The uses of outcomes research for medical effectiveness, quality of care, and reimbursement in type II diabetes

Randomized controlled trials (RCTs), such as the Diabetes Control and Complications Trial (DCCT), usually evaluate the efficacy of a single treatment strategy. The DCCT, for example, evaluates intensive diabetes management aimed at achieving glucose levels as close to normal as possible to modify specific pathophysiological outcomes--specifically, the development or worsening of microvascular disease. In contrast, longitudinal observational studies, such as the type II diabetes Patient Outcome Research Team (PORT) study, address medical effectiveness; that is, how well prevailing treatments work in clinical practice settings. The PORT relies heavily on patient-reported measures of general and diabetes-specific health status, in addition to using complications as major study outcomes. In the type II diabetes PORT, 4,000 patients with type II diabetes and a wide range of socioeconomic, demographic, and disease characteristics, from three widely dispersed geographic settings and varying systems of care, are being followed for a 2.5-year period. Data are collected from periodic self-administered patient questionnaires and from administrative data bases. In the PORT study, nonmutable confounders, such as case-mix, and potentially mutable features, such as patients' preferences for treatment, health habits, regimen adherence, family support, and physician's interpersonal style, are carefully measured. The PORT study will examine the effectiveness of preventive care and established disease treatment in relation to eye, cardiovascular, and extremity disease, measuring and relating use of health-care services to patient outcomes. The results have the potential for maximizing quality of care and minimizing use of services in type II diabetes by matching physician-level profiles of patient outcomes with medical-care-process data and making this information accessible to practicing physicians.

The influence of age on clinical and patient-reported outcomes after cholecystectomy

OBJECTIVE

To examine the relationship between the age of cholecystectomy patients and surgical complications, length of stay, symptom relief, and postdischarge functional status.

DESIGN

Patients' medical records were reviewed and patients were sent a questionnaire three months after hospital discharge.

SETTING

Four university-affiliated teaching hospitals.

PATIENTS

372 patients who had a primary operation of total cholecystectomy.

OUTCOME MEASURES

In-hospital complications, length of stay, patient satisfaction, symptom relief, and functional status after discharge.

RESULTS

Patients over the age of 60 years experienced a higher major postoperative complication rate than did younger patients (p < 0.01), although the overall major complication rate was too low to determine whether factors other than age were important predictors. There was no age-related difference in minor postoperative complication rates. The older patients had a longer mean length of stay, even after statistical adjustment for covariates (p < 0.05). The older patients reported similar levels of patient satisfaction, but reported recurrence of preoperative abdominal pain less often than did the younger patients (OR = 0.4, 95% CI = 0.2, 0.7). There was no statistically significant difference between the older and younger patients in postoperative functioning, except for work performance. The younger patients reported improvement in postoperative work performance, while the older patients reported a decline (p < 0.01).

CONCLUSIONS

Older cholecystectomy patients may experience more postoperative complications but report less recurrence of preoperative abdominal pain than do younger patients. The decline in work performance in older patients may indicate the need for a longer recuperation period.

Recall of recommendations and adherence to advice among patients with chronic medical conditions

BACKGROUND

Patient adherence to treatment regimens may be a critical mediator between physician recommendations and patient outcomes, but levels of adherence have not been compared across disease groups, and patient self-reports have not been well validated.

METHODS

To determine recall of and adherence to physicians' recommendations among patients with chronic medical conditions and to measure the correspondence between self-reported adherence and disease activity, we analyzed data from the Medical Outcomes Study. A total of 1751 patients with diabetes mellitus, hypertension, and heart disease were identified among 20,223 patients visiting family physicians, general internists, cardiologists, and endocrinologists in 1986. Main outcome measures included recall of 15 disease-specific recommendations, self-reported general and specific adherence, and correlations between adherence and clinical measures of disease activity and control.

