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PubMed1998

The quality of care for treatment of early stage breast carcinoma: is it consistent with national guidelines?

BACKGROUND: In response to the importance of early stage breast carcinoma as a public health concern and to the complexity of the clinical literature devoted to treatment of the disease, the National Institutes of Health has held a series of Consensus Development Conferences on the treatment of early stage breast carcinoma. The authors assessed compliance with standards of care for women treated in two states. METHODS: The authors identified patients diagnosed at 18 randomly selected hospitals (N = 1514) in Massachusetts and at 30 hospitals (N = 1061) in Minnesota. They collected data from medical records, patients, and their surgeons to assess compliance with four indicators of quality of care: radiation therapy after breast-conserving surgery, axillary lymph node dissection, chemotherapy for premenopausal women with positive lymph nodes, and hormonal therapy for postmenopausal women with positive lymph nodes and positive estrogen receptor status. RESULTS: Rates of compliance for 3 of the 4 standards of care were > 80% in both states. Only the rate for hormonal therapy for postmenopausal women was low (< 64%). However, the proportion of these women who received either chemotherapy or hormonal therapy was > 90% in both states. CONCLUSIONS: In the states studied, practice appears to be consistent with the results of national consensus conferences and clinical trials regarding the treatment of early stage breast carcinoma. For practices demonstrated to be associated definitively with better outcomes (for example, chemotherapy for premenopausal women with positive lymph nodes) or to be important with respect to prognosis (axillary lymph node dissection) high rates of compliance were observed.

Adult↗

PubMed1991

Assuring quality of care: nursing home resident councils.

Increasing concern over the quality of care in nursing homes has prompted the National Institute of Medicine to recommend that residents have regular input into nursing home administration, primarily through the development of resident councils. Yet little is known of the effectiveness of resident councils. The literature is divided in its assessment of the potential of the institutionalized to represent themselves. Rather than suggesting either that resident councils are impotent or that they are a cure-all, these data, which examine the activities and effectiveness of existing resident councils, suggest that resident councils are successful in accomplishing some but not all of their objectives, that their success is maximized when professional organizers are available to help residents overcome the many barriers they face, and that there are many institutional factors that resident councils are seldom in any position to control.

Aged↗

PubMed1991

Quality screening and management using claims data in a managed care setting.

Quality screening and management (QSM), developed by United HealthCare Corporation for its own health plans but applicable to other settings, analyzes health care provided to an enrolled population using claims and administrative data supplemented, when necessary, with medical record review. For selected topics/conditions, QSM compares the care received by patients to that recommended by established practice guidelines and also reports and describes quality through incidence rates, condition-specific process and outcome measures, occurrence of adverse events, and use of preventive services. Results of the analyses are linked to appropriate quality management actions and are used to identify strategies for improvement. Data permit health plans to make performance comparisons on individual indicators and longitudinal comparisons on the effectiveness of quality improvement initiatives.

Humans↗

PubMed1997

Alternative/complementary therapies.

The national trends and our regional experience of the utilization of complementary therapies suggest that a significant number of our patients will continue to employ remedies that are outside the mainstream of what has been defined as conventional Western medicine. The data obtained from our survey is very consistent with the national survey published in 1993. Indeed the national interest in alternative/complementary therapies seems to be growing. A recent newspaper article from Minneapolis noted that Allina, one of Minnesota's largest hospital and HMO systems, found, in a 1995 survey, that two-thirds of surveyed households had a least one member who had used some type of alternative or holistic care over the prior two year period. Certainly continued study of the safety and efficacy of alternative/complementary therapies is warranted. This work is being done on many fronts, including the Office of Alternative Medicine at the National Institutes of Health. A most important aspect of such investigations is to improve the understanding of why patients choose these unconventional remedies. For many patients, the answer is simple. They believe these alternative treatments work. For such patients, alternative therapies may constitute a practical way to move from the sterile "high tech" realm of traditional medicine to a more intimate, "high touch" intervention offered by non-physicians. In the end, physicians' most pressing mandate is "to be of use" to patients in their struggles with illness, disability, and impending death. None of us have all the answers, and the studies alluded to in this essay suggest that a significant segment of the population yearns for interventions that have been traditionally outside the practice of most physicians and nurses. The data from our survey corroborates the high utilization rate of alternative/complementary therapies, regionally and is consistent with national data. Our challenge, as caregivers, is to appropriately respond to the notable prevalence of alternative health practices and to the complex societal factors which nurture this usage.

Adolescent↗

PubMed2003

Community-based care and risk of nursing home placement.

