Analysis of colorectal cancer stage among HMO members targeted for screening.

BACKGROUND: This study is a retrospective analysis of data collected from patient medical records, a fecal occult blood test (FOBT) screening program, and computerized health maintenance organization (HMO) claims and encounters records. OBJECTIVE: To identify factors associated with a diagnosis of early (Dukes A and B) colorectal cancer among older adults targeted for annual FOBT screening. METHODS: Study subjects were insured by the former US Healthcare Inc (Blue Bell, Pa), an independent practice association-type HMO. The HMO was recently integrated into Aetna-US Healthcare. Before diagnosis, subjects were eligible for free annual FOBT screening through the HMO's colorectal cancer screening program. The study subjects included men and women (N = 222) who were aged 50 years or older and had a diagnosis of colorectal cancer between 1987 and 1990. Variables considered were patient age, gender, socioeconomic status, medical history, screening history, length of enrollment in the HMO, and stage of disease at diagnosis. RESULTS: Univariate analyses indicate that colorectal cancer diagnosis due to FOBT screening (P = .03), frequency of FOBT screening (P = .09), and length of HMO membership (P = .10) were positively related to being diagnosed as having early stage colorectal cancer. Multivariable analysis shows that having a screen-detected colorectal cancer was significantly and positively related (P = .03) to being diagnosed as having early stage disease. CONCLUSIONS: Findings support annual FOBT screening among older adults. Results illustrate the value of applying standard methods to the collection and analysis of patient data in a managed care context. The study also highlights a need for research on patient adherence to screening and physician follow-up of abnormal screening test results.

Physician intention to recommend complete diagnostic evaluation in colorectal cancer screening.

Primary care physicians (PCPs) often do not recommend complete diagnostic evaluation (CDE; i.e., diagnostic colonoscopy or the combination of flexible sigmoidoscopy and barium enema X-ray procedures) for patients with an abnormal screening fecal occult blood test (FOBT+) result. Information is needed to understand why PCPs do not recommend CDE. In the spring of 1994, a telephone survey was carried out using a random sample of 520 PCPs in Pennsylvania or New Jersey who had patients that were targeted for an FOBT screening program. Survey data were obtained from 363 (70%) PCPs on physician practice characteristics; personal background; perceptions concerning FOBT screening, CDE performance, and patient behavior; social influence related to CDE; and intention to recommend CDE for FOBT+ patients. Physician CDE intention scores were distributed as follows: low (22%), moderate (51%), and high (27%). Multivariate analyses demonstrate that physician board certification status, time in practice, belief in CDE efficacy, and belief that CDE is standard practice were positively associated with CDE intention, whereas concern about CDE-related costs was negatively associated with CDE intention. Among physicians in larger practices, perceived FOBT screening efficacy was negatively associated with CDE intention, and belief in the benefit of CDE was positively associated with outcome. There is substantial variability in CDE intention among PCPs. Physician perceptions about FOBT screening and follow-up are associated with CDE intention, are likely to influence CDE performance, and may be amenable to educational intervention. Additional research is needed to evaluate the impact of educational interventions on CDE intention and performance.

U.S. Healthcare's quality-based compensation model.

U.S. Healthcare has developed a quality-based compensation model through which its primary care physicians, hospitals, and specialists can earn additional compensation based on the quality and cost-effectiveness of the care they provide to their patients. The model clearly delineates the expectations of U.S. Healthcare, and in contrast with traditional payment models, encourages improvement in performance. In addition, the model aligns the incentives of U.S. Healthcare purchasers, participating providers, and members in order to provide high-quality, cost-effective care that maximizes patient outcomes.

Bridging the gap between managed care and academic medicine: an innovative fellowship.

