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Lagging quality of care in the U.S. health care system has been a persistent problem and challenge. In the past, medical professionalism and professional certification have served as cornerstones for improving quality in health care. Among newer efforts to improve quality, pay for performance has been proposed to propel better results, but many observers are concerned that pay for performance is at odds with medical professionalism. The authors examine the potential conflicts between pay for performance and medical professionalism and conclude that properly designed pay-for-performance models can support professional objectives.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjmed.2008.06.038 Byline: Rodney M. Stuck (a)(b), Min-Woong Sohn (c)(d), Elly Budiman-Mak (c)(e), Todd A. Lee (c)(d), Kevin B. Weiss (d)(f) Keywords: Charcot arthropathy; Disease-disease interaction; Diabetes; Peripheral neuropathy Abstract: To examine the association of obesity, peripheral neuropathy, and other risk factors with the Charcot arthropathy incidence rate in a large diabetic population. Author Affiliation: (a) Surgical Service, Edward Hines Jr VA Hospital, Hines, Ill (b) Department of Orthopaedic Surgery, Loyola University Stritch School of Medicine, Maywood, Ill (c) Center for Management of Complex Chronic Care, Edward Hines Jr VA Hospital, Hines, Ill (d) Institute for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, Ill (e) Department of Medicine, Loyola University Stritch School of Medicine, Maywood, Ill (f) American Board of Medical Specialties, Evanston, Ill Article Note: (footnote) Financial support was received from the Center for Management of Complex Chronic Care, Hines VA Hospital, Hines, Illinois (LIP 42-512; Elly Budiman-Mak, MD, Principal Investigator). The article presents the findings and conclusions of the authors; it does not necessarily represent the Department of Veterans Affairs or Health Services Research and Development Service. The authors have no financial or personal conflict of interest to declare.

Background: Concerns exist regarding increased risk for mortality associated with some chronic obstructive pulmonary disease (COPD) medications. Objective: To examine the association between various respiratory medications and risk for death in veterans with newly diagnosed COPD. Design: Nested case--control study in a cohort identified between 1 October 1999 and 30 September 2003 and followed through 30 September 2004 by using National Veterans Affairs inpatient, outpatient, pharmacy, and mortality databases; Centers for Medicare & Medicaid Services databases; and National Death Index Plus data. Cause of death was ascertained for a random sample of 40% of those who died during follow-up. Case patients were categorized on the basis of all-cause, respiratory, or cardiovascular death. Mortality risk associated with medications was assessed by using conditional logistic regression adjusted for comorbid conditions, health care use, and markers of COPD severity. Setting: U.S. Veterans Health Administration health care system. Participants: 32 130 case patients and 320 501 control participants in the all-cause mortality analysis. Of 11 897 patients with cause-of-death data, 2405 case patients had respiratory deaths and 3159 case patients had cardiovascular deaths. Measurements: All-cause mortality; respiratory and cardiovascular deaths; and exposure to COPD medications, inhaled corticosteroids, ipratropium, long-acting [beta]-agonists, and theophylline in the 6 months preceding death. Results: Adjusted odds ratios (ORs) for all-cause mortality were 0.80 (95% Cl, 0.78 to 0.83) for inhaled corticosteroids, 1.11 (Cl, 1.08 to 1.15) for ipratropium, 0.92 (Cl, 0.88 to 0.96) for long-acting [beta]-agonists, and 1.05 (Cl, 0.99 to 1.10) for theophylline. Ipratropium was associated with increased cardiovascular deaths (OR, 1.34 [Cl, 1.22 to 1.47]), whereas inhaled corticosteroids were associated with reduced risk for cardiovascular death (OR, 0.80 [Cl, 0.72 to 0.88]). Results were consistent across sensitivity analyses. Limitations: Current smoking status and lung function were not measured. Misclassification of cause-specific mortality is unknown. Conclusion: The possible association between ipratropium and elevated risk for all-cause and cardiovascular death needs further study.

