A frequently used patient and physician-directed educational intervention does nothing to improve primary care of prostate conditions.

OBJECTIVES: To measure the impact of an educational intervention directed at both patients and their primary care physicians about prostate-related conditions. METHODS: We used a randomized, control design for 50 physicians in 33 rural primary care practices from New England and Arkansas and a probability sample of 2402 of their male patients. For the physicians, we mailed two newsletters, conducted two face-to-face research staff visits, and provided printed educational manuals about the management of prostate conditions. For the patients, mailed educational pamphlets were targeted to the baseline symptom levels. After 18 months, 87% of patients and 92% of physicians completed a final survey. The patient survey measured health status, urinary symptoms and bother, treatments received, and prostate-related knowledge. The final physician survey asked them about their management of common prostate conditions. RESULTS: Before randomization, most men (59%) said they knew little or nothing about prostate problems that affect urination, and 63% also reported "little" or "no" knowledge about prostate-specific antigen testing. Eighteen months later, we observed no differences between the intervention and control patients in the measures of health status, urinary symptoms and bother, treatments received, and prostate-related knowledge. The intervention, physicians' knowledge, and self-reported practices for managing common prostate conditions were no better than the control physicians'. CONCLUSIONS: This commonly used education strategy had no measurable impact on prostate-related care.

Treatments for prostate cancer in older men: 1984-1997.

OBJECTIVES: To examine the temporal trends in radical prostatectomy (RP), brachytherapy (BT), and external beam radiotherapy (EBRT) rates among men aged 65 years or older for the period 1984 to 1997. METHODS: We used the retrospective population-based analysis of treatments for prostate cancer among Medicare beneficiaries. The rates of RP were obtained from Part A (hospital) Medicare data for 20% of the national sample for 1984 to 1997. The BT and EBRT rates for the period 1993 to 1997 were obtained from a 5% national sample of Physician/Supplier Part B data. The rates of treatment, 30-day mortality, and readmissions were included. RESULTS: The rate of RP peaked in 1992. From 1993 to 1997, its use decreased by 6% among men aged 65 to 69 years, 34% among men aged 70 to 74 years, and 50% for men aged 75 years or older. However, by 1997, the RP + BT treatment rate again approached the 1992 levels of RP alone; BT was used twice as often as RP in men aged 75 years or older. By 1997, the RP + BT + EBRT rate exceeded the 1993 rate for men aged 65 to 69 years and was again approaching the 1993 rate for men aged 70 to 74 years. From 1984 to 1997, the presence of comorbid conditions gradually declined for RP and accounted for more than 60% of the decrease in the short term mortality during this period. Variations in RP use by geographic region have also decreased. CONCLUSIONS: RP is now more selectively targeted for treatment of prostate cancer in men older than 70 years than in the past. However, since BT has been substituted for radical surgery in many of these older men, the total population-based treatment rates have changed very little over time.

Implementation of Web-based interaction technology to improve the quality of a city's health care.

In the clinic, one method for improving the interaction is to ask patients to systematically report their health status, give them standard advice based on their responses, and ask them to discuss this advice with a health practitioner. In the school system, this approach provides aggregate information for targeting programs to meet student needs. In the workplace, this health assessment and personal feedback approach may be offered to employees to improve health care and lower health care costs. But why stop at the door of the clinic, school, or workplace when Internet technology can extend to an entire community the benefits of health assessment and feedback?

Routine, single-item screening to identify abusive relationships in women.

BACKGROUND: Abusive relationships are associated with several demographic factors and many clinical problems in women. However, practices often do not screen for abuse. METHODS: This is a descriptive study of 1526 women aged 19 to 69 years who completed a health survey in 31 office practices. The 53-item survey included a question designed to screen for an abusive relationship. Our analysis compared self-reported measures of symptoms (N = 13) and functional limitations (n = 6) of women who had abusive relationships with those who did not. We also examined the utility of using a constellation of clinical problems to identify risk for abuse. RESULTS: Women in abusive relationships were more likely to be poor (37% vs 14%; P < .001) and young (87% were younger than 51 years versus 69% of those who were not in such relationships; P < .001). They had twice as many bothersome symptoms (3.1 vs 1.7; P < .001) and functional problems (1.6 vs 0.8; P < .001). Approximately 40% (36/89) of low-income women with emotional problems were at risk for abuse versus only 6% (64/1025) of women with adequate financial resources and no emotional problems. However, because so many women were at low risk, almost twice as many in this group (n = 64) reported abusive relationships than in the high-risk group (n = 36). CONCLUSIONS: Women in abusive relationships have many symptoms and functional limitations. However, symptoms and clinical problems provide insufficient clues for abuse. It is better just to ask. A single-item screening question appears adequate for this purpose.

