Improving outpatient diabetes management through a collaboration of six competing, capitated Medicare managed care plans.

This report addresses diabetes care in the managed care setting and improvement in care brought about by collaboration between 6 Medicare managed care plans (MCPs) and a Peer Review Organization (PRO). The objective was to improve the quality of care of outpatient diabetes patients provided by primary care physicians through the mutual collaboration of 6 Medicare managed care plans and a Medicare Peer Review Organization. The design involved pre-post intervention trial based on 2 random samples, a baseline sample drawn in 1995 and a remeasurement sample drawn in 1996. Medical records of patients in both samples were reviewed by the PRO to determine provision of 14 quality indicator services over a 1-year period. The setting was 6 Arizona Medicare managed care plans comprising approximately 40% of the Arizona Medicare population. Two random samples were drawn from type 2 diabetes patients continuously enrolled in the same managed care plan for at least 1 year. The intervention was comparative feedback of baseline data by the PRO, enabling each plan to compare itself to any other plan on any or all indicators. Each plan developed and implemented its own intervention in response to the 1995 baseline results. The main outcome measures were mean HbA1c, the proportion of HbA1c values below 8%, and positive change in provision of 14 quality indicator services. At postintervention remeasurement, mean HbA1c values fell from 8.9 +/- 2.2 to 7.9% +/- 2.1, and the proportion of patients with HbA1c values below 8.0% rose from 40% to 61.6%. The proportion of the 14 indicator services provided to patients rose from 35% to 55%. The mean number of physician office visits fell 13% and the number of services provided per visit doubled. We conclude that improving the process of care improves glycemic control. Better outpatient diabetes management in competing, capitated managed care plans is an attainable goal when mediated through a neutral third party such as a PRO.

Outpatient management of diabetes mellitus in five Arizona Medicare managed care plans.

We report findings on the outpatient management of diabetes mellitus in Medicare beneficiaries enrolled in five Arizona Medicare-managed care plans. These findings are the baseline of an ongoing collaboration between the Health Services Advisory Group, Inc., Arizona's Peer Review Organization (PRO), and the five plans whose object is improved care of diabetes patients. The purpose of the study was to determine congruity between quality indicators identified by the five plans and the care actually received by diabetes patients enrolled in the five plans. The five plans agreed on a common set of quality indicators, including 10 services and 10 measures of patient status. Each plan has identified its diabetic population, 75 of whom are randomly selected each quarter by the PRO for chart review and inclusion in the study. The findings in this report cover two quarters of data. Data from chart review were examined to determine the extent to which actual practice reflected the indicators. The mean patient age was 71.8, and for most patients onset occurred between 55 and 69 years of age. About 25% had a positive family history, and we estimate the annual incidence of diabetes in this population to be about 1.1%. Mean hemoglobin A1c (HbA1c) was 8.9 +/- 2.1%; 46% were hypertensive; 42% continued to smoke cigarettes; 36% had retinopathy; 20% had proteinuria; and only 22% were on some kind of exercise program. Thirty-two percent were hospitalized during the 1-year baseline period, and the average number of outpatient visits per patient was 11.1 +/- 7.4. When care provided to diabetes patients enrolled in the plans was compared with the 10 quality standards identified by the plans themselves, only two of these standards was attained in more than 60% of patients: blood pressure, 98.7%; and foot examination, 62.7%. Two standards were achieved less than one-third of the time: urine dipstick, 10.4%, and appropriate use of angiotensin-converting enzyme (ACE) inhibitors, 31.25%. The others were all between 40 and 55%. Of the 10 service standards, about one-third received 1-4, one-third received 5-6, and one-third received 7-10. Only 5% of patients received 9 or 10 services. Outpatient management of diabetes patients in managed-care plans is similar to that in fee-for-service. When compared with fee-for-service or another HMO, a higher proportion of Arizona-managed care patients had HbA1c, and a much lower proportion had a dipstick test for urine protein. Values for other variables were usually within 10 percentage points of each other. Regardless of payment scheme, diabetes care is characterized by inconsistencies, omissions, and a lower than desirable level of services. Although few patients received most of the indicator services, diabetes patients are nevertheless high utilizers of medical care, both in and out of the hospital. The hospitalization rate is twice that of Arizona Medicare beneficiaries as a whole, and the number of office visits is three or four times that reported in other studies. Further, it seems that many visits are required to achieve even these modest service levels. Had the average number of visits been six or less, HbA1c rates, for example, would have fallen to less than one-third in three of the five plans. We believe that these data are conservative because it is likely that some and perhaps most of these indicators are underreported. It should be emphasized that these are baseline data whose purpose is to provide a basis against which subsequent improvements many be measured.

Validity of children's reports of parental alcohol abuse.