This guidance statement is derived from other organizations' guidelines and is based on an evaluation of the strengths and weaknesses of the available guidelines. We used the Appraisal of Guidelines, Research and Evaluation in Europe (AGREE) appraisal instrument to evaluate the guidelines from various organizations. On the basis of the review of the available guidelines, we recommend: Statement 1: To prevent microvascular complications of diabetes, the goal for glycemic control should be as low as is feasible without undue risk for adverse events or an unacceptable burden on patients. Treatment goals should be based on a discussion of the benefits and harms of specific levels of glycemic control with the patient. A hemoglobin Ale level less than 7% based on individualized assessment is a reasonable goal for many but not all patients. Statement 2: The goal for hemoglobin Ale level should be based on individualized assessment of risk for complications from diabetes, comorbidity, life expectancy, and patient preferences. Statement 3: We recommend further research to assess the optimal level of glycemic control, particularly in the presence of comorbid conditions.

Breast cancer is one of the most common causes of death for women in their 40s in the United States. Individualized risk assessment plays an important role when making decisions about screening mammography, especially for women 49 years of age or younger. The purpose of this guideline is to present the available evidence for screening mammography in women 40 to 49 years of age and to increase clinicians' understanding of the benefits and risks of screening mammography.

Background: Little is known about current use of pulmonary function testing in clinical practice. This study evaluated spirometry use in persons with COPD receiving care from the Veterans Health Administration [...]

Hereditary hemochromatosis is a genetic disorder of iron metabolism. Diagnosis of hereditary hemochromatosis is usually based on a combination of various genetic or phenotypic criteria. Decisions regarding screening are difficult because of the variable penetrance of mutations of the HFE gene and the absence of any definitive trials addressing the benefits and risks of therapeutic phlebotomy in asymptomatic patients or those with only laboratory abnormalities. The purpose of this guideline is to increase physician awareness of hereditary hemochromatosis, particularly the variable penetrance of genetic mutations; aid in case finding; and explain the role of genetic testing. This guideline provides recommendations based on a review of evidence in the accompanying background paper by Schmitt and colleagues. The target audience for this guideline is internists and other primary care physicians. The target patient population is all persons who have a probability or susceptibility of developing hereditary hemochromatosis, including the relatives of individuals who already have the disease.

In 1999, the American College of Physicians (ACP), then the American College of Physicians--American Society of Internal Medicine, and the American College of Cardiology/American Heart Association (ACC/AHA) developed joint guidelines on the management of patients with chronic stable angina. The ACC/AHA then published an updated guideline in 2002, which ACP recognized as a scientifically valid review of the evidence and background paper. This ACP guideline summarizes the recommendations of the 2002 ACC/AHA updated guideline and underscores the recommendations most likely to be important to physicians seeing patients in the primary care setting. This guideline is the second of 2 that provide guidance on the management of patients with chronic stable angina. This document covers treatment and follow-up of symptomatic patients who have not had an acute myocardial infarction or revascularization procedure in the previous 6 months. Sections addressing asymptomatic patients are also included. Asymptomatic refers to patients with known or suspected coronary disease based on a history or electrocardiographic evidence of previous myocardial infarction, coronary angiography, or abnormal results on noninvasive tests. A previous guideline covered diagnosis and risk stratification for symptomatic patients who have not had an acute myocardial infarction or revascularization procedure in the previous 6 months and asymptomatic patients with known or suspected coronary disease based on a history or electrocardiographic evidence of previous myocardial infarction, coronary angiography, or abnormal results on noninvasive tests.

In 1999, the American College of Physicians (ACP), then the American College of Physicians-American Society of Internal Medicine, and the American College of Cardiology/American Heart Association (ACC/AHA) developed joint guidelines on the management of patients with chronic stable angina. The ACC/AHA then published an updated guideline in 2002, which the ACP recognized as a scientifically valid review of the evidence and background paper. This ACP guideline summarizes the recommendations of the 2002 ACC/AHA updated guideline and underscores the recommendations most likely to be important to physicians seeing patients in the primary care setting. This guideline is the first of 2 that will provide guidance on the management of patients with chronic stable angina. This document will cover diagnosis and risk stratification for symptomatic patients who have not had an acute myocardial infarction or revascularization procedure in the previous 6 months. Sections addressing asymptomatic patients are also included. Asymptomatic refers to patients with known or suspected coronary disease based on history or on electrocardiographic evidence of previous myocardial infarction, coronary angiography, or abnormal results on noninvasive tests. A future guideline will cover pharmacologic therapy and follow-up.

