Prognostic value of genetic alterations in children with first bone marrow relapse of childhood B-cell precursor acute lymphoblastic leukemia.

Despite risk-adapted treatment, survival of children with relapse of acute lymphoblastic leukemia (ALL) remains poor compared with that of patients with initial diagnosis of ALL. Leukemia-associated genetic alterations may provide novel prognostic factors to refine present relapse treatment strategies. Therefore, we investigated the clinical relevance of 13 recurrent genetic alterations in 204 children treated uniformly for relapsed B-cell precursor ALL according to the ALL-REZ BFM 2002 protocol. The most common alterations were deletions of CDKN2A/2B, IKZF1, PAX5, ETV6, fusion of ETV6-RUNX1 and deletions and/or mutations of TP53. Multivariate analysis identified IKZF1 deletion and TP53 alteration as independent predictors of inferior outcome (P=0.002 and P=0.001). Next, we investigated how both alterations can improve the established risk stratification in relapsed ALL. Intermediate-risk relapse patients with low minimal residual disease are currently considered to have a good prognosis. In this group, deletion of IKZF1 and alteration of TP53 identify patients with significantly inferior outcome (P<0.001). In high-risk relapse patients, deletion of IKZF1 is strongly predictive of a second relapse after stem cell transplantation (P<0.001). We conclude that IKZF1 and TP53 represent relevant prognostic factors that should be considered in future risk assessment of children with relapsed ALL to indicate treatment intensification or intervention.

Using scenario analysis to determine managed care strategy.

In today's volatile healthcare environment, traditional planning tools are inadequate to guide financial managers of provider organizations in developing managed care strategies. These tools often disregard the uncertainty surrounding market forces such as employee benefit structure, the future of Medicare managed care, and the impact of consumer behavior. Scenario analysis overcomes this limitation by acknowledging the uncertain healthcare environment and articulating a set of plausible alternative futures, thus supplying financial executives with the perspective to craft strategies that can improve the market position of their organizations. By being alert for trigger points that might signal the rise of a specific scenario, financial managers can increase their preparedness for changes in market forces.

Physician resource profiling enhances utilization management.

Physician resource profiling, the analysis of a physician's resource consumption, enhances performance uniformity and efficiency and assists in utilization management. Developing reliable profiles requires the shared participation of an organization's finance personnel and physicians. Selecting or developing benchmarks for performance comparisons, assessing the integrity of the organizational data used, and testing the developed profiles all should be completed before the physician resource profiling can be used to support decision making.

Maximizing financial returns by meeting employer expectations.

Healthcare providers that understand the needs and priorities of employers that contract for managed care services can more accurately assess what strategies they need to adopt to succeed under managed care. Such strategies include determining which health plans to contract with to best meet employers' needs and which managed care products to be a part of or offer. In addition, because the number of employer self-funded health plans is growing, providers that develop working relationships directly with employers can increase their opportunities to sell and develop additional healthcare services and increase the number of enrollees to whom they provide care.

Development of physician networks.

This article provides a brief overview of the development of physician networks. The continued progression of managed care and the advent of managed care-based health care reform at the state and national level have escalated the development of physician networks. This article reviews the potential purposes and objectives for forming a physician network as well as the different desired characteristics such as geographic access, network size and composition, and targeted physician characteristics that are important in the network's development.