Relationship between quality of care and racial disparities in Medicare health plans

Context  Overall quality of care and racial disparities in quality are important and related problems in health care, but their relationship has not been well studied. In the Medicare managed care program, broad improvements in quality have been accompanied by reduced racial gaps in processes of care, but substantial disparities in outcomes have persisted. Objectives  To assess variations among Medicare health plans in overall quality and racial disparity in 4 Health Plan Employer and Data Information Set (HEDIS) outcome measures, to determine whether high-performing plans exhibit smaller racial disparities, and to identify plans with high quality and low disparity. Design, Setting, and Patients  We assessed the relationship between quality and racial disparity using multilevel multivariable regression models. The study sample included 431 573 individual-level observations in 151 Medicare health plans from 2002 to 2004. Main Outcome Measures  Hemoglobin A_1c of less than 9.5% or less than 9.0% for enrollees with diabetes; low-density lipoprotein cholesterol level of less than 130 mg/dL for enrollees with diabetes or after a coronary event; and blood pressure of less than 140/90 mm Hg for enrollees with hypertension. Results  Clinical performance on HEDIS outcome measures was 6.8% to 14.4% lower for black enrollees than for white enrollees (P<.001 for all). For each measure, more than 70% of this disparity was due to different outcomes for black and white individuals enrolled in the same health plan rather than selection of black enrollees into lower-performing plans. Health plans varied substantially in both overall quality and racial disparity on each of the 4 outcome measures. Adjusted correlations between overall quality and racial disparity were small and not statistically significant, ranging from 0.01 (blood pressure control) to –0.21 (cholesterol control in diabetes). Only 1 health plan achieved both high quality and low disparity on more than 1 measure. Conclusions  In Medicare health plans, disparities vary widely and are only weakly correlated with the overall quality of care. Therefore, plan-specific performance reports of racial disparities on outcome measures would provide useful information not currently conveyed by standard HEDIS reports.      

Quality of care in investor-owned vs not-for-profit HMOs.

CONTEXT: The proportion of health maintenance organization (HMO) members enrolled in investor-owned plans has increased sharply, yet little is known about the quality of these plans compared with not-for-profit HMOs. OBJECTIVE: To compare quality-of-care measures for investor-owned and not-for-profit HMOs. DESIGN, SETTING, AND PARTICIPANTS: Analysis of the Health Plan Employer Data and Information Set (HEDIS) Version 3.0 from the National Committee for Quality Assurance's Quality Compass 1997, which included 1996 quality-of-care data for 329 HMO plans (248 investor-owned and 81 not-for-profit), representing 56% of the total HMO enrollment in the United States. MAIN OUTCOME MEASURES: Rates for 14 HEDIS quality-of-care indicators. RESULTS: Compared with not-for-profit HMOs, investor-owned plans had lower rates for all 14 quality-of-care indicators. Among patients discharged from the hospital after myocardial infarction, 59.2% of members in investor-owned HMOs vs 70.6% in not-for-profit plans received a beta-blocker (P<.001); 35.1% of patients with diabetes mellitus in investor-owned plans vs 47.9% in not-for-profit plans had annual eye examinations (P<.001). Investor-owned plans had lower rates than not-for-profit plans of immunization (63.9% vs 72.3%; P<.001), mammography (69.4% vs 75.1%; P<.001), Papanicolaou tests (69.2% vs 77.1%; P<.001), and psychiatric hospitalization (70.5% vs 77.1%; P<.001). Quality scores were highest for staff- and group-model HMOs. In multivariate analyses, investor ownership was consistently associated with lower quality after controlling for model type, geographic region, and the method each HMO used to collect data. CONCLUSIONS: Investor-owned HMOs deliver lower quality of care than not-for-profit plans.     

