Does home-based exercise improve body mass index in patients with type 2 diabetes? Results of a feasibility trial.

AIMS: This feasibility trial evaluated the use, safety, and short-term benefits of a home-based exercise intervention designed to increase physical activity among adults with diabetes. METHODS: Participants with type 2 diabetes in a group practice were recruited and randomly assigned to the home-based exercise intervention or usual care. Participants were given diabetes self-management education, instructed to exercise 30 min 5 days/week, and were followed for 3 months. The intervention contained three exercise routines (aerobic and resistance exercises). Outcomes included changes from baseline at 3 months between groups in body mass index (BMI), quality of life, A1C, and blood pressure. RESULTS: Seventy-six sedentary adults completed the study: 49% intervention group, 68% women, 47% black, mean age 56.6+/-9.6 years. Using intention to treat analysis, a trend towards improvement between groups for BMI (mean change -0.4 versus 0.1, respectively; P=0.06) was identified. Thirty-eight percent of the intervention group adhered to 80% of the exercise recommendation and significantly improved BMI (-1.07; P<0.05). No other differences were detected between groups. CONCLUSIONS: Home-based exercise interventions have potential to reduce BMI in patients with diabetes. The results provide variance estimates necessary to power a larger study of longer duration.

Implementation of a mandatory rheumatology osteoporosis consultation in patients with low-impact hip fracture.

BACKGROUND: Osteoporosis remains an underdiagnosed and undertreated major health problem. The current treatment rate for patients who have experienced at least 1 osteoporotic fracture is 20%-25%. Therefore, the Rheumatology and Internal Medicine Departments of Ochsner Clinic Foundation New Orleans implemented a mandatory rheumatology osteoporosis consult as part of preprinted admission orders for all patients after hip fracture surgery on the Internal Medicine service. METHODS: We conducted a retrospective study of 78 patients admitted with a low-impact hip fracture between June 2004 and July 2005. These patients were seen by the rheumatology service in the hospital after hip fracture repair (exposed group). Osteoporosis evaluation was performed based on an interview questionnaire. Seventy-eight age-matched patients previously admitted for low-intensity or low-impact hip fracture in 2002-2003 but not exposed to the mandatory rheumatology consult served as our comparison group. Pearson chi2 test was used for statistical analysis. RESULTS: Mean patient age was 80 years. Of the 78 unexposed patients, 17 (22%) were on treatment (calcium, vitamin D, hormones or antiresorptive agents) before the hip fracture, and 18 (23%) were on treatment after fracture repair. Of the 78 patients exposed to the compulsory rheumatology consultation, 34 (44%) patients were receiving osteoporosis treatment before hip fracture and 75 (96%) patients were receiving treatment after fracture repair. Of the patients not treated before hip fracture repair, there was a significant increase in the percent treated for those patients exposed to the rheumatology consult versus those not exposed (97.6% vs. 2.4%, respectively, P < 0.0001). CONCLUSIONS: In our institution, we were successful in identifying and initiating appropriate therapy for osteoporosis patients through an automatic rheumatology osteoporosis consultation after hip fracture. The implementation of a mandatory osteoporosis consult resulted in a statistically significant increase in treatment of the exposed group compared with the unexposed group.

Comparing willingness to pay for telemedicine across a chronic heart failure and hypertension population.

This paper presents estimates of the willingness to pay for a new telemedicine technology in the absence of market data. The study utilizes a contingent valuation method to determine patient willingness to pay for access to telemedicine services. Willingness to pay was assessed in two populations: patients who are being treated for chronic heart failure (CHF) and patients who are being treated for hypertension. Patients who were approached to participate in these studies were asked about their preference for using telemedicine technologies. We find that patient willingness to pay has the expected negative relationship between price and the likelihood of purchase and that patients with CHF are less responsive to price changes than those with hypertension.

Willingness to pay for telemedicine assessed by the double-bounded dichotomous choice method.

We investigated the willingness of patients with chronic heart failure (CHF) to pay for access to medical care via telemedicine, as an alternative to visits to a physician's office. Willingness to pay was estimated using a double-bounded dichotomous choice contingent valuation method. One hundred and twenty-six patients were surveyed after their discharge from a CHF-related hospital stay. As expected, willingness to pay was negatively related to price. When people are presented with a survey question about value, particularly when the good being valued is not traded in the market, the question itself can affect the person's perception of value. However, the survey results showed no evidence of such a 'framing' effect. We found that 55% of the patients would be willing to pay $20 to access telemedicine instead of travelling to the physician's office, for at least some of their care. When the price was raised to $40, the proportion willing to pay fell to 19%. This suggests that telemedicine may be close to being commercially feasible in the USA.

