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Biomedical subjects

M Gold

Publications and source records attributed to M Gold.

At least 109 records · Page 6Linked to original sources
PubMed1996

Medicaid managed care: lessons from five states.

With Medicaid managed care enrollment accelerating, policymakers must quickly understand the lessons from the states so that the transition to managed care strengthens access and care systems and avoids problems. Our study of five recent state experiences shows that state objectives must be realistic and well planned. The experience of states with long histories of managed care underscores the conclusion that managed care is not a magic bullet for solving all access and cost concerns and that no amount of managed care can substitute for adequately financed programs that are well understood by beneficiaries, providers, and health plans alike. The results highlight ten lessons from the states.

California↗
PubMed1996

Shifting the paradigm: monitoring access in Medicare managed care.

Medicare managed care enrollment growth points to the need to develop an approach for monitoring access to care for the increasing number of beneficiaries who use these arrangements. This article describes the issues to be addressed in designing a system for monitoring managed care plan enrollees' ability to obtain needed medical care on a timely basis. We review components of the monitoring approach used for traditional fee-for-service (FFS) Medicare, including the conceptual framework, data, measures, and subgroups targeted in monitoring efforts, and discuss the adaptation of that approach for monitoring access in Medicare managed care.

Fee-for-Service Plans↗
PubMed1995

The in vitro translocase activity of lambda terminase and its subunits. Kinetic and biochemical analysis.

The terminase holoenzyme of bacteriophage lambda is a multifunctional protein composed of two subunits, gpNu1 and gpA. In vitro, under certain conditions, terminase can render DNAs from various sources, of varying lengths and termini, resistant to degradation by high concentrations of DNase I. This reaction is completely dependent on the presence of terminase, proheads, a hydrolyzable triphosphate, and a divalent metal ion, and we propose that it is the result of translocation of DNA into proheads by terminase. This reaction is stoichiometric with respect to terminase, DNA, and proheads and can be supported by all deoxyribo- and ribonucleoside triphosphates, but not by the corresponding diphosphates or nonhydrolyzable ATP analogs. Mg2+ and Ca2+ promote the reaction, but Mn2+ and Zn2+ do not. In the absence of spermidine, translocase activity is low, but addition of the Escherichia coli protein integration host factor (IHF) promotes specific translocation of only those DNA fragments containing the terminase-binding site, cosB. When spermidine is present, nonspecific translocation of DNA from any source is stimulated. Under these conditions IHF no longer promotes specificity, but translocation of only cosB-containing DNA fragments can be restored by addition of small amounts of a dialyzed and RNase-treated E. coli extract, suggesting that additional host factor(s) may be involved in determination of packaging specificity. To a limited extent, gpA alone can promote translocation, but gpNu1, which has no translocase activity on its own, must be added to approach the holoenzyme-like activity levels. Formation of viable phage cannot be accomplished by gpA in the absence of gpNu1.

Animals↗
PubMed1995

Improved specificity toward substrates with positively charged side chains by site-directed mutagenesis of the L-lactate dehydrogenase of Bacillus stearothermophilus.

The substrate specificities of L-alpha-hydroxy acid dehydrogenases, including L-lactate dehydrogenases (L-LDH's), can often be quite broad. However, an LDH with high catalytic activity toward alpha-keto acids with positively charged side chains, such as those containing ammonium groups, has not been described, even though there is evidence from metabolic studies that a natural dehydrogenase with such activity might exist in Nature. L-omega-Amino-alpha-hydroxy acids are important intermediates in the synthesis of pharmacologically active compounds, and enzymatic reduction of omega-amino-alpha-keto acids represents an attractive route to these compounds. Graphics analysis indicated that introduction of acidic amino acids at position 102 of the L-LDH of Bacillus stearothermophilus (BSLDH) would favor binding of such side chain ammonium groups. Accordingly, Q102E and Q102D mutant BSLDH's were constructed and the steady state kinetic parameters determined for these mutants for a broad range of alpha-keto acids, including omega-amino-keto acids. The results obtained show that, compared to WT-BSLDH, these mutants show up to 25-fold improvements in kcat/Km values for omega-amino-alpha-keto acid substrates.

Base Sequence↗
PubMed1995

Plasma and red blood cell thiamine deficiency in patients with dementia of the Alzheimer's type.

