Medicare+Choice: what lies ahead?

Health plans have continued to exit the Medicare+Choice program in recent years, despite efforts of Congress and the Centers for Medicare and Medicaid Services (CMS) to reform the program. Congress and CMS therefore stand poised to make additional, substantial reforms to the program. CMS has proposed to consolidate its oversight of the program, extend the due date for Medicare+Choice plans to file their adjusted community rate proposals, revise risk-adjustment processes, streamline the marketing review process, enhance quality-improvement requirements, institute results based performance assessment audits, coordinate policy changes to coincide with contracting cycles, expand its fall advertising campaign for the program, provide better employer-based Medicare options for beneficiaries, and take steps to minimize beneficiary costs. Congressional leaders have proposed various legislative remedies to improve the program, including creation of an entirely new pricing structure for the program based on a competitive bidding process.

Oral versus written feedback in medical clinic.

OBJECTIVE: To determine whether residents perceived oral, face-to-face feedback about their continuity clinic performance as better than a similar, written version. DESIGN: Single-blind, randomized controlled trial. SETTING: Two university-based, internal medicine residency clinics. PARTICIPANTS: All 68 internal medicine and combined program (medicine-pediatrics, medicine-psychiatry, medicine-neurology, and preliminary year) residents and their clinic preceptors. MEASUREMENTS AND MAIN RESULTS: Residents at each program were separately randomized to oral or written feedback sessions with their clinic preceptors. The oral and written sessions followed similar, structured formats. Both groups were later sent questionnaires about aspects of the clinic. Sixty-five (96%) of the residents completed the questionnaire. Eight of the 19 questions dealt with aspects of feedback. A feedback scale was developed from the survey responses to those eight questions (alpha = .86). There were no significant differences in the responses to individual questions or in scale means (p > .20) between the two feedback groups. When each university was analyzed separately, one had a higher scale mean (3.10 vs 3.57, p = .047), but within each university, there were no differences between the oral and written feedback groups (p > .20). CONCLUSIONS: No differences were observed between the oral and written feedback groups. In attempting to provide better feedback to their residents, medical educators may better apply their efforts to other aspects, such as the frequency of their feedback, rather than the form of its delivery.

Teaching dietary counseling skills to residents: patient and physician outcomes. The CADRE Study Group.

Our objective was to determine whether an educational intervention and prompting intervention for physicians improved dietary counseling of patients with high blood cholesterol and resulted in beneficial changes in patients' diets and cholesterol levels. We instituted a factorial design, multicenter, randomized, placebo-controlled trial to test two interventions. We tested the trial at continuity care clinics of internal medicine residents at seven community and university medical centers in the northern and eastern United States. Our participants were 130 internal medicine residents and 254 adult outpatients with blood cholesterol levels of 240-300 mg/dL. Interventions included an educational program for resident physicians designed to improve their skills and confidence in dietary counseling (two one-hour sessions with specially prepared printed materials for use in counseling) and a prompting intervention, which was a fingerstick blood cholesterol determination prior to the patient's clinic visit. Resident physicians' knowledge, attitudes, and self-reported behaviors were assessed prior to the intervention and 10 months later using chart audits and questionnaires. Residents' behaviors were also assessed by exit interviews with patients. Patients' knowledge, attitudes, behaviors, and fingerstick blood cholesterol levels were measured at baseline and 10 months later. The educational program increased the percentage of physicians who were confident in providing effective dietary counseling (baseline of 26% to 67%-78%; P < .01). The prompting intervention approximately doubled the frequency of physician counseling (P = .0005) and increased the likelihood that patients would try to change their diets. When both interventions were combined, most outcomes were better, although not statistically significant. Cholesterol levels, however, decreased only marginally and were no different among groups at 10-month follow-up. Despite success in changing physicians' attitudes and behaviors and increasing patients' willingness to change their diets, there was no significant change in patients' cholesterol levels. Medical Subject Headings (MeSH): randomized controlled trial; cholesterol; patient education; behavior therapy; education, medical; diet.

Dietary counseling of hypercholesterolemic patients by internal medicine residents.

