Managing total knee replacement under value-based payments.

OBJECTIVES: To evaluate opportunity gaps and set outcome goals in knee replacement (KR) between a primary care group taking financial risk for managing its patients and 6 fee-for-service (FFS) orthopedic groups that serve their patients. STUDY DESIGN: The opportunity gap analysis was a cross-sectional evaluation of the outcomes of interest on a risk-adjusted basis using orthopedic groups, the primary care group's patients, and regional comparisons. The impact evaluation was a historical cohort comparison tracking outcomes of interest over the time frame of the intervention. METHODS: Using risk-adjusted Medicare data, we defined opportunity gaps in the following outcomes: density of KR surgery, site of KR surgery, postacute care placement, and complications. RESULTS: Opportunity gap analysis demonstrated the following variation on a regional basis: a 2-fold difference in density of KR, a 3-fold difference in outpatient surgery, and a 2.5-fold difference in institutional postacute care placement. In the impact evaluation comparing 2019 with 2021, the primary care group's patients had reduced density of KR surgeries from 15.5 per 1000 to 13.0 per 1000, an increase in outpatient surgery from 31.0% to 81.6%, and a reduction in institutional postacute care utilization from 16.0% to 6.1%. Less pronounced trends were seen in the region for all Medicare FFS patients. These results were achieved with stable complication rates, which had an observed/expected ratio of 0.61 in 2019 and 0.63 in 2021. CONCLUSIONS: We achieved alignment of incentives through use of performance information with specific goals and promise of referrals to value-based partners. This approach resulted in improved value to patients with no evidence of harm and is translatable to other specialty care and markets.

Morphology and composition of Goldeye (Hiodontidae; Hiodon alosoides) otoliths.

We provide up-to-date morphological and compositional data on otoliths of the osteoglossomorph Goldeye (Hiodon alosoides). Using computed tomography (CT) X-ray, we documented the location of each of the three pairs of otoliths (lapilli, sagittae, and asterisci) in relation to the swim bladder, which extended forward in close proximity to the sagittae and asterisci. The lappili were the largest otoliths in terms of surface area and volume, but the sagittae were highly modified, appearing spiral in shape when viewed dorsally, with a surface area to volume ratio more than double that of the lapilli. Using scanning electron microscopy, the surface of each otolith was viewable in great detail, and small otoconia (~10.5 µm diameter) were observed on each, but were most numerous on the sagittae. On scanning electron micrographs, the sagittae appeared to be bi-lobed, with asymmetrical lobes each oriented in the same general direction. Using neutron and X-ray diffraction methods, we found three polymorphs of calcium carbonate crystals (aragonite, vaterite, and calcite), sometimes all within the same otolith. However, in general, lapilli and sagittae were composed predominately of aragonite whereas asterisci were composed chiefly of vaterite. With these results, we provide information on a unique species, whose inclusion in future studies would benefit our understanding of fish hearing, fish evolution, and fisheries ecology.

Evaluating mobile monitoring of on-road emission factors by comparing concurrent PEMS measurements.

Many countries have adopted portable emissions measurement system (PEMS) testing in their latest regulations to measure real-world vehicular emissions. However, its fleetwide implementation is severely limited by the high equipment costs and lengthy setup procedures, posing a need to develop more cost-effective, efficient emission measurement methods, such as mobile chasing tests. We conducted conjoint PEMS-chasing experiments for twelve heavy-duty diesel vehicles (HDDTs) to evaluate the accuracy of mobile measurement results. Two data processing approaches were integrated to automate the calculations of fuel consumption-based emission factors of nitrogen oxides (NOX). With a total of 245 plume chasing tests conducted, and then averaged by vehicle and road types, we found that the relative errors of vehicle-specific emission factors using an algorithm developed for this project were within approximately ±20% of the PEMS results for all tested vehicles. Stochastic simulations suggested reasonable results could be obtained using fewer chasing tests per vehicle (e.g., 71% for freeways and 94% for local road, equivalent to two chase tests per vehicle). This study improves the understanding of the accuracy of the mobile chasing method, and provides a practical approach for real-time emission measurements for future scaled-up mobile chasing studies.

