Healthcare resource utilization and costs among nonalcoholic fatty liver disease patients in Germany

Background

Patients with nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are associated with progression to advanced liver diseases that include compensated cirrhosis, decompensated cirrhosis, liver transplantation, and hepatocellular carcinoma (HCC). This study characterized comorbidities, healthcare resource utilization (HRU), and associated costs among NAFLD patients in Germany.

Methods

German healthcare claims data between 2011 and 2016 were analyzed retrospectively. Adult patients diagnosed with NAFLD and/or NASH were categorized as NAFLD, NAFLD non-progressors, compensated cirrhosis, decompensated cirrhosis, liver transplant, or HCC. Within each stage, annual all-cause HRU and costs were measured during the pre- and post-index periods.

Results

Among 4,580,434 patients in the database, proportion of NAFLD was 4.7% (n=215,655). Of them, 36.8% were non-progressors, 0.2% compensated cirrhosis, 9.6% decompensated cirrhosis, 0.0005% liver transplant, and 0.2% HCC. Comorbidity rates were significantly higher in compensated cirrhosis, decompensated cirrhosis, and HCC compared with non-progressors (52.07%, 56.46%, 57.58% vs. 27.49% for cardiovascular disease; 77.13%, 76.61%, 83.47% vs. 54.89% for hypertension; 47.20%, 53.81%, 52.89% vs. 35.21% for hyperlipidemia; 49.88%, 36.67%, 48.21% vs. 20.38% for type 2 diabetes mellitus). The mean annual numbers of post-index outpatient visits and inpatient hospitalizations were significantly higher in patients with advanced liver diseases versus non-progressors. Mean annual costs were significantly higher among patients with advanced liver diseases (compensated cirrhosis, €10,291; decompensated cirrhosis, €22,561; liver transplant, €34,089; HCC, €35,910) than non-progressors (€3,818, P<0.001, except liver transplant cohort). This trend remained consistent after adjusting for baseline demographics and comorbidities.

Conclusions

NAFLD patients in Germany are grossly underdiagnosed and exert substantial healthcare resource use and economic burden, particularly those with advanced liver diseases. Optimal strategies for early identification and management are needed to prevent disease progression and limit the rising costs.

Patterns and predictors of mortality and disease progression among patients with non-alcoholic fatty liver disease

BACKGROUND

Factors associated with mortality and disease progression in non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are poorly understood.

AIMS

To assess the impact of liver disease severity, demographics and comorbidities on all-cause mortality and liver disease progression in a large, real-world cohort of NAFLD patients.

METHODS

Claims data from the German Institut für angewandte Gesundheitsforschung database between 2011 and 2016 were analyzed retrospectively. Adult patients diagnosed with NAFLD and/or NASH were categorised as NAFLD, NAFLD non-progressors, compensated cirrhosis, decompensated cirrhosis, liver transplant or hepatocellular carcinoma (HCC). The longitudinal probability of mortality and incidence of progression were calculated for disease severity cohorts and multivariable analyses performed for adjusted mortality.

RESULTS

Among 4 580 434 patients in the database, prevalence of NAFLD was 4.7% (n = 215 655). Of those, 36.8% were non-progressors, 0.2% compensated cirrhosis, 9.6% decompensated cirrhosis, 0.0005% liver transplant and 0.2% HCC. Comorbidity rates were significantly higher in compensated cirrhosis, decompensated cirrhosis and HCC compared with non-progressors. The longitudinal probability of mortality for non-progressors, compensated cirrhosis, decompensated cirrhosis and HCC was 3.6%, 18.7%, 28.8% and 68%, respectively. Independent predictors of mortality included cardiovascular disease, type 2 diabetes mellitus, hypertension, obesity and renal impairment. The cumulative incidence of progression in NAFLD and compensated cirrhosis patients was 10.7% and 16.7%, respectively, over 5 years of follow-up.

CONCLUSION

NAFLD patients were severely under-diagnosed and had a high probability of mortality that increased with disease progression. Early identification and effective management to halt or reverse fibrosis are essential to prevent progression.

The burden of hyperkalemia in Germany - a real world evidence study assessing the treatment and costs of hyperkalemia

Background

Hyperkalemia (HK) can affect health outcomes and quality of life, as it is referred to as a potentially life-threatening condition caused by an increased serum potassium concentration in the blood. Patients suffering from heart failure or chronic kidney diseases are at a higher risk of HK, which can further be amplified by the treatment received. To date, data on HK prevalence is lacking for Germany and the aims of this study were to assess HK and compare health-relevant outcomes and healthcare costs between HK patients and non-HK patients.

Methods

The InGef research database containing healthcare claims of over 4 million individuals in Germany was utilized for this retrospective, matched cohort analysis. Patients with non-acute outpatient treated and a subgroup of patients with chronic HK, were identified in 2015 with an individual 1 year pre- and post-index period, taking the first observable HK diagnosis/treatment in 2015 into account as the index event. To identify non-acute outpatient treated HK patients, at least two ICD-10-GM diagnosis codes E87.5 “Hyperkalemia” and/or prescriptions of polystyrene sulfonate were required. Chronic HK patients had additional diagnoses and/or prescriptions in all quarters following the first observable HK diagnosis. Patients without HK were matched 1:1 to the respective HK cohorts.

Results

In the year 2015, 3333 patients with non-acute outpatient treated HK were identified of which 1693 were patients with chronic HK. After matching, 3191 and 1664 HK patients and controls were available for analysis. A significantly higher number of hospitalizations was observed for both HK cohorts in comparison to their matched controls. Dialysis initiation as well as the healthcare costs were higher for both HK cohorts when compared to their matched counterparts.

Conclusions

The disease burden was higher for patients with HK, based on a higher proportion of patients with dialysis initiation and higher healthcare costs.

Comedication prescription patterns and potential for drug-drug interactions with antiretroviral therapy in people living with human immunodeficiency virus type 1 infection in Germany

PURPOSE

Various first-line recommended antiretroviral therapy (ART) regimens have different drug-drug interaction (DDI)/contraindication profiles. The aim of this study was to estimate the rate of potential DDIs/contraindications of real-world prescribed non-ART comedication with first-line recommended ART in people living with HIV (PLHIV) in Germany.

