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OBJECTIVE: Performance measurement at various levels of the health care system promotes improved processes that can result in the provision of more consistent and effective care. This chapter articulates the methodology and criteria utilized in measures development to ensure accountability and serve the information needs of physicians, health care systems, health plans and consumers, using arthritis and osteoporosis as example conditions. METHODS: Observational studies conducted to assess the validity and feasibility of performance measures focused on arthritis and osteoporosis. Clinical expert panels were convened to develop measure specifications based on guidelines and evidence supporting critical aspects of care. The aspects of care that were assessed included: DMARD utilization for patients with rheumatoid arthritis; appropriate gastrointestinal prophylaxis for patients utilizing NSAIDS; comprehensive osteoarthritis care; comprehensive symptom assessment and medical management of woman over 65 years who experienced a bone fracture. RESULTS: The implementation of performance measures for key aspects of arthritis and osteoporosis care is challenged by the availability of administrative data. However, potential for improvement is evident in each of the areas studied. CONCLUSION: The key challenge to the feasibility of arthritis performance measures is the lack of administrative data to identify the eligible population. Administrative data capture suffers as a result of under-coding and under-recognition of arthritis. Consensus around a single set of measures creates a powerful tool for focusing on key components of care as a basis for quality improvement and allows for a valid comparison of care within and across health care settings.

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OBJECTIVE: To investigate the development of frontally recorded sleep spindles from infancy to adolescence to provide normative data for pediatric sleep medicine. METHODS: Sleep spindle activity was investigated in 120 healthy subjects aged 3 months to 16 years in 12 age groups. At 2 a.m. (min 1:17 a.m., max 3:18 a.m.) 10 min of NREM 2 was checked. Spindles were visually scored in the electroencephalogram from F4/A1. RESULTS: The age dependency of interspindle interval, length of spindle, and spindle density, was statistically significant (Kruskal-Wallis p<0.0001). There were U-shaped curves for spindle length, spindle density, and an inverted U-shaped curve for the interspindle interval. Results of the post hoc U-test p<0.05 (Bonferroni corrected, m=66): Spindle length was minimal at 1.7 up to 3.0 years. Spindle density (number of spindles) was minimal between the ages of 1.7 and 2.3 years, thereafter there was a high increase that reached a plateau at age 5 years and remained up to 16 years. Interspindle interval was maximal at 1.7 and 2.3 years. CONCLUSIONS: Sleep spindle activity changes with maturation in terms of length and density. SIGNIFICANCE: The establishment of age-related normative data of sleep spindle activity can improve identification of NREM 2 in infancy, childhood, and adolescence, and enable detection of delayed neural maturation and/or sleep instability.

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The diagnostic criteria of restless legs syndrome were defined in 1995 by the International Restless Legs Syndrome Study Group (IRLSSG). In light of the latest scientific evidence and increasing clinical experience, the diagnostic criteria were revised in a consensus workshop. Participants of the workshop considered the development of new diagnostic criteria especially important for the following subgroups: (1) for children and (2) for the cognitively impaired elderly. The common characteristic of both groups lies in their difficulty in expressing subjective symptoms adequately. This considerably impedes the diagnosis of restless legs syndrome. In 2002, a proposal for diagnostic criteria of restless legs syndrome in childhood was formulated by members of the study groups "Movement Disorders and Sleep" and "Paediatrics" of the German Sleep Society. The proposal was partially incorporated into the diagnostic criteria for restless legs syndrome in childhood suggested by the IRLSSG. The current criteria are recommendations to enhance further research and must be validated by clinical studies. The following article gives an overview of published studies on restless legs syndrome in childhood, reviews the proposals for diagnostic criteria, and summarizes the peculiarities to be considered in diagnosing restless legs syndrome in children.

