Evaluation of the effect of performance monitoring and feedback on care process, utilization, and outcome.

OBJECTIVE: We evaluated a program of performance measurement and monitoring by assessing care process, utilization of services, and outcomes. RESEARCH DESIGN AND METHODS: Information on 63,264 diabetic individuals who were continuously enrolled as members of Kaiser Permanente Southern California from 1 January 1994 to 31 December 1997 was used to evaluate the program. Time trends in testing for glycemic test and control and screening for dyslipidemia, use of lipid-lowering drugs, and microalbuminuria were evaluated as measures of care process. Time trends in hospitalization, outpatient appointments, prescriptions, and laboratory tests were evaluated as measures of utilization. Outcomes were hospitalization for myocardial infarction, ischemic stroke, and lower-limb amputation. RESULTS: Between 1994 and 1997, improvements were evident in the process measures. The mean number of hospitalizations and the mean and median number of outpatients visits did not change. The mean number of laboratory tests increased from 13.2 in 1994 to 23.6 in 1997. The mean number of prescriptions for any medication increased from 19.7 to 24.3. Hospitalization rates for myocardial infarction did not change, but rates increased for ischemic stroke and lower-limb amputation. CONCLUSIONS: Our findings suggest that measurement and monitoring of clinical performance can bring about modest improvements in measures of the processes of care in the absence of financial incentives, centrally driven interventions, and specialty care for all patients. In our setting, process improvements were associated with higher utilization of laboratory services and more prescriptions without an immediate return in terms of lower hospital utilization.

Diabetes managed care and clinical outcomes: the Harbor City, California Kaiser Permanente diabetes care system.

OBJECTIVE: To investigate diabetes clinical outcomes in a large patient population by comparing results of computer-supported team care to those of usual care. STUDY DESIGN: Patients enrolled in a diabetes care management program were tracked by a computerized system. Their subsequent healthcare outcomes were compared with those of usual-care patients and those of patients who had been discontinued from being managed in this program. PATIENTS AND METHODS: Screening rates for glycosylated hemoglobin (GHb), urinary protein, serum lipids, and glycemic and blood pressure control were compared between currently managed and usual-care patients. Hospital days and screening rates in a subset of the currently managed group, long-term managed patients, were compared with those of no longer managed patients. RESULTS: Screening rates for GHb, urinary protein, and serum lipids were higher in currently managed patients than in usual-care patients. Follow-up of initially elevated GHb in currently managed and usual-care patients showed an overall decrease in both groups. Follow-up of initially elevated blood pressure in currently managed patients showed a decrease in both mean systolic and mean diastolic measurements, while follow-up in usual-care patients showed no change in either mean systolic or mean diastolic measurements. Inpatient utilization for the long-term managed patients decreased between 1995 and 1997 and was lower in 1997 for this group than for no longer managed patients. Screening rates for GHb, urinary protein, and serum lipids were higher in the long-term managed patients than in the no longer managed patients. CONCLUSIONS: Computer-supported care management by a dedicated team appears to reduce the number of hospitalizations and improve screening rates and glycemic and blood pressure control.

Hormone pattern in pharmacologically feminized male transsexuals in the California State prison system.

The hormonal profile of 40 transsexual inmates from a pool of 86 inmates in the California State prison system was studied before and after therapy with feminizing hormones. Clinical and social data were obtained on all 86 inmates; the incidence of human immunodeficiency virus (HIV) seropositivity was examined in 76 of the 86 individuals. Despite similar degrees of feminization in all 40 individuals in whom hormonal studies were performed, variable suppression of serum testosterone concentrations was present. Based on their testosterone concentrations while on feminizing hormone therapy, the transsexual inmates could be divided into three groups. In Group I (the "suppressed" group), the serum testosterone concentrations were markedly depressed (less than 10 ng/dL); in Group II (the "non-suppressed" group), the values of testosterone were normal (446 to 1072 ng/dL); and in Group III (the "intermediate" group), the testosterone values were between those of the suppressed group and the nonsuppressed group. We speculate that feminizing hormone therapy may induce the development of a state of target hormone resistance to testosterone that results in similar degrees of feminization independent of the circulating concentrations of testosterone. The incidence of HIV seropositivity (3/76) was considerably less than anticipated based on previous studies in populations at high risk for developing the acquired immunodeficiency syndrome.

The endocrinology and pathophysiology of alcoholic cirrhosis and functional renal failure--a review.

The pathophysiology and characteristics of decompensated alcoholic cirrhosis and functional renal failure are reviewed. The review will be restricted to alcoholic cirrhosis, because most cases of functional renal failure in the United States occur in the setting of alcoholic cirrhosis, which is also the most common cause of ascites in North America and Europe. Moreover, hepatorenal syndrome may complicate other forms of liver disease besides alcoholic cirrhosis, but the pathogenesis in such circumstances may not be the same as in the cirrhotic state.

Concentrations of volume-regulatory hormones after acute exercise in physically conditioned males.

