Controlled trials of CQI and academic detailing to implement a clinical practice guideline for depression

BACKGROUND

The release of the Agency for Health Care Policy and Research (AHCPR)'s Guideline for the Detection and Treatment of Depression in Primary Care created an opportunity to evaluate under naturalistic conditions the effectiveness of two clinical practice guideline implementation methods: continuous quality improvement (CQI) and academic detailing. A study conducted in 1993-1994 at Kaiser Permanente Northwest Division, a large, not-for-profit prepaid group practice (group-model) HMO, tested the hypotheses that each method would increase the number of members receiving depression treatment and would relieve depressive symptoms.

METHODS

Two trials were conducted simultaneously among adult primary care physicians, physician assistants, and nurse practitioners, using the same guideline document, measurement methods, and one-year follow-up period. The academic detailing trial was randomized at the clinician level. CQI was assigned to one of the setting's two geographic areas. To account for intraclinician correlation, both trials were evaluated using generalized equations analysis.

RESULTS

Most of the CQI team's recommendations were not implemented. Academic detailing increased treatment rates, but--in a cohort of patients with probable chronic depressive disorder--it failed to improve symptoms and reduced measures of overall functional status.

CONCLUSIONS

New organizational structures may be necessary before CQI teams and academic detailing can substantially change complex processes such as the primary care of depression. New research and treatment guidelines are needed to improve the management of persons with chronic or recurring major depressive disorder.

Fidelity and processivity of Saccharomyces cerevisiae DNA polymerase eta

The yeast RAD30 gene functions in error-free replication of UV-damaged DNA, and RAD30 encodes a DNA polymerase, pol eta, that has the ability to efficiently and correctly replicate past a cis-syn-thymine-thymine dimer in template DNA. To better understand the role of pol eta in damage bypass, we examined its fidelity and processivity on nondamaged DNA templates. Steady-state kinetic analyses of deoxynucleotide incorporation indicate that pol eta has a low fidelity, misincorporating deoxynucleotides with a frequency of about 10(-2) to 10(-3). Also pol eta has a low processivity, incorporating only a few nucleotides before dissociating. We suggest that pol eta's low fidelity reflects a flexibility in its active site rendering it more tolerant of DNA damage, while its low processivity limits its activity to reduce errors.

Requirement of yeast SGS1 and SRS2 genes for replication and transcription

The SGS1 gene of the yeast Saccharomyces cerevisiae encodes a DNA helicase with homology to the human Bloom's syndrome gene BLM and the Werner's syndrome gene WRN. The SRS2 gene of yeast also encodes a DNA helicase. Simultaneous deletion of SGS1 and SRS2 is lethal in yeast. Here, using a conditional mutation of SGS1, it is shown that DNA replication and RNA polymerase I transcription are drastically inhibited in the srs2Delta sgs1-ts strain at the restrictive temperature. Thus, SGS1 and SRS2 function in DNA replication and RNA polymerase I transcription. These functions may contribute to the various defects observed in Werner's and Bloom's syndromes.

Sulfuric acid on Europa and the radiolytic sulfur cycle

A comparison of laboratory spectra with Galileo data indicates that hydrated sulfuric acid is present and is a major component of Europa's surface. In addition, this moon's visually dark surface material, which spatially correlates with the sulfuric acid concentration, is identified as radiolytically altered sulfur polymers. Radiolysis of the surface by magnetospheric plasma bombardment continuously cycles sulfur between three forms: sulfuric acid, sulfur dioxide, and sulfur polymers, with sulfuric acid being about 50 times as abundant as the other forms. Enhanced sulfuric acid concentrations are found in Europa's geologically young terrains, suggesting that low-temperature, liquid sulfuric acid may influence geological processes.

Akinesia and postural abnormality after unilateral dopamine depletion

Following unilateral nigrostriatal dopamine depletion rats engage in drug-induced and spontaneous turning. These asymmetric behaviors are associated with a hemispheric asymmetry in the dopamine function. Several tests of 'spontaneous' behavior have revealed other abnormalities, primarily in posture and akinesia. A test is described here which quantifies postural abnormalities, as well as difficulties in initiating and terminating movement. This test may be suitable for evaluating aspects of dopamine-mediated behaviors not addressed by drug tests and may prove valuable in evaluating the potential of new treatment strategies for Parkinson's disease.

Is cigarette smoking associated with impaired physical and mental functional status? An office-based survey of primary care patients

OBJECTIVE

To examine the relationship between cigarette smoking and self-reported physical and mental functional status.

DESIGN

Cross-sectional survey of 837 patients visiting 2 family-practice centers. Patients completed a self-administered survey about functional status, tobacco use, and demographic characteristics while waiting to be called back for their appointments.

SETTING

An inner-city family practice clinic in Richmond, Virginia, and a more affluent suburban practice outside Washington, DC.

MAIN OUTCOME MEASURES

Physical and mental functional status, as measured by the SF-36 (Medical Outcomes Trust, Boston, MA); current and former cigarette use; and demographic variables (age, gender, education, income).

RESULTS

Among current smokers, self-reported functional status scores were significantly lower than those of nonsmokers in all SF-36 domains (p < or = 0.02), a pattern that was more dramatic for mental functional status domains (social function, vitality, emotional role limitations, mental health). In several SF-36 domains, a dose-response relationship between smoking and functional status was noted. After multivariate adjustment for demographic confounders and practice site, the statistical significance of these differences diminished considerably, but it remained significant for certain domains and for the overall difference across all domains (MANCOVA p = 0.017).

CONCLUSIONS

Current smokers report lower functional status than nonsmokers, in physical and especially in mental domains. The meaning of this cross-sectional relationship is unclear without further longitudinal study. Smoking may be associated with other variables that have a causal role.

hRAD30 mutations in the variant form of xeroderma pigmentosum

Xeroderma pigmentosum (XP) is an autosomal recessive disease characterized by a high incidence of skin cancers. Yeast RAD30 encodes a DNA polymerase involved in the error-free bypass of ultraviolet (UV) damage. Here it is shown that XP variant (XP-V) cell lines harbor nonsense or frameshift mutations in hRAD30, the human counterpart of yeast RAD30. Of the eight mutations identified, seven would result in a severely truncated hRad30 protein. These results indicate that defects in hRAD30 cause XP-V, and they suggest that error-free replication of UV lesions by hRad30 plays an important role in minimizing the incidence of sunlight-induced skin cancers.

Requirement of DNA polymerase activity of yeast Rad30 protein for its biological function

The RAD30 gene of Saccharomyces cerevisiae encodes a DNA polymerase, Poleta. The Rad30 protein shares homology with the yeast Rev1 and the Escherichia coli DinB and UmuC proteins. Although these proteins contain several highly conserved motifs, only Rad30 has been shown to possess a DNA polymerase activity. To determine whether the DNA polymerase activity of Rad30 was essential for its biological function, we made a mutation in the highly conserved SIDE sequence in Rad30, in which the aspartate and glutamate residues have each been changed to alanine. The mutant Rad30 protein lacks the DNA polymerase activity, and the mutant gene does not complement the rad30Delta mutation. These findings indicate that DNA polymerase activity is indispensable for the biological function of RAD30.