METHODS

A retrospective, cross-sectional cohort design was used to collect non-ART comedication prescription data from a representative sample of a German health insurance claims database. PLHIV who were prescribed ART during 2016 were included in the analysis. Patients were stratified by sex, age, comorbidities, and time on ART. Prescribed comedications were used to estimate potential DDIs/contraindications for each recommended first-line ART per patient based on criteria from www.hiv-druginteractions.org.

RESULTS

Records from 2680 PLHIV were analyzed. Prescriptions for non-ART comedications were common (mean of seven per patient in the overall population, 10.2 in PLHIV aged 50 years and older). Antiretroviral regimens with the lowest proportion of patients with at least 1 potential DDI/contraindication were unboosted integrase inhibitor, non-tenofovir disoproxil fumarate-based regimens that included raltegravir + emtricitabine/tenofovir alafenamide fumarate (13%), dolutegravir + lamivudine (14%), dolutegravir/abacavir/lamivudine (14%), dolutegravir/emtricitabine/tenofovir alafenamide fumarate (15%), and bictegravir/emtricitabine/tenofovir alafenamide fumarate (19%). Boosted regimens and efavirenz-based regimens presented the highest potential for DDIs/contraindications.

CONCLUSIONS

Comedication with potential DDIs/contraindications with ART is frequently prescribed among PLHIV in Germany. Potential risks for DDIs/contraindications vary by ART, with the lowest potential seen in unboosted integrase strand transfer inhibitor-based regimens, including raltegravir + emtricitabine/tenofovir alafenamide fumarate, followed by three dolutegravir-based regimens.

Proactive text messaging (GetReady2Quit) and nicotine replacement therapy to promote smoking cessation among smokers in primary care: A pilot randomized trial protocol

INTRODUCTION

Most smokers see a physician each year, but few use any assistance when they try to quit. Text messaging programs improve smoking cessation in community and school settings; however, their efficacy in a primary care setting is unclear. The current trial assesses the feasibility and preliminary clinical outcomes of text messaging and mailed nicotine replacement therapy (NRT) among smokers in primary care.

METHODS

In this single-center pilot randomized trial, eligible smokers in primary care are offered brief advice by phone and randomly assigned to one of four interventions: (1) Brief advice only, (2) text messages targeted to primary care patients and tailored to quit readiness, (3) a 2-week supply of nicotine patches and/or lozenges (NRT), and (4) both text messaging and NRT. Randomization is stratified by practice and intention to quit. The text messages (up to 5/day) encourage those not ready to quit to practice a quit attempt, assist those with a quit date through a quit attempt, and promote NRT use. The 2-week supply of NRT is mailed to patients' homes.

RESULTS

Feasibility outcomes include recruitment rates, study retention, and treatment adherence. Clinical outcomes are assessed at 1, 2, 6, and 12-weeks post-enrollment. The primary outcome is ≥1self-reported quit attempt(s). Secondary clinical outcomes include self-reported past 7- and 30-day abstinence, days not smoked, NRT adherence, and exhaled carbon monoxide.

CONCLUSIONS

This pilot assesses text messaging plus NRT, as a proactively offered intervention for smoking cessation support in smokers receiving primary care and will inform full-scale randomized trial planning.

TRIAL REGISTRATION

ClinicalTrials.govNCT03174158.

Oral versus intravenous iron therapy in patients with inflammatory bowel disease and iron deficiency with and without anemia in Germany - a real-world evidence analysis

Background

Iron-deficiency anemia and iron deficiency are common comorbidities associated with inflammatory bowel disease (IBD) resulting in impaired quality of life and high health care costs. Intravenous iron has shown clinical benefit compared to oral iron therapy.

Aim

This study aimed to compare health care outcomes and costs after oral vs intravenous iron treatment for IBD patients with iron deficiency or iron deficiency anemia (ID/A) in Germany.

Methods

IBD patients with ID/A were identified by ICD-10-GM codes and newly commenced iron treatment via ATC codes in 2013 within the InGef (formerly Health Risk Institute) research claims database. Propensity score matching was performed to balance both treatment groups. Non-observable covariates were adjusted by applying the difference-in-differences (DID) approach.

Results

In 2013, 589 IBD patients with ID/A began oral and 442 intravenous iron treatment. After matching, 380 patients in each treatment group were analyzed. The intravenous group had fewer all-cause hospitalizations (37% vs 48%) and ID/A-related hospitalizations (5% vs 14%) than the oral iron group. The 1-year preobservation period comparison revealed significant health care cost differences between both groups. After adjusting for cost differences by DID method, total health care cost savings in the intravenous iron group were calculated to be €367. While higher expenditure for medication (€1,876) was observed in the intravenous iron group, the inpatient setting achieved most cost savings (€1,887).

Conclusion

IBD patients receiving intravenous iron were less frequently hospitalized and incurred lower total health care costs compared to patients receiving oral iron. Higher expenditures for pharmaceuticals were compensated by cost savings in other domains.

Healthcare resource use and costs of multiple sclerosis patients in Germany before and during fampridine treatment

Background

Multiple sclerosis (MS) patients often suffer from gait impairment and fampridine is indicated to medically improve walking ability in this population. Patient characteristics, healthcare resource use, and costs of MS patients on fampridine treatment for 12 months in Germany were analyzed.

Methods

A retrospective claims database analysis was conducted including MS patients who initiated fampridine treatment (index date) between July 2011 and December 2013. Continuous insurance enrollment during 12 months pre- and post-index date was required, as was at least 1 additional fampridine prescription in the fourth quarter after the index date. Patient characteristics were evaluated and pre- vs post-index MS-related healthcare utilization and costs were compared.

Results

A total of 562 patients were included in this study. The mean (standard deviation [SD]) age was 50.5 (9.8) years and 63% were female. In the treatment period, almost every patient had at least 1 MS-related outpatient visit, 24% were hospitalized due to MS, and 79% utilized MS-specific physical therapy in addition to the fampridine treatment. Total MS-related healthcare costs were significantly higher in the fampridine treatment period than in the period prior to fampridine initiation (€17,392 vs €10,960, P < 0.001). While this difference was driven primarily by prescription costs, MS-related inpatient costs were lower during fampridine treatment (€1,333 vs €1,565, P < 0.001).

