Search

Unlabelled: Patients may have concerns about their ability to manage postoperative symptoms at home after ambulatory surgery. We assessed patients' attitudes toward postoperative care at home or in the hospital after laparoscopic cholecystectomy. Thirty-eight patients undergoing elective laparoscopic cholecystectomy were pre- and postoperatively (within a week each) presented with scenarios describing symptoms of differing severity in either a home or hospital setting and were asked to rank and rate the relative desirability of the scenarios using rating scale, standard gamble, and willingness-to-pay techniques. Preoperatively, 16 (42%), 21 (55%), and 30 (79%) patients ranked pain of mild, moderate, and severe levels, respectively, as worse than the respective levels of nausea and vomiting. Of 24 patients, 19 (79%) preferred home care to hospital care for mild symptoms, and 12 of 22 patients (55%) preferred home care to hospital care for moderate symptoms. The average ratings were 20, 53, and 90 for mild, moderate, and severe symptoms, respectively, where 0 = no symptoms and 100 = the worst symptoms possible. Patients who preferred care outside the home indicated that they were willing to pay a mean of $142 (maximum $410) as a maximal copayment to have postoperative care in the hospital and a mean of $255 to receive care in a medical hotel-like facility. Postoperative assessment correlated highly with the preoperative assessment (correlation coefficient >0.6 for rating, standard gamble, and willingness-to-pay assessments). We conclude that patients vary in their attitudes toward where they would like to receive postoperative care. Attitudes assessed preoperatively may predict their attitudes postoperatively., Implications: Patients preferred to be at home for mild postoperative symptoms but in the hospital for worse postoperative symptoms. Preferences did not change with different methods of asking and were the same pre- and postoperatively. If patients made choices for their care before their procedure, they would still be happy with those decisions postoperatively.

Background: There is increasing pressure to perform traditional inpatient surgical procedures in an outpatient setting. The aim of the current trial was to determine the safety and cost savings of performing laparoscopic cholecystectomy in an outpatient setting using a "mock" outpatient setting., Methods: Patients who were scheduled for laparoscopic cholecystectomy by four attending surgeons and for whom operating time was available in the outpatient center were studied. All patients received a standardized anesthetic, including ondansetron, and were discharged from the outpatient postanesthesia care unit if appropriate. At discharge, all patients were admitted to a clinical research center where they were observed in a "mock home" setting and monitored for complications that would have necessitated readmission. A decision analysis was created assuming all patients underwent outpatient surgery with either direct admission or discharge to home and readmission if complications developed., Results: Of 99 patients who were enrolled in this study, 96 patients would have met the discharge criteria for home. No major complications were observed in these 96 patients. Eleven patients experienced postoperative nausea and vomiting, 3 of whom required an additional 24 h of hospital observation. In the decision model, the optimal strategy would be to perform the procedure on an outpatient basis and readmit patients only for complications, with an average baseline cost savings of $742/patient., Conclusions: The results show that outpatient laparoscopic cholecystectomy is safe and cost-effective in selected patients, and that the mock home setting provides a means of studying the safety of transition of care.

Objective: Many hospitals are investing in computer-based provider order-entry (POE) systems, and providers' evaluations have proved important for the success of the systems. The authors assessed how physicians and nurses viewed the effects of one modified commercial POE system on time spent patients, resource utilization, errors with orders, and overall quality of care., Design: Survey., Measurements: Opinions of 271 POE users on medicine wards of an urban teaching hospital: 96 medical house officers, 49 attending physicians, 19 clinical fellows with heavy inpatient loads, and 107 nurses., Results: Responses were received from 85 percent of the sample. Most physicians and nurses agreed that orders were executed faster under POE. About 30 percent of house officers and attendings or fellows, compared with 56 percent of nurses, reported improvement in overall quality of care with POE. Forty-four percent of house officers and 34 percent of attendings/fellows reported that their time with patients decreased, whereas 56 percent of nurses indicated that their time with patients increased (P < 0.001). Sixty percent of house officers and 41 percent of attendings/fellows indicated that order errors increased, whereas 69 percent of nurses indicated a decrease or no change in errors. Although most nurses reported no change in the frequency of ordering tests and medications with POE, 61 percent of house officers reported an increased frequency., Conclusion: Physicians and nurses had markedly different views about effects of a POE system on patient care, highlighting the need to consider both perspectives when assessing the impact of POE. With this POE system, most nurses saw beneficial effects, whereas many physicians saw negative effects.

Context: Morbidity and mortality rates in intensive care units (ICUs) vary widely among institutions, but whether ICU structure and care processes affect these outcomes is unknown., Objective: To determine whether organizational characteristics of ICUs are related to clinical and economic outcomes for abdominal aortic surgery patients who typically receive care in an ICU., Design: Observational study, with patient data collected retrospectively and ICU data collected prospectively., Setting: All Maryland hospitals that performed abdominal aortic surgery from 1994 to 1996., Patients and Participants: We analyzed hospital discharge data for patients in non-federal acute care hospitals in Maryland who had a principal procedure code for abdominal aortic surgery from January 1994 through December 1996 (n = 2987). We obtained information about ICU organizational characteristics by surveying ICU medical directors at the 46 Maryland hospitals that performed abdominal aortic surgery. Thirty-nine (85%) of the ICU directors completed this survey., Main Outcome Measures: In-hospital mortality and hospital and ICU length of stay., Results: For patients undergoing abdominal aortic surgery, in-hospital mortality varied among hospitals from 0% to 66%. In multivariate analysis adjusted for patient demographics, comorbid disease, severity of illness, hospital and surgeon volume, and hospital characteristics, not having daily rounds by an ICU physician was associated with a 3-fold increase in in-hospital mortality (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.9-4.9). Furthermore, not having daily rounds by an ICU physician was associated with an increased risk of cardiac arrest (OR, 2.9; 95% CI, 1.2-7.0), acute renal failure (OR, 2.2; 95% CI, 1.3-3.9), septicemia (OR, 1.8; 95% CI, 1.2-2.6), platelet transfusion (OR, 6.4; 95% CI, 3.2-12.4), and reintubation (OR, 2.0; 95% CI, 1.0-4.1). Not having daily rounds by an ICU physician, having an ICU nurse-patient ratio of less than 1:2, not having monthly review of morbidity and mortality, and extubating patients in the operating room were associated with increased resource use., Conclusions: Organizational characteristics of ICUs are related to differences among hospitals in outcomes of abdominal aortic surgery. Clinicians and hospital leaders should consider the potential impact of ICU organizational characteristics on outcomes of patients having high-risk operations.

Objectives: The authors compared the quality of cardiovascular care in health maintenance organizations (HMOs) versus traditional insurance arrangements through an analysis of existing literature., Methods: Data were derived from all peer-reviewed studies published through November 1995 that used process or outcome measures to evaluate the quality of cardiovascular care in HMO versus non-HMO settings. A standardized form was used to extract information from each study on: condition studied, study time frame, type of study design, type of comparison groups, characteristics of patients and physicians, process and outcome measures used, data collection methods, reliability and validity of quality measurements, risk adjustment techniques, findings about quality of care, summary of other findings, study limitations, and other comments that explained the context of the research., Results: Seven of the 11 studies that examined process measures for cardiovascular care in HMO versus non-HMO patients found more differences in one or more process measures that favored HMOs than non-HMOs. Seven of the 10 studies that examined outcome measures found no statistically significant differences in patient care between HMO and non-HMO settings. The other three studies presented contradictory results., Conclusions: The existing literature suggests that the outcomes of care for cardiovascular conditions do not differ between HMO and non-HMO settings, although selected measures of the process of cardiovascular care are actually better in HMO than in non-HMO settings.