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OBJECTIVE: To establish whether there is a first night effect (FNE) in children and adolescents with suspected obstructive sleep apnoea undergoing polysomnography (PSG) and whether this affects sleep and breathing, furthermore, to determine the extent to which age may influence the sleep and cardiorespiratory parameters. METHODS: One hundred and thirty-one children and adolescents (age classes-A: 2-6 years n=37; B: 7-12 years n=60; C: 13-17 years n=34) underwent PSG on 2 consecutive nights (I and II) under identical conditions for suspected sleep-related respiratory disorders. One hundred and five patients including 3 patients with obstructive sleep apnoea syndrome (OSAS) treated by adenotonsillectomy and 18 OSAS patients receiving nCPAP-therapy had no PSG-abnormalities (Group 1-A: n=28; B: n=53; C: n=24). A further 26 patients (Group 2) had clinically and polysomnographically confirmed untreated OSAS (A: n=9; B: n=12; C: n=5). RESULTS: There were no statistically significant differences between children with no PSG-abnormalities (Group 1) and those with OSAS (Group 2) in terms of sleep parameters (arousal indices excluded), oxygen saturation (SaO(2)) and heart rate (HR), and these parameters have, therefore, been pooled for the entire group (n=131) in the 3 age classes A, B and C. In the second and third age classes, sleep efficiency on the first night was reduced. In all age classes, there was significantly more wakefulness during the first night. In the second and third age ranges, the proportion of NREM 1 in the first night was significantly higher, with a correspondingly reduced proportion of NREM 4 in the third age group. In all age classes, REM sleep was significantly less during the first night, but REM latency was comparable on both nights. On the first night, the mean HR was higher. There were significant differences in apnoea/hypopnoea-index (AHI), electroencephalogram (EEG)-arousal-index (AI) and motoric arousal index (jerk index, JI) between Groups 1 and 2. In neither group, were there any significant differences in AHI, mean SaO(2) or number of EEG-arousals between nights 1 and 2. Only in the age class A, in Group 2 (n=9) was the number of motoric arousals significantly higher on the first night. Comparison of the age classes A, B, and C revealed that most polysomnographic parameters were age-dependent. Increasing age was found to correlate with a higher proportion of NREM 1, especially on the first night. Also, there was an age-dependent increase in NREM 2 on both nights, a decrease in NREM 3 on the first night, and a decrease in NREM 4 on both nights. In older children, we also found a lower proportion of REM sleep on the first night and a lower HR on both nights. In Group 1, we found a lowered AHI, AI and JI (for JI significant only on the first night) in older patients. No such age dependence of AHI, AI and JI was seen in OSAS patients (Group 2). CONCLUSIONS: In children and adolescents, there is an FNE comparable with that described in adults. In OSAS children and also in children with no PSG-abnormalities, there is night-to-night-variability in sleep parameters, but not in respiratory parameters. An adaptation night is, therefore, necessary when sleep architecture is to be studied, but not when only the nocturnal respiratory pattern is investigated. Sleep parameters, HR and arousal indices are all age-dependent.

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In recent years cultural competence has expanded beyond language provisions to include understanding and factoring into services provision the cultural perspectives clients may have that are different from the majority culture. The federal government requires state Medicaid programs to offer culturally competent services, but little is known about how states implement such mandates and monitor and enforce them. We reviewed the origins and implications of cultural competence mandates and conducted a brief case study of 5 states to learn about the implementation of cultural competence provisions in behavioral managed care contracts. We found that states and managed behavioral health organizations (MBHOs) vary in their definitions and implementation of standards to ensure mental health care access for vulnerable populations. Although states had a variety of oversight mechanisms, varying contractual requirements ranging from optional to required, vague contract language, no existing standardized indicators or definitions, and scant data on the cultural characteristics of the populations enrolled in Medicaid managed care hamper monitoring and enforcement of cultural competence by states. Implications for MBHOs, states, and the federal government, as well as services researchers, follow.

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Health issues unique to women and differences in healthcare experiences have recently gained attention as health plans and systems seek to extend and improve health promotion and disease prevention in the population. Successful efforts focused on enhancing quality of care will require information from the patient's perspective on how to improve such services to best support women's attempts to lead healthy and productive lives. The National Centers of Excellence in Women's Health program (CoE), sponsored by the Office on Women's Health within the Department of Health and Human Services, is based on an integrated model uniting research, training, healthcare, and community education and outreach. To examine women's concept and definitions of healthcare quality, 18 focus groups comprising 137 women were conducted nationwide on experiences and attributes of healthcare that women value in primary care. Following the focus groups, a woman-focused healthcare satisfaction instrument was developed for the purpose of assessing and improving healthcare delivery. We describe the qualitative results of the focus group study.