Conclusions

Physical therapy is mainly used concomitant to fampridine treatment. While healthcare costs were higher during fampridine treatment compared to the pre-treatment period, inpatient costs were lower. Further research is necessary to better understand the fampridine influence.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-017-0844-z) contains supplementary material, which is available to authorized users.

How Have Breast Cancer Screening Intervals Changed Since the 2009 USPSTF Guideline Update?

Background: Beginning in 2009, the U.S. Preventives Services Task Force (USPSTF) breast cancer screening guidelines recommended biennial mammography screening for women aged 50–74 years, and shared-decision making for women aged 40–49 years. We evaluated changes in screening interval after release of the 2009 recommendations. Methods: We compared screening intervals over the period between 2006 and 2012, expecting that the screening interval would lengthen over this time period, using data from the Breast Cancer Surveillance Consortium on 909,972 screening mammograms among 351,271 women aged 40–89 years. We stratified intervals based on whether the exam at the end of the interval occurred before or after the 2009 USPSTF decision. Differences in mean interval length by woman-level characteristics were compared using linear regression. Results: Contrary to expectations, the mean interval length (in months) minimally decreased after the 2009 USPSTF guideline compared to prior. Among women aged 40–49 years, the mean interval length decreased from 17.3 months to 17.1 months (difference −0.16, 95% confidence interval [CI] -0.30 to -0.01). Similar small reductions were seen for most age groups. The largest decreases in interval length in the post-USPSTF period were observed among women with a first-degree family history of breast cancer (difference −0.68, 95% CI, −0.82–−0.54) or a 5-year breast cancer risk ≥ 2.5% (difference −0.58, 95% CI, −0.73–−0.44). Conclusions: The 2009 USPSTF guideline update did not lengthen the average mammography screening interval among women routinely participating in mammography screening. Future studies should evaluate whether breast cancer screening intervals lengthen towards biennial intervals following new national 2015 breast cancer screening recommendations, particularly among women under 50 years.

Burden of disease of reoperations in instrumental spinal surgeries in Germany

PURPOSE

To estimate the incidence of instrumental spinal surgeries (ISS) and consecutive reoperations and to calculate the related resource utilization and costs.

METHODS

ISS and subsequent reoperations were identified retrospectively using surgery codes in claims data. The study period included January 01, 2009 to December 31, 2011. The reoperation rate was calculated for 1 year after the primary ISS. Resource utilization and costs were analyzed by group comparison.

RESULTS

A total of 3316 incident ISS patients were identified in 2010 with an annual reoperation rate of 9.98% (95% CI 8.98-11.02%). Mean costs per patient were €11,331 per ISS and €11,370 per reoperation, with €8432 directly attributed to the reoperation and €2938 to additional resources.

CONCLUSIONS

Costs of ISS and subsequent reoperations have a significant impact on health insurances budgets. The annual cost of reoperations exceeds the direct cost of the primary surgery driven by the need for further inpatient and outpatient care.

Inhibitory synaptic plasticity: spike timing-dependence and putative network function

While the plasticity of excitatory synaptic connections in the brain has been widely studied, the plasticity of inhibitory connections is much less understood. Here, we present recent experimental and theoretical findings concerning the rules of spike timing-dependent inhibitory plasticity and their putative network function. This is a summary of a workshop at the COSYNE conference 2012.

Shedding light on an extremophile lifestyle through transcriptomics

The tropical intertidal ecosystem is defined by trees - mangroves - which are adapted to an extreme and extremely variable environment. The genetic basis underlying these adaptations is, however, virtually unknown. Based on advances in pyrosequencing, we present here the first transcriptome analysis for plants for which no prior genomic information was available. We selected the mangroves Rhizophora mangle (Rhizophoraceae) and Heritiera littoralis (Malvaceae) as ecologically important extremophiles employing markedly different physiological and life-history strategies for survival and dominance in this extreme environment. For maximal representation of conditional transcripts, mRNA was obtained from a variety of developmental stages, tissues types, and habitats. For each species, a normalized cDNA library of pooled mRNAs was analysed using GSFLX pyrosequencing. A total of 537,635 sequences were assembled de novo and annotated as > 13,000 distinct gene models for each species. Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) orthology annotations highlighted remarkable similarities in the mangrove transcriptome profiles, which differed substantially from the model plants Arabidopsis and Populus. Similarities in the two species suggest a unique mangrove lifestyle overarching the effects of transcriptome size, habitat, tissue type, developmental stage, and biogeographic and phylogenetic differences between them.

Pre-pregnancy and pregnancy-related factors and the risk of excessive or inadequate gestational weight gain

OBJECTIVE

Gestational weight gain consistent with the Institute of Medicine's recommendations is associated with better maternal and infant outcomes. The objective was to quantify the effect of pre-pregnancy factors, pregnancy-related health conditions, and modifiable pregnancy factors on the risks of inadequate and excessive gestational weight gain.

METHOD

A longitudinal cohort of pregnant women (N=1100) who completed questions about diet and weight gain during pregnancy and delivered a singleton, full-term infant.

RESULTS

Gestational weight gain was inadequate for 14% and excessive for 53%. Pre-pregnancy factors contributed 74% to excessive gain, substantially more than pregnancy-related health conditions (15%) and modifiable pregnancy factors (11%). Pre-pregnancy factors, pregnancy-related health conditions, and modifiable pregnancy factors contributed fairly equally to the risk of inadequate gain.

CONCLUSION

Interventions to prevent excessive gestational gain may need to start before pregnancy. Women at risk for inadequate gain would also benefit from interventions directed toward modifiable factors during pregnancy.

Bupropion in breast milk: an exposure assessment for potential treatment to prevent post-partum tobacco use

OBJECTIVES

To assess potential infant exposure to bupropion and its active metabolites in breast milk such as would occur during treatment to prevent post-partum relapse to tobacco use, and to compare the concentrations of bupropion in urine and saliva with plasma and breast milk.

DESIGN AND SETTING

Cohort study, outpatient clinical research centre.

SUBJECTS

Ten healthy post-partum volunteers who agreed to take bupropion for seven days, pump and discard their breast milk, and have samples of breast milk, plasma, saliva, and urine analysed.

