Research contributions to improving managed health care outcomes.

Managed health care programs are beginning to look to findings from psychotherapy outcome research to help set policy, suggesting the need to consider outcomes research from the standpoint of usability or utility. It also provides an opportunity to integrate science and practice. Considering and applying outcomes in this context requires cooperation between scientists and practitioners, the willingness of each group to set aside guild agenda, and giving up favored but insupportable beliefs and practices on the parts of those in both scientist and practitioner camps. This type of cooperation may have mutual payoffs. This article considers some of the obstacles to this type of sacrifice and evaluates some of the potential costs of cooperating. It also provides perspectives on the new roles of psychological assessment and methods of outcome research that would provide a scientific basis for the function of managed health care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Managed care and outcomes of hospitalization among elderly patients with congestive heart failure

123I-radiolabeled metaiodobenzylguanidine (123I-MIBG) cardiac imaging has been used to evaluate the distribution of sympathetic nervous system (SNS) in the heart. Different heart diseases have shown impaired cardiac SNS distribution as reflected by MIBG activity. The aim of this study was to assess the cardiac distribution of SNS in normal subjects, using MIBG imaging. Ten normal subjects (1 male and 9 females, mean age 46 +/- 9 years) with no cardiac abnormalities underwent myocardial 123I-MIBG scintigraphy, Tc-99m methoxyisobutylisonitrile (MIBI) cardiac perfusion imaging and equilibrium radionuclide angiography (RNA). Regional myocardial MIBG and MIBI activities were quantitatively evaluated using a region of interest analysis. For this purpose, the left ventricle was divided into 6 myocardial regions as anterior, apical, inferior, septum, lateral and posterolateral. In particular, myocardial MIBG and MIBI activities were measured as myocardium to mediastinum ratio. Regional left ventricular function was assessed by RNA. Myocardial MIBG uptake was homogeneous in anterior (2.2 +/- 0.5), inferior (2.5 +/- 0.7), septal (2.4 +/- 0.4), lateral (2.3 +/- 0.4), and posterolateral (2.3 +/- 0.4) regions. Conversely, MIBG uptake was significantly lower in the apical region (1.9 +/- 0.3) compared to all other left ventricular segments (p < 0.05). Regional myocardial perfusion, as measured by MIBI uptake, was homogeneous in all regions. No regional left ventricular wall motion abnormalities were observed by RNA. In conclusion, our data suggest that a decreased MIBG uptake may be observed in the left ventricular apical region of normal subjects reflecting reduced sympathetic innervation of the apex. This finding is not related to myocardial perfusion or wall motion abnormalities. The knowledge of cardiac sympathetic innervation in normal subjects may be helpful to assess SNS abnormalities in heart disease.     

Estimating variability in outcomes attributable to therapists: A naturalistic study of outcomes in managed care.

To estimate the variability in outcomes attributable to therapists in clinical practice, the authors analyzed the outcomes of 6,146 patients seen by approximately 581 therapists in the context of managed care. For this analysis, the authors used multilevel statistical procedures, in which therapists were treated as a random factor. When the initial level of severity was taken into account, about 5% of the variation in outcomes was due to therapists. Patient age, gender, and diagnosis as well as therapist age, gender, experience, and professional degree accounted for little of the variability in outcomes among therapists. Whether or not patients were receiving psychotropic medication concurrently with psychotherapy did affect therapist variability. However, the patients of the more effective therapists received more benefit from medication than did the patients of less effective therapists. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Youth psychotherapy change trajectories and outcomes in usual care: Community mental health versus managed care settings.

Objective: The authors compared symptom change trajectories and treatment outcome categories in children and adolescents receiving routine outpatient mental health services in a public community mental health system and a private managed care organization. Method: Archival longitudinal outcome data from parents completing the Youth Outcome Questionnaire (Y-OQ) were retrieved for children and adolescents (4–17 years old) served in a community mental health system (n = 936, mean age = 12 years, 40% girls or young women, 28% from families of color) and a managed care organization (n = 3,075, mean age = 13 years, 45% girls or young women, race and ethnicity not reported). The authors analyzed Y-OQ data using multilevel modeling and partial proportional odds modeling to test for differences in change trajectories and final outcomes across the 2 service settings. Results: Although initial symptom level was comparable across the 2 settings, the rate of change was significantly steeper for cases in the managed care setting. In addition, 24% of cases in the community mental health setting demonstrated a significant increase in symptoms over the course of treatment, compared with 14% of cases in the managed care setting. Conclusions: These results emphasize the need for increased attention to negative outcomes in routine mental health services and provide a stronger foundation for identifying youth cases at risk for treatment failure. In addition, given the overall differences observed across treatment settings for average rate of change and deterioration rates, results suggest that setting-specific model heuristics should be used for identifying cases at risk for negative outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Hospice and managed care

Carbon dioxide (CO2) lasers are capable of producing surface irregularities in human enamel which resemble those resulting from etching of enamel with orthophosphoric acid. This report presents the results of a laboratory study which examined the effect of selected tooth-related variables on shear bond strength between a current generation bonding agent (Scotchbond MultiPurpose) and acid-etched or laser-conditioned human enamel. There were no significant differences in shear bond strength between human maxillary central incisor teeth, first premolars, and third molars in either the acid etch or laser-conditioned groups. Polishing of enamel to give a flat surface increased the shear bond strength obtained with acid etching, but did not alter significantly bond strengths achieved with laser conditioning. There was a tendency for a higher bond strength with acid etching, but not with laser conditioning, in porcine molar enamel compared with human molar and bovine incisor enamel. In terms of the mode of operation of the laser, the repetitively pulsed mode resulted in a two-fold improvement in shear bond strength compared with the single pulse mode. These results indicate that shear bond strengths in the order of 10 MPa can be obtained reliably on human teeth using laser conditioning with pulsed modes in the absence of any other preparation of the natural enamel surface.     

