Use of services by diabetes patients in managed care organizations. Development of a diabetes surveillance system. CDC Diabetes in Managed Care Work Group.

OBJECTIVE: To develop a diabetes surveillance system that estimates the prevalence of diabetes and characterizes service use in diverse managed care organizations (MCOs). RESEARCH DESIGN AND METHODS: Computerized inpatient, pharmacy, outpatient, and laboratory records were used to develop an algorithm to identify diabetes patients and to develop surveillance indicators common to the three participating MCOs. Using 1993 data, the availability, specifications, and limitations of various surveillance indicators were determined. RESULTS: An extensive set of diabetes surveillance indicators was identified from the four sources of data. Consistent data specifications across MCOs needed to consider variation in the type of data collected, a lack of documentation on level of coverage, differences in coding data, and different models of health care delivery. A total of 16,363 diabetes patients were identified. The age-adjusted prevalence of diabetes ranged from 24 to 29 per 1,000 enrollees. Approximately one-third of patients with diabetes (32-34%) were taking insulin. The majority had one or more visits to a primary care physician during the year (72-94%). Visits to specialists were less frequent. Ophthalmologists and optometrists were the most commonly used specialists: 29-60% of the patients with diabetes at the three MCOs had visited an ophthalmologist or optometrist. About one-fifth had an overnight hospital stay during the year. CONCLUSIONS: This diabetes surveillance system is a useful tool for MCOs to track trends in prevalence of diabetes, use of health services, and delivery of preventive care to individuals with diabetes. This system may also be useful for health care planning and for assessing use changes after new developments in diabetes care or new quality management initiatives.

Immunosuppressive therapy as a determinant of transplantation outcomes.

Although surgical proficiency is essential to the immediate outcome of transplantation, long-term success depends upon how adequately the transplantation recipient is managed. Immunosuppression, the most critical aspect of after care, is subject to wide variation. In January 1990, a survey was sent to the directors of all transplant programs in the United States performing one or more kidney, heart, liver, heart-lung, or pancreas transplant in 1988. Detailed data were obtained on both the drugs and methods used for induction and maintenance immunosuppression, as well as the treatment of rejection. Each program director was asked to rank each immunosuppressive approach according to its perceived impact on patient outcomes. Over 85% of all eligible program directors completed the survey. There is no evidence of survey respondent bias. The use of polyclonal and monoclonal agents for induction immunosuppression was favored most by pancreas program directors (72-76%). These agents were least preferred by liver transplant programs (35-37%). About half of kidney, heart, and heart-lung program directors preferred these agents. Triple-drug therapy consisting of CsA, PRED, and AZA was considered the most preferable maintenance protocol for all transplants (i.e., kidney, 89%; heart, 94%; liver, 88%; heart-lung, 86%; pancreas, 96%). Either i.v. steroids or OKT3 were regarded as the preferred approaches for the treatment of acute or resistant rejection. Finally, the acceptability of outpatient treatment of rejection varied by transplant type (i.e., kidney, 9%; heart, 58%; liver, 5%; heart-lung, 29%; pancreas, 8%). Although there are similarities in the ratings of various aspects of immunosuppressive therapy, there are important differences. This information is critical to anticipate the implications of new immunosuppressive agents and to evaluate changes in the use of existing drugs and therapeutic approaches.

An economic analysis of heart-lung transplantation. Costs, insurance coverage, and reimbursement.

Rarely has the cost of heart-lung transplantation received attention. Although the procedure is still largely regarded as experimental, this does not diminish the significance of costs. The National Cooperative Transplantation Study was undertaken to better understand the costs of all transplants, including heart-lung transplantation. Data on transplantation charges from date of procedure to discharge were obtained from more than 65% of all heart-lung transplantation programs active in 1988. These programs accounted for 61% of all transplantations performed in 1988. Valid sample survey data (no more than 25 procedures per center) were obtained for 42 patients, or approximately 58% of all procedures done in the United States. Detailed data were also collected on sources of payment and amount reimbursed. Because of outlier data, we report statistical medians, rather than means, as our measure of central tendency. The median charge for heart-lung transplantation was $134,881, with an average hospital stay of 31 days. Total charges fell between $99,535 and $216,639 for 50% of the cases studied. Half of the patients spent between 23 and 49 days in the hospital. Because of the small number of cases available for analysis, it was not meaningful to cross-classify the data according to various prognostic variables. More than 78% of the procedures studied were paid for by private insurers. Reimbursement exceeded 90% of billed charges for 84.6% of the cases analyzed. Despite the experimental status of heart-lung transplantation, insurance reimbursement has been favorable for those heart-lung transplantations that insurers have covered. Nevertheless, the future of heart-lung transplantation is unclear. The availability of donors remains a serious constraint, as is seen in the decrease of procedures performed annually. In fact, lung transplantation now appears to be the preferred approach to the treatment of pulmonary disease.