INTERVENTION

Bupropion 150 mg a day for three days and then 300 mg a day for four days.

MAIN OUTCOME MEASURES

Concentrations of bupropion and its active metabolites (hydroxybupropion, erythrohydrobupropion, threohydrobupropion) in breast milk, plasma, saliva, and urine. Determination of average infant exposure.

RESULTS

The calculated average dosage of bupropion in breast milk was 6.75 microg/kg/day. Therefore, the average infant exposure is 0.14% of the standard adult dose of bupropion, corrected for the difference in body weight. Considering the sum of bupropion and its active metabolites, the average infant exposure is expected to be 2% of the standard maternal dose on a molar basis. The concentration of bupropion and its active metabolites in breast milk was not associated with age, body mass index, use of oral contraceptive pills, age of infant, or the frequency of breast feeding at the time the study was initiated. The coefficient of determination (r2) between the concentration of bupropion in breast milk and in urine was 0.77 (p < 0.01).

CONCLUSIONS

Bupropion and its active metabolites are present in the breast milk of lactating women. The concentrations of bupropion in breast milk and urine were highly correlated. These results indicate that the daily dose of bupropion and metabolites that would be delivered to an infant of a woman taking a therapeutic dose of bupropion is small. These results suggest that the effectiveness of bupropion to prevent post-partum relapse to tobacco use should be evaluated without excluding women who plan to breast feed.

Intention to discontinue care among primary care patients: influence of physician behavior and process of care

BACKGROUND

Specific elements of health care process and physician behavior have been shown to influence disenrollment decisions in HMOs, but not in outpatient settings caring for patients with diverse types of insurance coverage.

OBJECTIVE

To examine whether physician behavior and process of care affect patients' intention to return to their usual health care practice.

DESIGN

Cross-sectional patient survey and medical record review.

SETTING

Eleven academically affiliated primary care medicine practices in the Boston area.

PATIENTS

2,782 patients with at least one visit in the preceding year.

MEASUREMENT

Unwillingness to return to the usual health care practice.

RESULTS

Of the 2,782 patients interviewed, 160 (5.8%) indicated they would not be willing to return. Two variables correlated significantly with unwillingness to return after adjustment for demographics, health status, health care utilization, satisfaction with physician's technical skill, site of care, and clustering of patients by provider: dissatisfaction with visit duration (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.4 to 7.4) and patient reports that the physician did not listen to what the patient had to say (OR, 8.8; 95% CI, 2.5 to 30.7). In subgroup analysis, patients who were prescribed medications at their last visit but who did not receive an explanation of the purpose of the medication were more likely to be unwilling to return (OR, 4.9; 95% CI, 1.8 to 13.3).

CONCLUSION

Failure of physicians to acknowledge patient concerns, provide explanations of care, and spend sufficient time with patients may contribute to patients' decisions to discontinue care at their usual site of care.

Influence of financial productivity incentives on the use of preventive care

PURPOSE

We examined whether physician factors, particularly financial productivity incentives, affect the provision of preventive care.

SUBJECTS AND METHODS

We surveyed and reviewed the charts of 4,473 patients who saw 1 of 169 internists from 11 academically affiliated primary care practices in Boston. We abstracted cancer risk factors, comorbid conditions, and the dates of the last Papanicolaou (Pap) smear, mammogram, cholesterol screening, and influenza vaccination. We obtained physician information including the method of financial compensation through a mailed physician survey. We used multivariable logistic regression to examine the association between physician factors and four outcomes based on Health Plan Employer Data and Information Set (HEDIS) measures: (1) Pap smear within the prior 3 years among women 20 to 75 years old; (2) mammogram in the prior 2 years among women 52 to 69 years old; (3) cholesterol screening within the prior 5 years among patients 40 to 64 years old; and (4) influenza vaccination among patients 65 years old and older. All analyses accounted for clus-tering by provider and site and were converted into adjusted rates.

RESULTS

After adjustment for practice site, clinical, and physician factors, patients cared for by physicians with financial productivity incentives were significantly less likely than those cared for by physicians without this incentive to receive Pap smears (rate difference, 12%; 95% confidence interval [CI]: 5% to 18%) and cholesterol screening (rate difference, 4%; 95% CI: 0% to 8%). Financial incentives were not significantly associated with rates of mammography (rate difference, -3%; 95% CI: -15% to 10%) or influenza vaccination (rate difference, -13%; 95% CI: -28% to 2%).

CONCLUSIONS

Our findings suggest that some financial productivity incentives may discourage the performance of certain forms of preventive care, specifically Pap smears and cholesterol screening. More studies are needed to examine the effects of financial incentives on the quality of care, and to examine whether quality improvement interventions or incentives based on quality improve the performance of preventive care.

Factors associated with the health care utilization of homeless persons

CONTEXT

Homeless persons face numerous barriers to receiving health care and have high rates of illness and disability. Factors associated with health care utilization by homeless persons have not been explored from a national perspective.

OBJECTIVE

To describe factors associated with use of and perceived barriers to receipt of health care among homeless persons.

DESIGN AND SETTING

Secondary data analysis of the National Survey of Homeless Assistance Providers and Clients.

SUBJECTS

A total of 2974 currently homeless persons interviewed through homeless assistance programs throughout the United States in October and November 1996.

MAIN OUTCOME MEASURES

Self-reported use of ambulatory care services, emergency departments, and inpatient hospital services; inability to receive necessary care; and inability to comply with prescription medication in the prior year.

RESULTS

Overall, 62.8% of subjects had 1 or more ambulatory care visits during the preceding year, 32.2% visited an emergency department, and 23.3% had been hospitalized. However, 24.6% reported having been unable to receive necessary medical care. Of the 1201 respondents who reported having been prescribed medication, 32.1% reported being unable to comply. After adjustment for age, sex, race/ethnicity, medical illness, mental health problems, substance abuse, and other covariates, having health insurance was associated with greater use of ambulatory care (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.19-5.42), inpatient hospitalization (OR, 2.60; 95% CI, 1.16-5.81), and lower reporting of barriers to needed care (OR, 0.37; 95% CI, 0.15-0.90) and prescription medication compliance (OR, 0.35; 95% CI, 0.14-0.85). Insurance was not associated with emergency department visits (OR, 0.90; 95% CI, 0.47-1.75).