Objective: To determine if women who experience low-severity violence differ in numbers of physical symptoms, psychological distress, or substance abuse from women who have never been abused and from women who experience high-severity violence., Design: Cross-sectional, self-administered, anonymous survey., Setting: Four community-based, primary care, internal medicine practices., Patients: Survey respondents were 1,931 women aged 18 years or older. SURVEY DESIGN: Survey included questions on violence; a checklist of 22 physical symptoms; the Symptom Checklist-22 (SCL-22) to measure depression, anxiety, somatization, and self-esteem; CAGE questions for alcohol use; and questions about past medical history. Low-severity violence patients had been "pushed or grabbed" or had someone "threaten to hurt them or someone they love" in the year prior to presentation. High-severity violence patients had been hit, slapped, kicked, burned, choked, or threatened or hurt with a weapon., Main Results: Of the 1,931 women, 47 met criteria for current low-severity violence without prior abuse, and 79 met criteria for current high-severity violence without prior abuse, and 1,257 had never experienced violence. The remaining patients reported either childhood violence or past adult abuse. When adjusted for socioeconomic characteristics, the number of physical symptoms increased with increasing severity of violence (4.3 for no violence, 5.3 for low-severity violence, 6.4 for high-severity violence, p < .0001). Psychological distress also increased with increasing severity of violence (mean total SCL22 scores 32.6 for no violence, 35.7 for low-severity violence, 39.5 for high-severity violence, p < .0001). Women with any current violence were more likely to have a history of substance abuse (prevalence ratio [PR] 1.8 for low-severity, 1.9 for high-severity violence) and to have a substance-abusing partner (PR 2.4 for both violence groups)., Conclusions: In this study, even low-severity violence was associated with physical and psychological health problems in women. The data suggest a dose-response relation between the severity of violence and the degree of physical and psychological distress.

Objective: To determine whether hospital volume is associated with clinical and economic outcomes for patients with pancreatic cancer who underwent pancreatic resection, palliative bypass, or endoscopic or percutaneous stent procedures in Maryland between 1990 and 1995., Summary Background Data: Previous studies have demonstrated that outcomes for patients undergoing a Whipple procedure improve with higher surgical volume, but only 20% to 35% of patients with pancreatic cancer qualify for curative resection. Most patients undergo palliative procedures instead with a surgical bypass or biliary stent., Methods: Analysis of hospital discharge data from all nonfederal acute care hospitals in Maryland identified all patients with pancreatic cancer who underwent a pancreatic resection, palliative bypass, or stent procedure between 1990 and 1995. Hospitals (n = 48) were categorized as high-, medium-, and low-volume providers according to their average annual volume of these procedures. Multivariate regression was used to examine the association between hospital volume and in-hospital mortality rate, length of stay, and hospital charges, after adjusting for differences in case mix and surgeon volume., Results: Increased hospital volume is associated with markedly decreased in-hospital mortality rates and a decreased or similar length of stay for all three types of procedures and with decreased or similar hospital charges for resections and stents. After adjustment for case mix differences, the relative risk (RR) of in-hospital death after pancreatic resection was 19.3 and 8 at the low- and medium-volume hospitals, respectively, versus the high-volume hospital; after bypasses, the RR of death was 2.7 and 1.9, respectively; and after stents, the RR was 4.3 and 4.8, respectively., Conclusions: Patients with pancreatic cancer who are to be treated with curative or palliative procedures appear to benefit from referral to a high-volume provider.

Objective: This study examined a statewide trend in Maryland toward regionalization of pancreaticoduodenectomy over a 12-year period and its effect on statewide in-hospital mortality rates for this procedure., Summary Background Data: Previous studies have demonstrated that the best outcomes are achieved in centers performing large numbers of pancreaticoduodenectomies, which suggests that regionalization could lower the overall in-hospital mortality rate for this procedure., Methods: Maryland state hospital discharge data were used to select records of patients undergoing a pancreaticoduodenectomy between 1984 and 1995. Hospitals were classified into high-volume and low-volume provider groups. Trends in surgical volume and mortality rates were examined by provider group and for the entire state. Regression analyses were used to examine whether hospital share of pancreaticoduodenectomies was a significant predictor of the in-hospital mortality rate, adjusting for study year and patient characteristics. The portion of the decline in the statewide in-hospital mortality rate for this procedure attributable to the high-volume provider's increasing share was determined., Results: A total of 795 pancreaticoduodenectomies were performed in Maryland at 43 hospitals from 1984 to 1995 (Maryland residents only). During this period, one institution increased its yearly share of pancreaticoduodenectomies from 20.7% to 58.5%, and the statewide in-hospital mortality rate for the procedure decreased from 17.2% to 4.9%. After adjustment for patient characteristics and study year, hospital share remained a significant predictor of mortality. An estimated 61% of the decline in the statewide in-hospital mortality rate for the procedure was attributable to the increase in share of discharges at the high-volume provider., Conclusions: A trend toward regionalization of pancreaticoduodenectomy over a 12-year period in Maryland was associated with a significant decrease in the statewide in-hospital mortality rate for this procedure, demonstrating the effectiveness of regionalization for high-risk surgery.

Background & Aims: The commercial availability of gene testing for familial adenomatous polyposis (FAP) represents an important advance in screening for inherited colon cancer. We investigated the financial impact of this diagnostic tool on colorectal screening for FAP., Methods: Decision analysis was used to compare per-person costs with third-party payers of three colorectal screening strategies used to diagnose FAP in at-risk persons. The strategies included conventional serial flexible sigmoidoscopy and two different APC gene testing approaches., Results: For 1 at-risk relative who begins screening at age 12 years, average screening costs are $2625 when genotyping the proband first, $2674 when genotyping the at-risk relative first, and $3208 for conventional sigmoidoscopy. The cost advantage of genotyping increases as the pedigree size increases. For a pedigree of 5 at-risk relatives, sigmoidoscopy would have to cost less than $85.60 (professional plus facility fee) for conventional screening to compete with genotyping. The cost advantage of genotyping is diminished for at-risk relatives who begin FAP screening at older ages., Conclusions: The choice of least expensive FAP screening strategy depends on the cost of flexible sigmoidoscopy, patient age when screening starts, and pedigree size. Genotyping can substantially reduce the cost of FAP screening and, when possible, should start with the proband.

