Toward a value-based health care system.
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Delivery of Health Care↗
Biomedical subjects
S M McCarthy
Publications and source records attributed to S M McCarthy.
Value-based partnering in health care.
Many companies are beginning to focus on value in their health care purchasing decisions, and some are going beyond value-based purchasing to value-based partnering. Value-based partnering recognizes the interdependencies among stakeholder groups in the health care system and creates a strategic reason for them to exchange information and create long-term strategic alliances. This article discusses the principles of value-based partnering, impediments to practicing it and its future role in the health care system.
Consumer Behavior↗
Aligning physician financial incentives in a mixed-payment environment.
Under a shadow-pricing approach to physician compensation, physicians who deliver healthcare services to a mix of fee-for-service (FFS) and capitated patients are compensated for services via a payment schedule that treats all patients as if they were capitated. By encouraging physicians to adopt the same care-management approach for all patients, shadow pricing helps a group practice prepare for a larger share of revenues to be derived from capitation, thereby making the organization more attractive to many managed care payers. An apparent drawback of shadow pricing is that it gives physicians an incentive to reduce FFS utilization, resulting in a loss of potential revenue to the healthcare organization. This loss can be strategically justified, however, as an investment in the organization's ability to remain viable under capitation and to retain patients for whom payment may shift from FFS to capitation. In developing a shadow-pricing compensation approach, healthcare organizations can include incentives that encourage physicians to meet specific utilization targets, establish review procedures to identify physicians who deviate from the targets, and account for differences in acuity levels among different physicians' patient panels.
Accounts Payable and Receivable↗
Myometrial tissue in uterine septa.
STUDY OBJECTIVE: To assess the frequency of myometrial tissue in the septa of septate uteri. DESIGN: Retrospective review (Canadian Task Force classification II-2). SETTING: University-affiliated tertiary referral center. PATIENTS: Twenty-nine consecutive women with uterine septa diagnosed by magnetic resonance imaging (MRI). INTERVENTIONS: The MRI examination was performed with a 1.5 Tesla scanner using high-resolution phased array coils with multiplanar fast-spin echo and T1-weighted sequences. Of resected septa, tissue was available in four for histologic evaluation for the presence of myometrial tissue. MEASUREMENTS AND MAIN RESULTS: In 17 women MRI showed a partial septum, all containing myometrium. The 12 patients with complete septum had evidence of myometrium in the upper part of the septum, with fibrous tissue constituting the lower part. Histology reviewed from four resected septa (2 partial, 2 complete) reported myometrial tissue. CONCLUSION: Uterine septa are frequently composed of myometrial tissue.
Adult↗
Nonmetastatic gestational trophoblastic neoplasia. Role of ultrasonography and magnetic resonance imaging.
OBJECTIVE: To determine whether routine imaging using grey-scale ultrasound, pulse and color Doppler flow, endovaginal ultrasound and magnetic resonance imaging (MRI) provide information that significantly helps determine therapy in patients with nonmetastatic gestational trophoblastic disease. STUDY DESIGN: A literature search was performed to seek all publications in English and German that reported on investigations of imaging by ultrasound and MRI in patients with a diagnosis of trophoblastic tumor without evidence of metastases. Studies performed to make a diagnosis of hydatidiform mole were excluded. Included were studies that investigated the clinical usefulness and efficacy of these imaging methods in the diagnosis of invasive mole as a visual confirmation of the diagnosis based on human chorionic gonadotropin (hCG) and histology. Furthermore, the usefulness and efficiency of imaging in determining the effectiveness of chemotherapy were investigated. RESULTS: Analysis of these reports showed that lesions are detectable by imaging modalities at relatively high levels of hCG but may not be visualized at lower levels of hCG, when chemotherapy is nevertheless indicated and the diagnosis of neoplasia is fully justified. Moreover, myometrial lesions have been observed by MRI in patients who subsequently achieved spontaneous resolution of their disease without chemotherapy. At lower levels of hCG (< 700 mIU/mL), intramyometrial lesions may not be visualized by either ultrasound or MRI. Myometrial abnormalities may persist with resolution of the tumor. Thus, the sensitivity of either method is no better than 70% and the specificity is even lower. CONCLUSION: Weekly serial levels of serum hCG remain the most accurate, reliable and definitive arbiter of treatment management. Pelvic ultrasound or MRI need not be an integral part of pretreatment assessment. Imaging techniques are expensive yet not decisive in managing nonmetastatic trophoblastic disease. This finding applies to nonmetastatic disease only. With metastases, ultrasound, MRI and computed tomography do play an integral role in diagnosis, staging and management.
