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In Reply —Dr Cooper's retrospective, observational study is consistent with several reports in the literature that former users of psychotropic drugs with sedative or autonomic effects have lower rates of falls and fractures than do current users. 1 We concur with Drs Bernabei and Carbonin that, because the study unit of randomization was the facility, imbalance between treatment and control facilities with regard to factors that influence risk of falls and injuries was of concern. For this reason, we collected information on falls in the 365 days preceding the study, which provides an integrated measure of how patient characteristics and facility factors that influence risk of falls differed between the study groups. If intervention facilities had more staff, safer environments, or other factors that prevented falls, study residents in these facilities should have had fewer falls in the previous year. As shown in Table 1 of our article, this did not occur.

In Reply —Choice of antihypertensive drug therapy may be linked to unmeasured patient attributes or prescriber behavior that could be associated with risk of hypoglycemia. For example, if prescribers were more cautious in avoiding hypoglycemia in persons using β-blockers, as Drs Suissa and Garbe describe, then our findings would underestimate the risk of hypoglycemia associated with exposure to β-blockade. We attempted to estimate degree of glycemic control in our population using 2 variables: use of capillary fingerstick equipment and the level of glycosylated hemoglobin reported in the medical records of the cases. Less than 2% of the study population submitted a claim for capillary fingerstick equipment, and glycosylated hemoglobin was virtually never found in medical records.1,2Even in this large study, the number of events associated with some of the drug-drug combinations was small, which resulted in wide CIs, as described by Dr Gambassi and colleagues. Because of the small numbers

Context. —Falls are a major health problem in nursing homes, but no interventions have been shown to prevent falls in nursing home residents. Objective. —To evaluate an intervention program designed to prevent falls and associated injuries in high-risk nursing home residents. Design. —Randomized controlled trial. Setting and Participatnts. —Seven pairs of middle Tennessee nursing homes with 1 facility in each pair randomly assigned to the intervention. Facilities had 482 (261 control, 221 intervention) residents who qualified for the study because they had high risk of falls and a potential safety problem that could be addressed by the intervention. Intervention. —Comprehensive structured individual assessment with specific safety recommendations that targeted suboptimal practices for environmental and personal safety, wheelchair use, psychotropic drug use, and transferring and ambulation. Facility staff were encouraged to implement the individual recommendations and to improve overall facility safety. Main Outcome Measures. —The mean proportion of recurrent fallers and incidence rate of injurious falls in the facility in the year following the intervention. Results. —The mean proportion of recurrent fallers in intervention facilities (43.8%) was 19.1% (95% confidence interval, 2.4%-35.8%) lower than that in control facilities (54.1%, P =.03). Intervention facilities had a nonsignificant trend toward a lower mean rate of injurious falls (13.7 vs 19.9 per 100 person-years, reduction of 31.2%, P =.22). Subgroup analyses suggested greatest benefits for residents for whom the recommended interventions were carried out or who had 3 or more falls in the preceding year. Conclusion. —The high rate of falls and related injuries in nursing homes should not be viewed as inevitable, but as outcomes that can be substantially improved through structured safety programs.

Context. —β-Blockers and angiotensin-converting enzyme (ACE) inhibitors are effective antihypertensive agents for patients with diabetes mellitus. However, β-blockers attenuate some components of the autonomic response to hypoglycemia and could increase the risk of hypoglycemia. ACE inhibitors may increase insulin sensitivity and predispose users to hypoglycemia. Objective. —To determine whether use of cardioselective β-blockers, nonselective β-blockers, ACE inhibitors, thiazide diuretics, calcium channel blockers, or other antihypertensive drugs alters the risk of developing serious hypoglycemia among older persons prescribed insulin or sulfonylureas. Design. —Retrospective cohort study. Setting. —Tennessee Medicaid Program. Patients. —A total of 13 559 elderly (mean age, 78±7 years) Medicaid enrollees, who were prescribed insulin (n=5171, 38%) or sulfonylureas (n=8368, 62%) from 1985 through 1989. These enrollees contributed a total of 33107 person-years of insulin or sulfonylurea use for follow-up. Measurements. —Hospitalization, emergency department admission, or death associated with hypoglycemic symptoms and a concomitant blood glucose determination of less than 2.8 mmol/L (50 mg/dL). Results. —We identified 598 persons with an episode of serious hypoglycemia during the study period. The rate of serious hypoglycemia was 2.01 per 100 person-years among those who were not prescribed antihypertensives. Crude rates of serious hypoglycemia were highest among users of ACE inhibitors (2.47 per 100 person-years) and lowest among users of cardioselective β-blockers (1.23 per 100 person-years). However, when we controlled for demographic characteristics and markers of comorbidity, there was no statistically significant increase or decrease in risk of serious hypoglycemia among users of any class of antihypertensive agents compared with nonusers of antihypertensive drugs. Using nonselective β-blockers as the reference group, each of these agents was associated with a lower, but not statistically significant, risk of hypoglycemia. Conclusions. —In this population, specific antihypertensive drug therapy had little impact on the risk of hypoglycemia in older diabetic patients. Therapy should be chosen based on other considerations of safety and effectiveness.

