Osteoarthritis-related difficulty walking and risk for diabetes complications.

OBJECTIVES: To examine the effect of Osteoarthritis (OA)-related difficulty walking on risk for diabetes complications in persons with diabetes and OA. DESIGN: A population cohort aged 55+ years with symptomatic hip and knee OA was recruited 1996-98 and followed through provincial administrative data to 2015 (n = 2,225). In those with confirmed OA (examination and radiographs) and self-reported diabetes at baseline (n = 359), multivariate Cox regression modeling was used to examine the relationship between baseline difficulty walking (Health Assessment Questionnaire (HAQ) difficulty walking score; use of walking aid) and time to first diabetes-specific complication (hospitalization for hypo- or hyperglycemia, infection, amputation, retinopathy, or initiation of chronic renal dialysis) and cardiovascular (CV) events. RESULTS: Participants' mean baseline age was 71.4 years; 66.9% were female, 77.7% had hypertension, 54.0% had pre-existing CV disease, 42.9% were obese and 15.3% were smokers. Median HAQ difficulty walking score was 2/3 indicating moderate to severe walking disability; 54.9% used a walking aid. Over a median 6.1 years, 184 (51.3%) experienced one or more diabetes-specific complications; 191 (53.2%) experienced a CV event over a median 5.7 years. Greater baseline difficulty walking was associated with shorter time to the first diabetes-specific complication (adjusted HR per unit increase in HAQ walking 1.24, 95% CI 1.04-1.47, P = 0.02) and CV event (adjusted HR for those using a walking aid 1.35, 95% CI 1.00-1.83, P = 0.04). CONCLUSIONS: In a population cohort with OA and diabetes, OA-related difficulty walking was a significant - and potentially modifiable - risk factor for diabetes complications.

Gender differences in the impact of poverty on health: disparities in risk of diabetes-related amputation.

AIMS: To assess the combined impact of socio-economic status and gender on the risk of diabetes-related lower extremity amputation within a universal healthcare system. METHODS: We conducted a population-based cohort study using administrative health databases from Ontario, Canada. Adults with pre-existing or newly diagnosed diabetes (N = 606 494) were included and the incidence of lower extremity amputation was assessed for the period 1 April 2002 to 31 March 2009. Socio-economic status was based on neighbourhood-level income groups, assigned to individuals using the Canadian Census and their postal code of residence. RESULTS: Low socio-economic status was associated with a significantly higher incidence of lower extremity amputation (27.0 vs 19.3 per 10,000 person-years in the lowest (Q1) vs the highest (Q5) socio-economic status quintile. This relationship persisted after adjusting for primary care use, region of residence and comorbidity, and was greater among men (adjusted Q1:Q5 hazard ratio 1.41, 95% CI 1.30-1.54; P < 0.0001 for all male gender-socio-economic status interactions) than women (hazard ratio 1.20, 95% CI 1.06-1.36). Overall, the incidence of lower extremity amputation was higher among men than women (hazard ratio for men vs women: 1.87, 95% CI 1.79-1.96), with the greatest disparity between men in the lowest socio-economic status category and women in the highest (hazard ratio 2.39, 95% CI 2.06-2.77 and hazard ratio 2.30, 95% CI 1.97-2.68, for major and minor amputation, respectively). CONCLUSIONS: Despite universal access to hospital and physician care, we found marked socio-economic status and gender disparities in the risk of lower extremity amputation among patients with diabetes. Men living in low-income neighbourhoods were at greatest risk.

End of life care for women with gynecologic cancers.

BACKGROUND: Little is known about patterns of end of life (EOL) care in gynecologic cancer patients. This paper reports on five EOL quality indicators: (1) chemotherapy in last 2 weeks of life (2) death in an acute care bed (3) emergency department visits in last 2 weeks of life (4) home care (nursing) visits in last 6 months of life (5) physician house calls in last 2 weeks of life. METHODS: A population-based, retrospective cohort study using administrative sources of health care data which was conducted as part of the Project for an Ontario Women's Health Report Card. It describes five health services received near the EOL by women who died of ovarian, uterine or cervical cancer in 2003-2004 in Ontario, Canada. Measures were stratified by age, income and region. RESULTS: The cohort included 2040 women. Four percent received chemotherapy, 34% visited the emergency department; 27% received a physician house call; 73% received a home care visit; and 51% died in an acute care bed. Older age was associated with lower use of each service. Living in a lower income neighborhood was associated with lower physician home visits. Regional variation across the province was observed for 3 indicators. INTERPRETATION: Observations made in this study can be used to inform interventions to improve EOL care for women with gynecological cancers. Tracking indicators over time serves to monitor response to improvement interventions. Reporting on the specific needs of this population helps assure that gaps in this domain of care are addressed.

