Estimating the proportion of community-associated methicillin-resistant Staphylococcus aureus: two definitions used in the USA yield dramatically different estimates.

The objective of this retrospective study was to compare the prevalence of community-associated methicillin-resistant Staphylococcus aureus (CAMRSA) and healthcare-associated MRSA (HAMRSA) using healthcare risk factor exposure criteria with that obtained using Centers for Disease Control and Prevention (CDC) criteria. Cases were defined as CAMRSA or HAMRSA based on the general CDC guidelines for nosocomial infections, and then re-assessed with healthcare risk factor exposure criteria using a medical chart review. One hundred MRSA cases occurred at a mid-Western veterans affairs medical centre from November 2001 to November 2003. The proportion of these cases classified as CAMRSA differed dramatically when classified by healthcare risk factor exposure criteria (5%) compared with CDC nosocomial infection criteria (49%). Estimating the role of healthcare-related exposures and developing strategies to control MRSA can be markedly affected by the criteria used to determine CAMRSA and HAMRSA.

Foot care practices, services and perceptions of risk among medicare beneficiaries with diabetes at high and low risk for future foot complications.

A cohort of Medicare beneficiaries with diabetes was identified from inpatient and outpatient claims data and their risk for foot complications was estimated based on claims reflecting services for recent foot problems. A telephone survey of a random sample from this cohort was conducted to assess their foot care practices, barriers, and perceptions of risk. Eight percent of respondents reported a history of foot ulcers and 7% a history of lower extremity amputation. Based on claims data, 30% of respondents were at high risk for future foot complications. Compared to those at low risk, those at high risk were more likely to report having an annual foot exam, using protective footwear, and perceiving themselves to be high risk for future foot complications. However, 50% of those with claims indicating a high risk perceived themselves to be at low risk for future foot complications. Overall, 20% of respondents seldom checked their feet daily for sores or irritations. Among this group, 60% felt that it was unimportant and 9% reported they were limited by poor vision or physical problems. Our findings suggest that strategies are needed to improve the delivery of preventive foot care services to older persons with diabetes. Additionally, emphasis is needed to help individuals understand their risk and seek and perform appropriate preventive foot care.

Improving glycemic control: can techniques used in a managed care setting be successfully adapted to a rural fee-for-service practice?

The objective of this work was to improve glycemic control using case management supported by electronic diabetes care monitoring. Information for patients with diagnosed diabetes in a rural community was maintained in the Diabetes Care Monitoring System. In September 1998, counseling and medication management for glycemic control was intensified during individual office visits. And, from September 1998 to February 1999, 2-hour cluster visits modeled after a successful urban program were offered for groups of patients with elevated HbA1c values. The median (and 75th percentile) HbA1c values for the patient population decreased from 8.7% (10.9%) in March 1998 (N = 173) to 7.5% (9.3%) in March 1999 (N = 182) and was maintained at 7.5% (9.1%) through March 2000 (N = 182). Case management, including cluster visits, can be accomplished in a rural physician's office with the support of an electronic diabetes care monitoring system. This intensified approach decreased and sustained the HbA1c level by more than a percentage point for the patient population.

Establishing surveillance for diabetes in American Indian youth.

OBJECTIVE: To determine prevalence estimates in order to monitor diabetes, particularly type 2 diabetes, in American Indian youth. RESEARCH DESIGN AND METHODS: To explore the feasibility of developing a case definition using information from primary care records, all youth aged <20 years with an outpatient visit or hospitalization for diabetes were identified from the Billings Area Indian Health Service database in Montana and Wyoming from 1997 to 1999, and the medical records were reviewed. Classification for probable type 1 diabetes was based on age < or =5 years, weight per age < or =15th percentile at diagnosis, or positive results of islet cell antibody test. Classification for probable type 2 diabetes was based on weight per age > or =85th percentile or presence of acanthosis nigricans at diagnosis, elevated C-peptide or insulin, family history for type 2 diabetes, or use of oral hypoglycemic agents with or without insulin or absence of current treatment 1 year after diagnosis. RESULTS: A total of 52 case subjects with diabetes were identified, 3 of whom had diabetes secondary to other conditions. Of the remaining 49 case subjects, 25 (51%) were categorized as having probable type 2 diabetes, 14 (29%) as having probable type 1 diabetes, and 10 (20%) could not be categorized because of missing or negative information. Prevalence estimates for diabetes of all types, type 1 diabetes, and type 2 diabetes were 2.3, 0.6, and 1.1, respectively, per 1,000 youth aged <20 years. CONCLUSIONS: Our definitions may be useful for surveillance in primary care settings until further studies develop feasible case definitions for monitoring trends in diabetes among youth.