In Reply. —The primary objective of our study was to determine whether OBRA-87 influenced antipsychotic and other psychotropic drug use in nursing homes. The relationship between staffing and other home variables on the degree of antipsychotic reduction in individual nursing homes is interesting and plausible, but requires verification by others before definitive conclusions can be drawn. We agree with Dr Venable that resident (and staff) outcomes would best determine the appropriateness of the reductions in antipsychotic drug use during implementation of OBRA-87. Unfortunately, Health Care Financing Administration regulations did not include provisions for concurrently evaluating the antipsychotic drug use guidelines (or other aspects) of OBRA-87. However, several lines of evidence suggest that decreases in antipsychotic drug use were not associated with adverse behavioral outcomes. First, OBRA-87 explicitly allows the use of antipsychotic drugs for treatment of behavioral disturbances that interfere with the provision of care. Thus, one would not observe

The National Institutes of Health Consensus Development Conference onHelicobacter pyloriin Peptic Ulcer Disease brought together specialists in gastroenterology, surgery, infectious diseases, epidemiology, and pathology, as well as the public to address the following questions: (1) What is the causal relationship ofH pylorito upper gastrointestinal disease? (2) How does one diagnose and eradicateH pyloriinfection? (3) Does eradication ofH pyloriinfection benefit the patient with peptic ulcer disease? (4) What is the relationship betweenH pyloriinfection and gastric malignancy? (5) WhichH pylori—infected patients should be treated? (6) What are the most important questions that must be addressed by future research inH pyloriinfections? Following 1½ days of presentations by experts and discussion by the audience, a consensus panel weighed the evidence and prepared their consensus statement. Among their findings, the consensus panel concluded that (1) ulcer patients withH pyloriinfection require treatment with antimicrobial agents in addition to antisecretory drugs whether on first presentation with the illness or on recurrence; (2) the value of treating of nonulcerative dyspepsia patients withH pyloriinfection remains to be determined; and (3) the interesting relationship betweenH pyloriinfection and gastric cancers requires further exploration. (JAMA. 1994;272:65-69)

Objectives. —To describe the changes in antipsychotic drug use in nursing homes during the period surrounding the implementation of federal legislation designed to reduce unnecessary use (the Omnibus Budget Reconciliation Act of 1987 [OBRA-87]) and to identify nursing home characteristics associated with such changes. Design. —Longitudinal study of 9432 Tennessee Medicaid enrollees 65 years of age or older who continuously resided in Tennessee from April 1, 1989, to September 30,1991, a 30-month period surrounding implementation of OBRA-87. Main Outcome Measures. —Changes in the use of antipsychotic and other psychotropic drugs. Results. —During the 30-month period, antipsychotic drug use decreased from 23.9 to 17.5 days per 100 days of residence, a 26.7% decline ( P P P P =.001) and third-shift staffing levels ( P =.003). Nursing homes with baseline antipsychotic drug use and third-shift staffing above the median reduced antipsychotic drug use by 41%, compared with a 2% increase in nursing homes where both of these factors were below the median ( P Conclusions. —A substantial decrease in antipsychotic drug use coincided with the implementation of OBRA-87. Although this decrease is consistent with an improvement in quality of nursing home care, further research is needed to determine the effects of this legislation on resident outcomes. ( JAMA . 1994;271:358-362)

