A packaged intervention to improve viral load monitoring within a deeply rural health district of South Africa.

BACKGROUND: The KwaZulu-Natal (KZN) province of South Africa has the highest prevalence of HIV infection in the world. Viral load (VL) testing is a crucial tool for clinical and programmatic monitoring. Within uMkhanyakude district, VL suppression rates were 91% among patients with VL data; however, VL performance rates averaged only 38·7%. The objective of this study was to determine if enhanced clinic processes and community outreach could improve VL monitoring within this district. METHODS: A packaged intervention was implemented at three rural clinics in the setting of the KZN HIV AIDS Drug Resistance Surveillance Study. This included file hygiene, outreach, a VL register and documentation revisions. Chart audits were used to assess fidelity. Outcome measures included percentage VL performed and suppressed. Each rural clinic was matched with a peri-urban clinic for comparison before and after the start of each phase of the intervention. Monthly sample proportions were modelled using quasi-likelihood regression methods for over-dispersed binomial data. RESULTS: Mkuze and Jozini clinics increased VL performance overall from 33·9% and 35·3% to 75·8% and 72·4%, respectively which was significantly greater than the increases in the comparison clinics (RR 1·86 and 1·68, p < 0·01). VL suppression rates similarly increased overall by 39·3% and 36·2% (RR 1·84 and 1·70, p < 0·01). The Chart Intervention phase showed significant increases in fidelity 16 months after implementation. CONCLUSIONS: The packaged intervention improved VL performance and suppression rates overall but was significant in Mkuze and Jozini. Larger sustained efforts will be needed to have a similar impact throughout the province.

Comparative analyses of published cost effectiveness models highlight critical considerations which are useful to inform development of new models.

Background: Comparative analyses of published cost effectiveness models provide useful insights into critical issues to inform the development of new cost effectiveness models in the same disease area.Objective: The purpose of this study was to describe a comparative analysis of cost-effectiveness models and highlight the importance of such work in informing development of new models. This research uses genotypic antiretroviral resistance testing after first line treatment failure for Human Immunodeficiency Virus (HIV) as an example.Method: A literature search was performed, and published cost effectiveness models were selected according to predetermined eligibility criteria. A comprehensive comparative analysis was undertaken for all aspects of the models.Results: Five published models were compared, and several critical issues were identified for consideration when developing a new model. These include the comparator, time horizon and scope of the model. In addition, the composite effect of drug resistance prevalence, antiretroviral therapy efficacy, test performance and the proportion of patients switching to second-line ART potentially have a measurable effect on model results. When considering CD4 count and viral load, dichotomizing patients according to higher cost and lower quality of life (AIDS) versus lower cost and higher quality of life (non-AIDS) status will potentially capture differences between resistance testing and other strategies, which could be confirmed by cross-validation/convergent validation. A quality adjusted life year is an essential outcome which should be explicitly explored in probabilistic sensitivity analysis, where possible.Conclusions: Using an example of GART for HIV, this study demonstrates comparative analysis of previously published cost effectiveness models yields critical information which can be used to inform the structure and specifications of new models.

Multilevel analysis of the Be Active Eat Well intervention: environmental and behavioural influences on reductions in child obesity risk.

BACKGROUND: The Be Active Eat Well (BAEW) community-based child obesity prevention intervention was successful in modestly reducing unhealthy weight gain in primary school children using a multi-strategy and multi-setting approach. OBJECTIVE: To (1) examine the relationship between changes in obesity-related individual, household and school factors and changes in standardised child body mass index (zBMI), and (2) determine if the BAEW intervention moderated these effects. METHODS: The longitudinal relationships between changes in individual, household and school variables and changes in zBMI were explored using multilevel modelling, with measurement time (baseline and follow-up) at level 1, individual (behaviours, n = 1812) at level 2 and households (n = 1318) and schools (n = 18) as higher levels (environments). The effect of the intervention was tested while controlling for child age, gender and maternal education level. RESULTS: This study confirmed that the BAEW intervention lowered child zBMI compared with the comparison group (-0.085 units, P = 0.03). The variation between household environments was found to be a large contributor to the percentage of unexplained change in child zBMI (59%), compared with contributions from the individual (23%) and school levels (1%). Across both groups, screen time (P = 0.03), sweet drink consumption (P = 0.03) and lack of household rules for television (TV) viewing (P = 0.05) were associated with increased zBMI, whereas there was a non-significant association with the frequency the TV was on during evening meals (P = 0.07). The moderating effect of the intervention was only evident for the relationship between the frequency of TV on during meals and zBMI, however, this effect was modest (P = 0.04). CONCLUSIONS: The development of childhood obesity involves multi-factorial and multi-level influences, some of which are amenable to change. Obesity prevention strategies should not only target individual behaviours but also the household environment and family practices. Although zBMI changes were modest, these findings are encouraging as small reductions can have population level impacts on childhood obesity levels.