RESULTS

Among patients in all three disease groups, the proportion recalling recommendations to take prescribed medications (> or = 90%) exceeded the fraction recalling recommendations to follow a restricted diet, exercise regularly, and perform various self-care activities (22% to 84%). Adherence to recalled recommendations was similar across conditions but varied markedly according to the nature of the recommendations; for example, 91% of diabetics took prescribed medications but 69% followed a diabetics diet and 19% engaged in regular exercise. Adherence to recommendations was correlated with reduced serum glucose (r = -.33) and glycohemoglobin (r = -.25) levels among insulin-dependent diabetics and with reduced diastolic blood pressure among patients with hypertension (r = -.15).

CONCLUSIONS

The majority of chronically ill patients failed to recall elements of potentially important medical advice and did not always adhere to advice that was recalled. Self-reported adherence was correlated with clinical measures of disease activity and control. Additional research is needed not only to improve adherence to medical advice in patients with chronic illnesses but also to determine which life-style changes are truly beneficial for these patients.

Differential cholinergic and non-cholinergic actions of acetylcholinesterase in the substantia nigra revealed by fasciculin-induced inhibition

The effects of the peptide fasciculin (FAS), a potent inhibitor of acetylcholinesterase (AChE) have been examined, following unilateral microinfusion, on tissue levels of monoamines in the rat substantia nigra and concomitant circling behaviour. Although FAS inhibited 87% of total AChE, the levels of dopamine and its metabolites remained unchanged. Furthermore, the treatment induced modest contraversive rotation which was markedly enhanced in the presence of a systemic challenge with apomorphine. This behavioural effect of FAS was partially reversed by systemically administered atropine. Any possible interaction of FAS with nigral dopamine systems was further investigated by testing the peptide in animals that five days earlier had undergone a 6-hydroxydopamine (6-OHDA) lesion of the SN such that dopamine and AChE were significantly but not completely reduced. In a majority of these animals, FAS treatment caused a reversal of the lesion induced ipsiversive rotation, ie restored contraversive rotation. It is concluded that in the SN, FAS can have biochemical and behavioural actions independent of local dopamine systems and linked to cholinergic transmission. In addition, treatment with FAS in the substantia nigra also reveals the possible existence of at least two distinct pools of AChE with, respectively, non-cholinergic and cholinergic actions.

Using patient reports to assess health-related quality of life after total hip replacement

Data on disease severity, co-morbidity, and process of care were obtained from the medical records of 356 patients without rheumatoid arthritis undergoing a first unilateral total hip replacement at four teaching hospitals in California and Massachusetts. Socio-demographic characteristics, functional status prior and subsequent to hospitalization, and improvement in health status were measured with a patient questionnaire 12 months after discharge. Completed questionnaires were received from 284 patients, a response rate of 79.8%. The questionnaire was acceptable to patients, reliable, and had good construct validity. The data indicate substantial benefits from hip arthroplasty. As expected, pre-surgical functioning was a strong predictor of outcomes 1 year after surgery. Controlling for pre-surgical functioning, age was not related to outcomes.

The importance of co-existent disease in the occurrence of postoperative complications and one-year recovery in patients undergoing total hip replacement. Comorbidity and outcomes after hip replacement

Co-existent or comorbid diseases are appreciated as prognostic factors in studies of quality and effectiveness of care when mortality is the end point. The need to measure and adjust for comorbidity in studies of postoperative hospital complications or long-term recovery from surgery has not been documented. In this study, we determined the impact of co-existent disease on post-operative complications and 1-year health-related quality of life in patients hospitalized for a total hip replacement. The study population consisted of a cohort of 356 patients who were hospitalized in four teaching hospitals in California and Massachusetts for a total hip replacement. Patients' medical records were reviewed to collect information regarding severity of illness, co-existent disease, and postoperative complications. The kind and amount of baseline preoperative co-existent disease was measured from medical record information at admission using a four level Index of co-existent Disease (ICED). Approximately 12 months after hospital discharge, 283 (80%) of the patients were surveyed by questionnaire. The presence and amount of co-existent disease were significant predictors of postoperative complications. The complication rates ranged from 3% to 41% between the lowest and highest levels of the ICED. Patients treated at the four study hospitals differed in functional outcomes 1 year after surgery. Functional outcomes were strongly related to ICED scores: patients in Level 4 ICED scored 26.8 points lower in instrumental activities of daily living than patients in Level 1. After controlling for gender, age, education, and marital status, ICED remained a significant predictor of functional status at 1 year. Furthermore, differences among hospitals in functional outcomes disappeared when the ICED was included in the model to adjust for patient characteristics at the time of surgery. A measure of co-existent disease was crucial in explaining differences among hospitals in recovery from total hip replacement patients.

