The Daoist Diaries

When you tell a patient her hemoglobin A1c result is 8%, how does she relate that number to the blood glucose levels she measures at home in units of mg/dL? Is an A1c of 8% equivalent to an average glucose of 180?

As if diabetes management isn't complicated enough, dealing with different types of blood glucose measures can make it more so.

Washington -- Although most roads to pandemic flu readiness remain riddled with potholes, some communities are making steady progress.

Those cities and towns that have made exemplary advances in planning for a surge of ill patients and ways to mitigate the flu's potential devastation were honored, and the lessons they learned were shared during the Second National Congress on Health System Readiness: Pandemic Influenza Community Preparedness Planning, held July 18 to 20 in Washington, D.C.

Alcohol dependence manifests itself in many ways, but patients with this problem have enough in common that they can be placed in five categories, according to a study published online June 26 by the journal, Drug and Alcohol Dependence. The authors hope that subtyping patients in this manner will lead to the discovery of genes that increase the risk for the disorder's specific variations and to treatments that may be more effective for particular individuals.

"Assuming that the subtyping holds up and meets the test of time, we hope to identify specific treatments for specific types of alcoholics," said Howard B. Moss, MD, lead author and associate director for clinical and translational research at the National Institute on Alcohol Abuse and Alcoholism. "Some may be more amenable to medications to treat alcohol dependence than others, and researchers might find this information useful as they're putting together trials for new agents to treat alcoholism."

Washington -- Ten large physician practices participating in one of the first Medicare pay-for-performance projects have proven that such programs lead to better performance, according to government officials. But only two practices were able to reduce costs enough to receive any additional pay.

Last month, the Centers for Medicare & Medicaid Services released first-year results from the Medicare Physician Group Practice Demonstration, which launched in April 2005. CMS asked 10 practices to implement care management improvements that would lead to higher quality of care. In return, the practices were eligible to receive as a bonus a portion of the money that they saved Medicare by improving patient care in a targeted group of Medicare enrollees.

CMS found that all of the participants were able to hit or exceed standards on at least seven out of the 10 clinical quality measures for the treatment of diabetes, the only condition targeted in the project's first year. For the pilot's second and third years, the agency is adding congestive heart failure, coronary artery disease and preventive care measures.

Two of the participants, Forsyth Medical Group in Winston-Salem, N.C., and St. John's Health System in Springfield, Mo., were able to make the grade on all diabetes measures.

The physicians and other health professionals involved in the pilot saved Medicare money, in part, by reducing repeat office visits, hospitalizations and trips to emergency departments, federal officials said.

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Private health plans' push for pay-for-performance and Medicare's first steps in that direction have garnered much attention. But the trend isn't confined to these two sectors. State Medicaid agencies have quietly entered the game in an effort to try to improve enrollees' care.

As of mid-2006, at least 28 states had 35 Medicaid pay-for-performance programs. Two were specifically designed for primary care physicians, although others involve doctors.

Physicians can expect to see more initiatives. In the next two years, at least 34 states are planning 47 new programs, including nine directly involving primary care doctors, according to a recent report by the Commonwealth Fund.

However, doctors shouldn't expect to see a tidal wave of comprehensive changes because most programs have tailored goals, such as improving childhood immunization rates and care of patients with chronic diseases, or controlling costs.

That narrow focus is partly due to a lack of evidence-based standards for children, said E. Susan Hodgson, MD, chair of the American Academy of Pediatrics' Steering Committee on Quality Improvement and Management. About half of Medicaid enrollees are children.

Many states are using or customizing the National Committee for Quality Assurance's Healthcare Effectiveness Data and Information Set measures. HEDIS standards mostly focus on adult care.

The Alliance for Pediatric Quality, formed in 2006 by four pediatric organizations, is working to fill the standards gap. The alliance, which includes the AAP, is developing evidence-based standards for children and electronic medical records compatible with children's care.

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