Racial disparities in the quality of care for enrollees in medicare managed care

Context  Substantial racial disparities in the use of some health services exist; however, much less is known about racial disparities in the quality of care. Objective  To assess racial disparities in the quality of care for enrollees in Medicare managed care health plans. Design and Setting  Observational study, using the 1998 Health Plan Employer Data and Information Set (HEDIS), which summarized performance in calendar year 1997 for 4 measures of quality of care (breast cancer screening, eye examinations for patients with diabetes, -blocker use after myocardial infarction, and follow-up after hospitalization for mental illness). Participants  A total of 305 574 (7.7%) beneficiaries who were enrolled in Medicare managed care health plans had data for at least 1 of the 4 HEDIS measures and were aged 65 years or older. Main Outcome Measures  Rates of breast cancer screening, eye examinations for patients with diabetes, -blocker use after myocardial infarction, and follow-up after hospitalization for mental illness. Results  Blacks were less likely than whites to receive breast cancer screening (62.9% vs 70.9%; P<.001), eye examinations for patients with diabetes (43.6% vs 50.4%; P = .02), -blocker medication after myocardial infarction (64.1% vs 73.8%; P<.005), and follow-up after hospitalization for mental illness (33.2 vs 54.0%; P<.001). After adjustment for potential confounding factors, racial disparities were still statistically significant for eye examinations for patients with diabetes, -blocker use after myocardial infarction, and follow-up after hospitalization for mental illness. Conclusion  Among Medicare beneficiaries enrolled in managed care health plans, blacks received poorer quality of care than whites.      

Quality of care in Medicaid managed care and commercial health plans

Context  In contrast to the commercially insured population, the proportion of Medicaid beneficiaries enrolling in health maintenance organizations continues to increase. Objective  To compare quality of care within and between the Medicaid and commercial populations in 3 types of managed care plans: Medicaid-only plans (serving predominantly Medicaid enrollees), commercial-only plans (serving predominantly commercial enrollees), and Medicaid/commercial plans (serving substantial numbers of both types of enrollees). Design, Setting, and Participants  All 383 health plans that reported quality-of-care data to the National Committee for Quality Assurance for 2002 and 2003, including 204 commercial-only plans, 142 Medicaid/commercial plans (plans reported data for the Medicaid and commercial populations separately); and 37 Medicaid-only plans. Main Outcome Measures  Eleven quality indicators from the Healthcare Effectiveness Data and Information Set (HEDIS) applicable to the Medicaid population. Results  Among Medicaid enrollees, performance on the 11 measures observed in this study were comparable for Medicaid-only plans and Medicaid/commercial plans. Similarly, among commercial enrollees, there was virtually no difference in performance between health plans that served only the commercial population and those that also served the Medicaid population. Overall across all health plan types, the performance for the commercial population exceeded the performance for the Medicaid population on all measures except 1, ranging from a difference of 4.9% for controlling hypertension (58.4% for commercial vs 53.5% for Medicaid; P = .002) to 24.5% for rates of appropriate postpartum care (77.2% for commercial vs 52.7% for Medicaid; P = .001). Differences of similar magnitude were observed for commercial and Medicaid populations treated within the same health plan. Conclusions  Medicaid managed care enrollees receive lower-quality care than that received by commercial managed care enrollees. There were no differences in quality of care for the Medicaid population between Medicaid-only plans and commercial plans that also served the Medicaid population.      

Association of Managed Care Market Share and Health Expenditures for Fee-for-Service Medicare Patients

Context  Managed care has the potential to transform fundamentally the structure and functioning of the entire health care system, including the care provided to patients who are not enrolled in managed care plans. Objective  To determine whether increasing health maintenance organization (HMO) market share is associated with decreased expenditures for the care of patients covered by Medicare's traditional fee-for-service plan, a group cared for well outside the boundaries of managed care. Design and Setting  Data from the Health Care Financing Administration were used to compare expenditures for the care of Medicare fee-for-service beneficiaries for 802 market areas, representing the entire United States, for 1990 to 1994. These data were matched with data on system-wide (Medicare and non-Medicare) HMO market share in these areas. Patients  All fee-for-service Medicare beneficiaries (1990-1994) except for those with end-stage renal disease. Main Outcome Measure  Average fee-for-service expenditure per fee-for-service Medicare beneficiary by market area. Results  In a regression model, increases in system-wide HMO market share were associated with declines in both Part A and Part B fee-for-service expenditures per Medicare beneficiary (P<.001). Increases from 10% market share to 20% market share were associated with 2.0% decreases in Part A fee-for-service expenditures and 1.5% decreases in Part B fee-for-service expenditures. Conclusions  Managed care can have widespread effects on the health care system. Health care for individuals who are not covered by managed care organizations can be influenced by the presence of managed care. Lower expenditures in areas with high HMO market shares may indicate that traditional Medicare beneficiaries in areas with high market shares received fewer or less intensive services than traditional Medicare beneficiaries in other areas.      