In an effort to provide internists and other primary care physicians with effective management strategies for diabetes care, the Clinical Efficacy Assessment Subcommittee (CEAS) of the American College of Physicians (ACP) decided to develop guidelines on the management of dyslipidemia, particularly hypercholesterolemia, in people with type 2 diabetes mellitus. The CEAS commissioned a systematic review of the currently available evidence on the management of lipids in type 2 diabetes mellitus. The evidence review is presented in a background paper in this issue. On the basis of this systematic review, the CEAS developed recommendations that the ACP Board of Regents then approved as policy. The target audience for this guideline is all clinicians who care for patients with type 2 diabetes. The target patient population is all persons with type 2 diabetes, including those who already have some form of microvascular complication and, of particular importance, premenopausal women. The recommendations are as follows. Recommendation 1: Lipid-lowering therapy should be used for secondary prevention of cardiovascular mortality and morbidity for all patients (both men and women) with known coronary artery disease and type 2 diabetes. Recommendation 2: Statins should be used for primary prevention against macrovascular complications in patients (both men and women) with type 2 diabetes and other cardiovascular risk factors. Recommendation 3: Once lipid, lowering therapy Is initiated, patients with type 2 diabetes mellitus should be taking at least moderate doses of a statin. Recommendation 4: For those patients with type 2 diabetes who are taking statins, routine monitoring of fiver function tests or muscle enzymes is not recommended except in specific circumstances.

The Joint Panel of the American Academy of Family Physicians and the American College of Physicians, in collaboration with the Johns Hopkins Evidence-based Practice Center, systematically reviewed the available evidence on the management of newly detected atrial fibrillation and developed recommendations for adult patients with first-detected atrial fibrillation. The recommendations do not apply to patients with postoperative or post-myocardial infarction atrial fibrillation, patients with class IV heart failure, patients already taking antiarrhythmic drugs, or patients with valvular disease. The target physician audience is internists and family physicians dedicated to primary care. The recommendations are as follows: Recommendation 1: Rate control with chronic anticoagulation is the recommended strategy for the majority of patients with atrial fibrillation. Rhythm control has not been shown to be superior to rate control (with chronic anticoagulation) in reducing morbidity and mortality and may be inferior in some patient subgroups to rate control. Rhythm control is appropriate when based on other special considerations, such as patient symptoms, exercise tolerance, and patient preference. Grade: 2A Recommendation 2: Patients with atrial fibrillation should receive chronic anticoagulation with adjusted-dose warfarin, unless they are at low risk of stroke or have a specific contraindication to the use of warfarin (thrombocytopenia, recent trauma or surgery, alcoholism). Grade: 1A Recommendation 3: For patients with atrial fibrillation, the following drugs are recommended for their demonstrated efficacy in rate control during exercise and while at rest: atenolol, metoprolol, diltiazem, and verapamil (drugs listed alphabetically by class). Digoxin is only effective for rate control at rest and therefore should only be used as a second-line agent for rate control in atrial fibrillation. Grade: 1B Recommendation 4: For those patients who elect to undergo acute cardioversion to achieve sinus rhythm in atrial fibrillation, both direct-current cardioversion (Grade: 1C+) and pharmacological conversion (Grade: 2A) are appropriate options. Recommendation 5: Both transesophageal echocardiography with short-term prior anticoagulation followed by early acute cardioversion (in the absence of intracardiac thrombus) with postcardioversion anticoagulation versus delayed cardioversion with pre- and postanticoagulation are appropriate management strategies for those patients who elect to undergo cardioversion. Grade: 2A Recommendation 6: Most patients converted to sinus rhythm from atrial fibrillation should not be placed on rhythm maintenance therapy since the risks outweigh the benefits. In a selected group of patients whose quality of life is compromised by atrial fibrillation, the recommended pharmacologic agents for rhythm maintenance are amiodarone, disopyramide, propafenone, and sotalol (drugs listed in alphabetical order). The choice of agent predominantly depends on specific risk of side effects based on patient characteristics. Grade: 2A

