To help or hinder: Which is more important in explaining a physician's willingness to recommend a health plan?

PURPOSE: To examine how specific health plan practices contribute to physicians' willingness to recommend a health plan to a patient, and whether the relative importance of plan practices is viewed differently when patients are seriously ill. METHODS: The Physician's Evaluation of Health Plans Project has surveyed 1,757 generalist physicians in 16 health plans in 5 areas nationwide. Each physician reported on one plan. Three multi-item scales assessed physicians' perceptions of health plan activities that facilitated or impeded high-quality care in the plans and the clinical capabilities of plan physicians. Regression analyses were used to explore relations between facilitators, barriers, and clinical capabilities, and two global physician judgments (the physician's willingness to recommend a plan and their judgment that a plan provided lower quality for sicker patients). RESULTS: A physician's willingness to recommend a health plan is more highly related to what plans do to facilitate care than to the barriers created by plans in managing care. However, barriers to care were substantially more important when evaluating health plan quality for sicker patients. CONCLUSIONS: From the physician's perspective, the relative importance of plan strategies to manage care is different for typical patients and patients who are more seriously ill. Efforts to collect information on health plan quality should separately evaluate care for sicker patients, in addition to evaluating the overall performance of the health plan.

Outcome trajectories for assisted living and nursing facility residents in Oregon.

OBJECTIVE: To compare assisted living residents and nursing home residents on outcome trajectories for three outcomes: ability to perform activities of daily living (ADLs), psychological well-being, and pain and discomfort. DATA SOURCES/STUDY SETTING: A representative sample of one-third of the census from 38 participating assisted living facilities (N = 605) and two-fifths of the census from 31 participating nursing facilities (N = 610). STUDY DESIGN: A longitudinal design using hierarchical linear models to examine how setting (being in an assisted living setting or in a nursing home) affected growth trajectories for each outcome studied when adjusting for other resident characteristics. DATA COLLECTION: Residents or their proxies were interviewed and chart reviews done at baseline, six months, and one year. All baseline data were collected between August 1995 and May 1996. PRINCIPAL FINDINGS: We found differences in case mix between assisted living and nursing facility residents but no differences in outcome trajectories for ADLs, psychological well-being, and pain and discomfort. For ADLs and pain and discomfort on average, residents in both settings experienced change over the study period. For psychological well-being, residents experienced no change on average. CONCLUSIONS: The lack of difference in growth trajectories for ADLs, pain and discomfort, and psychological well-being between the two settings was noteworthy.

The cost effectiveness of post-acute care for elderly Medicare beneficiaries.

This study used a novel method to examine the cost effectiveness of post-acute care (PAC) in different settings. The analysis found that home health care was more cost effective than PAC in skilled nursing facilities (SNFs) or rehabilitation facilities. The cost effectiveness for home health care was also more favorable relative to being home without formal care. Post-acute care in SNFs was not cost effective compared to being home without formal care. The cost-effectiveness analysis showed mixed support for PAC in rehabilitation facilities. These results, and the use of cost-effectiveness analysis in general, provide a basis for a more efficient Medicare reimbursement system for PAC.

Role of laparoscopic ultrasonography in the management of patients with oesophagogastric cancer.

BACKGROUND: Laparoscopy and laparoscopic ultrasonography (lapUS) have been shown to improve the staging of patients with oesophagogastric cancer but there remains doubt as to whether most benefit follows laparoscopy alone and how much is contributed by the addition of lapUS. METHODS: The role of lapUS in surgical decision making was evaluated prospectively in a consecutive series of patients with oesophagogastric cancer following conventional radiological assessment. The results of the lapUS findings over and above the laparoscopic findings were documented in order to identify the additional benefit of lapUS. RESULTS: After initial conventional assessment 41 patients were considered unsuitable for surgery and treated by palliation, with a further 25 patients proceeding to surgery without laparoscopy. Of the 93 patients who underwent laparoscopy, 18 were shown to have irresectable disease and avoided further surgery; a further seven avoided inappropriate surgery by the addition of lapUS. The open-close laparotomy rate was reduced from five of 25 in patients who did not undergo laparoscopy to nine (12 per cent) of 75 by the introduction of laparoscopy and to two (3 per cent) of 68 with the addition of lapUS. CONCLUSION: Laparoscopy alone prevented unnecessary surgery in 18 (19 per cent) of 93 patients with oesophagogastric cancer and the addition of lapUS identified a further seven patients (8 per cent) in whom unnecessary surgery was avoided.

Effects of post-hospital Medicare home health and informal care on patient functional status.

