An experiment shows that a well-designed report on costs and quality can help consumers choose high-value health care

Advocates of health reform continue to pursue policies and tools that will make information about comparative costs and resource use available to consumers. Reformers expect that consumers will use the data to choose high-value providers-those who offer higher quality and lower prices-and thus contribute to the broader goal of controlling national health care spending. However, communicating this information effectively is more challenging than it might first appear. For example, consumers are more interested in the quality of health care than in its cost, and many perceive a low-cost provider to be substandard. In this study of 1,421 employees, we examined how different presentations of information affect the likelihood that consumers will make high-value choices. We found that a substantial minority of the respondents shied away from low-cost providers, and even consumers who pay a larger share of their health care costs themselves were likely to equate high cost with high quality. At the same time, we found that presenting cost data alongside easy-to-interpret quality information and highlighting high-value options improved the likelihood that consumers would choose those options. Reporting strategies that follow such a format will help consumers understand that a doctor who provides higher-quality care than other doctors does not necessarily cost more.     

From patient education to patient engagement: Implications for the field of patient education

Objective

Advances in health care require that individuals participate knowledgeably and actively in their health care to realize its full benefit. Implications of these changes for the behavior of individuals and for the practice of patient education are described.

Methods

An “engagement behavior framework” (EBF) was compiled from literature reviews and key informant interviews. To assess the focus of research and interventions on the identified engagement behaviors, the EBF was used to code scientific sessions in professional conferences relevant to patient education in the US in 2006–2007.

Results

Many specific behaviors constitute engagement. Professional conferences on patient education show only modest attention to the full range of relevant behaviors.

Conclusion

People must make informed choices about insurance and clinicians, coordinate communications among providers and manage complex treatments on their own. Not doing so risks preventable illness, suboptimal outcomes and wasted resources.

Practice Implications

Increased responsibilities of individuals, sick and well, to find and actively participate in high quality health care provides an opportunity for patient education researchers and clinicians to improve health outcomes by developing innovative strategies to support all individuals to effectively participate in their care to the extent possible.     

Exercise differentially regulates synaptic proteins associated to the function of BDNF

We explored the capacity of exercise to impact select events comprising synaptic transmission under the direction of brain-derived neurotrophic factor (BDNF), which may be central to the events by which exercise potentiates synaptic function. We used a specific immunoadhesin chimera (TrkB-IgG) that mimics the BDNF receptor, TrkB, to selectively block BDNF in the hippocampus during 3 days of voluntary wheel running. We measured resultant synapsin I, synaptophysin, and syntaxin levels involved in vesicular pool formation, endocytosis, and exocytosis, respectively. Synapsin I is involved in vesicle pool formation and neurotransmitter release, synaptophysin, in the biogenesis of synaptic vesicles and budding, and syntaxin, in vesicle docking and fusion. Exercise preferentially increased synapsin I and synaptophysin levels, without affecting syntaxin. There was a positive correlation between synapsin I and synaptophysin in exercising rats and synapsin I with the amount of exercise. Blocking BDNF abrogated the exercise-induced increases in synapsin I and synatophysin, revealing that exercise regulates select properties of synaptic transmission under the direction of BDNF.     

Aligning quality for populations and patients: do we know which way to go?

Both the medical care and public health systems have invested considerable resources to define, measure, and improve quality and health outcomes. A movement toward accountability has generated performance indicators from the medical arena and "leading health indicators" from the public health arena. The focus on specific conditions by the medical care system has been at odds with public health's emphasis on improving population health and has perpetuated a bifurcated system. Aligning the goals of medical care with those of public health will require reformulation of performance measurement and accountability into a common language that is valued by both systems. Such a creation would amount to a whole that is stronger than the sum of the component parts.     