Cardiovascular disease and risk factors in Montana American Indians and non-Indians.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death for both American Indian and non-Indian adults. Few published studies have compared the prevalence of CVD and related risk factors in Indians to that in non-Indians in the same geographic area. OBJECTIVE: To compare CVD and risk factors in American Indian and non-Indian populations in Montana. METHODS: Adult American Indians (n=1000) living on or near Montana's seven reservations and non-Indian (n=905) Montanans statewide were interviewed through the 1999 Behavioral Risk Factor Surveillance Survey (BRFSS). RESULTS: Indians aged > or =45 years reported a significantly higher prevalence of CVD compared to non-Indians (18% vs 10%). In persons aged 18-44 years, Indians were more likely to report hypertension (15% vs 10%), obesity (29% vs 12%), and smoking (42% vs 24%) compared to non-Indians. For persons aged > or =45 years, Indians reported higher rates of diabetes (24% vs 9%), obesity (38% vs 16%), and smoking (32% vs 13%) compared to non-Indians. Non-Indians aged > or =45 years reported having been diagnosed with high cholesterol more frequently than did Indians (32% vs 24%). CONCLUSIONS: Both Indians and non-Indians in Montana reported a substantial burden of CVD. The CVD risk patterns differ in the two populations. Prevention programs should be tailored to the risk burdens in these communities with particular emphasis on smoking cessation and the prevention of obesity.

Comparing self-reported measures of diabetes care with similar measures from a chart audit in a well-defined population.

The objective of this study was to compare self-reported measures of diabetes care with measures derived from medical records in a well-defined population. Diabetes measures were collected through a 1997 Behavioral Risk Factor Surveillance System telephone survey of American Indians living on or near 7 Montana reservations (N = 398) and were compared with data collected from charts of a systematic sample of American Indians with diabetes seen in 1997 at Indian Health Service (IHS) facilities. Survey respondents were more likely to report a duration of diabetes > or = 10 years (44 vs 31%), annual dilated retinal exam (75 vs 59%), and an influenza immunization in the past year (73 vs 57%) compared with estimates from the chart audit. Estimates of pneumococcal immunization (88 vs 42%), annual cholesterol screening (86 vs 69%), and overweight, based on body mass index (67 vs 50%), were significantly higher from the chart audit. No significant differences were found between the survey respondents and the chart audit data for annual foot exams (65 vs 61%), annual blood pressure checks (98 vs 93%), high cholesterol (35 vs 41%), and high blood pressure (54 vs 64%). These findings suggest that self-reported data may over and underestimate specific measures of diabetes care.

Direct mail intervention to increase retinal examination rates in Medicare beneficiaries with diabetes.

The objective of this study was to identify the baseline frequency of eye examinations for Medicare beneficiaries with diabetes in Montana and to determine whether a direct mail reminder increased eye examinations. Using Medicare Part A and Medicare Part B claims data, a cohort of Medicare beneficiaries with diabetes was defined. Eye examination claims were identified using billing codes specific for retinal examinations, as well as visits to ophthalmologists and optometrists during which retinal exams were likely to have been performed. A random sample of the identified beneficiaries with diabetes received a letter encouraging regular annual retinal examinations. In the first 3-month period after the mailing, the billed eye examination rate for those to whom letters were sent was 2.2 percentage points greater than the rate for those to whom letters were not sent (19.4% vs 17.2%; relative risk, 1.13; 95% confidence interval, 1.01-1.26). However, 6 months after the letters were sent, there was no longer a significant difference in the rates for these 2 groups (32.9% vs 32.4%; relative risk, 1.02; 95% confidence interval, 0.94-1.10). In this study, direct mail outreach initially influenced the proportion of Medicare beneficiaries receiving an eye examination, but this pattern was not sustained over the 6-month follow-up period.