Hydrogen peroxide on the surface of Europa

Spatially resolved infrared and ultraviolet wavelength spectra of Europa's leading, anti-jovian quadrant observed from the Galileo spacecraft show absorption features resulting from hydrogen peroxide. Comparisons with laboratory measurements indicate surface hydrogen peroxide concentrations of about 0.13 percent, by number, relative to water ice. The inferred abundance is consistent with radiolytic production of hydrogen peroxide by intense energetic particle bombardment and demonstrates that Europa's surface chemistry is dominated by radiolysis.

Head-to-head evaluation of five chlamydia tests relative to a quality-assured culture standard

Nucleic acid amplification tests offer superior sensitivity for the detection of Chlamydia trachomatis infection, but many laboratories still use nonamplification methods because of the lower cost and ease of use. In spite of their availability for more than a decade, few studies have directly compared the nonamplification tests. Such comparisons are still needed in addition to studies that directly compare individual nonamplification and amplification tests. The purpose of this study was to evaluate and compare the performance characteristics relative to culture of five different tests for the detection of C. trachomatis with and without confirmation of positive results. The tests were applied to endocervical specimens from 4,980 women attending family planning clinics in the northwestern United States. The five nonculture tests included Chlamydiazyme (Abbott), MicroTrak direct fluorescent antibody (DFA) (Syva), MicroTrak enzyme immunoassay (EIA) (Syva), Pace 2 (Gen-Probe), and Pathfinder EIA (Sanofi/Kallestad). All positive results obtained with a nonculture test (except MicroTrak DFA) were confirmed by testing the original specimens with a blocking antibody test (Chlamydiazyme), a cytospin DFA (MicroTrak EIA and Pathfinder EIA), and a probe competition assay (Pace 2). The prevalence of culture-proven chlamydia was 3.9%. The sensitivities of the nonculture tests were in a range from 62 to 75%, and significant differences between tests in terms of sensitivity were observed. The positive predictive value for each test was 0.85 or higher. The specificities of the nonculture tests without performance of confirmations were greater than 99%. Performing confirmatory tests eliminated nearly all of the false positives.

Efficient bypass of a thymine-thymine dimer by yeast DNA polymerase, Poleta

The RAD30 gene of the yeast Saccharomyces cerevisiae is required for the error-free postreplicational repair of DNA that has been damaged by ultraviolet irradiation. Here, RAD30 is shown to encode a DNA polymerase that can replicate efficiently past a thymine-thymine cis-syn cyclobutane dimer, a lesion that normally blocks DNA polymerases. When incubated in vitro with all four nucleotides, Rad30 incorporates two adenines opposite the thymine-thymine dimer. Rad30 is the seventh eukaryotic DNA polymerase to be described and hence is named DNA polymerase eta.

Cranial polyneuropathies in multiple sclerosis: case report and literature review

Although cranial neuropathies are common disorders in multiple sclerosis patients, multiple cranial nerve involvement is an unusual occurrence. Correlation of clinical symptoms with magnetic resonance imaging evidence of demyelinating central nervous system lesions can confirm the diagnosis. The authors report on the case of a 43-year-old woman who initially was thought to have suffered a brainstem infarct but, in fact, had developed multiple cranial nerve functional deficits. Treatment of multiple sclerosis remains primarily supportive in nature, with corticosteroids used for acute exacerbations and chronic progression.

Toxicokinetics of inhaled 2-butoxyethanol and its major metabolite, 2-butoxyacetic acid, in F344 rats and B6C3F1 mice

2-Butoxyethanol (2BE) is used extensively in the production of cleaning agents and solvents. It is primarily metabolized in the liver to 2-butoxyacetic acid (2BAA), which is believed to be responsible for 2BE toxicities associated with hemolysis of red blood cells. The objective of the study was to characterize the systemic disposition of 2BE and 2BAA in rats and mice during 2-year 2BE inhalation toxicity studies. Male and female F344 rats and B6C3F1 mice (6-7 weeks old) were exposed to target 2BE concentrations of 0, 31.2, 62.5, or 125 ppm (rats), or 0, 62.5, 125, or 250 ppm (mice), by whole-body inhalation for 6 h/day, 5 days/week for up to 18 months. Postexposure blood samples were collected after 1 day, 2 weeks, and 3, 6, 12, and 18 months of exposure. Postexposure 16-h urine samples were collected after 2 weeks and 3, 6, 12, and 18 months of exposure. A separate set of mice was kept in the control chamber and exposed to 2BE for 3 weeks when they were approximately 19 months old. Postexposure blood samples were collected after 1 day and 3 weeks of exposure and 16-h urine samples were collected after 2 weeks of exposure from these aged mice. Blood samples were analyzed for both 2BE and 2BAA and urine samples were analyzed for 2BAA using GC/MS, and their kinetic parameters were estimated through the curve-fitting method using SAS. Systemically absorbed 2BE was rapidly cleared from blood (t1/2-RAT < 10 min; t1/2-MOUSE < 5 min after the 1-day exposure) independent of exposure concentration. Proportional increases in AUC2BE relative to increases in exposure concentration indicated linear 2BE kinetics. In contrast, the rate of 2BAA elimination from blood decreased as the exposure concentration increased. Nonproportional increases in AUC2BAA also indicated that 2BAA is eliminated following dose-dependent, nonlinear kinetics. Overall, mice eliminated both 2BE and 2BAA from blood faster than rats. Sex-related differences in 2BAA elimination were most significant with rats, in that females were less efficient in clearing 2BAA from the blood. Differences in renal excretion of 2BAA are possibly responsible for the sex-related difference in the 2BAA blood profiles in rats. As exposure continued, the rates of elimination for both 2BE and 2BAA decreased in both species, resulting in longer residence times in the blood. When 19-month-old naive mice were exposed to 125 ppm, 2BE was rapidly cleared from the systemic circulation, exhibiting clearance profiles similar to young mice. However, old mice eliminated 2BAA from blood > 10 times slower than young mice after 1-day of exposure. This delayed elimination of 2BAA in old mice was less obvious after 3 weeks of exposure, suggesting that there might be other factors in addition to the age of animals that could influence the apparent difference in 2BAA kinetics between old and young mice. It was concluded that the elimination kinetics of 2BE and 2BAA following repeated 2BE exposure appear to be dependent on species, sex, age, time of exposure, as well as the exposure concentration.