Quality management practices in Medicaid managed care: a national survey of Medicaid and commercial health plans participating in the Medicaid program

Bruce E. Landon, MD, MBA; Arnold M. Epstein, MD, MA

JAMA. 1999;282:1769-1775.

Context  Rapid expansion of Medicaid managed care has raised concerns about the capacity and willingness of health plans enrolling Medicaid beneficiaries to provide high-quality care. Recently, legislation has facilitated market entry of Medicaid plans, health plans that draw most of their enrollment from the Medicaid population.

Objective  To characterize and compare the organizational characteristics and programs related to quality of care of commercial and Medicaid health plans that participate in the Medicaid program.

Design  Cross-sectional survey conducted September 1997 to April 1998.

Setting  The Medicaid program in 11 states and the District of Columbia.

Participants  All 154 health plans in these localities that provided prepaid general medical care to Medicaid beneficiaries during June 1997, of which 130 (84%) responded to the survey.

Main Outcome Measures  Health plan reports of structural characteristics, services offered, performance measurement and feedback, disease management programs, information systems capabilities, and provider network composition and relationships.

Results  Half of the respondents were Medicaid plans, with 75% or more of enrollees drawn from the Medicaid population. Medicaid plans tended to be smaller and newer than commercial plans that also served the Medicaid population and had more enabling programs targeting the special needs of the Medicaid population, such as inadequate transportation (85% of Medicaid plans vs 62% of commercial plans; P = .003) and illiteracy (66% vs 38%, respectively; P = .002). Overall, 71% of Medicaid plans vs 43% of commercial plans had enabling programs targeted at 6 or more of the 8 special needs we specified (P = .001). While commercial plans had a higher proportion of board-certified primary care physicians (81% vs 73%; P = .01), we found no major differences between Medicaid plans and commercial plans in collection and dissemination of performance measures, designation of specific areas for quality improvement, or use of disease management programs targeted at conditions prevalent in the Medicaid population. Neither commercial nor Medicaid plans reported high success in improving quality of care.

Conclusions  Based on our survey, while Medicaid plans resemble commercial plans serving the Medicaid population in many aspects of quality management, they are more likely to target programs directed to the specific needs of the Medicaid population. Neither commercial nor Medicaid plans have notably strong records in actual quality improvement.

     

Pharmaceutical company payments to physicians: early experiences with disclosure laws in Vermont and Minnesota

Context  Recent legislation in 5 states and the District of Columbia mandated state disclosure of payments made to physicians by pharmaceutical companies. In 2 of these states, Vermont and Minnesota, payment disclosures are publicly available. Objectives  To determine the accessibility and quality of the data available in Vermont and Minnesota and to describe the prevalence and magnitude of disclosed payments. Design and Setting  Cross-sectional analysis of publicly available data from July 1, 2002, through June 30, 2004, in Vermont and from January 1, 2002, through December 31, 2004, in Minnesota. Main Outcome Measures  Accessibility and quality of disclosure data and the number, value, and type of payments of $100 or more to physicians. Results  Access to payment data required extensive negotiation with the Office of the Vermont Attorney General and manual photocopying of individual disclosure forms at Minnesota's State Board of Pharmacy. In Vermont, 61% of payments were not released to the public because pharmaceutical companies designated them as trade secrets and 75% of publicly disclosed payments were missing information necessary to identify the recipient. In Minnesota, 25% of companies reported in each of the 3 years. In Vermont, among 12 227 payments totaling $2.18 million publicly disclosed, there were 2416 payments of $100 or more to physicians; total, $1.01 million; median payment, $177 (range, $100-$20 000). In Minnesota, among 6946 payments totaling $30.96 million publicly disclosed, there were 6238 payments of $100 or more to physicians; total, $22.39 million; median payment, $1000 (range, $100-$922 239). Physician-specific analyses were possible only in Minnesota, identifying 2388 distinct physicians who received payment of $100 or more; median number of payments received, 1 (range, 1-88) and the median amount received, $1000 (range, $100-$1 178 203). Conclusions  The Vermont and Minnesota laws requiring disclosure of payments do not provide easy access to payment information for the public and are of limited quality once accessed. However, substantial numbers of payments of $100 or more were made to physicians by pharmaceutical companies.      