Quality assessment efforts to enhance public accountability in dialysis care and to support provider efforts to improve care have lacked patient input. To develop brief patient evaluation or satisfaction surveys suitable for busy clinical settings, knowing patients' priorities can be helpful in deciding which aspects of care should be tracked. We conducted a study to identify salient attributes of dialysis care and to rank the importance of these attributes from the perspective of dialysis patients. We analyzed the content of patient focus group transcripts to characterize dialysis care from the patients' perspective. We then surveyed 86 patients to determine how patients would rank the importance of each aspect to quality of dialysis care. The 18 broad aspects of care identified in the focus group included: (1) care provided by nephrologists, (2) care provided by other physicians (nonnephrologists), (3) care provided by dialysis center nurses, (4) care provided by social workers and psychologists, (5) care provided by dieticians, (6) clergy, (7) care provided by technicians and physician assistants/nurse practitioners, (8) care provided by dialysis center staff in general, (9) supplies, (10) treatment choice and effectiveness, (11) patient education and training, (12) self-care, (13) dialysis machines, (14) unit environment and policies, (15) cost containment, (16) billing, (17) cost of care, and (18) health outcomes. Items ranked in the top 10 by both groups of patients included issues related to nephrologists, other doctors, nurses, and patient education and training. Compared with hemodialysis patients, peritoneal dialysis patients gave higher ratings to hospital doctors' and nurses' attention to cleanliness when working with access sites, how correct the nephrologist's instructions to patients are, whether emergency room doctors check with nephrologists, the amount of information patients get about their diet, and how well nurses answer patients' questions. Patients value certain aspects of dialysis care highly, and these aspects differed in some respects for the relatively small number of hemodialysis and peritoneal dialysis patients studied. Construction of brief questionnaires for quality assessment and assurance requires thoughtful consideration of what questions to include. Knowing patients' priorities regarding the most important aspects of care that have high potential for dissatisfaction may be helpful to continuous quality improvement of end-stage renal disease care.

Context: Clinician-educators have concerns about their ability to be promoted and the criteria used by medical school promotion committees., Objective: To discover the criteria and methods that medical school promotion committees use to make decisions about the promotion of clinician-educators., Methods: In June 1996 we mailed a questionnaire to chairpersons of all medical school promotion committees in the United States and Canada., Results: Of 142 schools surveyed, 115 (81%) responded; 45% of respondents had a clinician-educator promotion track. On a scale from 1 (minimally important) to 7 (extremely important), the mean importance ratings of aspects of clinician-educators' performance were the following: teaching skills (6.3), clinical skills (5.8), mentoring (5.7), academic administration (5.3), developing educational programs (5.3), nonresearch scholarship (5.1), clinical research (4.8), service coordination (4.7), and education research (4.5). Methods to evaluate each aspect of performance were rated by respondents for importance and frequency of use. The 4 most important methods for evaluating teaching were awards, peer evaluation, learner evaluation, and teaching portfolio; 70% or more of schools used these frequently or always. The 4 most important methods of evaluating clinical skills were peer evaluation, awards, trainee evaluation, and objective measures, which were used frequently or always by 78%, 65%, 58%, and 29% of schools, respectively. Clinician-educators were expected to have fewer peer-reviewed publications to be promoted than investigators (5.7 vs 10.6, P<.001). Schools with separate clinician-educator tracks differed little in survey responses from schools without such tracks., Conclusion: Most, but not all, promotion committees now assign high importance to the special contributions of clinician-educators and use a variety of methods to assess these, regardless of whether they have a separate clinician-educator promotion track.

To assess how preference values that cataract surgery patients assign to their preoperative visual states relate to visual acuity and problems in specific aspects of daily life, the authors interviewed 47 patients scheduled to have cataract surgery. Using a rating-scale technique with a scale from 0 (death) to 1 (excellent health), the patients had a mean preference value of 0.68 for their preoperative vision. Patients' preference values for their preoperative vision were more closely related to problems in specific aspects of daily life (especially feelings of depression and problems interacting with people) than to visual acuity in the operative eye, better eye, or worse eye, or a weighted average of visual acuities in both eyes. These results provide a rationale for relying more on patients' views about the effects of visual impairment than on measures of visual acuity when assessing the need for cataract surgery.

The statistical and practical implications of including second eye surgeries were examined in a clinical trial designed to evaluate the impact of routine preoperative testing prior to cataract surgery on major medical events occurring within seven days following surgery. In order to detect a 0.8% difference in the rates of rare major medical events between the tested and untested groups, 20,000 surgeries must be randomized. About 30% of cataract operations were estimated to be done on second eyes of patients already included in the cohort. Different options for dealing with second eye surgeries were: (1) exclusion of all second eye surgeries, (2) inclusion of second eye surgeries only if the first eye is not enrolled, (3) inclusion of first and second eyes but randomization of patients rather than eyes, and (4) inclusion of first and second eyes but randomization of surgeries rather than patients. The final decision was to exclude second eye surgeries done within 28 days of first eye surgeries, but to rerandomize all other second eye surgeries. Differences in event rates between treatment groups can be estimated using Generalized Estimating Equations, and the association between outcomes of first and second eye operations estimated with pairwise odds ratios. An anticipated small positive correlation is likely to have minimal impact on statistical power and effective sample size.

Purpose: To prioritize competencies that should be addressed in the medicine core clerkship, assess factors influencing this prioritization, and estimate the percentage of clerkship time that should be devoted to inpatient versus outpatient care., Methods: A national survey of the Clerkship Directors in Internal Medicine (CDIM) was used. Using explicit criteria, respondents assigned priority scores, on a 1 to 5 scale, to 17 general competencies and 60 disease-specific clinical competencies pertinent to care of adult patients in inpatient. ambulatory, intensive care, and emergency settings., Results: Ninety-three (75%) of 124 CDIM members responded. The highest mean priority scores were assigned to 6 general competencies: case presentation skills (4.65), diagnostic decision-making (4.64), history and physical diagnosis (4.61), test interpretation (4.47), communication with patients (4.35), and therapeutic decision-making (4.12). Disease-specific clinical competency areas receiving the highest mean priority scores were: hypertension (4.57), coronary disease (4.53), diabetes mellitus (4.45), heart failure (4.42), pneumonia (4.39), chronic obstructive pulmonary disease (4.26), acid-base/electrolyte disorders (4.19), and acute chest pain (4.08). Priorities for general competencies were moderately correlated with importance to the practice of general internists (mean Spearman rho 0.49) and with importance to students pursuing careers outside internal medicine (mean Spearman rho 0.45), but only weakly correlated with the adequacy with which a competency was addressed in other parts of the curriculum. Respondents' mean recommended allocation of clerkship time was: 52% inpatient, 33% ambulatory care, 8% intensive care, and 7% emergency medicine. This time allocation did not differ by any characteristics of respondents., Conclusion: There is consensus among medicine clerkship directors that the medicine core clerkship should emphasize fundamental competencies and devote at least one third of the time to clinical competencies pertinent to ambulatory care.

Introduction: It is generally accepted that preoperative patient education and skin marking for a stoma location are important in avoiding stoma complications. At our institution, enterostomal therapists are available to educate and mark patients before their surgery. However, for various reasons, not all patients who had an elective stoma created, had preoperative skin marking or instructions on stoma care. Our registry of patients provided us with a means of comparing patients who have undergone an elective stoma with (Group I) and without (Group II) preoperative marking and education., Methods: Our stoma registry consisting of 1,790 patients was retrospectively reviewed from 1978 to 1996 to assess all patients who underwent elective stoma construction. Patients included for review had a total of 593 elective stomas. All patients with stomas are followed by the enterostomal therapists postoperatively and, therefore, were evaluated for both early and late complications. Early complications were defined as any adverse event occurring within 30 days of surgery and late complications as those occurring 30 days after surgery., Results: Our enterostomal therapists preoperatively evaluated 292 of the 593 patients planned for possible stoma creation. This included careful marking of the stoma site by having the patients lie down, sit, and stand and locating a stable flat area on the abdomen, taking into account the belt line and any abnormal skin creases or deformities. Patients were instructed on stoma appearance with a model and given basic stoma care instructions. In Group I, there were 95 (32.5 percent) complications (68 (23.3 percent) occurred early and 27 (9.25 percent) occurred late). There were 301 patients who did not receive preoperative evaluation (Group II). In this second group, 131 (43.5 percent) complications were found, (95 (31.6 percent) occurred early and 36 (12 percent) occurred late). The difference in total number of complications between groups was determined to be statistically significant, with a P value of <0.0075, as was the difference in early complications, with a P value of <0.03. The difference in late complications is not significant, with a P value of <0.34., Conclusions: These results confirm that preoperative evaluation by an enterostomal therapist, marking of the skin site, and providing patient education reduce adverse outcomes. All elective procedures that may result in stoma formation should, therefore, be assessed and marked preoperatively. Patients, likewise, should be informed and taught to care for their forthcoming stomas preoperatively and postoperatively.