Outcomes of a conservative care program for knee osteoarthritis through translation of research into practice.

INTRODUCTION: Evidence-based guidelines suggest a conservative, nonsurgical approach as first-line treatment for knee osteoarthritis. However, previous literature has documented underutilization of the fundamental components of condition management emphasized in the guidelines. The intervention aim is to apply organized conservative components of care for knee osteoarthritis in an evidence-based management program through the translation of research into practice with a target to observe meaningful functional improvement in a distinct population. METHODS: The program, modeled after the nonsurgical arm of a randomized, controlled trial, was designed as a single-arm observational cohort study with a pre- and post-program comparison for participants reporting presence of knee osteoarthritis who were attributed to a specific employer's health plan in the United States. The 12-week intervention consisted of condition education, group exercise, and a dietary intervention. RESULTS: Ninety-six participants enrolled in the program, of which 72% completed the protocol. The median change in pre- to post-program Knee Injury and Osteoarthritis Outcome Score values was 10.4 ± 0.8 (Z = 210.5, p < 0.001)-a clinically important change. Secondary outcomes were complementary to the primary outcome. CONCLUSIONS: Results of the program indicate that the clinically significant 3-month findings in the report by Skou et al. (2015) regarding functional improvement can be replicated in an alternate setting. Organizing and offering fundamental components of condition management in a group format with provider oversight could be a feasible and logical component in the continuum of care for knee osteoarthritis, while complementing other secondary management strategies following diagnosis.

On-Road Chemical Transformation as an Important Mechanism of NO2 Formation.

Nitrogen dioxide (NO2) not only is linked to adverse effects on the respiratory system but also contributes to the formation of ground-level ozone (O3) and fine particulate matter (PM2.5). Our curbside monitoring data analysis in Detroit, MI, and Atlanta, GA, strongly suggests that a large fraction of NO2 is produced during the "tailpipe-to-road" stage. To substantiate this finding, we designed and carried out a field campaign to measure the same exhaust plumes at the tailpipe-level by a portable emissions measurement system (PEMS) and at the on-road level by an electric vehicle-based mobile platform. Furthermore, we employed a turbulent reacting flow model, CTAG, to simulate the on-road chemistry behind a single vehicle. We found that a three-reaction (NO-NO2-O3) system can largely capture the rapid NO to NO2 conversion (with time scale ≈ seconds) observed in the field studies. To distinguish the contributions from different mechanisms to near-road NO2, we clearly defined a set of NO2/NO x ratios at different plume evolution stages, namely tailpipe, on-road, curbside, near-road, and ambient background. Our findings from curbside monitoring, on-road experiments, and simulations imply the on-road oxidation of NO by ambient O3 is a significant, but so far ignored, contributor to curbside and near-road NO2.

An Evaluation of Reach for a Work Site Implementation of the National Diabetes Prevention Program Focusing on Diet and Exercise.

PURPOSE: Our objective is to evaluate the "reach" component of the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework by comparing prediabetics who were and were not interested in enrolling in a free work site diabetes prevention program (DPP) during the first year of the program. Reach is defined as the proportion of eligible participants who enroll in a health program. DESIGN: A cross-sectional study design was used. SETTING: The setting was a large health system in the Midwest. PARTICIPANTS: Prediabetic health plan enrollees and spouses (N = 2158). MEASURES: An online health survey, annual voluntary biometric screenings delivered by a trained health-care professional using standardized protocols via point-of-care testing, and records from the DPP office were the sources of data for this study. ANALYSIS: Health behaviors and biometric screening results were simultaneously compared using multivariable logistic regression. RESULTS: The study population was 63% female, 79% white, and 16% black, and the mean age was 50.2 years (SD = 10.2). The reach of this program was 10%. Prediabetics were more likely to express interest in the DPP, if they were female (adjusted odds ratio [AOR]: 2.4; 95% confidence interval [95% CI]: 1.55-3.72; P < .001), black (AOR = 2.23; 95% CI: 1.43-3.47; P < .001), older in age (AOR: 1.08; 95% CI: 0.99-1.17; P = .05), or had a high-risk waist circumference (AOR = 1.44; 95% CI: 0.98-2.13; P = .07), lower self-efficacy to make healthy changes (AOR = 0.48; 95% CI: 0.26-0.91; P = .03), and 5 or more doctor visits in the last year (AOR = 2.13; 95% CI: 0.99-4.57; P = .05), after controlling for other covariates. CONCLUSION: Current recruitment and implementation strategies are reaching only a small group of individuals who are not representative of the larger prediabetic population. These findings inform future engagement strategies, and we recommend that public health practitioners evaluate reach to ensure that health promotion programs are of high value.