Priorities in identifying unmet need in older people attending general practice: a nominal group technique study

BACKGROUND: Primary care practitioners are encouraged to identify unmet need in older people, but the best mechanisms for doing this are not known. OBJECTIVE: To identify common unmet needs, as perceived by older people and professionals, that could be enquired about during routine encounters in primary care. METHODS: This was a nominal group technique qualitative study conducted with older people in London and primary care professionals working in the same localities. Subjects were seven nominal groups of 5-12 participants each, four with culturally diverse user groups recruited through local community and voluntary sector resources and three with primary care professionals (GPs and nurses). Group interviews were conducted with two facilitators and one observer recording field notes and were tape-recorded and transcribed for data collection. RESULTS: Older people and professionals share some ideas about unmet need, but there are important differences. Older people may emphasize their autonomy and right to make choices, while professionals may use epidemiological knowledge to justify their own agendas, which may be considered intrusive. Nominal groups can be useful tools for capturing perspectives of different groups, but prioritization of themes identified by nominal groups may not always be feasible. CONCLUSIONS: Unmet need is a complex concept, with different interpretations according to the perspective taken. Professionals relying on epidemiological knowledge to guide their enquiries about unmet needs in older patients may find that the needs that they identify are not perceived as unmet, or even meetable, by their patients.     

Revenge of the "sit": how lifestyle impacts neuronal and cognitive health through molecular systems that interface energy metabolism with neuronal plasticity

Exercise, a behavior that is inherently associated with energy metabolism, impacts the molecular systems important for synaptic plasticity and learning and memory. This implies that a close association must exist between these systems to ensure proper neuronal function. This review emphasizes the ability of exercise and other lifestyle implementations that modulate energy metabolism, such as diet, to impact brain function. Mechanisms believed to interface metabolism and cognition seem to play a critical role with the brain derived neurotrophic factor (BDNF) system. Behaviors concerned with activity and metabolism may have developed simultaneously and interdependently during evolution to determine the influence of exercise and diet on cognition. A look into our evolutionary past indicates that our genome remains unchanged from the times of our hunter-gatherer ancestors, whose active lifestyle predominated throughout almost 100% of humankind's existence. Consequently, the sedentary lifestyle and eating behaviors enabled by the comforts of technologic progress may be reaping "revenge" on the health of both our bodies and brains. In the 21st century we are confronted by the ever-increasing incidence of metabolic disorders in both the adult and child population. The ability of exercise and diet to impact systems that promote cell survival and plasticity may be applicable for combating the deleterious effects of disease and ageing on brain health and cognition.     

The effect of correction of anaemia in diabetics and non-diabetics with severe resistant congestive heart failure and chronic renal failure by subcutaneous erythropoietin and intravenous iron.

BACKGROUND: A mild anaemia is often found in patients with congestive heart failure (CHF), but its significance is uncertain. In an open uncontrolled study we investigated the effect of correcting this anaemia [haemoglobin (Hb) 9.5-11.5 g%] with subcutaneous (s.c.) erythropoietin (Epo) and intravenous (i.v.) iron (Fe) in 179 patients, 84 type II diabetics and 95 non-diabetics, with moderate to severe CHF which was resistant to maximally tolerated doses of standard CHF medications. METHODS: Epo, s.c., was given every 1-3 weeks to achieve and maintain the Hb at 12.5 g%. Fe (Fe sucrose-Venofer) was added i.v. as necessary to maintain the Fe stores. Duration of treatment was 11.8 + 8.2 months. RESULTS: With the Epo-Fe treatment the Hb increased from 10.41 +/- 1.0 to 13.1 +/- 1.3 g% in diabetics and from 10.5 +/- 1.0 to 12.9 +/- 1.2 g% in non-diabetics. Comparing the diabetics and non-diabetics, the New York Heart Association functional class improved by 34.8 and 32.4%, respectively. breathlessness and/or fatigue, as measured by a self-administered Visual Analogue Scale, improved by 69.7 and 67.4%, and the left ventricular ejection fraction improved by 7.4 and 11.5%, respectively. The number of hospitalizations fell by 96.4 and 95.3%, respectively, compared with the pre-treatment period. Although the glomerular filtration rate (GFR) was falling at a rate of approximately 1 ml/min/month before the study in both groups, neither the mean serum creatinine nor the GFR changed significantly during the study period. The mean dose of Epo needed, measured in IU/week/kg body weight, was similar in the two groups. CONCLUSION: The correction of the mild anaemia that was found in diabetics and non-diabetics with resistant CHF and mild to moderate chronic renal failure improved the cardiac function and patient functional status, stabilized the renal function and markedly reduced the need for hospitalization.