Increasing pneumococcal vaccination rates among residents of long-term--care facilities: provider-based improvement strategies implemented by peer-review organizations in four western states.

OBJECTIVE: To evaluate collaborative efforts and intervention strategies by peer-review organizations (PROs) and long-term-care facilities (LTCFs) for improving pneumococcal vaccination rates among residents of LTCFs. DESIGN: Prospective, before-after quality improvement project. SETTING: 133 LTCFs in Alaska, Idaho, Montana, and Wyoming. PATIENTS: All residents of participating LTCFs. METHODS: Baseline pneumococcal vaccination rates were determined by medical-record review, self-reporting by patient or family members, and review of Medicare claims information. Remeasurement of vaccination rates was accomplished from documentation of vaccination of eligible residents by each LTCF. RESULTS: 133 LTCFs with 7,623 residents from Alaska, Idaho, Montana, and Wyoming participated in this quality-improvement project. This accounted for 41% (133/321) of the potential nursing homes and resident population in the participating states. Baseline overall vaccination rates were 40% (3,050/7,589). The overall vaccination rate improved to 75% (5,720/7,623, P<.001). The number of facilities meeting the Healthy People 2000 vaccination goal of 80% improved from 18% (24/133) to 62% (83/133, P<.001). Initial use of chart stickers and implementation of standing orders led to similar increases in vaccination rates, but the standing-order strategy required commitment of fewer PRO resources at a statewide level. Remeasurement of vaccination rates in a subset of participating Idaho LTCFs 1 year after initial vaccination efforts demonstrated a sustained vaccination rate of 70% in facilities enforcing a standing-order policy. CONCLUSIONS: Simple and straightforward vaccination strategies implemented in LTCFs over a short period of time can have a significant impact on vaccination rates. Collaborative efforts between state PROs and LTCFs enhance implementation of these strategies and can result in the achievement of national vaccination objectives. Standing orders appear to be one intervention effective in sustaining successful vaccination efforts. Regardless of the specific interventions employed, PROs played a significant role in facilitating vaccination program development and intervention implementation.

Improving the pneumococcal immunization rate for patients with diabetes in a managed care population: a simple intervention with a rapid effect.

BACKGROUND: Pneumococcal disease kills more people in the United States than any other vaccine-preventable bacterial disease, and a national health objective for the year 2000 is that at least 60% of eligible persons be immunized with pneumococcal vaccine. METHODS: An electronic care monitoring system was used to track immunization of patients with diabetes in a managed care plan who were receiving their care through a staff-model primary care clinic in Guam. In November 1998 a letter was sent to all patients not known to be immunized. The letter invited these patients to attend immunization clinics and waived usual copayment. Standing orders were also created for the clinic nurses to administer pneumococcal vaccines. In addition, a diabetes care status report was placed on each patient's medical record. RESULTS: The immunization rate for the 1,278 actively enrolled patients with diagnosed diabetes increased from 42% in October 1998 to 62% in January 1999. Compared to November 1995, 1996, and 1997, the number of pneumococcal immunizations increased more than 15-fold in November 1998. DISCUSSION: The combined use of patient outreach letters, special immunization clinics, standing orders, and practitioner reminders on medical records resulted in a rapid, marked increase in the pneumococcal immunization rate for patients with diabetes. The electronic care monitoring system is being used to target get interventions for improvement opportunities for an array of diabetes care measures, including regular foot care and eye exams.

Impact of facility size and profit status on intermediate outcomes in chronic dialysis patients.

Little information is available regarding the influence of dialysis facility size or profit status on intermediate outcomes in chronic dialysis patients. We have combined data from the Health Care Financing Administration (HCFA) Core Indicators Project; the end-stage renal disease (ESRD) facility survey; and the HCFA On-Line Survey, Certification, and Reporting System to analyze trends in this area. For hemodialysis patients, larger facilities were more likely than smaller facilities to perform dialysis on patients who were younger than 65 years of age, black, or undergoing dialysis 2 years or more (P < 0.001). Nonprofit facilities were more likely to perform dialysis on patients with diabetes mellitus as a cause of ESRD and less likely to perform dialysis on patients with hypertension as a cause of ESRD compared with for-profit units (P < 0.05). By multivariate analysis, larger facility size was modestly associated with a greater Kt/V value and urea reduction ratio, but not with hematocrit or serum albumin values. Facility profit status was not associated with these intermediate outcomes. For peritoneal dialysis patients, there were no significant differences in patient demographics based on facility size. More patients in nonprofit units had been undergoing dialysis 2 or more years than patients in for-profit units (P < 0.05). By univariate analysis, patients in larger facilities were more likely to have an adequacy measure performed than patients from smaller facilities (P < 0.05). There were few substantial differences in intermediate outcomes in chronic dialysis patients based on facility size or profit status.

