Our healthcare system is fragmented, with a misalignment of incentives, or lack of coordination, that spawns inefficient allocation of resources. Fragmentation adversely impacts quality, cost, and outcomes. Eliminating waste from unnecessary, unsafe care is crucial for improving quality and reducing costs--and making the system financially sustainable. Many believe this can be achieved through greater integration of healthcare delivery, more specifically via integrated delivery systems (IDSs). An IDS is an organized, coordinated, and collaborative network that links various healthcare providers to provide a coordinated, vertical continuum of services to a particular patient population or community. It is also accountable, both clinically and fiscally, for the clinical outcomes and health status of the population or community served, and has systems in place to manage and improve them. The marketplace already contains numerous styles and degrees of integration, ranging from Kaiser Permanente-style full integration, to more loosely organized individual practice associations, to public-private partnerships. Evidence suggests that IDSs can improve healthcare quality, improve outcomes, and reduce costs--especially for patients with complex needs--if properly implemented and coordinated. No single approach or public policy will fix the fragmented healthcare system, but IDSs represent an important step in the right direction.

This study examined whether externally rated job demand and control were associated with depression diagnosis claims in a heavy industrial cohort. The retrospective cohort sample consisted of 7,566 hourly workers aged 18-64 years who were actively employed at 11 US plants between January 1, 1996, and December 31, 2003, and free of depression diagnosis claims during an initial 2-year run-in period. Logistic regression analysis was used to model the effect of tertiles of demand and control exposure on depression diagnosis claims. Demand had a significant positive association with depression diagnosis claims in bivariate models and models adjusted for demographic (age, gender, race, education, job grade, tenure) and lifestyle (smoking status, body mass index, cholesterol level) variables (high demand odds ratio = 1.39, 95% confidence interval: 1.04, 1.86). Control was associated with greater risk of depression diagnosis at moderate levels in unadjusted models only (odds ratio = 1.47, 95% confidence interval: 1.12, 1.93), while low control, contrary to expectation, was not associated with depression. The effects of the externally rated demand exposure were lost with adjustment for location. This may reflect differences in measurement or classification of exposure, differences in depression diagnosis by location, or other location-specific factors.

Abstract

Objectives. We assessed the potential health and economic benefits of reducing common risk factors in older Americans.
Methods. A dynamic simulation model tracked a national cohort of persons 51 and 52 years of age to project their health and medical spending in prevention scenarios for diabetes, hypertension, obesity, and smoking.
Results. The gain in life span from successful treatment of a person aged 51 or 52 years for obesity would be 0.85 years; for hypertension, 2.05 years; and for diabetes, 3.17 years. A 51- or 52-year-old person who quit smoking would gain 3.44 years. Despite living longer, those successfully treated for obesity, hypertension, or diabetes would have lower lifetime medical spending, exclusive of prevention costs. Smoking cessation would lead to increased lifetime spending. We used traditional valuations for a life-year to calculate that successful treatments would be worth, per capita, $198018 (diabetes), $137964 (hypertension), $118946 (smoking), and $51750 (obesity).
Conclusions. Effective prevention could substantially improve the health of older Americans, and—despite increases in longevity—such benefits could be achieved with little or no additional lifetime medical spending.

Sociologists and others studying aging in the U.S. uncover myths that dominate public perceptions of the elderly. Educating our society about the facts on aging is a necessary step to ensure that future policies will promote a more equitable and productive America for all ages.

BACKGROUND: The burden of hypertension and related health care needs among Mexican Americans will likely increase substantially in the near future.

OBJECTIVES: In a nationally representative sample of U.S. Mexican American adults we examined: 1) the full range of blood pressure categories, from normal to severe; 2) predictors of hypertension awareness, treatment and control and; 3) prevalence of comorbidities among those with hypertension.

DESIGN: Cross-sectional analysis of pooled data from the National Health and Nutrition Examination Surveys (NHANES), 1999-2004. PARTICIPANTS: The group of participants encompassed 1,359 Mexican American women and 1,421 Mexican American men, aged 25-84 years, who underwent a standardized physical examination.

MEASUREMENTS: Physiologic measures of blood pressure, body mass index, and diabetes. Questionnaire assessment of blood pressure awareness and treatment.

RESULTS: Prevalence of Stage 1 hypertension was low and similar between women and men ( approximately 10%). Among hypertensives, awareness and treatment were suboptimal, particularly among younger adults (65% unaware, 71% untreated) and those without health insurance (51% unaware, 62% untreated). Among treated hypertensives, control was suboptimal for 56%; of these, 23% had stage >/=2 hypertension. Clustering of CVD risk factors was common; among hypertensive adults, 51% of women and 55% of men were also overweight or obese; 24% of women and 23% of men had all three chronic conditions-hypertension, overweight/obesity and diabetes.

CONCLUSION: Management of hypertension in Mexican American adults fails at multiple critical points along an optimal treatment pathway. Tailored strategies to improve hypertension awareness, treatment and control rates must be a public health priority.