The medical and surgical determinants of heart transplantation outcomes: the results of a consensus survey in the United States.

Heart transplantation may well be the most successful transplantation procedure performed today. One-year patient survival rates now exceed 80%. Many factors are thought to account for differences in outcomes among transplantation centers. No attempt has been made to assess consensus among transplantation program directors regarding the major determinants of patient outcome. In the National Cooperative Transplantation Study we evaluated consensus through a detailed survey of all heart transplantation programs active in the United States in 1988. Of the eligible programs, 104 (91%) returned completed surveys. Data on the medical and surgical determinants of outcomes have been analyzed descriptively. Considerable consensus occurred among program directors about the importance of several factors. For example, over 90% of the respondents felt that heart biopsy should be used as the standard rejection monitoring technique and that left and right heart catheterization should be performed annually with coronary arteriography. Over 60% believed that the availability of a left ventricular assist device for temporary use would also enhance patient outcome. Several approaches were considered to have little beneficial effect on outcome. These included cytoimmunologic monitoring and electrocardiography as standard rejection monitoring techniques. Nearly one half of the respondents opposed steroid discontinuation after transplantation. On several other approaches there was a lack of consensus including the use of heterotopic heart transplantation and conversion from cyclosporine because of renal dysfunction. Consensus conferences are now regarded as a means by which technologic innovations can be evaluated and medical practice guidelines can be set. This analysis suggests that consensus is a useful approach toward assessing medical and surgical practices in heart transplantation.

Determinants of heart-lung transplantation outcomes: results of a consensus survey.

Substantial progress has been made in clinical heart-lung transplantation. Although outcomes vary across centers, 1-year patient survival is now 59%. This study was an attempt to assess consensus among transplant program directors regarding the major determinants of patient outcome. In the National Cooperative Transplantation Study we evaluated consensus through a survey of all heart-lung transplant programs active in 1988. Of the eligible programs, 23 (85%) returned completed surveys. Data on the medical and surgical determinants of outcome were analyzed. There was considerable consensus among program directors as to the importance of several factors. The three most critical predictors of favorable outcomes were periodic pulmonary function tests to detect rejection (85.7%), avoidance of use of prednisone during the first 14 days after transplantation (76.2%), and annual left and right heart catheterization with coronary arteriography (76.2%). Several approaches were considered undesirable or unnecessary. These included electrocardiogram as standard rejection monitoring technique (71.4%), cytoimmunological monitoring as standard rejection monitoring technique (66.7%), and routine steroid discontinuation after transplantation (66.7%). On various other treatment approaches there was little evidence of consensus. These included prophylaxis with acyclovir and severe bronchiolitis as a criterion for retransplantation. Although controversial, consensus conferences are one means by which to evaluate technological innovations. Based on their results, practice guidelines can be developed to better inform third-party payers on issues related to transplantation.

A longitudinal assessment of the health status of diabetic and nondiabetic renal transplant recipients.

This paper compares the health status of diabetic and nondiabetic renal transplant recipients. Data for the analysis were collected from 396 patients who received cadaveric transplants at 5 transplant centers in the United States. Health status was measured at several points in time, from 3 months to 15 months following transplantation. In addition to using several measures of perceived health status, 2 standardized health status measures--The Sickness Impact Profile and the Nottingham Health Profile--were used. The results of the study indicated that the health status of diabetic patients is lower than that of nondiabetic patients. Not surprisingly, nondiabetic patients are more satisfied with their health than are diabetic patients. The results of the study also showed that the health status of both diabetic and nondiabetic patients improves over time. However, with the exception of work disability, the improvement in the health status of transplant patients during the period from 3 to 12 months posttransplant is much greater for diabetic patients than for nondiabetic patients.