Chorionic Gonadotropin↗
Fetal anatomy with magnetic resonance imaging.
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Fetus↗
Clinical stage I endometrial carcinoma: pitfalls in preoperative assessment with MR imaging. Work in progress.
PURPOSE: To identify potential pitfalls in using magnetic resonance (MR) imaging to determine the depth of myometrial invasion in patients with clinical stage I endometrial carcinoma. MATERIALS AND METHODS: Forty women with clinical stage I endometrial carcinoma underwent preoperative pelvic MR imaging. Uterine length, tumor signal intensity, appearance of the junctional zone, presence of large polypoid tumors, leiomyomata, and congenital uterine anomalies were analyzed. Univariate logistic-regression analysis was performed to identify associations between incorrect MR staging and these variables. RESULTS: MR staging of IA, IB, and IC disease was 55% accurate (22 of 40 cases); MR differentiation of deep myometrial invasion (stage IC) from superficial disease (stages IA and IB) was 78% accurate (31 of 40 cases). Older age (P = .025), presence of polypoid tumors (P = .025), and difficulty in pathologic staging (P < .005) were significantly associated with incorrect MR assessment. CONCLUSION: When present, large polypoid tumors, leiomyomata, congenital anomalies, small uteri, and indistinct zonal anatomy may make it difficult to assess myometrial invasion at MR imaging.
Aged↗
Comprehensive care of the child with a chronic condition. Part 2. Primary care management.
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Acute Disease↗
Comprehensive care of the child with a chronic condition. Part 1. Understanding chronic conditions in childhood.
Understanding the care of children with chronic illnesses and disabilities is an important part of the practice of pediatrics. Children with special health care needs and their families benefit from the support which comprehensive, coordinated, accessible, and responsive services provide. Although the primary care pediatrician is often most appropriate to serve as the overall coordinator of such services, many challenges to providing such care exist. Part 2, "Primary Care Management," will suggest guiding principles and management structures that allow the pediatrician to respond most effectively over time to the needs of children with chronic conditions and their families.
Child↗
Cost effectiveness of magnetic resonance imaging of the knee.
When compared to diagnostic arthroscopy in patients with knee complaints consistent with internal derangement, MR imaging emerges as a cost effective diagnostic supplement to clinical examination. This article concludes that the results of MR imaging can be used as a guide for the management of knee pain.
Arthroscopy↗
Pelvic MR imaging findings in gestational trophoblastic disease, incomplete abortion, and ectopic pregnancy: are they specific?
Thirty-nine patients with abnormally elevated levels of serum beta subunit of human chorionic gonadotropin (beta-hCG) were studied to determine whether findings at magnetic resonance (MR) imaging are specific for primary molar disease, persistent gestational trophoblastic disease (GTD), incomplete abortion, and ectopic pregnancy. Among the latter three groups, the only significant differences were a higher prevalence of endometrial distention in the group with incomplete abortion (P < .0035) and the absence of junctional zone disruption in the group with ectopic pregnancy (P < .05). In the group with primary molar disease, total intrauterine volume was significantly increased (P < .001), and endometrial distention and presence of an endometrial mass had a significantly higher prevalence than that in the persistent GTD groups with (P < .04) or without (P < .001) metastases. Myometrial or extrauterine disease was identified in 65% of the patients with persistent disease and a beta-hCG level greater than 500 mIU/mL (500 IU/L). Thus, although MR imaging findings in persistent GTD, incomplete abortion, and ectopic pregnancy are relatively nonspecific, MR imaging can depict invasive disease that may alter therapeutic management in patients with documented GTD.
Abortion, Incomplete↗
Zonal anatomy of the cervix: correlation of MR imaging and histologic examination of hysterectomy specimens.
High-resolution magnetic resonance (MR) images of nine hysterectomy specimens were correlated with light microscopy, computer-aided image analysis, and immunohistochemical examination to investigate the histologic counterparts of the zonal anatomy of the cervix. A central stripe of high signal intensity, a surrounding middle layer of low signal intensity, and an outer layer of intermediate signal intensity were found in all specimens. Histologic correlation indicated that the central stripe most likely represents the secretions in the canal, the cervical mucosa, and the plicae palmatae; the other two layers represent fibromuscular stroma. The percentage of nuclear area in the inner zone of the fibromuscular stroma is 2.5 times greater than in the outer zone, which may account for the lower signal intensity of the inner zone. No difference in distribution of collagen, laminin, and fibronectin (common components of the extracellular matrix) was found between the two zones of the cervical fibromuscular stroma.
