MDS-based state Medicaid reimbursement and the ADL-decline quality indicator

PURPOSE: We examined the relationship between the quality indicator for decline in activities of daily living (ADL) and the use of the Minimum Data Set (MDS) for determining Medicaid skilled nursing facility reimbursement. DESIGN AND METHODS: We conducted a cross-sectional analysis using the 2004 National MDS Facility Quality Indicator reports as the dependent variable in a multilevel regression model. Our primary explanatory variable was a state-level binary variable distinguishing whether or not the state used an MDS-based Medicaid-reimbursement system in 2004. We obtained control variables through the Online Survey, Certification, and Reporting System. RESULTS: Skilled nursing facilities located in states that used the MDS for Medicaid reimbursement reported more ADL decline than did facilities in states that did not use the MDS for reimbursement. IMPLICATIONS: The finding suggests that the ADL-decline quality indicator captures more than just quality, including state-level policy differences. Therefore, the ADL-decline quality indicator should be investigated and refined prior to being relied on for pay-for-performance initiatives.     

Budesonide/formoterol vs. salmeterol/fluticasone in COPD: a systematic review and adjusted indirect comparison of pneumonia in randomised controlled trials

Aims: This analysis was designed to provide a comparison between budesonide/formoterol and salmeterol/fluticasone for the relative incidence of pneumonia adverse events, pneumonia serious adverse events and pneumonia‐related mortality in patients being treated for chronic obstructive pulmonary disease. Methods: An initial literature search revealed no suitable head‐to‐head trials between budesonide/formoterol and salmeterol/fluticasone and therefore a systematic review was conducted to find randomised controlled trials providing data for input into an adjusted indirect comparison of the two combination treatments using placebo as a common comparator. The Bucher adjusted indirect comparison method was used to calculate odds ratios and 95% confidence intervals. Results: Eight salmeterol/fluticasone trials and four budesonide/formoterol trials were identified as being relevant for the analyses. The proportion of patients experiencing a pneumonia adverse event was significantly lower with budesonide/formoterol than salmeterol/fluticasone (odds ratio, 0.47; 95% confidence interval, 0.28–0.80). The proportion of patients experiencing a pneumonia serious adverse event was also significantly lower with budesonide/formoterol than salmeterol/fluticasone (odds ratio, 0.41; 95% confidence interval, 0.19–0.86). However, there were too few events to draw any firm conclusions on pneumonia‐related mortality. Conclusions: The results of the indirect comparison support the hypothesis that budesonide/formoterol is associated with fewer pneumonia events than salmeterol/fluticasone in chronic obstructive pulmonary disease. The limitations of the analysis are that the results from a single study, TORCH, have a large bearing on the overall findings of the analysis, and that there is heterogeneity in the length and the dosing of the included studies, although it does not appear that heterogeneity affected the reported results. Another important limitation is the lack of predefined diagnostic standards for pneumonia in these studies.     

Diabetic Retinopathy and Cognitive Decline in Older People With Type 2 Diabetes: The Edinburgh Type 2 Diabetes Study

OBJECTIVE

Cerebral microvascular disease associated with type 2 diabetes may exacerbate the effects of aging on cognitive function. A considerable homology exists between the retinal and cerebral microcirculations; a hypothesized association between diabetic retinopathy (DR) and cognitive decline was examined in older people with type 2 diabetes.

RESEARCH DESIGN AND METHODS

In the population-based Edinburgh Type 2 Diabetes Study, 1,046 men and women aged 60–75 years with type 2 diabetes underwent standard seven-field binocular digital retinal photography and a battery of seven cognitive function tests. A general cognitive ability score (g) was generated by principal components analysis. The Mill-Hill Vocabulary Scale was used to estimate premorbid cognitive ability. DR was graded using a modification of the Early Treatment of Diabetic Retinopathy Scale.

RESULTS

After age and sex adjustment, a significant relationship was observed with increasing severity of DR (none, mild, and moderate to severe) for most cognitive measures. Participants with moderate-to-severe retinopathy had the worst g and the worst performances on the individual tests. There was a significant interaction between sex and retinopathy for g. In male subjects, the associations of retinopathy with g (and with tests of verbal fluency, mental flexibility, and processing speed but not memory and nonverbal reasoning) persisted (P < 0.05) when further adjusted for vocabulary (to estimate lifetime cognitive decline), depression, sociodemographic characteristics, cardiovascular risk factors, and macrovascular disease.

CONCLUSIONS

DR was independently associated with estimated lifetime cognitive decline in older men with type 2 diabetes, supporting the hypothesis that cerebral microvascular disease may contribute to their observed accelerated age-related cognitive decline. A sex interaction with stronger findings in men requires further confirmation.Type 2 diabetes is associated with an increased risk of age-related cognitive impairment and decline in addition to higher incidences of stroke and dementia (1–3). Relatively little is known about the risk factors associated with the deleterious effects of type 2 diabetes on accelerated cognitive aging, although cerebral microvascular disease may be important (4–6). However, direct in vivo evaluation of the cerebral microcirculation is difficult and the vessels themselves are too small to permit detailed visualization with current neuroimaging methods.Retinal and cerebral small vessels share similar embryological origin, size, structure, and physiological characteristics (including the blood-brain and blood-retinal barrier) (7,8). The retinal vascular bed can be directly visualized noninvasively with retinal photography. Typical retinopathic changes associated with diabetes are associated with white matter lesions in the brain, magnetic resonance imaging (MRI)-defined cerebral infarcts, and incident stroke (9–11). We hypothesized that increasing severity of diabetic retinopathy (DR) would be associated with poorer cognitive ability and with greater cognitive decline, thus providing evidence for an effect of cerebral microvascular disease on accelerated age-related cognitive decline in people with type 2 diabetes. Previous studies have found a significant association between the presence of microaneurysms and reduced performance on measures of fluid intelligence, processing speed, and attention ability in young adults with type 1 diabetes (12) and between retinopathy and risk of cognitive impairment and decline in the general population (13–15), but to our knowledge the relationship between DR and cognition in older people with type 2 diabetes has not been examined.The aim of the present investigation was to determine the association of DR with both cognitive ability and estimated lifetime cognitive decline in a large, well-characterized sample of men and women aged 60–75 years with type 2 diabetes (the Edinburgh Type 2 Diabetes Study [ET2DS]). Cognitive function was measured using a battery of neuropsychological tests assessing major cognitive domains, and cognitive decline was estimated by using a test of vocabulary to adjust for premorbid cognitive function.     