Temperature and Driving Cycle Significantly Affect Carbonaceous Gas and Particle Matter Emissions from Diesel Trucks.

The present study examines the effects of fuel [an ultralow sulfur diesel (ULSD) versus a 20% v/v soy-based biodiesel-80% v/v petroleum blend (B20)], temperature, load, vehicle, driving cycle, and active regeneration technology on gas- and particle-phase carbon emissions from light and medium heavy-duty diesel vehicles (L/MHDDV). The study is performed using chassis dynamometer facilities that support low-temperature operation (-6.7 °C versus 21.7 °C) and heavy loads up to 12 000 kg. Organic and elemental carbon (OC-EC) composition of aerosol particles is determined using a thermal-optical technique. Gas- and particle-phase semivolatile organic compound (SVOC) emissions collected using traditional filter and polyurethane foam sampling media are analyzed using advanced gas chromatograpy/mass spectrometry methods. Study-wide OC and EC emissions are 0.735 and 0.733 mg/km, on average. The emissions factors for diesel vehicles vary widely, and use of a catalyzed diesel particle filter (CDPF) device generally mutes the carbon particle emissions in the exhaust, which contains ~90% w/w gas-phase matter. Interestingly, replacing ULSD with B20 did not significantly influence SVOC emissions, for which sums range from 0.030 to 9.4 mg/km for the L/MHDDVs. However, both low temperature and vehicle cold-starts significantly increase SVOCs in the exhaust. Real-time particle measurements indicate vehicle regeneration technology did influence emissions, although regeneration effects went unresolved using bulk chemistry techniques. A multistudy comparison of the toxic particle-phase polycyclic aromatic hydrocarbons (PAHs; molecular weight (MW) ≥ 252 amu) in diesel exhaust indicates emission factors that span up to 8 orders of magnitude over the past several decades. This study observes conditions under which PAH compounds with MW ≥ 252 amu appear in diesel particles downstream of the CDPF and can even reach low-end concentrations reported earlier for much larger HDDVs with poorly controlled exhaust streams. This rare observation suggests that analysis of PAHs in particles emitted from modern L/MHDDVs may be more complex than recognized previously.

A Prognostic Indicator for Patients Hospitalized with Heart Failure.

BACKGROUND: Current methods for identifying patients at risk of dying within six months suffer from clinician biases resulting in underestimation of this risk. As a result, patients who are potentially eligible for hospice and palliative care services frequently do not benefit from these services until they are very close to the end of their lives. OBJECTIVE: To develop a prospective prognostic indicator based on actual survival within Centers for Medicare and Medicaid Services (CMS) claims data that identifies patients with congestive heart failure (CHF) who are at risk of six-month mortality. METHODS: CMS claims data from January 1, 2008 to June 30, 2009 were reviewed to find the first hospitalization for CHF patients with episode of care diagnosis-related groups (DRGs) 291, 292, and 293. Univariate and multivariable analyses were used to determine the associations between demographic and clinical factors and six-month mortality. The resulting model was evaluated for discrimination and calibration. RESULTS: The resulting prospective prognostic model demonstrated fair discrimination with an ROC of 0.71 and good calibration with a Hosmer-Lemshow statistic of 0.98. Across all DRGs, 5% of discharged patients had a six-month mortality risk of greater than 50%. CONCLUSION: This prospective approach appears to provide a method to identify patients with CHF who would potentially benefit from a clinical evaluation for referral to hospice care or for a palliative care consult due to high predicted risk of dying within 180 days after discharge from a hospital. This approach can provide a model to match at-risk patients with evidenced-based care in a more consistent manner. This method of identifying patients at risk needs further prospective evaluation to see if it has value for clinicians, increases referrals to hospice and palliative care services, and benefits patients and families.