The effect of education on patients' willingness to participate in a telemedicine study.

We assessed the effect of previous education on patients' willingness to participate in a clinical study of telemedicine for hypertensive patients. The design was a cross-sectional study of adult patients arriving for appointments in a hypertension clinic. Of the 259 patients approached, 86% completed a baseline survey and were subsequently asked if they would be willing to participate in a one-year telemedicine study. One hundred and fifty patients (58%) agreed to participate. A stepwise logistic regression analysis was performed to assess the effect of level of education on willingness to participate, while controlling for potentially confounding variables. In the final model, only education remained significant. The odds ratio for non-participation of patients with high-school education or less was 3.6 (95% confidence interval 1.9-7.0). Educational status should be carefully considered when designing, implementing and interpreting telemedicine studies.

Testing efficacy with detection controlled estimation: an application to telemedicine.

Detection controlled estimation (DCE) is a powerful new econometric estimator in the family of missing data estimators. By collecting measures from a variety of inspectors or inspection technologies, DCE is able to make inferences about the entire population, even when that population is not directly observed. Using this innovative method, we were able to assess whether telemedicine technology could be substituted for in-person visits when providing maintenance care for patients with hypertension. Our findings indicate that there is no support for the proposition that telemedicine is less effective than in-person visits for determining whether patients have high blood pressure. Indeed, our results imply that telemedicine misses 7% fewer cases of high blood pressure than in-person visits do. The results of this study indicate that DCE may be an effective tool for use in cost-effectiveness or cost-benefit analysis in health care.

Patient and physician satisfaction in a clinical study of telemedicine in a hypertensive patient population.

We studied patient and physician satisfaction with telemedicine for the care of a hypertensive population. Once recruited, participants were seen both in person and via telemedicine (in random order) on the same day. After each meeting, patient and physician satisfaction surveys were completed. In the 12-month study, there were 107 pairs of visits. The physicians reported a small but significant increase in workload, mental effort, technical skills and visit duration for telemedicine when compared with face-to-face consultations. They noted that the telemedicine system worked well in the majority of cases and could reduce the need for future treatment. Patients reported slightly but significantly higher satisfaction scores for the following for in-person than for telemedicine meetings: technical quality, interpersonal care and time spent. Patients reported high satisfaction scores for both telemedicine and in-person visits.

Combined quality improvement ratio: a method for a more robust evaluation of changes in screening rates.

INTRODUCTION: It has been proposed that a ratio of the discordant cells from a McNemar's Chi-square table be used as a measure of quality improvement, and that this measure be called the Quality Improvement Ratio (QuIR). As proposed, patients enrolled in only one year of a two-year study are excluded from the McNemar's table of the QuIR. Since the original proposal of the McNemar's Chi-square in 1947 included application to matched pair data, a more comprehensive analysis would be possible if the single-year enrollees were matched into pairs. METHODS: Patients enrolled in only the first study year are matched and paired with patients enrolled in only the second study year. The pairs are matched on variables important to the disease or process being evaluated. The matched pairs are combined with the repeatedly measured subjects to increase the statistical power of the analysis. The Combined Quality Improvement Ratio (CQuIR) is demonstrated with parameters from the original articles, in a--Markov chain Monte-Carlo simulation, so a direct comparison can be made. RESULTS: CQuIR improved statistical power, especially in simulations of small populations. In some simulations the statistical power was double that of the QuIR alone. DISCUSSION: Although the QuIR provides important information, the CQuIR allows more of the data to be used to evaluate the effect of interventions in policy, delivery, and practice. The increase in statistical power of the CQuIR over the QuIR can facilitate successful evaluation of health care services.

Technology meets healthcare: distance learning and telehealth.

In a time of increasing demands on physician productivity, computer and communication technologies allow health professionals to experiment with many applications that may provide opportunities to meet clinical demands while still participating in educational and research activities. "Telehealth" is a comprehensive term for the support of long distance clinical healthcare, patient and professional health-related education, public health, and health administration. Educational opportunities are growing exponentially for those who cannot attend traditional courses because of limited time or geographic considerations. Research and medical information and medical consultations are being delivered instantly across wide geographic areas. Nearly every federal agency has a web site providing health information. Integrated clinical management systems can facilitate the management of patients with chronic diseases and provide an efficient way to integrate consultations and patient education, monitoring, follow-up, and support. Administrative functions can be interfaced with clinical management providing practitioners with the ability to better organize their services. Information systems at all levels are expanding their capacities and capabilities to meet the growing demand for medical knowledge.

