A person-focused model of care for the twenty-first century: a system-of-systems perspective.

The US health care system is challenged to provide high-quality care and is burdened with unsustainable expenditures, making it difficult for health care participants (patients, payers, providers, caregivers) to create value. This communication presents the theoretical foundation for a person-focused model of care that addresses a number of these challenges. The model integrates aspects of prior models of chronic care with new empiric findings and complex adaptive system (CAS) theory. The model emphasizes the relationship among all health care stakeholders. The health care delivery process is examined in terms of the role of each stakeholder and the value each adds to and receives from the process. The authors present pilot results illustrating the implications of CAS theory in regard to multi-morbidity, disease management programs, multi-morbid households, and person- and household-focused care. The model incorporates the physical, mental, and social dimensions of health, and operationalizes an individual patient's health as a CAS, identifying CASs for each of the other stakeholders as well. Health care can then be conceptualized as a system-of-systems with a person's health as its output. Deploying the model need not require major infrastructure investments or changes. It can be implemented by repurposing, aligning, and better integrating currently available interventions. The authors believe that the model creates not only survival value (health) but also purposeful value. The model offers a unifying focus for all participants in the health care delivery process, thereby constructing a health care system that is structurally person-focused and meaningful for all participants.

A nonparametric statistical method that improves physician cost of care analysis.

OBJECTIVE: To develop a compositing method that demonstrates improved performance compared with commonly used tests for statistical analysis of physician cost of care data. DATA SOURCE: Commercial preferred provider organization (PPO) claims data for internists from a large metropolitan area. STUDY DESIGN: We created a nonparametric composite performance metric that maintains risk adjustment using the Wilcoxon rank-sum (WRS) test. We compared the resulting algorithm to the parametric observed-to-expected ratio, with and without a statistical test, for stability of physician cost ratings among different outlier trimming methods and across two partially overlapping time periods. PRINCIPAL FINDINGS: The WRS algorithm showed significantly greater within-physician stability among several typical outlier trimming and capping methods. The algorithm also showed significantly greater within-physician stability when the same physicians were analyzed across time periods. CONCLUSIONS: The nonparametric algorithm described is a more robust and more stable methodology for evaluating physician cost of care than commonly used observed-to-expected ratio techniques. Use of such an algorithm can improve physician cost assessment for important current applications such as public reporting, pay for performance, and tiered benefit design.

Beyond the efficiency index: finding a better way to reduce overuse and increase efficiency in physician care.

Current strategies for addressing health care costs stress physician performance measurement and commonly use an efficiency index (EI). During seven years of conducting individual practitioner pay-for-performance (P4P), we found that using EIs hindered our work on reducing overuse of services. This paper offers an alternative approach through the identification of variation in key cost drivers. As proof of concept, we apply this model to hypertension care. We then describe a project that decreased apparent overuse of fiberoptic laryngoscopy among otorhinolaryngologists. Focusing directly on reducing overuse improves cost efficiency without the barriers imposed by EI methodology.

Physician reactions to quantitative individual performance reports.

The purpose of this study was to learn how primary care physicians experienced the introduction and evolution of an individual physician pay-for-performance program. Thirty primary care physicians participated in audiotaped focus groups 13 and 26 months after beginning the program. Transcribed audiotapes were used to group comments into themes. Ten thematic groups were identified. Practitioners reviewed their profiles but found it difficult to use them to change behaviors. They were concerned about the data accuracy, the influence of specialists and patients on their "scores," and, less, the validity of quality measures. They described ways the program changed their practices and consideration of cost, quality, and satisfaction. There were important concerns about the influence of pay-for-performance programs on professionalism. Primary care physicians were skeptical of this pay-for-performance program. On the other hand, physicians described positive influences on making improvements in quality, satisfaction, and practice efficiency.

Introducing a multifaceted intervention to improve the management of otitis media: how do pediatricians, internists, and family physicians respond?

The objective of this study was to compare pediatricians, family practitioners, and internist's adherence rates to an individual practice association-developed otitis media practice guideline. The study included a cohort of primary care physicians treating acute otitis media between January 1, 1999, and December 31, 2001, using administrative data. All panel pediatricians, family practitioners, and internists were included in the analysis. Specialty otitis media guideline adherence rates were compared pre- and postintervention. The guideline was adapted from the 1999 Centers for Disease Control and Prevention's treatment recommendations. The outcome measure was overall and specific exceptions to practice guideline components prior to and after intervention per 1000 episodes. Pediatricians and internists significantly reduced overall exceptions per 1000 episodes (P < .000) from the pre- to postintervention periods. Family practitioners did not improve adherence to overall guideline recommendations postintervention (P > .05). Pediatricians had significantly higher compliance than did family practitioners (P < .000). Primary care physicians significantly increased adherence to an otitis media guideline. Pediatricians improved more than internists and significantly more than family physicians.

Abnormal urinary potassium metabolism in patients with interstitial cystitis.