Can dialysis therapy be improved? A report from the ESRD Core Indicators Project.

We assessed the association between quality improvement interventions conducted during the End-Stage Renal Disease (ESRD) Core Indicators Project and changes in the adequacy of hemodialysis between 1993 and 1996. Improvement of hemodialysis adequacy was measured by baseline and annual urea reduction ratios (URRs) in representative samples of ESRD Network patients. Random samples of in-center hemodialysis patients aged 18 years and older who had received hemodialysis during the fourth quarters of 1993, 1994, 1995, and 1996 were used to calculate Network-specific outcomes. A mean URR was calculated for each patient using the first pretreatment and posttreatment blood urea nitrogen for October, November, and December of each study year. Both national and Network-specific interventions were used to provide feedback reports and technical assistance to treatment centers to foster improvement in hemodialysis adequacy. All Networks distributed reports on the patterns of treatment center URR levels and physician and patient educational materials to each center in the Network. Each Network selected an annual 10% sample of treatment centers in 1994 and 1995 and conducted quality improvement activities to assist the selected centers to improve dialysis adequacy. We defined Network-specific interventions by a survey of the 18 Networks conducted during 1995 to determine the characteristics of Network-specific activities used to improve adequacy of hemodialysis. The outcome of interest was the change over time in Network-specific URR value. Sustained improvement in the URR occurred within all 18 Networks between 1993 and 1996. The mean national URR increased from 62.7% in 1993 to 66. 8% in 1996. The proportion of patients with URR >/= 65% increased from 43% in 1993 to 68% in 1996. Networks reported implementing a variety of intervention strategies that included educational activities, continuous quality improvement workshops, on-site assistance, and supervision of selected treatment facilities until care improved. Network-specific interventions independently associated with an increased rate of improvement in URR included prolonged supervision of the selected facilities. We concluded that the sustained improvement in hemodialysis care that occurred after the inception of the ESRD Core Indicators Project was associated with specific ESRD Network interventions.

Trends in clinical indicators of care for adult peritoneal dialysis patients in the United States from 1995 to 1997. ESRD Core Indicators Workgroup.

BACKGROUND: This article describes the changes in four core indicator variables: dialysis adequacy, hematocrit, serum albumin, and blood pressure in peritoneal dialysis CAPD and cycler patients over a three-year period. METHODS: A national random sample of adult peritoneal dialysis patients in the United States was drawn each study period. Clinical data abstraction forms were completed by facility staff for patients selected for the sample, returned to the respective network, then forwarded to the Health Care Financing Administration for analysis. RESULTS: The mean weekly Kt/V urea for CAPD patients increased from 1.91 in 1995 to 2.12 in 1997 (P < 0.001) and for cycler patients, from 2.12 in 1996 to 2.24 in 1997 (P < 0.05). The mean weekly creatinine clearance for CAPD patients increased from 61.48 liter/week/1.73 m2 in 1995 to 65.84 liter/week/1.73 m2 in 1997 (P < 0.05). For cycler patients, it increased from 63.37 liter/week/1.73 m2 in 1996 to 67.45 liter/week/1.73 m2 in 1997 (P < 0.05). Despite this increase in adequacy values, less than 40% of peritoneal dialysis patients in 1997 had weekly Kt/V urea or creatinine clearance values that met subsequently published National Kidney Foundation's Dialysis Outcomes Quality Initiative (DOQI) guidelines. These data suggest that the dialysis prescription may not be adequately modified to compensate for increased body weight and for decreased residual renal function as years on dialysis increase. The average hematocrit value increased modestly in both CAPD and cycler patients from 1995 to 1997, and the number of patients with a hematocrit of less than 25% decreased from 6% in 1995 to 1.4% in 1997 (P < 0.001). Both serum albumin values and systolic and diastolic blood pressure values were essentially unchanged during the three-year period of observation. CONCLUSIONS: Despite improvements in dialysis adequacy and hematocrit values, there remains much room for improvement in these core indicator values.

