Patient Opinions Regarding ‘Pay for Performance for Patients’

Background  Pay for performance (P4P) programs have shown only modest improvements in outcomes and do not target patient behaviors. Many large employers and payers are turning to pay for performance for patients (P4P4P) to reduce health costs and improve the health of their covered populations. How these programs may be perceived by patients is unknown. Objective  To assess patients’ opinion of the acceptability of P4P4P. Design  Cross-sectional self-administered survey. Participants  Patients in waiting rooms in two university-based primary care clinics. Measurements  Participants were asked their opinions about paying people to quit smoking, lose weight, control their blood pressure, or control their diabetes. Results  Respondents were split on whether P4P4P is desirable. Thrity-six to 42% thought it was a good/excellent idea to pay smokers to quit smoking, obese people to lose weight, people with hypertension to control their blood pressure, or people with diabetes to control their blood sugar, while 41–44% of the sample thought it was a bad/very bad idea. Smokers and patients who were obese endorsed P4P4P more favorably as a means to achieving tobacco cessation and weight loss than their non-smoking and non-obese counterparts. Conclusions  Acceptance of paying patients for performance by the general population is equivocal. Establishing the efficacy of paying patients for performance may help it gain wider acceptance. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

The diagnostic value of Rosemont and Japanese diagnostic criteria for ‘indeterminate’, ‘suggestive’, ‘possible’ and ‘early’ chronic pancreatitis

Background

Longitudinal data are lacking to support consensus criteria for diagnosing early chronic pancreatitis.

Chills in ‘early sepsis’: good for you?

We evaluated the predictive value of chills, bacteraemia and endotoxaemia for in-hospital mortality and survival at 5-10 years long-term follow-up in a prospective cohort of 'early sepsis' patients presenting with fever resulting from community-acquired pneumonia or pyelonephritis. Febrile patients with chills had bacteraemia more often (RR 3.1, 95% CI 1.8-5.4) than those without chills. Neither chills nor bacteraemia were significantly related to in-hospital mortality, but patients with endotoxaemia had a higher in-hospital mortality rate than those without endotoxaemia. Patients with chills had a significantly higher survival rate at long-term follow-up than those without chills on admission: the estimated risk of dying was 0.644 (95% CI 0.43-0.95, P = 0.029) for an individual with chills, compared to a person without chills, adjusting for the other factors [age cohort, underlying disease and the pro-inflammatory response in the blood, i.e. tumour necrosis factor-alpha (TNF-alpha) and blood leucocyte number, as scored on hospital admission] in the Cox proportional hazards model. Chills may characterize a patient subpopulation that upon pulmonary and urinary tract infection is able to raise a more rapid and/or efficient host response.     

Detection of abnormal proliferation in histologically ‘normal’ colonic biopsies using FTIR‐microspectroscopy

Background: Abnormal crypt proliferation and development in the colon has been associated with premalignant stages of colon cancer. Conventionally, molecular markers are used to detect abnormal crypt proliferation. Methods: In the present work, feasibility studies of FTIR‐MSP to distinguish between normal and abnormal crypts from colon biopsies that show normal histopathological features have been undertaken. Results: The results indicate that abnormal crypts show deviations in the pattern of absorbance in the Mid IR region along the crypt height when compared with the normal crypts. The crypts could be empirically classified into three groups such as crypts having a normal absorbance pattern for all biochemical components, crypts with abnormal absorbance pattern for some biochemical components and crypts with completely abnormal absorbance pattern along the height for all or most biochemical components studied by FTIR. The utilization of FTIR‐MSP is proposed for diagnosis of abnormal metabolism at the molecular level of histologically completely normal‐looking crypts, especially from those biopsies that are taken from sites far away from cancer. Conclusions: This method could give rise to a reduction in false‐negative results during examination of biopsies using the conventional histopathological methods. The present method may be complementary to existing methods for precise demarcation of the zone of colostomy prior to colon cancer surgery.     

Disease ‘Activity’, ‘Severity’ and ‘Impact’: Interrelationships in COPD; Is a Measure of Disease ‘Activity’ the Holy Grail for COPD,or a Variable Impossible to Quantify?

It is increasingly recognised that new measures of disease ‘activity’ for COPD are required, however the relationship between markers of disease ‘activity’, ‘severity’ and ‘impact’ though closely linked, is poorly understood. Additionally, while change in markers of disease ‘severity’ (e.g. change in FEV₁) may be considered a marker of disease ‘activity’, these quantify a single aspect of disease ‘activity’ in COPD rather than measuring the overall disease process and this has stimulated the search for new biomarkers of COPD that reflect the ‘activity’ of the disease process.

The ideal biomarker of disease ‘activity’ would be stable with respect to time since measurement at any time point would then relate to subsequent disease progression. This would allow the influence of a therapeutic intervention to be assessed early, facilitating both phase 2 and 3 clinical trials. Although a number of potential biomarkers of COPD disease ‘activity’ have been studied, to date none have been shown to conclusively relate to disease progression and the stability of underlying disease ‘activity’ therefore requires further consideration. Interestingly, while the variability of disease ‘activity’ of COPD is rarely mentioned in the current literature, and there is uncertainty whether ‘activity’ is constant or highly variable, there are clues from available data as discussed in the current article. Finally we consider how markers of disease ‘activity’, ‘severity’ and ‘impact’ may relate, which is of utmost importance in the ongoing search for new biomarkers in COPD and a greater understanding of the pathogenesis of the disease process.     

All patients with ‘idiopathic’ hypopituitarism should be screened for hemochromatosis

Hypopituitarism usually occurs as the result of a pituitary tumour or as a consequence of its treatment. If, however, pituitary imaging is negative then an alternative diagnosis should be sought. Patients are often diagnosed as having idiopathic hypopituitarism when imaging is normal. Our objective is to highlight the importance of screening for hemochromatosis in patients with presumed ‘idiopathic’ hypopituitarism. Our patients presented initially with biochemical hypopituitarism and, after initial investigation and normal imaging, were labelled as having idiopathic disease. They subsequently developed iron overload in cardiac and hepatic tissue respectively requiring regular venesection to deplete body stores. Genetic analysis revealed homozygosity for the C282Y mutation in our first patient thus explaining his more severe iron overload whereas our second case was a heterozygote for the same mutation, with iron overload confirmed on liver biopsy. We recommend that iron studies are performed in all patients who present with hypopituitarism and normal pituitary imaging. This may lead to reversal of the hypopituitarism and avoid development of any systemic consequences of hemochromatosis.     

CRT or CRT-D devices? The case for ‘high energy’ devices

The decision to implant a CRT or CRT-D device is an important one that requires a careful look at the patient and discussion with the patient as to the benefits and risks associated with each approach. The good news is that CRT provided in any device is a robust therapy that improves many measures of heart failure outcome in very high-risk patients. We argue that in most circumstances, it is much easier to turn a tachycardia device off than not to have the benefit of prompt defibrillation should a tachycardia event occur. While cost is always a consideration, the responsibility of the physician is to individualize patient care and advocate for each patient, based upon the best available therapies.