The rapid assessment of fatigue severity in cancer patients: use of the Brief Fatigue Inventory.

BACKGROUND: Fatigue is a major disease and treatment burden for cancer patients. Several scales have been created to measure fatigue, but many are long and difficult for very ill patients to complete, or they are not easy to translate for non-English speaking patients. The Brief Fatigue Inventory was developed for the rapid assessment of fatigue severity for use in both clinical screening and clinical trials. METHODS: The study enrolled 305 consecutive, consenting adult inpatients and outpatients with cancer who could understand and complete the self-report measures used in the study. The same instruments also were administered to 290 community-dwelling adults to obtain a comparison sample. Research staff completed a form that indicated the primary site and stage of the cancer, rated the Eastern Cooperative Oncology Group performance status of the patient, described the characteristics of the pain, and described the current pain treatment being provided to the patients. RESULTS: The BFI was shown to be an internally stable (reliable) measure that tapped a single dimension, best interpreted as severity of fatigue. It correlated highly with similar fatigue measures. Greater than 98% of patients were able to complete it. A range of scores defining severe fatigue was identified. CONCLUSIONS: The BFI is a reliable instrument that allows for the rapid assessment of fatigue level in cancer patients and identifies those patients with severe fatigue.

Results of a JCAHO accreditation survey in a university student health center.

This article describes the results of our initial accreditation survey by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). Strengths, as well as supplemental recommendations in our clinic and laboratory programs, were identified during the accreditation survey. Mechanisms for addressing the supplemental recommendations are described in this report. Direct and indirect costs of the accreditation process also are discussed.

How to build a specialty MSO.

The specialty-based management services organization (MSO), with its focus on management support, contracting, information systems and related benefits, is intended to help preserve specialist physician access to patients. It does this by enabling the MSO's physicians to clearly differentiate themselves from other specialist providers. To be successful, however, an MSO must be built on a shared vision of its goals. Considerations of structural, operational, ownership, antitrust and governance concerns should all follow from that ground. All parties should recognize that MSOs are best in the long-term; they are not short-term solutions.

How to save distressed IDS-physician marriages: a case study.

A hospital-driven IDS that encounters serious problems resulting from ownership of a physician practice should address those problems by focusing on three core areas: vision and leadership, effectiveness of operations, and physician compensation arrangements. If changes in these areas do not lead to improvements, the IDS may need to consider organizational restructuring. In one case study, a hospital-driven IDS faced the problem of owning a poorly performing MSO with a captive physician group. The IDS's governing board determined that the organization lacked effective communication with the physicians and that realization of the organization's vision would require greater physician involvement in organizational decision making. The organization is expected to undergo some corporate reorganization in which physicians will acquire an equity interest in the enterprise.

New Stark regulations: Key issues for health care decision-makers.

On Jan. 9, 1998, The Health Care Financing Administration (HCFA) issued long-awaited Proposed Regulations for what has become known as Stark II. The regulations are subject to a comment period and later refinement. However, they lay out HCFA's basic understanding of what kinds of practices constitute an illegal kickback. In general terms, the law prohibits physicians from referring Medicare or Medicaid patients to entities with which they (or an immediate family member) have a "financial relationship" for the delivery of a specific list of designated health services. There are, however, exceptions also included in the new proposal. Group practices will want to pay special attention to HCFA's new definition of group practice.