Laboratory testing for Neisseria gonorrhoeae by recently introduced nonculture tests: a performance review with clinical and public health considerations

Since 1992 two new nucleic acid-based tests (Gen-Probe Pace 2 and Abbott LCR) for the diagnosis of Neisseria gonorrhoeae infection have been approved by the U.S. Food and Drug Administration. We systematically assessed the quality of 21 studies that evaluated these tests' performance compared with that of culture for diagnosis of gonorrhea, on the basis of established criteria. We estimated overall test sensitivity and specificity by the testing method, sex, and anatomic site. None of the studies optimally fulfilled all quality criteria; few studies adequately used reference tests or described blinding. The sensitivity and specificity of nucleic acid hybridization (approximately 85%, approximately 98%) and amplification tests (approximately 95%, approximately 99%) were high and did not appear to differ substantially by sex or anatomic site. When proficiency in the performance of culture is high, the new tests are comparable to culture and may not offer a substantial advantage; in settings where optimization of culture is difficult, nucleic acid amplification may detect more infections than nucleic acid probe or culture.

Identification of APN2, the Saccharomyces cerevisiae homolog of the major human AP endonuclease HAP1, and its role in the repair of abasic sites

Abasic (AP) sites arise in DNA through spontaneous base loss and enzymatic removal of damaged bases. APN1 encodes the major AP-endonuclease of Saccharomyces cerevisiae. Human HAP1 (REF1) encodes the major AP endonuclease which, in addition to its role in DNA repair, functions as a redox regulatory protein. We identify APN2, the yeast homolog of HAP1 and provide evidence that Apn1 and Apn2 represent alternate pathways for repairing AP sites. The apn1Delta apn2Delta strain displays a highly elevated level of MMS-induced mutagenesis, which is dependent on the REV3, REV7, and REV1 genes. Our findings indicate that AP sites are highly cytotoxic and mutagenic in eukaryotes, and that the REV3, REV7-encoded DNA polymerase zeta mediates the mutagenic bypass of AP sites.

Recent patterns of hormone replacement therapy use in a large managed care organization

Rates of hormone replacement therapy (HRT) in women have varied substantially over the last 25 years. Data on the impact of recent recommendations for widespread use to prevent cardiovascular disease and osteoporosis and factors that influence use are needed. We attempted to (1) describe recent trends in HRT use, (2) investigate the relationship between HRT use and prepaid drug benefit, and (3) detail prescribing frequencies by provider specialty. We conducted a cross-sectional analysis of annual HRT pharmacy dispensings from 1986 to 1995 in a large HMO to all female HMO members aged 45 years and older. HRT rates increased among all age categories, although the magnitude of change varied by age. Highest rates of use were found in those 50-59 years old. Although combined estrogen-progestin use increased, 57% of all estrogen users did not receive progestin in 1995. Unopposed estrogen use was largely limited to hysterectomized women. Women of all ages with no prepaid drug benefit as part of their HMO coverage had the lowest HRT rates. Internal medicine, obstetrics/gynecology, and family practice providers prescribed over 90% of HRT, and prescriber specialty varied with user age. HRT use increased in the HMO from 1986 to 1995, especially among younger women. In 1995, about half of women aged 50-64 years received one or more HRT dispensings. As the benefits, risks, and cost effectiveness of HRT depend on the duration of use, additional information on current use duration is needed. Combined estrogen-progestin use increased and appeared appropriate to hysterectomy status. Research is needed to determine if lower HRT use rates among women without a prepaid drug benefit indicate less prophylactic HRT use, particularly among younger women, for whom this lack of coverage was relatively common.

The functional status of inner-city primary care patients. Diminished function in a family practice population and its potential determinants

BACKGROUND

Research on health care quality and effectiveness often relies on global health status measures, such as functional status, but little is known about the functional status of patients in the primary care setting (without limitation to specific diseases) and even less about the function of the poor or ethnic minorities. In preparation for a planned practice-based research network, we administered a functional-status survey to patients visiting an inner-city family practice center.

METHODS

Over 9 weeks, 555 established patients older than 18 years, as well as adolescents accompanied by a parent or guardian, completed a survey that included the SF-36 Health Survey and questions about demographic variables and cigarette use. The survey was self-administered in the waiting area and examination room, and patients received no assistance from staff.

RESULTS

Functional-status scores reported by this primary care cohort were significantly lower than those of the general population (P < .001) and comparable with those reported nationally for patients with chronic diseases (e.g., congestive heart failure, diabetes). Functional-status scores were associated with age, sex, and, most strikingly, socioeconomic status. For example, patients with a yearly income of less than $15,000 had lower mean physical function scores than those reported nationally for patients with hypertension, diabetes, depression, recent myocardial infarction, or hypertension (P < .05). Patients who currently smoked reported lower physical function (P = .004) and strikingly lower mental function (P < .001) than nonsmokers.

CONCLUSIONS

Although patients completing the survey included healthy persons seeking preventive care and sick patients with acute and chronic illnesses, their overall functional status resembled that reported nationally for patients with chronic disease, perhaps reflecting the influence of poverty. Few studies have reported the association we observed between smoking and lower functional status. Further longitudinal studies in the primary care setting are necessary to fully interpret these associations and to evaluate the true impact of interventions on outcomes.

Prevalence variations in psychotropic treatment of children

This study was undertaken to clarify several aspects of the estimation of prevalence of three commonly use pediatric psychotropic agents, namely, methylphenidate, desipramine, and imipramine. The study aims are threefold: (1) to show the variability of drug prevalence by comparing estimates from three data sources; (2) to show the misleading impression that can be created by reporting drug prevalence estimates based on counts of prescriptions rather than persons; (3) to show the utility of gender-by-age-specific prevalence of drug use as a marker for diagnosis. Two data sources that yield population-based prescription estimates were available: 1991 Medicaid administrative claims data for prescriptions from a mid-Atlantic state and 1991 prescription records of the northwest region of Kaiser Permanente, a staff-model health maintenance organization (HMO). Another source of data consists of the 1991 National Ambulatory Medical Care Survey, which records medication information reported during physician office visits. Data analysis consists of quantitative estimates of (1) drug prevalence from each source; (2) the ratio of prescription claims to persons; and (3) the proportion of drug use according to age and gender. Methylphenidate and desipramine prevalence had a twofold greater use among state Medicaid enrollees compared with HMO enrollees. Average claims-to-person ratios of 5:1 suggest better accuracy using persons with medication rather than prescription counts. Gender-by-age-specific prevalence rates showed that 75% of the drug use for desipramine among those less than 15 years old was found among males, whereas 75% of the desipramine use among those 15 or older was found among females, suggesting its use for the treatment of attention deficit-hyperactivity disorder among young males and for depression among older females. The variability of community physician decision making in pediatric psychopharmacology is better understood by observing drug prevalence rates from different settings. National sampling efforts should be undertaken to verify regional and setting-specific prevalence findings and to learn the reasons for their fluctuation.