Public attitudes and behavior regarding organ donation.

Organ transplantation has been the subject of much attention; unfortunately, relatively little has been published about public attitudes toward organ donation. To better document public perceptions on organ donation, a telephone survey of a nationally representative sample of 2,056 respondents was conducted. We found that nearly 94% of the population had heard about organ transplantation, but only 19% of these people carried donor cards. The results indicated that people are somewhat more likely to donate the organs of a relative who had just died (53%) than they are to donate their own organs (50%). People were most likely to donate kidneys (50%) and least likely to donate skin (40%). Most respondents (58%) felt that next of kin should not be able to override a person's desire to donate organs as signified by an organ donor card. Few people (7%) supported the concept of presumed consent. We conclude that while the public is supportive of organ transplantation, it is not overly enthusiastic about organ donation. Awareness of this paradox on behalf of the public may actually facilitate organ donation.

KIE: A telephone survey of 2,056 persons was conducted to ascertain public attitudes toward organ donation. Although 94% of the respondents had heard about organ transplantation, only 19% carried donor cards and only 28% of the others said they were willing to carry one. More persons (53%) were willing to donate a relative's organs than their own (50%), and people were more likely to donate kidneys (50%) than other organs. Only 7% supported the concept of presumed consent to donation, and 58% of those polled felt that relatives should not be able to override a person's wish to donate as signified by a donor card. The authors conclude that people are very supportive of organ transplantation but are not as enthusiastic about donating organs. Further study is needed to determine whether greater understanding of the concept of brain death would facilitate donation of cadaver organs.

Do adolescents who relinquish their children fare better or worse than those who raise them?

When background and other characteristics are controlled for, older adolescents who rear their children are as likely as those who place them for adoption to complete high school. However, relinquishers are more likely to complete vocational training and have higher educational aspirations. Further, relinquishers are more likely to delay marriage, to be employed six and 12 months after the birth and to live in higher income households than are child rearers. Child rearers are more likely to become pregnant again sooner and to resolve subsequent pregnancies by abortion. Adolescents who relinquish their children do not suffer more negative psychological consequences than do those who raise their children. Overall, both groups indicated very high levels of satisfaction with their decision to relinquish or to rear, although relinquishers were slightly less satisfied with their decision than were child rearers. The study sample consisted of 123 child rearers and 146 relinquishers who had attended a pregnancy-counseling program affiliated with a large adoption agency that practices open adoption. Hence, the findings are limited to a select sample and should not be generalized beyond adolescents who participate in a similar program.

The quality of life of hemodialysis recipients treated with recombinant human erythropoietin. Cooperative Multicenter EPO Clinical Trial Group.

Initial clinical trials with recombinant human erythropoietin provided evidence of a quality-of-life benefit for patients with anemic end-stage renal disease who received maintenance hemodialysis. As part of a phase III clinical trial of recombinant human erythropoietin, the quality of life of patients was systematically assessed. More than 300 patients at nine dialysis centers were evaluated. A statistically significant improvement was established between baseline and second follow-up on most objective and subjective quality-of-life parameters, including energy and activity level, functional ability, sleep and eating behavior, disease symptoms, health status, satisfaction with health, sex life, well-being, psychological affect, life satisfaction, and happiness. No change was observed in ability to work or employment status. We conclude that, in addition to substantial improvement in hematologic parameters, recombinant human erythropoietin greatly enhances the quality of life of anemic patients who receive maintenance hemodialysis.

Work disability, functional limitations, and the health status of kidney transplantation recipients posttransplant.