Transurethral resection of the prostate among medicare beneficiaries: 1984 to 1997. For the Patient Outcomes Research Team for Prostatic Diseases.

PURPOSE: We examine the epidemiology and associated risks of transurethral resection of the prostate among Medicare beneficiaries for the period 1984 to 1997. MATERIALS AND METHODS: We used hospital claims for transurethral resection of the prostate from a 20% national sample of Medicare beneficiaries for the period 1991 to 1997. Risk of mortality and reoperation were evaluated using life table methods and compared to those for the period 1984 to 1990. We also examined the association between surgical volume and adverse outcomes following resection using unique urologist identifier codes from the 1997 part B Medicare claims. RESULTS: Compared to 1984 to 1990, age adjusted rates of transurethral resection for benign prostatic hyperplasia (BPH) during 1991 to 1997 declined by approximately 50% for white (14.6 to 6.72/1,000) and 40% for black (11.8 to 6.58/1,000) men. Of the men who underwent resection for BPH during the recent period 53% were 75 years old or older but 30-day mortality in men 70 years old or older was significantly lower than that in 1984 to 1990. Since 1987 the 5-year risk for reoperation following transurethral resection for BPH has remained 5%. For resection performed in 1997 we observed no statistically significant association between urologist surgical volume and risks of reoperation or 30-day mortality. CONCLUSIONS: Compared to the peak period of its use in the 1980s, older men are now undergoing transurethral resection of the prostate. Nevertheless, outcomes for men 65 years old or older continue to be good.

How well does a single question about health predict the financial health of Medicare managed care plans?

CONTEXT: Responses to simple questions that predict subsequent health care utilization are of interest to both capitated health plans and the payer. OBJECTIVE: To determine how responses to a single question about general health status predict subsequent health care expenditures. DESIGN: Participants in the 1992 Medicare Current Beneficiary Survey were asked the following question: "In general, compared to other people your age, would you say your health is: excellent, very good, good, fair or poor?" To obtain each participant's total Medicare expenditures and number of hospitalizations in the ensuing year, we linked the responses to this question with data from the 1993 Medicare Continuous History Survey. SAMPLE: Nationally representative sample of 8775 noninstitutionalized Medicare beneficiaries 65 years of age and older. MAIN OUTCOME MEASURES: Annual age- and sex-adjusted Medicare expenditures and hospitalization rates. RESULTS: Eighteen percent of the beneficiaries rated their health as excellent, 56% rated it as very good or good, 17% rated it as fair, and 7% rated it as poor. Medicare expenditures had a marked inverse relation to self-assessed health ratings. In the year after assessment, age- and sex-adjusted annual expenditures varied fivefold, from $8743 for beneficiaries rating their health as poor to $1656 for beneficiaries rating their health as excellent. Hospitalization rates followed the same pattern: Respondents who rated their health as poor had 675 hospitalizations per 1000 beneficiaries per year compared with 136 per 1000 for those rating their health as excellent. CONCLUSIONS: The response to a single question about general health status strongly predicts subsequent health care utilization. Self-reports of fair or poor health identify a group of high-risk patients who may benefit from targeted interventions. Because the current Medicare capitation formula does not account for health status, health plans can maximize profits by disproportionately enrolling beneficiaries who judge their health to be good. However, they are at a competitive disadvantage if they enroll beneficiaries who view themselves as sick.

MediCaring: development and test marketing of a supportive care benefit for older people.