Information about barriers to planned change: a randomized controlled trial involving continuing medical education lectures and commitment to change

PURPOSE

To determine whether practicing physicians receiving only clinical information at a traditional continuing medical education (CME) lecture (control group) and physicians receiving clinical information plus information about barriers to behavioral change (study group) would alter their clinical behaviors at the same rate.

METHOD

In a randomized controlled trial, the investigators matched 13 pairs of U.S. and Canadian medical schools, assigning one school from each pair to study or control conditions. Following the commitment-to-change model, the investigators asked the primary care physicians attending control or study lectures on the management of cardiovascular risks whether they intended to make behavioral changes as a result of participating in the lectures and, if so, to indicate the specific changes. Thirty to 45 days later, the investigators surveyed the responding physicians to learn whether they had implemented those changes.

RESULTS

Information about barriers to change did not increase the likelihood that physicians in the study group would report successful changes; they were no more likely to change than those in the control group. However, the physicians in both study and control groups were significantly more likely to change (47% vs 7%, p < .001) if they indicated an intent to change immediately following the lecture.

CONCLUSIONS

Successful change in practice may depend less on clinical and barriers information than on other factors that influence physicians' performances. To further develop the commitment-to-change strategy in measuring the effects of planned change, it is important to isolate and learn the powers of individual components of the strategy as well as their collective influence on physicians' clinical behaviors.

Induction with levomethadyl acetate: safety and efficacy

BACKGROUND

Levomethadyl acetate hydrochloride (known as LAAM) is a mu-opioid agonist approved for the treatment of opioid dependence. Clinical trials comparing LAAM and methadone have reported lower patient retention rates during LAAM induction; however, this may reflect dose and schedule differences. Few studies have systematically examined LAAM dose induction. This study compared induction with 3 different LAAM dosage levels.

METHODS

In a randomized, double-blind trial, male and female opioid-dependent patients (N = 180) were assigned to 1 of 3 LAAM doses. The low-dose (25 mg) induction was constant from the onset of treatment, the medium-dose (50 mg) induction lasted 7 days, and the high-dose (100 mg) induction lasted 17 days. Safety and efficacy were assessed on retention, urinalysis and self-reported drug use, symptoms, and patient ratings of medication adequacy.

RESULTS

The high-dose group had significantly fewer illicit opioid-positive urine samples in weeks 3 and 4 as compared with the low-dose group. The high-dose group had significantly lower self-reported heroin craving in weeks 2 and 3. All groups demonstrated significant decreases in illicit drug use, withdrawal symptoms, and depression. There were no between-group differences in retention; however, there was a trend (P = .08) for lower retention and a greater number of agonist adverse effects were observed in the high-dose group. Overall, LAAM doses were well tolerated by most patients.

CONCLUSION

Induction with low and medium LAAM doses can be safely and effectively achieved within 7 days. Induction with higher LAAM doses can be safely achieved within 17 days, but may result in greater rates of patient dropout and opioid agonist adverse effects. Therefore, higher doses should be approached more slowly.

Primary-care--physician supply: policy analysis on the state level

OBJECTIVE

To describe a method for policy analysis on the state level for understanding frequently overlooked determinants of the current status and dynamics of primary-care-physician supply.

DESIGN

The method used is systems analysis. The approach takes account of the changing interstate migration, tracking the professional origins of physicians, their uneven age distribution, and the considerable time delays in the system. The forecasting mathematical model consists of the physician-aging submodel, the undergraduate and graduate medical education submodel, and the migration subsystem.

SETTING

The necessary data were restored fully from the Virginia Board of Medicine archive database.

RESULTS

The analysis shows the outstanding importance of out-of-state migration for the state of Virginia: approximately two thirds of primary-care physicians are out-of-state medical graduates. In the next decade, the attrition of primary-care physicians will start to increase steadily because of the prominent bulge in the physician age distribution. Similar bulges were observed in the age distributions for some other states.

CONCLUSIONS

The method reveals the underlying mechanisms and principles of physician work-force reproduction. It may show which goals are feasible, and it may be used in any state for the research necessary for rational policy formulation.

Behind the physician licensure numbers: false impressions, retirement crisis, and migration

This communication examines the supply of primary-care physicians at the state level. It shows that the number of actively practicing physicians is considerably less than the number of licensed physicians; the age distribution of primary-care physicians has a bulge in the ages younger than 50, and this bulge may lead in the near future to an unexpected increase in physician attrition due to retirement; and, at the state level, migration may be playing the dominant role in determining the total supply of primary-care physicians.

A patient-initiated system for preventive health care. A randomized trial in community-based primary care practices

OBJECTIVE

To test the effectiveness of a patient-initiated, touch-sensitive computer system (TSCS) for improving screening rates for cancers of the breast, cervix, colon and rectum, and oral cavity.

DESIGN

One-year, randomized, controlled trial with primary care practice as the unit of analysis.

SETTING

Sixty primary care practices, randomly recruited from 329 nonteaching practices in a southeastern state.

SUBJECTS

Random sample of the medical records of 50 male and female adult patients before intervention and 50 adult patients after intervention in each practice and a random sample of 507 TSCS users.

INTERVENTIONS

Touch-sensitive computer system and a registered nurse who served as liaison to the study practices. The TSCS provided patient-specific preventive service recommendations and facilitated work flow to increase the completion of these interventions.

MAIN OUTCOME MEASURE

Average change, adjusted for health maintenance examination (HME) and use of the TSCS, in the proportion of eligible patients undergoing screening mammography, clinical breast examination, digital rectal examination, fecal occult blood test, flexible sigmoidoscopy, Papanicolaou smear, and oral cavity examination.

RESULTS

We observed a significant increase in the completion of screening mammography (6.6%; P < or = 0.5) and clinical breast examination (6.1%; P < or = .01) in women 50 years of age and older, particularly for those who had an HME during the study year.

CONCLUSIONS

Patients who have HMEs are more likely to receive cancer screening; however, a computer-based system for preventive services can contribute to improvement in screening. Among those patients who did not have an HME, TSCS users had higher rates of breast cancer screening than nonusers.

Role of yeast Rth1 nuclease and its homologs in mutation avoidance, DNA repair, and DNA replication

The RTH1(RAD27) gene of Saccharomyces cerevisiae encodes a structure-specific endonuclease that cleaves 5'-ended single-stranded DNA at its junction with duplex DNA. Genetic and biochemical studies have indicated a role of Rth1 nuclease in the removal of RNA primers formed during DNA replication. The rth1Delta mutation confers temperature-sensitive lethality, and increases sensitivity to alkylating agents. The instability of repetitive DNA is greatly enhanced in the rth1Delta mutant. The conditional lethality of the rth1Delta mutation indicates that another nuclease can function in DNA replication in the absence of RTH1. RAD2, a homolog of RTH1, is required for nucleotide-excision repair. Here, we examine three other homologs of RTH1/RAD2 - YEN1, EXO1, and DIN7. Deletion of any of these genes in the rth1Delta strain has no effect on cell viability, suggesting the involvement of another, and as yet unidentified, nuclease in the maturation of Okazaki fragments. Our data also indicate that only RTH1 functions in the repair of alkylation damage. Deletions of YEN1, EXO1, DIN7, or RAD2, either singly or when combined with one another and with the rth1Delta mutation, have no effect on the rate of instability of dinucleotide repeats or on the rate of formation of large duplications in the CAN1 gene. These data provide evidence of a high degree of specificity for the role of RTH1 in DNA replication and in base-excision repair, and for the requirement of RAD2 in nucleotide-excision repair. The possibility that both Rth1 and Exo1 function in DNA mismatch repair is discussed.