OBJECTIVE: To test the substitution hypothesis, that community-based care reduces the probability of institutional placement for at-risk elderly. RESEARCH DESIGN: The closure of the Social Health Maintenance Organization (Social HMO) at HealthPartners (HP) in Minnesota in 1994 and the continuation of the Social HMO at Kaiser Permanente Northwest (KPNW) in Oregon/Washington comprised a "natural experiment." Using multinomial logistic regression analyses, we followed cohorts of Social HMO enrollees for up to 5 years, 1995 to 1999. To adjust for site effects and secular trends, we also followed age- and gender-matched Medicare-Tax Equity and Fiscal Responsibility Act (TEFRA) cohorts, enrolled in the same HMOs but not in the Social HMOs. SUBJECTS: All enrollees in the Social HMO for at least 4 months in 1993 and an age-gender matched sample of Medicare-TEFRA enrollees. To be included, individuals had to be alive and have a period out of an institution after January 1, 1995 (total n = 18,143). MEASURES: The primary data sources were the electronic databases at HP and KPNW. The main outcomes were long-term nursing home placement (90+ days) or mortality. Covariates were age, gender, a comorbidity index, and geographic site effect. RESULTS: Adjusting for variations in the 2 sites, we found no difference in probability of mortality between the 2 cohorts, but approximately a 40% increase in long-term institutional placement associated with the termination of the Social HMO at HealthPartners (odds ratio, 1.43; 95% confidence interval, 1.15-1.79). CONCLUSIONS: The Social HMO appears to help at-risk elderly postpone long-term nursing home placement.

Aged↗

PubMed1994

Post-hospital home health care for Medicare patients.

Medicare patients in five diagnosis-related groups (DRGs) associated with heavy use of post-hospital care discharged from 52 hospitals in 3 cities were followed up at 6 weeks, 6 months, and 1 year to determine the factors associated with their being discharged home with or without home health care and the correlates of improvement in their functional status. Models correctly predicted those discharged home from those going to institutions in a range from 54 to 82 percent of cases. The amount of the variance in the change in function for those who went home (with or without home health care) explained by the models tested ranged from 19 percent to 73 percent. Total Medicare costs for the patients who went home were considerably less in the year subsequent to the hospitalization compared with those discharged to institutional care.

Activities of Daily Living↗

PubMed1990

Pediatric cardiac care consortium. Demonstrated value of a physician-directed quality assessment system.

A quality assessment system for analyzing the results of inpatient care of children with cardiac abnormalities is described. Three Minnesota institutions (the Mayo Clinic, Minneapolis Children's Medical Center, and the University of Minnesota) participate with 15 other similar centers elsewhere in the United States in this system. Patient data are analyzed and adjusted for case mix to allow for differences in patient populations and referral patterns. The statistical methods used are shown for two conditions: ventricular septal defect and aortic valvotomy. Data presented show reduction in length of stay for cardiac catheterization. This change occurred as physicians annually reviewed and discussed the data and, as a result, instituted changes. This physician-directed program seeks improvement in patient care through physician education.

Aortic Valve↗

PubMed1992

The impact of home monitoring and daily diary recording on patient status in cystic fibrosis.

An experimental home monitoring system for assessing the progress and planning changes in the care of patients with cystic fibrosis (CF) has been implemented at the University of Minnesota Cystic Fibrosis Center. One group of patients and families did daily recording of physical measurements and symptoms, and sent the diary to the data coordinating center weekly for analysis. The remaining patients were not part of the home monitoring program. Twenty-five patients were randomly selected from the home monitoring group. They were compared to an age- and sex-matched control group not doing home monitoring to ascertain if home self-measurement and daily diary recording, in the absence of any therapeutic intervention, produced any change in physical or psychological status, pulmonary function, or growth over a 4-year study period. Subjects ranged in age from 6 to 43 years. Clinical status was measured by the National Institutes of Health cystic fibrosis scoring system. Pulmonary function was assessed as percent of predicted forced vital capacity and percent of predicted forced expiratory volume in 1 sec (FEV1). Growth was analyzed as percent of predicted weight based on age-, sex-, and height-dependent equations. Psychological status was determined by self-assessment and referral for conseling. Only percent predicted FEV1 in the control group declined significantly. There were no statistically significant changes in any other measures either within or between diary and nondiary groups over the 4-year period.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1999

Patterns in child and adolescent consumption of fruit and vegetables: effects of gender and ethnicity across four sites.

