The role of performance measures for improving quality in managed care organizations

OBJECTIVES

To understand how managed care plans use performance measures for quality improvement and to identify the strengths and weaknesses of currently used standardized performance measures such as the Health Plan Employer Data and Information Set (HEDIS) and the Consumer Assessment of Health Plans (CAHPS) survey.

DATA SOURCES/STUDY SETTING

Representatives (chief executive officers, medical directors, and quality-improvement directors) from 24 health plans in four states were surveyed. The overall response rate was 58.3 percent, with a mean of 1.8 respondents per plan.

STUDY DESIGN

This exploratory qualitative research used a purposive sample of respondents. Two study authors conducted separate one-hour tape-recorded telephone interviews with multiple respondents from each health plan.

PRINCIPAL FINDINGS

All managed care organizations interviewed use performance measures for quality improvement but the degree and sophistication of use varies. Many of our respondent plans use performance measures to target quality-improvement initiatives, evaluate current performance, establish goals for quality improvement, identify the root cause of problems, and monitor performance.

CONCLUSION

Performance measures are used for quality improvement in addition to informing external constituents, but additional research is needed to understand how the benefits of measurement can be maximized.

Are managed care plans organizing for quality?

This article examines the degree to which managed care organizations (MCOs) are reorganizing to take responsibility for the quality of care and service they provide. Specifically, factors prompting plans to focus on quality improvement (QI) and how they may be building the capacity to improve quality are considered. The authors' analysis is based on executive interviews with the plan medical directors, QI directors, and chief executive officers (CEOs) in a sample of 24 health plans. The overall response rate was 58.3 percent (medical director = 62.5 percent, QI director = 79.2 percent, CEO = 33.3 percent). The authors queried respondents about (1) perceived drivers and obstacles to the development of an effective QI program, (2) plan organizational structure for QI, and (3) technical capacities for data collection, management, and performance measurement. The results suggest that MCOs are responding to outside pressures to engage in QI. They are reorganizing their management structures and more slowly and tentatively are building technical capacity for QI.

Co-inheritance of mutations in the uroporphyrinogen decarboxylase and hemochromatosis genes accelerates the onset of porphyria cutanea tarda

Porphyria cutanea tarda is a skin disease caused by photosensitization by porphyrins whose accumulation is caused by deficiency of hepatic uroporphyrin- ogen decarboxylase activity. Mutations in the uroporphyrinogen decarboxylase gene are present in the low-penetrant, autosomal dominant familial form but not in the commoner sporadic form of porphyria cutanea tarda. We have investigated the relationship between age of onset of skin lesions and mutations (C282Y, H63D) in the hemochromatosis gene in familial (19 patients) and sporadic porphyria cutanea tarda (65 patients). Familial porphyria cutanea tarda was identified by mutational analysis of the uroporphyrinogen decarboxylase gene. Five previously described and eight novel mutations (A80S, R144P, L216Q, E218K, L282R, G303S, 402-403delGT, IVS2 + 2 delTAA) were identified. Homozygosity for the C282Y hemochromatosis mutation was associated with an earlier onset of skin lesions in both familial and sporadic porphyria cutanea tarda, the effect being more marked in familial porphyria cutanea tarda where anticipation was demonstrated in family studies. Analysis of the frequencies of hemochromatosis genotypes in each type of porphyria cutanea tarda indicated that C282Y homozygosity is an important susceptibility factor in both types but suggested that heterozygosity for this mutation has much less effect on the development of the disease.

