Multistate utilization, processes, and outcomes of carotid endarterectomy.

OBJECTIVES: The purpose of this study was to describe variation in utilization, care processes, and outcomes for carotid endarterectomy (CEA) procedures in 10 states. METHODS: We reviewed the medical records of Medicare patients who underwent 10,561 CEA procedures between June 1, 1995, and May 31, 1996, in 10 different states to determine indications, care processes, and outcomes. This study also included medical record review of hospital readmissions within 30 days of the procedure and identification of out-of-hospital deaths from the Medicare beneficiary files. RESULTS: Utilization rates of CEA varied from 25.7 to 38.4 procedures per 10,000 Medicare beneficiaries among states. The overall combined event rate (30-day stroke or mortality) was 5.2% for primary CEA alone (n = 9945). The mortality rate was 1.5%, and the nonfatal stroke rate was 3.7%. Combined event rates (CEA alone) by surgical indication were 7.7% for stroke (n = 1037), 7.4% for transient ischemic attack (n = 1304), 5.3% for nonspecific symptoms (n = 3713), and 3.7% for asymptomatic patients (n = 3891). The combined event rates (CEA alone) among states ranged from 4.1% to 7.7% with the event rates in asymptomatic patients ranging from 2.3% to 6.7%. In a multivariate analysis (correcting for indication), the use of preoperative antiplatelet agents (odds ratio [OR], 0.70), intraoperative heparin (OR, 0.49), and patch angioplasty (OR, 0.73) was significantly associated with lower combined event rates. There were significant differences among states in the use of preoperative antiplatelet therapy (range, 56%-70%) and patch angioplasty (range, 11%-49%). Combined event rates for repeat procedures (n = 380) and CEA combined with coronary artery bypass grafting (n = 236) were 6.3% and 17.4%, respectively. CONCLUSIONS: The striking variation among states suggests that there is room for improvement in the utilization, care processes, and outcomes of CEA. All surgeons performing CEA should participate in outcome assessment and adopt protocols that include the routine administration of antiplatelet agents preoperatively, the use of heparin intraoperatively, and patch angioplasty of the endarterectomy site.

Quality of medical care delivered to Medicare beneficiaries: A profile at state and national levels.

CONTEXT: Despite condition-specific and managed care-specific reports, no systematic program has been developed for monitoring the quality of medical care provided to Medicare beneficiaries. OBJECTIVE: To create a monitoring system for a range of measures of clinical performance that supports quality improvement and provides repeated, reliable estimates at the national and state levels for fee-for-service (FFS) Medicare beneficiaries. DESIGN, SETTING, AND PARTICIPANTS: National study of repeated, cross-sectional observational data collected in 1997-1999 on all Medicare FFS beneficiaries or on a representative sample of beneficiaries with a particular condition. Data were collected using medical record abstraction for inpatient care, analysis of Medicare claims for some ambulatory services, and surveys for immunization rates. Separate samples were drawn for each topic for each state. MAIN OUTCOME MEASURES: Beneficiary patients' receipt of 24 process-of-care measures related to primary prevention, secondary prevention, or treatment of 6 medical conditions (acute myocardial infarction, breast cancer, diabetes mellitus, heart failure, pneumonia, and stroke) for which there is strong scientific evidence and professional consensus that the process of care either directly improves outcomes or is a necessary step in a chain of care that does so. RESULTS: Across all states for all measures, the percentage of patients receiving appropriate care in the median state ranged from a high of 95% (avoidance of sublingual nifedipine for patients with acute stroke) to a low of 11% (patients with pneumonia screened for pneumococcal immunization status before discharge). The median performance on an indicator is 69% (patients discharged with heart failure diagnosis who received angiotensin-converting enzyme inhibitors; diabetic patients having an eye examination in the last 2 years). Some states (particularly less populous states and those in the Northeast) consistently ranked high in relative performance while others (particularly more populous states and those in the Southeast) consistently ranked low. CONCLUSIONS: It is possible to assemble information on a diverse set of clinical performance measures that represent performance on the range of services in a health insurance program. These findings indicate substantial opportunities to improve the care delivered to Medicare beneficiaries and urgently invite a partnership among practitioners, hospitals, health plans, and purchasers to achieve that improvement. JAMA. 2000;284:1670-1676.