Effects of Cold Temperature and Ethanol Content on VOC Emissions from Light-Duty Gasoline Vehicles.

Emissions of speciated volatile organic compounds (VOCs), including mobile source air toxics (MSATs), were measured in vehicle exhaust from three light-duty spark ignition vehicles operating on summer and winter grade gasoline (E0) and ethanol blended (E10 and E85) fuels. Vehicle testing was conducted using a three-phase LA92 driving cycle in a temperature-controlled chassis dynamometer at two ambient temperatures (-7 and 24 °C). The cold start driving phase and cold ambient temperature increased VOC and MSAT emissions up to several orders of magnitude compared to emissions during other vehicle operation phases and warm ambient temperature testing, respectively. As a result, calculated ozone formation potentials (OFPs) were 7 to 21 times greater for the cold starts during cold temperature tests than comparable warm temperature tests. The use of E85 fuel generally led to substantial reductions in hydrocarbons and increases in oxygenates such as ethanol and acetaldehyde compared to E0 and E10 fuels. However, at the same ambient temperature, the VOC emissions from the E0 and E10 fuels and OFPs from all fuels were not significantly different. Cold temperature effects on cold start MSAT emissions varied by individual MSAT compound, but were consistent over a range of modern spark ignition vehicles.

Temperature effects on particulate emissions from DPF-equipped diesel trucks operating on conventional and biodiesel fuels.

UNLABELLED: Emissions tests were conducted on two medium heavy-duty diesel trucks equipped with a particulate filter (DPF), with one vehicle using a NOx absorber and the other a selective catalytic reduction (SCR) system for control of nitrogen oxides (NOx). Both vehicles were tested with two different fuels (ultra-low-sulfur diesel [ULSD] and biodiesel [B20]) and ambient temperatures (70ºF and 20ºF), while the truck with the NOx absorber was also operated at two loads (a heavy weight and a light weight). The test procedure included three driving cycles, a cold start with low transients (CSLT), the federal heavy-duty urban dynamometer driving schedule (UDDS), and a warm start with low transients (WSLT). Particulate matter (PM) emissions were measured second-by-second using an Aethalometer for black carbon (BC) concentrations and an engine exhaust particle sizer (EEPS) for particle count measurements between 5.6 and 560 nm. The DPF/NOx absorber vehicle experienced increased BC and particle number concentrations during cold starts under cold ambient conditions, with concentrations two to three times higher than under warm starts at higher ambient temperatures. The average particle count for the UDDS showed an opposite trend, with an approximately 27% decrease when ambient temperatures decreased from 70ºF to 20ºF. This vehicle experienced decreased emissions when going from ULSD to B20. The DPF/SCR vehicle tested had much lower emissions, with many of the BC and particle number measurements below detectable limits. However, both vehicles did experience elevated emissions caused by DPF regeneration. All regeneration events occurred during the UDDS cycle. Slight increases in emissions were measured during the WSLT cycles after the regeneration. However, the day after a regeneration occurred, both vehicles showed significant increases in particle number and BC for the CSLT drive cycle, with increases from 93 to 1380% for PM number emissions compared with tests following a day with no regeneration. IMPLICATIONS: The use of diesel particulate filters (DPFs) on trucks is becoming more common throughout the world. Understanding how DPFs affect air pollution emissions under varying operating conditions will be critical in implementing effective air quality standards. This study evaluated particulate matter (PM) and black carbon (BC) emissions with two DPF-equipped heavy-duty diesel trucks operating on conventional fuel and a biodiesel fuel blend at varying ambient temperatures, loads, and drive cycles.