ETK2 receptor tyrosine kinase promotes survival of factor-dependent FDC-P1 progenitor cells

By virtue of its high expression in both developing hematopoietic tissues and many myeloid leukemia cells lines, the embryonic tyrosine kinase receptor ETK2 (also known as Tyro3, Sky, and Rse) has been postulated to play a role in early hematopoiesis. To investigate this role, we expressed murine ETK2 in the interleukin 3 (IL-3) dependent myeloid progenitor cell line FDC-P1 and examined its effect on growth factor dependence.ETK2 cDNAs encoding full-length or kinase domain-deleted receptor were retrovirally transduced into murine FDC-P1 cells. Survival, cell cycle status, and proliferative responses of ETK2 expressing clones were studied at normal and reduced growth factor concentrations. ETK2 was expressed as a functional tyrosine kinase of 110 and 150 kDa. This proto-oncogene altered the growth of FDC-P1 cells, allowing survival at reduced growth factor concentrations and delaying apoptosis after IL-3 withdrawal. ETK2-expressing clones contained a higher fraction of cells in the S/G2/M phases of the cell cycle, both after cytokine withdrawal and in the presence of IL-3. Furthermore, these cells had a modestly enhanced proliferative response to IL-3 and granulocyte-macrophage colony-stimulating factor, suggesting that ETK2 intracellular signaling may converge with that of hematopoietic growth factors. The effects of ETK2 expression on viability and proliferation were largely dependent on a functional intracellular tyrosine kinase domain. These results support a role for ETK2 in the survival and/or expansion of primitive hematopoietic cells and suggest that this tyrosine kinase may be implicated in myeloid leukemogenesis as well.

Lethal paralysis of Caenorhabditis elegans by Pseudomonas aeruginosa

Identification of host factors that interact with pathogens is crucial to an understanding of infectious disease, but direct screening for host mutations to aid in this task is not feasible in mammals. The nematode Caenorhabditis elegans is a genetically tractable alternative for investigating the pathogenic bacterium Pseudomonas aeruginosa. A P. aeruginosa toxin, produced at high cell density under control of the quorum-sensing regulators LasR and RhlR, rapidly and lethally paralyzes C. elegans. Loss-of-function mutations in C. elegans egl-9, a gene required for normal egg laying, confer strong resistance to the paralysis. Thus, activation of EGL-9 or of a pathway that includes it may lead to the paralysis. The molecular identity of egl-9 was determined by transformation rescue and DNA sequencing. A mammalian homologue of EGL-9 is expressed in tissues in which exposure to P. aeruginosa could have clinical effects.

Activation of three classes of nonreceptor tyrosine kinases following Fc gamma receptor crosslinking in human monocytes

Fc gamma receptors on monocytes/macrophages play an important role in both host defense and autoimmune disorders. Fc gamma receptor signaling can lead to such downstream events as phagocytosis and the release of intracellular cytokines and reactive oxygen species. Freshly isolated human monocytes express two major classes of Fc gamma receptor proteins, Fc gamma RI (CD64) and Fc gamma RII (CD32). Crosslinking of Fc gamma RI and Fc gamma RII gives rise to rapid and transient phosphorylation of multiple monocyte intracellular proteins including proteins of 40, 68-72, 75-85, 95, and 115-165 kDa. A 72-kDa protein was earlier identified as the tyrosine kinase Syk. Here we identify one of the proteins in the 115- to 165-kDa cluster as FAK, a protein tyrosine kinase localized to focal adhesions. A 68-kDa phosphoprotein was identified as paxillin, a cytoskeleton associated substrate for tyrosine kinases, and a 95-kDa protein was found to be the proto-oncogene product Vav. The Src family protein tyrosine kinase Fgr (p58) also displayed enhanced tyrosine phosphorylation after Fc gamma RI and Fc gamma RII crosslinking. Although Fc gamma RIIA utilizes tyrosines within its own cytoplasmic domain for signaling while Fc gamma RI utilizes the cytoplasmic tyrosines of its associated gamma subunit, our results indicate sharing of several proteins for signaling in monocytes by these Fc receptors. These molecules include three distinct classes of tyrosine kinases, Syk, FAK, and Fgr, and the functionally diverse proteins Vav and paxillin.