Quality of care for children in commercial and Medicaid managed care

Context  Many states have turned to commercial health plans to serve Medicaid beneficiaries and to achieve cost-containment goals. Assumptions that the quality of care provided to Medicaid beneficiaries through these programs is acceptable have not been tested. Objective  To compare the quality of care provided to children and adolescents in commercial and Medicaid managed care in the United States. Design, Setting, and Population  Using 1999 data collected through the Health Plan Employer Data and Information Set, we examined reported quality-of-care indicators for children and adolescents. Results from 423 commercial and 169 Medicaid plans were compared. Matched pairs analyses were performed using data from each of the 81 companies serving both populations to control for corporate differences. Correlation coefficients and regression procedures were used to examine observed variations in health plan performance. Main Outcome Measures  Quality indicators including prenatal care, childhood immunizations, well-child visits, adolescent immunizations, and myringotomy and tonsillectomy rates. Results  Using standard indicators of clinical performance, children and adolescents enrolled in Medicaid received worse care compared with their commercial counterparts. For most of the 81 health plans serving both populations, Medicaid enrollees had statistically significantly (P<.001) lower rates than commercial plans for clinical quality indicators (eg, childhood immunization rates of 69% vs 54%); for clinical access indicators (eg, well-child visits in the first 15 months of life, 53% vs 31%); and for common procedures (eg, myringotomies for children aged 0-4 years, 35 vs 2 per 1000 members). Conversely, some plans demonstrated equal and high-quality care for both populations. Regression models failed to identify consistent plan characteristics that explained the observed differences in quality of care. Conclusions  Most commercial health plans do not deliver high-quality care on a number of performance indicators for children enrolled in Medicaid. Policy makers and the public need plan-specific quality information to inform purchasing decisions.      

Error reporting and disclosure systems: views from hospital leaders

Context  The Institute of Medicine has recommended establishing mandatory error reporting systems for hospitals and other health settings. Objective  To examine the opinions and experiences of hospital leaders with state reporting systems. Design and Setting  Survey of chief executive and chief operating officers (CEOs/COOs) from randomly selected hospitals in 2 states with mandatory reporting and public disclosure, 2 states with mandatory reporting without public disclosure, and 2 states without mandatory systems in 2002-2003. Main Outcome Measures  Perceptions of the effects of mandatory systems on error reporting, likelihood of lawsuits, and overall patient safety; attitudes regarding release of incident reports to the public; and likelihood of reporting incidents to the state or to the affected patient based on hypothetical clinical vignettes that varied the type and severity of patient injury. Results  Responses were received from 203 of 320 hospitals (response rate = 63%). Most CEOs/COOs thought that a mandatory, nonconfidential system would discourage reporting of patient safety incidents to their hospital’s own internal reporting system (69%) and encourage lawsuits (79%) while having no effect or a negative effect on patient safety (73%). More than 80% felt that the names of both the hospital and the involved professionals should be kept confidential, although respondents from states with mandatory public disclosure systems were more willing than respondents from the other states to release the hospital name (22% vs 4%-6%, P = .005). Based on the vignettes, more than 90% of hospital leaders said their hospital would report incidents involving serious injury to the state, but far fewer would report moderate or minor injuries, even when the incident was of sufficient consequence that they would tell the affected patient or family. Conclusions  Most hospital leaders expressed substantial concerns about the impact of mandatory, nonconfidential reporting systems on hospital internal reporting, lawsuits, and overall patient safety. While hospital leaders generally favor disclosure of patient safety incidents to involved patients, fewer would disclose incidents involving moderate or minor injury to state reporting systems.      

Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: a randomized controlled trial

