Identifying High-Cost Medicare Beneficiaries: Impact of Neighborhood Socioeconomic Disadvantage.

The objective of this observational longitudinal study of Maryland fee-for-service Medicare beneficiaries (2015-2016) was to investigate whether using data on neighborhood socioeconomic disadvantage in addition to individual clinical risk data improves identification of high-cost Medicare beneficiaries. Neighborhood socioeconomic disadvantage is measured using the Area Deprivation Index (ADI), a validated composite measure based on publically-available US census data (2011-2015) for Maryland census block groups. Hierarchical Condition Categories (HCC) score, health care utilization, and spending were obtained from Centers for Medicare & Medicaid Services Chronic Condition Warehouse beneficiary file and Part A and Part B claims data (2015). Total cost of care (TCOC) was calculated for 2016. Descriptive and multivariate analyses were performed to examine the relationship of residency in neighborhoods with high ADI and subsequent year health care spending. Among 615,637 Maryland Medicare fee-for-service beneficiaries, those living in neighborhoods with the greatest disadvantage vs. the least disadvantage incur significantly greater costs in the subsequent year (ADI Quintile 5 $12,439 versus Quintile 1 $8920, P < .001). Clinical risk exacerbates this disparity. Among beneficiaries in the highest HCC score quintile, costs are 27% ($5458, P < .001) higher among beneficiaries in the highest compared with the lowest ADI quintiles without risk adjustment and 24% ($4599, P < .001) higher with risk adjustment. Several sensitivity analyses found the relationship between ADI and TCOC robust. Association between neighborhood socioeconomic disadvantage and health care cost is most pronounced among the most clinically complex Maryland Medicare beneficiaries. Using ADI in combination with HCC score may facilitate more precise targeting of care management resources.

Improving Value of Care for Older Adults With Advanced Medical Illness and Functional Decline: Cost Analyses of a Home-Based Palliative Care Program.

CONTEXT: Identifying high-value health care delivery for patients with clinically complex and high-cost conditions is important for future reimbursement models. OBJECTIVES: The objective of this study was to assess the Medicare reimbursement savings of an established palliative care homebound program. METHODS: This is a retrospective cohort study involving 50 participants enrolled in a palliative care homebound program and 95 propensity-matched control patients at Mayo Clinic in Rochester, Minnesota, between September 1, 2012, and March 31, 2013. Total Medicare reimbursement was compared in the year before enrollment with the year after enrollment for participants and controls. RESULTS: No significant differences were observed in demographic characteristics or prognostic indices between the two groups. Total Medicare reimbursement per program participant the year before program enrollment was $16,429 compared with $14,427 per control patient, resulting in $2004 higher charges per program patient. In 12 months after program enrollment, mean annual payment was $5783 per patient among participants and $22,031 per patient among the matched controls. In the second year, the intervention group had a decrease of $10,646 per patient; the control group had an increase of $7604 per patient. The difference between the participant group and control group was statistically significant (P < 0.001) and favored the palliative care homebound program enrollees by $18,251 (95% CI, $11,268-$25,234). CONCLUSION: The Mayo Clinic Palliative Care Homebound Program reduced annual Medicare expenditures by $18,251 per program participant compared with matched control patients. This supports the role of home-based palliative medicine in delivering high-value care to high-risk older adults.

Cardiorespiratory Fitness (Peak Oxygen Uptake): Safe and Effective Measure for Cardiovascular Screening Before Kidney Transplant.

