The oral-systemic personalized medicine model at Marshfield Clinic.

Periodontal disease and diabetes, two diseases that have achieved epidemic status, share a bidirectional relationship driven by micro-inflammatory processes. The present review frames the current understanding of the pathological processes that appear to link these diseases and advances the hypothesis that reversal of the epidemic is possible through application of interdisciplinary intervention and advancement of oral-systemic personalized medicine. An overview of how Marshfield Clinic's unique clinical, informatics and bio-repository resources and infrastructures are being aligned to advance oral-systemic personalized medicine is presented as an interventional model with the potential to reverse the epidemic trends seen for these two chronic diseases over the past several decades. The overall vision is to engineer a transformational shift in paradigm from 'personalized medicine' to 'personalized health'.

Specialist/generalist division of responsibility for patients with mental disorders.

The division of responsibility between general medical staff and mental specialists for care of persons with medical record diagnoses of mental disorders is documented in four organized health care settings. Rates of mental disorders identified in all departments ranged from 35.6 to 122.8 per 1,000 population. Specialty mental health departments treated most severe psychotic and personality disorders, plus transient situational disturbances, whereas neurotic, childhood behavior, and psychophysiological disorders received as much or greater attention in general medical departments. Mental disorder diagnoses were associated with greater patient use of general medical departments. However, joint specialty mental health/general medical treatment of these patients was associated with lower general medical department visit rates in all settings. Such joint care was facilitated by the low average visit frequency use of mental health departments. (2.2 to 8.9 visits per patient per year).

Screening for mental disorder among primary care patients. Usefulness of the General Health Questionnaire.

The General Health Questionnaire (GHQ) and a structured psychiatric interview (lifetime version of the Schedule for Affective Disorders and Schizophrenia) were administered to a sample of primary care patients in the United States. Responses to the GHQ tended to form factors that have substantive interpretations, such as depression, anxiety, sleep problems, and social functioning. However, there seems to be little gain in using subscale scores to help identify persons with different types of psychiatric disorders.

The limited utility of fibrinogen I 125 leg scanning.

Using venography as the reference procedure, this study examined the utility of fibrinogen I 125 scanning for the detection or demonstration of deep venous thrombosis. The results demonstrate the inability of leg scanning to detect accurately the presence or absence of thrombi in the deep venous system. Most striking was the lack of sensitivity of this procedure in areas where the propensity for embolization is greatest. Sensitivity is extremely low in the anatomic areas where leg scanning demonstrates reasonable specificity. The results are nearly identical in the extremity not operated upon. The validity of all prior studies relying heavily or exclusively on 125I leg scans to determine the presence or absence of thrombi must be critically reassessed.

Diagnosis of mental disorder in adults and increased use of health services in four outpatient settings.

The differential use of medical services by patients with and those without a diagnosis of mental disorder was examined in four adult populations by age, sex, diagnosis, and medical department used. The four settings offered comprehensive services to patients who varied greatly in socioeconomic status. In all four settings patients with a diagnosis of mental disorder used all services and general health services more than patients without such a diagnosis. Results document increased medical morbidity and a greater likelihood of a diagnosis of an ill-defined condition in patients with mental disorder than that found in patients without a diagnosis of mental disorder.

Composition of the subscribers in a rural prepair group practice plan.

To determine the degree to which enrollees of the Greater Marshfield Community Health Plan were representative of the community the plan was designed to serve, a telephone survey of 1,838 households in the 30-township area was undertaken. The response rate was 93%, and data were obtained from 1,718 households containing 5,260 persons. Of these, 484 households had at least one health plan member. Since the plan accepts only persons under age 65, analysis of the data was limited to those persons aged 64 and younger. Results indicate that enrollees showed good representation of demographic variables such as age, sex, and relationship to the household head when they were compared to the under 65 population of the area. When the enrollee's socioeconomic characteristics (education, income, and occupation) were studied, it was found that, although enrollees showed good representation for most categories they tended to underrepresent the under 65 area population in the lowest income and education classes, as well as in the semiskilled or unskilled occupations. The opposite was true for the upper income and educational classes. Data on location of residence indicated that a strong relationship existed between enrollment and proximity to Marshfield, where the major health care center is located. The use of health services was found to be positively related to membership, with enrollees overrepresented among those with recent hospital or physician contacts. The ability to obtain coverage through employment or by other means was found not to be related to membership. Satisfaction as expressed by participants was much higher in the prepaid program than among those with other forms of coverage.

Co-occurrence of psychiatric and medical morbidity in primary care.

This study examines the co-occurrence of psychiatric and medical morbidity in primary care patients utilizing a health care clinic in Marshfield, Wisconsin. Previous research has shown that individuals with psychiatric disorders have higher rates of medical illness than people without psychiatric illness, but most prior studies have tended to confound the measures of psychiatric and medical morbidity. In addition, appropriate controls for bias resulting from different medical utilization patterns have sometimes been absent. The present study reports the medical diagnoses of persons who had been assessed for psychiatric disorder with a standardized psychiatric interview using research diagnostic criteria independent of their medical assessment. Psychiatric diagnoses are analyzed in relation to medical diagnoses at the time of the interview and for a one-year period--six months before and six months after that date. The results indicate that persons with mental disorder diagnoses have significantly more morbidity for the one-year study period. Although considerable congruence exists in the physical diagnoses recorded for both groups, those with mental disorders are more likely to have diagnoses of the digestive and genitourinary systems. Some sex differences are also explored.