Prospective randomised study comparing tacrolimus (Prograf) and cyclosporin (Neoral) as primary immunosuppression in cadaveric renal transplants at a single institution: interim report of the first 80 cases

As part of an ongoing study, 80 patients undergoing cadaveric renal transplantation were randomised to receive either Prograf [PTT (patients receiving Prograf); n = 40]- or Neoral [NTT (patients receiving Neoral); n = 40]-based immunosuppression as part of a triple therapy regimen. Prograf was commenced at a dose of 0.2 mg/kg per day and Neoral at 8 mg/kg per day. Both groups received identical azathioprine and corticosteroid regimens. Trough levels for Prograf were maintained between 5 and 15 ng/ml and for Neoral between 100 and 200 ng/ml. During the 3-month follow up 40% of PTT and 33% of NTT experienced biopsy-proven acute rejection. In each group 81% of rejection episodes were classified as either borderline or grade 1. The median 3-month serum creatinine levels were 128 mumol/l and 135 mumol/l, respectively, for PTT and NTT. Six grafts were lost in the NTT group including three deaths with functioning grafts whilst none were lost in the PTT group (chi 2, P < 0.02). The prevalence of other complications was similar for the two groups. We conclude that Prograf represents an effective and safe therapy as a primary immunosuppressive agent following cadaveric renal transplantation and appears to have a similar side-effect profile to Neoral.

Screening of patients with iron overload to identify hemochromatosis and porphyria cutanea tarda

OBJECTIVE

To assess the importance of iron overload as a risk factor for porphyria cutanea tarda (PCT).

DESIGN

Prospective study during a 4-month period.

SETTING

Departments of emergency care, gastroenterology, and dermatology in a tertiary referral center.

PATIENTS

Patients were deemed eligible for inclusion in the study if serum ferritin levels were greater than 500 micrograms/L (normal range: females, < 125 micrograms/L; males, < 325 micrograms/L).

MAIN OUTCOME MEASURES

Porphyrin excretion profiles were analyzed on all patients included in the study, where clinically relevant. A diagnosis of PCT was confirmed biochemically in all cases. The HLA typing was then performed on newly diagnosed cases of PCT.

RESULTS

Of 4127 patients tested, 240 patients with an elevated serum ferritin level were identified, of whom 74 had an elevated serum ferritin level of more than 500 micrograms/L. Of the latter group, 17.5% had hemochromatosis and 6.7% had PCT. The incidence of PCT in the hemochromatosis group was 23%; HLA typing revealed the presence of at least 1 of the hemochromatosis markers.

CONCLUSIONS

A high serum ferritin level in the absence of evident cause should prompt investigation for both hemochromatosis and PCT. The HLA heterozygosity for hemochromatosis in some patients with PCT may be a cause of hepatic siderosis.

Porphyrin abnormalities in acquired immunodeficiency syndrome

OBJECTIVE

To examine prospectively porphyrin metabolism in a human immunodeficiency virus (HIV)-positive population.

SETTING

Specialist referral unit at the Department of Genitourinary Medicine, St James's Hospital, Dublin, Ireland.

PATIENTS

Twenty-eight men and 5 women (age range, 18-35 years). Twenty-nine were current or previous intravenous drug abusers. Four were thought to have sexually acquired HIV infection. All had a history of acquired immunodeficiency syndrome-defining illnesses. The patients were selected as a consecutive sample from the inpatient department. Eligibility criteria were cooperation with urine and stool collection and confirmed HIV seropositivity. The patients were matched to 2 groups: 1 with normal results of porphyrin studies and the other with abnormal findings from porphyrin studies.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Plasma, urine, and stool porphyrin excretion patterns.

RESULTS

Of the 33 patients in the study, 13 (40%) had increased urinary porphyrin excretion. All but 2 of these patients were seropositive for hepatitis C virus. No study patient had clinical evidence of porphyria. Four patients (12%), however, had urine and stool porphyrin excretion patterns that were classic for porphyria cutanea tarda. All 4 of these patients were hepatitis C virus-positive. Patients with porphyrinuria had a greater degree of immunosuppression (P = .002) than those with normal porphyrin metabolism, and they were more likely to be taking zidovudine (P = .009).

CONCLUSIONS

Commonly, porphyrin metabolism is abnormal in persons with established HIV infection. Hepatitis C may contribute to abnormal porphyrin metabolism. An unexpected number of patients studied had porphyrin excretion patterns that were characteristic of porphyria cutanea tarda, and all of these were hepatitis C virus-positive. A diagnosis of porphyria cutanea tarda, especially in a young patient, should prompt investigation for underlying HIV and hepatitis C virus infections. Dermatologists should be aware of the infectious risk associated with the vesicles and erosions in these patients. Porphyrin studies should be performed in any patient with HIV and photosensitivity.

