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Background: Metformin is the first-line treatment for type 2 diabetes mellitus. Observational studies show lower rates of use than would be expected from clinical guidelines. Objective: We undertook a qualitative study of barriers to metformin use from the patient and provider perspective. Design: Patient focus group, patient individual interviews, provider interviews, and chart review. Purposive sampling of patients and providers in New York State. Participants: Seven one-on-one patient interviews, one focus group with 13 patients, 10 provider interviews, and manual review of 1259 charts. Approach: Grounded theory. Results: Both providers and patients cited potential health benefits as strong reasons to take metformin and describe it as the first-line drug for diabetes. Patients and providers both cited gastrointestinal side effects as the primary barrier to metformin use. Patients described adapting to these side effects and taking metformin at a time that minimizes them. In contrast, providers emphasized dose titration and the use of extended-release formulation as tools for minimizing side effects but were uncertain about the effectiveness of these strategies. Conclusion: Metformin is positively viewed by patients and providers, but gastrointestinal side effects are a barrier to its use. There is some consensus on basic measures to improve its tolerability, but these measures are not consistently applied and lack evidence establishing their effectiveness. Pragmatic clinical trial research on optimal dose, formulation, and counseling for new metformin users should be considered. [ABSTRACT FROM AUTHOR]

Context Implantable cardioverter-defibrillators (ICDs) have diffused rapidly into clinical practice with little evaluation of their real-world effectiveness. Objectives To determine the effect of the adoption of ICD on patient safety, particularly with respect to physician volume and early outcomes. Design Retrospective cohort of all ICD implantations in New York state from 1997 to 2006, with follow-up at 90 days and 1 year. Setting New York state non-federal hospital discharges in which an ICD was implanted during the admission. Patients were followed forward for 1 year for subsequent admissions. Patients New York state residents undergoing ICD implantation. Main outcome measures Effects of annual and career ICD implantation volume on 90-day complication, readmission, reprogramming, mortality and revision of the ICD within 1 year. Results This cohort (N¼38 992) represents a period of rapid adoption and implementation of this new technology, with frequency more than tripling between 1997 and 2006. We identified 6439 (16.5%) postimplantation complications and 1093 (2.8%) deaths within 90 days of implantation. The majority (73.4%) of physicians implanted one or fewer ICDs per year, and 11.0% of all implantations were performed by these very-low-volume operators. Patients treated by very-lowvolume operators were more likely to die (RR¼1.8, 95% CI 1.3 to 2.4) or experience cardiac complications (RR¼4.7, 95% CI 3.3 to 6.8) even after the adjustment for case mix compared to operators who frequently performed ICD implantation. Conclusions These findings suggest a need for safe and effective implementation strategies for new medical technologies, which minimize patient risk due to rapid diffusion among inexperienced providers and assure that the intended benefit can be maximised rapidly. [ABSTRACT FROM AUTHOR]

Background: More than 6 million Americans have undiagnosed diabetes. Several national organizations endorse screening for diabetes by physicians, but actual practice is poorly understood. Our objectives were to measure the rate, the predictors and the results of glucose testing in primary care, including rates of follow-up for abnormal values. Methods: We conducted a retrospective cohort study of 301 randomly selected patients with no known diabetes who received care at a large academic general internal medicine practice in New York City. Using medical records, we collected patients' baseline characteristics in 1999 and followed patients through the end of 2002 for all glucose tests ordered. We used multivariate logistic regression to measure associations between diabetes risk factors and the odds of glucose testing. Results: Three-fourths of patients (78%) had at least 1 glucose test ordered. Patient age (=45 vs. <45 years), non-white ethnicity, family history of diabetes and having more primary care visits were each independently associated with having at least 1 glucose test ordered (p < 0.05), whereas hypertension and hyperlipidemia were not. Fewer than half of abnormal glucose values were followed up by the patients' physicians. Conclusion: Although screening for diabetes appears to be common and informed by diabetes risk factors, abnormal values are frequently not followed up. Interventions are needed to trigger identification and further evaluation of abnormal glucose tests. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the association between contracting practices of managed care organizations (MCOs) with cardiac surgeons and the quality of the cardiac surgeons.Data Sources/study Setting: The study included all cardiac surgeons offering coronary artery bypass graft (CABG) surgery and 78 percent of MCOs in New York State in 1998. Primary data: The MCOs' panel composition with respect to hospitals and cardiac surgeons. Secondary data: New York State (NYS) Cardiac Surgery Reports.Study Design: Statistical analyses of the probability of a contract between cardiac surgeons and MCOs conditional on the surgeon's risk-adjusted mortality rates (RAMR), outlier and low volume status, and controlling for other confounding variables, were performed.Principal Findings: Contract probability exhibited a tendency to decrease with RAMR, low volume and low-quality outlier status and to increase with high-quality outlier status. These effects were statistically significant for RAMR and high-quality outliers in Downstate and for low volume in Downstate and Upstate.Conclusions: In some, but not all cases, MCOs are seeking higher-quality providers. Further research is required to understand regional variability and the effect of market structure on the quality profile of MCOs. [ABSTRACT FROM AUTHOR]

Examines the role played by quality report cards in the contracting practices of health maintenance organizations in New York. Consideration for quality by managed care organizations (MCO) during cardiac surgeons; Low use of quality report cards by MCO; Recommendations for policy initiatives to increase the use of report cards.