Use of exposure databases for status and trends analysis

Exposure databases are useful for monitoring status and trends in environmental health. However, other supporting data are usually needed to infer human exposure or internal dose. Program planning and evaluation, environmental health surveillance, epidemiologic research, and contributions to international efforts are four major purposes for monitoring environmental exposure status and trends. Although databases play an important role in monitoring human exposure, certain methodological problems need to be overcome. The work group developed six criteria for meeting information needs for human exposure assessment. Areas that need attention are (1) specification of location, (2) specification of facility and chemical identifiers, (3) documentation of special populations at risk, (4) provision of early warning of new problems, (5) monitoring changes over time, and (6) enhancement of documentation. We tested these criteria by examining six available databases that might be used for monitoring exposure to contaminants in drinking water. Available data fell short of information needs. We drew four conclusions and offered several recommendations for each. First, available data systems lack adequate measures of human exposure. Second, data for monitoring exposures for many important population subgroups and environmental settings are inadequate. Third, an "early warning" system that monitors human exposures is needed. Fourth, designers of data-collection systems should consider the needs of users who monitor status and trends of human exposure.

Differential actions of acetylcholinesterase on the soma and dendrites of dopaminergic substantia nigra neurons in vitro

In the substantia nigra, acetylcholinesterase (AChE) has non-cholinergic action on dopaminergic neurons. The subset of neurons particularly sensitive to AChE are characterized by functionally active apical dendrites extending into the pars reticulata and generating a powerful calcium conductance. This study thus attempted to establish directly the importance of these dendrites regarding the action of AChE. Segregation of the pars compacta from the pars reticulata did not affect the AChE-induced hyperpolarization on this sub-set of dopaminergic neurons. However, the ionic basis of the hyperpolarization was related to the integrity of the neurons: AChE caused an opening of potassium channels in intact cells. On the other hand when the pars reticulata containing apical dendrites was removed, an action of AChE involving the closure of calcium/sodium channels was revealed. The results demonstrate that the net effect of AChE need not be related to any particular segment of the dopaminergic neurons, whereas the nature of the mechanism underlying that effect depends on the presence, or otherwise, of the apical dendrites.

Reactive fibromyalgia syndrome

OBJECTIVE

To determine the frequency of a precipitating event occurring prior to the onset of fibromyalgia syndrome, in a consecutive series of patients. Outcome in patients in whom there was a causative factor was compared with that in patients with primary fibromyalgia.

METHODS

Records of patients presenting over a 4-year period who fulfilled criteria for fibromyalgia were reviewed, and patients were classified as having reactive fibromyalgia if a specific event prior to the onset of illness could be identified. Outcome features, including employment status and disability compensation, were compared in patients with reactive fibromyalgia versus those with primary fibromyalgia.

RESULTS

Twenty-nine of 127 patients (23%) with a primary rheumatologic diagnosis of fibromyalgia reported having trauma, surgery, or a medical illness before the onset of fibromyalgia, and were classified as having reactive fibromyalgia. Patients in this group were more disabled than those with primary fibromyalgia, resulting in loss of employment in 70%, disability compensation in 34%, and reduced physical activity in 45%.

CONCLUSION

The development of fibromyalgia after a precipitating event may represent the onset of a prolonged and disabling pain syndrome with considerable social and economic implications.