Plasma renin activity and plasma concentrations of atrial natriuretic peptide (ANP), arginine vasopressin (AVP) and aldosterone (Aldo) were determined in six physically conditioned male volunteers and five unconditioned volunteers who served as controls. All volunteers were subjected to acute exercise for 15 min or until exhaustion. In the conditioned volunteers, the plasma concentrations of all hormones did not change when compared with pre-exercise values measured immediately after and 60 min after exercise. Similarly, plasma renin activity (PRA) after exercise was unchanged when compared with pre-exercise levels. In contrast, the unconditioned volunteers showed elevation of the plasma concentrations of AVP, and Aldo. PRA also increased in the unconditioned volunteers, but plasma ANP concentrations were not significantly different from base-line pre-exercise levels. These data suggest a decrease in central volume with exercise in the unconditioned individuals, which probably does not occur in the conditioned individual because of adaptive mechanisms. The data also suggest that in the physically conditioned individual, significant atrial distention with resultant release of atrial natriuretic peptide does not occur, or alternatively, that significant atrial distention in these subjects fails to produce the expected release of atrial natriuretic peptide. In the unconditioned individual, the postulated decrease in effective central volume following exercise would not be expected to trigger any rise in ANP.

Insulin and C-peptide levels following oral administration of insulin in intestinal-enzyme protected capsules.

1. Crystalline beef insulin was administered orally in capsules composed of a methacrylic acid copolymer which prevented breakdown of the insulin by enteric and pancreatic peptidases. 2. In studies performed in 3 individuals blood was sampled before oral ingestion of the insulin (40 144 units), and at 15 or 30 min intervals thereafter for 5.5 hr for measurement of immunoreactive insulin and C-peptide concentrations. 3. Following the administration of oral insulin, plasma immunoreactive insulin concentrations became elevated 4-5 hr after ingestion. 4. The rise in plasma insulin concentrations was associated with a corresponding fall in the concentration of C-peptide. 5. The data suggest that this preparation of oral insulin can produce significant enteric absorption of the peptide, and that further investigation of agents that facilitate insulin absorption from the gut might render the use of methacrylic acid copolymer coated capsules a physiologically sound and a commercially feasible method of oral insulin administration.

Male hypogonadism due to nontumorous hyperestrogenism.

Male hypogonadism due to the nontumorous production of estrogen was studied in a patient with gynecomastia and bilateral small testicles. Both the gynecomastia and the decrease in testicular size developed in the 5-year period before presentation. Peripheral serum concentrations of testosterone were in the low to low-normal range, while those of 17 beta-estradiol (E2) were significantly elevated, as were the urinary concentrations of total estrogen. Steroid hormone concentrations were measured in the left and right spermatic veins and the left and right adrenal veins in the basal state, and after stimulation with GnRH and ACTH. Spermatic vein concentrations of E2 were 3 to 20 times higher than concentrations previously reported in normal males. Spermatic vein concentrations of testosterone were normal. The spermatic vein concentrations of androstenedione were approximately three times higher than the mean concentration of androstenedione previously reported in the spermatic vein of normal males. The concentrations of E2 and androstenedione in the adrenal veins were also significantly elevated when compared to the concentrations previously reported in normal subjects. The authors postulate that the hyperestrogenism in this patient was due to increased aromatization of the precursor substrates, testosterone in the testes, and androstenedione in the adrenals to E2 and E1 in the testes and adrenals, respectively. Alternatively, an increased abundance or activity of the 17 beta-hydroxysteroid dehydrogenase isoenzyme which converts estrone (E1) to E2 or a relative deficiency of the 17 beta-hydroxysteroid dehydrogenase isoenzyme, which converts androstenedione to testosterone, could theoretically account for the reported abnormalities.

Atrial natriuretic peptide, arginine vasopressin, aldosterone and plasma renin activity in carbon tetrachloride-induced cirrhosis in rats.

The concentrations of atrial natriuretic peptide, arginine vasopressin, aldosterone and the plasma renin activity were studied in male rats with carbon tetrachloride-induced compensated cirrhosis, and the results were compared to those of normal control animals. The rats with cirrhosis exhibited significantly higher plasma renin activity values when compared with the control group. However, plasma concentrations of atrial natriuretic peptide and arginine vasopressin were not significantly different in the two groups. Plasma aldosterone concentrations were significantly higher than those found in the normal control group in approximately 50% of the cirrhotic animals, and were equal to or less than the control values in the rest. This dissociation between plasma renin activity and aldosterone values in some of the cirrhotic animals is interesting and parallels observations made in humans with alcoholic cirrhosis. The results suggest that experimentally induced, apparently compensated cirrhosis may be associated with a perceived decrease in effective circulating volume, and that there is no absolute deficiency of atrial natriuretic peptide in this model of cirrhosis.

Correlation between macrovascular disease as assessed by bioimpedance plethysmography and various parameters used to assess diabetic "control".

Blood flow in a segment of the leg was determined by bioimpedance plethysmography in 47 diabetic patients and in 19 normal volunteers. The blood flow through the limb, expressed as stroke volume/m2 (SV/m2), was not significantly different in the two populations. SV/m2 showed significant negative correlation with the presence of peripheral vascular disease, fasting serum cholesterol concentration, glycosylated hemoglobin (HbA1c) concentration, and the duration of diabetes. The presence or absence of retinopathy (27.7% of cases) or nephropathy (4.3% of cases) did not show strong association with the SV/m2. Neither the duration of the hypertension nor the systolic or diastolic blood pressure correlated significantly with blood flow in the extremity. These data suggest that only some of the parameters used to assess "control" of diabetic patients can be useful predictors of macrovascular as well as microvascular disease in diabetic patients.