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Care coordination programmes are an important aspect of HIV management whose success depends largely on HIV primary care provider (PCP) and case manager collaboration. Factors influencing collaboration among HIV PCPs and case managers remain to be studied. The study objective was to test an existing theoretical model of interprofessional collaborative practice and determine which factors play the most important role in facilitating collaboration. A self-administered, anonymous mail survey was sent to HIV PCPs and case managers in New York City. An adapted survey instrument elicited information on demographic, contextual, and perceived social exchange (trustworthiness, role specification, and relationship initiation) characteristics. The dependent variable, perceived interprofessional practice, was constructed from a validated scale. A sequential block wise regression model specifying variable entry order examined the relative importance of each group of factors and of individual variables. The analysis showed that social exchange factors were the dominant drivers of collaboration. Relationship initiation was the most important predictor of interprofessional collaboration. Additional influential factors included organisational leadership support of collaboration, practice settings, and frequency of interprofessional meetings. Addressing factors influencing collaboration among providers will help public health programmes optimally design their structural, hiring, and training strategies to foster effective social exchanges and promote collaborative working relationships.

The patient-centered medical home model of primary care has received considerable attention for its potential to improve outcomes and reduce health care costs. Yet little information exists about the model's ability to achieve these goals for Medicaid patients. We sought to evaluate the effect of patient-centered medical home certification of Louisiana primary care clinics on the quality and cost of care over time for a Medicaid population. We used a quasi-experimental pre-post design with a matched control group to assess the effect of medical home certification on outcomes. We found no impact on acute care use and modest support for reduced costs and primary care use among medical homes serving higher proportions of chronically ill patients. These findings provide preliminary results related to the ability of the patient-centered medical home model to improve outcomes for Medicaid beneficiaries. The findings support a case-mix-adjusted payment policy for medical homes going forward.

Background. Although approximately 82 percent of the US population was covered by some form of law that restricted smoking in public establishments as of 2014, most research examining the relationship between smoke-free laws and health has been focused at the state level.Purpose. To examine the effect of county workplace smoke-free laws over and above the effect of other (restaurant or bar) smoke-free laws on adult asthma.Methods. The study estimated the effect of rates of adult asthma discharges before and after the implementation of county nonhospitality workplace smoke-free laws and county restaurant and bar smoke-free laws. Data were from 2002 to 2009, and all analyses were performed in 2011 through 2013.Results. A statistically significant relationship (−5.43,p<.05) was found between county restaurant or bar smoke-free laws and reductions in working age adult asthma discharges. There was no statistically significant effect of nonhospitality workplace smoke-free laws over and above the effect of county restaurant or bar laws.Conclusions. This study suggests that further gains in preventable asthma-related hospitalizations in the US are more likely to be made by focusing on smoke-free laws in bars or restaurants rather than in nonhospitality workplaces.

Object This study analyses inappropriate use of emergency department (ED) services among type 2 diabetics under an evidence-based management programme. Methods Using 1999-2006 databases of Louisiana Health Care Services Division (HCSD) eight public hospitals ED visits among the uninsured and other patients in Louisiana, we termed urgent ED visits appropriate and less-urgent visits inappropriate. Eliminating weekend ED visits, 17 458 urgent and 22 395 less-urgent visits by 8596 patients were analysed, using generalized estimating equation methods. Results Caucasians were 0.82 times (95% CI: 0.751–0.889) less likely to use the ED inappropriately compared with African Americans. Patients with commercial insurance, Medicaid and Medicare used the ED more inappropriately than uninsured, with odds ratios of 1.28, 1.32 and 1.28, respectively. Patients hospitalized the prior year were 0.84 times (95% CI: 1.08–1.31) less likely for inappropriate. Patients in larger hospitals used the ED more inappropriately, with an odds ratio of 1.44 (95% CI: 1.32–1.56). Conclusions The study suggests that inappropriate use of the ED among diabetic patients in an evidence-based management programme is more likely to occur among African American, patients with insurance coverage and those seeking care in larger hospitals. Reinforcing the regular use of clinic services for diabetes management, providing clinic access in off-hours, and engaging the health plans in providing incentives for more appropriate use of the ED might reduce inappropriate ED visits. Notably, uninsured patients with diabetes from HCSD were more efficient users of the ED.