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OBJECTIVE: Observations of children with obstructive sleep apnea syndrome (OSAS) show a restless sleep. But there is no significant disturbance of sleep macrostructure as in adult OSAS patients. It will be proved, whether the analysis of arousals permits a comprehensive characterization of this respiratory related sleep disturbance. Considering the problems in EEG-arousals detection in dependence of age and maturation we will compare the results of analysis of EEG- and movement arousals to find out a more practicable way for arousal analysis in childhood. METHODS: Twenty OSAS pediatric patients (aged 3.1-14.3 years, median 7.5 years) and 20 age matched children with no OSAS (aged 3.3-13.9 years, median 7.9 years) were examined polysomnographically. Clinically confirmed OSAS patients with an apnea/hypopnea index (AHI) > or = 5/h TST (total sleep time) were examined during 1 whole night before treatment (diagnostic night - baseline) and after/under receiving therapy. Various polygraphic parameters to describe the macrostructure of sleep (sleep efficiency, NREM 1-4, REM) and the microstructure of sleep (EEG- and movement arousals) were analyzed. Furthermore the AHI, heart rate and oxygen saturation were evaluated. RESULTS: Patients with clinically and polysomnographically confirmed OSAS had significantly more EEG (median 21.0/interquartile range 9.31 /h TST) and movement arousals (20.4/13.1 /h TST) before therapy than after/under therapy (EEG: 9.9/6.3 /h TST; movement: 9.2/3.8/h TST). The frequency of arousals was comparable in OSAS children after/under treatment and controls (EEG: 9.0/4.2/h TST; movement 9.3/3.4/h TST). In the 3 groups there was no significant correlation between AHI and number of EEG-arousals and movement arousals. AHI was significantly higher in OSAS children in comparison to controls and treated OSAS. In contrast to adults, sleep efficiency and macrostructure of sleep were not different in controls and OSAS children with or without treatment. Also, oxygen saturation and heart rate, had the same values in controls, OSAS children and OSAS children after/under treatment. CONCLUSIONS: OSAS in children is characterized by a restless sleep, i.e. by an enhanced number of movement and EEG-arousals. The microstructure of sleep but not the macrostructure is changed. There is a high coincidence between EEG arousals and movement arousals. The evaluation of arousals especially the analysis of movement arousals is helpful to estimate treatment effect in OSAS patients.

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The methylxanthine derivates are known to have respiratory stimulant properties. Therefore theophylline is used in sleep related disturbances of breathing. Theophylline reduces central apneas and periodic breathing in infants. The efficiency of theophyllin is confirmed in reducing central apneas in patients with neurologic diseases or Cheyne Stokes breathing in patients with congestive heart failure. In patients with obstructive sleep apnoea the effect of theophylline is doubtful. An effect of therapy exists in some mild forms of sleep apnoea (apnoea index < 20/h total sleep time). Further studies are necessary to investigate the precise mechanism of of theophylline in obstructive sleep apnoea.

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OBJECTIVE: To examine differences by physician gender in the identification and treatment of childhood psychosocial problems. DESIGN: Survey of patients (n = 19,963) and physicians (n = 366) in primary care offices in 2 large, practice-based research networks. Multivariate regressions were used to control for patient, physician, and visit characteristics, with a correction for the clustered sample. SUBJECTS: Children ages 4 to 15 years seen consecutively for nonemergent care. MEASURES: Physician report of attitudes, training, practice factors, and identification and treatment of psychosocial problems. Parental report of demographics and behavioral symptoms. RESULTS: Compared with male physicians, female physicians were less likely to view care for psychosocial problems as burdensome. They were more likely to see children who were female, younger, black or Hispanic, in single-parent households, enrolled in public or managed health plans, and with physical health limitations. Children seen by male physicians had higher symptom counts. Male physicians were more likely to report having primary care responsibility for their patient and that parents agree with their care plan. Female physicians spent more time with patients. After controlling for these differences, female physicians did not differ from male physicians in identification or treatment of childhood psychosocial problems. CONCLUSIONS: Male and female physicians see different kinds of children for different visit purposes and have different kinds of relationships with their patients. After controlling for these factors, management of childhood psychosocial problems does not differ by physician gender. Improving management of psychosocial conditions depends on identifying modifiable factors that affect diagnosis and treatment; our work suggests that characteristics of the practice environment, physician-patient relationship, and patient self-selection deserve more research.

