Assessing the value of diabetes education

PURPOSE

The purpose of this study was to evaluate the impact of diabetes self-management education/training (DSME/T) on financial outcomes (cost of patient care).

METHODS

Commercial and Medicare claims payer-derived datasets were used to assess whether patients who participate in diabetes education are more likely to follow recommendations for care than similar patients who do not participate in diabetes education, and if claims of patients who participate in diabetes education are lower than those of similar patients who do not.

RESULTS

Patients using diabetes education have lower average costs than patients who do not use diabetes education. Physicians exhibit high variation in their referral rates to diabetes education.

CONCLUSIONS

The collaboration between diabetes educators and physicians yields positive clinical quality and cost savings. The analysis indicates that quality can be improved, and cost reduced, by increasing referral rates to diabetes education among low-referring physicians, specifically among men and people in disadvantaged areas. More needs to be done to inform physicians about ways to increase access to diabetes education for underserved populations.

Understanding patient risk and its impact on chronic and non-chronic member trends

A common method of performing commercial and government (ie, Medicare, Medicaid) disease management (DM) program savings evaluations--and the basis of DMAA's Guidelines--is the adjusted historical control method. This method uses a trend adjustment to adjust for the effects of utilization and unit cost changes over time. An appropriate trend adjuster is one that is based on a population with a constant-risk profile, so that utilization and price effects may be measured without being confounded by population changes. Previous literature has demonstrated that the method of identification of chronic and non-chronic members and the timing of the member's transfer between populations has a significant influence on the measured trends in the 2 populations, and thereby on the measured savings from a DM intervention program. The application of risk-adjustment methods to the non-chronic population can correct for this change in risk profiles and ensure a constant-risk population. This method may be used for the non-chronic trend estimation, and will result in an unbiased population trend estimate. However, the chronic population presents different problems for trend adjustment. Because the chronic population is subject to intervention, the application of risk adjustment to this population would potentially neutralize the effect of the outcome that the evaluation is attempting to capture. This paper addresses an alternative method of performing the standard DM savings calculation, which aims to avoid confounding from changes in the chronic population risk profiles due to extrinsic factors.

Regulation of the Drosophila distal antennal determinant spineless

The transformation of antenna to leg is a classical model for understanding segmental fate decisions in Drosophila. The spineless (ss) gene encodes a bHLH-PAS transcription factor that plays a key role in specifying the identity of distal antennal segments. In this report, we identify the antennal disc enhancer of ss and then use enhancer-lacZ reporters to work out how ss antennal expression is regulated. The antennal determinants Distal-less (Dll) and homothorax (hth) are key activators of the antennal enhancer. Dll is required continuously and, when present at elevated levels, can activate the enhancer in regions devoid of hth expression. In contrast, homothorax (hth) is required only transiently both for activation of the enhancer and for specification of the aristal portion of the antenna. The antennal enhancer is repressed by cut, which determines its proximal limit of expression, and by ectopic Antennapedia (Antp). Repression by Antp is not mediated by hth, suggesting that ss may be a direct target of Antp. Finally, we show that ss+ is not a purely passive target of its regulators: ss+ partially represses hth in the third antennal segment and lies upstream of Dll in the development of the maxillary palp primordia.

Trial of management of borderline and other low-grade abnormal smears (TOMBOLA): Trial design

Cervical screening reduces the risk of cervical cancer by detecting and treating cervical intraepithelial neoplasia (CIN). The management of women with low-grade cervical abnormalities is controversial. Two management policies exist: repeat smears in primary care and colposcopy examination. It is not clear which of these is the more effective and efficient. There is also uncertainty as to the most effective and efficient management of women at colposcopy when an area of abnormality is seen on the cervix - immediate treatment or biopsy and selective recall for treatment if the biopsy result suggests this is necessary. The result of a human papillomavirus (HPV) test might assist in deciding the appropriate management of women with low-grade abnormalities. TOMBOLA, a pragmatic randomised-controlled trial set within the cervical screening programmes in Scotland and England, addresses these three areas of uncertainty. Almost four and a half thousand women aged 20-59 with a low-grade cervical abnormality have been recruited and randomised to either repeat smears or colposcopy examination. Women in the colposcopy arm of the trial are further randomised to a policy of either immediate treatment or biopsy and selective recall for treatment if they have an abnormal transformation zone. Women are followed up to an exit examination at 3 years. HPV testing is undertaken at recruitment and at the exit examination. The primary endpoint is cumulative incidence of CIN2/3. A range of other clinical, psychosocial and economic outcomes is being considered. This paper describes the design of the trial, and discusses the rationale underlying aspects of the design and the challenges faced in designing and implementing the trial.

