one of three conditions associated with pain: cancer, arthritis, and neuropathic diagnoses. From each group, 145 patients were randomly selected to receive a mailed survey. The overall eligible response rate was 73%. About two thirds had experienced pain for over a year, and the same percentage was experiencing pain at the time of the survey. Seventy-three percent of respondents with cancer pain (RCs) rated their pain in the moderate range, compared to 37.5% of respondents with arthritis pain (RAs) and neuropathic pain (RNPs). More RAs and RNPs (41.5%) rated their pain in the severe range. Twenty-three percent of both RCs and RAs and 31% of RNPs had received no effective treatment for their pain. The percentage of respondents using prescription narcotics at the time of the survey was low (16%), and had dropped by almost half from the proportion using them in the past (29%). Side effects of pain medications and attitudes toward opioids were implicated as reasons for discontinuing pain medications. Respondents described substantial negative impact of pain on their abilities to perform various activities, but this had improved from the time when they first experienced their pain. Overall, the findings indicate that improvements have been made in the treatment of pain, particularly for patients with cancer pain. There is still room for improvement, particularly for individuals with chronic neuropathic pain. Specific recommendations are discussed.