Objective Determine the degree of congruence between several measures of adverse events. Design Cross-sectional study to assess frequency and type of adverse events identified using a variety of methods. Setting Mayo Clinic Rochester hospitals. Participants All inpatients discharged in 2005 ( n = 60 599). Interventions Adverse events were identified through multiple methods: (i) Agency for Healthcare Research and Quality-defined patient safety indicators (PSIs) using ICD-9 diagnosis codes from administrative discharge abstracts, (ii) provider-reported events, and (iii) Institute for Healthcare Improvement Global Trigger Tool with physician confirmation. PSIs were adjusted to exclude patient conditions present at admission. Main outcome measure Agreement of identification between methods. Results About 4% (2401) of hospital discharges had an adverse event identified by at least one method. Around 38% (922) of identified events were provider-reported events. Nearly 43% of provider-reported adverse events were skin integrity events, 23% medication events, 21% falls, 1.8% equipment events and 37% miscellaneous events. Patients with adverse events identified by one method were not usually identified using another method. Only 97 (6.2%) of hospitalizations with a PSI also had a provider-reported event and only 10.5% of provider-reported events had a PSI. Conclusions Different detection methods identified different adverse events. Findings are consistent with studies that recommend combining approaches to measure patient safety for internal quality improvement. Potential reported adverse event inconsistencies, low association with documented harm and reporting differences across organizations, however, raise concerns about using these patient safety measures for public reporting and organizational performance comparison.

Explore effects of comorbidity and prior health care utilization on choice of employee health plans with different levels of cost sharing.Mayo Clinic employees in Rochester, Minnesota (MCR) under age 65 in January 2004; N = 20,379.Assessment of a natural experiment where self-funded medical care benefit options were changed to contain costs within a large medical group practice. Before the change, most employees were enrolled in a plan with first dollar coverage, while 18% had a plan with copays and deductibles. In 2004, 3 existing plans were replaced by 2 new options, one with lower premiums and higher out-of-pocket costs and the other with higher premiums, a lower coinsurance rate, and lower out-of-pocket maximums.Data on employees were merged across insurance claims, medical records, eligibility files, and employment files for 2003 and 2004.As the number of chronic comorbidities among family members increased, the probability of choosing high-premium option also increased. Seventy-two percent of employees with at least 1 family member with comorbidity chose the high-cost option versus 54.7% of employees with no comorbidities. High-premium and low-premium plans seem to subdivide population into discrete risk categories, which may adversely affect the future stability of the insurance plan options.Various factors affect decision making of employees regarding the choice of plan with different levels of cost-sharing. In a natural experiment setting where all options were redesigned, the health status of employees and their dependents played a very significant role in plan choice.

Introduction: On August 29, 2005, Hurricane Katrina made landfall along the US Gulf Coast, resulting in the evacuation of >1.5 million people, including nearly 6000 physicians. This article examines the relocation patterns of physicians following the storm, determines the impact that the disaster had on their lives and practices, and identifies lessons learned.Methods: An Internet-based survey was conducted among licensed physicians reporting addresses within Federal Emergency Management Agency–designated disaster zones in Louisiana and Mississippi. Descriptive data analysis was used to describe respondent characteristics. Multivariate logistic regression was performed to identify the factors associated with physician nonreturn to original practice. For those remaining relocated out of state, bivariate analysis with χ2 or Fisher exact test was used to determine factors associated with plans to return to original practice.Results: A total of 312 eligible responses were collected. Among disaster zone respondents, 85.6% lived in Louisiana and 14.4% resided in Mississippi before the hurricane struck. By spring 2006, 75.6% (n = 236) of the respondents had returned to their original homes, whereas 24.4% (n = 76) remained displaced. Factors associated with nonreturn to original employment included family or general medicine practice (OR 0.42, 95% CI 0.17–1.04; P = .059) and severe or complete damage to the workplace (OR 0.24, 95% CI 0.13–0.42; P < .001).Conclusions: A sizeable proportion of physicians remain displaced after Hurricane Katrina, along with a lasting decrease in the number of physicians serving in the areas affected by the disaster. Programs designed to address identified physician needs in the aftermath of the storm may give confidence to displaced physicians to return. (Disaster Med Public Health Preparedness. 2007;1:21–26)

