Faculty Bibliography

BACKGROUND: Pay-for-performance initiatives have been suggested as a way to improve the quality of patient care and provide incentives to improve providers' performance. The Centers for Medicare & Medicaid Services has endorsed such programs to improve quality of care. OBJECTIVE: To examine the state of quality initiatives endorsed by the Centers for Medicare & Medicaid Services in which institutions, provider groups, and physicians are awarded incentives based on adherence to composite metrics. METHOD: A literature search was conducted using the keywords "pay-for-performance," "quality improvement," "medical errors," and "physician incentive plans." RESULTS: Although quality of care has improved in healthcare settings that engage in pay-for-performance initiatives, what can be attributed to payer-incentive programs is uncertain. Studies demonstrate that, of the 25 hospitals classified by the Centers for Medicare & Medicaid Services to be in the lowest decile of quality improvements, all still made significant progress in adhering to quality metrics after participation in the study. Financial rewards, however, were distributed based on a predetermined threshold established by the Centers for Medicare & Medicaid Services to be given only to participants who fell in the top 2 deciles. Penalties were incurred by the 51 hospitals that were within the bottom 2 deciles despite making substantial improvements. At such institutions, large minority communities and Medicaid populations comprise the patient populations. Other pay-for-performance schemes, such as employer-based purchasing, consumer health-spending accounts, and collaborative groups, were studied, with little data to support definite benefits. CONCLUSIONS: Examining rates of improvement in adherence to pay-for-performance initiatives when determining how to distribute financial rewards should be studied alongside the current classification by absolute deciles. By rewarding rates of improvement, potential elimination of quality disparities for hospitals that serve large Medicaid and minority populations can be achieved, because such organizations are encouraged to invest in quality improvement as a result of substantial progress made. Although alternative strategies like employer-driven value-based purchasing and collaboratives seem promising, the long-term effects of such initiatives still need to be studied. Creating greater financial incentives for individual providers to participate in pay-for-performance programs for many years to come will remain a challenge.

BACKGROUND: Police responders to the 2001 World Trade Center (WTC) disaster were previously reported to have an increased prevalence of probable posttraumatic stress disorder (PTSD). METHODS: Four thousand seventeen police responders (3,435 men and 582 women) were interviewed 2-3 years after 9/11/01 as part of the World Trade Center Health Registry. Demographic, occupational, and event-specific risk factors were evaluated for probable PTSD, determined by DSM-IV criteria using the Posttraumatic Stress Checklist (PCL). RESULTS: Overall prevalence of probable PTSD was 8.3% (women: 13.9%; men: 7.4%, P < 0.001). Risk factors for both genders included 9/11-related injury and older age. For men, specific risk factors were: presence in WTC Towers on 9/11 and Hispanic ethnicity; and for women, witnessing horror and education less than a college degree. CONCLUSIONS: Significantly higher prevalence of probable PTSD was found for female police responders. Although consistent with civilian populations, this finding contrasts with other studies of PTSD and WTC rescue and recovery workers, and police prior to 9/11.

BACKGROUND: Several types of forceps are available for use in sampling Barrett's esophagus (BE). Few data exist with regard to biopsy quality for histologic assessment. OBJECTIVE: To evaluate sampling quality of 3 different forceps in patients with BE. DESIGN: Single-center, randomized clinical trial. PATIENTS: Consecutive patients with BE undergoing upper endoscopy. INTERVENTIONS: Patients randomized to have biopsy specimens taken with 1 of 3 types of forceps: standard, large capacity, or jumbo. MAIN OUTCOME MEASUREMENTS: Specimen adequacy was defined a priori as a well-oriented biopsy sample 2 mm or greater in diameter and with at least muscularis mucosa present. RESULTS: A total of 65 patients were enrolled and analyzed (standard forceps, n = 21; large-capacity forceps, n = 21; jumbo forceps, n = 23). Compared with jumbo forceps, a significantly higher proportion of biopsy samples with large-capacity forceps were adequate (37.8% vs 25.2%, P = .002). Of the standard forceps biopsy samples, 31.9% were adequate, which was not significantly different from specimens taken with large-capacity (P = .20) or jumbo (P = .09) forceps. Biopsy specimens taken with jumbo forceps had the largest diameter (median, 3.0 mm vs 2.5 mm [standard] vs 2.8 mm [large capacity]; P = .0001). However, jumbo forceps had the lowest proportion of specimens that were well oriented (overall P = .001). LIMITATIONS: Heterogeneous patient population precluded dysplasia detection analyses. CONCLUSIONS: Our results challenge the requirement of jumbo forceps and therapeutic endoscopes to properly perform the Seattle protocol. We found that standard and large-capacity forceps used with standard upper endoscopes produced biopsy samples at least as adequate as those obtained with jumbo forceps and therapeutic endoscopes in patients with BE.