BACKGROUND: It is unclear whether functional status before dialysis is maintained after the initiation of this therapy in elderly patients with end-stage renal disease (ESRD). METHODS: Using a national registry of patients undergoing dialysis, which was linked to a national registry of nursing home residents, we identified all 3702 nursing home residents in the United States who were starting treatment with dialysis between June 1998 and October 2000 and for whom at least one measurement of functional status was available before the initiation of dialysis. Functional status was measured by assessing the degree of dependence in seven activities of daily living (on the Minimum Data Set-Activities of Daily Living [MDS-ADL] scale of 0 to 28 points, with higher scores indicating greater functional difficulty). RESULTS: The median MDS-ADL score increased from 12 during the 3 months before the initiation of dialysis to 16 during the 3 months after the initiation of dialysis. Three months after the initiation of dialysis, functional status had been maintained in 39% of nursing home residents, but by 12 months after the initiation of dialysis, 58% had died and predialysis functional status had been maintained in only 13%. In a random-effects model, the initiation of dialysis was associated with a sharp decline in functional status, indicated by an increase of 2.8 points in the MDS-ADL score (95% confidence interval [CI], 2.5 to 3.0); this decline was independent of age, sex, race, and functional-status trajectory before the initiation of dialysis. The decline in functional status associated with the initiation of dialysis remained substantial (1.7 points; 95% CI, 1.4 to 2.1), even after adjustment for the presence or absence of an accelerated functional decline during the 3-month period before the initiation of dialysis. CONCLUSIONS: Among nursing home residents with ESRD, the initiation of dialysis is associated with a substantial and sustained decline in functional status. 2009 Massachusetts Medical Society

Despite current emphasis on health insurance expansions in developing countries, inefficient consumer incentives for over-use of medical care are an important counterbalancing concern. However, three factors that are more acute in poor countries (credit constraints, principal-agent problems, and positive externalities) result in substantial under-use and misuse as well. This paper studies Colombia's Régimen Subsidiado, the first major developing country effort to expand insurance in a way that purposefully addresses these inefficiencies. Using a regression discontinuity design, we find that Colombia's insurance program has provided risk protection while substantially increasing the use of traditionally under-utilized preventive services (with measurable health gains) through high-powered supply-side incentives.

Description: The American College of Physicians developed this guideline to present the available evidence on hormonal testing in and pharmacologic management of erectile dysfunction. Current pharmacologic therapies include phosphodiesterase-5 (PDE-5) inhibitors, such as sildenafil, vardenafil, tadalafil, mirodenafil, and udenafil, and hormonal treatment.

Methods: Published literature on this topic was identified by using MEDLINE (1966 to May 2007), EMBASE (1980 to week 22 of 2007), Cochrane Central Register of Controlled Trials (second quarter of 2007), PsycINFO (1985 to June 2007), AMED (1985 to June 2007), and SCOPUS (2006). The literature search was updated by searching for articles in MEDLINE and EMBASE published between May 2007 and April 2009. Searches were limited to English-language publications. This guideline grades the evidence and recommendations by using the American College of Physicians' clinical practice guidelines grading system.

Recommendation 1: The American College of Physicians recommends that clinicians initiate therapy with a PDE-5 inhibitor in men who seek treatment for erectile dysfunction and who do not have a contraindication to PDE-5 inhibitor use (Grade: strong recommendation; high-quality evidence).

Recommendation 2: The American College of Physicians recommends that clinicians base the choice of a specific PDE-5 inhibitor on the individual preferences of men with erectile dysfunction, including ease of use, cost of medication, and adverse effects profile (Grade: weak recommendation; low-quality evidence).

Recommendation 3: The American College of Physicians does not recommend for or against routine use of hormonal blood tests or hormonal treatment in the management of patients with erectile dysfunction (Grade: insufficient evidence to determine net benefits and harms).

BACKGROUND: Safety climate refers to shared perceptions of what an organization is like with regard to safety, whereas safety culture refers to employees' fundamental ideology and orientation and explains why safety is pursued in the manner exhibited within a particular organization. Although research has sought to identify opportunities for improving safety outcomes by studying patterns of variation in safety climate, few empirical studies have examined the impact of organizational characteristics such as culture on hospital safety climate.

PURPOSE: This study explored how aspects of general organizational culture relate to hospital patient safety climate.

METHODOLOGY: In a stratified sample of 92 U.S. hospitals, we sampled 100% of senior managers and physicians and 10% of other hospital workers. The Patient Safety Climate in Healthcare Organizations and the Zammuto and Krakower organizational culture surveys measured safety climate and group, entrepreneurial, hierarchical, and production orientation of hospitals' culture, respectively. We administered safety climate surveys to 18,361 personnel and organizational culture surveys to a 5,894 random subsample between March 2004 and May 2005. Secondary data came from the 2004 American Hospital Association Annual Hospital Survey and Dun & Bradstreet. Hierarchical linear regressions assessed relationships between organizational culture and safety climate measures.

FINDINGS: Aspects of general organizational culture were strongly related to safety climate. A higher level of group culture correlated with a higher level of safety climate, but more hierarchical culture was associated with lower safety climate. Aspects of organizational culture accounted for more than threefold improvement in measures of model fit compared with models with controls alone. A mix of culture types, emphasizing group culture, seemed optimal for safety climate.

PRACTICE IMPLICATIONS: Safety climate and organizational culture are positively related. Results support strategies that promote group orientation and reduced hierarchy, including use of multidisciplinary team training, continuous quality improvement tools, and human resource practices and policies.