Beta-blockers and depression: the more the murkier?

OBJECTIVE

To review the literature regarding the purported association between oral ingestion of beta-blocker drugs and depressed mood.

DATA SOURCE

MEDLINE was searched for published articles using the key words propranolol, atenolol, metoprolol, nadolol, timolol, beta-blocker, beta-adrenergic antagonist, or beta-adrenergic blocker in combination with the key words depression, depressive symptomatology, major depressive disorder, or depressed mood from January 1966 through December 1996.

DATA SYNTHESIS

Findings regarding the association are equivocal. Plausible explanations include study design, case definition, and confounding disease states. Most of the evidence supporting an association has used case series and case reports. Findings from cross-sectional observational studies and case-control studies are equivocal. Case definition and measurement instruments may partially explain these inconsistencies. Studies using a diagnosis of depression generally do not support the relationship. Trials using depressive symptoms are about evenly split, but they have generally enrolled a small number of patients and have questionable statistical power. Studies defining antidepressant prescriptions dispensed as a marker for depression generally support the association. Evidence exists both for and against the hypothesis that lipophilic beta-blockers cause more depression than do hydrophilic beta-blockers.

CONCLUSIONS

beta-Blockers may have been unjustly associated with depression and their use avoided for that reason. Future studies into the association between depression and beta-blocker use should evaluate whether the association is affected by case definition and study design characteristics, including disease, dose-response, bias, measurement error, or ability to precisely measure the length of the exposure.

A pilot study of the prevalence of chlamydial infection in a national household survey

BACKGROUND

The prevalence of Chlamydia trachomatis genital infection in the United States population is unknown. Using a new urine test for C. trachomatis, we conducted a pilot survey as part of the National Health and Nutrition Examination Survey III (NHANES III).

GOAL

To determine whether the prevalence of chlamydial infection in a convenience sample of NHANES participants was high enough to justify testing for C. trachomatis in a national survey.

STUDY DESIGN

NHANES III, conducted from 1988 to 1994, was based on a stratified multistage probability sample of the United States population. Non-Hispanic blacks and Mexican-Americans were oversampled. Using the ligase chain reaction assay for C. trachomatis, we tested urine from participants 12 to 39 years of age from 10 of the 89 sites of NHANES III. The prevalence of infection was calculated by racial or ethnic group.

RESULTS

We tested 1,144 study participants, of whom 65% were female, 30% were non-Hispanic blacks, and 30% were Mexican-American. Prevalence was higher for non-Hispanic blacks (7%) than for Mexican-Americans (3%) and non-Hispanic whites (2%). Prevalence was higher for women than men in non-Hispanic blacks (7% vs. 6%), Mexican-Americans (5% vs. 2%), and non-Hispanic whites (2% vs. 1%). In 15- to 19-year-old women, prevalence was 13% in non-Hispanic blacks, 11% in Mexican-Americans, and 5% in non-Hispanic whites.

CONCLUSION

The prevalence of C. trachomatis genital infection was high enough to suggest that a reliable national prevalence estimate could be obtained in a national probability sample survey.

Dose-response analysis of opioid cross-tolerance and withdrawal suppression during LAAM maintenance

Levo-alpha-acetylmethadol (LAAM) currently is approved as an opioid maintenance treatment. This double-blind study was designed to characterize withdrawal suppression and opioid blockade produced by two different LAAM maintenance doses. Outpatient opioid-dependent volunteers were stabilized (5-7 weeks) on 25 (n = 8) or 75 mg (n = 8) LAAM administered every-other-day with placebo administered on intervening days. After stabilization, four inpatient, randomly ordered experimental sessions were conducted at 24, 48, 72 and 96 hr after LAAM dosing; the timing of these sessions corresponds to intervals that occur during typical thrice-weekly treatment and after a missed dose. During each session, after baseline assessments, ascending doses of hydromorphone (0, 6 and 12 mg i.m.) were administered 45 min apart; physiological, subjective and observer-rated effects were recorded throughout the session. Physiological and subjective indices of opioid withdrawal measured at session base lines increased with time since the last LAAM dose, but did not depend on the maintenance dose. Withdrawal symptoms were mild in both groups, even at 96 hr after LAAM dosing. Hydromorphone produced dose-related opioid agonist effects at all intervals in the 25 mg LAAM group; these effects were attenuated substantially in the 75 mg LAAM group. Time since last LAAM dose had little influence on hydromorphone effects in either group. Thus, 75 mg LAAM provides opioid blockade and withdrawal suppression for up to 96 hr, whereas 25 mg LAAM is relatively ineffective at producing significant opioid blockade.

Intravenous and oral l-alpha-acetylmethadol: pharmacodynamics and pharmacokinetics in humans

Levo-alpha-acetylmethadol (LAAM) is a long-acting opioid agonist approved for use as a maintenance treatment for opioid dependence. Previous clinical studies report that the onset of the effects of LAAM is slower after parenteral administration than oral administration; however, preclinical studies suggest otherwise. This study examined the pharmacodynamic and pharmacokinetic profile of LAAM when given orally and intravenously to humans. Opioid-experienced volunteers (n = 6), who were not physically dependent on opioids, received LAAM (20 and 40 mg/70 kg i.v. and p.o.) and placebo under double-blind, double-dummy conditions during five weekly experimental sessions. Behavioral, physiological, subjective and pharmacokinetic measures were collected before and for 96 hr after drug administration. Intravenous LAAM produced significant subjective and physiological effects that appeared within 5 min, whereas the effects of oral LAAM appeared more slowly within 1 to 2 hr after drug administration. Pharmacokinetic data indicate that the immediate effects of intravenous LAAM are largely attributable to the parent drug rather than the active metabolites, nor-LAAM and dinor-LAAM. LAAM produced prototypic opioid agonist effects (i.e., miosis, subjective ratings of high, nodding) that were of equal magnitude across routes, dose-related and of long duration (up to 60 hr). These data are in contrast to previous clinical reports and indicate that LAAM produces effects of immediate onset when administered parenterally, which suggests that intravenous LAAM possesses greater abuse potential than previously believed.