OBJECTIVES: To determine the prevalence of plasma thiamine deficiency in patients referred to a memory disorder clinic and to compare plasma thiamine levels with red blood cell (RBC) thiamine levels. To determine if patients with senile dementia of the Alzheimer's type (SDAT) differ from those without SDAT in either plasma or RBC thiamine levels. DESIGN: Case-control study. SETTING: Ambulatory care referral center. PATIENTS: Consecutive sample of 34 patients; 17 patients who met the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association criteria for probable Alzheimer's disease and 17 patients with other forms of dementia. METHODS: Plasma and RBC thiamine levels were determined in all patients with the use of a microbiologic assay known for its specificity to biological forms of thiamine. Vitamin supplementation was determined by chart review. OUTCOME MEASURES: Plasma and RBC thiamine levels. RESULTS: Patients with SDAT were found to have significantly lower plasma thiamine levels than patients without SDAT. Low plasma thiamine levels were detected in a significantly larger proportion of patients with SDAT than in patients without SDAT. Red blood cell thiamine levels did not correlate with the clinical diagnosis of SDAT. Vitamin supplementation did not correlate with diagnosis and plasma or RBC thiamine levels. CONCLUSIONS: A significant proportion of patients with SDAT may have a thiamine deficiency, which may have an impact on cognitive function. Currently used assays may not be adequate to assess thiamine status.

Aged↗
PubMed1995

Right-left confusion in Gerstmann's syndrome: a model of body centered spatial orientation.

Gerstmann's syndrome encompasses the tetrad of finger agnosia, agraphia, acalculia and right-left confusion and is associated with lesions of the dominant angular gyrus. The localizing value of this syndrome has been questioned because multiple mechanisms can account for each of the components of the syndrome. We present the case of a man who developed Gerstmann's syndrome following a focal infarct of the left angular gyrus. The patient's right-left confusion could not be accounted for by either an aphasia or a degraded body schema. A series of experiments that investigated the patient's spatial mapping system by progressively restricting the degrees of freedom for spatial rotation revealed an isolated defect in deriving the relative position of an object along the horizontal axis. Defective horizontal mapping can account for the other components of Gerstmann's syndrome because they all share a common dependency on relative horizontal positioning.

Aged↗
PubMed1995

Community physicians' cooperation with a program of in-home comprehensive geriatric assessment.

OBJECTIVES: To study the cooperation of primary care physicians with a community-based prevention and health promotion program for older persons, to study physician factors related to cooperation, and to determine any relationship between physician cooperation and patient adherence to program recommendations and patient satisfaction with health care. DESIGN AND SETTING: A survey administered in subjects' homes and physicians' offices in Santa Monica, California. PARTICIPANTS: Patients (n = 81) were intervention group subjects in a 3-year, randomized, controlled trial of in-home comprehensive geriatric assessment paired with prevention and health promotion. Physicians (n = 50) were selected if they had been contacted at least once by a study nurse practitioner about one of these patients. MEASUREMENTS: Physician cooperation was rated by study nurse practitioners. Physicians were interviewed to identify factors associated with cooperation. Patients' satisfaction with health care and adherence were measured prospectively throughout the 3-year program. MAIN RESULTS: Physicians exhibiting better cooperation had fewer years in practice (P = .03) and were more likely to discuss the program with their patients (P = .005), see benefit for their patients from the program (P = .02), and rate program information as useful (P = .002). Higher physician cooperation did not predict higher patient satisfaction (P = .23) but did predict higher patient adherence to program recommendations (P = .02). CONCLUSIONS: Physicians rated as cooperative were more likely to have a positive appraisal of the program, and their patients had higher adherence to program recommendations. These findings suggest that strategies for increasing primary care physician cooperation might improve effectiveness of similar community-based prevention and health promotion programs.

Aged↗
PubMed1995

Employment supports for people with mental illness.

People with psychiatric disabilities often require extensive support to maintain employment. The authors describe five areas that supported employment programs should carefully examine when creating a supportive workplace environment: "natural" co-worker supports, personal network supports, training supports, self-management supports, and organizational supports. The different support needs of persons with developmental disabilities and those with psychiatric disabilities are highlighted, particularly in regard to how social stereotypes of these two groups influence decisions about how to provide support. The authors also discuss strategies that can be used by transitional employment programs for creating more effective supports within the limitations of the transitional setting.

Employment, Supported↗
PubMed1995

Behind the curve: a critical assessment of how little is known about arrangements between managed care plans and physicians.

Extraordinary growth in managed care arrangements over the past decade has been both widely praised and criticized. Proponents and critics agree that the nature of medical practice is being profoundly altered by this growth, even if they cannot articulate the direction and consequences of this change. We explore the roots of this uncertainty by examining the available evidence on critical features of the arrangements managed care plans currently have with affiliated physicians. Our approach is to review and synthesize the literature in several key substantive areas from a broad range of sources. We found that existing knowledge is dated, derived form a limited subset of plans, inattentive to important structural differences between plans, and responsive to a very narrow set of issues poorly reflecting the range of medical practice and change introduced by managed care. We highlight key questions of interest and the knowledge gaps critical to address so that policy and management decisions can both reflect and be informed on these issues that define the arrangements managed care plans make with physicians and ultimately influence medical practice.