CONCLUSIONS

In this nationally representative survey, homeless persons reported high levels of barriers to needed care and used acute hospital-based care at high rates. Insurance was associated with a greater use of ambulatory care and fewer reported barriers. Provision of insurance may improve the substantial morbidity experienced by homeless persons and decrease their reliance on acute hospital-based care.

Differences in the quality of care for women with an abnormal mammogram or breast complaint

OBJECTIVE

To examine factors associated with variation in the quality of care for women with 2 common breast problems: an abnormal mammogram or a clinical breast complaint.

DESIGN

Cross-sectional patient survey and medical record review.

SETTING

Ten general internal medicine practices in the Greater Boston area.

PARTICIPANTS

Women who had an abnormal radiographic result from a screening mammogram or underwent mammography for a clinical breast complaint (N = 579).

MEASUREMENTS AND MAIN RESULTS

Three measures of the quality of care were used: (1) whether or not a woman received an evaluation in compliance with a clinical guideline; (2) the number of days until the appropriate resolution of this episode of breast care if any; and (3) a woman's overall satisfaction with her care. Sixty-nine percent of women received care consistent with the guideline. After adjustment, women over 50 years (odds ratio [OR], 1.58; 95% [CI], 1.06 to 2.36) and those with an abnormal mammogram (compared with a clinical breast complaint: OR, 1.75; 95% CI, 1.16 to 2.64) were more likely to receive recommended care and had a shorter time to resolution of their breast problem. Women with a managed care plan were also more likely to receive care in compliance with the guideline (OR, 1.72; 95% CI, 1.12 to 2.64) and have a more timely resolution. There were no differences in satisfaction by age or type of breast problem, but women with a managed care plan were less likely to rate their care as excellent (43% vs 53%, P <.05).

CONCLUSIONS

We found that a substantial proportion of women with a breast problem managed by generalists did not receive care consistent with a clinical guideline, particularly younger women with a clinical breast complaint and a normal or benign-appearing mammogram.

Obstacles to collaborative quality improvement: the case of ambulatory general medical care

OBJECTIVE

To assess the effectiveness of inter-site collaboration and report-card style feedback of quality measures on quality improvement in the outpatient setting and to identify major barriers to improvement.

DESIGN

A collaborative quality improvement effort consisting of a large cross-sectional data collection effort (chart reviews and patient surveys), feedback of comparative quality of care data to improvement teams, and collaboration between sites.

SETTING

Eleven primary care sites in the Boston area.

STUDY PARTICIPANTS

Quality improvement teams at each site with physician leaders.

INTERVENTION

Education about techniques of rapid-cycle quality improvement, coaching of on-site teams, and report-card style feedback of comparative site-specific quality of care data.

RESULTS

Multiple quality improvement projects were undertaken through this collaboration. However, though we were careful to educate teams on methods of continuous quality improvement and to name specific clinical leaders, the degree of collaboration and quality improvement fell short of expectations. Major impediments to improvement included lack of team members' time and resources, lack of incentives, and unempowered team leadership. The primary obstacle to collaboration was the diversity of sites and inability of teams to create interventions that were relevant to other sites.

CONCLUSION

Despite ample quality of care data, quality improvement education, and a structured collaborative process, achieving quality improvement in the ambulatory setting is still a difficult challenge. Organizations need to find ways of overcoming the obstacles faced by improvement teams in order to maximize quality improvement.

Drug complications in outpatients

OBJECTIVE

Outpatient drug complications have not been well studied. We sought to assess the incidence and characteristics of outpatient drug complications, identify their clinical and nonclinical correlates, and evaluate their impact on patient satisfaction.

DESIGN

Retrospective chart reviews and patient surveys.

SETTING

Eleven Boston-area ambulatory clinics.

PATIENTS

We randomly selected 2,248 outpatients, 20 to 75 years old.

MEASUREMENTS AND MAIN RESULTS

Among 2,248 patients reporting prescription drug use, 394 (18%) reported a drug complication. In contrast, chart review revealed an adverse drug event in only 64 patients (3%). In univariate analyses, significant correlates of patient-reported drug complications were number of medical problems, number of medications, renal disease, failure to explain side effects before treatment, lower medication compliance, and primary language other than English or Spanish. In multivariate analysis, independent correlates were number of medical problems (odds ratio [OR] 1.17; 95% confidence interval [95% CI] 1.05 to 1.30), failure to explain side effects (OR 1.65; 95% CI, 1.16 to 2.35), and primary language other than English or Spanish (OR 1.40; 95% CI, 1.01 to 1.95). Patient satisfaction was lower among patients who reported drug complications (P <.0001). In addition, 48% of those reporting drug complications sought medical attention and 49% experienced worry or discomfort. On chart review, 3 (5%) of the patients with an adverse drug event required hospitalization and 8 (13%) had a documented previous reaction to the causative drug.

CONCLUSIONS

Drug complications in the ambulatory setting were common, although most were not documented in the medical record. These complications increased use of the medical system and correlated with dissatisfaction with care. Our results indicate a need for better communication about potential side effects of medications, especially for patients with multiple medical problems.

Is the professional satisfaction of general internists associated with patient satisfaction?

BACKGROUND

The growth of managed care has raised a number of concerns about patient and physician satisfaction. An association between physicians' professional satisfaction and the satisfaction of their patients could suggest new types of organizational interventions to improve the satisfaction of both.

OBJECTIVE

To examine the relation between the satisfaction of general internists and their patients.

DESIGN

Cross-sectional surveys of patients and physicians.

SETTING

Eleven academically affiliated general internal medicine practices in the greater-Boston area.

PARTICIPANTS

A random sample of English-speaking and Spanish-speaking patients (n = 2,620) with at least one visit to their physician (n = 166) during the preceding year.

MEASUREMENTS

Patients' overall satisfaction with their health care, and their satisfaction with their most recent physician visit.

MAIN RESULTS

After adjustment, the patients of physicians who rated themselves to be very or extremely satisfied with their work had higher scores for overall satisfaction with their health care (regression coefficient 2.10; 95% confidence interval 0.73-3.48), and for satisfaction with their most recent physician visit (regression coefficient 1.23; 95% confidence interval 0.26-2.21). In addition, younger patients, those with better overall health status, and those cared for by a physician who worked part-time were significantly more likely to report better satisfaction with both measures. Minority patients and those with managed care insurance also reported lower overall satisfaction.