PURPOSE We wanted to identify risk factors for persistently high use of primary care. METHODS We analyzed outpatient office visits to practitioners in family medicine, general internal medicine, general pediatrics, and obstetrics for 1997–1999 among patients in a small Midwestern city covered by a fee-for-service insurance plan with no co-payments for physician visits and no requirement for referral to specialty care. Logistic regression was used to predict which patients with 10 or more primary care visits in 1997 would repeat high use in 1998 based on demographic and diagnostic categories (adjusted clinical groups [ACGs]). A confirmatory data set (high primary care use in 1998 persistent into 1999) was used to evaluate the model. RESULTS Two percent of the 54,074 patients had 10 or more primary care visits in 1997, and of these, almost 19% had 10 or more visits in the next year. Among adults, 4 ambulatory diagnosis groups (ADGs) were simultaneously positive predictors of repeated high primary care visits: unstable chronic medical conditions, see and reassure conditions, minor time-limited psychosocial conditions, and minor signs and symptoms. Meanwhile, pregnancy was negatively associated. The area under the receiver operating characteristic (ROC) curve was 0.794 for adults in the developmental data set and 0.752 in the confirmatory data set, indicating a moderately accurate assessment. A satisfactory model was not developed for pediatric patients. CONCLUSIONS Many persistently high primary care users appear to be overserviced but underserved, with underlying problems not addressed by a medical approach. Some may benefit from psychosocial support, whereas others may be good candidates for disease management interventions.

The passage of the Patient Protection and Affordable Care Act of 2010 (PPACA) may create an estimated 16 million new Medicaid enrollees. This underscores the need to develop innovative strategies to provide efficient care to this population without compromising quality. To address concerns that consumer-driven health plans (CDHPs) and cost sharing discourage individuals from seeking needed care, we examined the Healthcare Effectiveness Data Information Set (HEDIS) measures of secondary prevention for a CDHP offered to uninsured, non-Medicaid eligible adults with incomes under 200% of the federal poverty level and compared them to the National Committee for Quality Assurance (NCQA) benchmarks achieved by national Medicaid and commercially insured health plans. Results suggest that the cost-sharing component in the CDHP plan did not deter these low-income enrollees from pursuing or receiving appropriate care when compared to either Medicaid or commercially insured populations. As these results are only descriptive and not statistical measures, further research is needed with comparable populations and more detailed data for hypothesis testing.

The objective was to investigate the effect of admission health status on hospital adverse events and added costs. Secondary data were from merged administrative and clinical sources for Mayo Clinic Rochester, Minnesota hospital discharges in 2005 (N = 60,599). This was a retrospective cross-sectional study of the effect of demographics, diagnosis group, comorbidity, and admission illness severity on adverse events, incremental costs, and length of stay (LOS) using the Agency for Healthcare Research and Quality Patient Safety Indicators and provider-reported events with harm. Estimates are derived from generalized linear models. Admission severity increased the likelihood of all types of adverse events (7.2% per unit acute physiology score for any event); 7 specific comorbidities were associated with increased events and 2 with decreased events. High admission severity increased incremental costs and LOS. Selected comorbidities increased incremental LOS but had no significant effect on incremental costs. Adverse event reporting should incorporate comorbidity and admission severity. Reimbursement incentives to improve patient safety should consider adjustment for admission health status.