Capitation Fee↗
PubMed1995

Design and feasibility of a national Medicaid Access Survey with state-specific estimates.

This article presents the results of a study to design and assess the feasibility of conducting a national Medicaid Access Survey to generate timely, state-specific estimates of access to care for Medicaid enrollees. State-specific data on Medicaid access is especially relevant because state programs and environments vary considerably and are changing rapidly in ways that could influence access. We analyze (1) basic survey design parameters and instrument content, (2) alternative sampling approaches and their feasibility, (3) pilot test results, (4) the feasibility of using existing national surveys to generate comparison estimates for state-based surveys, and (5) estimates of the required sample size and costs for such a national Medicaid Access Survey. We conclude that a survey generating timely, state-specific estimates of Medicaid access is both feasible and affordable if attention is paid to key design challenges while keeping objectives and design simple.

Budgets↗
PubMed1995

Dissociation of anosognosia for hemiplegia and aphasia during left-hemisphere anesthesia.

The stroke literature indicates that the explicit denial of hemiplegia, a form of anosognosia, is associated more commonly with right- than left-hemisphere lesions. Some investigators have suggested that this asymmetry may be an artifact and that the aphasia that often accompanies left-hemisphere dysfunction may mask some instances of anosognosia. Mechanisms suggested for anosognosia have been either "global" or "modular" in nature. Mechanisms posited in global explanations include psychological denial and general mental deterioration; modular explanations include feedback and feedforward theories. Videotapes of 54 patients with medically intractable seizures who had selective barbiturate anesthesia (Wada test) as part of their evaluation for seizure surgery were assessed for anosognosia of hemiplegia and aphasia after hemispheric anesthesia had worn off. The results suggest that, although aphasia may confound the reported rate of anosognosia for hemiplegia following left-hemisphere dysfunction, the frequency of anosognosia for hemiplegia is still higher with right- than left-side dysfunction. Anosognosia for hemiplegia and aphasia were dissociable, providing support for the postulate that awareness of dysfunction is mediated by a modular system.

Adult↗
PubMed1995

Anosognosia during intracarotid barbiturate anesthesia: unawareness or amnesia for weakness.

Previous studies have demonstrated asymmetric hemispheric contributions to deficit awareness during hemisphere inactivation with intracarotid barbiturate infusion (Wada studies). These observations provide insight into the neuropsychological basis of anosognosia for hemiparesis (AHP), arguing against earlier explanations based upon psychological denial, global cognitive disturbance, or emotional indifference. Although prior Wada studies equated AHP after the procedure with AHP during the period of deficit, a selective memory failure could also account for these findings. We, therefore, assessed the occurrence of AHP during and after right-hemisphere inactivation in a group of epilepsy patients undergoing preoperative Wada testing. Because aphasia obscures assessment of deficit awareness during left carotid studies, we compared the frequency of AHP between right- and left-hemisphere inactivation only after recovery. As noted in earlier reports, AHP was present significantly more often after right- than left-hemisphere inactivation. The proportions of subjects with AHP during right-hemisphere anesthesia compared with the proportion of subjects with AHP after the procedure were statistically equivalent, suggesting that the AHP observed after right-hemisphere anesthesia results from true failure of deficit awareness rather than inability to recall the deficit.

Amnesia↗
PubMed1995

Surveying consumer satisfaction to assess managed-care quality: current practices.

Growing interest in using consumer satisfaction information to enhance quality of care and promote informed consumer choice has accompanied recent expansions in managed care. This article synthesizes information about consumer satisfaction surveys conducted by managed-care plans, government and other agencies, community groups, and purchasers of care. We discuss survey content, methods, and use of consumer survey information. Differences in the use of consumer surveys preclude one instrument or methodology from meeting all needs. The effectiveness of plan-based surveys could be enhanced by increased information on alternative survey instruments and methods and new methodological studies, such as ones developing risk-adjustment methods.

Cultural Characteristics↗
PubMed1995

Reconciling practice and theory: challenges in monitoring Medicaid managed-care quality.

The massive shift to managed care in many State Medicaid programs heightens the importance of identifying effective approaches to promote and oversee quality in plans serving Medicaid enrollees. This article reviews operational issues and lessons from the ongoing evaluation of a three-State demonstration of the Health Care Financing Administration's (HCFA) Quality Assurance Reform Initiative (QARI) for Medicaid managed care. The QARI experience to date shows the potential utility of the system while drawing attention to the challenges involved in translating theory to practice. These challenges include data limitations and staffing constraints, diverse levels of sophistication among States and health plans, and the practical limitations of using quality indicators for a population that is often enrolled only on a discontinuous basis. To overcome these challenges, we suggest using realistically long timeframes for system implementation, with intermediate short-term strategies that could treat States and managed-care plans differently depending on their stage of development.

Centers for Medicare and Medicaid Services, U.S.↗