OBJECTIVES: To develop an alternative healthcare benefit (called MediCaring) and to assess the preferences of older Medicare beneficiaries concerning this benefit, which emphasizes more home-based and supportive health care and discourages use of hospitalization and aggressive treatment. To evaluate the beneficiaries' ability to understand and make a choice regarding health insurance benefits; to measure their likelihood to change from traditional Medicare to the new MediCaring benefit; and to determine the short-term stability of that choice. DESIGN: Focus groups of persons aged 65+ and family members shaped the potential MediCaring benefit. A panel of 50 national experts critiqued three iterations of the benefit. The final version was test marketed by discussing it with 382 older people (men > or = 75 years and women > or = 80 years) in their homes. Telephone surveys a few days later, and again 1 month after the home interview, assessed the potential beneficiaries' understanding and preferences concerning MediCaring and the stability of their responses. SETTINGS: Focus groups were held in community settings in New Hampshire, Washington, DC, Cleveland, OH, and Columbia, SC. Test marketing occurred in New Hampshire, Cleveland, OH; Columbia, SC, and Los Angeles, CA. PARTICIPANTS: Focus group participants were persons more than 65 years old (11 focus groups), healthcare providers (9 focus groups), and family decision-makers (3 focus groups). Participants in the in-home informing (test marketing group) were persons older than 75 years who were identified through contact with a variety of services. MEASUREMENTS: Demographics, health characteristics, understanding, and preferences. RESULTS: Focus group beneficiaries between the ages of 65 and 74 generally wanted access to all possible medical treatment and saw MediCaring as a need of persons older than themselves. Those older than age 80 were mostly in favor of it. Test marketing participants understood the key points of the new benefit: 74% generally liked it, and 34% said they would take it now. Preferences were generally stable at 1 month. In multivariate regression, those preferring MediCaring were wealthier, more often white, more often living in senior housing, and using more homecare services. However, they were not more often in poor health or needing ADL assistance. CONCLUSIONS: Older persons aged more than 80 years can understand a health benefit choice; most liked the aims of a new supportive care benefit, and 34% would change immediately from Medicare to a supportive care benefit such as MediCaring,. These findings encourage further development of special programs of care, such as MediCaring, that prioritize comfort and support for the old old.

Streamlining nutritional care for the physician's office.

OBJECTIVE: Nutritional care needs are overlooked in clinical practice. We review nutritional needs and describe an approach for improving nutritional care in clinical practice. DESIGN: Data from a controlled trial and several population cohorts. SETTING: Primary care practices and a population survey in New Hampshire and Vermont, USA. SUBJECTS: The controlled trial involved 1651 persons aged 70+years. The cohorts include information from 1879 persons aged 12+. INTERVENTION: All patients completed standard surveys which included information about nutritional needs. 22 practices participated in the trial. RESULTS: The higher the BMI, the less healthy the population. 15 30% of patients report problems or concerns with eating/weight and nutrition. Patients with problems or concerns are often bothered by other health and social problems. Patients who have productive interactions with clinicians have improved nutritional care and are more likely to report help with eating problems (68% vs 86%; Odds ratio 5.0 (95% CI: 0.9-27.0). CONCLUSIONS: Nutritional issues are common and complex. A productive provider-patient interaction can improve the nutritional care of patients. Essential elements for a productive interaction include an informed, educated patient and a provider (or clinical team) prepared to assess and manage the broad range of issues that are important to the patient. Technology facilitates necessary feedback between patient and provider.

Have complication rates decreased after treatment for localized prostate cancer?

PURPOSE: The American Urological Association Prostate Cancer Clinical Guidelines Panel reviewed 12,501 publications on prostate cancer from 1955 to 1992 to determine whether the complication rates of external beam radiation therapy, interstitial radiotherapy and radical prostatectomy have decreased. MATERIALS AND METHODS: Complications reported in at least 6 series, study duration and sample sizes were extracted. Year specific study weighted mean patient ages and complication rates were computed. Regression analysis was performed of the study year on weighted mean patient age and complication rate. RESULTS: Study year had a significant effect on mean patient age and rate of the majority of complications examined. Data indicated a gradual increase in study patient age and a simultaneous decrease in complications from 1960 to 1990. CONCLUSIONS: Complication rates in the treatment of localized prostate cancer have decreased during the last 20 to 40 years. This decrease occurred despite evidence that the average age of treated patients had increased during the same period.

A randomized trial of the use of patient self-assessment data to improve community practices.

