The implications of plan design options for Medicare beneficiaries.

To make an informed selection between traditional Medicare and a Medicare managed care plan, a consumer needs to understand the implications of choosing one over the other. What are the implications of plan design for care, cost, and patient autonomy? Consumers need information about these questions. However, a barrier to developing this consumer information is the lack of a consistent body of evidence. An intermediate step is to tap expert knowledge. The purpose of this study is to use expert consensus (across a spectrum of health care experts) to identify the implications of plan design. Experts were surveyed and the degree to which there is consensus provides an initial picture of what experts judge to be important to the consumer. The findings show that experts agree on several implications associated with choosing managed care over the traditional Medicare plan. They also agree that many of these attributes vary considerably across health plans.

Can Medicare beneficiaries make informed choices?

This DataWatch assesses Medicare beneficiaries' understanding of the differences between their managed care and fee-for-service Medicare options. A telephone survey was used to evaluate knowledge levels among 1,673 beneficiaries residing in five Medicare markets with high managed care penetration. Half of the sample were enrolled in health maintenance organizations (HMOs) and half in the traditional Medicare program. The findings show that 30 percent of beneficiaries know almost nothing about HMOs; only 11 percent have adequate knowledge to make an informed choice; and HMO enrollees have significantly lower knowledge levels of the differences between the two delivery systems. These findings have implications for educating beneficiaries about their expanded choices.

Will quality report cards help consumers?

This study assesses the relationship between the salience of quality information and how well it is understood by consumers. The analysis is based on survey data and content analysis from focus-group data (104 participants). The findings show that poorly understood indicators are viewed as not useful. Consumers often do not understand quality information because they do not understand the current health care context. All of this suggests that salience alone is not sufficient to determine which indicators should be included in report cards.

Informing consumer decisions in health care: implications from decision-making research.

Despite the wider dissemination of health plan report cards, little is known about whether consumers will use this information in making plan and provider choices. Studies of human judgment and decision making are reviewed, as are their implications for devising strategies to inform consumers. The limitations of human information processing suggest that many consumers will not use performance information in making choices. Strategies are needed to support consumers who prefer to rely on intermediaries as well as those who wish to apply the information for their own use. Many current strategies are based on assumptions not supported by existing decision-making research. Although there is much to learn about assisting consumers in making informed choices, a great deal is known from decision-making research. Our approaches and our research agenda must be based on this existing foundation of knowledge.

Choosing a health plan: do large employers use the data?

Significant private and public resources go into the production of various types of performance measures: from patient satisfaction with nonclinical service to clinical outcomes. While recent investigations have focused on the effect of clinical outcomes information on clinical practice, almost no work examines its effect on purchasers' decisions. This study examines how large employers use performance information, including clinical outcomes, in purchasing decisions. Representatives of thirty-three large employers that purchase for 1.8 million covered lives were interviewed in early 1997. Findings suggest that purchasers are not always aware of clinical outcomes data and that measures do not meet their decision-making needs. Further, the variety and amount of performance information to process for purchasing decisions is a barrier to effective decision making. Recommendations for supporting purchasers' use of performance information, especially clinical outcomes data, are included.

Comprehension of quality care indicators: differences among privately insured, publicly insured, and uninsured.

This study explores consumers' comprehension of quality indicators appearing in health care report cards. Content analyses of focus group transcripts show differences in understanding individual quality indicators and among three populations: privately insured; Medicaid; and uninsured. Several rounds of coding and analysis assess: the degree of comprehension; what important ideas are not understood; and what exactly is not understood about the indicator (inter-rater reliability exceeded 94 percent). Thus, this study is an educational diagnosis of the comprehension of currently disseminated quality indicators. Fifteen focus groups (5 per insurance type) were conducted with a total of 104 participants. Findings show that consumers with differing access to and experiences with care have different levels of comprehension. Indicators are not well understood and are interpreted in unintended ways. Implications and strategies for communicating and disseminating quality information are discussed.

Condition-specific performance information: assessing salience, comprehension, and approaches for communicating quality.

This study assesses how consumers view condition-specific performance measures and builds on an earlier study to test an approach for communicating quality information. The study uses three separate designs: a small experiment, a cross-sectional analysis of survey data, and focus groups. We test whether providing information on the health care context affects consumer understanding of indicators. Focus groups were used to explore how consumers view performance measures. The cross-sectional survey analysis used survey data from the experiment and the focus groups to look at comprehension and the salience of condition-specific performance measures. Findings show that a general consumer population does view condition-specific performance measures as salient. Further, the findings provide evidence that information on the health care context makes a difference in how consumers understand performance measures.