To examine the predictors of duloxetine monotherapy versus other antidepressants among patients with major depressive disorder (MDD) in the Veterans Health Administration (VHA).Patients initiating duloxetine or other antidepressants between October 1, 2005 and October 1, 2007 were extracted from the Veterans Integrated Service Network (VISN)16 data warehouse. All patients included had at least one MDD diagnosis prior to the initiation of duloxetine or other antidepressants. Patients with prior diabetes, schizophrenia, or bipolar disorder diagnosis were excluded. Logistic regression was used to identify predictors of duloxetine initiation versus other antidepressants.Among 448 duloxetine and 11,629 non-duloxetine patients identified, more duloxetine-treated patients had pre-index opioid use (62.72% vs. 22.03%), substance abuse (36.38% vs. 27.72%), or reported pain (60.94% vs. 46.29%) than non-duloxetine treated patients (all p-values0.001). Prior users of long-acting (odds ratio [OR] = 8.98, 95% confidence interval [CI]: 6.95, 11.60) and short-acting (OR = 3.32, 95% CI: 2.60, 4.23) opioids were more likely to initiate duloxetine than those not. Patients who experienced moderate or severe pain or substance abuse were also more likely to initiate duloxetine (OR = 1.43, 95% CI: 1.07, 1.90; 1.50, 95% CI: 1.16, 1.92; 1.41, 95% CI: 1.14, 1.75; respectively). Other significant predictors included being female, white, having non-VHA insurance, prior hospitalization, emergency room visits, dyslipidemia and hypertension (all p-values0.05).It is a retrospective analysis among VHA patients of a single VISN.Among the VHA patients with MDD, prior opioid use was the strongest predictor of duloxetine initiation, followed by moderate-to-severe pain and substance abuse diagnosis.

When Americans voted in November 2008, many had the presidential candidates' positions on health care reform in mind. Health savings accounts, which are high deductible health plans coupled with a tax-protected savings account, are 1 type of consumer-directed health plan (CDHP) that gained strong support from the Bush administration. Despite evidence of the effectiveness of CDHPs in constraining costs in other countries, the Obama health plan contains no mention of their role in future US health reform. This article seeks to provide the reader with a better understanding of how CDHPs can help to improve the use of health resources and reduce national health care expenditures by exploring the history and previous research on several types of consumer-directed plans and by providing a comparative analysis of the use of CDHPs in other countries.

Summary Objectives In order to make tuberculosis (TB) treatment more effective and to lower the default rate of the disease, the Bureau of National Health Insurance (BNHI) in Taiwan implemented the "pay-for-performance on Tuberculosis" program (P4P on TB) in 2004. The purpose of this study is to investigate the effectiveness of the P4P system in terms of default rate. Methods This is a retrospective study. National Health Insurance Research Datasets in Taiwan from 2002 to 2005 has been used for the study. The study compared the differences of TB default rate before and after the implementation of P4P program, between participating and non-participating hospitals, and between P4P hospitals with and without case managers. Furthermore, logistic regression analysis was conducted to explore the related factors influencing TB patients default treatment after TB detected. Results The treatment default rate after "P4P on TB" was 11.37% compared with the 15.56% before "P4P on TB" implementation. The treatment default rate in P4P hospitals was 10.67% compared to 12.7% in non-P4P hospitals. In addition, the default rate was 10.4% in hospitals with case managers compared with 12.68% in hospitals without case managers. Conclusions The results of the study showed that "P4P on TB" program improved the treatment default rate for TB patients. In addition, case managers improved the treatment outcome in controlling patients' default rate.