Molecular analysis of a major antigenic region of the 240-kD protein of Mi-2 autoantigen.

Anti-Mi-2 autoantibody is strongly associated with dermatomyositis and found in sera of 20% of patients. Mi-2 antigen contains at least eight components and previous evidence suggested that the 240-kD protein was the antigenic component for at least some sera. In this study, anti-M-2 patient sera were used to screen human thymocyte and HeLa cell lambda gt11 expression libraries, and two clones from each had plaques specifically reactive with anti-Mi-2 sera. Studies with affinity-purified antibody supported the identification of the clones. All of 44 anti-Mi-2 sera reacted with the plaques, but none of 44 control sera reacted significantly. The cDNAs were identical, and full sequencing of one revealed an open reading frame spanning a 1,054-bp insert. Rescreening the library with the cDNA yielded a 1,589-bp cDNA that continued the open reading frame. The Mi-2 cDNA hybridized to a single 7.5-8.0 kb mRNA of HeLa cells, by Northern blot. Rabbit antiserum directed at a portion of the cDNA product reacted with HeLa 240-kD Mi-2 protein. The sequence was notable for four potential zinc-fingers and several charged regions. The protein encoded by the cDNA produced in vitro reacted with only one of five of the Mi-2 sera. These findings indicate that the Mi-2 240 kD is a novel protein that is antigenic for all Mi-2 sera, and strongly suggests that a major common epitope is conformational in nature.

Surgical trends in the treatment of diseases of the lumbar spine in Utah's Medicare population, 1984 to 1990.

Chronic low back pain is a major source of disability in this country. The rate of surgical treatment for back disorders varies between small geographic areas in the northeastern United States. A statewide database was utilized to determine rate of surgery for mechanical low back problems in Utah's Medicare population from 1984 to 1990. The average surgery rate for Medicare enrollees was 274.7 per 100,000, and the Utah laminectomy and discectomy rates were at least 20% higher than the U.S. average. Back surgery rates rose by 55% over the study period, primarily because of increasing rates of surgery for spinal stenosis. There was statistically significant variation in surgery rates among regions in the state, with the highest region having a rate 50% greater than the lowest region. Rates of surgery for spinal stenosis had more variation than those for herniated disc surgery. There was no significant correlation between the number of surgeons performing back surgery and the rate of surgery. The variation and increase in back surgery rates in Utah's Medicare population are likely related to changes in the use of surgery for treatment of spinal stenosis and not to an increase in the number of back surgeons. Further investigation is needed to understand better the reasons for the observed increase in back surgery rates.

Analysis of the Mi-2 autoantigen of dermatomyositis.

OBJECTIVE: To determine the biochemical structure and antigenic components of Mi-2 autoantigen, the target of autoantibodies in 15-20% of dermatomyositis patients. METHODS: Immunoprecipitation from 35S-labeled HeLa cell extract, immunoblotting, and purification from bovine thymus by immunoaffinity chromatography. RESULTS: All 46 sera that had anti-Mi-2 autoantibodies demonstrated by immunodiffusion immunoprecipitated a major protein of approximately 240 kd. Additional proteins of 200, 150, 72, 65, 63, 50, and 34 kd appeared to be part of the antigen. Fractions of purified bovine Mi-2 with antigenic activity showed high molecular weight bands comparable with immunoprecipitated HeLa Mi-2. Twenty-four of 47 anti-Mi-2 positive sera reacted with the 240-kd protein by immunoblot against anti-Mi-2 immunoprecipitates. CONCLUSION: Mi-2 antigen consists of multiple proteins, of which the 240-kd protein appears to be the major reactive component.