A method to report utilization for quality initiatives in medical facilities.

OBJECTIVE: We undertook this project to outline a methodology for quantifying aggregate health care utilization of medical "technologies" that could be rank ordered by volume. The identification of specific high-volume technologies could guide future efforts for quality initiatives such as program planning, preventive services implementation, quality improvement activities, and innovative and cost-effective technology development. DESIGN: This study utilized a retrospective cross-sectional study design. METHODS: We generated combined ranks for the top 200 high-volume procedures from three data sources that incorporated in- and outpatient procedures. Data were collected using primarily ICD-9 and CPT-4 codes; all codes were translated into CPT-4 codes and collapsed into categories using truncated three-digit CPT-4 codes. Frequencies for each collapsed code were determined with each dataset; procedures were reranked based on the mean rank of the three sources. MAIN OUTCOME MEASURES: We itemized the individual procedure codes making up each of the top 20 categories and reported the unique codes making up at least 80% of the procedure code category. RESULTS: The top five procedure categories identified in this study were patient visits (inpatient and outpatient), chest x-rays, mammograms, ophthalmological services, and electrocardiograms. CONCLUSION: The methodology described provides a new way to combine and concisely report on utilization of procedures that is relevant to data obtained from different sources. This methodology may be of potential benefit to health care administrators, technology developers, and other planners as they contemplate ways to identify quality and technology development initiatives that can have a broad impact on populations served by health care organizations.

Practical considerations in the measurement of outcomes in healthcare.

In the current era of accountability in medicine, information regarding outcomes of care can play a pivotal role in medical decision making for physicians, other healthcare providers, patients, and administrators. Although the field of outcomes assessment has not fully matured, a number of tools and methods can be reliably used to produce valid information. Systematic collection and analysis of outcomes data can add to the complexity of the medical encounter. Yet, if appropriately collected, the information derived can facilitate medical decision making and enhance the quality of medical care. This article defines and discusses healthcare outcomes, reviews the relevance of outcomes measurement, describes practical considerations in, and examples of, outcomes measurement in medical practice, and reviews some resources available for outcomes studies or projects.

Effects of caregiver specialty on cost and clinical outcomes following hospitalization for heart failure.

In 614 consecutive hospitalizations with the primary discharge diagnosis of diagnosis-related group (DRG) 127 (heart failure and shock), we sought to assess the effect of caregiver specialty (generalist, n = 217; cardiologist, n = 397) on hospital costs, length of stay, and in-hospital mortality. Patients treated by cardiologists were younger (68 vs 71 years) and less likely to have hypertension (52% vs 61%), but were more likely to be men (61% vs 44%), require an intensive care stay (13% vs 5%), have coronary artery disease (49% vs 23%), have a left ventricular ejection fraction <40% (74% vs 49%), and have lower systolic (132 vs 146 mm Hg) and diastolic (76 vs 81 mm Hg) blood pressures on admission. Predictors of acute disease severity were similarly distributed between the 2 groups. No difference was found between patients treated by cardiologists versus those treated by generalists with respect to crude or adjusted hospital cost, length of stay, and in-hospital mortality. However, in subsets of patients who required intensive care during hospitalization (n = 64), as well as those who did not (n = 550), care by cardiologists was associated with a lower adjusted hospital cost. Any potential cost savings that could have accrued from care by cardiologists was, however, negated by the higher proportion of patients treated by cardiologists who required intensive care during hospitalization. We conclude that when differences in clinical variables are adjusted, care by cardiologists versus generalists is associated with similar or lower hospital cost for patients with DRG 127. Our findings challenge the notion that in-patient care provided by specialists is more expensive than that provided by generalists.

Comparing comorbid-illness indices assessing outcome variation: the case of prostatectomy.