A primary objective of renal replacement therapy is patient rehabilitation. Studies have consistently shown that transplant recipients are better rehabilitated than patients maintained on dialysis, but diabetic transplant recipients do not do as well as nondiabetics. Few studies have evaluated the rehabilitation status of transplant recipients based upon their outcome following transplantation. Data were collected from 226 patients associated with 5 major transplant centers in the United States at 2.5-3.5 years posttransplant. Established survey procedures were followed and standard measures of work status, functional ability, and health status were incorporated into self-administered questionnaires. Patients were stratified into 3 groups based upon transplant outcome--those with functioning grafts, those whose grafts failed and were retransplanted, and those who returned to dialysis after graft failure. The presence of diabetes was also documented. Regardless of graft outcome, more patients were able to work than were actually working (61.5% vs 43.4%), although patients with successful transplants, and those who were retransplanted, were both better able to work than patients whose grafts had failed, necessitating a return to dialysis. Diabetic and nondiabetic patients differed in their ability to work (74.4% vs 34.7%). All patient groups reported work-related limitations in activity and associated functional impairments. These were less severe for patients who had functioning grafts. Perceived as well as actual health status varied according to graft outcome and primary disease diagnosis, with both dialysis patients and diabetics reporting poorer health status than patients who had retained their first grafts or who had been retransplanted. Graft outcome and primary renal diagnosis prior to transplant are important predictors of ability to work, functional ability, and health status posttransplant. Retransplantation is not detrimental to patient rehabilitation, whereas return to dialysis results in a measurable decline in activity status. Despite a successful graft, diabetes severely limits the rehabilitation potential of transplant recipients.

The center effect in heart transplantation.

Transplantation outcomes vary across centers, prompting interest in the notion of a "center effect." The components of this effect are not well understood, although experience is often regarded as the primary factor. Most studies, however, have failed to confirm an association between transplant program activity level and outcome. While there have been several published reports on the kidney transplant center effect, only 1 such (unpublished) report exists concerning heart transplantation. Data for this analysis were obtained from several sources that include: the Registry of the International Society for Heart and Lung Transplantation; the Medicare Provider Analysis and Review data maintained by the Health Care Financing Administration (HCFA), various hospital-specific data compiled by the American Hospital Association (AHA); and finally, 91% of all eligible heart programs participated in a special purpose survey intended to obtain critical data on transplant center characteristics. These 4 data sources were combined into a single data base representing 1,602 patients at 114 centers. The data were then analyzed using a discrete piecewise exponential hazards model. This is a nonparametric approach toward the modeling of risk, wherein no assumption is made about the shape of the survival curve. Risk was assessed up to 2 years posttransplant. Overall 1-year patient survival was 82.4%. In the multivariate models, neither recipient nor donor sociodemographic characteristics were associated with patient survival. Clinical characteristics were the most critical predictors of outcome, including use of an artificial device and retransplantation, both of which had a strong adverse effect. This was predictable based upon univariate analyses alone. The results of this analysis suggest that experience is positively related to heart transplant patient survival; however, due to sample size and other considerations, the experience effect did not achieve statistical significance. Nevertheless, while outcomes did vary by center, the extent of variation was not nearly as great as some commentators have argued. This suggests that heart transplantation is a technology that can be acceptably applied in diverse settings with excellent outcomes.

An economic analysis of pancreas transplantation: costs, insurance coverage, and reimbursement.

Since 1988 the demand for the pancreas transplantation has continued to increase. This has been accompanied by a growth in the number of centers offering the procedure, and an increase in the number of transplants performed. The National Cooperative Transplantation Study was undertaken to document the costs of all transplants, including pancreas transplantation. Data on transplantation procedure charges, from date of transplant to discharge, were obtained from 66.7% of all pancreas transplantation programs active in 1988. These programs accounted for 72% of all transplants performed that year. Valid sample survey data (no more than 25 transplants per center) were obtained for 133 randomly selected patients. This constituted 54% of all procedures done in the United States in 1988. Detailed data were also collected on sources of payment and amount reimbursed. Due to outlier data, we report statistical medians, rather than means, as our measure of central tendency. The median charge for a pancreas transplant with or without a kidney was $66917, with a hospital length of stay of 21 days, compared with a kidney transplant alone at $39625 and a hospital length of stay of 14 days. Total pancreas transplant charges fell between $45260 and $105375 for 50% of the cases studied. Half of the patients had a hospital length of stay between 16 and 33. Due to the small number of cases available for analysis, it was not meaningful to cross-classify the data according to various prognostic variables.(ABSTRACT TRUNCATED AT 250 WORDS)

An economic analysis of liver transplantation. Costs, insurance coverage, and reimbursement.

Liver transplantation is an expensive surgical procedure. In 1988, the median procedure charge was $145,795. Charges varied according to numerous prognostic variables. Insurance reimbursement often fell short of billed charges. Nonetheless, relative to other medical and surgical procedures, liver transplantation is cost-effective.