Background The prevalence of both unintended pregnancy and psychiatric disorders in pregnancy is high. Each is associated with compromised birth outcomes and challenges in child-rearing. This study examines the relationship between mental illness and unintended pregnancy in seeking to improve the care provided to women and our ability to minimize the number of children born unwanted or ill-cared for. Methods The sample consisted of 744 pregnant Women, Infants, and Children (WIC) participants with a stratified enrollment design by residence and representative by race for each WIC county. Analysis consisted of post-stratification by developmental age group with logistic regression models estimating odds of unintended pregnancy among women with and without a psychiatric disorder. Covariates included race, education, and marital status. Findings Almost one third (30.9%) had at least one psychiatric disorder with over two thirds (67.3%) reporting their pregnancy as unintended. No grouped psychiatric disorder was associated with unintended pregnancy with all ages combined. However, adolescents (ages 15–19) with a substance disorder were less likely to have an unintended pregnancy (adjusted odds ratio [aOR], 0.3; 95% confidence interval [CI], 0.1–0.7) than women without a substance disorder and emerging adult women (ages 20–23) with an anxiety disorder were less likely to have an unintended pregnancy (aOR, 0.4; 95% CI, 0.2–1.0) compared with those without the targeted disorder. Conclusion The prevalence of unintended pregnancy is not associated with having a psychiatric disorder, although substance use disorders and anxiety disorders were associated with a decreased likelihood for an unintended pregnancy in a specific age group. Importantly, targeted efforts are needed to identify and counsel women with mental illness about pregnancy planning.

Too often, public health decisions are based on short-term demands rather than long-term research and objectives. Policies and programmes are sometimes developed around anecdotal evidence. The Evidence-Based Public Health (EBPH) programme trains public health practitioners to use a comprehensive, scientific approach when developing and evaluating chronic disease programmes. Begun in 2002, the EBPH programme is an international collaboration. The course is organized in seven parts to teach skills in: 1) assessing a community's needs; 2) quantifying the issue; 3) developing a concise statement of the issue; 4) determining what is known about the issue by reviewing the scientific literature; 5) developing and prioritizing programme and policy options; 6) developing an action plan and implementing interventions; and 7) evaluating the programme or policy. The course takes an applied approach and emphasizes information that is readily available to busy practitioners, relying on experiential learning and includes lectures, practice exercises, and case studies. It focuses n using evidence-based tools and encourages participants to add to the evidence base in areas where intervention knowledge is sparse. Through this training programme, we educated practitioners from 38 countries in 4 continents. This article describes the evolution of the parent course and describes experiences implementing the course in the Russian Federation, Lithuania, and Chile. Lessons learned from replication of the course include the need to build a “critical mass” of public health officials trained in EBPH within each country and the importance of international, collaborative networks. Scientific and technologic advances provide unprecedented opportunities for public health professionals to enhance the practice of EBPH. To take full advantage of new technology and tools and to combat new health challenges, public health practitioners must continually improve their skills.

Context: Many attempts to identify hospital complications rely on secondary diagnoses from billing data. To be meaningful, diagnosis codes must distinguish between diagnoses after admission and those existing before admission. Objective: To assess the influence of diagnoses at admission on patient safety, comorbidity, severity measures, and case mix groupings for Medicare reimbursement. Design: Cross-sectional association of various diagnosis-based clinical and performance measures with and without diagnosis present on admission. Setting: Hospital discharges from Mayo Clinic Rochester hospitals in 2005 (N = 60,599). Patients: All hospital inpatients including surgical, medical, pediatric, maternity, psychiatric, and rehabilitation patients. About 33% of patients traveled more than 120 miles for care. Main Outcome Measures: Hospital patient safety indicators, comorbidity, severity, and case mix measures with and without diagnoses present at admission. Results: Over 90% of all diagnoses were present at admission whereas 27.1% of all inpatients had a secondary diagnosis coded in-hospital. About one-third of discharges with a safety indicator were flagged because of a diagnosis already present at admission, more likely among referral patients. In contrast, 87% of postoperative hemorrhage, 22% of postoperative hip fractures, and 54% of foreign bodies left in wounds were coded as in-hospital conditions. Severity changes during hospitalization were observed in less than 8% of discharges. Slightly over 3% of discharges were assigned to higher weight diagnosis-related groups based on an in-hospital complication. Conclusions: In general, many patient safety indicators do not reliably identify adverse hospital events, especially when applied to academic referral centers. Except as noted, conditions recorded after admission have minimal impact on comorbidity and severity measures or on Medicare reimbursement.