Context  Depression is a common condition associated with significant morbidity in adolescents. Few depressed adolescents receive effective treatment for depression in primary care settings. Objective  To evaluate the effectiveness of a quality improvement intervention aimed at increasing access to evidence-based treatments for depression (particularly cognitive-behavior therapy and antidepressant medication), relative to usual care, among adolescents in primary care practices. Design, Setting, and Participants  Randomized controlled trial conducted between 1999 and 2003 enrolling 418 primary care patients with current depressive symptoms, aged 13 through 21 years, from 5 health care organizations purposively selected to include managed care, public sector, and academic medical center clinics in the United States. Intervention  Usual care (n = 207) or 6-month quality improvement intervention (n = 211) including expert leader teams at each site, care managers who supported primary care clinicians in evaluating and managing patients’ depression, training for care managers in manualized cognitive-behavior therapy for depression, and patient and clinician choice regarding treatment modality. Participating clinicians also received education regarding depression evaluation, management, and pharmacological and psychosocial treatment. Main Outcome Measures  Depressive symptoms assessed by Center for Epidemiological Studies-Depression Scale (CES-D) score. Secondary outcomes were mental health–related quality of life assessed by Mental Health Summary Score (MCS-12) and satisfaction with mental health care assessed using a 5-point scale. Results  Six months after baseline assessments, intervention patients, compared with usual care patients, reported significantly fewer depressive symptoms (mean [SD] CES-D scores, 19.0 [11.9] vs 21.4 [13.1]; P = .02), higher mental health–related quality of life (mean [SD] MCS-12 scores, 44.6 [11.3] vs 42.8 [12.9]; P = .03), and greater satisfaction with mental health care (mean [SD] scores, 3.8 [0.9] vs 3.5 [1.0]; P = .004). Intervention patients also reported significantly higher rates of mental health care (32.1% vs 17.2%, P<.001) and psychotherapy or counseling (32.0% vs 21.2%, P = .007). Conclusions  A 6-month quality improvement intervention aimed at improving access to evidence-based depression treatments through primary care was significantly more effective than usual care for depressed adolescents from diverse primary care practices. The greater uptake of counseling vs medication under the intervention reinforces the importance of practice interventions that include resources to enable evidence-based psychotherapy for depressed adolescents.      

Physician scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities

Context  Poor patient-physician communication increases the risk of patient complaints and malpractice claims. To address this problem, licensure assessment has been reformed in Canada and the United States, including a national standardized assessment of patient-physician communication and clinical history taking and examination skills. Objective  To assess whether patient-physician communication examination scores in the clinical skills examination predicted future complaints in medical practice. Design, Setting, and Participants  Cohort study of all 3424 physicians taking the Medical Council of Canada clinical skills examination between 1993 and 1996 who were licensed to practice in Ontario and/or Quebec. Participants were followed up until 2005, including the first 2 to 12 years of practice. Main Outcome Measure  Patient complaints against study physicians that were filed with medical regulatory authorities in Ontario or Quebec and retained after investigation. Multivariate Poisson regression was used to estimate the relationship between complaint rate and scores on the clinical skills examination and traditional written examination. Scores are based on a standardized mean (SD) of 500 (100). Results  Overall, 1116 complaints were filed for 3424 physicians, and 696 complaints were retained after investigation. Of the physicians, 17.1% had at least 1 retained complaint, of which 81.9% were for communication or quality-of-care problems. Patient-physician communication scores for study physicians ranged from 31 to 723 (mean [SD], 510.9 [91.1]). A 2-SD decrease in communication score was associated with 1.17 more retained complaints per 100 physicians per year (relative risk [RR], 1.38; 95% confidence interval [CI], 1.18-1.61) and 1.20 more communication complaints per 100 practice-years (RR, 1.43; 95% CI, 1.15-1.77). After adjusting for the predictive ability of the clinical decision-making score in the traditional written examination, the patient-physician communication score in the clinical skills examination remained significantly predictive of retained complaints (likelihood ratio test, P < .001), with scores in the bottom quartile explaining an additional 9.2% (95% CI, 4.7%-13.1%) of complaints. Conclusion  Scores achieved in patient-physician communication and clinical decision making on a national licensing examination predicted complaints to medical regulatory authorities.      

Change in the quality of care delivered to Medicare beneficiaries, 1998-1999 to 2000-2001