OBJECTIVE: We investigated and compared the effects of three different comorbid indices on selection of procedure and outcome variation to determine which, if any, could be used for interpreting outcomes data. DESIGN: Retrospective cohort study. SETTING: Large multispecialty group practice. PATIENTS: Patients (aged 55-85 years) with residence in the United States who underwent a first-time prostatectomy for benign prostatic hyperplasia: 302 total; 253 transurethral procedures (TURF) versus 49 open procedures (OP). MEASUREMENTS AND MAIN RESULTS: The following indices were used to assess comorbid disease: Charison index (CI), index of coexistent disease (ICED), and Kaplan-Feinstein index (KFI). The main outcome measure was the five-year mortality rate. The unadjusted five-year mortality rates were 16% (40/ 253) for TURP and 4% (2/49) for OP; survival analysis revealed this difference to be marginally significant at the p = -05 level. In an effort to control for the effect of comorbidity, CI, ICED, and KFI were independently assessed: together with age, they each had similar effects in rendering the risk of death associated with procedure type insignificant. However, comorbidity, as derived with ICED (not CI or KFI), was identified as a confounding variable when assessing the five-year mortality rate after prostatectomy as ICED was associated with the procedure type (predictor variable) and the five-year mortality (outcome variable). CONCLUSION: Differences in the composition and scoring of comorbid indices may have important implications for interpreting outcomes data. Nevertheless, these results, together with those of previous studies, suggest that the reported increased mortality for patients undergoing TURP is probably due to case-mix differences.

Health status assessment in a hypertension section of an internal medicine clinic.

The authors obtained health status instrument information with the SF-36 and COOP charts distributed in random order (along with selected items from the Hypertension Technology of Patient Experience [TyPE] tool) to patients attending the hypertension section of an internal medicine clinic. The goal was to examine and compare potential associations of clinical, demographic, and/or treatment variables with SF-36/COOP health status scale variables in a nonuniversity urban clinic. One hundred fifty-eight pairs of health status instruments were returned (62% response rate). One hundred (64%) had a diagnosis of hypertension, 81 (51%) were males, 94 (60%) were older than 65 years, and 122 (78%) were white. Clinical, demographic, and treatment measurements were studied using regression analysis; the estimated regressions accounted for 4-32% of the variation in the COOP scales and 8-19% in the SF-36 scales. The number of coexisting diseases, gender, and diagnosis of hypertension were the most frequent significant variables associated with health status scale outcomes for each health status instrument. For most COOP and some SF-36 scales, there was a significant hypertension by gender interaction indicating that women with a hypertension diagnosis report better health status than women seen for other conditions; hypertension diagnosis had little effect on men's reported health status for most scales. Further study is necessary to confirm these results, yet the regression models developed in this study suggest that health status as assessed by these instruments is affected by multiple and not always obvious factors.

Predicting work status for patients in an occupational medicine setting who report back pain.

OBJECTIVE: To determine the ability of patient-reported health status information to predict physician-determined fit-for-work status for patients reporting complaints of low back pain. DESIGN: Cross-sectional study using survey methods. SETTING: Occupational medicine section of a large multispecialty private clinic. PATIENTS: Four hundred sixty-two questionnaire packets were distributed to patients who were seen for work-related conditions or disorders over a 13-week period; 235 questionnaires were returned (51% response rate). One hundred seven responders reported low back pain and completed the Low Back Pain TyPE (Technology of Patient Experience) Tool. The mean (+/- SD) age of respondents was 39 (+/- 12) years; 67% of respondents were male, 70% were white, 87% were receiving worker's compensation, 58% were married, and 55% had a high school education or less. INTERVENTIONS: Questionnaire packets for self-administration containing health/functional status questions (short form [SF]-36, COOP Charts) and the Low Back Pain TyPE Tool were distributed to the patients. Other variables were abstracted from the medical records and administrative databases. MAIN OUTCOME MEASURES: The primary study outcome measured was fitness for work; patients were examined and categorized as fit or not fit for work by physicians who were unaware of the questionnaire results. RESULTS: Logistic regression analysis consisted of variables from 107 patients who reported low back pain. The final model contained the physical functioning scale (SF-36), employment status, smoking status, and physical functioning (SF-36) by gender interaction. Seventy-seven percent of the fit-for-work cases and 90% of the not-fit-for-work cases were correctly classified. CONCLUSION: Patient-reported physical function (as modified by gender), smoking status, and employment status predicted physician-determined work status for patients reporting low back pain in this study. Larger studies will be required to confirm this finding.

How to use continuous quality improvement theory and statistical quality control tools in a multispecialty clinic.

The management philosophy of continuous quality improvement (CQI) and the tools of statistical quality control (SQC) have the potential for advancing quality management in medicine as they have in industry. The authors report their favorable experience with the approach and explain how to adapt CQI principles and SQC charts and graphs, citing examples from their participation in a quality improvement effort in a multispecialty clinic serving a large hospital. The coupling of statistical techniques with modern approaches to outcome analysis may provide powerful tools not only for quality assurance and assessment but also for technology evaluation and resource allocation.