Relationship of plasma buprenorphine and norbuprenorphine to withdrawal symptoms during dose induction, maintenance and withdrawal from sublingual buprenorphine

AIMS

Examine the relationship between buprenorphine and norbuprenorphine plasma concentrations with subject-reported withdrawal symptomatology during buprenorphine dose induction, maintenance treatments (daily and alternate-day dosing) and withdrawal.

DESIGN

Two groups of randomly assigned subjects inducted onto buprenorphine and maintained on 8 mg daily by the sublingual route for 18 days. Group 1 continued to receive daily buprenorphine to day 36. Group 2 subjects received alternate-day dosing of buprenorphine and placebo on days 19 to 36. Both groups received placebo on days 37 to 52.

SETTING

Inpatient facilities at the Addiction Research Center, Intramural Research Center, NIDA, Baltimore, MD.

PARTICIPANTS

Eleven male, heroin-dependent volunteers participating in a research study.

INTERVENTION

Medications for treatment of withdrawal symptoms were prescribed as needed after day 39 (72 hours after the last dose of buprenorphine).

MEASUREMENTS

Plasma concentrations of buprenorphine and norbuprenorphine, withdrawal symptomatology and pupil diameter.

FINDINGS

The mean steady-state buprenorphine plasma concentration (24 hours) after daily administrations of sublingual buprenorphine for study days 21-35 was 0.80 ng/ml, and the mean alternate day steady-state buprenorphine plasma concentration (24 hours) was 0.77 ng/ml. Daily and alternate day steady-state norbuprenorphine plasma concentrations were 1.10 and 0.90 ng/ml, respectively. Predicted alternate day steady-state buprenorphine and norbuprenorphine plasma concentrations at 48 hours were 0.49 ng/ml and 0.57 ng/ml, respectively. Withdrawal scores varied inversely with plasma concentration. There were no significant differences between Groups 1 and 2 during steady-state (days 21-35) with regard to withdrawal scale scores or pupillary diameter. The overall, mean terminal elimination half-lives for buprenorphine and norbuprenorphine were 42 and 57 hours, respectively.

CONCLUSIONS

during daily buprenorphine maintenance, plasma concentrations greater than 0.7 ng/ml of buprenorphine and norbuprenorphine were associated with minimal withdrawal symptoms. The long elimination half-life of buprenorphine suggested that increasing the buprenorphine dose with alternate-day administration may provide an effective, flexible therapy regimen for the treatment of opioid dependence.

Evaluation of bias in diagnostic-test sensitivity and specificity estimates computed by discrepant analysis

When a new diagnostic test is potentially more sensitive than the reference test used to classify persons as infected or uninfected, a substantial number of specimens from infected persons may be reference-test negative but new-test positive. Discrepant analysis involves the performance of one or more additional tests with these specimens, reclassification as infected those persons for whom the new-test-positive results are confirmed, and recalculation of the estimates of new-test sensitivity and specificity by using the revised classification. This approach has been criticized because of the bias introduced by the selective use of confirmation testing. Under conditions appropriate for evaluating a nucleic acid amplification (NAA) test for Chlamydia trachomatis infection with cell culture as the reference test, we compared the bias in estimates based on the discrepant-analysis classification of persons as infected or uninfected with that in estimates based on the culture classification. We concluded that the bias in estimates of NAA-test specificity based on discrepant analysis is small and generally less than that in estimates based on culture. However, the accuracy of discrepant-analysis-based estimates of NAA-test sensitivity depends critically on whether culture specificity is equal to or is slightly less than 100%, and it is affected by competing biases that are not fully taken into account by discrepant analysis.

The effects of linear acceleration on distortion product otoacoustic emissions in human ears

BACKGROUND

The effect of high levels of linear acceleration (G) on the cochlea has never been studied prospectively.

HYPOTHESIS

Linear acceleration at high levels has no effect on the human cochlea as demonstrated by a comparison of pre- and post-exposure measurements.

METHODS

There were 22 healthy volunteers who underwent exposure to up to 9 G in a military aviation training centrifuge. Prior to exposure they were screened for cochleovestibular disorders and underwent tympanometry, audiometry and distortion product otoacoustic emissions testing (DPOAE). Immediately after exposure, they underwent serial testing of each of these parameters until they returned to baseline.

RESULTS

There was no significant change in tympanometry in any subject. Audiometry revealed a temporary threshold shift of 30 db at 6 kHz in one ear of a single subject. This was accompanied by a complete loss of DPOAE at the same frequency. DPOAE did not return to baseline at 2 weeks even though the audiogram had reverted to baseline by 8 d. Four other ears displayed significant losses of emissions at single frequencies without an accompanying change on the audiogram.

CONCLUSIONS

This study demonstrates that accelerative stress may cause transient injury to the cochlea. The mechanism of injury due to acceleration is probably ischemia, although a purely mechanical effect on the outer hair cells cannot be precluded. These data also reinforce a growing body of evidence that demonstrates the greater sensitivity of DPOAE over psychoacoustic testing in detecting early or subclinical cochlear damage.

Benzodiazepine exposure and functional status in older people

OBJECTIVE

To determine the association between benzodiazepine exposure and functional status in older patients.

DESIGN

A nonexperimental, observational study design.

SETTING

Kaiser Permanente, Northwest Division, a health maintenance organization (HMO) providing prepaid, comprehensive inpatient and outpatient care for more than 410,000 persons.

PATIENTS

Patients were the 4192 Social HMO Project members 65 years of age and older, enrolled for 1 full year, who returned their annual health status survey during 1990.

MEASUREMENTS

Functional status was measured using self-reported activities of daily living and instrumental activities of daily living. Predictor variables were self-reported medical conditions and benzodiazepine exposure during the previous 12 months.

RESULTS

Age, gender, and living status were associated with functional status. Severe memory loss, stroke, Parkinson's disease, circulation problems, lung problems, hip fracture, urinary problems, arthritis, heart trouble, diabetes, stomach/bowel problems, and cancer were associated independently with functional status. Persons exposed to a benzodiazepine scored lower on the functional status measure. Benzodiazepine exposure added significantly to the prediction of functional status after controlling for patients' socio-demographic characteristics and medical conditions.

CONCLUSIONS

Age and medical conditions were the most significant predictors of functional status. Benzodiazepine exposure was associated with functional status to the same extent as several chronic medical conditions. When prescribing benzodiazepines for older people, caution should be taken to minimize the possibility of iatrogenic-functional limitations.

The effect of increased prescription drug cost-sharing on medical care utilization and expenses of elderly health maintenance organization members

OBJECTIVES

The nature and extent of prescription drug benefits for the elderly are a continuing concern for health-care managers and policy makers. This study examined the impact of increased prescription drug cost-sharing on the drug and medical care utilization and expenses of the elderly.

METHODS

Two groups of well-insured Medicare risk-based members of a large health maintenance organization (HMO) had their copayments increased in different years during a 3-year period. Four 2-year analysis periods were established for comparing these elderly groups. During one analysis period, copayments did not change in either group.