Constructs of burden of illness in older patients with breast cancer: a comparison of measurement methods.

OBJECTIVE: The burden of illness can influence treatment decisions, but there are limited data comparing the performance of different illness burden measures. We assessed the correlations between five previously validated measures of illness burden and global health and physical function and evaluated how each measure correlates with breast cancer treatment patterns in older women. DATA SOURCE: A cohort of 718 women > 67 years with early-stage breast cancer formed the study group. STUDY DESIGN/DATA COLLECTION METHODS: The study made a cross-sectional comparison of illness burden measures (Charlson index, Index of Co-existent Diseases, cardiopulmonary burden of illness, patient-specific life expectancy, and disease counts) and physical function and self-rated global health status. Data were collected from records and patient interviews. PRINCIPAL FINDINGS: All of the measures were significantly correlated with each other and with physical function and self-rated health (p < .001). After controlling for age and stage, life expectancy had the largest effect on surgical treatment, followed by self-rated physical function and health; life expectancy was also independent of physical function. For instance, women with higher life expectancy and better self-rated physical function and health were more likely to receive breast conservation and radiation than sicker women. Women with higher physical functioning were more likely to receive adjuvant chemotherapy than women with lower functioning. CONCLUSIONS: Several measures of illness burden were associated with breast cancer therapy, but each measure accounted for only a small amount of variance in treatment patterns. Future work is needed to develop and validate measures of burden of illness that are feasible, comprehensive, and relevant for diverse clinical and health services objectives.

Making capitated Medicare work for women: policy and research challenges.

Growth in capitated Medicare has special ramifications for older women who comprise the majority of Medicare beneficiaries. Older women are more likely than men to have chronic conditions that lead to illness and disability, and they often have fewer financial and social resources to cope with these problems. Gender differences in health status have a number of important implications for the financing and delivery of care for older women under both traditional fee-for-service Medicare and capitation. The utilization of effective preventive interventions, new therapeutic interventions for the management of common chronic disorders, and more cost-effective models of chronic disease management could potentially extend the active life expectancy of older women. However, there are financial and delivery system barriers to achieving these objectives. Traditional FFS Medicare has gaps in coverage of care for chronic illness and disability that disproportionately impact women. Managed care potentially offers flexibility to allocate resources creatively, to develop new models of care, and offer enhanced benefits with lower out-of-pocket costs. However, challenges to realizing this potential under Medicare managed care with unique implications for older women include: possible gender bias in capitation payments, risk selection, inadequacy of risk adjustment models, benefit and market instability, and disenrollment patterns.

Quality and outcomes of care for older women with chronic disease.

This is the fourth in a series of six papers that will be published from the 1999 lecture series on "Quality Assessment in Women's Health Care" held at the University of Michigan School of Public Health. The lectures are presented by leaders in women's health research, and they explore key issues in the definition, measurement, and improvement of quality in women's health services. The series is supported by an unrestricted educational grant from Pfizer Inc. and is presented by the Interdepartmental Concentration in Reproductive and Women's Health at the University of Michigan School of Public Health; the University of Michigan National Center of Excellence in Women's Health; and the Michigan Initiative for Women's Health. The series coordinator is Carol S. Weisman, PhD, and Catherine L. Maroney prepared the summary of the discussants' comments.

Implementing a strategy for improving care: lessons from studying those age 80 and older in a health system.

This article describes some potential solutions to the many practical barriers that arise when trying to improve clinical care in everyday practice. A useful mnemonic for incorporating measurement into daily work is called GAPS--setting Goals, Assessing the current processes, Planning a new approach, and Starting it. The 80+ Project represents a foundation of information and offers promise to create durable, productive interactions for elderly individuals and their health care providers.

Assessing access as a first step toward improving the quality of care for very old adults.

