The National Quality Forum (NQF, Washington) late last year issued a report on what it considers to be the major priorities for improving healthcare in the U.S. in 2005. The NQF focused on the need to reduce disparities in health and healthcare among "vulnerable populations" and added to this two infrastructure priorities: greater emphasis on healthcare information technology and patient safety. The report says, "Given the national crisis in disparities of care that many inner city and rural areas continue to be medically underserved, and that up to 90 million Americans are estimated to be 'health illiterate' it was determined that focusing efforts in this area would lead to healthcare quality improvement across domains." Titled "National Priorities for Healthcare Quality Measurement and Reporting," the new report is based on improvement recommendations in a 2003 Institute of Medicine (IOM; Washington) report that focused on 20 clinical conditions and healthcare needs.

"As American quality improvement work moves forward, it is clear that we must focus on specific areas; we cannot do everything at once," said Kenneth Kizer, MD, president of NQF. "This report builds on the important work done by the IOM and has the benefit of input from all healthcare stakeholders, including consumers, purchasers, providers and researchers." In addition to vulnerable populations, information and patient safety, the report also addresses processes of care (including care coordination and communication), end-of-life care, immunizations and pain management. More than 16 healthcare conditions, such as asthma, cancer, heart disease, kidney disease, stroke and mental illness also were identified.

Established in 1999 to develop and implement a national strategy for healthcare quality measurement and reporting, NQF is a coalition of more than 250 consumer, healthcare provider, payer and research organizations, including the American Medical Association (Chicago), American Hospital Association (Chicago), AARP (Washington), General Motors (Detroit), the March of Dimes (White Plains, New York), Kaiser Permanente (Oakland, California), American Nurses Association (Silver Spring, Maryland) and the Leapfrog Group (Washington), as well as many federal agencies. More information on the study can be found at www.qualityforum.org.

More Americans moving fast to dialysis

Millions in the U.S. are on the verge of needing dialysis or a kidney transplant and may not even know it, according to study findings released recently by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health (NIH; both Bethesda, Maryland). The NIDDK study estimates 10 million to 20 million Americans with kidney disease but unaware of the fact. Over the past decade the number of people with kidney failure has doubled and the number starting dialysis or having a first kidney transplant increased by 50%, according to the NIH. That means more than 400,000 Americans are now being treated for kidney failure at a cost of $25 billion annually, the agency estimates. People with chronic kidney disease are at high risk for premature death, heart attacks and strokes, as well as hypertension, anemia, bone disease and malnutrition.

The study found that the number of people with earlier stages of kidney disease remained stable. About 7.4 million people have less than half the kidney function of a healthy young adult. Another 11.3 million have at least half of what's considered normal function, but they also have persistent protein in their urine, a sign of kidney disease. Researchers said they can't explain the contradiction between stable prevalence of kidney disease and rising incidence of kidney failure, but they suggest that fewer patients may be dying and more may be progressing faster to dialysis. "Given the high prevalence of chronic kidney disease, we need to increase awareness, diagnosis and treatment if we are going to reduce the rate of progression and complications. Most critical are control of diabetes and hypertension," said Josef Coresh, MD, lead author of the study and professor of epidemiology, medicine and biostatistics at the Bloomberg School of Public Health at Johns Hopkins University (Baltimore).

Coresh and his colleagues estimated awareness of chronic kidney disease among 4,101 people in the U.S. from 1999 to 2000 and compared disease prevalence in those years with that from 1988 to 1994, when 15,488 people were surveyed. Researchers said that less than 10% of adults with moderately decreased kidney function (one-half to one-quarter the filtering capacity of a young healthy adult) reported being told they had weakened or failing kidneys. Awareness was low in all but the most severe stages of kidney disease. Women with moderately decreased kidney function were significantly less aware of their illness when compared to similarly affected men, the study said. The researchers determined actual kidney function from blood and urine tests and estimated glomerular filtration rate (GFR), which is a measure of how well the kidneys are filtering waste from the blood.

Study authors estimated that a lack of awareness may be due in part to physicians' sole reliance on the blood level of a substance known as creatinine. Because muscle mass and other person-to-person variables can alter creatinine levels, a "normal" reading can provide a false sense of security. Instead, creatinine should be considered along with a patient's age, gender, and race to estimate GFR. "Kidney disease can be well-advanced before it's found with creatinine alone. GFR is a more accurate gauge of how well the kidneys work, and our free calculator makes finding the rate a snap," said Thomas Hostetter, MD, senior author of the study and director of NIDDK's National Kidney Disease Education Program. "The earlier we identify kidney disease the sooner we can treat it."