OBJECTIVE: To examine the effect of post-hospital Medicare home health and informal care on the functional status of 755 Medicare beneficiaries six weeks after hospital discharge for treatment of stroke, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hip procedures, and hip fractures. STUDY SETTING/DATA SOURCES: Consecutive patients enrolled in the study between March 1988 and February 1989 prior to discharge from one of 52 hospitals in three cities. Data sources included patient interviews, medical records, and the Medicare Automated Data Retrieval System (MADRS). ANALYSIS: The effect of the two types of care on patients' subsequent functional status was estimated using a selectivity corrected least squares regression of functional status six weeks post-discharge on hours of informal care, Medicare home health expenditures, and patient prior functional and cognitive status. DATA COLLECTION/EXTRACTION METHODS: Patients were interviewed before hospital discharge and six weeks later. The patient's primary caregiver was interviewed by telephone six weeks post-discharge. Patient data included demographic characteristics, illness severity, cognitive status, functional status at discharge and six weeks later, post-discharge expenditures for Medicare home health, and hours of informal care. PRINCIPAL FINDINGS: More informal care after discharge was associated with greater patient functional impairment six weeks later. The amount of Medicare home health that patients used had a nonsignificant effect on subsequent functional status. CONCLUSIONS: Post-acute home care may maintain the patient at home and compensate for functional limitations, rather than promote restoration of function. Future studies are needed to examine the effects of specific types of care, services, and providers as well as factors that mediate their effects on patient functional outcomes.

An 8-year experience of hepatic resection: indications and outcome.

BACKGROUND: Most reports highlighting decreasing operative morbidity and mortality rates following hepatic resection have focused on the management of metastatic disease. Information on the full range of hepatic disease is lacking. METHODS: The indications for hepatic resection in a specialist hepatobiliary unit have been reviewed and the operative morbidity and mortality rates assessed. RESULTS: Among 129 patients undergoing 133 hepatic resections between October 1988 and September 1996, the principal indication for resection was hepatic malignancy (102 resections), metastatic in 66 cases. Other indications included contiguous tumour (n = 20), primary tumour (n = 16) and benign disease (n = 31). Some 116 procedures were classical anatomical resections. Blood transfusion was required in 40 per cent of cases but major morbidity occurred in 20 per cent. There were six deaths following surgery, five of which were due to hepatic failure and followed resection for malignancy or trauma. The 3-year survival rate in patients resected for colorectal metastases was 65 per cent. CONCLUSION: This experience has demonstrated an increasing role for hepatic resection in a wide variety of hepatobiliary pathologies. Despite the low postoperative mortality rate, the significant risk of complications in the postoperative period serves to emphasize the need for careful selection of patients for such surgery, which should be undertaken in specialist centres.

Who is still uninsured in Minnesota? Lessons from state reform efforts.

OBJECTIVE: To describe Minnesota's health care system reform efforts and their implications for other state and national reform initiatives, document the rate of uninsurance in 1990 and 1995 with special attention to childrens' access to health insurance, and examine the effectiveness of MinnesotaCare, a voluntary state-subsidized health care plan, in serving its target population. DESIGN: Three cross-sectional telephone surveys: 2-stage random samples of Minnesotans of all ages in 1990 and 1995 and a stratified random sample of MinnesotaCare enrollees in 1994. PARTICIPANTS: For the 2 statewide surveys, 10310 respondents participated in 1990 and 11519 in 1995; more detailed information was collected on approximately 1600 respondents in each survey. Eight hundred MinnesotaCare enrollees participated in the third survey conducted in 1994. MAIN OUTCOME MEASURE: Changes in rates of uninsurance. RESULTS: While the rate of uninsurance increased at the national level, the point-in-time Minnesota rate remained stable and low at 6% between 1990 and 1995. The proportion of children uninsured for 12 months or more decreased from 5.2% in 1990 to 3.1% in 1995, while the proportion of uninsured single adults remained stable at approximately 11%. There was no evidence that MinnesotaCare enrollees are gaming the program, or that the program has resulted in significant erosion from the private market. CONCLUSIONS: MinnesotaCare has enabled the state to maintain a low rate of uninsurance and has reduced this rate among its primary target: children. The program has been less effective in enrolling single adults, although it may be too early to witness the effects of recent expansions targeting this group. Minnesota's experience suggests that other state and national reform efforts aimed at reducing uninsurance, particularly among children, are likely to be successful.

Laparoscopic ultrasonography for staging gastroesophageal cancer.