CONCLUSIONS

The patients of physicians who have higher professional satisfaction may themselves be more satisfied with their care. Further research will need to consider factors that may mediate the relation between patient and physician satisfaction.

Outcomes and health status of socially disadvantaged women during pregnancy

We sought to examine the health status of disadvantaged pregnant women more broadly and to consider if poor maternal health predisposes a woman to an adverse birth outcome. We surveyed 250 women recruited from six health centers in the greater Boston area during their third trimester. The main predictor variables were maternal physical functioning (PF), emotional health (EH), and overall health status in the month prior to pregnancy. The main outcome variables were the decline of maternal PF and EH during pregnancy and adverse birth outcomes. Mean PF scores fell from 91.9 prior to pregnancy to 63.7 during the third trimester (mean scores transformed 0 to 100, where a higher score represents better health). EH remained unchanged during pregnancy. After adjustment, women with a preexisting medical condition reported a lower PF score prior to pregnancy (87.8 versus 94.5, p < 0.05). Poor PF prior to pregnancy or during the third trimester was associated with an increased risk of preterm labor (odds ratio 2.02, 95% confidence interval 1.03-3.97). This study is the first to employ general health status measures to examine changes in health during pregnancy. Our findings support the use of preconception care to improve the health status of disadvantaged women with pre-existing conditions. This study suggests that poor maternal health may predispose a woman to an increased risk of preterm labor.

The stability of preferences for life-sustaining care among persons with AIDS in the Boston Health Study

BACKGROUND

Clinicians recognize the importance of eliciting patient preferences for life-sustaining care, yet little is known about the stability of those preferences for patients with serious disease.

OBJECTIVES

To examine the stability of preferences for life-sustaining care among persons with AIDS and to assess factors associated with changes in preferences.

DESIGN

Two patient surveys and medical record reviews, administered four months apart in 1990-1991.

SETTING

Three health care settings in Boston.

PATIENTS

252 of 505 eligible persons with AIDS who participated in both baseline and follow-up surveys.

MAIN OUTCOME MEASURES

A single question assessing desire for cardiac resuscitation and a scale of preferences for life-extending treatment conditional on hypothetical health states.

RESULTS

Approximately one-fourth of the respondents changed their minds about life-sustaining care during a four-month period. Of patients who initially desired cardiac resuscitation, 23% decided to forego it four months later, and of those who initially said they would decline care, 34% later said they would accept it. Of those who initially desired any of the life-extending treatments, 25% decided to forego them four months later, and of those who initially said they would decline life-extending care, 24% later said they would accept some treatment. Patients reporting changes in physical function, pain, or suicide ideation were more likely to modify their desires to be resuscitated (all p< or =0.05). Patients lacking an advance directive, not completing high school, or becoming more severely ill were more likely to change their preferences on the Life Extension scale (p< or =0.05). Patients who discussed their preferences with at least one physician were just as likely as others to change desires for cardiac resuscitation. Age, gender, race, emotional health, clinical severity, social support, and site of care were not significant correlates of change for either measure.

CONCLUSIONS

Health care providers should periodically reassess preferences for life-sustaining care, particularly for patients with progressive disease, given the instability in patient preferences. However, predictors of instability may vary with how preferences are measured. In particular, changes in health status may be related to instability of preferences for certain types of treatments.

Differences in the professional satisfaction of general internists in academically affiliated practices in the greater-Boston area. Ambulatory Medicine Quality Improvement Project Investigators

Managed care has created more professional constraints for general internists. We surveyed 198 general internists at 12 academically affiliated practices in the greater-Boston area to examine professional satisfaction. Overall, these physicians were moderately satisfied (mean of 59.1 on a 100-point scale). Before adjustment, women had lower overall satisfaction than men, as well as poorer satisfaction with the domains of career concerns and patient access. Gender had no independent effect on satisfaction after adjustment for age, income, percentage of time providing direct patient care, work status, and site. Younger physicians also had lower overall satisfaction, and these differences remained after adjustment. Improvements in professional satisfaction may be required to ensure the continued recruitment of young physicians, particularly women, into general internal medicine.

Hospital use and health status of women during the 5 years following the birth of a premature, low-birthweight infant

OBJECTIVE

This study examined the health status and hospital use of women after the birth of a premature, low-birthweight infant.

METHODS

The subjects were women with infants who participated in a multisite, randomized trial of an early intervention program. The outcomes examined were (1) a maternal health rating of poor or fair (i.e., poorer health) 5 years following delivery and (2) hospital use for a non-pregnancy-related condition.

RESULTS

By the fifth year after delivery, 29.7% of the women had been hospitalized for a non-pregnancy-related condition. Women who reported poorer health status (adjusted relative risk [RR] = 2.39; 95% confidence interval [CI] = 1.86, 3.07) or who had asthma (RR = 2.24; CI = 1.31, 3.80) were at greatest risk. After 5 years, 16.9% of the women said they were in poorer health. The number of intervening years in poorer health (1 year, RR = 3.17; CI = 2.04, 4.94; > 1 year, RR = 8.42; CI = 2.20, 12.88), more than 1 year of poverty (RR = 3.28; CI = 1.90, 5.66), obesity (RR = 3.30; CI = 1.44, 7.55), and more than 1 year of employment (RR = 0.55; CI = 0.36, 0.86) were all significantly associated with poorer health.

CONCLUSIONS

The continued, substantial morbidity and hospital use of women with a premature, low-birthweight infant has not previously been reported. This observation needs to be verified.

A possible chemical explanation for the events associated with the death of Gloria Ramirez at Riverside General Hospital

The events associated with the death of Gloria Ramirez at Riverside General Hospital on 19 February 1994 have been portrayed as a major medical mystery. A potential chemical explanation for this incident has been developed. The hypothetical scenario depends upon the oxidation of a common solvent, dimethyl sulfoxide, through dimethyl sulfone to dimethyl sulfate. The latter compound is a volatile and highly toxic agent that can be quite hazardous to humans in small amounts. It is also environmentally nonpersistent. Much of the mystery surrounding the circumstances at the hospital may be explainable if this postulated metabolic pathway took place at the time of the emergency room incident. Although dimethyl sulfate was not detected in any analyses pertinent to this event, there are plausible scientific explanations to account for that fact. The sulfate anion, a hydrolysis product of dimethyl sulfate, was measured at an appreciably elevated concentration in Ramirez' blood. The descriptions of the symptoms of the hospital-staff victims appear quite consistent with dimethyl sulfate exposures. This paper attempts to make some sense of the reported data and eyewitness accounts, and perhaps provide new insight for any future research that could further explain this reported occurrence of toxic exposure.