Understanding the barriers to obtaining care that the population of people age 80 and older (80+) experiences is one of the first steps toward developing organizational and clinical strategies aimed at improving care. This article reviews the data from the 80+ Project's survey to assess the prevalence of barriers to care and identify the characteristics that place the 80+ population at risk. Barriers to access for older adults occur on many levels. Ultimately, the ability to improve health outcomes through reducing barriers to care is dependent on the effectiveness and quality of care received. By recognizing the barriers to care that limit access, health care professionals can begin to develop strategies to eliminate these barriers and improve the health care of older adult patients.

The population of people age 80 and older: a sentinel group for understanding the future of health care in the United States.

Those age 80 years or older (80+) constitute a relatively small percentage of a health care system's population. However, because of the associated risks, costs, and variation of their medical care, 80+ patients are sentinel for elder care quality. This article describes the survey components of the 80+ Project. This project was designed to help clinicians gain a complete picture of the special needs of the 80+ population. The information about these patients' health and functional status, how they utilize health care resources, how they obtain access to care, and their satisfaction with the care is useful for clinicians who wish to improve health care delivery.

Health disparities among older women: identifying opportunities to improve quality of care and functional health outcomes.

Older women experience a high burden of chronic illness, disability, and comorbidity, and this burden is highest among socioeconomically disadvantaged and minority women. The consequences of a mismatch between the organization, delivery, and financing of health care for older women and their actual needs fall disproportionately on low-income and minority women. New sources of data, such as the Medicare Health Outcomes Survey, a new quality measure for Medicare+Choice plans, will provide valuable information to practitioners about the health and functioning of older women in general and about socioeconomically disadvantaged and minority women in particular. This information can be used to develop and implement interventions to improve the quality and outcomes of care for vulnerable subgroups of older women. There is cause for optimism that by improving the quality of clinical preventive services and the management of common chronic conditions and geriatric syndromes it will be possible to improve functional health outcomes, prevent or postpone disability, and extend active life expectancy for all older women while making progress toward eliminating health disparities among the most disadvantaged.

Functional health outcomes as a measure of health care quality for Medicare beneficiaries.

OBJECTIVE: the Medicare Health Outcomes Survey (HOS), a new quality measure in the Health Plan Employer Data and Information Set, is designed to assess physical and mental functional health outcomes of Medicare beneficiaries enrolled in Medicare+Choice organizations. We discuss the rationale for the HOS measure together with methodologic challenges in its use and interpretation, using descriptive data from the baseline Medicare HOS to illustrate some of these challenges. DATA SOURCES/STUDY DESIGN: The 1999 Cohort 2 Medicare HOS baseline data were used for a cross-sectional descriptive analysis. A random sample of 1,000 beneficiaries from each health plan with a Medicare+Choice contract was surveyed (N = 156,842; 282 organizations included in these analyses) . PRINCIPAL FINDINGS: The HOS measure is designed to assess a previously unmeasured dimension of quality. Plan-level variation was seen across all baseline measures of sociodemographic characteristics and illness burden. At the individual level socioeconomic position as measured by educational attainment was strongly associated with functional status. The least educated beneficiaries had the highest burden of illness on all measures examined, and there was a consistent and significant gradient in health and functional status across all levels of education. In analyses stratified by race and ethnicity, socioeconomic gradients in f un ct ion persist ed. CONCLUSIONS Despite limitations, by focusing at t en t ion on the need to improve functional health out comes among elderly Medicare beneficiaries enrolled in Medicare+Choice, the HOS can serve as an important new tool to support efforts to improve health care quality. The HOS provides valuable information at the federal, state, and health plan levels that can be used to identify, prioritize, and evaluate quality improvement interventions and monitor progress for the program overall as well as for vulnerable subgroups. To interpret the HOS as a quality measure individual-and plan-level differences in functional status and illness burden, as well as methodologic issues in health status measurement, need to be recognized and addressed.

How well does a single question about health predict the financial health of Medicare managed care plans?