Study objective: The purpose of this study was to assess trends in emergency department (ED) asthma care in a single large community and to address how these trends meet expectations [...]

All patients with type 2, or adult onset, diabetes who also have high blood pressure should take either an ACE inhibitor or a thiazide diuretic to bring their blood pressure down to 135/80. Several studies have shown that blood pressure control can reduce a diabetic's risk of cardiovascular disease. More research will be needed to determine whether it can also prevent some of the other complications of diabetes.

Background: Mounting evidence suggests that indoor allergens and irritants contribute to childhood asthma. National asthma guidelines highlight the importance of their reduction as part of comprehensive asthma treatment. Objectives: To assess the prevalence of potential environmental triggers, to identify risk factors for such exposures, and to determine whether prior parental education about trigger avoidance is associated with fewer such exposures. Setting and Patients: Children with asthma in practices affiliated with 3 managed care organizations. Interventions: Parents of 638 children, aged 3 to 15 years, were interviewed on enrollment in a randomized trial of asthma care improvement strategies. Parents reported recent asthma symptoms and exposures to potential environmental triggers. Multivariate models were used to identify specific demographic risk factors for environmental exposures and to determine if prior education was associated with fewer such exposures. Results: Exposures to environmental triggers were frequent: 30% of households had a smoker, 18% had household pests, and 59% had furry pets. Other exposures included bedroom carpeting (78%) and forced-air heat (58%). Most children did not have mattress (65%) or pillow (84%) covers. Of the parents, 45% reported ever receiving written instructions regarding trigger avoidance and 11% reported them given in the past year. However, 42% reported discussing triggers in the home environment with a clinician in the past 6 months. In multivariate models, predictors of smoking at home included low annual family income and lower parental educational attainment. Dog ownership was associated with low educational attainment, and dog and cat ownership were less likely with black race. Reports of pests were increased for black children compared with white children. Black race was associated with lower rates of other exposures, including bedroom carpeting. After controlling for potential confounders, there was no association of reduced exposures with prior receipt of environmental control instructions. Conclusions: Exposure to potential environmental triggers is common, and recommended trigger avoidance measures are infrequently adopted. While specific exposures may vary with demographic and socioeconomic variables, all children are at risk. New methods for educating parents to reduce such exposures should be tested.

Objective: To characterize perceived access and barriers to quality health care for asthma among the care-givers of children in the inner city. Design: Multicenter, cross-sectional survey. Setting: Eight sites in 7 major metropolitan US inner cities. Participants: A systematic sample of children with asthma, aged 4 to 9 years, and their caregivers who resided in census tracts in which at least 30% of the households were below the 1990 federal poverty guidelines, recruited from 25 primary care clinics and 13 emergency departments (EDs) from November 1, 1992, through October 31, 1993. Results: Of the 1528 children enrolled, 1376 had physician-diagnosed asthma and form the basis of this report. This group was further divided into 284 children (20.6%) who met all recruitment criteria for severe asthma and 207 (15.0%) with mild asthma who met none. Of parents in the total sample, 95.6% reported a usual place for short-term asthma care for their child; 75.4% used the ED. Children with severe asthma were significantly more likely to use the ED than those with mild asthma (84.3%) vs 63.0%; P [is less than].01). A usual place for follow-up asthma care was reported by 96.7% of subjects. There were no differences in access or type of facility used by asthma severity. More than half the study group reported difficulty in accessing care for acute asthma attacks and for follow-up care with no differences by asthma severity. Among those with severe asthma, 47.5% used inhaled steroids or cromolyn, 52.8% used a spacer device if they had been prescribed a metered dose inhaler, and 21.2% of children older than 6 years were prescribed a peak flowmeter. Patients with mild asthma were significantly less likely to report use of all 3 items (steroids or cromolyn, 1.4%; spacer device, 15.4%; and peak flowmeter, 3.1%, respectively; P [is less than] .01). Conclusion: Although access to asthma care among children in US inner cities appears adequate as determined by the traditional measure of reporting a regular source of care, barriers are frequently reported, as are deficiencies in the quality of medical care. Arch Pediatr Adolesc Med. 1998;152:333-339, Inner-city children with asthma may disproportionately rely on emergency departments for medical care and may underutilize preventive medications. Researchers assessed asthma care for 1,376 children 4 to 9 years of age in seven metropolitan inner-city, low-income areas. Seventy-five percent relied on the emergency department for short-term asthma care. Fifty-three percent of children with severe asthma did not use inhaled corticosteroids or cromolyn to prevent asthma attacks, although treatment guidelines recommend them. Lack of childcare and transportation were common barriers to care.