The Boston AIDS Survival Score (BASS): a multidimensional AIDS severity instrument

OBJECTIVES

This study developed a new acquired immunodeficiency syndrome (AIDS) severity system by including diagnostic, physiological, functional, and sociodemographic factors predictive of survival.

METHODS

Three-hundred five persons with AIDS in Boston were interviewed; their medical records were reviewed and vital status ascertained.

RESULTS

Overall median (+/- SD) survival for the cohort from the first interview until death was 560 +/- 14.4 days. The best model for predicting survival, the Boston AIDS Survival Score, included the Justice score (stage 2 relative hazard [RH] = 1.25, 95% confidence interval [CI] = 0.80, 1.96; stage 3 RH = 1.76, 95% CI = 1.15, 2.70), a newly developed opportunistic disease score (Boston Opportunistic Disease Survival Score; stage 2 RH = 1.35, 95% CI = 0.90, 2.02; stage 3 RH = 2.10, 95% CI = 1.38, 3.18), and measures of activities of daily living (any intermediate limitations, RH = 1.84, 95% CI = 1.05, 3.21; any basic limitations, RH = 2.60, 95% CI = 1.44, 4.69). This model had substantially greater predictive power (R2 = .17, C statistic = .68) than the Justice score alone (R2 = .09, C statistic = .61).

CONCLUSIONS

Incorporating data on clinically important events and functional status into a physiologically based system can improve the prediction of survival with AIDS.

Chemical and elemental comparison of two formulations of oleoresin capsicum

In-custody deaths following the application of pepper spray weaponry by law enforcement personnel have increased in California over the last few years. Oleoresin capsicum (OC), an oily extract of hot peppers, is the active ingredient in the spray, but little detailed information on product mixtures is available. Since OC extracts contain a multitude of natural compounds at irregular concentrations, there could be considerable, variation in overall chemical composition among the different formulations of both 'natural' and 'synthetic' OC preparations. This was confirmed by organic and inorganic analyses performed on OC sprays produced by two manufacturers licensed for distribution within the state of California. The results indicated that the differences could lead to considerable inconsistency in weapon effectiveness, and suggested that more comprehensive studies are warranted.

The influence of health-related quality of life and social characteristics on hospital use by patients with AIDS in the Boston Health Study

OBJECTIVES

The authors examine whether health-related quality of life (HRQL) and social factors were independent predictors of future hospital use for persons with acquired immunodeficiency syndrome (AIDS).

METHODS

A panel of 305 patients with AIDS treated at three provider settings in the Boston, Massachusetts area were enrolled during 1990 and 1991. Data were collected at baseline study enrollment and again 4 months later. Patient interviews, hospital bills, and medical charts were used to measure hospital use (admissions and days during the 4 months after enrollment), sociodemographic characteristics (age, gender, race, education, insurance, homelessness, alcohol use, and AIDS risk factors), disease burden (patient severity and a three-level opportunistic diseases and complications score), HRQL (patient-reported symptoms, activities of daily living, neuropsychological status, and global health assessment), system of care, and use of prophylactic drugs. Logistic regression was used to estimate the odds of admission. Total days of hospital care by patients with at least one admission were analyzed using multiple linear regression. Clinical models of hospital use were developed first from the variables measuring disease burden and system of care. Models estimating the associations between hospital use and all other predictor variables measured at baseline then were estimated using stepwise techniques, controlling for variables in the core model.

RESULTS

Patients were more likely than their reference groups to be hospitalized if they had serious opportunistic diseases (adjusted odds ratio [OR] = 2.7), had poorer neuropsychological status (OR = 1.9), were non-white (OR = 2.0), or were homeless (OR = 3.3) (all P < or = 0.05). Activities of daily living were associated moderately (OR = 1.3; P = 0.07). Only system of care and neuropsychological status predicted total hospital days.

CONCLUSIONS

The results indicate that future hospital use by persons with AIDS may be influenced by social and other health-related factors in addition to the more clinically related characteristics that are recorded in a medical chart. It therefore may be appropriate to assess these factors when considering options for intervention or when comparing patterns of use among patient groups or settings.

Prenatal hospitalization and compliance with guidelines for prenatal care

OBJECTIVES

This study examined the relationship between compliance with the US Public Health Service guidelines for prenatal care and the rate of prenatal hospitalization.

METHODS

For all women admitted to a Boston referral center during January and February 1993 with a pregnancy of at least 18 weeks gestation (n = 1400), a proportional hazards model was used to examine factors associated with prenatal hospitalization.

RESULTS

Prenatal hospitalization occurred during 248 (17.7%) pregnancies. The median length of stay for all prenatal admissions was 4 days; the medial total charge was $5667. Prior medical and obstetrical problems were strongly associated with prenatal hospitalization. After adjustment for age, race, and medical and obstetrical complications, women who received less than 70% of the prenatal care recommended were significantly more likely to be hospitalized (relative risk [RR] = 2.14, 95% confidence interval [CI] 1.50, 3.06).

CONCLUSIONS

Prenatal hospitalization is a common, costly complication of pregnancy. Because of its association with compliance with the Public Health Service guidelines for the content of prenatal care, prenatal hospitalization may be a sentinel indicator of inadequate prenatal care amenable to intervention.

The relationship between physicians' qualifications and experience and the adequacy of prenatal care and low birthweight

OBJECTIVES

The purpose of this study was to examine the relationship between physicians' qualifications and experience and rates of completion of the recommended number of prenatal visits and delivery of a low-birthweight infant.

METHODS

All deliveries performed by a permanently licensed physician in Massachusetts in 1990 (n = 80,537) were examined. Qualification was measured by board certification. Experience was measured by both volume of deliveries and duration of practice.