Relationship between urea reduction ratio, demographic characteristics, and body weight for patients in the 1996 National ESRD Core Indicators Project.

The 1996 Health Care Financing Administration's (HCFA) Core Indicators Project for in-center, hemodialysis patients collects information on the quality of care delivered in four clinical areas that were anticipated to predict patient outcomes. Included among these clinical performance measurements is the delivered dose of hemodialysis, measured by the fractional reduction of urea achieved during a single hemodialysis session (urea reduction ratio [URR]). A random sample (N = 7,310) of adult (aged > or =18 years), in-center hemodialysis patients was selected, and a one-page data collection form for each patient was sent to the dialysis facility in which care was provided during the last quarter of 1995. The dialysis facilities provided information for 6,861 (94%) patients, and at least one paired predialysis and postdialysis blood urea nitrogen (BUN) concentration was reported for 6,655 (97%) of these patients. The URR of this cohort was 65.5% +/- 8.0% (mean +/- SD), and 41% of patients had a URR less than 65%. The mean dialysis session length was 203 minutes, and more than half of the patients received dialysis with a dialyzer membrane with a KUf less than 10 mL/mm Hg/h. The patients with a URR less than 65% had a mean body weight approximately 10 kg greater than patients with a URR of 65% or greater. This relationship was present for all demographic characteristics studied, including age, gender, race, and primary cause of end-stage renal disease (ESRD). Patients receiving dialysis for less than 6 months were more likely to have a URR less than 65% than patients on dialysis for longer periods. By multivariate analysis, variables significantly associated with a delivered URR less than 65% were body weight in the heaviest quartile (odds ratio [OR] = 6.1), male gender (OR = 2.6), on dialysis therapy less than 6 months (OR = 2.5), youngest quartile of age (<49 years) (OR = 2.0), lowest quartile of serum albumin values less than 3.6 g/dL (bromcresol green method) or less than 3.3 g/dL (bromcresol purple method) (OR = 1.6), black (OR = 1.5), dialyzed with a dialyzer KUf less than 20 mL/mm Hg/h (OR = 1.8), lowest quartile hematocrit (<29.7%) (OR = 1.2), and shorter dialysis session length (OR = 1.02/min). In conclusion, both patient-specific demographic variables and treatment-specific parameters are significantly associated with ESRD patients receiving a URR less than 65%. Furthermore, these data suggest statistically significant linkages between the delivered dose of hemodialysis and other independent outcome predictors such as serum albumin concentration. Prospective study is required to determine whether intervention strategies to improve the delivered dose of hemodialysis will affect this outcome predictor or whether serum albumin and dialysis dose share a common cause not amenable to increasing the URR.

Report from the 1995 Core Indicators for Peritoneal Dialysis Study Group.

The 1995 Peritoneal Dialysis Core Indicators Study was conducted by the Health Care Financing Administration to ascertain standard practices and outcomes in chronic peritoneal dialysis patients. Data from 1,202 patients who did not receive hemodialysis but who were on chronic ambulatory peritoneal dialysis (CAPD) for at least part of the 6-month period between November 1, 1994, and April 30, 1995, are reported. The mean serum albumin level for this cohort was 3.5 g/dL by the bromcresol green method and 3.2 g/dL by the bromcresol purple method. Data sufficient to calculate a weekly Kt/V(urea) or weekly creatinine clearance were available for only 34% of patient submissions. In these patients, the median weekly Kt/V(urea) was 1.7 using a fixed value for V of 0.58 x body weight and was 2.0 using the Watson equation to calculate V; the median weekly creatinine clearance was 60.7 L/wk/1.73 m2. The mean hematocrit for this cohort was 32% and the average weekly recombinant human erythropoietin (rHmEPO) dose was 115 u/kg. Hematocrit values < or = 30% were found in 50% of black patients and 31% of white patients. The average blood pressure among peritoneal dialysis patients was 139/80 mm Hg, with 29% of patients having a systolic blood pressure exceeding 150 mm Hg and 18% a diastolic blood pressure greater than 90 mm Hg. In summary, serum albumin levels were significantly lower in peritoneal dialysis patients than in hemodialysis patients. Approximately one third of peritoneal dialysis patients did not have an adequacy measure obtained during the 6-month observation period. A significant minority of patients had either inadequately treated anemia of chronic renal disease or hypertension. There is an opportunity to substantially improve the medical care provided to chronic peritoneal dialysis patients.