Stochastic spineless expression creates the retinal mosaic for colour vision

Drosophila colour vision is achieved by R7 and R8 photoreceptor cells present in every ommatidium. The fly retina contains two types of ommatidia, called 'pale' and 'yellow', defined by different rhodopsin pairs expressed in R7 and R8 cells. Similar to the human cone photoreceptors, these ommatidial subtypes are distributed stochastically in the retina. The choice between pale versus yellow ommatidia is made in R7 cells, which then impose their fate onto R8. Here we report that the Drosophila dioxin receptor Spineless is both necessary and sufficient for the formation of the ommatidial mosaic. A short burst of spineless expression at mid-pupation in a large subset of R7 cells precedes rhodopsin expression. In spineless mutants, all R7 and most R8 cells adopt the pale fate, whereas overexpression of spineless is sufficient to induce the yellow R7 fate. Therefore, this study suggests that the entire retinal mosaic required for colour vision is defined by the stochastic expression of a single transcription factor, Spineless.

A randomised comparison of treosulfan and carboplatin in patients with ovarian cancer: a study by the Scottish Gynaecological Cancer Trials Group (SGCTG)

The management of older and unfit women with advanced ovarian cancer requires post-operative chemotherapy but many of these patients are not suitable for high-dose cisplatin-based regimes. Carboplatin has been an easier alternative and can be given in the ambulatory setting. Historical data suggests that oral alkylating agents to be just effective with similar efficacy. In this study we have compared platinum-based carboplatin to the alkylating agent treosulfan in a population unfit to receive high-dose cisplatin. The trial randomised patients to either intravenous carboplatin or treosulfan as single agent. The trial was stopped prematurely after the interim analysis showed improved survival and response rates in the carboplatin arm. We conclude that carboplatin is a safe and effective drug in a population that is unfit for high-dose cisplatin. Treosulfan showed limited activity but may be considered along with other oral drugs in limited circumstances. With the exception of myelosuppression, toxicity was mild in both arms. Carboplatin remains the gold standard in this older and less fit group of patients.

Abdominal pigmentation variation in drosophila polymorpha: geographic variation in the trait, and underlying phylogeography

Drosophila polymorpha is a widespread species that exhibits abdominal pigmentation variation throughout its range. To gain insight into this variation we combined phenotypic and genotypic data to test a series of nested hypotheses. First, we tested the null hypothesis that geographic variation in pigmentation is due to neutral factors. We used nested clade analysis to examine the distribution of haplotypes from a nuclear and a mitochrondrial locus. Restricted gene flow via isolation by distance, the primary inference of this phylogeographic analysis, was then used to generate and test the hypothesis of increasing average abdominal pigmentation difference with increasing geographic distance. We found no correlation between geographic distance and phenotypic distance. We then tested the hypothesis that pigmentation is affected by environmental differences among localities. We found a significant effect of habitat type on the average abdominal pigmentation phenotype of different localities. Finally, we tested the hypothesis that pigmentation in D. polymorpha is associated with desiccation resistance. We found that dark individuals of both sexes survived significantly longer in a desiccating environment than light individuals. These patterns combined lead us to hypothesize that abdominal pigmentation variation in D. polymorpha is important in mediating the organism's interactions with local ecological factors.

A screen for genes that interact with the Drosophila pair-rule segmentation gene fushi tarazu

The pair-rule gene fushi tarazu (ftz) of Drosophila is expressed at the blastoderm stage in seven stripes that serve to define the even-numbered parasegments. ftz encodes a DNA-binding homeodomain protein and is known to regulate genes of the segment polarity, homeotic, and pair-rule classes. Despite intensive analysis in a number of laboratories, how ftz is regulated and how it controls its targets are still poorly understood. To help understand these processes, we conducted a screen to identify dominant mutations that enhance the lethality of a ftz temperature-sensitive mutant. Twenty-six enhancers were isolated, which define 21 genes. All but one of the mutations recovered show a maternal effect in their interaction with ftz. Three of the enhancers proved to be alleles of the known ftz protein cofactor gene ftz-f1, demonstrating the efficacy of the screen. Four enhancers are alleles of Atrophin (Atro), the Drosophila homolog of the human gene responsible for the neurodegenerative disease dentatorubral-pallidoluysian atrophy. Embryos from Atro mutant germ-line mothers lack the even-numbered (ftz-dependent) engrailed stripes and show strong ftz-like segmentation defects. These defects likely result from a reduction in Even-skipped (Eve) repression ability, as Atro has been shown to function as a corepressor for Eve. In this study, we present evidence that Atro is also a member of the trithorax group (trxG) of Hox gene regulators. Atro appears to be particularly closely related in function to the trxG gene osa, which encodes a component of the brahma chromatin remodeling complex. One additional gene was identified that causes pair-rule segmentation defects in embryos from homozygous mutant germ-line mothers. The single allele of this gene, called bek, also causes nuclear abnormalities similar to those caused by alleles of the Trithorax-like gene, which encodes the GAGA factor.