Data from interviews with parents and 9-12 year old children from 303 families were used to test the validity of children's reports of parental alcoholism or problem drinking status. Children's responses to several single-item screening questions that had been used previously to identify children of alcoholics, as well as their responses to the Short Michigan Alcoholism Screening Test for each parent, were compared to parents' alcoholism diagnosis and screening test scores. In general, children's responses correctly identified only a small portion of alcoholic parents and, when all screening items were combined into a single screening tool to increase sensitivity, the false positive rate became unreasonable for most applications. The screening items were better at identifying active alcoholics than abstaining alcoholics but were also better at identifying problem drinking parents than alcoholic parents. None of the screening options tested had optimal characteristics for use in research or intervention applications.

Linking empirically based theory and evaluation: the Family Bereavement Program.

Evaluated the effects of a theoretically derived program to prevent mental health problems in children who had experienced the death of a parent. The program was designed to improve variables in the family environment which were specified as mediators of the effects of parental death on child mental health. The evaluation design involved the random assignment of families to either an intervention or control group. The program led to parental ratings of increased warmth in their relationships with their children, increased satisfaction with their social support, and the maintenance of family discussion of grief-related issues. The program also led to parent ratings of decreased conduct disorder and depression problems and overall problems in older children. Significant correlations between the family environment variables and child mental health problems provided further empirical support for the theory underlying the program. Implications for program redesign were derived by reconsidering the adequacy of the program components to change theoretically mediating variables.

Theory-based screening for prevention: focusing on mediating processes in children of divorce.

Prevention programs in mental health theoretically can benefit from selecting participants who have a greater likelihood of developing psychological problems because of their exposure to the putative mediators targeted for change in an intervention. Screening on mediators may increase statistical power to detect program effects, enhance the cost-effectiveness of intervention trials, and decrease the possibility of iatrogenic effects. The circumstances that optimize the strategy of screening on the basis of mediating variables are discussed, and data are presented to illustrate the development of a mediational selection strategy to identify families who might best benefit from a preventive intervention for children of divorce. In addition, we present evidence that adjustment problems for children experiencing a divorce, as with most mental health problems, are not the result of one specific factor, but are jointly determined by several mediating processes that occur subsequent to the divorce. The mediational selection strategy developed illustrates the utility of measuring a set of mediational processes central to conferring risk for mental health problems to children of divorce.

Small theory and the strategic choices of prevention research.

Our comments on the discussion of mediational screening for prevention research highlight two issues: (a) There are advantages to giving a high priority to theory in a strategic sequence of prevention research studies. (b) Screening to identify a subgroup that is experiencing problems on processes the program is designed to change may be useful in accomplishing specific goals within an overall strategy of prevention research studies.

The use of structural equation modeling in generative research: toward the design of a preventive intervention for bereaved children.

Describes a generative study of processes which may lead to symptomatology in children who have experienced the death of a parent. Based on existing literature, four putative mediating variables were identified: parental demoralization, family warmth, negative family events, and positive stable family events. Structural equation modeling techniques were used to compare several potential causal models involving these variables. The results were most consistent with a model in which bereavement was not directly related to the child symptomatology, but rather its effects were transmitted through these four mediational mechanisms. The implications of the results of the structural modeling for the design and evaluation of preventive interventions are discussed briefly.

Epidemiology and preventive interventions: parental death in childhood as a case example.

Illustrates how standard epidemiologic principles form the knowledge base to justify a preventive intervention for an at-risk population. These principles were applied to a sample of 92 from the population of children aged 8 to 15 at alleged risk for mental health disorders because a parent died. Prior work on this alleged risk population is sparse and flawed. Validly determining the population effect of an alleged risk factor requires assessing the influence of sampling bias. The bias found, underrepresentation of deaths of a mother, did not influence the relations among death of a parent and children's depression and conduct disorder, and the modifiable mediators of risk to be changed by the preventive intervention. The epidemiologic measure of effect indicated that death of a parent is a risk factor for major depression but not for conduct disorder among youth. Families recruited for the preventive intervention by epidemiologic methods (ES families) did not differ significantly from the earlier families on whom the knowledge base was formed. Families referred to the intervention by self or others significantly differed from the ES families in two ways that constituted serious biases. The implications of these biases for prevention were discussed.

Effect of exercise on muscle function decline with aging.

As people age, changes in muscle occur that are associated with a decrease in strength and endurance. These changes result in decreased functional capacity and quality of life. A substantial portion of this decrease is the result not of aging but of the sedentary life-style so frequently associated with aging. In "healthy old" persons and in older animals in experiments, an appropriate exercise program can result in increased strength and endurance. This is true both in longitudinal and short-term studies. As physical impairment increases, the exercise program must be individualized, and results are not as readily predictable. Much work remains before we may be certain how much exercise can be tolerated in these more impaired persons and what the effects may be.

Mie scattering interferometer and its application to the study of Raman scattering from molecules at a mercury interface.