RESULTS

Moderate increases of from $1 to $3, from $3 to $5 per copayment, and from 50% per dispensing to 70% per dispensing with a maximum payment per dispensing resulted in lower annual per capita prescription drug use and expenses. No consistent annual changes were observed in either medical care utilization (office visits, emergency room visits, home health-care visits, hospitalizations) or total medical care expenses across analysis periods.

CONCLUSIONS

No consistent relationships were observed between increased copayments per dispensing and medical care utilization and expense. Future research needs to address the impact on the classes of medications received and related health status, and the impact of larger increases in copayments per dispensing on medical care and health-related factors.

Herpes simplex virus type 2 in the United States, 1976 to 1994

BACKGROUND

Herpes simplex virus type 2 (HSV-2) infection is usually transmitted sexually and can cause recurrent, painful genital ulcers. In neonates the infection is potentially lethal. We investigated the seroprevalence and correlates of HSV-2 infection in the United States and identified changes in HSV-2 seroprevalence since the late 1970s.

METHODS

Serum samples and questionnaire data were collected during the National Health and Nutrition Examination Surveys (NHANES) II (1976 to 1980) and III (1988 to 1994). HSV-2 antibody was assessed with an immunodot assay specific for glycoprotein gG-2 of HSV-2.

RESULTS

From 1988 to 1994, the seroprevalence of HSV-2 in persons 12 years of age or older in the United States was 21.9 percent (95 percent confidence interval, 20.2 to 23.6 percent), corresponding to 45 million infected people in the noninstitutionalized civilian population. The seroprevalence was higher among women (25.6 percent) than men (17.8 percent) and higher among blacks (45.9 percent) than whites (17.6 percent). Less than 10 percent of all those who were seropositive reported a history of genital herpes infection. In a multivariate model, the independent predictors of HSV-2 seropositivity were female sex, black race or Mexican-American ethnic background, older age, less education, poverty, cocaine use, and a greater lifetime number of sexual partners. As compared with the period from 1976 to 1980, the age-adjusted seroprevalence of HSV-2 rose 30 percent (95 percent confidence interval, 15.8 to 45.8 percent). The seroprevalence quintupled among white teenagers and doubled among whites in their twenties. Among blacks and older whites, the increases were smaller.

CONCLUSIONS

Since the late 1970s, the prevalence of HSV-2 infection has increased by 30 percent, and HSV-2 is now detectable in roughly one of five persons 12 years of age or older nationwide. Improvements in the prevention of HSV-2 infection are needed, particularly since genital ulcers may facilitate the transmission of the human immunodeficiency virus.

Detection of ozone on Saturn's satellites Rhea and Dione

The satellites Rhea and Dione orbit within the magnetosphere of Saturn, where they are exposed to particle irradiation from trapped ions. A similar situation applies to the galilean moons Europa, Ganymede and Callisto, which reside within Jupiter's radiation belts. All of these satellites have surfaces rich in water ice. Laboratory studies of the interaction of charged-particle radiation with water ice predicted the tenuous oxygen atmospheres recently found on Europa and Ganymede. However, theoretical investigations did not anticipate the trapping of significantly larger quantities of O2 within the surface ice. The accumulation of detectable abundances of O3, produced by the action of ultraviolet or charged-particle radiation on O2, was also not predicted before being observed on Ganymede. Here we report the identification of O3 in spectra of the saturnian satellites Rhea and Dione. The presence of trapped O3 is thus no longer unique to Ganymede, suggesting that special circumstances may not be required for its production.

Analysis of the costs of NSAID-associated gastropathy. Experience in a US health maintenance organisation

Clinicians recognise nonsteroidal anti-inflammatory drugs (NSAIDs) as valuable first-line agents in the treatment of rheumatic disorders and as dangerous irritants to the gastrointestinal tract. This has led to questions about the economic impact of NSAID-induced gastropathy in populations. This study estimated the 1992 costs of NSAID-associated gastropathy episodes, and calculated an iatrogenic cost factor for NSAID-associated gastropathy among elderly members of a health maintenance organisation (HMO), the Northwest Region of Kaiser Permanente. Using data retrieved from automated databases and from medical records, NSAID and antiulcer drug costs were calculated, and estimates were made of the incidence rates of inpatient and outpatient NSAID-associated gastropathies, the services provided to treat them, and the cost of those services. Kaiser Permanente Northwest spent $US0.35 for each $US1.00 spent on NSAID therapy for the elderly, an iatrogenic cost factor of 1.35. The estimated average treatment per NSAID-associated gastropathy episode was $US2172. The average outpatient pharmacy cost per elderly NSAID user was $US80 and estimated average NSAID-associated treatment cost per elderly NSAID user was $US43. Although the findings were specific to the HMO because of the databases used, the methodology employed and the drug formulary influence on NSAID selection, they show that a substantial amount of resources were used to treat NSAID-induced gastropathies in the elderly, underscoring the risk of prescribing NSAIDs and reinforcing the need for their prudent use in elderly patients.

Quantification of surgical margin shrinkage in the oral cavity

BACKGROUND

Obtaining adequate surgical margins, free of tumor, is crucial for success in oncologic surgery. The head and neck surgeon often finds that the tumor-free margin reported from histopathologic measurement is significantly smaller than the margin measured in-situ. It was the purpose of this study to quantify the change in size of mucosal and muscle surgical margins following excision, formalin fixation, and slide preparation of tongue and labiobuccal tissue in a canine model.

METHODS

Ten mongrel dogs under general anesthesia for a concurrent project were used in this study. Changes in mucosal and muscle dimensions around custom-made brass disks, one with a needle depth gauge, were measured immediately following excision after formalin fixation and after slide preparation.

RESULTS

The mean shrinkage from initial resection to final microscopic assessment of the lingual surface mucosal margins was 30.7% (p < 0.0001). The deep tongue margin shrank 34.5% (p < 0.0001). The mean shrinkage of the labiobuccal mucosal margin was 47.3% (p < 0.0001). In all cases, the greatest proportion of shrinkage occurred immediately upon resection.

CONCLUSIONS

From the in-situ measurement by the surgeon to final pathologic evaluation on the microscope slide, the measured dimensions of oral cavity mucosal and tongue muscle margins shrink significantly. To obtain 5 mm of pathologically clear margin an in-situ margin of resection of at least 8 to 10 mm needs to be taken. Studies reporting clinical correlation of recurrence and survival information with surgical margin status should include a detailed description of the technique used to determine the reported surgical margin status.

Dose-related efficacy of levomethadyl acetate for treatment of opioid dependence. A randomized clinical trial

OBJECTIVE

To compare the clinical efficacy of different doses of levomethadyl acetate hydrochloride (known as LAAM) in the treatment of opioid dependence.