Context  Despite widespread concern regarding the quality and safety of health care, and a Medicare Quality Improvement Organization (QIO) program intended to improve that care in the United States, there is only limited information on whether quality is improving. Objective  To track national and state-level changes in performance on 22 quality indicators for care of Medicare beneficiaries. Design, Patients, and Setting  National observational cross-sectional studies of national and state-level fee-for-service data for Medicare beneficiaries during 1998-1999 (baseline) and 2000-2001 (follow-up). Main Outcome Measures  Twenty-two QIO quality indicators abstracted from state-wide random samples of medical records for inpatient fee-for-service care and from Medicare beneficiary surveys or Medicare claims for outpatient care. Absolute improvement is defined as the change in performance from baseline to follow-up (measured in percentage points for all indicators except those measured in minutes); relative improvement is defined as the absolute improvement divided by the difference between the baseline performance and perfect performance (100%). Results  The median state's performance improved from baseline to follow-up on 20 of the 22 indicators. In the median state, the percentage of patients receiving appropriate care on the median indicator increased from 69.5% to 73.4%, a 12.8% relative improvement. The average relative improvement was 19.9% for outpatient indicators combined and 11.9% for inpatient indicators combined (P<.001). For all but one indicator, absolute improvement was greater in states in which performance was low at baseline than those in which it was high at baseline (median r = -0.43; range: 0.12 to -0.93). When states were ranked on each indicator, the state's average rank was highly stable over time (r = 0.93 for 1998-1999 vs 2000-2001). Conclusions  Care for Medicare fee-for-service plan beneficiaries improved substantially between 1998-1999 and 2000-2001, but a much larger opportunity remains for further improvement. Relative rankings among states changed little. The improved care is consistent with QIO activities over this period, but these cross-sectional data do not provide conclusive information about the degree to which the improvement can be attributed to the QIOs' quality improvement efforts.      

Varicella disease after introduction of varicella vaccine in the United States, 1995-2000

Context  Before licensure of varicella vaccine in 1995, varicella was a universal childhood disease in the United States, causing 4 million cases, 11 000 hospitalizations, and 100 deaths every year. Objective  To examine population-based disease surveillance data in 3 communities to document the impact of the varicella vaccination program. Design, Setting, and Subjects  Active surveillance for varicella conducted among the populations of Antelope Valley, Calif; Travis County, Tex; and West Philadelphia, Pa; from January 1, 1995, to December 31, 2000. Reporting sites included child care centers, schools, universities, physicians, public health clinics, hospitals, emergency departments, and households. Main Outcome Measures  Trends in number and rate of varicella cases and hospitalizations; varicella vaccine coverage. Results  From 1995 through 1998, in each surveillance area, the number of verified varicella cases varied from year to year with marked springtime seasonality. In 1999, the number and rates of varicella cases and hospitalizations declined markedly. From 1995 through 2000, in Antelope Valley, Travis County, and West Philadelphia, varicella cases declined 71%, 84%, and 79%, respectively. Cases declined to the greatest extent among children aged 1 to 4 years, but cases declined in all age groups, including infants and adults. In the combined 3 surveillance areas, hospitalizations due to varicella declined from a range of 2.7 to 4.2 per 100 000 population in 1995 through 1998 to 0.6 and 1.5 per 100 000 population in 1999 and 2000, respectively (P = .15). By 2000, vaccine coverage among children aged 19 to 35 months was 82.1%, 73.6%, and 83.8% in Los Angeles County, Texas, and Philadelphia County, respectively. Conclusions  Varicella disease has declined dramatically in surveillance areas with moderate vaccine coverage. Continued implementation of existing vaccine policies should lead to further reductions of varicella disease in these communities and throughout the United States.      

Association between licensure examination scores and practice in primary care

Context  Standards for licensure are designed to provide assurance to the public of a physician's competence to practice. However, there has been little assessment of the relationship between examination scores and subsequent practice performance. Objective  To determine if there is a sustained relationship between certification examination scores and practice performance and if licensing examinations taken at the end of medical school are predictive of future practice in primary care. Design, Setting, and Participants  A total of 912 family physicians, who passed the Québec family medicine certification examination (QLEX) between 1990 and 1993 and entered practice. Linked databases were used to assess physicians' practice performance for 3.4 million patients in the universal health care system in Québec, Canada. Patients were seen during the follow-up period for the first 4 years (1993 cohort of physicians) to 7 years (1990 cohort of physicians) of practice from July 1 of the certification examination to December 31, 1996. Main Outcome Measures  Mammography screening rate, continuity of care index, disease-specific and symptom-relief prescribing rate, contraindicated prescribing rate, and consultation rate. Results  Physicians achieving higher scores on both examinations had higher rates (rate increase per SD increase in score per 1000 persons per year) of mammography screening ( for QLEX, 16.8 [95% confidence interval {CI}, 8.7-24.9]; for Medical Council of Canada Qualifying Examination [MCCQE], 17.4 [95% CI, 10.6-24.1]) and consultation ( for QLEX, 4.9 [95% CI, 2.1-7.8]; for MCCQE, 2.9 [95% CI, 0.4-5.4]). Higher subscores in diagnosis were predictive of higher rates in the difference between disease-specific and symptom-relief prescribing ( for QLEX, 3.9 [95% CI, 0.9-7.0]; for MCCQE, 3.8 [95% CI, 0.3-7.3]). Higher scores of drug knowledge were predictive of a lower rate (relative risk per SD increase in score) of contraindicated prescribing for MCCQE (relative risk, 0.88; 95% CI, 0.77-1.00). Relationships between examination scores and practice performance were sustained through the first 4 to 7 years in practice. Conclusion  Scores achieved on certification examinations and licensure examinations taken at the end of medical school show a sustained relationship, over 4 to 7 years, with indices of preventive care and acute and chronic disease management in primary care practice.      

Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990-1992 to 2001-2003

Context  Little is known about trends in suicidal ideation, plans, gestures, or attempts or about their treatment. Such data are needed to guide and evaluate policies to reduce suicide-related behaviors. Objective  To analyze nationally representative trend data on suicidal ideation, plans, gestures, attempts, and their treatment. Design, Setting, and Participants  Data came from the 1990-1992 National Comorbidity Survey and the 2001-2003 National Comorbidity Survey Replication. These surveys asked identical questions to 9708 people aged 18 to 54 years about the past year’s occurrence of suicidal ideation, plans, gestures, attempts, and treatment. Trends were evaluated by using pooled logistic regression analysis. Face-to-face interviews were administered in the homes of respondents, who were nationally representative samples of US English-speaking residents. Main Outcome Measure  Self-reports about suicide-related behaviors and treatment in the year before interview. Results  No significant changes occurred between 1990-1992 and 2001-2003 in suicidal ideation (2.8% vs 3.3%; P = .43), plans (0.7% vs 1.0%; P = .15), gestures (0.3% vs 0.2%; P = .24), or attempts (0.4%-0.6%; P = .45), whereas conditional prevalence of plans among ideators increased significantly (from 19.6% to 28.6%; P = .04), and conditional prevalence of gestures among planners decreased significantly (from 21.4% to 6.4%; P = .003). Treatment increased dramatically among ideators who made a gesture (40.3% vs 92.8%) and among ideators who made an attempt (49.6% vs 79.0%). Conclusions  Despite a dramatic increase in treatment, no significant decrease occurred in suicidal thoughts, plans, gestures, or attempts in the United States during the 1990s. Continued efforts are needed to increase outreach to untreated individuals with suicidal ideation before the occurrence of attempts and to improve treatment effectiveness for such cases.      

Recreational physical activity and the risk of breast cancer in postmenopausal women: the Women's Health Initiative Cohort Study

Context  Women who are physically active have a decreased risk for breast cancer, but the types, amounts, and timing of activity needed are unknown. Objective  To prospectively examine the association between current and past recreational physical activity and incidence of breast cancer in postmenopausal women. Design, Setting, and Patients  Prospective cohort study in 74 171 women aged 50 to 79 years who were recruited by 40 US clinical centers from 1993 through 1998. Main Outcome Measure  Incident invasive and in situ breast cancer. Results  We documented 1780 newly diagnosed cases of breast cancer over a mean follow-up of 4.7 years. Compared with less active women, women who engaged in regular strenuous physical activity at age 35 years had a 14% decreased risk of breast cancer (relative risk [RR], 0.86; 95% confidence interval [CI], 0.78-0.95). Similar but attenuated findings were observed for strenuous physical activity at ages 18 years and 50 years. An increasing total current physical activity score was associated with a reduced risk for breast cancer (P = .03 for trend). Women who engaged in the equivalent of 1.25 to 2.5 hours per week of brisk walking had an 18% decreased risk of breast cancer (RR, 0.82; 95% CI, 0.68-0.97) compared with inactive women. Slightly greater reduction in risk was observed for women who engaged in the equivalent of 10 hours or more per week of brisk walking. The effect of exercise was most pronounced in women in the lowest tertile of body mass index (BMI) (<24.1), but also was observed for women in the middle tertile of BMI (24.1-28.4). Conclusions  These data suggest that increased physical activity is associated with reduced risk for breast cancer in postmenopausal women, longer duration provides most benefit, and that such activity need not be strenuous.      