Interference fringes are observed produced by Mie scattering of laser light from a single microstructure or from a random array of microstructures supported above a reflecting surface. These fringes are the basis of a simple interferometer which can be used to measure distances from thousands of angstroms to centimeters. The interferometer is used to measure the height of liquid above a mercury surface. Raman scattering (RS) from the liquid is measured, and an upper limit of 10(3) is placed on the enhancement of RS from molecules at the interface. Enhancement of RS in a wedge between mercury and solid is examined theoretically.

A quantitative electromyographic index that is independent of the force of contraction.

Quantitative EMG has been used to improve the accuracy of the diagnosis of myopathy. Equipment is available commercially that utilizes the Willison method of quantification, but the technique has not been widely used because of the necessity of measuring muscle contraction force. An analysis of the basic parameters of the Willison method of quantification was performed for forces of 10, 20, 40 and 60% of maximum for 16 normal subjects for the deltoid muscle. An index was derived from the basic parameters that is independent of the force of contraction. The index is a standardized value for turns/sec expressed as a logarithm. The index has a mean of 1.171 with a standard error of 0.059 for a sample size of 10 muscle sites. Quantitative EMG can be utilized in routine clinical examinations by applying mild to moderate resisting forces to patients, and the proposed index can be determined graphically. The force applied to patients can be maintained within the range of the forces investigated by estimating the force of contraction, evaluating patient effort and fatigue, and monitoring the parameter of total amplitude per second.

Fluorescent lifetimes of molecules on silver-island films.

The fluorescence of molecules on silver-island films exhibits nonexponential decay and is several orders of magnitude more rapid than on a silica surface, while the total emission intensity is slightly increased. This behavior results from the electromagnetic coupling between the fluorescing molecules and the plasmon resonances of the silver islands. We obtain good agreement with a model that uses the same theory for the electromagnetic coupling as has been used to account for surface-enhanced Raman scattering.

Light touch thresholds in normal persons and cerebral vascular disease patient: bilateral deficit after unilateral lesion.

Sensory thresholds, using the 2-alternative forced choice technique, were studied in normal subjects and in patients with unilateral cerebral vascular disease, as documented by clinical-radiologic correlation. In normal person the absolute threshold for light touch increased with age. Bilateral impairment of sensation with unilateral cerebral vascular lesions occurred in 30% of the patients. Tactile deficit was always greater on the side contralateral to infarction or hemorrhage. An ipsilateral deficit did not exist independent of contralateral deficity, and was more likely to occur with complete sensory loss contralaterally. There was a tendency for persons with larger lesions as determined clinically and by CAT scan to have ipsilateral as well as contralateral deficit. The incidence or severity of ipsilateral deficit was not related to lesion laterality.

Transfer factor is ineffective in amyotrophic lateral sclerosis.

Sixty-six patients with amyotrophic lateral sclerosis (ALS) participated in a double-blind, placebo-controlled study of transfer factor. A structured rating score of neurological function was recorded after each monthly administration of transfer factor or placebo. Statistical analysis of mean scores for all patients and for those with specific clinical abnormalities showed no significant difference between the two groups. There was no evidence of therapeutic value for transfer factor. During the observation period of nearly one year, more than two-thirds of the deterioration occurred in the first six months. Meaningful clinical trials of other potential therapeutic agents could probably be conducted within six months in double-blind crossover trials.

Effect of pelvic-femoral position on vertebral separation produced by lumbar traction.

The purpose of this study was to determine the relationship between hip position and the amount of vertebral separation produced by intermittent lumbar traction. Ten subjects received intermittent lumbar traction at a force of 31.8 kg (70 lb) for 15 minutes in each of three positions of hip flexion (supine): 0 degrees, 45 degrees, and 90 degrees. Vertebral separation was measured on lateral roentgenograms by outlining and marking the vertebral bodies and measuring interspaces with fine-point calipers. Except for the T12-L1 interspace, traction produced greater posterior interspace separation as the angle of hip flexion increased from 0 to 90 degrees. These differences were statistically significant at interspaces L4-5 and L5-S1. We found no systematic changes in anterior interspace distance. To produce maximal posterior vertebral interspace separation, pelvic traction should be applied with the hip flexed 90 degrees.

Provision of rehabilitation services for a rural mountainous region in Colorado.

1. Four alternative methods for provision of rehabilitative services to a rural, mountainous region of Colorado were examined. These concepts were: minicenter, clinic-on-wheels, ambulance taxi, and temporary rest home. 2. From the standpoint of breakeven facts and resource efficiency the minicenter and clinic-on-wheels were similar and superior to the other two. 3. Further comparison between the minicenter and clinic-on-wheels in eight areas revealed that the former had more areas of superiority. Since the items were not weighed, final choice between these two alternatives would have to depend upon the value judgement of the community.