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PURPOSE: To determine the proportion of primary care physicians who screen sexually active teenage women for chlamydia and to determine demographic factors, practice characteristics, and attitudes associated with chlamydia screening. METHODS: We obtained a random sample of 1600 Pennsylvania physicians from the American Medical Association masterfile, stratified to include at least 40% women and equal numbers of family physicians, internists, obstetricians/gynecologists, and pediatricians. In January 1998, physicians received mailed questionnaires; nonrespondents received two follow-up mailings. Physician characteristics associated with chlamydia screening were determined using bivariate and logistic regression analyses. RESULTS: Only one-third of physicians responded that they would screen asymptomatic, sexually active teenage women for chlamydia during a routine gynecologic examination. In multivariate analysis, physicians were significantly (p <.05) more likely to screen if they were female (43% vs. 24%), worked in a clinic versus solo practice (60% vs. 18%), worked in a metropolitan location (46% vs. 26%), or had a patient population > or = 20% African-American (54% vs. 25%). Attitudes associated with screening included the belief that most 18-year-old women in their practice were sexually active (36% vs. 12%), feeling responsible for providing information about the prevention of sexually transmitted diseases to their patients (42% vs. 21%), or knowing that screening for chlamydia prevents pelvic inflammatory disease (37% vs. 13%). Physicians were less likely to screen if they believed that the prevalence of chlamydia was low (10% vs. 41%). CONCLUSIONS: A majority of physicians do not adhere to recommended chlamydia screening practices for teenage women. Interventions to improve chlamydia screening might target physicians who are male, in private practice, or who practice in rural areas, and should focus on increasing awareness of the prevalence of chlamydia and benefits of screening.

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BACKGROUND: Conducting research on low-prevalence conditions presents an ongoing challenge for clinical and services researchers. Recruitment through health professionals versus other forms of self-referral may affect study group composition. METHODS: We compared members of a voluntary case registry for bipolar disorder who were recruited through a variety of sources including health professionals, support groups, an Internet website, and mailings, brochures, and other general public relations activities. We also compared the cost of recruitment methods. We hypothesized that self-referred registry members would be of higher socioeconomic status and less likely to be in treatment compared to members recruited through health professionals. RESULTS: Registrants referred through the Internet and patient support groups were better educated and more likely to be married than other registrants. However, Internet registrants were younger, had fewer lifetime hospitalizations and were more likely to be working. Nearly all registrants were in treatment with a psychiatrist. Local registrants were predominantly recruited through health professionals and public presentations. Registrants outside of the local region most often learned about the registry from patient support groups and the Internet. Local registrants were less likely to be using non-lithium mood stabilizers. Recruitment through public relations efforts was the most expensive method of recruitment, and the Internet website was the cheapest. CONCLUSIONS: Diverse recruitment methods can expand the population available for clinical trials. For services research, the Internet and patient support groups are less expensive ways to identify persons served in diverse settings and health plans, but these recruitment methods yield a sample that is better educated than the remainder of the population. It remains a difficult task to identify minorities and persons not in treatment.

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This study was performed to determine if adding a health advocate (HA) to the care team for postmenopausal women increased the number of women for whom the physician recommended screening tests or prevention strategies: cholesterol level, mammography, depression counseling, smoking cessation, or weight reduction. The study took place in two locations of a private obstetrician-gynecologist practice. In one location, an HA reviewed screening forms and counseled women about preventive services recommended by the physician. In the second location, women completed the screening form, but treatment occurred as usual. Women were eligible if they were postmenopausal or age 50 or over and were being seen for preventive care. A total of 210 postmenopausal women were screened. Women who were screened when the HA was present (n = 85) did not differ from women screened at the intervention location when the HA was not present (n = 68) or screened at a second practice location (n = 57) in the prevalence of risk factors. Women were significantly more likely to receive indicated preventive recommendations when the HA was present (24% versus 73%, p < 0.001). For breast cancer screening, nearly all women screened when the HA was present received a referral compared to about one third of women screened when the HA was not present (OR = 3.0, 95% CI 1.8-5.2). Women are more likely to receive recommendations based on screening data when ancillary staff are available to assist in patient education and referral and to encourage physician recommendations. Further work is needed to identify cost-effective methods for supporting physicians' preventive care efforts.

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This paper describes efforts by the National Centers of Excellence in Women's Health to develop a woman-specific primary care satisfaction instrument suitable for quality improvement and research.