A computer-generated reminder system improves physician compliance with diabetes preventive care guidelines.

Computerized reminder systems have been shown to be effective in improving physician compliance with preventive services guidelines. Very little has been published about the use of computerized reminders for preventive care in diabetes. We implemented a computer-generated reminder system for diabetes care guidelines in a randomized controlled study in the outpatient clinics of 35 internal medicine residents at the University of Utah and Salt Lake Veterans Affairs Hospitals. After a six month study period, compliance with the recommended care significantly improved in both the intervention group that received patient-specific reminders about the guidelines (38.0% at baseline, 54.9% at follow-up) and the control group that received a nonspecific report (34.6% at baseline, 51.0% at follow-up). There was no significant difference between the two groups. Both clinic sites showed similar improvement over baseline levels of compliance. Residents who completed encounter forms used by the system showed a significantly greater improvement in compliance than those who did not complete encounter forms (19.7% vs. 7.6%, p = 0.006). The improvements in guideline compliance were seen in all areas of diabetes preventive care studied, and significant improvements were seen with recommended items from the medical history, physical exam, laboratory testing, referrals, and patient education. The use of encounter forms by the providers significantly improved documented compliance with the guidelines in almost all categories of preventive care. These results suggest that computerized reminder systems improve compliance with recommended care more by facilitating the documentation of clinical findings and the ordering of recommended procedures than by providing the clinician with patient-specific information about guideline compliance status. Further study is needed to understand the implications of these findings to the development of future computerized reminder systems for chronic diseases such as diabetes.

Development and implementation of a computer-generated reminder system for diabetes preventive care.

Diabetes mellitus is a chronic condition with several late complications that can be delayed or avoided through proper preventive health care. Although practice guidelines have been established to improve the preventive care in diabetics, dissemination of these guidelines among physicians and educational programs have been only moderately successful in changing physicians' practice patterns. Previous efforts, however, did not utilize computer-generated reminders. We developed a system of computer-generated reminders for diabetic preventive care. We completed an implementation of the system in the outpatient clinics of internal medicine residents at our institution. This paper describes the development and implementation of this system. Our results showed that the system flagged an average of 13 items that deviated from diabetes guideline compliance, out of a possible 21 items per patient. The residents completed encounter forms used by the system for 37% of patients seen during a six month period. Physician users exhibited positive attitudes toward the use of guidelines which they judged improved quality at no additional cost of care. However, the complexity and length of the guideline encounter forms and the additional time demands proved to be significant obstacles to current routine use. Our experience will help to improve the system so that it is more usable and acceptable to physicians, especially in the future as health care increasingly makes use of electronic medical record systems.

The effect of age at smoking initiation on lung cancer risk.

It has been assumed that a younger age at initiation of cigarette smoking is associated with an increased risk of lung cancer, but previous studies have not adjusted for two strong risk factors, the amount smoked and duration smoked. We used data from a population-based case-control study with 282 histologically confirmed lung cancer cases matched to 3,282 random controls to determine whether age at initiation of smoking plays an independent role in the occurrence of lung cancer. After controlling for age, sex, and amount of tobacco exposure, men who began to smoke before age 20 had a substantially higher risk of developing lung cancer [odds ratio (OR) = 12.7; 95% confidence interval (CI) = 6.39-25.2] compared with men who began smoking at age 20 or older (OR = 6.03; 95% CI = 2.82-12.9). For women, the heavy increase in risk continued until age 25 (OR = 9.97; 95% CI = 4.68-21.2) compared with women who began smoking at age 26 or older (OR = 2.58; 95% CI = 0.53-12.4). There was no predisposition toward a specific histologic type of lung cancer. In this study, up to 52.4% of lung cancer cases in men and up to 73.0% of lung cancer cases in women could be attributed to this effect of early age of first smoking.