OBJECTIVES: Few studies have examined the association of gender and ethnicity with fruit and vegetable consumption. We examined these associations using baseline data from four school-based sites funded under the National Cancer Institute's 5 A Day for Better Health Program. METHODS: Diet was measured using 24-hour recalls at three sites and seven-day food records at one site. Demographics were obtained via self-report or school records. Regression analyses for clustered data were employed with fruit and vegetables combined and fruit and vegetables separately. RESULTS: Girls ate more fruit, more vegetables and more fruit and vegetables combined than boys at the Georgia site. Ethnicity was significant in two sites: In Georgia, African-Americans ate more fruit and more fruit and vegetables combined than European-Americans; in Minnesota, Asian-American/Pacific Islanders and African-Americans ate more fruit than European-Americans, and European-Americans and African-Americans ate more vegetables than Asian-Americans. No significant effects were found at the Alabama or Louisiana sites. CONCLUSIONS: Ethnicity was related to fruit and vegetable consumption in Georgia and Minnesota. Consistent with prior studies, gender was related to fruit and vegetable consumption, with girls consuming more servings than boys; however, this was observed at one site only, Georgia. Consumption levels were similar to national estimates for children and varied by region. Further studies are needed using a single methodology to facilitate regional comparisons.

Adolescent↗

PubMed1991

Family medicine education and rural health: a response to present and future needs.

The importance of family medicine in providing rural health services has been established for quite some time. The need to train physicians who select the specialty of family medicine is critical at a time when medical student interest in the primary care specialties appears to be diminishing. Renewed efforts by educational institutions and incentives at the state and federal levels will be necessary to assist in the alleviation of shortages of rural physicians. The educational program at the University of Minnesota, Duluth, School of Medicine has achieved a great deal of success in training rural family physicians. A coordinated program effort, featuring the efforts of more than 200 family physicians during the past 15 years, has led to 52.5 percent of all graduates selecting family practice and more than 41 percent choosing practice sites with a population fewer than 20,000. Elements of the program at Duluth could serve as a model for other schools desiring to increase the number of students entering family medicine and rural practice.

Career Choice↗

PubMed1997

Pesticide prioritization for a brain cancer case-control study.

The incidence of brain cancer is rising in the United States while the causes remain largely unknown. Epidemiologic studies indicate that individuals working in agriculture have an increased risk of brain cancer. The National Institute for Occupational Safety and Health is conducting a case-control study of incident brain cancer cases in Iowa, Michigan, Minnesota, and Wisconsin to evaluate the risk associated with several environmental exposures, in particular agricultural pesticides. Hundreds of different pesticides are used in agriculture and it is not feasible to evaluate the association between brain cancer and exposure to each of these chemicals; therefore, a strategy was developed to identify which pesticides would be targeted in the study. First lists of pesticides were created, documenting usage in each of the four states and the United States as a whole, by using data from reports prepared by the U.S. Department of Agriculture and Departments of Agriculture and land grant colleges within the four states. Then the following factors were considered in prioritizing pesticides for evaluation in the study: total volume of use prior to 1985, ranking of use in the four states and the United States as a whole by pesticide category, and toxicological evidence of carcinogenic, teratogenic, or mutagenic effects. Pesticide usage prior to 1985 was determined to allow for a minimum 10-year latency for the incident brain cancer cases diagnosed in 1995 or later. The selected pesticides include 56 herbicides, 49 insecticides, 12 fungicides, and 17 fumigants, accounting for over 99% of the total pounds of herbicides and insecticides and over 98% of the total pounds of fungicides and fumigants applied pre-1985. Prompt lists of the pesticides are sent to study participants a few days before the study questionnaire is administered to allow them time to recall past use of pesticides; the lists include the common chemical names, trade names, the crops that the pesticides are most commonly used on, and the years that the pesticides have been marketed. The methods used to select this subset of 134 pesticides document historical usage and may be useful in prioritizing pesticides for other research studies.

Brain Neoplasms↗

PubMedDate not supplied

Clinical laboratory employment and workload patterns.

