Context: Fetuin-A inhibits the insulin receptor in vitro. Higher serum fetuin-A concentrations are associated with type 2 diabetes longitudinally and greater adiposity in cross-sectional analyses. Whether higher fetuin-A concentrations are associated with accumulation of adiposity over time is unknown.

Objective: To determine the association of fetuin-A levels with changes in body composition over 5 yr.

Study Design: Observational cohort study nested in the Health Aging and Body Composition Study.

Predictor: Serum fetuin-A levels.

Outcomes: Visceral adipose tissue (VAT), abdominal sc adipose tissue, and thigh muscle area by computed tomography, and waist circumference and body mass index were measured at baseline and again after 5 yr. Percent change and extreme change (>1.5 SDs) in each measure were calculated.

Results: Over 5 yr, subjects lost body mass in each measure, including 6% decline in VAT. Yet each SD (0.42 g/liter) higher fetuin-A concentration was associated with a 5.5% increase in VAT over 5 yr (95% confidence interval 1.9-9.2%; P = 0.003) in models adjusted for age, sex, race, clinical site, diabetes, physical activity, triglycerides, kidney function, and the baseline VAT score. Similarly, higher fetuin-A concentrations were associated with extreme VAT gain (relative risk 1.70, 95% confidence interval 1.12-2.60, P = 0.01). Fetuin-A concentrations were not statistically significant associated with change in any other measures of body composition (P > 0.20).

Conclusions: Higher fetuin-A concentrations are associated with the accumulation of VAT in well-functioning, community-living older persons. The mechanisms linking fetuin-A, VAT, and insulin resistance remain to be determined.

Magnetic resonance imaging (MRI) is a technology frequently used to evaluate low back pain, despite evidence that challenges the usefulness of routine MRI and the surgical interventions it may trigger. We analyze the relationship between MRI supply and care for fee-for-service Medicare patients with low back pain. We find that increases in MRI supply are related to higher use of both low back MRI and surgery. This is worrisome, and careful attention should be paid to assessing the outcomes for patients.

Economics influences how medical care is delivered, organized, and progresses. Fee-for-service payment encourages delivery of services. Fee-for-individual-service, however, offers no incentives for clinicians to efficiently organize the care their patients need. Global capitation provides such incentives; it works well in highly integrated practices but not for independent practitioners. The failures of utilization management in the 1990s demonstrated the need for a third alternative to better align incentives, such as bundling payment for an episode of care. Building on Medicare's approach to hospital payment, one can define expanded diagnosis-related groups that include all hospital, physician, and other costs during the stay and appropriate preadmission and postdischarge periods. Physicians and hospitals voluntarily forming a new entity (a care delivery team) would receive such bundled payments along with complete flexibility in allocating the funds. Modifications to gainsharing and antikickback rules, as well as reforms to malpractice liability laws, will facilitate the functioning of the care delivery teams. The implicit financial incentives encourage efficient care for the patient; the episode focus will facilitate measuring patient outcomes. Payment can be based on the resources used by those care delivery teams achieving superior outcomes, thereby fostering innovation improving outcomes and reducing waste.

BACKGROUND: Many hospitals enrolled in the American Heart Association's Get With The Guidelines (GWTG) Program achieve high levels of recommended care for heart failure, acute myocardial infarction (MI) and stroke. However, it is unclear if outcomes are better in those hospitals recognized by the GWTG program for their processes of care. METHODS: We compared hospitals enrolled in GWTG and receiving achievement awards for high levels of recommended processes of care with other hospitals using data on risk-adjusted 30-day survival for heart failure and acute MI reported by the Center for Medicare and Medicaid Services. RESULTS: Among the 3,909 hospitals with 30-day data reported by Center for Medicare and Medicaid Services 355 (9%) received GWTG achievement awards. Risk-adjusted mortality for hospitals receiving awards was lower for both heart failure (11.0% vs 11.2%, P = .0005) and acute MI (16.1% vs 16.5%, P < .0001) compared to those not receiving awards. After additional adjustment for hospital characteristics and noncardiac performance measures, the reduction in mortality remained significantly lower for GWTG award hospitals for acute myocardial infraction (-0.19%, 95% CI -0.33 to -0.05), but not for heart failure (-0.11%, 95% CI -0.25 to 0.02). Additional adjustment for cardiac processes of care reduced the benefit of award hospitals by 28% for heart failure mortality and 43% for acute MI mortality. CONCLUSIONS: Hospitals receiving achievement awards from the GWTG program have modestly lower risk adjusted mortality for acute MI and to a lesser extent, heart failure, explained in part by better process of care.

Background. Helicobacter pylori vaccines are under development to prevent infection. We quantified the cost‐effectiveness of such a vaccine in the United States, using a dynamic transmission model.

Methods. We compartmentalized the population by age, infection status, and clinical disease state and measured effectiveness in quality‐adjusted life years (QALYs). We simulated no intervention, vaccination of infants, and vaccination of school‐age children. Variables included costs of vaccine, vaccine administration, and gastric cancer treatment (in 2007 US dollars), vaccine efficacy, quality adjustment due to gastric cancer, and discount rate. We evaluated possible outcomes for periods of 10-75 years.