OBJECTIVE Attempts to provide information to consumers about patient safety on specific hospitals have conflicted with organization self-perceptions and led to confusion among the general public. This article presents organizational theory framework and criteria to classify organizations as single versus multiple reporting entities. PARTICIPANTS AND METHODS Operational definitions are presented. A case study comparing institutions both within and across state boundaries in the Mayo Clinic Health System is used to demonstrate their utility. The study includes analysis of an employee survey on employee satisfaction and patient safety climate in 2004 among nurses and physicians at the 2 Mayo Clinic hospitals in Rochester, Minn. RESULTS AND CONCLUSIONS The criteria for a single organization are more strongly supported for the Mayo Clinic hospitals located in the same city than for hospitals in the same system but separated geographically. Although there is debate about the measurement of organizational culture, employee surveys provide some evidence of a commonality across hospitals in the same city. The case study comparing institutions both within and across state boundaries in the Mayo Clinic Health System demonstrate the utility of the proposed criteria.

Objectives. We examined the association between psychiatric disorders and tobacco use during pregnancy. Methods. Data were derived from a population-based cohort of 744 pregnant African American and White low-income women living in urban and rural areas. The Diagnostic Interview Schedule was used to assess women for 20 different psychiatric disorders. Results. In comparison with nonusers, persistent tobacco users (women who had used tobacco after confirmation of their pregnancy) and nonpersistent users (women who had used tobacco but not after pregnancy confirmation) were 2.5 and 2 times as likely to have a psychiatric disorder. Twenty-five percent of persistent users had at least 1 of the following diagnoses: generalized anxiety disorder, bipolar I disorder, oppositional disorder, drug abuse or dependence, and attention deficit–hyperactivity disorder. Conclusions. In this cohort study, 5 diagnoses were more prevalent among persistent tobacco users than among nonusers, suggesting that several psychiatric disorders contribute to difficulty discontinuing tobacco use during pregnancy. Smoking cessation efforts focusing on pregnant women may need to address co-occurring psychiatric disorders if they are to be successful.

To estimate the prevalence of posttraumatic stress disorder and its treatment in economically disadvantaged pregnant women.The sample included 744 pregnant Medicaid-eligible women from Women, Infants and Children Supplemental Nutrition Program sites in 5 counties in rural Missouri and the city of St. Louis. Race (black and white) was proportional to clients seen at each site. Women were assessed by using standardized measures of posttraumatic stress disorder, 18 other psychiatric disorders, environmental stressors, and pregnancy characteristics. Logistic regression identified risk factors associated with posttraumatic stress disorder.Posttraumatic stress disorder prevalence was 7.7% (n = 57/744). Comorbid disorders were common. Women with posttraumatic stress disorder were 5 times more likely to have a major depressive episode (odds ratio 5.17; 95% confidence interval 2.61, 10.26) and more than 3 times as likely to have generalized anxiety disorder (odds ratio 3.25; 95% confidence interval 1.22, 8.62). Besides these comorbid disorders, risk factors for posttraumatic stress disorder included a history of maternal separation for 6 months and multiple traumatic events. Although most women with posttraumatic stress disorder reported moderate impairment in their daily lives, only 7 of the 57 women with this disorder reported speaking with any health professional about it in the last 12 months.The prevalence of posttraumatic stress disorder in pregnancy and low treatment rates suggest that screening for this disorder should be considered in clinical practice.II-2

Evaluating disparities in healthcare outcomes is not an easy task for policy makers. This requires access to outcome indicators at the patient level. Patient level data are not easily available because of privacy considerations and costs of collection. One approach to assess health disparities is to examine variations in mortality from conditions known to be amenable to medical care. Mortality amenable to healthcare (MAHC) is defined as deaths before the age of 75 from selected causes that should not occur in the presence of timely and effective medical care (Nolte ad McKee, 2004). This study describes the differences in age-adjusted standardised mortality rates (ASMRs) from all cause MAHC and ASMRs for diabetes mellitus and ischemic heart disease separately, by parish, in Louisiana; and estimates the Spearman correlation between ASMR from all cause MAHC and socio-economic factors.