Mr. [Daniel Okrent]'s description of the Prohibition era is a narrative delight. The Republicans, who controlled the White House and Congress in the 1920s, were largely indifferent to its success. Even those who did care were unwilling to spend the king's ransom needed to enforce it. There were never enough agents, and very few of them proved "untouchable." The accompanying laws, meanwhile, provided enough loopholes to guarantee failure. Sacramental wine was permitted, allowing fake clergymen to lead bogus congregants in nonreligious romps. Farmers who fermented their own cider and "fruit juices" were given special exemptions, making them extremely popular neighbors. Doctors, dentists and even veterinarians were free to write prescriptions for remedies like "Richardson's Concentrated Sherry Wine Bitters," which contained 47.5 percent alcohol (95 proof). In the 1920s, Charles Walgreen expanded his drugstore chain from 20 stores to an astounding 525 -- a spurt ludicrously attributed to his introduction of the milkshake. Much of the illegal liquor had a foul taste, leading to the introduction of mixed drinks with tonic water and ginger ale. The lure of the speakeasy, with its dance floor and powder room, led to the sexual integration of the all-male drinking culture. "Social life in America," Mr. Okrent writes, "was changed forever." What was America's wettest city? Mr. Okrent lists a number of contenders -- including Baltimore, Chicago, New Orleans and San Francisco -- but hands the title to Detroit, the corrupt, booming blue-collar metropolis known widely as "the city on a still." At its lawbreaking best in the 1920s, Detroit housed more than 20,000 speakeasies, about one for every 30 adults. The local Board of Commerce estimated that the illegal-alcohol business employed 50,000 people, excluding sticky-fingered police officers and politicians; it was the city's second-largest industry, behind automobile manufacturing. Geography also played a role, as Canadian bootleggers, assisted by Detroit's notorious Purple Gang, smuggled alcohol freely across the border in trucks, railroad cars and high-powered speedboats. Huge fortunes were made and multiplied, Mr. Okrent says, perhaps the biggest by Sam Bronfman, who bought Joseph E. Seagram & Sons after he had come to dominate "the large-scale, cross-border smuggling trade." As the chief Prohibition enforcement officer admitted, "You cannot keep liquor from dripping through a dotted line."

Few people know this better than [Wilbert Rideau]. Convicted of the murder of a white bank teller in 1961, Mr. Rideau, who is black, spent 44 years in prison, most of them at Angola, before being released. His painfully candid memoir, "In the Place of Justice," is indeed, as its subtitle promises, "a story of punishment and deliverance," told by a high school dropout who escaped Angola's electric chair to become an award-winning prison journalist. As such, Mr. Rideau is the rarest of American commodities -- a man who exited a penitentiary in better shape than when he arrived. Angola, though, was a living hell. Like other prisons in the Deep South, it used a trusty system in which violent, gun-toting inmates served as guards. Everyone carried a weapon for protection, usually a blade. The weakest inmates served as slaves, or "galboys," a process that began with the "turn-out," in which the new arrivals were sized up, challenged and frequently gang-raped. "Slavery was commonplace in Angola," Mr. Rideau writes, "with perhaps a quarter of the population in bondage." In 2005, the man Life magazine had featured as "The Most Rehabilitated Prisoner in America" was granted yet another trial. This time, the jury convicted Mr. Rideau of manslaughter, and the judge sentenced him to a term of 21 years. "Because I had served more than double that," he explains, "I was freed on the spot."

Because Barack Obama and his communist-Nazi-progressive gorillas don't want you to have them, that's why! In Beck's "all is possible" world, viewers learn that Obama may (or may not) have a secret "enemies list" and that his health-care bill may (or may not) extend coverage to house pets