Cytomegalovirus causing acute colonic pseudo-obstruction in a renal transplant recipient

A female patient presented with pyrexia and features of large intestinal obstruction, 10 weeks posttransplantation, with biopsy-proven colitis caused by cytomegalovirus (CMV) and positive CMV antigenaemia and IgM tests. The symptoms resolved after treatment with ganciclovir, nasogastric aspiration and intravenous fluid replacement.

Porphyrin metabolism in hepatitis C infection

Hepatitis C virus has been implicated as a major precipitating factor in porphyria cutanea tarda (PCT). To determine whether hepatitis C infection alone is sufficient to induce PCT, we screened two groups of patients with hepatitis C infection. The first group comprised women who had become HCV positive secondary to immunization with anti-D immunoglobulin (group 1). Group 2 included males and females who were HCV positive but HIV negative secondary to intravenous drug abuse. Though both groups had very abnormal liver function tests, we found no significant abnormalities in porphyrin metabolism in these groups of patients. Therefore, in this study population, we conclude that HCV infection alone is insufficient to cause porphyrin metabolic derangement.

Stimulation of macrophage Fc gamma RIIIA activates the receptor-associated protein tyrosine kinase Syk and induces phosphorylation of multiple proteins including p95Vav and p62/GAP-associated protein

The role of tyrosine phosphorylation during signal transduction by the phagocytic macrophage (Mphi) FcR Fc gamma RIIIA was investigated. Cross-linking Fc gamma RIIIA on pulmonary Mphi or cultured monocytes used as in vitro model for differentiated Mphi induced rapid and transient phosphorylation of multiple protein substrates. The lymphocyte/mast cell 72-kDa protein tyrosine kinase (PTK) designated PTK72 or Syk, whose expression in Mphi was previously unknown, was identified as a major substrate by immunoprecipitation and phosphopeptide mapping. Activation of Fc gamma RIIIA stimulated a fourfold increase in Syk kinase activity assessed by autophosphorylation. Under mild lysis conditions several specific proteins were co-precipitated with the gamma subunit of Fc gamma RIIIA. Tyrosine kinase activity was also co-precipitated with gamma, as shown by in vitro phosphorylation of gamma. One of these kinases was identified as Syk by phosphopeptide mapping, suggesting a physical association between this PTK and the receptor. Two additional phosphoproteins induced by Fc gamma RIIIA cross-linking were identified: the hematopoietic proto-oncogene product p95Vav, previously implicated in B lymphocyte and mast cell signaling; and p62, a protein associated with p21Ras-GAP. Our results also establish that there are important functional similarities in signal transduction between a phagocytic Mphi FcR and other multi-subunit Ig gene family receptors in diverse cell lineages.

Stimulation of macrophage Fc gamma RIIIA activates the receptor-associated protein tyrosine kinase Syk and induces phosphorylation of multiple proteins including p95Vav and p62/GAP-associated protein

The role of tyrosine phosphorylation during signal transduction by the phagocytic macrophage (Mphi) FcR Fc gamma RIIIA was investigated. Cross-linking Fc gamma RIIIA on pulmonary Mphi or cultured monocytes used as in vitro model for differentiated Mphi induced rapid and transient phosphorylation of multiple protein substrates. The lymphocyte/mast cell 72-kDa protein tyrosine kinase (PTK) designated PTK72 or Syk, whose expression in Mphi was previously unknown, was identified as a major substrate by immunoprecipitation and phosphopeptide mapping. Activation of Fc gamma RIIIA stimulated a fourfold increase in Syk kinase activity assessed by autophosphorylation. Under mild lysis conditions several specific proteins were co-precipitated with the gamma subunit of Fc gamma RIIIA. Tyrosine kinase activity was also co-precipitated with gamma, as shown by in vitro phosphorylation of gamma. One of these kinases was identified as Syk by phosphopeptide mapping, suggesting a physical association between this PTK and the receptor. Two additional phosphoproteins induced by Fc gamma RIIIA cross-linking were identified: the hematopoietic proto-oncogene product p95Vav, previously implicated in B lymphocyte and mast cell signaling; and p62, a protein associated with p21Ras-GAP. Our results also establish that there are important functional similarities in signal transduction between a phagocytic Mphi FcR and other multi-subunit Ig gene family receptors in diverse cell lineages.