BACKGROUND: Significant heterogeneity exists in practice patterns and algorithms used for cardiac screening before kidney transplant. Cardiorespiratory fitness, as measured by peak oxygen uptake (VO2peak), is an established validated predictor of future cardiovascular morbidity and mortality in both healthy and diseased populations. The literature supports its use among asymptomatic patients in abrogating the need for further cardiac testing. METHODS AND RESULTS: We outlined a pre-renal transplant screening algorithm to incorporate VO2peak testing among a population of asymptomatic high-risk patients (with diabetes mellitus and/or >50 years of age). Only those with VO2peak <17 mL/kg per minute (equivalent to <5 metabolic equivalents) underwent further noninvasive cardiac screening tests. We conducted a retrospective study of the a priori dichotomization of the VO2peak <17 versus ≥17 mL/kg per minute to determine negative and positive predictive value of future cardiac events and all-cause mortality. We report a high (>90%) negative predictive value, indicating that VO2peak ≥17 mL/kg per minute is effective to rule out future cardiac events and all-cause mortality. However, lower VO2peak had low positive predictive value and should not be used as a reliable metric to predict future cardiac events and/or mortality. In addition, a simple mathematical calculation documented a cost savings of ≈$272 600 in the cardiac screening among our study cohort of 637 patients undergoing evaluation for kidney and/or pancreas transplant. CONCLUSIONS: We conclude that incorporating an objective measure of cardiorespiratory fitness with VO2peak is safe and allows for a cost savings in the cardiovascular screening protocol among higher-risk phenotype (with diabetes mellitus and >50 years of age) being evaluated for kidney transplant.

Prediction of critical illness in elderly outpatients using elder risk assessment: a population-based study.

RATIONALE: Identifying patients at high risk of critical illness is necessary for the development and testing of strategies to prevent critical illness. The aim of this study was to determine the relationship between high elder risk assessment (ERA) score and critical illness requiring intensive care and to see if the ERA can be used as a prediction tool to identify elderly patients at the primary care visit who are at high risk of critical illness. METHODS: A population-based historical cohort study was conducted in elderly patients (age >65 years) identified at the time of primary care visit in Rochester, MN, USA. Predictors including age, previous hospital days, and comorbid health conditions were identified from routine administrative data available in the electronic medical record. The main outcome was critical illness, defined as sepsis, need for mechanical ventilation, or death within 2 years of initial visit. Patients with an ERA score of 16 were considered to be at high risk. The discrimination of the ERA score was assessed using area under the receiver operating characteristic curve. RESULTS: Of the 13,457 eligible patients, 9,872 gave consent for medical record review and had full information on intensive care unit utilization. The mean age was 75.8 years (standard deviation ±7.6 years), and 58% were female, 94% were Caucasian, 62% were married, and 13% were living in nursing homes. In the overall group, 417 patients (4.2%) suffered from critical illness. In the 1,134 patients with ERA >16, 154 (14%) suffered from critical illness. An ERA score ≥16 predicted critical illness (odds ratio 6.35; 95% confidence interval 3.51-11.48). The area under the receiver operating characteristic curve was 0.75, which indicated good discrimination. CONCLUSION: A simple model based on easily obtainable administrative data predicted critical illness in the next 2 years in elderly outpatients with up to 14% of the highest risk population suffering from critical illness. This model can facilitate efficient enrollment of patients into clinical programs such as care transition programs and studies aimed at the prevention of critical illness. It also can serve as a reminder to initiate advance care planning for high-risk elderly patients. External validation of this tool in different populations may enhance its generalizability.

Diabetes Knowledge, Attitudes and Behaviors Among Somali and Latino Immigrants.

Persons from Somalia constitute the largest group of immigrants and refugees from Africa among whom diabetes-related health disparities are well documented. As one of the first steps toward developing a behavioral intervention to address diabetes among Somali immigrants and refugees, we administered a face to face interview-based survey to Somali and Latino adults with diabetes in a single community to assess diabetes knowledge, attitudes and behaviors. Respondents (N = 78) reported several barriers to optimal diabetes management for physical activity and glucose self-monitoring, as well as a high burden of disease and negative perceptions of diabetes. High participant engagement in disease management, self-efficacy, and social support were important assets. Similarities suggest that the shared experiences of immigration and related systemic socioeconomic and linguistic factors play a significant role in the understanding and self-management of diabetes in these populations. Together with previously collected qualitative work, the survey findings will inform development of a behavioral intervention to improve outcomes and reduce diabetes-related health disparities among immigrant and refugee groups to the U.S.