Adult↗
Diagnosis of uterine anomalies: relative accuracy of MR imaging, endovaginal sonography, and hysterosalpingography.
The purpose of this study was to compare the relative accuracy of magnetic resonance (MR) imaging (n = 26), endovaginal sonography (EVS) (n = 14), and hysterosalpingography (HSG) (n = 20) in the classification of müllerian duct anomalies in 26 patients. There were 24 cases of surgically proved anomaly, and two patients had normal uteri (one with a vaginal septum). MR imaging allowed diagnosis of 24 of 24 cases (accuracy, 100%), and EVS was correct in 11 of 12 cases (accuracy, 92%). HSG was correct in only four cases. In the diagnosis of septate uterus, MR imaging demonstrated a sensitivity and specificity of 100% and EVS demonstrated a sensitivity of 100% and a specificity of 80%. Both MR imaging and EVS demonstrated a sensitivity and specificity of 100% in distinguishing those anomalies that did not require surgery. The high accuracy of MR imaging and EVS permit noninvasive differentiation of uterine anomalies and can spare women diagnostic laparoscopy, promoting cost-effective diagnosis.
Congenital Abnormalities↗
Value of lipid- and water-suppression MR images in distinguishing between blood and lipid within ovarian masses.
The distinction between blood and lipid in ovarian masses on MR imaging is important in the differential diagnosis of these lesions. However, this is often difficult on routine MR images because both blood and lipid within tumors can have the same signal intensity as subcutaneous fat. Accordingly, we studied the value of lipid- and water-suppression MR images in making this distinction in 16 patients (21 lesions). As proved by surgery (six patients) or laparoscopy (10 patients), there were 16 endometriomas, one hemorrhagic leiomyosarcoma, and four lipid-containing mature cystic teratomas. The signal intensity in all 17 hemorrhagic lesions was greater than that of subcutaneous fat on lipid-suppression images and less than that of fat on water-suppression images. This compared with the signal intensity of the four lesions that contained lipid, in which the signal intensity was similar to that of subcutaneous fat on both the lipid- and water-suppression images. Thus, the lipid- and water-suppression MR images allowed an accurate distinction between the two. Our experience suggests that the appearance of blood and lipid in ovarian tumors is sufficiently different on lipid- and water-suppression MR images to allow an accurate distinction between the two. The two techniques should be useful in the differential diagnosis of such lesions by MR imaging.
Adipose Tissue↗
A case illustration of family management style.
Chronic illness management is a way of life for many children and their families. For these chronically ill children, the ability of the family to respond to the daily relentless demands of management dictates the quality of the child's and family's life. In an effort to better understand how a family responds to a chronic illness, Knafl and Deatrick's Family Management Style (FMS) model is applied to a family with a child with type I diabetes using a case-study analysis. Gallo derived dimensions of the model's components in an earlier application. These dimensions are applied to interview data obtained on the same family 1 year later to address the dynamic nature of family management style.
Adaptation, Psychological↗
An evaluation of MRI contrast in the uterus using synthetic imaging.
Using a 1.5-T system, we investigated the contrast in MR images of the uterus using a synthetic imaging program that was capable of producing images with TR values of 20 to 10220 ms and TE values of 1 to 511 ms. Synthetic images were calculated from images obtained on six normal women of reproductive age. The synthesized uterine images were essentially indistinguishable from acquired images with the same TR and TE parameters. Cervical and uterine anatomy could be clearly differentiated in synthetic images with a TE = 80 ms when the TR was as low as 100 ms. We conclude that the zonal anatomy of the uterus can be demonstrated using TR values that are much lower than those usually used for demonstrating uterine anatomy.
Cervix Uteri↗
Imaging of ovarian masses: magnetic resonance imaging.
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Dermoid Cyst↗
Junctional zone of the uterus: correlation of MR imaging and histologic examination of hysterectomy specimens.
High-resolution magnetic resonance (MR) images of 12 hysterectomy specimens were correlated with results of light microscopy, image analysis, and immunohistochemical studies to investigate the histologic counterpart of the low-signal-intensity band, or junctional zone (JZ), that surrounds the bright central uterine stripe. All specimens were imaged with a 1.5-T superconducting magnet within 21/2 hours (on average) after hysterectomy. Comparison of histologic findings with measurements obtained at MR imaging indicates that the JZ represents the innermost layer of the myometrium. A threefold increase in percentage of nuclear area was found in the JZ in comparison with the outer myometrium, reflecting an increase in both size and number of nuclei. No difference in distribution of common components of the extracellular space (collagen, laminin, and fibronectin) was found between the two layers.
Adult↗