Background This study analyzed the likelihood of less-urgent emergency department (ED) visits among type 2 diabetic patients receiving care under a diabetes disease management (DM) program offered by the Louisiana State University Health Care Services Division (LSU HCSD). Methods All ED and outpatient clinic visits made by 6,412 type 2 diabetic patients from 1999 to 2006 were extracted from the LSU HCSD Disease Management (DM) Evaluation Database. Patient ED visits were classified as either urgent or less-urgent, and the likelihood of a less-urgent ED visit was compared with outpatient clinic visits using the Generalized Estimating Equation methodology for binary response to time-dependent variables. Results Patients who adhered to regular clinic visit schedules dictated by the DM program were less likely to use the ED for less urgent care with odds ratio of 0.1585. Insured patients had 1.13 to 1.70 greater odds of a less-urgent ED visit than those who were uninsured. Patients with better-managed glycated hemoglobin (A1c or HbA1c) levels were 82 times less likely to use less-urgent ED visits. Furthermore, being older, Caucasian, or a longer participant in the DM program had a modestly lower likelihood of less-urgent ED visits. The patient's Charlson Comorbidity Index (CCI), gender, prior hospitalization, and the admitting facility showed no effect. Conclusion Patients adhering to the DM visit guidelines were less likely to use the ED for less-urgent problems. Maintaining normal A1c levels for their diabetes also has the positive impact to reduce less-urgent ED usages. It suggests that successful DM programs may reduce inappropriate ED use. In contrast to expectations, uninsured patients were less likely to use the ED for less-urgent care. Patients in the DM program with Medicaid coverage were 1.3 times more likely to seek care in the ED for non-emergencies while commercially insured patients were nearly 1.7 times more likely to do so. Further research to understand inappropriate ED use among insured patients is needed. We suggest providing visit reminders, a call centre, or case managers to reduce the likelihood of less-urgent ED visit use among DM patients. By reducing the likelihood of unnecessary ED visits, successful DM programs can improve patient care.

Crises in financial markets and widespread failures of financial institutions are marked characteristics of the 1980s. These phenomena may be more prevalent in the United States than in the other financially important centres. As a result, the seemingly irresistible drive to deregulate the financial services industries that dominated policy in the United States since the 1970s has been replaced by a search for an appropriate structure of intervention and regulation to maintain the orderly functioning of financial institutions and markets.

The effects of chronic pretreatment with amiodarone on ischemic ventricular arrhythmias were evaluated in fully conscious instrumented dogs. In control dogs (n = 14) with large myocardial infarcts, early (first 30 min) ventricular arrhythmias occurred in a bimodal distribution with peaks at 3-5 min and at 12-25 min, with only the former associated with epicardial conduction delay. Ventricular fibrillation occurred equally frequently during each peak of early ventricular arrhythmias. Amiodarone (30 mg/kg daily) for 3-4 weeks had no significant effect (n = 11) on anatomic infarct size (28 +/- 6 vs. 30 +/- 5% of left ventricular weight) nor on collateral blood flow in the center of the infarct (19 +/- 11 vs. 15 +/- 7 ml/min/100 g of tissue) or on the ratio of endocardial/epicardial perfusion (0.23 +/- 0.19 vs. 0.28 +/- 19). Despite significant lengthening of peak epicardial conduction delay (191 +/- 20 to 239 +/- 81 ms, p less than 0.05), the frequency of early ventricular arrhythmias, especially during the second peak of ectopic activity, were markedly attenuated by amiodarone pretreatment, with the extrasystole-free intervals often being as long as 6 h. The incidence of ventricular fibrillation was 9% in the treated animals compared with 29% in the controls. In the control animals, arrhythmias always supervened when epicardial fractionation was significant, and no ectopy-free interval was present in the first 6 h following coronary occlusion. The data indicate that chronic amiodarone pretreatment exerts a beneficial effect on the frequency and severity of such ventricular tachyarrhythmias, with reduction in the incidence of ventricular fibrillation and ectopic activity in the early phases following coronary occlusion.