The relationship between Elder Risk Assessment (ERA) scores and cardiac revascularization: a cohort study in Olmsted County, Minnesota, USA.

PURPOSE: The aging population is predisposed to cardiovascular disease. Our goal was to determine the relationship between a higher Elder Risk Assessment (ERA) score and coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), in adults over 60 years. METHODS: This was a retrospective cohort study in a primary care internal medicine practice. Patients included community-dwelling individuals aged 60 years or older on January 1, 2005. The primary outcome was a combined outcome of CABG and PCI in 2 years. The secondary outcome was mortality 5 years after CABG or PCI. The primary predictor variable was the score on the ERA Index, an instrument that predicts emergency room visits and hospitalization. The outcomes were obtained using administrative data from electronic medical records. The analysis included logistic regression, with odds ratios for the primary outcome and time-to-event analysis for mortality. RESULTS: The records of 12,650 patients were studied. A total of 902 patients (7.1%) had either CABG or PCI, with an average age of 74.5 years (±8.3 years). There were 205 patients (23%) who experienced CABG or PCI in the highest-score group (top 10%) compared with 29 patients (3%) in the lowest score group, for an odds ratio of 15.4; 95% confidence interval, 10.1-23.5. There was a greater association of revascularization events by increasing score group. We noted increased mortality by increasing ERA score, in patients undergoing CABG or PCI. The patients in the highest-scoring group had a 50% 5-year survival rate compared with a 97% 5-year survival rate in the lowest-scoring group (P < 0.001). CONCLUSION: Older adults in the highest-ERA-scoring group had the highest utilization of CABG or PCI. Patients with high ERA scores undergoing coronary revascularization were also at the highest risk of mortality. Providers should be aware that higher ERA scores can potentially predict outcomes in high-risk patients.

Characteristics of exclusive users of mind-body medicine vs. other alternative medicine approaches in the United States.

CONTEXT: Persons using one group of complementary and alternative medicine (CAM) may differ in important ways from users of other CAM therapies. OBJECTIVES: The aim of this study was to characterize the United States (US) adult population using exclusively mind-body medicine (MBM) and to determine if their characteristics differed from those using exclusively non-vitamin natural products. DESIGN/SETTING: Using the 2007 National Health Interview Survey (NHIS) and its periodic supplement on CAM use, descriptive characteristics of exclusive MBM users, as well as those using exclusively non-vitamin natural products were identified. PATIENTS: A total of 75,764 persons completing the 2007 NHIS with adults aged 18 years and older. MAIN OUTCOME MEASURES: Characteristics of MBM users, prevalence of MBM use, and characteristics of exclusive MBM users compared to exclusive non-vitamin natural product users. RESULTS: Among CAM users (N = 83,013,655), 21.8% of the adult population (age 18 or older) reported using exclusive MBM therapy. In multivariate models, exclusive MBM use was associated with female gender, higher educational attainment, younger age, residing in Northeast US, being Asian or black race, and a current smoker compared to those using exclusive non-vitamin natural products. Using bivariate comparisons, individuals that exclusively used MBM were more likely to be white females (60.5%), in a younger age category (18-39 years), educated beyond high school (68.3%), and more likely from the Southern US (32.4%). A greater level of depression in MBM users was noted compared to non-vitamin natural product users (6.6%).

Association of HbA1c with emotion regulation, intolerance of uncertainty, and purpose in life in type 2 diabetes mellitus.