Cold temperature and biodiesel fuel effects on speciated emissions of volatile organic compounds from diesel trucks.

Speciated volatile organic compounds (VOCs) were measured in diesel exhaust from three heavy-duty trucks equipped with modern aftertreatment technologies. Emissions testing was conducted on a chassis dynamometer at two ambient temperatures (-7 and 22 °C) operating on two fuels (ultra low sulfur diesel and 20% soy biodiesel blend) over three driving cycles: cold start, warm start and heavy-duty urban dynamometer driving cycle. VOCs were measured separately for each drive cycle. Carbonyls such as formaldehyde and acetaldehyde dominated VOC emissions, making up ∼ 72% of the sum of the speciated VOC emissions (∑VOCs) overall. Biodiesel use led to minor reductions in aromatics and variable changes in carbonyls. Cold temperature and cold start conditions caused dramatic enhancements in VOC emissions, mostly carbonyls, compared to the warmer temperature and other drive cycles, respectively. Different 2007+ aftertreatment technologies involving catalyst regeneration led to significant modifications of VOC emissions that were compound-specific and highly dependent on test conditions. A comparison of this work with emission rates from different diesel engines under various test conditions showed that these newer technologies resulted in lower emission rates of aromatic compounds. However, emissions of other toxic partial combustion products such as carbonyls were not reduced in the modern diesel vehicles tested.

Associations between preoperative physical therapy and post-acute care utilization patterns and cost in total joint replacement.

BACKGROUND: Health-care costs following acute hospital care have been identified as a major contributor to regional variation in Medicare spending. This study investigated the associations of preoperative physical therapy and post-acute care resource use and its effect on the total cost of care during primary hip or knee arthroplasty. METHODS: Historical claims data were analyzed using the Centers for Medicare & Medicaid Services Limited Data Set files for Diagnosis Related Group 470. Analysis included descriptive statistics of patient demographic characteristics, comorbidities, procedures, and post-acute care utilization patterns, which included skilled nursing facility, home health agency, or inpatient rehabilitation facility, during the ninety-day period after a surgical hospitalization. To evaluate the associations, we used bivariate and multivariate techniques focused on post-acute care use and total episode-of-care costs. RESULTS: The Limited Data Set provided 4733 index hip or knee replacement cases for analysis within the thirty-nine-county Medicare hospital referral cluster. Post-acute care utilization was a significant variable in the total cost of care for the ninety-day episode. Overall, 77.0% of patients used post-acute care services after surgery. Post-acute care utilization decreased if preoperative physical therapy was used, with only 54.2% of the preoperative physical therapy cohort using post-acute care services. However, 79.7% of the non-preoperative physical therapy cohort used post-acute care services. After adjusting for demographic characteristics and comorbidities, the use of preoperative physical therapy was associated with a significant 29% reduction in post-acute care use, including an $871 reduction of episode payment driven largely by a reduction in payments for skilled nursing facility ($1093), home health agency ($527), and inpatient rehabilitation ($172). CONCLUSIONS: The use of preoperative physical therapy was associated with a 29% decrease in the use of any post-acute care services. This association was sustained after adjusting for comorbidities, demographic characteristics, and procedural variables. CLINICAL RELEVANCE: Health-care providers can use this methodology to achieve an integrative, cost-effective, patient care pathway using preoperative physical therapy.

OMT associated with reduced analgesic prescribing and fewer missed work days in patients with low back pain: an observational study.