Preventive health care for adults with HIV infection.

OBJECTIVE: To assess the level of evidence for preventive health interventions for adults with human immunodeficiency virus (HIV) infection. DATA SOURCES: A MEDLINE literature search for each intervention, supplemented by reviewing conference proceedings and the recommendations of experts. STUDY SELECTION: English-language studies of interventions that contribute to one of the following goals were reviewed: (1) prevention of complications of HIV infection; (2) early detection of complications, before symptoms develop, at a stage in which early treatment could lead to improved outcome; (3) slowing of HIV disease progression; (4) reduction in the risk of transmission of infectious agents, such as HIV itself; and (5) prevention of psychological distress and improvement in the quality of life. DATA EXTRACTION: The importance of interventions and quality of supporting evidence were evaluated using criteria modified from the US Preventive Services Task Force. DATA SYNTHESIS: Existing evidence strongly supports the efficacy of some preventive measures: primary and secondary Pneumocystis carinii pneumonia prophylaxis; secondary prophylaxis of Cryptococcus, Toxoplasma, and cytomegalovirus infections; tuberculin testing, with chemotherapy for individuals with positive test results; syphilis screening; Papanicolaou tests; educational measures to reduce the transmission of HIV and other infections; T-lymphocyte monitoring; and antiretroviral therapy in selected patients. Recommended measures of possible, but less certain, effectiveness include vaccines to prevent influenza, Haemophilus influenzae, pneumococcal, and hepatitis B infections; prophylaxis for recurrent esophageal and vaginal candidiasis; primary prophylaxis of Mycobacterium avium complex; tuberculosis prophylaxis for anergic, high-risk individuals; routine physical examination; screening for gonorrhea and Chlamydia in high-risk women; monitoring Toxoplasma titers, complete blood cell counts, and serum chemistry values; attempting to maintain weight through nutritional interventions; and exercise. Mental health and substance abuse interventions are probably very important, but documentation of their benefits is limited. Some measures require further study before they can routinely be recommended, including vitamin and mineral supplementation; specific nutritional diets; and laboratory tests, other than CD4 counts, for monitoring disease progression. CONCLUSIONS: Persons with HIV infection have different stage-specific health maintenance needs that form an important part of comprehensive care for people in all stages of infection.

Hormonal induction of low affinity receptor guanylyl cyclase.

We describe a unique transient binding phenomenon for atrial natriuretic peptide (ANP) binding to the natriuretic peptide receptor-A (NPR-A) guanylyl cyclase stably expressed in 293 cells. The time course of ANP binding to intact cells peaked at 15 min followed by a subsequent decrease. Reduced binding was a consequence of an ANP induced low affinity state of NPR-A, and required the receptors' kinase homology domain. In a particulate fraction, ANP-stimulated cGMP production was dependent on ATP as a cofactor, and ATP promoted a lower affinity state. Our findings suggest that the kinase homology domain of NPR-A mediates the regulatory action of ATP, not only for signal transduction, but in the modulation of NPR-A hormone affinity.

Extracellular domain-IgG fusion proteins for three human natriuretic peptide receptors. Hormone pharmacology and application to solid phase screening of synthetic peptide antisera.

The natriuretic peptide receptors (NPRs) are a family of three cell surface glycoproteins, each with a single transmembrane domain. Two of these receptors, designated NPR-A and NPR-B, are membrane guanylyl cyclases that synthesize cGMP in response to hormone stimulation. The third receptor, NPR-C, has been reported to function in the metabolic clearance of ligand and in guanylyl cyclase-independent signal transduction. We engineered three chimeric proteins consisting of the natriuretic peptide receptor extracellular domains fused to the Fc portion of human IgG-gamma 1. These molecules provide material for detailed studies of the human receptor's extracellular domain structure and interaction with the three human natriuretic peptides, atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), and type-C natriuretic peptide (CNP). The homodimeric fusion proteins, designated A-IgG, B-IgG, and C-IgG, were secreted from Chinese hamster ovary cells and purified by protein-A affinity chromatography. We present here the primary characterization of these fusion proteins as represented by the intrinsic hormone affinities measured by saturation binding and competition assays. The dissociation constant of 125I-ANP for A-IgG was 1.6 pM and for C-IgG, 1.2 pM. The dissociation constant of 125I-Y0-CNP (CNP with addition of tyrosine at the amino terminus) for B-IgG was 23 pM. The rank order of potency in competitive binding for A-IgG was ANP greater than BNP much greater than CNP, whereas for B-IgG the ranking was CNP much greater than ANP greater than BNP. For C-IgG, we observed ANP greater than CNP greater than or equal to BNP. These data demonstrate that the receptor-IgG fusion proteins discriminate among the natriuretic peptides in the same manner as the native receptors and provide a basis for future structural studies with these molecules. The purified fusion proteins have a variety of potential applications, one of which we illustrate by a solid phase screening assay in which rabbit sera from a series of synthetic-peptide immunizations were titered for receptor reactivity and selectivity.