BACKGROUND: The extant literature lacks breadth on psychological variables associated with health outcome for type 2 diabetes mellitus (T2DM). This investigation extends the scope of psychological information by reporting on previously unpublished factors. OBJECTIVE: To investigate if intolerance of uncertainty, emotion regulation, or purpose in life differentiate T2DM adults with sustained high HbA(1c) (HH) vs. sustained acceptable HbA(1c) (AH). SUBJECTS AND METHODS: Cross-sectional observational study. Adult patients with diagnosed T2DM meeting inclusionary criteria for AH, HH, or a nondiabetic reference group (NDR) were randomly selected and invited to participate. Patients who consented and participated resulted in a final sample of 312 subgrouped as follows: HH (n = 108); AH (n = 98); and NDR (n = 106). Data sources included a survey, self-report questionnaires, and electronic medical record (EMR). RESULTS: HH individuals with T2DM reported lower purpose in life satisfaction (p = 0.005) compared to the NDR group. The effect size for this finding is in the small-to-medium range using Cohen's guidelines for estimating clinical relevance. The HH-AH comparison on purpose in life was nonsignificant. The emotion regulation and intolerance of uncertainty comparisons across the three groups were not significant. CONCLUSIONS: The present study determined that lower purpose in life satisfaction is associated with higher HbA(1c). In a T2DM patient with sustained high HbA(1c), the primary care clinician is encouraged to consider screening for purpose in life satisfaction by asking a single question such as "Do the things you do in your life seem important and worthwhile?" The patient's response will assist the clinician in determining if meaning or purpose in life distress may be interferring with diabetes self-care. If this is the case, the clinician can shift the conversation to the value of behavioral and emotional health counseling.

Self-rated stress is noncontributory to coronary artery disease in higher socioeconomic strata.

Stress and its attendant psychosocial and lifestyle variables have been associated with coronary artery disease (CAD), yet the contribution of socioeconomic status (SES) has not been addressed. The aim of this study is to determine if stress assessment is associated with CAD independent of SES, and is incremental to the Framingham Score. The study group consisted of 325 executive patients undergoing comprehensive health assessment. Stress was assessed utilizing the validated "Self-Rated Stress" (SRS) instrument. Coronary artery calcification (CAC) served to assess the degree of atherosclerosis, a CAD equivalent and risk assessment tool. The relationship between SRS and CAC was assessed, with adjustment by potential confounders. CAC was modeled by a variety of cut points (>0, ≥5, ≥100, ≥200) for the test of trend across stress levels per Mantel-Haenszel chi-square (1 df) with nonsignificant P values of 0.9960, 0.5242, 0.1692, 0.3233, respectively. A logistic regression model with SRS as a categorically ranked and continuous variable to predict binary outcome of calcification yielded P values of 0.2366 and 0.9644; this relationship, further adjusted by age, fruit and vegetable consumption, exercise, and education, yielded no statistically significant association. No improvement of fit was observed for the established Framingham Score to CAC relation utilizing SRS. The study concluded that SRS did not play a role in early CAD when focusing on a population in higher socioeconomic strata, and SRS did not add predictive value beyond patient age or calculated Framingham risk. Future studies should focus on additional validated instruments of stress to differentiate between subtypes of stress for varying SES strata.

The Elders Risk Assessment Index, an electronic administrative database-derived frailty index, can identify risk of hip fracture in a cohort of community-dwelling adults.

OBJECTIVE: To determine whether an Elders Risk Assessment (ERA) index can predict incident hip fractures without the need for physician-patient encounter or bone mineral density testing. PATIENTS AND METHODS: A retrospective cohort study was conducted in a community-based cohort of 12,650 patients aged 60 years and older. An ERA score was computed for each subject at index time (January 1, 2005). Incidents of hip fracture from January 1, 2005, through December 31, 2006, were obtained from electronic medical records. We divided the cohort into 5 groups, with the lowest ERA scores forming group A (<15%); 15% to 49%, group B; 50% to 74%, group C; 75% to 89%, group D; and the top 11%, group E. With group A as a reference group, we used logistic regression to compute odds ratios of sustaining hip fracture during a 2-year period (January 1, 2005, through December 31, 2006) for groups B, C, D, and E. Sensitivity and specificity of each possible ERA score were calculated, and a receiver operating characteristic curve was created. RESULTS: Two hundred sixty-five patients (2.1%) sustained at least 1 hip fracture from January 1, 2005, through December 31, 2006. Odds ratios (95% confidence intervals) for groups B, C, D, and E were 1.6 (0.7-3.4), 4.5 (2.2-9.4), 6.9 (3.3-14.3), and 18.4 (8.9-37.9), respectively. The area under the receiver operating characteristic curve was 74.5%. CONCLUSION: An electronic medical record-based, easily derived ERA index might be useful in hip fracture risk stratification.