Conserved cytoplasmic tyrosine residues of the gamma subunit are required for a phagocytic signal mediated by Fc gamma RIIIA

Fc receptors for immunoglobulins are found on many cells and are important in host defense. We transfected Fc gamma RIIIA, present on macrophages and natural killer (NK) cells, into COS-1 cells to study its role in phagocytosis and calcium mobilization in the absence of other Fc gamma receptors. Human Fc gamma RIIIA-alpha (CD16) was cotransfected with its associated chains, either Fc gamma RIIIA gamma or zeta. Both gamma and zeta were observed to induce a phagocytic signal, but gamma was at least sixfold more effective than zeta. Conservative substitution by phenylalanine of either one of the two cytoplasmic tyrosine residues in the gamma chain resulted in markedly diminished phagocytosis and calcium mobilization. Tyrphostin 23, an inhibitor of tyrosine kinases, reversibly inhibited phagocytosis. Further, in vitro kinase assays with the wild type and mutant gamma chains demonstrated that the wild type gamma chain, but not the mutant gamma chains, is phosphorylated. These results suggest that the cytoplasmic tyrosine residues and tyrosine phosphorylation are required for Fc gamma RIIIA to mediate two signal transduction events: phagocytosis and calcium mobilization.

In vivo glucocorticoid modulation of guinea pig splenic macrophage Fc gamma receptors

Although glucocorticoids are widely used in the treatment of immunohematologic disease, their relative efficacy is uncertain. We used an animal model, which has helped to elucidate the role of splenic macrophage Fc gamma receptors in the clearance of IgG-coated cells, to investigate whether each Fc gamma receptor is modulated by glucocorticoids to the same extent and to examine the relative potency of three commonly used glucocorticoids. Cortisol, prednisone, and dexamethasone all impaired the clearance of IgG-coated erythrocytes. However, dexamethasone was more effective than either prednisone or cortisol (P less than 0.001). Furthermore, splenic macrophages isolated from glucocorticoid-treated animals expressed impaired Fc gamma receptor function. This effect was greater in macrophages isolated from dexamethasone-treated animals, as compared to either cortisol- or prednisone-treated animals (P less than 0.001). To assess the effect of glucocorticoids on the two types of guinea pig splenic macrophage Fc gamma receptors, Fc gamma R1,2 and Fc gamma R2, specific immunoglobulin isotypes were used to measure macrophage binding of IgG-sensitized erythrocytes. Cortisol and prednisone primarily affected Fc gamma R2, whereas dexamethasone inhibited the function of both guinea pig Fc gamma receptors. Furthermore, dexamethasone was more effective (P less than 0.01) than either prednisone or cortisol in inhibiting the ability of both receptors to bind IgG-sensitized cells. Fluorescence-activated cell sorter analysis and fluorescence microscopy with monoclonal antibodies specific for each of these two receptors demonstrated that essentially all splenic macrophages expressed both receptors, and that these glucocorticoids decreased the level of each Fc gamma receptor protein expressed, rather than altering receptor mobility and clustering in the macrophage membrane. The effect on both Fc gamma receptors was greatest with dexamethasone and least with cortisol. These studies demonstrate the significant role of guinea pig splenic macrophage Fc gamma R2 in immune clearance and in the binding of IgG-coated cells. They demonstrate a differential effect of glucocorticoid hormones on Fc gamma receptor function and on surface receptor protein. Furthermore, they suggest that dexamethasone may be a more effective glucocorticoid than either prednisone or cortisol in inhibiting the clearance of IgG-coated cells by its effect on splenic macrophage Fc gamma receptors.