In Reply.— We agree that our data do not prove DTP immunization never causes encephalopathy; our study of 38 171 children with 107154 immunizations did not have sufficient power to detect rare events. However, the consistency of our findings with those of two other recent controlled studies of this question1,2led us to comment that if there are encephalopathies caused by DTP immunization, they must be rare. We disagree with the presumption of Tilelli and Manniello that it is established that DTP immunization can cause encephalopathies. Uncontrolled case reports and observations by individual pediatricians do not constitute a scientific basis for establishing causality. The information cited from the 1986 "Redbook"3is based on the British National Childhood Encephalopathy Study; recent reanalysis of these data4have cast doubt on the original finding of an association between DTP immunization and permanent neurological damage. Thus, the extant data are

To investigate the effects of a 1985 Tennessee Medicaid regulatory change that expanded eligibility coverage specifically for married women during pregnancy, we studied vital statistics files linked to Medicaid enrollment files. The greatest Medicaid coverage increase in terms of an absolute difference in rates and the number of women covered occurred in white married women younger than 25 years with less than 12 years of education, where enrollment increased 18% However, in that group of mothers, as well as for the total of all mothers studied, there were no concomitant improvements in use of early prenatal care, birth weight, or neonatal mortality. Analysis of the timing of enrollment relative to the beginning of pregnancy showed that more than two thirds of the women who enrolled did so after the first trimester. (JAMA. 1990;264:2219-2223)

In Reply. — Mr Jacobs and Ms Das raise six questions concerning our study. (1) Is the point prevalence of current long-half-life benzodiazepine use in the case subjects different from that of the entire elderly population in Saskatchewan? (2) Does a direct comparison between long- and short—half-life benzodiazepine users show a difference in hip fracture risk? (3) Does use of diazepam for convulsions result in confounding? (4) Should other fall-related injuries have been included as outcomes? (5) Do nonsignificant differences in confounder prevalence for sampled cases that would have been significant in a larger sample indicate inadequate confounder control? (6) Can we rule out any spurious association, particularly with regard to mental impairment? One of the strengths of this study is that control subjects were sampled randomly from the entire elderly Saskatchewan population of persons without hip fractures, with stratification by demographic characteristics associated with both benzodiazepine use and

We evaluated the risks of seizures and other neurological events following diphtheria-tetanus-pertussis (DTP) immunization for 38 171 Tennessee Medicaid children who received 107 154 DTP immunizations in their first 3 years of life. There were 2 children with encephalitis; both had disease onset more than 2 weeks following DTP immunization. There were 277 children who had febrile seizures, 42 with afebrile seizures, and 37 with seizures associated with other acute neurological illness (acute symptomatic). The risk of febrile seizures in the 0 to 3 days following DTP immunization (n = 6) was 1.5 (95% confidence interval, 0.6 to 3.3) times that of the control period 30 or more days following DTP immunization. There was no evidence that in the 0 to 3 days following DTP immunization the risk of afebrile seizures (n = 1) or acute symptomatic seizures (n = 0) was increased. No child who was previously normal without a prior history of seizures had a seizure in the 0 to 3 days following immunization that marked the onset of either epilepsy or other neurological or developmental abnormality. ( JAMA . 1990;263:1641-1645)

We evaluated persistence of the prescribing improvement seen in a previous statewide controlled trial, which measured improvement in the prescribing of contraindicated antibiotics and oral cephalosporins in the year after an educational intervention. Doctors visited by physician-counselors substantially improved their prescribing of both classes of drugs. The beneficial effect of the physician-counselors persisted throughout year 2, with attributable reductions in prescribing of 30% and savings of $950 for each doctor visited. The marked and lasting improvement in prescribing produced by the physician-counselors suggests using this model to develop ongoing programs to improve prescribing. ( JAMA 1985;253:1774-1776)

To determine if the risk of hip fracture differed between persons receiving benzodiazepines with long (≥24 hours) or short ( (JAMA. 1989;262:3303-3307)

Unlike many other texts with both "drugs" and "elderly" in the title, this book does not provide clinical guidelines for care of the older patient. Rather, the authors review and summarize recent research into generic problems related to the prescribing of medications for the elderly: inappropriate prescribing, adverse drug reactions, the adequacy of premarketing testing of drugs frequently taken by older patients, the burden of high medication costs, non-compliance, and available methods to improve the quality of medication prescribing by physicians and medication taking by patients. This review is particularly timely because the recent changes in Medicare coverage include a prescription benefit that, when fully implemented, will shift an appreciable portion of medication costs for the elderly to the public sector and thus focus greater attention on these issues. The book is organized in four parts. The first reviews research that assesses the appropriateness of prescribing by physicians and medication