Disparities in preventive health services among Somali immigrants and refugees.

African immigrants and refugees-almost half of them from Somalia-account for one of the fastest-growing groups in the United States. There is reason to suspect that Somali-Americans may be at risk for low completion of recommended preventive health services. This study's aim was to quantify disparities in preventive health services among Somali patients compared with non-Somali patients in an academic primary care practice in Rochester, Minn. It also examined the effect of medical interpreters, emergency department visits, and primary care visits on the completion of preventive services. Rates of pap smears, vaccinations (influenza, pneumococcus, and tetanus), lipid screening, colorectal cancer screening, and mammography were assessed in Somali and non-Somali patients during the second quarter of 2008. Data were collected regarding the utilization of medical interpreters, emergency services, and primary care services among Somali patients. Results were reported using standard descriptive statistics. Of the 91,557 patients identified in the database, 810 were Somali. Somali patients had significantly lower completion rates of colorectal cancer screening, mammography, pap smears, and influenza vaccination than non-Somali patients. Use of medical interpreters and primary care services were generally associated with higher completion rates of preventive services. There are significant discrepancies in the provision of preventive health services to Somali patients compared with that of non-Somali patients. These findings suggest the need to identify the root causes of these discrepancies so that interventions may be crafted to close the gap.

Diabetes care among Somali immigrants and refugees.

The risk for development of diabetes and associated complications among immigrants increases in the years after arrival to the United States. Somali immigrants and refugees represent the largest subset of African immigrants to the United States, yet little is known about the quality of their diabetes care. Therefore, adherence with diabetes quality indicators (Hemoglobin A1C <7%, LDL cholesterol <100 mg/dl, blood pressure <130/80 mm Hg) were compared between Somali and non-Somali patients with diabetes at a large academic primary care practice in the United States in 2008. Demographic and health-seeking behavior variables were assessed for association with adherence among the Somali population. A total of 5,843 non-Somali and 81 Somali patients with diabetes were identified. Somali patients with diabetes were less likely to meet the criteria for optimal glycemic control than non-Somali patients (40.6% vs. 53.9%; P=0.02). There was a similar, though statistically non-significant, trend towards lower rates of lipid control among Somali patients. There was no difference in achievement of optimal blood pressure between the two groups. There was a strong association between number of primary care visits during the study interval and achievement of all three diabetes care quality goals. This study demonstrates disparities in achievement of diabetes management quality goals among Somali patients compared with non-Somali patients, highlighting the need for additional system and practice changes to target this particularly vulnerable population.

Risk factors for pressure ulceration in an older community-dwelling population.

BACKGROUND: Older adults frequently experience pressure ulcers (PrUs) and suffer the risks of the ulceration. Risk factors for PrUs remain unclear in a community population. OBJECTIVE: The objective of this study was to determine the risk factors for future pressure ulceration in a community sample. DESIGN: This was a retrospective cohort study. PATIENTS: All patients older than 60 years in a primary care panel in Olmsted County, Minnesota, on January 1, 2005, were enrolled (n = 12,650). METHODS AND OUTCOMES: The primary outcome was a new diagnosis of pressure ulceration within 40 months of index date. The predictor risk variables included demographic and comorbid health risk factors. The data were analyzed using univariable and multivariable logistic regression. The authors created a final model based on multivariable risk factors. MAIN RESULTS: Of 12,650 patients, 366 patients developed an incident PrU (2.9%). In the final model, age, male sex, and long-term-care facility admission were significant factors. Prior pressure ulceration with an odds ratio of 5.60 (95% confidence interval, 3.86-8.14) was the largest risk factor. Diabetes, falls, cataracts, renal insufficiency, and peripheral vascular disease were also associated with PrU development. CONCLUSION: PrU development involves important risk factors of prior PrU development and long-term-care facility placement as the 2 largest risk factors. Both factors are easily determined by history. Increasing age and comorbid medical conditions also impact PrU development as important risk factors for PrU development.