Earlier HIV treatment possible

A study of HIV-positive and HIV-negative people funded by the National Institute of Allergy and Infectious Diseases (NIAID; Bethesda, Maryland), part of the National Institutes of Health, has found that people with more copies of a certain gene that helps to fight HIV are less likely to become infected with the virus or to develop AIDS than those of the same geographical ancestry, such as European-Americans, who have fewer copies of the gene.

Those findings could lead scientists to a screening test to determine the number of copies a person has in order to determine if earlier treatment might be necessary in some patients infected with HIV.

"There are a couple of potential uses for at least this line of research, and one is that it would allow you to make a more accurate prognosis about clinical outcomes in people with HIV infection," Matthew Dolan, MD, of the U.S. Air Force's Wilford Hall Medical Center and Brooks City-Base (San Antonio), told The BBI Newsletter. Dolan said, "It would let you, just like a viral load measurement does, be able to say at a certain point, what the rate at which somebody might reach clinical endpoints is. It might let you down the road, for example, be able to tailor therapy better."

Currently, there is a "one size fits all" approach to HIV treatment, he said. Unfortunately, "immune responses have great variation." Such a test might indicate who could begin therapy earlier, and those patients who could wait until later. Based on the study, those with fewer copies of the gene would possibly need therapy sooner, because they may be more likely not only to contract the HIV infection, but also more likely to have a worse prognosis. In addition to the screening test for individuals, Dolan and his fellow researchers are interested in determining if "there is a role for evaluating HIV vaccines with this test."

Dolan, along with co-senior author Sunil Ahuja, MD, of the University of Texas Health Science Center and the Veterans Administration Center for AIDS and HIV-1 Infection (also San Antonio), focused on the gene that encodes CCL3L1, which the NIH called a "potent HIV-blocking protein that interacts with CCR5." CCR5 is a major receptor protein that "HIV uses as a doorway to enter and infect cells," it said.

It was Ahuja's years of study in the area of chemokines and chemokine receptors that led the researchers to focus on CCL3L1, Dolan said. Ahuja had been successful in adapting an assay developed by someone else to a point where he was able to "correctly measure the number of copies of this gene on a single chromosome," he said. "With that technical advance, then we were able to match that up with the genetic epidemiology and really study the impact in a cohort," Dolan told BBI. "And there we see that there is prognostic information both in time-to-disease progression in people who are infected, but also in the ability to become infected in the first place."

That, in a nutshell, is the "new and novel" aspect of their findings. "There's been a lot that's been written about duplication of genes in human disease, but as far as I know, this is the first one that deals with susceptibility to an infectious disease," Dolan said.

The researchers analzyed blood samples from more than 4,300 HIV-positive and -negative people of different ancestral origins to determine the average number of CCL3L1 gene copies in each group. The study included a cohort of HIV-infected individuals in the Air Force that have been followed since the mid-1980s. For example, they found that HIV-negative African-American adults had an average of four CCL3L1 copies, while HIV-negative Europeanand Hispanic-American adults averaged two to three copies, respectively.

Low back pain an indicator

A patient's status on a clinical prediction rule for low back pain indicates the likelihood of successful outcome from spinal manipulation treatment, according to a recent study in the Annals of Internal Medicine. Physical therapist Major John Childs, PhD, of Wilford Hall Medical Center at Lackland Air Force Base, Texas, and other physical therapist researchers validated a clinical prediction rule that determined the likelihood that a patient with low back pain will benefit from spinal manipulation. Factors in the prediction rule include symptom duration, symptom location, fear-avoidance beliefs, lumbar mobility and hip rotation range of motion. The best results were from those patients who were positive on the rule, defined as meeting at least four of the five criteria.

"Attempts to identify effective interventions for individuals with low back pain have been largely unsuccessful, especially where spinal manipulation is concerned," Childs said. "Conflicting conclusions may be attributable to the failure of researchers to adequately consider the importance of classification. Developing methods for matching patients with low back pain to treatments that are most likely to benefit them is an important research priority."

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