OBJECTIVE: Because of time constraints in the office environment, problems of concern to elderly patients may not be raised during clinic visits. To facilitate communication about geriatric health problems, we examined the impact of a strategy that used patient self-assessment data to improve community practices. DESIGN: Twenty-two primary care practices were randomized to participate in the intervention strategy (intervention practices) or to provide usual care (usual care practices). SETTING: Primary care practices in 16 towns in New Hampshire (total, 45 physicians). PATIENTS: 1651 patients 70 years of age or older. INTERVENTION: All patients received a mailed survey that asked about their health problems and about how well these problems were being addressed by their physicians. In the intervention practices, these data were used to generate a customized letter that directed the patient to specific sections in an 80-page modified version of the National Institute on Aging's Age Pages and were summarized and communicated to the patient's physician. MAIN OUTCOME MEASURE: Change from baseline in patients' overall assessment of health care. RESULTS: In 8 of 11 intervention practices, patients felt that their care had improved over the 2-year study period. This improvement occurred in only 1 of 11 usual care practices (P = 0.003). Patients in intervention practices reported receiving significantly more help with physical function, fall prevention, and assistance for memory problems. Self-assessed health status did not differ in the two groups. CONCLUSION: A standard, easy-to-implement strategy to improve the quality of provider--patient interactions can improve the satisfaction of older patients cared for in community practices.

Setting the revisit interval in primary care.

OBJECTIVE: Although longitudinal care constitutes the bulk of primary care, physicians receive little guidance on the fundamental question of how to time follow-up visits. We sought to identify important predictors of the revisit interval and to describe the variability in how physicians set these intervals when caring for patients with common medical conditions. DESIGN: Cross-sectional survey of physicians performed at the end of office visits for consecutive patients with hypertension, angina, diabetes, or musculoskeletal pain. PARTICIPANTS/SETTING: One hundred sixty-four patients under the care of 11 primary care physicians in the Dartmouth Primary Care Cooperative Research Network. MEASUREMENTS: The main outcome measures were the variability in mean revisit intervals across physicians and the proportion of explained variance by potential determinants of revisit intervals. We assessed the relation between the revisit interval (dependent variable) and three groups of independent variables, patient characteristics (e.g., age, physician perception of patient health), identification of individual physician, and physician characterization of the visit (e. g., routine visit, visit requiring a change in management, or visit occurring on a "hectic" day), using multiple regression that accounted for the natural grouping of patients within physician. MAIN RESULTS: Revisit intervals ranged from 1 week to over 1 year. The most common intervals were 12 and 16 weeks. Physicians' perception of fair-poor health status and visits involving a change in management were most strongly related to shorter revisit intervals. In multivariate analyses, patient characteristics explained about 18% of the variance in revisit intervals, and adding identification of the individual provider doubled the explained variance to about 40%. Physician characterization of the visit increased explained variance to 57%. The average revisit interval adjusted for patient characteristics for each of the 11 physicians varied from 4 to 20 weeks. Although all physicians lengthened revisit intervals for routine visits and shortened them when changing management, the relative ranking of mean revisit intervals for each physician changed little for different visit characterizations-some physicians were consistently long and others were consistently short. CONCLUSION: Physicians vary widely in their recommendations for office revisits. Patient factors accounted for only a small part of this variation. Although physicians responded to visits in predictable ways, each physician appeared to have a unique set point for the length of the revisits interval.

Building an idealized measurement system to improve clinical office practice performance.

The aim of this article is to introduce key concepts and approaches for building a better practice-based measurement. Physicians are being challenged to produce measurably higher quality of services, lower costs, and better clinical outcomes to remain viable. In the absence of provider-driven practice improvements and independent measurement systems, office practices will remain dependent on performance data from external forces as drivers of change. Three key questions will be addressed in our pursuit of better measurement systems for continuous improvement and competitive advantage: (1) What do we want a measurement system to tell us in the first place? (2) What might an idealized measurement system look like if we had one? (3) What are some of the challenges that office practices face in closing the gap between building an idealized measurement system and the current state of office practice measurement?

Prostate cancer screening and beliefs about treatment efficacy: a national survey of primary care physicians and urologists.

PURPOSE: To describe practice patterns and beliefs of primary care physicians and urologists regarding early detection and treatment of prostate cancer. SUBJECTS AND METHODS: National probability samples of primary care physicians (n=444) and urologists (n=394) completed mail survey instruments in 1995. Physicians were asked about their use of prostate-specific antigen (PSA) testing for men of different ages and their beliefs about the value of radical prostatectomy, external-beam radiation therapy, and watchful waiting for men with differing life expectancies. RESULTS: Most primary care physicians report doing PSA tests during routine examination of men older than 50 years of age. The majority say they continue to do them on patients over 80 years and to refer men with abnormal values for biopsy. In contrast, only a minority of urologists would recommend PSA tests or biopsy for abnormal values for men over 75 years of age. More than 80% of primary care physicians and urologists doubt the value of radical prostatectomy for men with < 10 years of life expectancy; more primary care physicians than urologists see probable survival benefit in radiation therapy for patients with life expectancy < 10 years (48% versus 36%) or > 10 years (67% versus 53%). Thirteen percent of primary care physicians and only 3% of urologists consider watchful waiting to be as appropriate as aggressive therapy for men with > 10 years of life expectancy. CONCLUSIONS: Primary care physicians are more aggressive about PSA testing and referral for biopsy than most urologists recommend. Both groups recommend PSA testing and believe that aggressive treatment is more beneficial than existing evidence indicates.