A reliable billing method for internal medicine resident clinics: financial implications for an academic medical center.

BACKGROUND: The financial success of academic medical centers depends largely on appropriate billing for resident-patient encounters. Objectives of this study were to develop an instrument for billing in internal medicine resident clinics, to compare billing practices among junior versus senior residents, and to estimate financial losses from inappropriate resident billing. METHODS: For this analysis, we randomly selected 100 patient visit notes from a resident outpatient practice. Three coding specialists used an instrument structured on Medicare billing standards to determine appropriate codes, and interrater reliability was assessed. Billing codes were converted to US dollars based on the national Medicare reimbursement list. Inappropriate billing, based on comparisons with coding specialists, was then determined for residents across years of training. RESULTS: Interrater reliability of Current Procedural Terminology components was excellent, with κ ranging from 0.76 for examination to 0.94 for diagnosis. Of the encounters in the study, 55% were underbilled by an average of $45.26 per encounter, and 18% were overbilled by an average of $51.29 per encounter. The percentages of appropriately coded notes were 16.1% for postgraduate year (PGY) 1, 26.8% for PGY-2, and 39.3% for PGY-3 residents (P < .05). Underbilling was 74.2% for PGY-1, 48.8% for PGY-2, and 42.9% for PGY-3 residents (P < .01). There was significantly less overbilling among PGY-1 residents compared with PGY-2 and PGY-3 residents (9.7% versus 24.4% and 17.9%, respectively; P < .05). CONCLUSIONS: Our study reports a reliable method for assessing billing in internal medicine resident clinics. It exposed large financial losses, which were attributable to junior residents more than senior residents. The findings highlight the need for educational interventions to improve resident coding and billing.

Quantitative assessment of strain and strain rate by velocity vector imaging during dobutamine stress echocardiography to predict outcome in patients with left bundle branch block.

BACKGROUND: Abnormal septal motion in left bundle branch block (LBBB) may compromise the interpretation of regional wall motion. Velocity vector imaging (VVI) has been proposed as an objective method to quantify regional myocardial deformation. The aim of this study was to determine whether VVI during dobutamine stress echocardiography (DSE) has prognostic value in patients with LBBB. METHODS: In 84 patients with (mean age, 75 +/- 9 years) undergoing DSE, longitudinal peak systolic strain (epsilon(sys)) and strain rate (SR(sys)) were measured in 16 segments using VVI. Results were expressed as average SR(sys) and epsilon(sys) per patient. Follow-up was obtained for the combined endpoint of mortality, myocardial infarction, and coronary revascularization. Contributions of clinical, conventional dobutamine stress echocardiographic, and epsilon(sys) and SR(sys) variables to outcome were assessed using Cox models. RESULTS: During a mean follow-up period of 18.3 +/- 13.8 months, 23 patients had endpoints. Wall motion score index at rest was the only independent predictor in a model combining clinical and conventional dobutamine stress echocardiographic variables. However, when epsilon(sys) and SR(sys) variables were considered, average SR(sys) at peak stress (hazard ratio, 2.38 per 0.2/s increment; 95% confidence interval, 1.53-3.88; P < .0001) became the only independent predictor of outcome. Using average SR(sys) at peak of -0.5/s as the cut point maximized the model chi(2) value for the prediction of outcomes (model chi(2) = 18.71, P = .002). The annualized event-free survival in patients with average SR(sys) at peak stress lower and higher than -0.5/s were 89.9% and 45.9%, respectively (P < .0001). CONCLUSION: Average SR(sys) at peak stress during DSE offers prognostic information incremental to wall motion analysis in patients with LBBB.

Educational effectiveness of a personal digital assistant-based geriatric assessment tool.