Objective: To evaluate the association between cataract extraction and atherosclerosis and its complications., Design: A nationwide case-control study., Setting and Participants: Using a 5% random sample of all Medicare beneficiaries, we analyzed Medicare claims data on 60803 persons 65 years of age and older who underwent cataract extraction in 1986 or 1987 and a control group of 63765 persons matched to the cases for age, race, sex, ZIP code, and reason for Medicare entitlement., Main Outcome Measure: Atherosclerosis and atherosclerosis-related disease and procedures were defined by International Classification of Diseases, Ninth Revision, Clinical Modification, codes or by Health Care Financing Administration Common Procedure Classification System (Current Procedural Terminology) codes. The strength of evidence for atherosclerotic disease was categorized on the basis of the types of bills in the Medicare claims file., Results: Odds of atherosclerosis-related morbidity and procedures were higher for cases than for controls. The association decreased with patient age and was strongest in beneficiaries aged 65 to 69 years (odds ratio, 1.30; 95% confidence interval, 1.13-1.48)., Conclusion: Our findings suggest that there is a weak association between a visually significant cataract requiring surgery and atherosclerosis in the younger elderly.

Purpose: Previous analyses of Medicare claims data, as well as clinical series, have suggested that performance of neodymium:YAG (Nd:YAG) laser posterior capsulotomy after extracapsular cataract surgery increases significantly the risk of retinal detachment. However, methodologic problems with previous research limit the strength of conclusions that can be drawn from these earlier studies. This study was designed to resolve those methodological limitations while using a population-based approach for assessment of the independent association between the performance of Nd:YAG laser posterior capsulotomy and pseudophakic retinal detachment., Methods: A nested case-control study was conducted. Medicare beneficiaries who had undergone extracapsular cataract extraction from 1988 to 1990 were identified from a 5% sample of Medicare claims data. Within this cohort, people who were diagnosed or treated for retinal detachment during the years 1988 through 1991 (cases) were identified from Medicare records. Four controls were matched to each case of retinal detachment using an incidence density design. Providers of the patients' cataract and retinal surgery were contacted and asked to provide clinical data for all cases and controls that they had treated., Results: Seven hundred six cases of retinal detachment were originally identified from Medicare records. After exclusions due to ineligibility, a total of 291 cases and 870 matched controls were available for analysis. Conditional logistic regression models showed that a number of factors were associated independently with an excess risk of retinal detachment after cataract surgery. These included Nd:YAG laser capsulotomy (odds ratio [OR] = 3.8; 95% confidence interval [CI], 2.4-5.9), a history of retinal detachment (OR = 2.7; 95% CI, 1.2-6.1), a history of lattice degeneration (OR = 6.6; 95% CI, 1.6-27.1), axial length (OR = 1.21/mm; 95% CI, 1.03-1.43), refractive error (OR = 0.92/diopter; 95% CI, 0.88-0.95), and a history of ocular trauma after cataract surgery (OR = 6.1; 95% CI, 4.3-28.2)., Conclusion: Performance of Nd:YAG laser posterior capsulotomy is associated with a significantly elevated risk of retinal detachment in patients who have undergone extracapsular cataract extraction. Other independent risk factors for retinal detachment include axial length, myopia, posterior capsular rupture during surgery, history of retinal detachment or lattice degeneration, and ocular trauma after cataract surgery.

Objectives: To assess the frequency and content of post-operative examinations by ophthalmologists and optometrists for cataract surgery patients without operative complications and to assess the referral patterns of optometrists when complications are identified., Design: In 1992 we conducted a survey of randomly selected members of the American Academy of Ophthalmology and American Optometric Association. Responses were obtained from 538 (82%) of 655 eligible ophthalmologists and 130 (84%) of 154 eligible optometrists., Results: Eighty-eight percent of responding ophthalmologists reported that patients had 4 or more visits within 4 months after surgery, 97% of ophthalmologists performed the first postoperative examination on their cataract surgery patients, and 60% of ophthalmologists reported that no other eye professional saw their patients postoperatively. Forty-six percent of responding optometrists participated in postoperative care of cataract surgery patients, and usually performed their first postoperative examination 7 days after surgery; 78% of these optometrists reported that they saw patients 3 or more times after surgery. Postoperatively, 83% of ophthalmologists and 75% of optometrists usually performed at least 1 dilated fundus examination, 87% of ophthalmologists and 47% of optometrists performed 4 or more slit-lamp examinations, 74% of ophthalmologists and 42% of optometrists performed 4 or more tonometry tests, and 83% of both groups performed 2 or more refractions. More than 80% of responding optometrists involved in postoperative care of cataract surgery patients immediately refer a patient to an ophthalmologist if there is evidence of acute glaucoma or an unexplained decrease in vision in the eye that was operated on. For less urgent complications, most optometrists promptly make a referral to an ophthalmologist., Conclusions: In 1992, a small percentage of ophthalmologists and optometrists were performing fewer follow-up examinations and tests for cataract patients than recommended by the American Academy of Ophthalmology. Not all optometrists immediately refer to an ophthalmologist any acute complication that they identify postoperatively.

To determine features of the presentation of clinical practice guidelines that may enhance their use by internists, we conducted a cross-sectional survey to which 1,513 (60%) of 2,513 eligible internists responded. Endorsements by respected colleagues and by major organizations were identified as very important by 72% and 69% of respondents, respectively. Respondents preferred short pamphlets and manuals summarizing a number of guidelines and felt that concise recommendations (86%), synopsis of supporting evidence (85%), and quantification of benefit (77%) were important in guideline presentation. We conclude that guideline developers should gain the endorsement of major organizations and present key aspects in brief, easily assimilated formats.