Results. H. pylori vaccination of infants would cost $2.9 billion over 10 years; savings from cancer prevention would be realized decades later. Over a long time horizon (75 years), incremental costs of H. pylori vaccination would be $1.8 billion, and incremental QALYs would be 0.5 million, yielding a cost‐effectiveness ratio of $3871/QALY. With school‐age vaccination, the cost‐effectiveness ratio would be $22,137/QALY. With time limited to <40 years, the cost‐effectiveness ratio exceeded $50,000/QALY.

Conclusion. When evaluated with a time horizon beyond 40 years, the use of a prophylactic H. pylori vaccine was cost‐effective in the United States, especially with infant vaccination.

In 2008 Medicare stopped reimbursing hospitals for treating eight avoidable hospital-acquired conditions. Using 2006 California data, we modeled the financial impact of this policy on six such conditions. Hospital-acquired conditions were present in 0.11 percent of acute inpatient Medicare discharges; only 3 percent of these were affected by the policy. Payment reductions were negligible (0.001 percent, or $0.1 million-equivalent to $1.1 million nationwide) and are unlikely to encourage providers to improve quality. Options to strengthen the incentives include further payment modifications for hospital-acquired conditions or expanding the hospital-acquired condition policy to exclude payment for consequences, additional procedures, and readmissions.

Background: An increasing number of people suffer from chronic illness. Processes exist to provide better chronic illness care and yet for the most part, they are not used.

Objective: To examine the change in use of commonly recommended chronic illness care management processes (CMPs) in large medical groups between 2000 and 2006 and the factors associated with the change.

Design and Measures: Cohort analysis of data from a national telephone survey in year 2000 and again in 2006. Participants provided information on their organizations' ownership, size, use of defined chronic illness CMPs, financial incentives, quality improvement involvement, profitability, and use of electronic medical records.

Setting: Medical groups and independent practice associations of 20 physicians or more (N = 369) that treat patients with asthma, congestive heart failure, depression, and diabetes, and that responded to the survey in 2000 and 2006.

Results: Use of CMP increased from 6.25 to 7.67 (of a total of 17; P ≤ 0.001), that is, by 23%, between 2000 and 2006. Increases were greatest for those practices receiving financial rewards for quality; those participating in quality improvement activities; and those practices that were profitable. Most of the increase was in use of registries and in patient self-management support services.

Conclusions: There is significant opportunity for improving chronic illness care even in larger physician organizations. Public policies that promote financial rewards for improving quality and that encourage quality improvement initiatives are likely to be associated with improved chronic illness care.

Controlling health care cost growth remains a high priority for policymakers and private decisionmakers, yet little is known about sources of this growth. We examined spending growth among the privately insured between 2001 and 2006, separating the contributions of price changes from those driven by consumption. Most spending growth was driven by outpatient services and pharmaceuticals, with growth in quantities explaining the entire growth in outpatient spending and about three-quarters of growth in spending on prescription drugs. Rising prices played a greater role in growth in spending for brand-name than for generic drugs. These findings can inform efforts to control private- sector spending.

Background: The rates of induction of labor and elective induction of labor are increasing. Whether elective induction of labor improves outcomes or simply leads to greater complications and health care costs is commonly debated in the literature.

Purpose: To compare the benefits and harms of elective induction of labor and expectant management of pregnancy.

Data Sources: MEDLINE (through February 2009), Web of Science, CINAHL, Cochrane Central Register of Controlled Trials (through March 2009), bibliographies of included studies, and previous systematic reviews.

Study Selection: Experimental and observational studies of elective induction of labor reported in English.

Data Extraction: Two authors abstracted study design; patient characteristics; quality criteria; and outcomes, including cesarean delivery and maternal and neonatal morbidity.

Data Synthesis: Of 6117 potentially relevant articles, 36 met inclusion criteria: 11 randomized, controlled trials (RCTs) and 25 observational studies. Overall, expectant management of pregnancy was associated with a higher odds ratio (OR) of cesarean delivery than was elective induction of labor (OR, 1.22 [95% CI, 1.07 to 1.39]; absolute risk difference, 1.9 percentage points [CI, 0.2 to 3.7 percentage points]) in 9 RCTs. Women at or beyond 41 completed weeks of gestation who were managed expectantly had a higher risk for cesarean delivery (OR, 1.21 [CI, 1.01 to 1.46]), but this difference was not statistically significant in women at less than 41 completed weeks of gestation (OR, 1.73 [CI, 0.67 to 4.5]). Women who were expectantly managed were more likely to have meconium-stained amniotic fluid than those who were electively induced (OR, 2.04 [CI, 1.34 to 3.09]).

Limitations: There were no recent RCTs of elective induction of labor at less than 41 weeks of gestation. The 2 studies conducted at less than 41 weeks of gestation were of poor quality and were not generalizable to current practice.

Conclusion: RCTs suggest that elective induction of labor at 41 weeks of gestation and beyond is associated with a decreased risk for cesarean delivery and meconium-stained amniotic fluid. There are concerns about the translation of these findings into actual practice; thus, future studies should examine elective induction of labor in settings where most obstetric care is provided.