Determining numbers and types of personnel to staff clinical laboratories is important to employers and educators. At 5-year intervals over the last 25 years, employment patterns among laboratory personnel have been examined in the 5 county Minneapolis-St. Paul (Twin Cities) area that includes 2.2 million persons, almost 50% of Minnesota's population. The 1995 survey was distributed to laboratory administrators of 28 major laboratories. All (100%) responded with information regarding personnel numbers and types. Data from 1995 were compared to that from 1970, 1980, and 1990. In 1970 there were 30 hospitals in the Twin Cities area with over 10,000 hospital beds; there were also 2 blood banks and 4 clinic laboratories. Altogether approximately 1300 laboratorians were employed. In 1980 there were still 10,000 hospital beds among 29 hospitals. However there were 8 other major employers of clinical laboratory personnel, including blood banks, clinics, and a reference laboratory. Between 1970 to 1980, the number of laboratory personnel almost doubled to 2500. The impact of managed care together with the Prospective Payment System, a government initiative of 1983, profoundly affected health care institutions and their personnel. By 1990 hospital mergers and closures reduced the number of Twin Cities hospitals to 20 with a total of 7500 beds. There were 11 blood banks, clinics, reference labs, and HMOs, including 3 reference (independent) laboratories. Laboratory employees increased slightly to 2600. By 1995, hospitals were reduced to 18 and hospital beds to fewer than 7000. The number of all personnel in the 28 laboratories surveyed rose to 2900. Between 1980 and 1995, 10 major hospitals closed or were converted to a different type of facility. Four hospitals merged to form 2 consolidated hospitals. Only 2 small suburban hospitals were built. However, despite the decrease in hospitals, laboratory personnel numbers increased after 1980, due largely to the emergence of 3 independent laboratories, as well as a result of an increase in overall testing volume. Seventy-five percent of the 28 administrators surveyed reported more laboratory testing in 1995 than in 1990. The number of laboratory personnel in the Minneapolis-St. Paul area has more than doubled in the past 25 years, despite the closure of 1/3 of the Twin Cities hospitals and efforts by the government to reduce laboratory testing. One reason for the expanded employment of laboratories and greater testing volume is the expansion of the laboratory itself--into new diagnostic technologies, as well as into new laboratory sites.

Blood Banks↗

PubMed2004

Building the case for asthma as a disease management program.

Asthma is a common disease that affects between 5.5% and 7.0% of the population. It is an example of a disease where good guidelines and an accepted model of treatment exist, but have not been fully implemented. In the latter part of 2000, Blue Cross Blue Shield of Minnesota (BCBSM) had existing and successful disease management (DM) programs for diabetes and heart disease and was looking to expand the concept to other diseases. Asthma was one of the conditions under consideration. This study, done in conjunction with PharMetrics, Inc. of Watertown, MA was done to establish the opportunity present to help Blue Cross members with the disease, and to help decide whether developing such a program made sense for the health plan. In addition, if the answer to the second question were yes, the study would lay the groundwork for that program. Using 2 years of BCBSM claims data, the study identified, stratified, and analyzed the cohort of BCBSM members with a diagnosis of asthma according to severity of illness, individual drug or drug combination treatment, emergency room usage, hospitalization, and total episode costs for asthma. Health plan results were bench-marked against the experience of others across the country represented in the (then) 20+ million managed care lives in PharMetrics' Integrated Outcomes Database. The results showed that in some of the recommended guidelines for asthma care BCBSM members led the nation in compliance, but that there was ample opportunity for improvement thus justifying moving forward in developing a disease management program. The results also seemed to validate many of the recommendations for asthma care expressed in the Expert Panel Report 2 on the diagnosis and treatment of asthma from the National Heart Lung and Blood Institute of the National Institutes of Health.

Asthma↗

PubMed1997

Identifying nursing research priorities in a newly merged healthcare system.

Merging of nursing services led to key opportunities to identify nursing research priorities in the authors' institution. The literature suggested that a Delphi study would best accomplish these goals. Using a 110-member panel, a study was begun that identified two final topics that were focused on nursing administration research. Collecting these data served many purposes, including increased organizational awareness about nursing research and development of a nursing research council to facilitate future activities.

Delivery of Health Care, Integrated↗

PubMed1994

The pediatric cardiac care consortium--revisited.

BACKGROUND: The Pediatric Cardiac Care Consortium (PCCC) is a collaborative, voluntary effort of pediatric cardiologists to gather and analyze data regarding operative results. METHODS: PCCC collects information on each child who undergoes cardiac catheterization, electrophysiologic study, or a cardiac operation, or dies with a cardiac malformation. The data are analyzed annually and individual reports are created for each center. Also, representatives from the centers meet annually, and data-on the major operative procedures, including risk factors, patient profiles, and variations in adjusted mortality-are presented. RESULTS: Since PCCC's founding in 1982, overall operative mortality has decreased from 14% to 4.1% in 1991 (22% to 8.2% for infants). In one center, for example, in which overall and infant operative mortality dropped in seven years from 15% and 28% to 8% and 15%, respectively, the cardiologists and surgeon used the PCCC data to identify areas of weakness and adopt new diagnostic and treatment methods for particular cardiac conditions. They now opt for safer initial operative approaches. Another center reduced its operative mortality for coarctation of the aorta in infants after data review led to a decision to be more aggressive in early referral of infants for operations and for changes in perioperative management. DISCUSSION: Use of the study group model, in which key members work with their institution to use and interpret the data, has been an effective strategy for data dissemination. The PCCC is exploring the concept of "model centers," which would probably be procedure specific. With additional funding, the database could be expanded to include morbidity measures, functional outcome, and long-term follow-up.