Objectives: To assess the test-retest reliability and responsiveness of the VF-14, which is an index of functional impairment in patient with cataracts., Design: Observational longitudinal study. Patients were enrolled prior to undergoing their first cataract surgery between July 15 and December 15, 1991, and they were followed up for 1 year after surgery., Setting: Patients were recruited from 72 ophthalmologists' practices in three US cities., Patients: Five hundred fifty-two patients who had undergone a surgical procedure in only one eye by the 4-month postoperative follow-up (responsiveness analyses) and a subset of these (n = 426) who had not subsequently undergone surgery for the second eye by the 12-month postoperative follow-up (reproducibility analyses)., Main Outcome Measures: Two health status measures (the VF-14 and the Sickness Impact Profile, two global measures of a patient's trouble and satisfaction with his or her vision, and best corrected visual acuity in each eye., Results: The VF-14 is highly reproducible, with an intraclass correlation coefficient of .79 when patient-rated criteria are used to define stable patients. The intraclass correlation coefficient was lower (.57 to .71) when various measures of visual acuity were used to define stable patients. The VF-14 is also about three times more responsive to a change in vision than the Sickness Impact Profile, which is a generic health status measure (effect size of approximately 1.00 vs 0.30). Estimates of the responsiveness of the VF-14 and the Sickness Impact Profile were not associated with preoperative visual acuity in the operated on or better eye. Responsiveness of the VF-14, however, was higher in patients with greater self-rated trouble with vision preoperatively., Conclusions: The VF-14 was reproducible in stable patients during an 8-month period, and it was more responsive to clinically significant changes in vision than was a generic health status measure (ie, the Sickness Impact Profile).

Objective: To describe the relationship between patients' preoperative expectations regarding the outcome of cataract surgery and actual postoperative experience., Methods: A longitudinal study of 772 patients undergoing first eye cataract surgery recruited from 75 ophthalmology practices in three metropolitan areas was conducted. Prior to surgery and approximately 4 months after surgery, a detailed interview was conducted that included general and vision-specific health status measures (including the Visual Function 12-Item Scale [VF-12]), patient-reported level of trouble and satisfaction with vision, and questions addressing patients' preoperative expectations regarding the outcomes of surgery. In addition, detailed clinical data were collected preoperatively and postoperatively. A total of 552 patients had only single eye cataract surgery by 4 months postoperatively and are included in this analysis., Results: Patients' preoperative expectations regarding the impact of cataract surgery were very high and were unrelated to their demographic or ocular characteristics. The preoperative VF-12 score, however, was positively correlated with expected postoperative VF-12 score (Spearman correlation, .45, P < .001). Only 61% of patients achieved or surpassed their expected level of postoperative functioning. The difference between expected and actual postoperative VF-12 scores was not associated with patients' demographic characteristics or provider-related variables. Older patients (> 75 years) and patients with ocular comorbidity had a larger difference between expected and actual postoperative functioning than younger patients and those without ocular comorbidity., Conclusion: Expectations regarding visual functioning after cataract surgery are very high, and in most cases such expectations are fulfilled. In selected cases, more comprehensive counseling may reduce the discrepancy between expectations and actual outcomes of cataract surgery.

To assess variation in reported use of preoperative medical tests in patients undergoing cataract surgery and to identify factors that influence test use by different physician groups we performed a national survey of ophthalmologists, anesthesiologists, and internists. Participants included randomly selected members of American professional societies who provided care to one or more patients undergoing cataract surgery in 1991. Responses were obtained from 538 (82%) of 655 eligible ophthalmologists, 109 (76%) of 143 anesthesiologists, and 54 (44%) of 122 internists. Fifty percent of ophthalmologists, 40% of internists, and 33% of anesthesiologists frequently or always obtained a chest x-ray film, while 20% of ophthalmologists, 27% of internists, and 37% of anesthesiologists never obtained a chest x-ray film for patients being considered for cataract surgery who had no history of major medical problems (P < .01 for differences between ophthalmologists and the other groups). Similarly, 70% to 90% of ophthalmologists, 73% to 79% of internists, and 41% to 79% of anesthesiologists frequently or always obtained a complete blood cell count, electrolyte panel, and electrocardiogram, while 4% to 11% of ophthalmologists, 13% to 17% of internists, and 9% to 28% of anesthesiologists never obtained these tests for such patients. Many respondents (32% to 80%) believed tests were unnecessary but cited multiple reasons for obtaining tests (eg, medicolegal concerns and institutional requirements). Many physicians in each group viewed preoperative evaluations as screening opportunities or believed that one of the other two types of physicians "required" tests. We conclude that marked variation exists within and across physician specialties in the use and rationale for use of medical tests in patients undergoing cataract surgery.

To characterize the intraoperative procedures employed by cataract surgeons in the United States and the beliefs underlying the practices, a standardized questionnaire was sent to a systematic random sample of members of the American Academy of Ophthalmology in 1992. Of 667 surveyed ophthalmologists, 550 completed the questionnaire (response rate, 82.5%). Phacoemulsification was used for more than 75% of routine cataract surgery by 46% of respondents, whereas standard extracapsular surgery was used for more than 75% of routine cataract surgery by 41% of respondents. Preferential use of phacoemulsification was independently associated with more recent graduation from medical school and higher reported annual surgical volume. Continuous tear capsulotomy was employed by 52% of ophthalmologists. Preference for this technique was independently associated with both the use of phacoemulsification and higher annual surgical volume. Seventy-one percent of respondents used retrobulbar anesthesia, whereas 28% used peribulbar anesthesia. Use of peribulbar anesthesia was independently associated with both greater surgical volume and performance of surgery in an ambulatory surgical center. Beliefs regarding comparative safety and effectiveness were reported to influence surgeons' preferences strongly among all of the competing techniques studied. Those performing phacoemulsification, in comparison with those performing extracapsular cataract extraction, reported that the expectation of reduced astigmatism and shorter recovery time strongly influenced their choice of procedure. Variation in preferred intraoperative techniques is substantial for cataract surgery and the beliefs that underlie the preferences. Such variation highlights the need to determine which techniques maximize patient outcomes and are most cost-effective.

The increased demand for health status measures in evaluating medical interventions has increased the importance of clarifying when to use generic versus disease-specific health status measures. The authors compared the performance of a well known generic health status measure, the Sickness Impact Profile (SIP), and a disease-specific measure of functional impairment related to vision (the VF-14) in detecting functional impairment in 426 cataract patients before and at 12 months after first eye cataract surgery. Using analysis of covariance models, the associations were assessed between the SIP and VF-14 and four criterion variables--patient ratings of trouble and satisfaction with their vision and overall health, and best corrected visual acuity--after controlling for patient age and medical comorbidities. Preoperative patient ratings of trouble and satisfaction with vision were significantly associated with VF-14 scores (P < 0.001), but not with SIP scores. Preoperative visual acuity in the better eye was significantly associated with both VF-14 and SIP scores (P < 0.001). Patient general health ratings were significantly associated with SIP scores (P < 0.001), but not with VF-14 scores. Postoperative changes in patient ratings of their vision and in visual acuity were significantly associated with changes in VF-14 scores (P < 0.05), but not with changes in SIP scores. Changes in patient ratings of overall health were significantly associated with changes in SIP scores (P < 0.01), but not with changes in VF-14 scores. In patients undergoing cataract surgery, a disease-specific health status measure is more sensitive to preoperative functional impairment related to vision, and to change in functional impairment after cataract surgery, than is a generic health status measure.