Numerous challenges face academic medicine in the era of managed care. This environment is stimulating the development of innovative educational programs that can adapt to changes in the healthcare system. The U.S. Quality Algorithms Managed Care Fellowship at Jefferson Medical College is one response to these challenges. Two postresidency physicians are chosen as fellows each year. The 1-year curriculum is organized into four 3-month modules covering such subjects as biostatistics and epidemiology, medical informatics, the theory and practice of managed care, managed care finance, integrated healthcare systems, quality assessment and improvement, clinical parameters and guidelines, utilization management, and risk management. The fellowship may serve as a possible prototype for future post-graduate education.

Evolution of a quality-based compensation model: the third generation.

U.S. Healthcare (USHC) contracts for care with primary care physicians who are compensated through capitation (i.e., a fixed payment at specific intervals per member for all care provided, irrespective of the number of services). The amount of capitation is dependent upon their quality assessment rating and their ability to manage the cost of care effectively. In January of 1992 USHC implemented its current, third-generation incentive model and significantly altered its Quality Care Compensation System. The evolution of this model is presented to demonstrate that this third-generation Quality Care Compensation Model is a fair and effective means of measuring and valuing the delivery of health care to a population. It rewards physicians who expend the extra effort to manage both quality and cost. The experience of USHC continues to demonstrate that it is possible to develop and monitor incentive mechanisms in a systematic fashion with quality improvement as the outcome.

The measurement of physician performance.

There is growing interest in measuring the performance of physicians. At U.S. Healthcare (USHC), performance assessment is the responsibility of U.S. Quality Algorithms, one of its subsidiaries. This article discusses the development and application of certain measures employed to assess the performance of physicians and how compensation is linked to performance in USHC's quality-based compensation model.

Integration of quality assessment and physician incentives.

The ultimate challenge in dealing with any type of risk incentive system is to be able to integrate the quality of care and the cost of care into an equitable system and to monitor the system and detect either barriers to care or the withholding of appropriate services. We believe it is possible to do this and have based our incentive model upon this premise. At U.S. Healthcare, we have been successful in developing some measures of quality in the ambulatory setting and have tied the measurements to our payment mechanism.

The quality care cycle.

This paper describes an HMO--US Healthcare--which is based on a philosophy of quality-based managed health care. The paper shows how an individual patient interacts with the cycle of care in terms of risk evaluation, health education and prevention, diagnosis, treatment, referral, case management, and outcome. Other components of the cycle of care include primary certification and recertification of providers, criteria for procedure and site appropriateness, and evaluation of the professional qualifications of providers.

Organophosphates--a pediatric hazard.

These agents act as anticholinesterases. Signs of toxicity are: overactivity of the parasympathetic nervous system, nausea, vomiting, diarrhea, sweating, abdominal cramps and copious secretions. Large doses may cause sustained depolarization of the motor end plate, leading to muscular paralysis. Death may ensue from respiratory failure. The extensive and often careless use of insecticides, fungicides and pesticides makes organophosphates a particular pediatric hazard. Atropine and pralidoxime chloride are effective for therapy.

Myelofibrosis in children with chronic renal insufficiency.

During investigation of splenomegaly in a boy with chronic renal failure and osteodystrophy, bone marrow aspirates resulted in "dry taps," whereas biopsied material provided evidence that the marrow had been replaced by fibrous tissue. In a study of six other children with chronic renal failure, similar changes were observed. These findings suggest that the anemia of chronic renal failure may in part be a result of myelofibrosis, and the resulting reduction of functional bone marrow may limit the tolerance to immunosuppressive agents in patients who undergo renal transplantation.

Medicare managed care and the need for quality measurement.

With the increasing penetration of managed care as health insurance coverage for Medicare beneficiaries, accountability for quality of care is being demanded. While HEDIS 2.5 has become the standard for assessing the performance of health plans in caring for their commercial members, no such standard exists for Medicare enrollees. U.S. Quality Algorithms, the performance measurement subsidiary of U.S. Healthcare, has developed the Medicare Quality Report Card as a tool for performance assessment and quality improvement. This article describes how the measures of quality important to the Medicare population were chosen, how the measures were calculated, and how they have been used in programs designed to improve the quality of care for U.S. Healthcare Medicare members.