PURPOSE: If most patients with interstitial cystitis (IC) have epithelial leakage allowing urinary K to penetrate the interstitium and provoke symptoms, urinary K should be lower in untreated patients than in healthy subjects and it should increase with successful heparinoid treatment. This study tested these hypotheses. MATERIALS AND METHODS: Na, K and creatinine (Cr) were determined in spot urine samples from new, symptomatic, untreated patients with IC meeting all National Institute of Diabetes and Digestive and Kidney Diseases clinical diagnostic criteria, returning patients with IC reporting 50% or greater symptom improvement after 4 or greater months of oral heparinoid therapy and control subjects, and in 24-hour urine samples from new untreated patients and controls. RESULTS: In spot urine specimens of 37 new patients with IC K-to-Cr ratios were significantly lower than in 18 controls (0.51 vs 0.88 mg/mg Cr, p = 0.001). A total of 50 successfully treated patients with IC had significantly higher K-to-Cr ratios than those in 37 new patients (0.66 vs 0.51 mg/mg Cr, p = 0.025). Na-to-Cr ratios in the 3 groups were not significantly different. In 24-hour urine specimens 30 new patients had lower average K (31.0 vs 46.2 mEq/l, p = 0.01) and lower K-to-Cr ratios (0.43 vs 0.52 mg K/mg Cr, p = 0.01) than in 47 controls, while Na was not significantly different. CONCLUSIONS: Our finding of lower urinary K in new, untreated patients supports the concept of abnormal epithelial permeability and K absorption in IC. Higher urinary K in successfully treated vs untreated patients may reflect decreasing urinary K absorption due to mucosal repair and a resulting decrease in epithelial permeability. K/mg Cr appears accurate for normalizing urinary K.

Increasing adherence to a community-based guideline for acute sinusitis through education, physician profiling, and financial incentives.

OBJECTIVES: To implement a large-scale multifaceted intervention consisting of physician education, profiling, and a financial incentive, to improve treatment quality for acute sinusitis. STUDY DESIGN: Cohort trial using a historical control of treatment patterns among approximately 500 internists, 200 family practitioners, and 200 pediatricians in a northeastern community-wide individual practice association. PARTICIPANTS AND METHODS: Episode treatment group methods were adapted to identify cases (episodes) and to assess care patterns for acute sinusitis among 420,000 health maintenance organization patients seen between January 1, 1999, and December 31, 2001. The intervention consisted of care pathway development, physician and patient education, physician profiling, and a financial incentive. RESULTS: A statistical process control chart showed a shift toward recommended treatment patterns after our intervention. The rate of exceptions per episode of acute sinusitis decreased 20%, from 326 exceptions per 1000 episodes between January 1, 1999, and October 31, 2000, to 261 between November 1, 2000, and December 31, 2001. Decreased use of less effective or inappropriate antibiotics accounted for most of the change (199 to 136 exceptions per 1000 episodes [32% change]). Azithromycin use decreased 30%, from 97 to 68 prescriptions per 1000 episodes. Firstline antibiotic (amoxicillin and doxycycline) use increased 14%, from 451 to 514 prescriptions per 1000 episodes. Inappropriate radiology use decreased 20%, from 15 to 12 per 1000 episodes. These changes were significant at P < .005. CONCLUSION: A multifaceted program, including education, physician profiling with actionable recommendations, and a financial incentive, significantly increased physicians' adherence to a community-developed care pathway and was successful at improving adherence to recommended patterns of antibiotic use in acute sinusitis.

Comparative DNA sequence analysis of wheat and rice genomes.

The use of DNA sequence-based comparative genomics for evolutionary studies and for transferring information from model species to crop species has revolutionized molecular genetics and crop improvement strategies. This study compared 4485 expressed sequence tags (ESTs) that were physically mapped in wheat chromosome bins, to the public rice genome sequence data from 2251 ordered BAC/PAC clones using BLAST. A rice genome view of homologous wheat genome locations based on comparative sequence analysis revealed numerous chromosomal rearrangements that will significantly complicate the use of rice as a model for cross-species transfer of information in nonconserved regions.

The role of reproductive hormones in maintaining cognition.

This article briefly reviews the impact of hormones on cognition. Estrogen has the most profound impact on brain functioning. Testosterone also seems to have significant brain-related benefits, whereas progesterone seems to have minor or possibly even adverse effects. As the field of neuroscience progresses, more definitive conclusions will follow. As the focus is shifted, however, from extending life to improving the quality of life, the existing data are very compelling. The brain is a target for the sex steroid hormones. Clearly, this is an exciting and dynamic area for further study. Although skeptics may believe that more definitive proof is necessary before recommending hormone replacement for their patients to preserve their cognitive health, it seems prudent to discuss the evidence available to empower the patient further to guide their own treatment options and validate their symptoms. For those who still subscribe to the menopause-is-natural philosophy this question is posed, "why does the brain naturally have sex hormone receptors if they are not necessary?"