Cancer-related maternal mortality in Massachusetts, 1954-1985.

Cancer-related maternal mortality is a rare event. We report the first population-based study of this issue using data collected by the Committee on Maternal Welfare of the Massachusetts Medical Society between 1954 and 1985. The incidence of cancer-related maternal mortality during the study period fell from 3.16 to 0 per 100,000 live births. The most common cancer-associated maternal deaths were due to central nervous system tumors and hematological cancers. To determine the effects of pregnancy on cancer mortality, we compared our data with figures from the Connecticut Register of Mortality for Women aged 15-44. In the pregnant group there was a significantly higher incidence of mortality due to central nervous system tumors and a significantly lower incidence of mortality due to breast cancer. The data suggest that pregnancy may not be contraindicated for a woman with a history of breast cancer, but may be contraindicated for a woman with a history of a central nervous system tumor.

Patterns of mortality in pulp and paper workers.

A proportionate mortality ratio (PMR) analysis utilizing death certificates and work histories was performed on 201 white male decedents who had been employed in pulp and paper production plants and had died between 1970 and 1984. PMRs for all malignant neoplasms (PMR = 131) and lung cancer (PMR = 151) were significantly elevated, whereas PMRs for lymphopoietic system cancer (PMR = 190) and cancer of the large intestine (PMR = 147) showed nonsignificant excesses. Most of the excess cancers of the lung and large intestine were limited to those with greater than 30 years between initial employment in a pulp and paper plant and death. Excess lung and lymphopoietic system cancers have been found in other studies of paperworker mortality, although this study failed to support previous findings of excess stomach cancer. These results continue to raise concerns that paperworkers are at elevated risk for some occupational cancers.

Anesthetic-related maternal mortality, 1954 to 1985.

This is a population-based study of the safety of obstetrical anesthesia in the Commonwealth of Massachusetts between 1954 and 1985. We used data collected by the state Committee on Maternal Mortality, which was founded in 1941. There were a total of 37 maternal deaths during the study period due to anesthetic-related complications. During the same time period, there were 886 maternal deaths. Thus, anesthetic-related mortality comprised 4.2% of all deaths, and the mortality rate was 1.5 per 100,000 live births between 1955 and 1964, 1.5 per 100,000 live births between 1965 and 1974, and 0.4 per 100,000 live births between 1975 and 1984. In the first decade of this study, aspiration during administration of a mask anesthetic was the primary cause of death. During the second decade, cardiovascular collapse associated with regional anesthesia was the primary cause of death. During the last decade of this study, all deaths were associated with general endotracheal anesthesia. As a result of this study and having identified the changes in the standard of care in Massachusetts that led to the reduction in maternal mortality, we offer recommendations to further improve the safety of anesthesia for childbirth in this country.

Maternal mortality in the United States: report from the Maternal Mortality Collaborative.

To better define the incidence, causes, and risk factors associated with maternal deaths, the Maternal Mortality Collaborative in 1983 initiated national voluntary surveillance of maternal mortality. The Maternal Mortality Collaborative reported 601 maternal deaths from 19 reporting areas for 1980-1985, representing a maternal mortality ratio of 14.1 per 100,000 live births. Overall, 37% more maternal deaths were reported by the Maternal Mortality Collaborative than by the National Center for Health Statistics for these reporting areas. Older women and women of black and other races continued to have higher mortality than younger women and white women. The five most common causes of death for all reported cases were embolism, nonobstetric injuries, hypertensive disease of pregnancy, ectopic pregnancy, and obstetric hemorrhage. Compared with national maternal mortality for 1974-1978, ratios were lower for all causes except for indirect causes, anesthesia, and cerebrovascular accidents. Fatal injuries among pregnant women are not commonly reported to maternal mortality committees. As maternal mortality from direct obstetric causes continues to decline, clinicians will need to emphasize preventing deaths from nonobstetric causes.