Recent developments and future issues in the use of health status assessment measures in clinical settings

This paper provides a broad overview of the assessment of health status in clinical practice in three parts. Yesterday: The nation has undergone a paradigm shift in health-related thinking. The former paradigm emphasized only disease; the new emphasizes health, functioning, well-being, and disease. Measures of health and disease have evolved to reflect the new paradigm. Many are designed for clinical settings, based on measurement science, and are relatively brief. These newer measures have been used to document the natural history of disease, evaluate treatment effectiveness, and improve clinical case management. Today: Two barriers block full-scale use in clinical settings. The first barrier involves the meaning and interpretation of health status scores. Patients' scores are influenced by several types of patient mix variables and the timing of measurements. Interpretation is enhanced by valid normative data displaying the variability in health status among homogenous patient groups. The second barrier is utilization and mainstreaming. It involves all of the issues associated with changing the day-to-day behavior of clinicians and providers' routine processes to facilitate routine use of health status measures in clinical settings. Tomorrow: In the next decade, the nation will attempt to overhaul the health care system. As it does so, it will struggle with many issues: 1) clarifying the true aim of health care; 2) standardizing measures of health across patients, providers, and settings to evaluate benefit; 3) establishing cause and effect among structural-input factors, care delivery processes, and health outcomes valued by society; and 4) determining if and when cost containment actions have adverse effects on health outcomes. In this context, the importance of interpreting change in health status has a central role.

Ambulatory testing for capitation and fee-for-service patients in the same practice setting: relationship to outcomes

Previous studies of the impact of varying reimbursement incentives on physician behavior have not explored the simultaneous implications for patients' health outcomes. Using a single group of physicians who provided care for hypertensive patients with either capitation (N = 99) or fee-for-service (N = 66) health insurance plans, physicians' test-ordering behavior and patients' subsequent health outcomes were examined. After controlling for patients' age, severity of hypertension, and level of comorbidity, it was found that patients with capitation health insurance had fewer laboratory tests and lower overall charges than the fee-for-service patients, with no clinical or statistically significant differences in 1-year health outcomes, specifically blood pressure control. The study concludes that capitation can result in reduction in charges associated with management of hypertension, without apparent compromise in proximate health outcomes.

How the medical comorbidity of depressed patients differs across health care settings: results from the Medical Outcomes Study

OBJECTIVE

Although depression is one of the most common problems of medical and psychiatric outpatients, it has not been clear whether the extent of medical comorbidity among depressed patients varies across major types of clinical settings in which depressed patients receive care--especially by type of treating clinician (general medical versus mental health specialty) or type of payment for services (prepaid versus fee-for-service).

METHODS

The authors examined these issues using data on 1,152 adult outpatients with current depressive symptoms and a lifetime history of unipolar depressive disorder who received care in one of three health care delivery systems in three U.S. sites.

RESULTS

Depressed patients had a similarly high prevalence (64.9%-71.0%) of any of eight common chronic medical conditions whether they were seen in the general medical or specialty mental health sector; however, those visiting medical clinicians had a significantly higher prevalence of the two most common chronic medical conditions, hypertension and arthritis. Among depressed patients with hypertension, those visiting the general medical sector were more likely to be taking antihypertensive medication than were those visiting the mental health specialty sector. Type of payment (prepaid versus fee-for-service) was unrelated to either prevalence or severity of comorbid medical conditions, suggesting that the typical depressed patient in all types of practices studied had medical comorbidity.

CONCLUSIONS

These data suggest that clinicians in all health care settings must be prepared to encounter chronic medical conditions and complaints in the depressed patients who visit them.

Assessing quality of life after surgery

Researchers and clinicians increasingly are recognizing the importance of assessing a wide range of outcomes when evaluating the efficacy of medical therapies or procedures. We developed and evaluated a set of self-report scales that assessed both generic and condition-specific aspects of health-related quality of life before and after surgery. We report data from a study of patients having one of four types of surgery at six teaching hospitals in California and Massachusetts. The four surgical conditions studied were: total hip replacement, transurethral prostatectomy, cholecystectomy, and coronary artery bypass graft surgery. All the outcome scales, except for those assessing cognitive functioning and fatigue, had internal consistencies greater than 0.70. The pattern of correlations between the scales and other measures of health status are similar to those reported in other studies and provide evidence of their construct validity. The scales also appeared to be sensitive to differences between presurgical and postsurgical health-related quality of life. The results suggest that the scales used were easy to administer, reliable, valid, and offered important information about outcomes of surgery that is not provided by more traditional clinical indicators.