Purpose: The influence of both blood flow and anastomotic technique on the development of anastomotic stricture formation was studied using a dog model., Methods: Fifty-three dogs underwent distal colocolonic anastomosis with either an EEA (U.S. Surgical Corp., Norwalk, CT) circular stapler or a Czerny-Lembert two-layered, handsewn anastomosis. Blood flow was measured by Laser Doppler Velocimetry using the Laserflo BPM2 (Vasamedics Inc., St. Paul, MN). The animals were separated into three blood flow groups: greater than or equal to 62.5 percent of normal blood flow, between 37.5 percent and 62.5 percent of normal blood flow, and less than or equal to 37.5 percent of normal blood flow. Each blood flow group had an anastomosis performed by either stapling or by hand sewing techniques. At six weeks, the anastomoses were opened longitudinally and fixed to determine the anastomotic index (AI). AI is defined as two times the anastomotic circumference over the proximal circumference plus the distal circumference. Blood flow groups and anastomotic technique groups were compared with an interaction variable for the outcome, AI using a two-way analysis of variance., Results: The AI of the stapled anastomoses was found to be significantly higher than handsewn anastomoses (P < 0.006). There was no difference in AI between different blood flow groups and no correlation of observed histologic findings with AI., Conclusion: Clinically relevant ischemia does not directly influence stricture formation in either handsewn or stapled distal colonic anastomoses.

Objective: To assess variation in optometrists' use of ophthalmic tests in the evaluation of patients being considered for cataract surgery who have no history of other eye disease., Design/participants: National survey of a systematic sample of practicing members of the American Optometric Association (St Louis, Mo), who had referred at least one patient to an ophthalmologist for consideration of cataract surgery in 1991., Results: Ninety-two of 130 eligible responding optometrists reported that they routinely performed preoperative testing on patients being considered for cataract surgery. Of these 92 optometrists, 91 (99%) frequently or always performed refraction, and 82 (89%) frequently or always performed a dilated fundus examination in their evaluation of patients being considered for cataract surgery who had no history of other eye disease. None of these 92 optometrists reported using B-scan ultrasonography or electroretinograms frequently or always, and few used A-scan ultrasonography or visual evoked responses frequently or always. A substantial percentage frequently or always used formal visual field testing (47%), formal color vision testing (40%), fundus photography (24%), potential acuity measurement (25%), glare testing (23%), contrast sensitivity testing (19%), and specular microscopy (14%), while 11% to 81% of optometrists never performed these tests on such patients. More recent graduation from optometry school was associated with a decreased frequency of use of potential acuity measurement and contrast sensitivity testing and with an increased use of dilated fundus examinations., Conclusion: There is a substantial variation in optometrists self-reported use of a number of ophthalmic tests in the preoperative evaluation of patients being considered for cataract surgery who have no history of other eye disease.

To estimate patient preferences for gallstone-related treatments and outcomes, and assess how preferences vary by patient characteristics and scaling technique, the authors randomly assigned 40 patients without gallstones to interviews based on a rating scale (n = 22) and a standard gamble (n = 18). The patients assigned preference values (possible values 0 to 1) to open cholecystectomy (mean 0.45 by rating scale, 0.78 by standard gamble), laparoscopic cholecystectomy (0.71, 0.91), extracorporeal shock-wave lithotripsy (0.77, 0.89), acute cholecystitis (0.36, 0.77), lifetime biliary colic (0.41, 0.71), postcholecystectomy syndrome (0.43, 0.79), asymptomatic stone necessitating treatment with bile acids (0.76, 0.96), and surgical scar (0.79, 0.998). Preferences varied little by age, gender, or race. Standard gamble values were highly correlated with, but significantly greater than, rating scale values. The authors conclude that patients' preferences for gallstone-related conditions generally are significantly less than one, and differ markedly by the scaling technique used to derive them. These results should be considered when patient preferences are incorporated into analyses of gallstone treatments.

Little information is available either for the clinical value of many ophthalmic tests performed preoperatively in the evaluation of patients for cataract surgery or for variation in ophthalmologists' use of such tests. To assess variation in ophthalmologists' use of ophthalmic tests, we conducted a national survey of American Academy of Ophthalmology members. Thirty-three percent, 17%, 37%, and 19% of the respondents reported that they "frequently" or "always" perform glare testing, contrast sensitivity testing, potential acuity measurement, and specular microscopy, respectively, in patients being considered for cataract surgery who have no history of eye disease other than cataract. In contrast, 27%, 54%, 24%, and 48% of respondents reported that they never perform each of these four tests in such patients. Two ophthalmologist characteristics--a surgical volume of greater than 200 cataract extractions per year and performance of surgery in an ambulatory surgical center or private office (as opposed to a hospital)--were independently associated with an increased probability of performing each of these four tests frequently or always. Ten percent or less of the respondents reported that they frequently or always perform electroretinography, visual evoked response testing, photography of fundus or anterior segment, B-scan ultrasonography, formal color vision testing, and formal visual field testing in such patients. Thus, there is considerable variation in ophthalmologists' use of glare testing, contrast sensitivity testing, potential acuity measurement, and specular microscopy. A small percentage of ophthalmologists may be overusing several other tests in the evaluation of patients being considered for cataract surgery.

Objective: To assess internists' familiarity with, confidence in, and attitudes about practice guidelines issued by various organizations., Design: Cross-sectional, self-administered survey., Participants: Questionnaires were mailed to a stratified random sample of 2600 members of the American College of Physicians (ACP) in 1992. Of the 2513 internists who met our eligibility criteria, 1513 responded (60%)., Measurements and Results: Familiarity with guidelines varied from 11% of responders for the ACP guideline on exercise treadmill testing to 59% of responders for the National Cholesterol Education Program guideline. Confidence was reported in ACP guidelines by 82% of responders but by only 6% for Blue Cross and Blue Shield guidelines. Subspecialists had greatest confidence in guidelines developed by their own subspecialty organizations. It was thought that guidelines would improve the quality of health care by 70% of responders, increase health care costs by 43%, be used to discipline physicians by 68%, and make practice less satisfying by 34%. More favorable attitudes were held by internists who were paid a fixed salary, saw patients for less than 20 hours per week, had recently graduated from medical school, or were not in private practice., Conclusions: Although most ACP members studied recognized the potential benefits of practice guidelines, many were concerned about possible effects on clinical autonomy, health care costs, and satisfaction with clinical practice.

Background: Although ophthalmologists have long recognized that visual acuity alone is an inadequate measure of visual impairment, the need for and outcomes of cataract surgery historically have been assessed in terms of visual acuity., Purpose: To examine the relation among different cataract surgery outcome measures, including a 14-item instrument designed to measure functional impairment caused by cataract (the VF-14), at 4 months after cataract surgery., Methods: The authors performed a longitudinal study of 552 patients undergoing first eye cataract surgery by 1 of 75 ophthalmologists practicing in Columbus, Ohio, St. Louis, Missouri, or Houston, Texas. Patients were interviewed, and clinical data were obtained preoperatively (July 15, 1991-March 14, 1992) and 4 months postoperatively., Results: The percentage of patients judged to be improved at 4 months after cataract surgery varied by the outcome measure used: Snellen visual acuity (96%); VF-14 score (89%); satisfaction with vision (85%); self-reported trouble with vision (80%); and Sickness Impact Profile score (67%). The change in patients' ratings of their trouble with vision and their satisfaction with vision were correlated more strongly with the change in VF-14 score than with the change in visual acuity (operated eye or better eye). The average change in VF-14 score was unrelated to the preoperative visual acuity in the eye undergoing surgery., Conclusion: Estimates of the proportion of patients benefiting from cataract surgery vary with the outcome measure used to measure benefit. Change in VF-14 score, a measure of functional impairment related to vision, may be a better measure of the benefit of cataract surgery than change in visual acuity.