CONTEXT: Randomized controlled trials (RCTs) are considered the standard for establishing practice guidelines; however, they are expensive and time-consuming, and often the generalizability of the results is limited. OBJECTIVES: To conduct an observational study using the findings of the American Osteopathic Association's Clinical Assessment Program (AOA-CAP) low back pain module, and to compare these findings with those of a major back pain-related RCT to determine the validity and generalizability of this pseudoexperimental model. METHODS: Data were abstracted from the AOA-CAP for Residencies platform from April 1, 2006, through October 5, 2007, with a diagnosis code consistent with low back pain. Process and outcome measures were compared after segregating a similar patient population to an RCT that compared "osteopathic spinal manipulation" with standard care. RESULTS: A total of 1013 medical records were abstracted and entered into the AOA-CAP low back pain module. Mean (standard deviation [SD]) age was 44.7 (15.9) years, and body mass index was 29.6 (8.1). The eligible patients comprised 415 men (41.0%) and 598 women (59.0%), and common comorbid disease was found in 69 patients (6.8%). Activities of daily living were limited in 402 patients (42.4%), whereas 546 (57.6%) had no limitations. Previous exacerbations of low back pain occurred in 653 patients (65.9%). Most patients had no sensory or proprioception deficit (729 [87.7%]), and motor function was normal in 636 patients (74.5%). Normal ankle and knee reflexes were found in 744 of 814 (91.4%) and 755 of 829 (89.0%) patients, respectively. Osteopathic manipulative treatment (OMT) was performed on the lumbar spine (576 patients [56.9%]), thoracic spine (411 [40.6%]), sacrum/pelvis (440 [43.4%]), rib (261 [25.8%]), and lower extremity (256 [25.3%]). A segregated patient cohort (n=539) showed statistically significant differences between patients who received OMT and those who did not with the use of analgesics, steroids, spinal injections, straight-leg raising, and days off or limited work duties. CONCLUSION: The observational findings of the present study, which suggest that analgesic medication use is lower in patients who receive OMT, align with previous findings of RCTs and support the generalizability of these findings.

Carbonaceous aerosols emitted from light-duty vehicles operating on gasoline and ethanol fuel blends.

This study examines the chemical properties of carbonaceous aerosols emitted from three light-duty gasoline vehicles (LDVs) operating on gasoline (e0) and ethanol-gasoline fuel blends (e10 and e85). Vehicle road load simulations were performed on a chassis dynamometer using the three-phase LA-92 unified driving cycle (UDC). Effects of LDV operating conditions and ambient temperature (-7 and 24 °C) on particle-phase semivolatile organic compounds (SVOCs) and organic and elemental carbon (OC and EC) emissions were investigated. SVOC concentrations and OC and EC fractions were determined with thermal extraction-gas chromatography-mass spectrometry (TE-GC-MS) and thermal-optical analysis (TOA), respectively. LDV aerosol emissions were predominantly carbonaceous, and EC/PM (w/w) decreased linearly with increasing fuel ethanol content. TE-GC-MS analysis accounted for up to 4% of the fine particle (PM2.5) mass, showing the UDC phase-integrated sum of identified SVOC emissions ranging from 0.703 µg km(-1) to 18.8 µg km(-1). Generally, higher SVOC emissions were associated with low temperature (-7 °C) and engine ignition; mixed regression models suggest these emissions rate differences are significant. Use of e85 significantly reduced the emissions of lower molecular weight PAH. However, a reduction in higher molecular weight PAH entities in PM was not observed. Individual SVOC emissions from the Tier 2 LDVs and fuel technologies tested are substantially lower and distributed differently than those values populating the United States emissions inventories currently. Hence, this study is likely to influence future apportionment, climate, and air quality model predictions that rely on source combustion measurements of SVOCs in PM.

Racial disparities in African Americans with diabetes: process and outcome mismatch.

BACKGROUND: Over the past 2 decades, numerous studies have demonstrated the existence of racial disparities in patient care in the United States. Specifically, African Americans with diabetes are less likely to have recommended process of care measures performed and outcome benchmarks for quality of care. OBJECTIVES: To evaluate the delivery of diabetes care (processes and outcomes) associated with racial categories using a national web-based registry-the American Osteopathic Association Clinical Assessment Program (AOA-CAP). STUDY DESIGN: A retrospective analysis of data retrieved from the AOA-CAP database on outcomes and process measures for diabetes. METHODS: A total of 10,699 Caucasian and African American patients who received diabetes care had data entered into the AOA-CAP registry between July 1, 2005, and October 30, 2010. African Americans represented 3123 patients (29%), Caucasians 7576 (71%). Demographic, process of care, and outcomes comparisons between ethnicities were carried out using ?2 and t tests. Composite measures of process and outcomes of diabetes care were created to investigate the effect of race on care. RESULTS: The process of care composite measure was significantly different among African American patients (P = .02) who were more likely to receive all indicated care than Caucasian patients (33.9% vs 31.6%). Evaluation of the composite outcome measure, which quantifies the percentage of patients achieving control of all 3 intermediate outcomes, was (P <.001) lower in African Americans than in Caucasians (8.1% vs 12.3%). CONCLUSIONS: African American patients with diabetes were as likely or more likely to have recommended process of care measures performed. In spite of this, intermediate diabetes outcomes were still poorer in the same African American population.