Variations in length of stay and outcomes for six medical and surgical conditions in Massachusetts and California

OBJECTIVES

--To determine the extent to which interinstitutional variations in length of stay are explained by differences in patient characteristics and to determine whether patients in hospitals with shorter lengths of stay had worse outcomes.

DESIGN

--We reviewed patients' medical records and surveyed patients between 3 and 12 months after hospital discharge using a questionnaire.

SETTING

--Six teaching hospitals in California and Massachusetts.

PATIENTS

--A cohort of 2484 selected patients who had been hospitalized for acute myocardial infarction or to rule out acute myocardial infarction, coronary artery bypass graft surgery, total hip replacement, cholecystectomy, or transurethral prostatectomy. Between 73% and 84% of the patients with each condition completed a follow-up questionnaire.

OUTCOME MEASURES

--In-hospital complications, deaths, length of stay, functional status after hospital discharge, readmission, and patient satisfaction with hospital care were analyzed.

RESULTS

--Significant interinstitutional differences in length of stay were noted for all conditions except rule-out acute myocardial infarction. Statistical adjustment for case-mix differences accounted for most of the interinstitutional differences in length of stay for total hip replacement but explained little of the differences in the other conditions. When we controlled statistically for other predictors, length of stay did not have a significant impact on deaths, functional status after hospital discharge, the probability of readmission, or patient satisfaction with hospital care.

CONCLUSION

--More research is needed to determine the medical practices that are related to variations in lengths of stay. Routinely available outcome data may help preserve quality in the face of efforts to decrease costs by effecting more standardized practices of care.

Patterns of care related to age of men with prostate cancer

A chart review study was done of 242 Stages A2 to D1 cancer patients to determine whether the age of patients with prostate cancer influenced their physicians' management strategies. Ten hospitals of varying size, medical-school affiliation, and patient socioeconomic status participated in this study. Patterns of prostate cancer care were examined using sets of branching logic standards in the form of criteria maps. A chart-based comorbidity index was used to control for the effect of coexisting diseases on cancer management. Regression models indicated that patient age affected the intensity of both the diagnostic evaluation and therapy, even after controlling for independent factors such as comorbid disease and individual hospital differences. Patients aged 75 years and older had significantly less intensive clinical staging workups and use of surgical and radiation therapies compared with patients aged 65 to 74 years and patients aged 50 to 64 years. In conjunction with similar results noted in studies of elderly patients with other malignancies, these results suggest that age bias is likely to be widespread. Physicians need to consider life expectancy, the ability of the patient to tolerate diagnostic procedures and therapies, and the quality of life in making treatment decisions.

Medical practice guidelines: current activities and future directions

OBJECTIVE

To examine the state of the art in the field of medical practice guidelines, to identify limitations, and to suggest future directions.

DESIGN

Informal descriptive survey using a questionnaire administered by telephone, supplemented by comments, by opinions, and by examples solicited from the participating organizations.

PARTICIPANTS

Eight prominent organizations representing prototypic approaches to guideline development; these organizations included three medical societies, two health care organizations, two insurers, and one private health benefits management company.

RESULTS

Improving the quality of medical care was a stated goal of all eight surveyed organizations. However, their objectives have not been stated in operational terms, reflecting the lesser emphasis placed on methods and means for both implementing guidelines and evaluating their impact on health practices and outcomes. In contrast, several systematic methods for developing guidelines exist. They differ in the stress placed on formal literature reviews, reliance on local as opposed to national experts, and formal methods of group judgment, but no evidence exists on which approaches produce sounder and more usable guidelines.