Improvement in adequacy of delivered dialysis for adult in-center hemodialysis patients in the United States, 1993 to 1995.

The objective of this review is to describe the adequacy of delivered dialysis provided to in-center hemodialysis patients in the United States and to compare the findings with published guidelines. The medical records of random samples of 6,138, 6,919, and 6,861 patients in hemodialysis facilities were studied from all Medicare-eligible adult in-center hemodialysis patients alive on December 31, 1993, 1994, and 1995, respectively. The main clinical measure used was the urea reduction ratio (URR), the mean of which was 0.63 in 1993, 0.64 in 1994, and 0.66 in 1995. The proportion of patients with URR > or = 0.65, as recommended by the Renal Physicians Association and a National Institutes of Health Consensus Development Conference Statement, increased from 43% in 1993 to 49% in 1994 and 59% in 1995. In each of these 3 years, women were more likely than men to have a URR > or = 0.65 (1993: 54% v 31%, odds ratio 2.6; 1994: 61% v 38%, odds ratio 2.5; and 1995: 70% v 50%, odds ratio 24), as were older patients (65+ years) compared with younger patients (18 to 44 years) (1993: 47% v 37%, odds ratio 1.4; 1994: 54% v 45%, odds ratio 1.5; and 1995: 65% v 53%, odds ratio 1.6) and white patients compared with black patients (1993: 46% v 36%, odds ratio 1.5; 1994: 53% v 43%, odds ratio 1.5; and 1995: 63% v 54%, odds ratio 1.4). There was also substantial geographic variation in the proportion of patients receiving hemodialysis with a URR > or = 0.65. In conclusion, marked differences existed in 1993, 1994, and 1995 between observed practice and consensus guidelines for the delivery of adequate dialysis. Nevertheless, notable improvement occurred during this time period. A system to monitor further improvements in hemodialysis care in the United States is in place.

Implementing the Health Care Quality Improvement Program in the Medicare ESRD Program: a new era of quality improvement in ESRD.

Improving the quality of health care is a central challenge for America's health care system. The mission of the End-Stage Renal Disease (ESRD) program is to promote the quality, effectiveness, and efficiency of ESRD patient care and program administration. The program provides an ideal opportunity to demonstrate the use of information to help clinicians analyze and improve the care they deliver to patients in an ambulatory setting. This is possible because the program has established regional surveillance systems, called ESRD Networks, that gather information on the occurrence and outcomes of treatment of Medicare beneficiaries with ESRD. The Health Care Financing Administration, which is responsible for the administration of the program, and the renal community have worked together since 1990 to identify ways of incorporating new methods of quality improvement into the program. These methods include statistical evaluation of the processes and outcomes of care in dialysis populations; communicating recommended practices with clinical guidelines and algorithms; regional peer review and feedback (ie, technical assistance and/or collaborations for quality improvement); interventions that focus on the provision of assistance for quality improvement efforts; continuing collection and active feedback of data to providers; and a commitment to continue to evaluate and revise quality improvement activities to reflect lessons learned and newly identified needs. These ideas have been included in the 1994-1997 scope of work for the ESRD Networks and is called the ESRD Health Care Quality Improvement Program (HCQIP). This article describes the background for the ESRD HCQIP and the program's elements.

A data-driven approach to improving the care of in-center hemodialysis patients.

Health care providers, patients, the end stage renal disease (ESRD) networks, and HCFA have developed the ESRD Health Care Quality Improvement Program (HCQIP) in an effort to assess and improve care provided to ESRD patients. Currently, the ESRD HCQIP focuses on collecting information on quality indicators (QIs) for treatment of anemia, delivery of adequate dialysis, nutritional status, and blood pressure control for adult in-center hemodialysis patients. QIs were measured in a national probability sample of ESRD patients, and interventions and evaluations of the interventions are beginning. The ESRD HCQIP illustrates a way to mobilize the strengths of the public and private sectors to achieve improved care for special populations.