DESIGN

A randomized controlled, double-blind, parallel group, 17-week study.

SETTING

Outpatient facilities at Johns Hopkins University Bayview Medical Center, Baltimore, Md.

PATIENTS

Opioid-dependent volunteers (N=180) applying to a treatment-research clinic.

INTERVENTION

Thrice-weekly (Monday/Wednesday/Friday) oral LAAM dose conditions of 25/25/35 mg, 50/50/70 mg, and 100/100/140 mg and nonmandatory counseling.

MAIN OUTCOME MEASURES

Retention in treatment, self-reported heroin use, and opioid-positive urine specimens.

RESULTS

Retention was independent of subjects' sex and dose. Self-reported heroin use decreased in a dose-related manner. At final assessment, patients in the high-dose condition reported using heroin 2.5 of 30 days as compared with 4.1 or 6.3 days for patients in the medium-dose and low-dose conditions, respectively (high dose vs low dose, P<.05); urinalysis results were similarly dose related. Overall, 20 (34%) of 59 patients in the high-dose condition remained opioid-abstinent for 4 consecutive weeks, as compared with 8 (14%) of 59 in the medium-dose and 7 (11%) of 62 in the low-dose conditions (P<.01). Self-report and urinalysis data are consistent with a greater than 90% reduction in illicit opioid use by the high-dose group relative to pretreatment levels.

CONCLUSION

Opioid substitution treatment with LAAM substantially reduces illicit opioid use. The clinical efficacy of LAAM is positively related to dose.

Controlled opioid withdrawal evaluation during 72 h dose omission in buprenorphine-maintained patients

Buprenorphine's clinical utility as an opioid dependence pharmacotherapy may be enhanced with less-than-daily dosing. This study assessed opioid withdrawal after an acute 72 h dose omission in buprenorphine-maintained patients (8 mg/day s.l.). Eight outpatients required to remain free of opioids, cocaine and benzodiazepines completed four double-blind, double-dummy, Latin-square ordered conditions. Test conditions of 8 or 16 mg s.l. buprenorphine were followed by 2 days of placebo dosing. Control conditions were buprenorphine maintenance (8 mg/day), to provide a reference for evaluation of placebo test days and naloxone administration (10 mg 70 kg i.m.) during 8 mg buprenorphine maintenance to assess withdrawal measure sensitivity. Subjective measures and pupil diameter were significantly influenced only by naloxone. The lack of subjective symptoms and physiological signs of opioid withdrawal during 72 h of acute dose omission supports the feasibility of less-than-daily dosing at buprenorphine doses of 8 mg/day in patients who have demonstrated an ability to remain drug-free for an extended period.

The impact of increasing patient prescription drug cost sharing on therapeutic classes of drugs received and on the health status of elderly HMO members

OBJECTIVE

To assess the impact of increased prescription drug copayments on the therapeutic classes of drugs received and health status of the elderly. HYPOTHESES TESTED: Increased prescription drug copayments will reduce the relative exposure to, annual days use of, and prescription drug costs for drugs used in self-limiting conditions, but will not affect drugs used in progressive chronic conditions and will not reduce health status.

STUDY DESIGN

Each year over a three-year period, one or the other of two well-insured Medicare risk groups in an HMO setting had their copayments per dispensing increased. Sample sizes ranged from 6,704 to 7,962.

DATA SOURCES/DATA COLLECTION

Automated administrative data systems of the HMO were used to determine HMO eligibility, prescription drug utilization, and health status. ANALYSIS DESIGN: Analysis of variance or covariance was employed to measure change in dependent variables.

FINDINGS

Relative exposure, annual days of use, and prescription drug costs for drugs used in self-limiting conditions and in progressive chronic conditions were not affected in a consistent manner across years by increases in prescription drug copayment. Health status may have been adversely affected. Larger increases in copayments appeared to generate more changes.

CONCLUSIONS

Small changes in copayments did not appear to substantially affect outcomes. Large changes in copayments need further examination.

Evaluation of a self-report screening instrument to predict frailty outcomes in aging populations

The purpose of this study is to investigate the utility of a self-report screening instrument, the Health Status Form (HSF), to predict elderly members at risk of frailty in the subsequent year. The predictive ability of self-report HSF data was also compared to the predictive ability of inpatient discharges and pharmacy dispensings from administrative utilization databases. Four HSF variables best predicted elderly members at risk of frailty: (a) age, (b) indicating that health conditions interfered with daily activities, (c) needing or receiving assistance from another person for bathing, and (d) needing or receiving assistance from another person for taking medications. The predictive model yielded sensitivity 50.7%, specificity 97.8%, and correctly classified 90.9% of the population. Self-report population-based screening is a reliable method for predicting elderly members at risk of frailty in the coming year. Further studies should test a new brief instrument composed of portions of validated measures as a stand alone screener to select frail members for care management purposes.

Whither triazolam?

OBJECTIVES

The authors compare the extent and nature of triazolam use before and after its deletion from a health maintenance organization's (HMO) open and advisory-type drug formulary.

METHODS

Benzodiazepine dispensings of HMO members were collected for the 3 years before (1989-1991) and for the 2 years after (1992-1993) the deletion of triazolam from the HMO's drug formulary. The number of triazolam users, their sex and ages, total annual exposure, estimated daily doses, and total days of annual exposure were calculated and compared before and after its deletion from the formulary.

RESULTS

From being the most frequently dispensed short-acting benzodiazepine in the HMO in 1989, the prescribing and use of triazolam decreased tenfold by the end of 1993. The effect on who was using the drug and how it was being used was less dramatic. The elderly were frequent long-term users and had the longest exposure to the drug.

CONCLUSIONS

An open and advisory-type formulary can affect providers' drug selection behavior.

Utilization and Safety of Oral Acyclovir over an 8-Year Period

The primary purpose of this project was to develop and implement surveillance systems to monitor the short- and long-term safety of acyclovir in oral dosage forms in a general population, the Kaiser Permanente Northwest (KPNW) region membership. KPNW is a group model HMO providing comprehensive care to over 390,000 members located primarily in the Portland, Oregon-Vancouver, Washington metropolitan area. Data were collected from the automated outpatient prescription, hospital discharge, tumor registry, KPNW membership information, and from medical record reviews, over an 8-year period. The findings showed oral acyclovir use increased substantially, and females were twice as likely to receive oral acyclovir as males. Most use was short-term. When the hospitalizations of oral acyclovir users with select serious morbidities conditions were examined following the receipt of acyclovir, no temporal association was observed between exposure to oral acyclovir and the hospitalizations. Similarly, where oral acyclovir was being used within a time frame possibly associated with serious life-threatening conditions, other morbidities rather than acyclovir were the likely cause of the condition, and no mention was made in the medical record that acyclovir might have been involved in the condition. In summary, oral acyclovir was a safe drug within the use patterns of the HMO population over an 8-year period.