Objectives: To determine whether US emergency department care for pediatric asthma conforms to the National Institutes of Health guidelines and whether the guidelines are likely to be adopted in clinical practice. Design: Mail survey conducted from January to April 1992, and stratified by hospital type (children's, public, and community). Settings: Emergency departments of US hospitals. Participants: Simple stratified random sample of emergency department directors from 376 sampled hospitals. Measurements: Self-reported data on emergency department pediatric asthma care, and knowledge and attitudes about the National Institutes of Health guidelines. Data are reported as mean ([+ or -] SE). Results: Sixty-eight percent of the surveyed emergency department directors responded. During 1991, there were an estimated 1.6 million visits for pediatric asthma care. Asthma accounted for 16.9% ([+ or -] 9.0%) of all pediatric emergency department visits. Only 2.1% ([+ or -] 1.0%) reported the use of written protocols or guidelines, with significant variation by hospital type. Sixty-seven percent ([+ or -] 3.0%) reported the use of pulse oximetry. Eighty percent reported the use of [beta]-agonists by inhalation as the initial treatment. Only 44.7% ([+ or -] 2.9%) reported the use of steroids if there was a poor response to the initial treatment. An estimated 45.5% ([+ or -] 3.9%) of respondents had heard of the guidelines at the time of this survey; approximately 24% reported that they had read the guidelines. Most respondents reported that the guidelines were credible, clear and concise, and likely to be adopted in their emergency department. Conclusions: These data suggest that reported pediatric asthma care in US emergency departments differs substantially from the National Institutes of Health guidelines, with considerable variation by hospital type. The guidelines appear to provide an acceptable tool for emergency departments to use in assessing their pediatric asthma care. However, in light of the lack of evidence that the guidelines will improve outcomes, the impact of national guideline adoption remains unclear., Emergency department treatment for pediatric asthma appears to diverge from the National Asthma Education Program (NAEP) guidelines. Researchers surveyed 216 emergency department directors to study pediatric asthma care and familiarity with the NAEP guidelines. Staff in 2.1% of the emergency departments followed written asthma treatment guidelines. Approximately one-third of all eligible children had peak flow measurements. The NAEP guidelines recommend this lung function test as part of the initial patient assessment and after beta-agonist therapy in children older than five years. Emergency department physicians followed the NAEP guidelines for corticosteroid treatment in approximately half of all eligible patients. Sixty percent of children obtained follow-up care in two or three days as recommended in the NEAP guidelines. Approximately 24% of the emergency department directors had read the NAEP guidelines.

Financing policies for HIV and AIDS should seek to expand support for care outside hospitals while providing needed funding for inhospital treatment. Public and teaching hospitals in the U.S. are shouldering the burden of care for HIV-related illnesses and AIDS, and reporting losses that eventually may require them to ration health care. Of 1,981 hospitals participating in a 1991 survey, 773 reported treating HIV patients, with a 68% increase in numbers of HIV patients treated between 1988 and 1991. The average loss to hospitals was $92,025 for treating these patients. Medicaid paid for 45.5% of AIDS inpatient visits and 53.3% of other HIV-related illnesses. Changes in Medicaid and reimbursement arrangements should be instituted to meet a greater demand for hospital inpatient care.