Effects of repeated use of the American Osteopathic Association's Clinical Assessment Program on measures of care for patients with diabetes mellitus.

CONTEXT: The American Osteopathic Association developed its Clinical Assessment Program (AOA-CAP) for Residencies to provide a mechanism for osteopathic residency programs to measure and improve their quality of patient care. OBJECTIVE: To compare program performance in processes of care and intermediate outcomes for patients with diabetes mellitus in residency programs that contributed data to the AOA-CAP for the first time vs residency programs that contributed data repeatedly. METHODS: Osteopathic family medicine residency programs that entered data into the AOA-CAP diabetes registry between July 1, 2005, and December 31, 2007, were included in the present study. Residency programs were separated into those that entered data into the registry for the first time during the 2005-2007 cycle (ie, first-time programs) and those that also entered data into the registry during the previous cycle (2003-2005) (ie, repeat programs). Measures of processes of care were annual foot examination, annual referral for ophthalmologic examination, annual microalbuminuria screening, use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) if albuminuria is present, use of ACE inhibitors or ARBs if hypertension is present, glycosylated hemoglobin (HbA(1c)) test in the previous year, and low-density lipoprotein cholesterol (LDL-C) test in the previous year. Measures of intermediate outcomes were control of blood pressure, HbA(1c), and LDL-C. Processes of care and outcome composite scores were also computed. RESULTS: Data from 52 osteopathic family medicine residency programs consisting of 2568 patient cases were analyzed. Twenty-three first-time programs with 992 cases and 29 repeat programs with 1576 cases entered data into the registry in the 2005-2007 cycle. Repeat programs had statistically significant better performance than first-time programs in the composite measure of processes of care (P=.0023)-largely the result of increased use of ACE inhibitors and ARBs in patients with albuminuria (P=.0087). The difference in the composite measure of intermediate outcomes was not statistically significant between the 2 groups. CONCLUSION: Repeated participation in the AOA-CAP registry was associated with improved residency program performance on the composite process of care measure but not on intermediate outcome measures for patients with diabetes mellitus. This finding suggests that osteopathic residency programs need to provide better training on adjusting patient care according to performance results.

Methods of characterizing the distribution of exhaust emissions from light-duty, gasoline-powered motor vehicles in the U.S. fleet.

Mobile sources significantly contribute to ambient concentrations of airborne particulate matter (PM). Source apportionment studies for PM10 (PM < or = 10 microm in aerodynamic diameter) and PM2.5 (PM < or = 2.5 microm in aerodynamic diameter) indicate that mobile sources can be responsible for over half of the ambient PM measured in an urban area. Recent source apportionment studies attempted to differentiate between contributions from gasoline and diesel motor vehicle combustion. Several source apportionment studies conducted in the United States suggested that gasoline combustion from mobile sources contributed more to ambient PM than diesel combustion. However, existing emission inventories for the United States indicated that diesels contribute more than gasoline vehicles to ambient PM concentrations. A comprehensive testing program was initiated in the Kansas City metropolitan area to measure PM emissions in the light-duty, gasoline-powered, on-road mobile source fleet to provide data for PM inventory and emissions modeling. The vehicle recruitment design produced a sample that could represent the regional fleet, and by extension, the national fleet. All vehicles were recruited from a stratified sample on the basis of vehicle class (car, truck) and model-year group. The pool of available vehicles was drawn primarily from a sample of vehicle owners designed to represent the selected demographic and geographic characteristics of the Kansas City population. Emissions testing utilized a portable, light-duty chassis dynamometer with vehicles tested using the LA-92 driving cycle, on-board emissions measurement systems, and remote sensing devices. Particulate mass emissions were the focus of the study, with continuous and integrated samples collected. In addition, sample analyses included criteria gases (carbon monoxide, carbon dioxide, nitric oxide/nitrogen dioxide, hydrocarbons), air toxics (speciated volatile organic compounds), and PM constituents (elemental/organic carbon, metals, semi-volatile organic compounds). Results indicated that PM emissions from the in-use fleet varied by up to 3 orders of magnitude, with emissions generally increasing for older model-year vehicles. The study also identified a strong influence of ambient temperature on vehicle PM mass emissions, with rates increasing with decreasing temperatures.