Insights into managed care--operational, legal and actuarial.

Understanding the operational, legal and actuarial dimensions of managed care is essential to developing managed care contracts between managed care organizations and individual health care providers or groups such as provider-sponsored organizations or independent practice associations. Operationally, it is important to understand managed care and its trends, emphasizing business issues, knowing your practice and defining acceptable levels of reimbursement and risk. Legally, there are a number of common themes or issues relevant to all managed care contracts, including primary care vs. specialist contracts, services offered, program policies and procedures, utilization review, physician reimbursement and compensation, payment schedule, terms and conditions, term and termination, continuation of care requirements, indemnification, amendment of contract and program policies, and stop-loss insurance. Actuarial issues include membership, geography, age-gender distribution, degree of health care management, local managed care utilization levels, historical utilization levels, health plan benefit design, among others.

Converting new antitrust guidance into action.

The "Statements of Antitrust Enforcement Policy in Healthcare" that were passed in August 1996, represent efforts by the Department of Justice and the Federal Trade Commission to meet health care industry demands for more guidance regarding the application of the federal antitrust laws to the business activities of physicians and provider-sponsored organizations. This article translates the safety zone guidelines into practical language covering the basic requirements, economic integration and clinical integration, the messenger model used in non-integrated networks, and the implications for physician group practices.

Integration from the small group practice perspective.

For small group practices, ¿appropriate integration¿ is of critical importance because small groups are at high risk of being left behind if they are not well positioned for managed care. Small group practices, however, may find the tasks of evaluating potential partners and getting started on the road to integration rather daunting. Small group practices face unique integration challenges and must plan carefully if they are to integrate effectively.

Integrated provider networks--a primer.

Integrated provider networks are burgeoning. With acronyms like MSO, IPA, PHO, IPN, etc., integration can be confusing to the uninitiated. Gerald A. Niederman, J.D., of Faegre & Benson, and Bruce A. Johnson, J.D., M.P.A., of the MGMA Management Consulting Services, offer a primer on integrated provider networks.

Positioning for vertical integration through clinics "without walls".

Authors Bruce A. Johnson, J.D., M.P.A., and Darrell Schryver, D.P.A., offer the clinic without walls model as a transitory step to full vertical integration. They write that this model "may enable physicians to address the key issues associated with managed care and integration in a more gradual, controlled fashion.

Establishing a group practice "without walls".

The group practice "without walls" has become a health care delivery system that is preferred by an increasing number of physicians. This article traces the experience of Premier Medical Group, PC, a "second generation" clinic without walls in the Denver Metropolitan area, to highlight the potential benefits and the key issues related to the development and implementation of a group practice-without-walls model of health-care delivery. The model promises to address physician business and professional needs by building on the best aspects of a traditional group practice, in an overall organizational structure that maximizes each physician's autonomy, individual practice style, and practice identity. The successful implementation of a group practice without walls depends upon physician leadership and impetus, clear goals-and-objectives, competent professional staff, and legal-and-financial guidance.

Cesarean section. Assessment of the convenience factor.

To assess the potential input of physician convenience on the performance of cesarean sections (C-sections), analysis of C-sections by time of day and day of the week was undertaken at four Chicago-area hospitals. The primary C-section rate at the University of Chicago Chicago Lying-In Hospital, with a relatively high-risk patient population and a full-time salaried resident and faculty staff, was lower than at three other hospitals staffed predominantly by private practitioners. Indications for primary C-sections were classified as "acute," "semiacute" or "nonacute." Acute and semiacute C-sections were performed without demonstrated time biases in regard to the time of day or the day of the week at all four hospitals. Nonacute C-sections (70% cephalopelvic disproportion) were not performed as frequently at night (12-8 A.M.) as at other times at three of the four hospitals, but there were no differences in the individual characteristics of the outcomes of such deliveries between day and night. There was also no Friday afternoon or Monday morning frequency increase. The data failed to reveal significant variations in the performance of acute C-sections but did show day-night variability in C-sections done for non-acute indications.