USQA Health Profile Database as a tool for health plan quality improvement.

Managed care organizations are in a unique position to evaluate and improve the quality of care delivered to their defined memberships. Traditionally, health services delivery has been claims-focused. We describe a potentially richer, patient-centered approach, whereby patients with certain chronic diseases are first identified and then used as the unit of analysis. U.S. Quality Algorithms (USQA), a subsidiary of U.S. Healthcare (USHC) based in Blue Bell, Pennsylvania, has developed selection criteria for 36 different chronic diseases and a new database, the USQA Health Profile Database (HPD), to identify and archive patients with those diseases. Examples of how this approach and database can be used as a quality tool are demonstrated.

Use of cancer susceptibility testing among primary care physicians.

Primary care physicians (PCPs) are assuming greater roles in cancer risk assessment and susceptibility testing of patients. The objective of this study was to assess the beliefs and practices of PCPs relative to genetic susceptibility testing for cancer. A cross-sectional survey was mailed to 726 PCPs in community-based practices in southeastern Pennsylvania and southern New Jersey. Data were collected on physician background, cognitive and psychosocial factors, practice environment, and patient factors. The main outcome measure was physician self-reported recommendation or referral of patients for cancer genetic susceptibility testing in a 12-month period prior to the survey. Of those surveyed, 475 (65%) PCPs responded. Complete survey data were available for 433 PCPs. Multivariable analyses show that factors positively associated with PCP recommendation/referral included: patient inquiry about their need for genetic testing for cancer (p < 0.001); PCP belief that patient age is the best predictor of cancer risk (p = 0.01); PCP self-reported frequency of collecting patient diet information (p = 0.01) and medical history information (p = 0.01); and PCP participation in an integrated health system (p = 0.01). PCP use of cancer genetic susceptibility testing may be influenced by patient inquiry, provider beliefs about factors that affect cancer risk, provider collection of risk-assessment data, and provider practice environment.

Measuring complete diagnostic evaluation in colorectal cancer screening.

Complete diagnostic evaluation, or CDE (i.e., a colonoscopy or combined barium enema X-ray and flexible sigmoidoscopy) is recommended for individuals who have an abnormal screening fecal occult blood test result. Accurate measures of CDE use are needed in colorectal cancer (CRC) screening programs. This study compares the sensitivity and specificity of different methods for measuring CDE recommendation and performance. We identified 17 primary-care practices with 120 patients who had a positive fecal occult blood test result in a CRC screening program operated by a managed-care organization. Approaches used to measure CDE recommendation and performance included external chart audit (ECA) only; internal chart audit (ICA) only; administrative data review (ADR) of electronic claims data; ICA plus ADR; and ECA plus ADR (the "gold standard"). Sensitivity and specificity of each method were assessed relative to CDE recommendation and performance as measured by ECA plus ADR. For CDE recommendation, sensitivity measures were ECA only, 0.926; ICA only, 0.790; ADR only, 0.617; and ICA plus ADR, 0.901. The specificity of each method for CDE recommendation was no less than 0.95. In terms of CDE performance, sensitivity measures were ECA only, 0.877; ICA only, 0.790; ADR only, 0.877; and ICA plus ADR, 0.965. The specificity of each method for CDE performance was 1.0. The ICA-plus-ADR method was a highly sensitive and specific measure of CDE use. This method should be considered in situations that involve primary-care physician follow-up of patients with abnormal CRC screening test results.

Developing an AHC-MCO alliance for research and care.

Academic health centers (AHCs) and managed care organizations (MCOs) appear to be on a collision course. Is it possible to develop a partnership to enable both parties to achieve their respective goals and objectives? The Kimmel Cancer Center of Thomas Jefferson University and AEtna US Healthcare, one of the nation's largest MCOs, have developed an alliance designed to generate cancer prevention and control research. This arrangement engages the participants in a collaborative effort that is aimed at creating new knowledge that can be used to enhance the provision of health care to a defined population.