Monitoring consumer satisfaction with the clinical services provided to 'exceptional' children.

Given recent federal and state legislation mandating all necessary services for children with handicapping conditions, it is incumbent upon the providers of health care services to demonstrate accountability for their services to children with special needs. A procedure to assess the satisfaction of parents and community-based case coordinators with clinical services provided to such children has been demonstrated. By focusing on specific service elements, it is possible to align optimum versus actual consumer satisfaction. Through an analysis of observed variance, the modification of documented weaknesses can decrease the difference between optimum and actual consumer satisfaction levels. This procedure will be continued on a bi-annual, longitudinal follow-up basis to monitor progress. The concept of consumer input into the provision of clinical services is relevant to other developments in the field of health care which place importance on administration accountability. Those health care providers who recognize the value of consumer input and allow for its incorporation into their service programs will be better able to adapt their systems to the emerging trend towards medical accountability. Self-ordered accountability is more meaningful, is easier to understand than government imposed regulations, and can be smoothly blended into an organization's goals and objectives.

A view from under the microscope. Medicare prospective risk contracting.

The authors provide an overview of the Marshfield Clinic's four-year demonstration contract with HCFA that resulted in the enrollment under a prospective risk contract of over 8,900 Medicare beneficiaries. Public policy implications are discussed along with recommendations for group practices contemplating Medicare prospective contracts. Recommendations include the attention which must be paid to potential adverse selection, hospital utilization control, and potential technical and methodological problems with the prospective reimbursement system. Data from the demonstration will be of significant value to other groups interested in prospective contracting with HCFA. The concept of prepaid Medicare, if appropriately refined, can serve the best interests of Medicare beneficiaries, providers, and

Occupational health services for farmers.

There are many unmet health needs in the farming community, needs that are peculiar to the agriculture industry. Health research and regulations to protect the safety of the farmer have lagged far behind those for other sectors of our economy. At a time when health needs are increasing, there is a decreasing availability of hospitals, physicians, nurses, and other health care personnel. The ability of the rural section to pay for these services is also declining. The evidence calls for a multifaceted solution, with improved cooperation and understanding on the part of the consumer as well as the provider. The regional health network is one system that may help solve some of these dilemmas.

The identification of psychiatric illness by primary care physicians: the effect of patient gender.

OBJECTIVE: This study tested several hypotheses about why women are more likely than men to have psychiatric disorders noted by their primary care physicians. DESIGN: Patients were screened for mental disorders using the General Health Questionnaire. A stratified sample was assessed using the Schedule for Affective Disorders and Schizophrenia. Information on utilization and identification of mental health problems was abstracted from the medical records. SETTING: The study was conducted at a multispecialty group practice in a semirural area of Wisconsin. PATIENTS: Study participants consisted of a stratified probability sample of 247 patients seeking primary care. RESULTS: Patients with a psychiatric illness who were relatively frequent users of the clinic were most likely to be identified by a physician as having a mental health problem. When psychiatric illness and utilization rates were statistically controlled, men and women had comparable identification rates.

Medicare risk contracting. Lessons from an unsuccessful demonstration.

The Tax Equity and Fiscal Responsibility Act of 1982 provided a full-risk Medicare capitation financing option for health maintenance organizations and competitive medical plans. Two rounds of demonstrations were conducted, followed by the publication of final regulations in January 1985. The first-round demonstration at Marshfield, Wis, was operational for 28 months. Thirty-seven percent of all resident beneficiaries enrolled. Aggregate losses exceeded $3 million (11.6% of revenue). Management implemented increasingly more stringent utilization review. Overall hospital utilization declined 261.7 days per 1000 from fiscal year 1981 to 1982; nonetheless, federal reimbursement was insufficient to meet program costs and the demonstration was terminated. The central reimbursement method used in Medicare risk contracting (adjusted average per capita cost) does not adequately control for enrollment selection, unmet medical need, or recent regional cost variations. Reimbursement set at 95% of estimated fee-for-service costs does not recognize, and in the long run will not support, an efficiently operating delivery system.

The usefulness of screening for mental illness.

The study assessed the effect of screening for mental disorder by means of the General Health Questionnaire (GHQ) on the rate of detection of mental disorder by fourteen physicians in a primary-care clinic. After completing the GHQ, patients were randomised into control (722 patients) and experimental (730 patients) groups. GHQ results of the experimental group were made available to the physicians; those of the control group were not. Sociodemographic factors influenced the physicians' rate of diagnosis of mental disorders (rates were lower for men, students, and patients with at least a partial college education than in subjects who had a low income, less than 7 years of school, or were widowed) but there was no difference between control and experimental groups (16.8% vs 16.0%). Among patients with a prior diagnosis of a mental disorder, twice as many were found to have mental disorders by the physicians as by the GHQ (70% vs 33%).