"All-or-none" (bundled) process and outcome indicators of diabetes care.

OBJECTIVES: To evaluate processes and outcomes of diabetes care using bundled indicators from a primary care registry of osteopathic training programs. STUDY DESIGN: Retrospective cohort analysis. METHODS: This study examined care delivered to 7333 patients across 95 family practice and internal medicine residency programs (July 1, 2005, through September 15, 2008) to determine diabetes care performance using measures of processes of care and outcomes. Two summary (bundled) reports of care for each measure were constructed. The first used the frequency of indicated care delivered (indicator-level bundle), and the second used the frequency of patients' receiving all indicated care (patient-level bundle). RESULTS: Use of the indicator-level bundle demonstrated that outcomes goals were achieved at a rate of 44.5%. Use of the patient-level bundle demonstrated that outcomes goals were achieved at a rate of only 16.2%, a significant difference (P <.001). Eight evidence-based processes of diabetes care were then examined using the 2 bundling methods. The indicator-level analysis mean rate for the bundled processes of care was 77.3%, whereas the patient-level analysis mean rate was only 33.5%. This was also significantly different (P <.001). CONCLUSIONS: The method of bundling care measures can have a profound effect on the reporting of goals achieved. This can in turn influence the assessment of provider performance and opportunity gaps in diabetes care delivery. In this study, providers were more likely to achieve processes-of-care goals when diabetes care was bundled at the indicator level than at the patient level. Standardization of summary reporting of diabetes care should be developed to enhance consistent interpretation of performance.

Randomized trial assessing the impact of a musculoskeletal intervention for pain before participating in a weight management program.

PURPOSE: Obesity increases the risk of developing physical disability and pain. Persons with a body mass index (BMI) of 30 kg/m or more have an increased risk for osteoarthritis compared with those with a BMI between 25 and 29 kg/m. The purpose of this study was to examine the effect of treatment directed at reducing musculoskeletal pain on weight loss in obese subjects prior to participation in a 6-month weight management (WM) program. METHODS: Subjects (BMI > or = 30 kg/m; n = 54, female = 41, male = 13) with musculoskeletal pain, as assessed by a visual analog scale score of more than 5, were randomized to a physician musculoskeletal evaluation with treatment and physical therapy prior to participation in a 6-month WM program (intervention) or direct entry into the WM program (control) between November 10, 2003, and January 20, 2005. RESULTS: Seventy-six percent of subjects completed the study (intervention, n = 18 [67%]; control, n = 23 [85%], P = .10). The intervention group demonstrated a significant decrease in visual analog scale score after musculoskeletal therapy (2.3 +/- 1.8, P < .0001). Despite a reduction in pain levels in the intervention group compared with the control group at the start of the WM program, there were no significant differences between the groups in percentage weight loss (P = .80), body fat composition (P = .20), or BMI (P = .06), all significantly improved in both groups. CONCLUSIONS: Musculoskeletal and physical therapy intervention directed at decreasing musculoskeletal pain in obese individuals prior to participation in a WM program reduces reported musculoskeletal pain for those participants completing the program but does not significantly improve weight loss over 6 months, compared with individuals with comparable musculoskeletal pain who enter directly into a WM program.