Assessing the quality of asthma care provided to Medicaid patients enrolled in managed care organizations in Connecticut.

BACKGROUND: Many states have enrolled Medicaid beneficiaries in managed care organizations (MCOs). Few assessments of the quality of asthma care provided by these new programs are available. OBJECTIVE: To describe the quality of care provided to asthmatic Medicaid children enrolled in MCOs. METHODS: For this cross-sectional survey, a chart abstraction tool was developed to evaluate fulfillment of key performance measures chosen from a national guideline for asthma diagnosis and management. These measures were prescription of an inhaled anti-inflammatory medication, accomplishment of patient education, evaluation of exposure to environmental triggers of asthma, and administration of influenza vaccination. From State of Connecticut administrative databases, a random sampling of Medicaid children, ages 5 to 18 years, enrolled in four MCOs was selected. Chart entries from July 1, 1996 to June 30, 1997 were reviewed using the abstraction tool. Accomplishment of performance measures was evaluated for the total sample and for children who were high utilizers of medical services (at least one ED visit or hospitalization during the study period). RESULTS: For 80 high utilizers among 315 children, completion of performance measures was suboptimal: 46% were prescribed inhaled steroids; an action plan was outlined for 43%; evaluation of patient or family tobacco use was documented for 56%; evaluation of the presence of a pet for 43% or mite exposure for 19%; and allergy skin testing or RAST was accomplished for 15%. CONCLUSIONS: This information suggests that opportunities exist to improve the quality of care for these children.

Factors influencing mammography use among women in Medicare managed care.

This article presents findings about the mammography screening experience of Medicare members of a health maintenance organization (HMO). Based on a mail survey of 309 women, we assessed factors that may be facilitators or barriers to this service for older women. The results indicate that these respondents generally are receiving timely mammograms; over three-quarters (79 percent) reported having a mammogram in the past 2 years. Multivariate analysis showed that women who were younger (under 75 years of age), believed in the importance of screening, had been told by a physician to obtain a mammogram, and were more satisfied with their physician and more likely to report mammography use.

The status of prenatal care among Medicaid Managed Care patients in Connecticut.

Providing quality prenatal care to high-risk, pregnant adolescents represents an important challenge to health care providers and health plans. Using national prenatal care guidelines, this study sought to evaluate the quality of important processes and outcomes of prenatal care delivered to women age 21 years and younger enrolled in three health plans serving the Connecticut Medicaid population. Some important findings include 93% compliance with recommended processes of prenatal care, an 11% C-section rate, an average length of hospital stay of 4.0 days for women having a C-section, and a 10% premature delivery rate. Opportunities for improvement include 40% failing to begin prenatal care in the first trimester, 31% not receiving the recommended number of prenatal care visits, and 8% delivering a low-birth-weight infant. This study provides important descriptive information on processes and outcomes of care for pregnant adolescents within Medicaid Managed Care and also identifies opportunities for improvement.

When consultants write orders: physicians' attitudes, beliefs, and practices.

The process by which a consultation is performed may significantly impact the extent to which the content of the consultation contributes positively to patient care. The practice of consultants writing orders independent of the explicit permission of the consultation requester is a common event. A survey of 211 multispecialty physicians on the medical staff of a large, urban, Northeastern, teaching hospital about their attitudes, beliefs, and practices regarding consultation on the inpatient service reveal that the majority of respondents in all specialties were unaware of departmental or hospital policy regarding the practice of consultant order writing. Significant differences between specialties existed in the perception of the impact of consultant order writing on patient outcomes, in the practice of discussion with the primary attending prior to order writing, and in the documentation practices. The authors discuss such results and their policy implications in light of important medico-legal and ethical principles, and best practice standards.

Mental retardation and decision making: balancing autonomy and protection.

Balancing autonomy with protection in caring for patients with mental retardation remains a formidable task for many clinicians. Though historical debate has resulted in an attitude supporting increased autonomy for all patients generally, and in legislation for enhanced decision making for the developmentally disabled specifically, the operationalization of such attitudes and policies lacks sufficient attention in the literature. The authors discuss three important areas of decision making as these relate to the care of patients with mental retardation: competence, respect, and multiple stakeholders; and, offer recommendations in each area to provide clinicians with some guidance in balancing the goals of autonomy and protection in clinical care when treating people with mental retardation.