Objective: To describe the development and the performance of a brief questionnaire designed to measure functional impairment caused by cataract (the VF-14)., Design: Observational cross-sectional study. Patients were recruited between July 15 and December 15, 1991., Setting: Patients were recruited from the practices of 70 ophthalmologists, located in Columbus, Ohio (N = 21), St Louis, Mo (N = 26), and Houston, Tex (N = 23)., Patients: Seven hundred sixty-six patients undergoing cataract surgery for the first time., Main Outcome Measures: Preoperative best corrected visual acuity in each eye; scores on the VF-14, a new index of functional impairment in patients with cataract; patient reports of overall trouble and satisfaction with their vision; and scores on the Sickness Impact Profile, a measure of general health status., Results: The VF-14 has high internal consistency (Cronbach's alpha = .85) and correlates more strongly with the overall self-rating of the amount of trouble and satisfaction patients have with their vision than do several measures of visual acuity or the Sickness Impact Profile score. The VF-14 score is moderately correlated with visual acuity in the better eye., Conclusions: The VF-14 is a reliable and valid measure of functional impairment caused by cataract and provides information not conveyed by visual acuity or a general measure of health status.

Social/aggressive behavior in adult rat offspring (beginning at postnatal Day 180) prenatally exposed to saline, cocaine, or amfonelic acid (AFA) was examined. Pregnant rats received injections of 15 mg/kg of cocaine, or 0.9% saline twice daily, s.c., or on 2 consecutive days at 4-day intervals, or 1.5 mg/kg amfonelic acid daily throughout gestational Days 1-20. Frequency, duration, and latency of 11 social/aggressive behaviors were recorded for two 15-min sessions during which a smaller male intruder replaced an ovariectomized female in the resident's home cage. Subjects received a s.c. saline injection before Session 1 and 2.0 mg/kg of gepirone, a 5HT1a partial agonist, prior to Session 2. Prenatal cocaine treatment resulted in alterations of aggressive behavior. Aggressive behavior was reduced by gepirone in all groups but to a lesser extent in the AFA group.

Background: Since 1989, laparoscopic cholecystectomy has been widely adopted as a treatment for gallstone disease. We analyzed the association between the introduction of this procedure and three variables: the rate at which cholecystectomy was performed in Maryland, the characteristics of patients undergoing cholecystectomy in routine clinical practice, and operative mortality., Methods and Results: We used 1985-1992 hospital-discharge data from all 54 acute care hospitals in Maryland, to identify open and laparoscopic cholecystectomies, characteristics of patients undergoing these procedures, and deaths occurring during hospitalizations in which these procedures were performed. The annual rate of cholecystectomy, adjusted for age, rose from 1.69 per 1000 state residents in 1987-1989 to 2.17 per 1000 residents in 1992, an increase of 28 percent (P < 0.001). As compared with patients undergoing open cholecystectomy, patients undergoing laparoscopic cholecystectomy tended to be younger, less likely to have acute cholecystitis or a common-duct stone, and more likely to be white and have private health insurance or belong to a health maintenance organization (P < 0.001). Although the operative mortality associated with laparoscopic cholecystectomy was less than that with open cholecystectomy (adjusted odds ratio, 0.22; 95 percent confidence interval, 0.13 to 0.37) and the overall mortality rate for all cholecystectomies declined from 0.84 percent in 1989 to 0.56 percent in 1992, there was no significant change in the total number of cholecystectomy-related operative deaths because of the increase in the cholecystectomy rate., Conclusions: In Maryland, although the adoption of laparoscopic cholecystectomy has been accompanied by a 33 percent decrease in overall operative mortality per procedure, the total number of cholecystectomy-related deaths has not fallen because of a 28 percent increase in the total rate of cholecystectomy.

To assess the efficacy of immune globulin in preventing CMV infection, interstitial pneumonia, GVHD and death after BMT, we reviewed and synthesized data from 12 published studies (with 1282 patients) in which immune globulin was used prophylactically in BMT patients, controls were included and clinical outcomes were assessed. Data synthesis indicates that immune globulin significantly reduces fatal CMV infection (odds ratio (OR) 0.47, 95% confidence interval (CI) 0.23-0.99), CMV pneumonia (OR 0.61, CI 0.42-0.89), non-CMV interstitial pneumonia (OR 0.57, CI 0.35-0.95) and total mortality (OR 0.74, CI 0.55-0.99). The reduction in acute GVHD was not quite significant (OR CI 0.45-1.02). Complications decrease with both hyperimmune and conventional immune globulin. For CMV-negative transplant recipients, immune globulin decreases symptomatic CMV infection (OR 0.55, CI 0.31-0.94) and interstitial pneumonia (OR 0.34, CI 0.15-0.77). For CMV-positive recipients, immune globulin prevents interstitial pneumonia (OR 0.45, CI 0.26-0.80) but not symptomatic CMV infection (CI 0.41-2.80). We conclude that immune globulin is efficacious in preventing major complications of BMT in both CMV-negative and CMV-positive recipients.

Although more than 1 million cataract surgeries are performed annually in the United States, little is known about the frequency of use or cost of various services provided in connection with this procedure. To assess the frequency with which various ophthalmic, optometric, anesthesia, and medical services are provided in conjunction with cataract surgery and to estimate the cost to Medicare associated with those services, we analyzed 1985 through 1988 Medicare claims records of a nationally representative 5% sample of Medicare beneficiaries. The experience of 57,103 Medicare beneficiaries who underwent extracapsular cataract surgery in 1986 or 1987 that was not combined with another ophthalmologic procedure formed the basis of our analysis. Projections for current costs were performed using 1991 charges allowed by Medicare for physician services. We estimate that the median charge allowed by Medicare for a "typical" episode of cataract surgery in 1991 was approximately $2500. In addition to the $3.4 billion that Medicare spent in 1991 on such "typical" episodes, Medicare spent more than $39 million on miscellaneous "atypical" preoperative ophthalmologic tests, such as specular microscopy (14% of cases) and potential acuity testing (8% of cases), more than $7 million on postoperative ophthalmologic diagnostic tests, such as fluorescein angiography (3% of cases), and more than $18 million on perioperative medical services (most commonly electrocardiography and chest roentgenography). The major determinants of the cost to Medicare associated with cataract surgery are the rate of performance of cataract surgery and neodymium-YAG laser capsulotomy and the charges allowed for these procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

To assess how payer costs for allogeneic BMT relate to patient characteristics and clinical complications, a retrospective cohort study of 402 persons undergoing allogeneic BMT between 1980 and 1987 at a university-based BMT center was designed to determine total inpatient payer costs, including hospital and physician costs, and number of days hospitalized during the first 180 days following BMT. The average total inpatient payer cost (in 1990 dollars) during the first 180 days following BMT was $208,410. Inflation-adjusted inpatient payer costs increased from $227,806 in 1980 to $308,545 in 1983, and then decreased to $156,163 by 1987. In multivariate analysis, inpatient payer costs were strongly associated with occurrence of CMV infection (increase of $53,517; p = 0.0001) or acute GVHD (increase of $46,500; p = 0.001), and significantly associated with malignant (versus non-malignant) disease (decrease of $36,633; p = 0.05), even after adjusting for length of survival and year of BMT. Inpatient payer costs were not related to patient age, sex or race. Despite recent reductions in inpatient payer costs for BMT, CMV infection and acute GVHD continue to be associated with tremendous costs to third party payers. Further reductions in the costs of BMT may require improved prevention of CMV infection and GVHD.