OBJECTIVE: To assess the knowledge, attitudes, and practices of internal medicine residents concerning dietary counseling for hypercholesterolemic patients. DESIGN: Cross-sectional, self-administered questionnaire survey. SETTING: Survey conducted August 1989 in seven internal medicine residency programs in four southeastern and middle Atlantic states. PARTICIPANTS: All 130 internal medicine residents who were actively participating in outpatient continuity clinic. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Only 32% of the residents felt prepared to provide effective dietary counseling, and only 25% felt successful in helping patients change their diets. Residents had good scientific knowledge, but the degree of practical knowledge about dietary facts varied. Residents reported giving dietary counseling to 58% of their hypercholesterolemic patients and educational materials to only 35%. Residents who felt more self-confident and prepared to counsel reported more frequent use of effective behavior modification techniques in counseling. Forty-three percent of residents had received no training in dietary counseling skills during medical school or residency. CONCLUSION: Internal medicine residents know much more about the rationale for treatment for hypercholesterolemia than about the practical aspects of dietary therapy, and they feel ineffective and ill-prepared to provide dietary counseling to patients.

Validity of the in-training examination for predicting American Board of Internal Medicine certifying examination scores.

OBJECTIVE: To determine whether the results of the Internal Medicine In-Training Examination (ITE) can predict subsequent performance on the American Board of Internal Medicine certifying examination (ABIMCE). DESIGN: Retrospective data review. SETTING: A mixture of six community hospital and university-based internal medicine training programs in the Eastern United States. SUBJECTS: 109 residents who first took the ABIMCE in 1988 or 1989, and who had also taken at least one ITE. MEASUREMENTS: Scores for the composite and subspecialty sections of the ITE were compared with those for the ABIMCE. An R2 was obtained to relate the scores on the two examinations. A cutoff score was derived to maximize the ability of the ITE to discriminate between residents who were likely to pass and those who were likely to fail the ABIMCE. MAIN RESULTS: ABIMCE scores were available for 109 residents who had also taken the ITE during PGY-2 (19), PGY-3 (50), or both years (40). Composite scores on the ABIMCE were highly correlated with those on the ITE-PGY-2 (R2 = 0.593) and the ITE-PGY-3 (R2 = 0.677) (p less than 0.0001 for each). Most of the subspecialty sections on the two examinations were significantly correlated, although less strongly (range of R2 = 0.041 to 0.32) than were the composite scores. An empirically derived cutoff score of the 35th percentile on the ITE-PGY-2 had a positive predictive value of 89% (probability of passing ABIMCE) and a negative predictive value of 83% (probability of failing ABIMCE). CONCLUSIONS: Performance on the ITE can accurately predict and is highly correlated with performance on the ABIMCE. ITE results may therefore be useful in counseling residents about their educational needs in preparation for the ABIMCE.

Interaction of indomethacin and sulindac with labetalol.

The effects of sulindac and indomethacin on the blood pressure response to labetalol were determined in well-controlled predominantly obese hypertensive patients (n = 26). A stabilized dose of labetalol alone was administered on weeks 1 and 3, and either indomethacin or sulindac was administered with labetalol on week 2, with cross-over to the other drug on week 4. Indomethacin and sulindac increased the sitting and standing systolic blood pressure (BP) to a statistically significant extent compared with placebo. The effects of indomethacin on systolic BP, diastolic BP, and weight were not significantly different from those with sulindac. Indomethacin but not sulindac produced minor increases in diastolic BP and weight compared with placebo.

Effect of naproxen and sulindac on blood pressure response to atenolol.

Twenty-eight patients with mild to moderate essential hypertension well controlled by atenolol entered a five-week, double-blind, placebo-controlled trial of the effects of sulindac and naproxen on blood pressure (BP) control. Atenolol alone was administered during weeks 1, 3, and 5. Naproxen or sulindac was administered with atenolol during week 2, with crossover during week 4. Data were analyzed for 27 of the patients (one dropped out after developing a skin rash). Naproxen significantly increased the systolic BP compared with placebo (mean 4.0 mm Hg; 95 percent confidence interval, 1.1-7.0; p less than 0.05). There were no significant differences in systolic BP during sulindac administration compared with placebo or naproxen. No significant effects on diastolic BP were observed. Weight was increased by naproxen and sulindac compared with placebo (mean 0.6-0.8 kg, p less than 0.05), although not to a clinically significant extent. One-week therapy with naproxen has a greater potential than sulindac to increase systolic BP in well-controlled hypertensive patients receiving atenolol; however, the increase is minor and unlikely to be of clinical significance.

Prospective analysis of liver biopsies before and after methotrexate therapy in rheumatoid patients.

