Cost and effects of performance feedback and nurse case management for medicare beneficiaries with diabetes: a randomized controlled trial.

Nurse case management has been shown to improve the quality of diabetes care in closed model health maintenance organizations and Veterans Affairs medical clinics. A randomized controlled trial of a similar intervention within HealthTexas Provider Network, a fee-for-service primary care network in North Texas, demonstrated no benefit in processes of care or clinical outcomes for Medicare diabetes patients. To investigate whether the case management model impacted the cost of diabetes care from the Medicare perspective, we compared the average payments and charges incurred between intervention arms: claims-based audit and feedback; claims- and medical-record-based audit and feedback; and claims- and medical-record-based audit and feedback plus a practice-based diabetes resource nurse. Following adjustment for baseline differences between groups, no significant differences were observed. Thus, within this setting, it appears the nurse case management model produced no improvement in either clinical quality or in costs associated with diabetes from a Medicare perspective.     

High-dose chemotherapy in ovarian carcinoma

High-dose chemotherapy supported by bone marrow transplantation is being seriously investigated as a way to increase response and prolong survival in women with ovarian carcinoma. This report is a broad review of attempts over the past several years to demonstrate advantages of the high-dose approach. The existing data for dose escalation, short of doses requiring hematopoietic stem-cell transplant, demonstrate increased response rates, but no survival advantage. When even higher doses of chemotherapy are used in concert with autologous transplant to combat hematologic toxicities, even higher response rates have been reported. Despite this, all survival data from these later studies are limited. There is some hint of survival benefit in certain populations, such as those women with limited disease or perhaps in more advanced disease that has not been previously treated. All of the studies taken as a whole effectively demonstrate the need for randomized trials to address the issue of whether this approach provides any advantage over standard-dose chemotherapy. Future efforts at studying high-dose chemotherapy and autologous transplantation for ovarian carcinoma should be focused in this area; until results are available from such trials, high-dose chemotherapy with transplant will remain an experimental procedure.     

Toward Spanning the Quality Chasm: An Examination of Team Functioning Measures

Objective

To examine the effect of 5 measures of team functioning on patient outcomes.

Design

Observational, exploratory, measurement. Team functioning surveys and patient outcomes collected 1 year apart in a clinical trial were analyzed. The findings are discussed in context of the domains of team functioning, team effectiveness, and quality improvement.

Setting

27 Veterans Affairs medical centers.

Participants

Staff (t1: N=356; t2: N=273) on inpatient teams and patients (t1: N=4266; t2: N=3213) treated by the teams.

Interventions

Not applicable.

Main Outcome Measures

Five measures of team functioning (Physician Engagement, Shared Leadership, Supervisor Team Support, Teamness, and Team Effectiveness scales) and 3 measures of patient outcomes (functional improvement, discharge destination, and length of stay) were assessed at 2 time points with hierarchical generalized linear models to evaluate the association between team functioning measures and changes in patient outcomes.

Results

Associations (P<.05) between team functioning measures and patient outcomes were found for 3 of the 15 analyses over the study period. Higher Physician Engagement scale score was associated with lower length of stay (P=.017), and increased scores on Teamness and Team Effectiveness scales correlated with higher rates of community discharge (P=.044 and .049, respectively).

Conclusions

This exploratory analysis revealed trends that team functioning corresponds with patient outcomes in clinically relevant patterns. An increase in community discharge and a decrease in length of stay were associated with higher scores of team functioning. Here, we find evidence that modifiable attributes of team functioning have a measurable effect on patient outcomes. Such findings are promising and support the need for further research on team effectiveness.     