BACKGROUND: TNM staging of gastroesophageal cancer is improved by the use of laparoscopy for the detection of occult metastases and endoscopic ultrasonography for T and possibly N staging. Laparoscopic ultrasonography may combine the strengths of both of these techniques. The purpose of this study was to compare TNM staging by means of laparoscopic ultrasonography (Lap US), laparoscopy, and conventional computed tomography (CT). METHODS: TNM stage was determined by using Lap US, laparoscopy, and CT scanning in 26 surgical candidates with gastric or esophageal cancer in a blinded fashion. CT scans were also reviewed separately by an expert radiologist. Validation of findings was by means of final pathologic examination. RESULTS: Resectability for potential cure was determined by means of Lap US with a sensitivity of 100% and a specificity of 91% versus 100% and 73% for laparoscopy and 75% and 60% for CT, respectively. Overall TNM staging was 82% accurate for Lap US versus 67% for laparoscopy and 47% for CT (chi-squared, 8.64, p < 0.005, and 10.4, p < 0.005, respectively). Accuracies for Lap US versus laparoscopy versus CT for N stage were 92% versus 84% versus 70%, respectively, for T stage were 92% versus 42% versus 60%, respectively, and for M stage were 89% versus 44% versus 62%, respectively. CONCLUSIONS: T and N staging by Lap US were comparable to published results for endoscopic ultrasonography, and overall TNM staging was better. Lap US may provide the optimal preoperative staging for gastric cancer and has the potential to complement endoscopic ultrasonography in staging esophageal cancer.

Hereditary pancreatitis and familial pancreatic cancer.

Important advances in the understanding of pancreatic diseases have taken place through the application of molecular methods in the study of the inherited form of pancreatitis and pancreas cancer. Mutations of the cationic trypsinogen gene have been found to be causative for hereditary pancreatitis with important implications for the molecular pathogenesis of acute and chronic pancreatitis. A variety of cancer syndromes involving the P16 and BRCA2 genes, for example, also lead to pancreatic cancer, but the gene responsible for familial pancreatic cancer has not been identified so far. The establishment of a European Registry of Hereditary Pancreatitis and Pancreatic Cancer (EUROPAC) will facilitate future developments.

The effects of work intensity on adolescent mental health, achievement, and behavioral adjustment: new evidence from a prospective study.

This article examines the effects of work intensity on adolescent mental health, academic achievement, and behavioral adjustment. Questionnaire data were collected yearly from an initial panel of 1,000 randomly selected ninth graders (14-15 years old). Consistent with other studies, students who worked at higher intensity engaged in more alcohol use. The methodological strengths of this research (a representative panel studied prospectively over a 4-year period with minimal attrition and an analysis incorporating key control and lagged variables) provide strong evidence that adolescent work fosters alcohol use. The contention that work of high intensity has deleterious effects on mental health, academic achievement, and 2 other indicators of behavioral adjustment did not withstand our stringent tests. However, high school seniors who worked at moderate intensity (1-20 hours per week) had higher grades than both nonworkers and students who worked more hours per week.

Who cares? The size, scope, and composition of the caregiver support system.

The informal care networks of 242 impaired older people were examined in terms of the primary caregiver and secondary helpers. Most primary caregivers had at least one secondary helper; 88% identified helpers who provided hands-on help, 19% reported that helpers contributed financially, and 44% had helpers involved in care decisions. The size of the network was larger for direct care compared to financial or decision-making assistance. Almost half of primary caregivers reported that their spouse helped. It was expected that after controlling for characteristics of the primary caregiver and of the older person, that characteristics of the secondary caregiver network would influence the amount and type of primary caregiver assistance and formal care used by the older person. However, both hours and type of care by the primary caregiver were independent of size, scope, and composition of the secondary helper network. This independence suggests that efforts to alter the secondary caregiver network may have limited effects on the primary caregiver.

Self-reactive antibody expression by human carcinoma cells engineered with monoclonal antibody genes.

The purpose of this study was to determine if human colon cancer cells transduced with monoclonal antibody (MAb) genes become sensitive to immune destruction through coexpression of both the MAb and its reactive antigen. Murine retroviral expression vectors were constructed with the heavy or light chain genes of an anti-human colon carcinoma MAb, D612, that mediates antibody-dependent cell-mediated cytotoxicity (ADCC). Transduction of D612 MAb genes into the D612 antigen-positive (> 95%) human colon carcinoma cell line, LS-174T, was carried out by sequential cocultivation with PA317 packaging cells producing infectious virions containing the light or heavy chain expression vectors. Six cultures survived drug selection, two of which were found to have elevated levels of both light and heavy immunoglobulin chain activity in their supernatants. IgG secretion levels (24 h) were 1-2 ng/1 x 10(6) cells. Low but definite antigen reactivity was also present in supernatants obtained from these LS-174T transductants. Immunocytochemical staining of transduced tumor cells revealed that > 95% of the cells were positive for IgG expression. Thus, LS-174T transductants were capable of producing both the D612 MAb and D612-reactive antigen. Analysis of transductants by flow cytometry further revealed that > 95% of the cells had murine immunoglobulin on their surfaces. ADCC mediated by human natural killer cells against nontransduced tumor cells was observed when the latter cells were co-cultivated in the presence of transductants producing both D612 heavy and light chains but not in the presence of tumor cells transduced with light chain only. LS-174T cells transduced with both D612 heavy and light chain genes were more sensitive to cytotoxicity mediated by natural killer cells than were light chain gene only transductants. ADCC contributed to the greater sensitivity of the former transductants to cytotoxicity based on its inhibition by anti-FcR gamma III antibody. Thus, these studies demonstrate that tumor cells transduced with genes encoding for MAbs that can participate in ADCC reactions are able to sensitize nontransduced tumor cells to immune destruction as well as to direct killer cells against themselves. These studies may lead to a new immunotherapeutic approach for the treatment of cancer based on MAb gene therapy.