Cardiac Care Facilities↗

PubMedDate not supplied

The Aggregate Demand Index: measuring the balance between pharmacist supply and demand, 1999-2001.

OBJECTIVE: To describe the development and 2-year performance of the Aggregate Demand Index (ADI) survey, a tool for longitudinally tracking the difficulty of filling open pharmacist positions throughout the United States. DESIGN: From August 1999 through July 2001, panelists completed a monthly survey on the difficulty of filling open pharmacist positions by state. Results are reported on the Web (www.pharmacymanpower.com). SETTING: Panelists estimated difficulty filling pharmacist vacancies in the community, institutional, both community and institutional, and nonpatient care pharmacy settings. PARTICIPANTS: A panel of individuals involved in the direct hiring of pharmacists. INTERVENTION: A monthly survey. MAIN OUTCOME MEASURES: Monthly indices reflecting the level of difficulty filling open pharmacy positions at the state, regional, and national levels and by pharmacy position type. Over time, these data formed a longitudinal record of the balance between the supply of and demand for pharmacists. RESULTS: Cumulative data from 50 states and the District of Columbia showed, on average, excess demand over available supply. The five states with the highest unmet demand level (i.e., where it was most difficult to fill open positions) were Minnesota, California, Wisconsin, Iowa, and Kentucky. The only states in which demand was in balance with supply were Hawaii and Rhode Island. Over 2 years, at least 92% of the U.S. population each month resided in areas where demand for pharmacists exceeded supply. The demand level in the Northeast was significantly lower than in other regions. Unmet demand was greatest for organizations with both community and institutional positions and least for organizations with primarily community positions. CONCLUSION: For the study period, the demand for pharmacists exceeded the available supply in the United States; ADI survey data indicated than open pharmacist positions were "somewhat difficult" to "difficult" to fill. Substantial but unexplained differences were noted by state, by region, and by type of pharmacy position. Other health care professions could use the ADI survey methodology to study workforce issues.

Pharmacies↗

PubMed1986

Depression in myotonic muscular dystrophy.

Depression was studied in adults with myotonic muscular dystrophy (MMD). The subject groups consisted of 27 MMD patients, an able-bodied control group of 27 adults (CON), a nonprogressively disabled control group of 17 adult paraplegics (SCI), and a progressively disabled neuromuscular disease control group of 11 adults with limb-girdle syndrome (LGS). The study utilized a test battery consisting of the Minnesota Multiphasic Personality Inventory (MMPI), the Institute of Personality and Ability (IPAT) Depression test, the Suicide Probability Scale (SPS), and the California Psychological Inventory (CPI). The MMD group scored significantly higher on the MMPI Depression scale, the IPAT Depression Test, and the SPS Hopelessness subscale, than the CON or SCI groups. Conversely, the MMD group showed lower levels of positive mental health than these two groups on the MMPI Ego Strength and CPI Well-Being scale scores. The MMD group did not differ significantly from the LGS group in any of the five measures. A definite tendency toward depression was evident among MMD patients. A similar tendency was noted in the small LGS group. The progressive and disabling nature of the disease appears to be the major reason for depression in MMD patients. Our data do not support the concept that depression is an intrinsic characteristic of MMD.

Adult↗

PubMedDate not supplied

The Electronic Primary Care Research Network (ePCRN): a new era in practice-based research.

The electronic Primary Care Research Network (ePCRN) is an electronic infrastructure that facilitates the conduct of randomized controlled trials (RCTs) in primary care and promotes the translation of research findings into practice. It provides a highly secure, Internet-based electronic infrastructure that will enable primary care practices anywhere in the United States to link with researchers in academic centers or the National Institutes of Health (NIH) to facilitate recruitment, entry, and follow-up of participants in multidisciplinary RCTs. The ePCRN also establishes a standardized clinic-based registry using distributed database technology to promote the translation of research findings into practice and to facilitate the process of clinical trials recruitment. The overall goals of the ePCRN are to provide the ability to perform large national collaborative studies throughout the United States, improve efficiency and reduce costs for individual trials, provide easier access for data retrieval and analysis, and involve primary care practices in the discovery and the translation of research findings into practice.

Databases as Topic↗