Can we afford comprehensive, supportive care for the very old?

OBJECTIVE: To address the question, "Is there enough overuse of Medicare reimbursement to hospitals that reallocation of excess could provide sufficient funds to enhance home care and community services?" DESIGN: Simulation using data from the Medicare Current Beneficiary Survey (MCBS) to estimate dollars that might be reallocated from hospital reimbursement. PARTICIPANTS: A total of 3577 persons aged 80 and older in a stratified sample of Medicare beneficiaries interviewed in September 1992 in the MCBS. MEASUREMENTS: We ranked the United States hospital service areas' (HSAs) Medicare hospital discharge rates. We assigned the beneficiaries in the MCBS to the HSAs based on their residence zip codes. The hospitalization expenditures and mortality rates of MCBS respondents living in HSAs in each quartile were compared. RESULTS: By reducing hospital utilization to the mean level now used by the lowest quartile of HSAs, $560 would be saved per Medicare beneficiary aged 80 or older (P=.004) with no difference in mortality rates. These savings could purchase 40 visiting nurse visits per year for those in need. Potential savings would be $152 per Medicare beneficiary if hospital utilization were reduced from that used by the highest quartile to the level of the lower three quartiles of HSAs, enough to purchase about 11 additional visiting nurse visits. CONCLUSION: This simulation suggests that the very old might safely receive less hospital care. Because relatively few older people need home and community services in a year, these per capita savings could be reallocated to purchase many services for those having the greatest need.

Looking at care from the inside out: a conceptual approach to geriatric care.

Today, managing care from the "outside in" is the predominant model for changing health care. The risk of this outside-in approach is that the health care system may lose sight of the people and communities for which it serves and cares. In this article, an "inside-out" model for viewing health care in a geriatric population is presented from the perspective of patients and providers, placing the provider in a proactive rather than reactive role. By focusing attention on the outcomes or value a patient is experiencing, providers are challenged to consider new ways of managing care.

Assessing access as a first step toward improving the quality of care for very old adults.

Understanding the barriers to obtaining care that the population of people age 80 and older (80+) experiences is one of the first steps toward developing organizational and clinical strategies aimed at improving care. This article reviews the data from the 80+ Project's survey to assess the prevalence of barriers to care and identify the characteristics that place the 80+ population at risk. Barriers to access for older adults occur on many levels. Ultimately, the ability to improve health outcomes through reducing barriers to care is dependent on the effectiveness and quality of care received. By recognizing the barriers to care that limit access, health care professionals can begin to develop strategies to eliminate these barriers and improve the health care of older adult patients.

The population of people age 80 and older: a sentinel group for understanding the future of health care in the United States.

Those age 80 years or older (80+) constitute a relatively small percentage of a health care system's population. However, because of the associated risks, costs, and variation of their medical care, 80+ patients are sentinel for elder care quality. This article describes the survey components of the 80+ Project. This project was designed to help clinicians gain a complete picture of the special needs of the 80+ population. The information about these patients' health and functional status, how they utilize health care resources, how they obtain access to care, and their satisfaction with the care is useful for clinicians who wish to improve health care delivery.

An easy way to measure quality of physician-patient interactions.

This article describes a simple method for rating the patient-clinician interaction from the perspective of the older adult patient, with the goal of improving patient outcomes. A measure for rating the quality of an interaction with a patient who is bothered by a problem is called the Functional Education Index or FNXEI. Usually, sicker patients are known to be less satisfied with their medical care. What is unique about the FNXEI is that it is not affected by a patient's overall health, giving clinicians an accurate account of their interactions with patients. Considering this, the FNXEI becomes a useful tool for improving care because it has face validity and specificity about the type of care clinicians are providing for their older adult patients.