AOTA and managed care

The process of becoming a medical doctor in the Russian Federation is detailed in this paper. There has been a decline in the number of students entering the medical profession, as well as a marked decrease in the faculty members at the medical institutes since perestroika. This is secondary to a marked decrease in financial support as well as falling morale.     

Temporal changes in the care and outcomes of elderly patients with acute myocardial infarction, 1987 through 1990

OBJECTIVE: To investigate changes between 1987 and 1990 in the care and outcomes associated with acute myocardial infarction (AMI) in elderly patients. DESIGN: Retrospective cohort study using a longitudinal database created from Medicare administrative files. PATIENTS: Cohorts comprising a total of 856,847 AMI patients insured by Medicare between 1987 and 1990. MAIN OUTCOME MEASURES: Annual rates of mortality at 30 days and 1 year following AMI, and the use of coronary angiography, coronary artery bypass graft surgery, and percutaneous transluminal coronary angioplasty during the first 90 days after a new AMI. RESULTS: Between 1987 and 1990, mortality rates decreased 10% overall from 26% to 23% at 30 days (P < .001) and from 40% to 36% at 1 year following AMI (P < .001). Declines in mortality and adjusted risks of 1-year mortality were similar in men and women and in blacks and whites, but mortality declines were more evident in those younger than 85 years. Meanwhile, the proportion of elderly AMI patients having angiography within the first 90 days after their index admission increased from 24% to 33% (P < .001); proportions increased for both genders and all races. The proportion of patients undergoing revascularization procedures increased from 13% to 21%; while rates of bypass surgery increased from 8% to 11%, rates of angioplasty doubled from 5% to 10% (all P < .001). CONCLUSIONS: Between 1987 and 1990, survival of elderly patients following AMI improved significantly. While changes in patient treatment may be responsible, the increased use of thrombolytic therapy appears to be only a partial explanation. Also, while the use of coronary angiography and revascularization procedures increased dramatically, the degree to which it caused the improvement in survival could not be determined.     

Self-perceived unmet health care needs of persons enrolled in HIV care

This study investigated the actual growth rate of 30 low stage operable non-small cell lung carcinomas, including disease-free surviving and deceased patients. The actual growth rate was defined as the cell production rate and was calculated from the growth fraction and the cell cycle time of each tumor at the time of surgical resection. The growth fraction was assessed by the Ki67 index while the cell cycle time was assumed to be reflected by the AgNORs content in the cells positive for Ki67. AgNORs content was evaluated by means of image analysis of double-stained AgNOR-Ki67 tissue section. The actual growth rate did not discriminate between the disease-free surviving and deceased patients but the AgNORs content in Ki67 cells correlated with the survival time of those patients who died of the tumor. Patients expressing a small AgNORs content, which might indicate a long cell cycle, may die but later; patients with a high AgNORs content, which might indicate a short cell cycle, die early or will survive. A twilight curve was derived from this data and might provide new prognostic indicators.     

The primary care physician and managed care

I have explored the major options open to PCPs. There are multiple variations on these themes. While the Connecticut market is fluid, one thing is clear, the solutions will vary from place to place. Health-care reorganization is a local phenomenon. Individual doctor groups can have a major influence on the direction of their local market. The future is uncertain, but whatever happens in Connecticut it will be evolutionary. PCPs must understand the realities of the current marketplace and plan a strategy to work with those realities to achieve their long-term goals. The choices we make today will have ramifications flowing far into future decades. PCPs and their patients will have to live with the consequences of these decisions. Please choose wisely.     

Liability issues in managed care

The explosive growth in Managed Care Organizations as a mechanism for providing health care in the United States has generated an equal explosion in litigation and new legislation related to problems within this delivery system. Abuses have included the "gagging" of physicians from providing full disclosure of medical options for their patients, inappropriate denial of care, denial of specialty referral, false claims data, insurer insolvency, economic credentialling, deselection, financial disincentives to render care, and lack of appeal or grievance mechanisms. These issues and others have resulted in injuries to patients and damage to the patient/physician relationship. This article discusses some of the more dramatic litigated cases and endeavors to alert both physicians and patients to potential legal matters that should be considered before becoming involved within this structure.     

Medicaid managed care in thirteen states

This study examines the recent expansion of Medicaid managed care from the perspective of the thirteen states in the Urban Institute's Assessing the New Federalism project. States are moving to managed care for Medicaid both to improve beneficiaries' access and to control the growth in program costs. However, we find that despite dramatic growth in enrollment during this decade, few states are enrolling the elderly or the disabled--the most expensive Medicaid beneficiaries. We also conclude that cost-savings objectives are often at odds with goals of contracting with mainstream plans and protecting safety-net providers.