Trends in bariatric surgical procedures

Context  The increasing prevalence and associated sociodemographic disparities of morbid obesity are serious public health concerns. Bariatric surgical procedures provide greater and more durable weight reduction than behavioral and pharmacological interventions for morbid obesity. Objective  To examine trends for elective bariatric surgical procedures, patient characteristics, and in-hospital complications from 1998 to 2003 in the United States. Design, Setting, and Patients  The Nationwide Inpatient Sample was used to identify bariatric surgery admissions from 1998-2002 (with preliminary data for 12 states from 2003) using International Classification of Diseases, Ninth Revision, codes for foregut surgery with a confirmatory diagnosis of obesity or by diagnosis related group code for obesity surgery. Annual estimates and trends were determined for procedures, patient characteristics, and adjusted complication rates. Main Outcome Measures  Trends in bariatric surgical procedures, patient characteristics, and complications. Results  The estimated number of bariatric surgical procedures increased from 13 365 in 1998 to 72 177 in 2002 (P<.001). Based on preliminary state-level data (1998-2003), the number of bariatric surgical procedures is projected to be 102 794 in 2003. Gastric bypass procedures accounted for more than 80% of all bariatric surgical procedures. From 1998 to 2002, there were upward trends in the proportion of females (81% to 84%; P = .003), privately insured patients (75% to 83%; P = .001), patients from ZIP code areas with highest annual household income (32% to 60%, P<.001), and patients aged 50 to 64 years (15% to 24%; P<.001). Length of stay decreased from 4.5 days in 1998 to 3.3 days in 2002 (P<.001). The adjusted in-hospital mortality rate ranged from 0.1% to 0.2%. The rates of unexpected reoperations for surgical complications ranged from 6% to 9% and pulmonary complications ranged from 4% to 7%. Rates of other in-hospital complications were low. Conclusions  These findings suggest that use of bariatric surgical procedures increased substantially from 1998 to 2003, while rates of in-hospital complications were stable and length of stay decreased. However, disparities in the use of these procedures, with disproportionate and increasing use among women, those with private insurance, and those in wealthier ZIP code areas should be explored further.      

Daily activity energy expenditure and mortality among older adults

Context  Exercise is associated with mortality benefits but simply expending energy through any activity in an individual's free-living environment may confer survival advantages. Objective  To determine whether free-living activity energy expenditure is associated with all-cause mortality among older adults. Design, Setting, and Participants  Free-living activity energy expenditure was assessed in 302 high-functioning, community-dwelling older adults (aged 70-82 years). Total energy expenditure was assessed over 2 weeks using doubly labeled water. Resting metabolic rate was measured using indirect calorimetry and the thermic effect of meals was estimated at 10% of total energy expenditure. Free-living activity energy expenditure was calculated as: (total energy expenditure x 0.90) – resting metabolic rate. Participants were followed up over a mean of 6.15 years (1998-2006). Main Outcome Measures  Free-living activity energy expenditure (3 tertiles: low, <521 kcal/d; middle, 521-770 kcal/d; high, >770 kcal/d) and all-cause mortality. Results  Fifty-five participants (18.2%) died during follow-up. As a continuous risk factor, an SD increase in free-living activity energy expenditure (287 kcal/d) was associated with a 32% lower risk of mortality after adjusting for age, sex, race, study site, weight, height, percentage of body fat, and sleep duration (hazard ratio, 0.68; 95% confidence interval, 0.48-0.96). Using the same adjustments, individuals in the highest tertile of free-living activity energy expenditure were at a significantly lower mortality risk compared with the lowest tertile (hazard ratio, 0.31; 95% confidence interval, 0.14-0.69). Absolute risk of death was 12.1% in the highest tertile of activity energy expenditure vs 24.7% in the lowest tertile; absolute risks were similar to these for tertiles of physical activity level. The effect of free-living activity energy expenditure changed little after further adjustment for self-rated health, education, prevalent health conditions, and smoking behavior. According to self-reports, individuals expending higher levels of free-living activity energy were more likely to work for pay (P = .004) and climb stairs (P = .01) but self-reported high-intensity exercise, walking for exercise, walking other than for exercise, volunteering, and caregiving did not differ significantly across the activity energy expenditure tertiles. Conclusions  Objectively measured free-living activity energy expenditure was strongly associated with lower risk of mortality in healthy older adults. Simply expending energy through any activity may influence survival in older adults.