CONCLUSIONS

Guidelines are being vigorously promoted as a means to improve the effectiveness of the health care system. Current initiatives show both strengths and weaknesses. In particular, the attention now paid to the development of guidelines needs to be matched by attention to implementation strategies and to the scientific evaluation of their effectiveness in real clinical settings. Also, more agreement is needed on acceptable methods for developing guidelines, assessing their content, and evaluating their impact on professional behavior, patient outcomes, and health care costs. Fortunately, several initiatives to bring greater order and quality to this field are under way.

Unusual radiographic presentation of IgA nephropathy

An adolescent male presented with hematuria and flank pain. Transient focal renal parenchymal defects were demonstrated by ultrasonography, radionuclide scintigraphy and computed tomography. Renal biopsy revealed IgA nephropathy with acute tubular necrosis. This peculiar radiographic pattern has not, to our knowledge, been previously described in IgA nephropathy and may relate to tubule cell damage by red blood cell casts or patchy renal ischemia.

What's the next step for outcomes assessment?

A series of initiatives are being launched nationwide to provide health status and clinical information to physicians in a variety of settings. What needs to be done, though, to ensure their validity and clinical usefulness?

Detection of depressive disorder for patients receiving prepaid or fee-for-service care. Results from the Medical Outcomes Study

We estimated clinicians' awareness of depression for patients with current depressive disorder (N = 650) who received care in either a single-specialty solo or small group practice, a large multispecialty group practice, or a health maintenance organization in three US sites. Depressive disorder was determined by independent diagnostic assessment shortly after an office visit. Detection and treatment of depression were determined from visit-report forms completed by the treating clinician. Depending on the setting, from 78.2% to 86.9% of depressed patients who visited mental health specialists had their depression detected at the time of the visit, compared with 45.9% to 51.2% of depressed patients who visited medical clinicians, after adjusting for case-mix differences. Among patients of mental health specialists, there were no significant differences by type of payment in the likelihood of depressive disorder being detected or treated. Among patients of medical clinicians, however, those receiving care financed by prepayment were significantly less likely to have their depression detected or treated during the visit than were similar patients receiving fee-for-service care.

Functional status and well-being of patients with chronic conditions. Results from the Medical Outcomes Study

Enhancing daily functioning and well-being is an increasingly advocated goal in the treatment of patients with chronic conditions. We evaluated the functioning and well-being of 9385 adults at the time of office visits to 362 physicians in three US cities, using brief surveys completed by both patients and physicians. For eight of nine common chronic medical conditions, patients with the condition showed markedly worse physical, role, and social functioning; mental health; health perceptions; and/or bodily pain compared with patients with no chronic conditions. Each condition had a unique profile among the various health components. Hypertension had the least overall impact; heart disease and patient-reported gastrointestinal disorders had the greatest impact. Patients with multiple conditions showed greater decrements in functioning and well-being than those with only one condition. Substantial variations in functioning and well-being within each chronic condition group remain to be explained.

The Medical Outcomes Study. An application of methods for monitoring the results of medical care

The Medical Outcomes Study was designed to (1) determine whether variations in patient outcomes are explained by differences in system of care, clinician specialty, and clinicians' technical and interpersonal styles and (2) develop more practical tools for the routine monitoring of patient outcomes in medical practice. Outcomes included clinical end points; physical, social, and role functioning in everyday living; patients' perceptions of their general health and well-being; and satisfaction with treatment. Populations of clinicians (n = 523) were randomly sampled from different health care settings in Boston, Mass; Chicago, Ill; and Los Angeles, Calif. In the cross-sectional study, adult patients (n = 22,462) evaluated their health status and treatment. A sample of these patients (n = 2349) with diabetes, hypertension, coronary heart disease, and/or depression were selected for the longitudinal study. Their hospitalizations and other treatments were monitored and they periodically reported outcomes of care. At the beginning and end of the longitudinal study, Medical Outcomes Study staff performed physical examinations and laboratory tests. Results will be reported serially, primarily in The Journal.