The significance of hepatic changes in methotrexate-treated RA patients is unclear at this time. In our group of RA patients, there was a slight increase in the incidence of triaditis and fat during methotrexate therapy. Disease duration greater than or equal to 10 years was associated with increased hepatic triaditis before treatment. Age greater than 50 years was associated with increased hepatic fat before and after treatment. It appears that patients' ages and duration of underlying RA account for some changes, independent of methotrexate therapy. Several of our patients changed from higher to lower histologic grade or had an apparent decrease in fibrosis, fat, or triaditis on the pathologists' reports and the blind readings of the repeat biopsies. This may be explained by sampling error. More importantly, some of these changes may not be of clinical significance. One report of methotrexate-induced cirrhosis in patients with psoriasis demonstrated that in all but one of 14 patients who continued receiving methotrexate the cirrhosis decrease or did not progress. This may also be true of the hepatic fibrosis seen in RA after methotrexate treatment. In this study, there did not appear to be changes seen on pretreatment liver biopsy that were predictive of subsequent fibrosis or cirrhosis. Our data indicate that pretreatment biopsy is unwarranted in a population similar to ours. However, our practice has been to try to avoid methotrexate in patients with diabetes, prior liver disease, alcoholism, or obesity because of previous reports suggesting that these patients are at increased risk for the development of cirrhosis. Only the above-mentioned patient, eventually diagnosed as having cirrhosis, might have been handled differently. Including the study, none of the approximately 700 RA patients in the literature having liver biopsies after methotrexate therapy have developed cirrhosis consequent to its use. Most of these had received a total dose of approximately 1,500 mg in small weekly doses, and alcohol was prohibited. Below this cumulative dose the risk of clinically significant liver damage in carefully selected patients is very low. In view of this experience, the recommendation that RA patients have liver biopsies after 1,500 mg of methotrexate (a holdover from the psoriasis literature) may be too conservative in low-risk RA patients, provided methotrexate is administered weekly and alcohol is prohibited. Recognizing that the absolute need for biopsy is unproven, a more realistic milestone for those choosing biopsy might be after each 2,000 to 2,500 mg.(ABSTRACT TRUNCATED AT 400 WORDS)

Methotrexate therapy in rheumatoid arthritis.

Rheumatoid arthritis (RA) is a common disease with a significant economic and social impact on Americans. Many patients with RA are unresponsive to or intolerant of conventional therapy or the limited therapeutic options available. For many of those patients, immunosuppressive drugs have been the mainstay of therapy. Our experience with methotrexate for these patients indicates that this drug provides symptomatic relief and improvement in objective parameters. Significant toxicity was uncommon. Methotrexate should be considered for selected patients with severe rheumatoid arthritis when conventional measures have been exhausted.

Hemolytic-uremic syndrome--an outbreak in Sacramento, California.

Between July and November 1982, 14 cases of the hemolytic-uremic syndrome occurred in the Sacramento, California, metropolitan area; 9 of the 14 patients lived within a 7.5-mile radius in northeast Sacramento, 10 were female, 12 were white non-Hispanic and 13 were children with a mean age of 3.6 years. Of the 14 patients, 13 were admitted to hospital; 7 required peritoneal dialysis. The 14th child, a 3-month-old white female infant, was found dead in her crib and had renal histopathologic findings consistent with the hemolytic-uremic syndrome. Of the 13 nonfatal cases, 12 patients had diarrhea before being admitted to hospital. A case-control study involving 11 cases and 22 controls did not show any significant differences in exposure to a variety of possible risk factors including restaurants, specific foods and water supply. Stool specimens were negative for enteric bacterial pathogens by culture and for viruses by tissue culture assay, suckling mouse inoculation and immune electron microscopy; no serologic evidence was found for infection due to enteroviruses, respiratory viruses or arenaviruses. Two of four children tested, however, showed serologic evidence of infection by Vero-cytotoxin-producing Escherichia coli. These 14 cases represent one of the largest reported outbreaks of the hemolytic-uremic syndrome in the United States.

Response of Peach Seedlings to Infection by the Root Lesion Nematode Pratylenchus penetrans under Controlled Conditions.

Twenty-one open pollinated populations of peach rootstock seedlings were evaluated for their response to infection by the root lesion nematode, Pratylenchus penetrans, over a period of 98 days. Nematode-infected peach seedling populations were shorter in plant height and had less shoot weight but more dry root weight than nematode-free controls. Rootstock differences were demonstrated for nematode increase over the 98-day period, and average total numbers of nematodes in soil and roots. Rootstocks were classified into three groups differing in total nematode population levels, ratio of nematode increase, and the number of nematodes per root. The heritable nature of rootstock response to nematodes was evident. Rootstocks showing the lowest response to nematode infection included Tzim Pee Tao, Rutgers Red Leaf, and two progenies of a cross of these two rootstocks.