The burden of asthma on the US population is increasing.[1-3] Between 1980 and 1987, US asthma prevalence increased 29%, asthma hospitalization rates increased 6%, and asthma mortality rates increased as [...]

Asthma is a common malady, affecting persons of all ages. Much of our understanding of the natural history of this condition has come from community-based studies, [1,2] including the Harvard [...]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjmed.2006.03.003 Byline: Todd A. Lee (a)(b), Brian Bartle (a), Kevin B. Weiss (a)(b) Keywords: Osteoarthritis; Nonsteroidal anti-inflammatory agent; Mortality; Coronary artery disease; Pharmacoepidemiology Abstract: Evidence indicates increased risk of cardiovascular events with certain nonsteroidal anti-inflammatory drug (NSAID) use; however, less is known about NSAID use and mortality. In addition, it is unclear whether risks observed with NSAIDs are modified by coronary artery disease (CAD). The association between NSAID exposure and mortality, cardiovascular, and cerebrovascular events was examined. Author Affiliation: (a) Midwest Center for Health Services and Policy Research, Hines Veterans Affairs Hospital, Chicago, Ill (b) Institute for Healthcare Studies and Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill Article Note: (footnote) The Midwest Center for Health Services and Policy Research, Hines VA Hospital provided funding. The funding agency had no role in any aspect of the study. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or of the United States Government.

Clinical audits and practice profiling have become popular tools in the attempt to change physician behavior to improve quality of care. Unfortunately, the growing need for information on quality of [...]

(CHEST 1999; 116:196S-197S) Abbreviations: CEDAC = Chicago Emergency Department Asthma Collaborative; ED = emergency department Emergency departments (EDs) play a crucial role in the management of asthma, often beyond the [...]

A Community Coalition Targeting Reductions in Asthma Morbidity The problem of asthma in Chicago remains a complex one, and it is too early to know whether any programs and efforts [...]

(CHEST 1999; 116:198S) The problems of asthma have attracted concern, coupled with a desire to intervene at many levels of care--from voluntary organizations to community-based clinics, and from hospitals to [...]

The Chicago Community Asthma Survey Little is known about the general public's perception of the diagnosis of asthma and the impact of asthma on individuals, their families, and their communities. [...]

Introduction: The Chicago Community Asthma Survey (CCAS-32) is an instrument for characterizing the general public's knowledge, attitudes, and beliefs related to asthma. The purpose of this study was to examine [...]

Introduction: Emergency departments (EDs) represent an important source of asthma care, yet there are few studies detailing how ED asthma practices vary and to what extent EDs meet expectations of [...]

Introduction: Although primary-care physicians were a principal target audience for the National Asthma Education and Prevention Program (NAEPP), there is little published information describing the postguideline asthma care practices of [...]

Introduction: Few studies have closely explored how well physicians who consider themselves specialists in asthma adhere to national guideline recommendations for the diagnosis and treatment of asthma. The purpose of [...]

Results From the Chicago Asthma Surveillance Initiative Introduction: Managed care, both via staff model health maintenance plans and nonstaff model plans, has become a major source of health-care funding in [...]

Results From the Chicago Asthma Surveillance Initiative Introduction: Little is known of the approaches of United States hospitals to the management of persons with asthma. The purpose of this study [...]

A Community-Based Approach to Understanding Asthma Care Nearly all of the asthma surveillance literature focuses on national-, regional-, or state-based estimates of prevalence, health-care utilization (specifically hospitalizations, emergency department, and [...]

(CHEST 1999; 116:132S-134S) Abbreviation: CAC = Chicago Asthma Consortium It is difficult to discern exactly when asthma switched from being a common medical concern to a major public health epidemic [...]