Objective: To examine associations between demographic characteristics and use of interventional procedures in patients with peripheral arterial disease., Design: Case series drawn from a statewide hospital discharge database., Setting: Nonfederal acute-care hospitals in Maryland., Patients and Interventions: A total of 7080 cases of angioplasty, bypass surgery, or amputation for lower-extremity peripheral arterial disease in 1988 through 1989., Main Outcome Measure: Use of angioplasty, bypass surgery, and lower-extremity amputation., Results: A total of 1185 angioplasties, 4005 bypass operations, and 1890 amputations were identified. Population-based annual rates showed that angioplasty use peaked at about 70 per 100,000 at the age of 65 to 74 years, bypass surgery use peaked at more than 250 per 100,000 at 75 to 84 years of age, and amputation use peaked at about 225 per 100,000 at 85 years of age and older. The age-adjusted likelihood of having a procedure for peripheral arterial disease was 1.7 times higher in men than in women and 1.6 times higher in blacks than in whites. Compared with patients who had angioplasty or bypass surgery, patients who had amputations were more likely to be more than 65 years old, to be black (odds ratio, 2.5), to have Medicaid or no insurance (odds ratio, 1.7), to have diabetes mellitus (odds ratio, 3.0), and not to have hypertension (odds ratio, 3.1). Compared with patients who had bypass surgery, patients who had angioplasty were more likely to be under 65 years old, to be white (odds ratio, 1.7), and not to have diabetes mellitus (odds ratio, 1.3)., Conclusion: Patient race is associated with differences in the frequency with which angioplasty, bypass surgery, and amputation are performed for peripheral arterial disease, and insurance status is associated with the likelihood of having amputation.

The purpose of this study was to estimate the net cost effect to Medicare of the increasing use of recombinant human erythropoietin (EPO) instead of red blood cell transfusions or androgens in the management of anemia for the approximately 100,000 hemodialysis patients in the U.S. End-Stage Renal Disease (ESRD) program. A computerized decision model that takes into account the effectiveness and possible side effects of transfusions, androgens, and EPO and predicts 1- and 5-yr direct medical costs to Medicare associated with each therapy was constructed. Probability estimates for clinical events were derived from the literature. Costs were assigned by use of the amounts Medicare pays providers of ESRD care for: (1) use of EPO, transfusions, and androgens; and (2) health care services related to the treatment of anemia (including complications of treatment and possible reductions in morbidity). For every 10,000 hemodialysis patients treated with EPO, net Medicare expenditures will be much greater than if only transfusions are used by $42,530,000 at 1 yr (6% of ESRD program costs) and by $118,050,000 at 5 yr and also much greater than if androgens are used (by $42,700,000 at 1 yr and $118,370,000 at 5 yr). The increase in cost was highly sensitive to the dose of EPO; moderately sensitive to changes in estimated anemia response rates for EPO, frequency of EPO-induced vascular access clotting, and reduction in cardiovascular or overall morbidity; and slightly sensitive to transfusion rates, estimated anemia response rates for androgens, frequency of EPO-induced seizure or hypertensive complications (stroke, myocardial infarction), frequency of transfusion-related viral infection, and frequency of androgen-induced virilization. Considering both effectiveness and side effects of alternative treatments for the anemia of ESRD, it was projected that the increasing use of EPO will markedly increase the cost to Medicare of ESRD medical care.

This paper will review the applicability of VXIbus based instruments to the needs of the bioengineering and biomedical measurement communities. Peak signal bandwidths supported by VXIbus extend to the GHz range which is well above most biological signal requirements. Similarly, environmental compatibility specifications including electromagnetic compatibility, cooling, shock, and vibration may exceed most needs and add to unnecessary cost. Despite these potential mismatches, the instrument-on-a-card and the virtual instrument capabilities of VXIbus offer advantages over existing RS-232, IEEE488.1/.2, plug-in cards, and other "rack-and-stack" systems. Expansion and flexibility inherent in VXIbus devices make them resistant to obsolescence and easy to upgrade. Users are faced with a number of selection criteria when making instrumentation decisions. Bandwidth, power, isolation, cost, performance, software for control, and future development needs are among the issues that must be evaluated. A list of systems, devices, and suppliers is provided as part of this paper.

Two studies were conducted to assess the effects of buspirone and alprazolam on a three-choice working memory water escape task. Both studies involved giving rats three daily trials, each trial consisting of an information run during which guillotine doors forced the rats to swim into the correct escape alley and a test run during which the rats could enter any of the three alleys but escape only on entering the same alley to which they had been forced on the information run. In the first experiment, rats were trained to a 70% correct choice criterion with 5-min interrun intervals and then tested for performance with 5, 20, 20 with distraction, and 60-min interrun intervals. In the second experiment, rats in each of the drug groups were tested after receiving one of three different doses of their respective drug. Results suggest that 1.0, 3.0, and 10.0 mg/kg buspirone but not 0.5, 1.0, and 2.0 mg/kg alprazolam impaired performance of rats on a three-choice working memory water escape task.

All dual-arch impression techniques utilize special stock impression trays of various designs. These trays are made of flexible plastic with fabric or mesh material placed across the occlusal surfaces of the teeth connecting their buccal and lingual flanges. The presence of this material will result in errors by (1) not allowing complete intercuspation during impression-taking; (2) producing incorrect recording of centric occlusion; and (3) because of the elastic memory of the tray/fabric, creating distortion of the elastic impression material. An impression technique is presented which provides a simple and effective method of obtaining dual-arch impressions for single restorations, post and cores, and small bridges. This technique obivates the need for impression trays thus eliminating the errors outlined.

Background: Percutaneous transluminal angioplasty has been adopted widely as a treatment for patients with peripheral vascular disease of the lower extremities. However, the effect of this procedure on the overall management of peripheral vascular disease and on the outcomes of patients has not been clearly delineated. In particular, it is not known whether angioplasty has replaced other treatments for peripheral vascular disease., Methods: To assess the extent to which angioplasty is used and the associated changes in the surgical management of peripheral vascular disease of the lower extremities, we used data on hospital discharges in Maryland to identify all angioplasty procedures, peripheral bypass operations, and lower-extremity amputations performed for peripheral vascular disease in Maryland hospitals between 1979 and 1989., Results: We estimated that from 1979 to 1989 the annual rate of percutaneous transluminal angioplasty for peripheral vascular disease of the lower extremities, adjusted for age and sex, rose from 1 to 24 per 100,000 Maryland residents (P less than 0.0001 by linear regression). Despite this increase in the use of angioplasty, the adjusted annual rate of peripheral bypass surgery also rose substantially, from 32 to 65 per 100,000 (P less than 0.001), whereas the adjusted annual rate of lower-extremity amputation remained stable at about 30 per 100,000. Total charges for hospitalizations during which a peripheral revascularization procedure was performed increased from $14.7 million in 1979 (in 1989 dollars) to $30.5 million in 1989., Conclusions: In Maryland, the adoption of percutaneous transluminal angioplasty for peripheral vascular disease of the lower extremities has been associated with an increase in the use of peripheral bypass surgery and with no decline in lower-extremity amputations. These results could be due to increased diagnosis of peripheral vascular disease, expanded indications for procedural interventions, or an increased number of repeat procedures performed in patients with peripheral vascular disease of the lower extremities.