From data to policy ... to politics. The Minnesotans health care plan for universal access to care.

Calls for major reform of the health care delivery system have been sounded at both the state and federal level. However, given the lack of consensus on health care reform at a federal level, more than half of the states are developing initiatives for universal access to care. In 1989, the Minnesota legislature created the Health Care Access Commission to develop a blueprint for universal access in Minnesota. To assist this effort, we studied the extent and nature of uninsurance and underinsurance within the state. In this article we report the findings of that study and discuss how the findings were first used to develop recommendations for universal access legislation. We then describe the fate of the legislation. Finally, we describe the veto and the creation of HealthRight, the recently enacted plan for health care reform bill in Minnesota. This plan simultaneously expands access to care and aims to contain health care costs.

Predictors of cognitive and functional progression in patients with probable Alzheimer's disease.

We followed 65 patients with probable Alzheimer's disease, who were initially mildly to moderately impaired, with semiannual assessments of cognitive and functional performance for up to 4 years. Scores on the Mini Mental State Examination and a combination of instrumental and self-maintenance scale of activities of daily living were regressed on time of examination (measured in 6-month increments) to estimate cognitive and functional progression rates in individual patients. Lower scores on the verbal neuropsychological tests at the time of study entry, more aggressive behavior, and sleep disturbance during the first year of observation predicted faster cognitive progression. Faster functional progression was predicted by paranoid behavior, hallucinations and activity disturbances during the first year and the presence of extrapyramidal signs and lower scores on nonverbal neuropsychological tests at the time of entry into the study. Hallucinations occurred independently of cognitive severity and may identify a distinct subgroup of patients with rapid functional progression. Because of the greater significance of functional progression for caregivers' ability to manage patients, the presence of specific behavior problems early in the disease course may help to identify individuals who will experience greater functional decline and be at risk for earlier institutionalization.

Self-report versus medical record functional status.

The importance of assessing functional status in the hospitalized patient is gaining recognition. However, the availability and accuracy of medical record functional status data are uncertain. We collected data on 2,504 patients greater than 65 years of age discharged alive. A personal interview conducted 2 days before discharge recorded the patient's self-reported ability to perform 5 activities of daily living scales. Medical record abstraction was used independently to determine ability to perform the same activities of daily living scales. Patients who required any human assistance to perform a function were considered dependent. Patients were also contacted after discharge to determine the site of posthospital care (28% discharged to a nursing home). The amount of missing medical record functional status data varied by function from 20% for bathing to 50% for dressing. Ten percent of patients had no medical record functional status documentation concerning any of the five functions. The prevalence of self-reported dependence at discharge varied by function from 24% for feeding to 93% for bathing. The total number of dependencies differed between the two methods (medical records, 2.3 +/- 1.9; self-report data, 3.2 +/- 1.5). There was exact agreement between the two methods on the total number of dependencies in 28% of cases and differences of greater than or equal to 3 in 20%. In a stepwise logistic model predicting discharge to a nursing home and adjusting for other relevant variables, the number of dependencies as determined by self-report and medical record data each remained significant (Odds Ratios = 1.6). Self-report and medical record functional status data differ substantially, and the medical record data remain independently associated with nursing home placement. Several possible explanations for this finding are explored.

Patient characteristics and outcomes in institutional and community long-term care.

This paper examines the three-way relationships among patient characteristics, type of care (admission to a nursing home or community setting), and 6-month outcomes of 352 long-term care patients. The study found that patient characteristics influenced the type of care received and that substantial portions of the variance in the outcomes were attributable to initial differences among patients in the two types of care. Controlling for the effect of selective admission, type of care had no significant impact on patients' ADL scores, mobility scores, or disposition after 6 months in the long-term care setting.