The association between early outcome, health-related quality of life, and survival following elective open-heart surgery

We investigated the impact of perioperative complications on patients' health-related quality of life (HRQL) and intermediate-term survival after cardiac surgery. Improved results for cardiac surgery are well demonstrated in low rates of operative mortality and morbidity. However, the association between perioperative morbid events, HRQL at 1 year, and survival is unclear. We performed a prospective study among 836 elective cardiac surgery patients to assess the impact of perioperative outcomes on survival and HRQL at 1 year. Health-related quality of life was generated using the 20-item short-form questionnaire. Kaplan-Meier and life-table estimates were used to examine the relationship of HRQL at 1-year and intermediate-term survival. All HRQL domains were statistically improved at 1 year, with the highest gains in general health perception (+19.4%) and the least gains in social (+5.1%) and mental (+5.1%) domains. Patients experiencing 1 or more perioperative complication or increased length of stay reported similar HRQL scores as patients with no complications. Patients with negative changes in social (94.5% vs 99.2%, P < .001) and general health perception (99.4% vs 95.5%, P < .001) domains showed a reduced survival compared with patients with positive HRQL gains at 2 to 5 years after surgery. Perioperative complications had minimal or no effect on HRQL at 1 year after cardiac surgery.     

A finite-element analysis study of the metatarsophalangeal joint of the hallux rigidus

Hallux rigidus was first described in 1887. Many aetiological factors have been postulated, but none has been supported by scientific evidence. We have examined the static and dynamic imbalances in the first metatarsophalangeal joint which we postulated could be the cause of this condition. We performed a finite-element analysis study on a male subject and calculated a mathematical model of the joint when subjected to both normal and abnormal physiological loads. The results gave statistically significant evidence for an increase in tension of the plantar fascia as the cause of abnormal stress on the articular cartilage rather than mismatch of the articular surfaces or subclinical muscle contractures. Our study indicated a clinical potential cause of hallux rigidus and challenged the many aetiological theories. It could influence the choice of surgical procedure for the treatment of early grades of hallux rigidus.     

Co-ordinated expression of MMP-2 and its putative activator, MT1-MMP, in human placentation

The spatial expression of mRNA for matrix metalloproteinase 2 (MMP-2), its putative activator, the membrane-type 1 matrix metalloproteinase (MT1-MMP), and the MMP-2 substrate type IV collagen was investigated in human placentas of both normal and tubal ectopic pregnancies and in cyclic endometrium using in-situ hybridization. Cytokeratin staining applied to adjacent sections was used to identify epithelial and trophoblast cells. In both normal and tubal pregnancies MT1-MMP, MMP-2 and type IV collagen mRNA were highly expressed and co-localized in the extravillous cytotrophoblasts of anchoring villi, in cytotrophoblasts that had penatrated into the placental bed and in cytotrophoblastic cell islands. In addition, the decidual cells of normal pregnancies in some areas co-expressed MT1-MMP and MMP-2 mRNA, with moderate signals for both components. Fibroblast-like stromal cells in tubal pregnancies were positive for MMP-2 mRNA but generally negative for MT1-MMP mRNA. The consistent co-localization of MT1-MMP with MMP-2 and type IV collagen in the same subset of cytotrophoblasts strongly suggests that all three components co-operate in the tightly regulated fetal invasion process. The co-expression of MT1-MMP and MMP-2 mRNA in some of the decidual cells indicates that these cells are also actively involved in the placentation process.      

Genetic and cellular basis of cerebral cavernous malformations: implications for clinical management

Bacigaluppi S, Retta SF, Pileggi S, Fontanella M, Goitre L, Tassi L, La Camera A, Citterio A, Patrosso MC, Tredici G, Penco S. Genetic and cellular basis of cerebral cavernous malformations: implications for clinical management. Cerebral cavernous malformations (CCMs) are a diffuse cerebrovascular disease affecting approximately 0.5% of the population. A CCM is characterized by abnormally enlarged and leaky capillaries arranged in mulberry‐like structures with no clear flow pattern. The lesion might predispose to seizures, focal neurological deficits or fatal intracerebral hemorrhage. However, a CCM can also remain neurologically silent. It might either occur sporadically or as an inherited disorder with incomplete penetrance and variable expressivity. Due to advances in imaging techniques, the incidence of CCM diagnoses are increasing, and the patient must be managed on a multidisciplinary basis: genetic counselling, treatment if needed, and follow‐up. Advances have been made using radiological and pathological correlates of CCM lesions adding to the accumulated knowledge of this disease, although management of these patients is very variable among centers. This review is aimed at providing an update in genetic and molecular insights of this condition. Included are implications for genetic counselling, and possible approaches to prevention and treatment that derive from the understanding of pathogenetic mechanisms.