BACKGROUND: Although personal digital assistant use among residents is common, few outcomes-based studies have examined the impact of this technology on medical education. AIMS: We evaluated the educational effectiveness of a personal digital assistant-based geriatric assessment tool. METHODS: Internal medicine residents were enrolled as subjects. Personal digital assistant users were randomly assigned to receive or not receive a geriatric assessment tool for use on their device. Outcome measures included pretest/posttest performance and tabulation of geriatric functional issues on hospital dismissal summaries. RESULTS: Seventy-two residents participated. Of these, 38 (53%) reported personal digital assistant use. Twenty were assigned to receive the geriatric assessment tool. Average change between pretest and posttest scores was highest for the group using the geriatric assessment tool on a personal digital assistant (2.8, P=0.01). This group also had the highest average posttest score and the highest average number of geriatric functional issues identified on dismissal summaries, but neither value was significantly different from respective averages for the other study groups. CONCLUSIONS: Residents who used a personal digital assistant-based geriatric assessment tool demonstrated greater improvement in geriatric knowledge than peers who did not use this resource. Curricula adapted to this technology may prove useful in medical education.

Quality of care for acute myocardial infarction at urban safety-net hospitals.

Safety-net hospitals are experiencing increasing financial strains, possibly affecting their quality of care. We compare quality at safety-net and non-safety-net urban hospitals for Medicare beneficiaries admitted with acute myocardial infarction (AMI). Although safety-net hospitals had modestly higher risk-standardized thirty-day all-cause mortality rates and modestly lower adherence to quality-of-care performance measures than non-safety-net hospitals, there was much heterogeneity among safety-net hospitals and substantial overlap with non-safety-net hospitals. We examine the implications of these findings for the millions of vulnerable Americans who rely on safety-net hospitals for their care.

Innovative reflecting interview: effect on high-utilizing patients with medically unexplained symptoms.

This pilot study was conducted to determine the effect of an innovative reflecting interview on the health care utilization, physical health, mental function, and health care satisfaction of high-utilizing primary care patients with medically unexplained physical symptoms. Twenty-four high-utilizing patients met study selection criteria and were randomly assigned to a no-intervention control group or a reflecting interview intervention group. Outcomes were measured at 4 weeks, 6 months, and 1 year after the date of study enrollment. Results indicated that high-utilizing patients with medically unexplained physical symptoms who participated in a reflecting interview had reduced total health care costs, primarily through the reduction of hospitalization or inpatient expenses, despite a modest increase in outpatient primary care clinic visits. These data suggest that participation in a reflecting interview and regular visits with a primary care clinician can decrease health care utilization without adversely affecting patient satisfaction.

Two-dimensional echocardiographic methods for assessment of left atrial volume.

Left atrial (LA) size is an important predictor of cardiovascular events. Various methods of LA volume assessment exist, but their differences have not been defined. This prospective study included 631 patients (331 men; mean age of 68 +/- 14 years) without a history of atrial arrhythmias, stroke, valvular heart disease, pacemaker implantation, or congenital heart disease. All underwent echocardiography with comprehensive diastolic function assessment and LA volume measurement by 3 commonly used methods: biplane area-length, biplane Simpson's method, and the prolate-ellipsoid method. Mean LA volumes were 39 +/- 14 ml/m2 by the area-length method, 38 +/- 13 ml/m2 by the Simpson's method, and 32 +/- 14 ml/m2 by the prolate-ellipsoid method. In 92% of patients, the prolate measurement was smaller than the 2 biplane methods. Pairwise correlations (r) were 0.98 for area-length versus Simpson's, 0.85 for prolate versus area-length, and 0.86 for prolate versus Simpson's (all p values <0.001). For distinguishing normal (n = 62) from pseudonormal diastolic function (n = 240) using receiver-operating curve analysis, areas under the curves were 0.76, 0.78, and 0.75 for the area-length, Simpson's, and prolate methods, respectively (all p values <0.001, no significant intermethod differences). In conclusion, our findings suggest that there are systematic differences among existing LA volume methods. Biplane area-length and Simpson's methods compare closely, whereas the prolate-ellipsoid method generally yields smaller volumes.