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The rapid growth of managed care, and especially that of managed behavioral healthcare organizations (MBHOs), is likely to diminish the role of developmental-behavioral pediatrics and separate care for medical and behavioral problems. Thus, a rethinking of the practice of developmental-behavioral pediatrics is required. This study reviews the structure of MBHOs, identifies barriers to the provision of services by developmental-behavioral pediatricians, describes alternative practice models for consideration, and makes recommendations. The aims of the recommendations are to stimulate an active discussion about these issues, spark an advocacy effort, and ensure the continued participation of developmental-behavioral pediatricians in the care of children with special needs. The study concludes that managed care will push developmental-behavioral pediatricians into integration with primary care group practices or into specialty mental health networks. Immediate discussion, action, and advocacy will be required to ensure a presence in these decisions for developmental-behavioral pediatricians.

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OBJECTIVE: To provide estimates of physical abuse and use of health services among depressed women in order to inform efforts to increase detection and treatment of physical abuse. DESIGN: Retrospective assessment of abuse and health services use over 1 year in a cohort of depressed women. SETTING: Statewide community sample from Arkansas. PARTICIPANTS: We recruited 303 depressed women through random-digit-dial screening. MEASUREMENTS AND MAIN RESULTS: Exposure to physical abuse based on the Conflict Tactics Scale, multi-informant estimate of health and mental health services. Over half of the depressed women (55.2%) reported experiencing physical abuse as adults, with 14.5% reporting abuse during the study year. Women abused as adults had significantly more severe depressive symptoms, more psychiatric comorbidity, and more physical illnesses than nonabused women. After controlling for sociodemographic and severity-of-illness factors, recently abused, depressed women were much less likely to receive outpatient care for mental health problems as compared to other depressed women (odds ratio [OR] 0.3; p = .013), though they were more likely to receive health care for physical problems (OR 5.7, p = .021). CONCLUSIONS: Because nearly all depressed women experiencing abuse sought general medical rather than mental health care during the year of the study, primary care screening for physical abuse appears to be a critical link to professional help for abused, depressed women. Research is needed to inform primary care guidelines about methods for detecting abuse in depressed women.

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This study compares the documentation of ambulatory care visits and diagnoses in Medicaid paid claims and in medical records. Data were obtained from Maryland Medicaid's 1988 paid claims files for 2407 individuals who were continuously enrolled for the fiscal year, had at least one billed visit for one of six indicator conditions, and had received the majority of their care from one provider. The patients sampled were also stratified on the basis of the case-mix adjusted cost of their usual source of care. The medical records for these individuals as maintained by their usual source of care were abstracted by trained nurse reviewers to compare claims and record information. Linked claim and medical record data for sampled patients were used to calculate: (i) the percent of billed visits documented in the record, (ii) the percent of medical record visits where both the date and the diagnosis agreed with the claims data, and (iii) the ratio of medical record visits to visits from billed claims. Included in the analysis were independent variables specifying place of residence, type and costliness of usual care source, level of patient utilization, and indicator condition on which patient was sampled. Ninety percent of the visits chronicled in the paid claims were documented in the medical record with 82% agreeing on both date and diagnosis. Compared to the medical records kept by private physicians and community health centers, a significantly lower percent of hospital medical records agreed with the claims data. Total volume of visits was 2.6% higher in the medical records than in the claims. Claims data substantially understated visits in the medical record by 25% for low cost providers and by 41% for patients with low use rates (based on claims information). Conversely, medical records substantially understated billed visits by 19% for rural patients and by 10% for persons with high visit rates. Although Medicaid claims are relatively accurate and useful for examining average ambulatory use patterns, they are subject to significant biases when comparing subgroups of providers classified by case-mix adjusted cost and patients classified by utilization rates. Medicaid programs are using claims data for profiling and performance assessment need to understand the limitations of administrative data.

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The most common cause of obstructive apnoeas in children is adenotonsillar hyperplasia. Possibilities of therapy are surgical intervention (adeniodectomy, tonsillectomy) or nasal CPAP. The decision on the most appropriate therapy must be individual. 26 children aged 2-5 years were investigated polysomnographically before therapy, after operation or with nCPAP-therapy. Polygraphy is a helpful aid in making up one's mind in favour of one of the possibilities of therapy, but also for controlling the therapeutic effect.

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