Principles for Assessing Disease Management Outcomes

Disease management (DM) is rapidly becoming an important force in the late 20th and early 21st century as a strategy for managing the chronic illness of large populations. Given the increasing visibility of DM programs, the clinical, economic and financial impact of this support are vital to DM program accountability and its acceptance as a solution to the twin challenges of achieving affordable, quality health care. Measuring and reporting outcomes in DM is difficult. DM programs must adapt to local market conditions and customer desires, which in turn limits generalizability, and still account for the overlapping/interlocking/multifaceted nature of the interventions included in any DM program. The Disease Management Association of America convened a Steering Committee to suggest a preferred approach, not a mandated or standardized approach for DM program evaluation. This paper presents the Steering Committee's "Consensus Statement" and "Guiding Principles" for robust evaluation.

Cyanide levels near fairy rings affect the growth of grasses and fungi

Field and laboratory experiments were conducted to test the hypothesis that cyanide produced by Marasmius oreades (Bolt ex Fr.) Fr., and further concentrated by a decrease in soil moisture near fairy rings, would reach levels inhibitory to grasses and soilborne fungi. Soil water content, cyanide levels per gram dry mass of soil, and micromolar concentrations of cyanide in soil solutions were determined for two fairy rings at five dates. Within 50-60 cm of the rings, increases in soil water and decreases in cyanide per gram dry mass of soil led to a steep decline in cyanide concentrations with distance from the rings. Seven fungi and four turfgrasses were exposed to different cyanide levels in vitro to estimate the cyanide concentration required to reduce fungal biomass or grass root length by 50% (EC50). These EC50 values were then compared with the observed cyanide concentrations in soil solutions near fairy rings. Within 25 cm of the rings, cyanide concentrations were sufficiently high to inhibit grass root growth and greatly inhibit the growth of some fungi, while having a negligible effect on others.Key words: cyanide, Marasmius oreades, fairy ring, turfgrass.

Cervical screening in women over the age of 50: results of a population-based multicentre study

OBJECTIVE

It has been suggested that women over 50 with a satisfactory negative smear history are at low risk for dyskaryosis and might be suitable for withdrawal from the cervical screening programme. The objectives of this study are to document the pattern of dyskaryosis in the cervical smears of women over 50 and to relate the risk of dyskaryosis in these women to the prior smear history.

DESIGN

Available computerised smear data were analysed.

SETTING

Five regions in England and Scotland; Aberdeen, Dundee, Birmingham, Gateshead and Nottingham.

POPULATION

All women aged 50 or over who had a satisfactory smear between 1988 and 1996.

METHODS

Smear results were sorted into individual smear records. The first smear after the age of 50 was identified as well as all smears before and after the age of 50.

MAIN OUTCOME MEASUREMENTS

The smear history before and after the age of 50 was determined for all women. The relative risk of dyskaryosis as well as the time to dyskaryosis was calculated for women whose raw data were available.

RESULTS

The study included 170,436 women with at least one satisfactory smear after 50. No results of previous smears were available in 90,546 (54%) of women but 36,512 (21%) of women had a satisfactory negative smear history. Women with prior dyskaryosis or borderline nuclear abnormalities (BNA) had an increased risk of dyskaryosis after the age of 50 compared with women with a negative history (RR 4.39 and 3.08 respectively). It was notable that 1.8% of women with a negative history still demonstrated subsequent dyskaryosis.

CONCLUSIONS

Women with either dyskaryosis or BNA before 50 are not suitable for withdrawal from cervical screening. Well-screened women with a negative smear history at the age 50 still have a residual risk of subsequently developing a new abnormality.

A prediction model for targeting low-cost, high-risk members of managed care organizations

OBJECTIVE

To describe the development and validation of a predictive model designed to identify and target HMO members who are likely to incur high costs.

STUDY DESIGN

Split-sample multivariate regression analysis.

PATIENTS AND METHODS

We studied enrollees in a 350000-member HMO with > or = 1 claim in 1998 and 1999. The prediction model uses a combination of clinical and behavioral vaiables and 1998 and 1999 claims data. The prediction model was applied and used to rank low-cost patients (1998 cost < dollars 2000) according to their estimated probability of incurring costs > or = dollars 2000 in 1999. For prospective testing, we applied our models to data that are not available in advance. The same prediction model was applied to rank a different set of low-cost patients (1999 cost < dollars 2000) according to estimated probability of incurring costs > or = dollars 2000 in 2000. Because the predictions were used for disease management purposes, the outcomes of a randomly selected control group not intervened on for the disease management program was analyzed. The predictive accuracy of the model was tested by comparing the percentages of "targeted" vs all low-cost patients who incurred high costs in the subsequent year.

RESULTS

Of the low-cost, top-ranked 1998 patients, 47.8% incurred high (> or = dollars 2000) medical expenses in 1999 vs 14.2% of randomly selected patients who were low cost in 1998. Of the top-ranked 1999 patients, 39.7% incurred high costs in 2000 vs 12.2% of the randomly selected low-ranked patients.

CONCLUSIONS

The prediction model successfully identifies low-cost, high-risk patients who are likely to incur high costs in the next 12 months.