This report advocates conceptual separation and parallel assessment of medically diagnosed health conditions and functional disability in clinical and epidemiological studies of the aged. Data from a study of urban elderly are presented to demonstrate how this can be done and to reexamine the meaning of self-reported illness and disability. One hundred thirteen subjects 74 to 95 years old, recruited from a longitudinal study of a representative sample of the elderly population of Cleveland, Ohio, participated in structured interviews and epidemiologically based medical examinations, conducted by a physician-nurse team at the place of residence. The presence or absence of 11 common chronic conditions was determined according to preestablished criteria, by self-report and, separately, by medical diagnostic evaluation. Functional disability was estimated by self-report and by physician-nurse assessment, using established measures of mobility and activities of daily living. Results indicate that interview self-report can provide useful estimates of the prevalence of medical conditions and functional disabilities in elderly populations, although self-report alone is not a sufficiently sensitive measure to be used for case-finding or diagnosis. When functional disabilities are matched against the specific medical conditions that cause them and disease-specific mortality is also taken into account, a three-dimensional classification results that has implications for future clinical and survey work with the elderly.

A moment analysis of multibreath nitrogen washout has been developed to provide a sensitive, quantitative measure that characterizes the inhomogeneity of pulmonary ventilation. To test the analysis scheme, we studied 5 normal subjects and 16 subjects with obstructive lung disease who performed each washout test at constant tidal volume and frequency. Subjects executed the wahout test 3-4 times at different tidal volumes (0.5-1.5 liters) and frequencies (10-30/min). Plotting washout data as dimensionless end-tidal nitrogen concentration versus the cumulative expired volume normalized by the functional residual capacity (CEV/FRC) renders the washout curves of each individual almost superposab le despite changes in breathing frequency and tidal volume from test to test. The dimensionless washout curve is treated as a distribution from which the normalized first (M1/Mo) and second (M2/Mo) moments are obtained. These parameters clearly display diagnostic clustering for various disease states. With respect to the normal subjects, the magnitude of M1/Mo was 26% greater for asthmatics, 38% greater for bronchitics, and 52% greater for emphysematics. This moment analysis provides an objective, quantitative assessment of the extent of ventilation inhomogeneities without specification of a lung model.

Cigna's Collaborative Accountable Care initiative provides financial incentives to physician groups and integrated delivery systems to improve the quality and efficiency of care for patients in commercial open-access benefit plans. Registered nurses who serve as care coordinators employed by participating practices are a central feature of the initiative. They use patient-specific reports and practice performance reports provided by Cigna to improve care coordination, identify and close care gaps, and address other opportunities for quality improvement. We report interim quality and cost results for three geographically and structurally diverse provider practices in Arizona, New Hampshire, and Texas. Although not statistically significant, these early results revealed favorable trends in total medical costs and quality of care, suggesting that a shared-savings accountable care model and collaborative support from the payer can enable practices to take meaningful steps toward full accountability for care quality and efficiency.

We investigated the effect of airway closure and alveolar collapse on the large-volume deflation and inflation transpulmonary pressure-volume (Ptp-V) curves of five postmortem excised human lungs. For stepwise static cycles, no inflection occurred on the deflation curve, while either one or two inflections occurred on the inflation curve. These relations were stimulated by a multicompartment model, which assumed a bimodal distribution of compartmental collapse-pressure differences. The simulations indicate that alveolar collapse can occur without causing an inflection on the deflation curve and that hysteresis in reopening of collapsed alveoli on inflation can account for a major portion of Ptp-V hysteresis. In contrast, for slow dynamic cycles, an inflection occurred on the experimental deflation Ptp-V curve, and when inflations were begun at sufficiently low volumes, volume did not change until a threshold pressure difference was reached about which PtP began to oscillate as lung volume increased. These differences in the stepwise static and dynamic Ptp-V curves can result from sustained airway closure on deflation and popping-opening on inflation.