CONTEXT: Responses to simple questions that predict subsequent health care utilization are of interest to both capitated health plans and the payer. OBJECTIVE: To determine how responses to a single question about general health status predict subsequent health care expenditures. DESIGN: Participants in the 1992 Medicare Current Beneficiary Survey were asked the following question: "In general, compared to other people your age, would you say your health is: excellent, very good, good, fair or poor?" To obtain each participant's total Medicare expenditures and number of hospitalizations in the ensuing year, we linked the responses to this question with data from the 1993 Medicare Continuous History Survey. SAMPLE: Nationally representative sample of 8775 noninstitutionalized Medicare beneficiaries 65 years of age and older. MAIN OUTCOME MEASURES: Annual age- and sex-adjusted Medicare expenditures and hospitalization rates. RESULTS: Eighteen percent of the beneficiaries rated their health as excellent, 56% rated it as very good or good, 17% rated it as fair, and 7% rated it as poor. Medicare expenditures had a marked inverse relation to self-assessed health ratings. In the year after assessment, age- and sex-adjusted annual expenditures varied fivefold, from $8743 for beneficiaries rating their health as poor to $1656 for beneficiaries rating their health as excellent. Hospitalization rates followed the same pattern: Respondents who rated their health as poor had 675 hospitalizations per 1000 beneficiaries per year compared with 136 per 1000 for those rating their health as excellent. CONCLUSIONS: The response to a single question about general health status strongly predicts subsequent health care utilization. Self-reports of fair or poor health identify a group of high-risk patients who may benefit from targeted interventions. Because the current Medicare capitation formula does not account for health status, health plans can maximize profits by disproportionately enrolling beneficiaries who judge their health to be good. However, they are at a competitive disadvantage if they enroll beneficiaries who view themselves as sick.

Potentially inappropriate medication use in the community-dwelling elderly: findings from the 1996 Medical Expenditure Panel Survey.

CONTEXT: Inappropriate medication use is a major patient safety concern, especially for the elderly population. Using explicit criteria, prior studies have found that 23.5% and 17.5% of the US community-dwelling elderly population used at least 1 of 20 potentially inappropriate medications in 1987 and 1992, respectively. OBJECTIVES: To determine the prevalence of potentially inappropriate medication use in community-dwelling elderly persons in 1996, to assess trends over 10 years, categorize inappropriate medication use according to explicit criteria, and to examine risk factors for inappropriate medication use. DESIGN, SETTING, AND PARTICIPANTS: Respondents aged 65 years or older (n = 2455) to the 1996 Medical Expenditure Panel Survey, a nationally representative survey of the US noninstitutionalized population were included. A 7-member expert panel was convened to categorize inappropriate medications. MAIN OUTCOME MEASURE: Prevalence of use of 33 potentially inappropriate medications. RESULTS: In 1996, 21.3% (95% confidence interval [CI], 19.5%-23.1%) of community-dwelling elderly patients in the United States received at least 1 of 33 potentially inappropriate medications. Using the expert panel's classifications, about 2.6% of elderly patients (95% CI, 2.0%-3.2%) used at least 1 of the 11 medications that should always be avoided by elderly patients; 9.1% (95% CI, 7.9%-10.3%) used at least 1 of the 8 that would rarely be appropriate; and 13.3% (95% CI, 11.7%-14.9%) used at least 1 of the 14 medications that have some indications but are often misused. Use of some inappropriate medications declined between 1987 and 1996. Persons with poor health and more prescriptions had a significantly higher risk of inappropriate medication use. CONCLUSIONS: Overall inappropriate medication use in elderly patients remains a serious problem. Despite challenges in using explicit criteria for assessing inappropriate medications for elderly patients, such criteria can be applied to population-based surveys to identify opportunities to improve quality of care and patient safety. Enhancements of existing data sources to include dosage, duration, and indication may augment national improvement and monitoring efforts.

The future of capitation: the physician role in managing change in practice.

Capitation-based reimbursement significantly influences the practice of medicine. As physicians, we need to assure that payment models do not jeopardize the care we provide when we accept higher levels of personal financial risk. In this paper, we review the literature relevant to capitation, consider the interaction of financial incentives with physician and medical risk, and conclude that primary care physicians need to work to assure that capitated systems incorporate checks and balances which protect both patients and providers. We offer the following proposals for individuals and groups considering capitated contracts: (1) reimbursement for primary care physicians should recognize both individual patient encounters and the administrative work of patient care management; (2) reimbursement for subspecialists should recognize both access to subspecialty knowledge and expertise as well as patient care encounters, but in some situations, subspecialists may provide the majority of care to individual patients and will be reimbursed as primary care providers; (3) groups of physicians should accept financial risk for patient care only if they have the tools and resources to manage the care; (4) physicians sharing risk for patient care should meet regularly to discuss care and resource management; and (5) physicians must disclose the financial relationships they have with health plans and medical care organizations, and engage patients and communities in discussions about resource allocation. As a payment model, capitation offers opportunities for primary care physicians to influence the future of health care by improving the management of resources at a local level.