Hemorrhage, infection, toxemia, and cardiac disease, 1954-85: causes for their declining role in maternal mortality.

Hemorrhage, infection, toxemia, and cardiac disease are no longer the leading causes of maternal death. We studied factors causing their decline in incidence using data collected by the Committee on Maternal Welfare of the Massachusetts Medical Society between 1954 and 1985. The dramatic decline in incidence of these conditions in the Commonwealth during the study period appears to have been due to both legislative actions and improvements in medical practice. The legislative actions included licensing of maternity services, blood banks, and legalization of abortion. Cardiac-related mortality has declined due to a reduction in the prevalence of rheumatic heart disease. Changes in clinical practice that stand out were the aggressive control of the hypertensive component of toxemia leading to a reduced incidence of intracranial hemorrhage, the prompt recourse to blood transfusion for hemorrhage, and the use of broad spectrum antibiotics.

Cesarean section-related maternal mortality in Massachusetts, 1954-1985.

We analyzed the data of the Maternal Mortality Committee of the Massachusetts Medical Society to investigate cesarean section-associated maternal deaths. Between 1954-1985, the number of cesarean section-related deaths per 100,000 live births did not significantly change despite a quadrupling of the cesarean section rate. Between 1976-1984, there were 649,375 births and 121,217 cesarean sections in the state. Seven deaths were directly related to cesarean section, a rate of 5.8 per 100,000 cesarean sections. In contrast, the rate for vaginal deliveries was 10.8 per 100,000 vaginal deliveries. We conclude that the risk of maternal death from cesarean section is low.

Maternal mortality in Massachusetts. Trends and prevention.

To identify ways in which the safety of childbirth might be increased, we investigated the causes of death among the 886 women who died during pregnancy or within 90 days post partum ("maternal deaths") in Massachusetts from 1954 through 1985. The maternal mortality rate declined from 50 per 100,000 live births in the early 1950s to the current rate of 10 per 100,000 live births. Between one third and one half of the maternal deaths were considered to have been preventable. The leading causes of maternal death from 1954 through 1957 were infection, cardiac disease, pregnancy-induced hypertension, and hemorrhage. In contrast, from 1982 through 1985 the leading causes of death were trauma (suicide, homicide, and motor vehicle accidents) and pulmonary embolus. We observed a rapid increase in the frequency of death among women who received little or no antenatal care. From 1980 through 1984 the maternal mortality rate for white women was 9.6 per 100,000 live births, whereas for nonwhites it was 35 per 100,000 live births (relative risk, 2.9; 95 percent confidence limits, 2.5 and 3.2). Fifty percent of the nonwhite women who died during pregnancy or within 90 days post partum received little or no antenatal care, in contrast to only 15 percent of the white women. These data show that the leading causes of maternal death have changed markedly in Massachusetts during the past 30 years. Although the overall maternal mortality rate has declined sharply, further improvement may occur with better antenatal care and specific efforts to prevent trauma and pulmonary embolus.

Reproductive mortality in Massachusetts in 1981.

PIP: This study analyzed reproductive deaths (all deaths from pregnancy-related causes, including abortion and ectopic pregnancy, as well as from causes related to contraception) among women 15-44 years of age in the state of Massachusetts in 1981. Of the 971 deaths recorded in this age group, 14 were classified as reproductive deaths, for an overall reproductive mortality rate of 1.8/10,000 live births (1/100,000 women). 10 of these deaths were pregnancy related, and 4 were due to pregnancy prevention (oral contraception). 4 of the pregnancy-related and 3 of the contraception-related deaths were considered preventable since they occurred in women in whom oral contraception (OC) had been contraindicated. The risks related to OC use were higher than those related to pregnancy for women over 35 years of age, suggesting that the reproductive mortality rate could be reduced by proscribing OC use in women in this age group, especially in women who smoke or have hypertension. It is concluded that the reproductive mortality rate is a better measure of the risk associated with reproduction that the maternal mortality rate, and it is recommended that committees on maternal mortality expand their surveillance to include deaths due to the side effects of contraception.^ieng