Increased nuclear factor-kappaB and angiotensinogen gene expression in posttransplant recurrent focal segmental glomerulosclerosis

In an attempt to identify potential markers of steroid-resistance in focal segmental glomerulosclerosis (FSGS) we evaluated intra-graft gene expression of IkappaBalpha, nuclear factor-kappaB (NF-kappaB), and angiotensinogen in 60 biopsies from 27 pediatric renal transplant recipients. Intra-graft NF-kappaB expression was significantly elevated in recurrent FSGS (R-FSGS) (218.3 + 55.6 ag/fg versus NON-FSGS 121.1 + 19.9, P=0.04) but not in acute rejection. NF-kappaB:IkappaBalpha ratios were higher in cadaveric donor versus living related donor recipients (15.7 + 2.8 vs. 8.8 + 1.3, respectively, P=0.015), and in African-American versus Caucasian recipients (15.6 + 2.9 vs. 9.1 + 1.3, respectively, P=0.03). Intra-graft angiotensinogen gene expression was significantly elevated in R-FSGS (30.5 + 8.8 ag/fg R-FSGS vs. 16.0 + 4.7 NON-FSGS, P=0.009). We conclude that increased NF-kappaB and angiotensinogen gene expression are associated with R-FSGS. Increased NF-kappaB:IkappaBalpha ratios are associated with cadaveric donor recipients and African-American race.     

Oral anticholinergics and gastric emptying

The quarternary ammonium antimuscarinic drugs propantheline bromide and clidinium bromide, given orally at the usual therapeutic doses, delayed gastric emptying of a swallowed radiolabeled liquid meal as measured by a gamma camera. Delay of emptying was dose dependent. If an identical meal was given by gastric tube, there was no slowing of emptying by propantheline in the group as a whole. Six subjects who emptied the intubated meal more quickly with placebo had slowed emptying after 30 mg propantheline. In five others, intubation alone slowed gastric emptying while the addition of 30 mg propantheline caused a paradoxical acceleration of gastric emptying. Clidinium bromide, 5 mg, delayed gastric emptying to the same extent as 15 mg propantheline bromide without the marked suppression of salivary secretion induced by the latter.     

Team functioning and patient outcomes in stroke rehabilitation

OBJECTIVE: To evaluate the relationship between rehabilitation team functioning and stroke patient outcomes. DESIGN: Prospective observational study. SETTING: Veterans Administration (VA) inpatient and subacute rehabilitation units. PARTICIPANTS: Forty-six VA rehabilitation teams, including 530 rehabilitation team members from 6 disciplines (medicine, nursing, social work, physical therapy, occupational therapy, speech language pathology) and 1688 stroke patients treated by the teams. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Ten scales assessing team member perceptions of team functioning (communication, perceived effectiveness, physician involvement, physician support, teamness, utility of quality information, innovation, interprofessional relationships, order and organization, task orientation) and 3 primary patient outcome variables-functional improvement, discharge home, and length of rehabilitation stay (LOS). RESULTS: Three of the 10 measures of team functioning were significantly associated with patient functional improvement ( P <.05): task orientation, order and organization, and utility of quality information. One measure of team functioning-effectiveness-was significantly associated with LOS ( P <.05). None of the team variables predicted discharge destination. Aspects of team functioning that were important to outcomes differed depending on the outcome of interests. Efforts directed toward improving team activities and relationships, including collaborative planning and problem solving and the use of feedback information, may enhance rehabilitation treatment effectiveness. CONCLUSIONS: Characteristics of team functioning predict selected rehabilitation outcomes.     

The influence of hospital culture on rehabilitation team functioning in VA hospitals

A conceptual model of rehabilitation effectiveness, in which team functioning is influenced by hospital culture, has been previously suggested by several authors of this study. The current study tested the efficacy of the hospital culture portion of the model using survey data from 523 rehabilitation team members and 162 administrators from 50 participating Veterans Administration Hospitals (VAHs). We assessed four types of hospital culture (personal, dynamic, formal, and production-oriented) using an instrument developed originally for a Competing Values Model. Rehabilitation team members and administrators perceived three of the four hospital cultures differently (p < 0.0001), agreeing only on production-oriented culture. With the use of VAH dominant culture as the independent variable, statistically significant differences were found among all nine measures of team functioning (dependent variables). The major contrast was between personal versus formal hospital culture types.