RESULTS

Women cared for by a non-board-certified physician were less likely to receive the recommended number of prenatal visits (odds ratio [OR] = 0.67, 95% confidence interval [CI] = 0.54, 0.85) and were more likely to have a low-birthweight infant (OR = 1.20, 95% CI = 1.00, 1.42). Physicians with a smaller volume of deliveries or a shorter duration of practice were more likely to deliver a low-birthweight infant.

CONCLUSIONS

The data show an association of board certification with rates of the recommended number of prenatal visits and low birthweight. In addition, volume and duration of practice were significantly associated with low birthweight. Further research should examine whether these associations are related to differences in patient referral or to physicians' judgement and efficiency in provision of prenatal care.

Acutely injured patients with trauma in Massachusetts: differences in care and mortality, by insurance status

OBJECTIVES

This study was designed to determine whether resource use and mortality differed by insurance status for patients with acute trauma.

METHODS

All adults emergently hospitalized in Massachusetts during 1990 with acute trauma (n = 15,008) were examined.

RESULTS

After adjustment for confounders, uninsured patients were as likely to receive care in an intensive care unit as were patients with private insurance (odds ratio [OR] = 0.97, 95% confidence interval [CI] = 0.85, 1.11) but were less likely to undergo an operative procedure (OR = 0.68, 95% CI = 0.63, 0.74) or physical therapy (OR = 0.61, 95% CI = 0.57,0.67) and were more likely to die in a hospital (OR = 2.15, 95% CI = 1.44, 3.19). Compared with patients with private insurance, those with Medicaid were less likely to receive an operative procedure (0.85, 0.75-0.97), were equally likely to receive care in an intensive care unit (OR = 1.05, 95% CI = 0.86, 1.30) or physical therapy (OR = 0.90, 95% CI = 0.79, 1.02), and were no more likely to die (OR = 1.28, 95% CI = 0.69,2.39).

CONCLUSIONS

These results suggest that the uninsured receive less trauma-related care and have a higher mortality rate. The excess mortality in uninsured patients may be avoided if their resource use is increased to that of insured patients.

The impact of socioeconomic status on the intensity of ambulatory treatment and health outcomes after hospital discharge for adults with asthma

OBJECTIVES

To examine whether differences in intensities of care by socioeconomic status and race result in worse health among adults with asthma post-hospital discharge.

DESIGN

Patients were enrolled during hospitalization and recontacted three months after discharge.

PATIENTS

Those aged 18-55 years, with a primary diagnosis of asthma (n = 97).

MAIN OUTCOME MEASURES

Regular source of care, "intensive" therapy (use of an anti-inflammatory agent, pulmonary function testing, or an asthma specialist), and patient-reported (Intermediate Activities of Daily Living Scale [IADL] score, dyspnea) and performance-based (peak flow rate) measures of health status post-discharge.

RESULTS

28% of patients with a yearly income less than $16,000 had no regular source of care, compared with 11% of those with an income from $16,000 to $29,999 and no patient with an income of at least $30,000 (p = 0.003). Similarly, intensive therapy was received by 40%, 67%, and 81% of these groups (p = 0.005). Education had similar associations. Patients with no regular source of care or who did not receive intensive therapy had significantly worse health. Patients of lower socioeconomic status had health outcomes that were up to 25% lower than those of patients of higher socioeconomic status (p < 0.05 for differences in LADL score, dyspnea, and peak flow by educational levels and for differences in dyspnea by income levels), after adjustment for age, gender, race, insurance status, and baseline health. After further adjustment for source of care and intensity of therapy, differences in health outcomes by socioeconomic status uniformly decreased in magnitude and only the differences in LADL scores and dyspnea by educational levels remained statistically significant. Although nonwhite patients were less likely to have a regular source of care or to receive intensive therapy, there was no difference in health outcomes by race.

CONCLUSIONS

Patients of lower socioeconomic status who have asthma have worse health outcomes post-hospital discharge, which appear to be due in part to less continuous and less intensive treatment.

The effect of health coverage for uninsured pregnant women on maternal health and the use of cesarean section

OBJECTIVES

Although there has been substantial policy interest in interventions to improve the neonatal outcomes of disadvantaged women, little attention has been paid to the health status of pregnant women themselves. We therefore examined whether the provision of health coverage to uninsured low-income pregnant women affects maternal health status or the use of cesarean section.

DESIGN

Natural experiment in Massachusetts.

PATIENTS

All in-hospital, single-gestation births in 1984 (N = 57,257) and 1987 (N = 64,346).

INTERVENTION

Healthy Start is a statewide health coverage program for uninsured pregnant women. In 1985, it covered women with incomes below 185% of the federal poverty level.

MAIN OUTCOME MEASURES

Rates of adverse maternal outcome (severe pregnancy-related hypertension, placental abruption, and a length of stay at least 1 day longer than infants' stay) and cesarean section for uninsured women, and for two concurrent control groups, women with Medicaid and women with private insurance. We calculated the difference in rates between the uninsured and each concurrent control. We then examined the change in these interpayer differences in rates between 1984 and 1987 to measure the effect of Healthy Start.

MAIN RESULTS

In 1984, uninsured women had higher rates of adverse maternal health outcome than privately insured women (5.5% vs 5.1%, respectively; interpayer difference, 0.4%) and received fewer cesarean sections (17.2% vs 23.0%; interpayer difference, -5.8%). Between 1984 and 1987 there was no statistically significant change in the interpayer difference in adverse outcome relative to women with private insurance. However, the interpayer difference in cesarean sections between the uninsured and the privately insured was reduced by 2.3% (95% confidence interval [CI], +0.4% to +4.2%), although the uninsured continued to undergo fewer cesarean sections (22.4% vs 25.9%). Similar results were observed when the uninsured women were compared with women with Medicaid.

CONCLUSIONS

The provision of health insurance alone to low-income pregnant women may not be associated with an improvement in maternal health. Expanded coverage was associated, however, with an increase in the rate of cesarean section.

Discussion of preferences for life-sustaining care by persons with AIDS. Predictors of failure in patient-physician communication

OBJECTIVES

To assess the determinants of communication about resuscitation between persons with acquired immunodeficiency syndrome (AIDS) and their physician.

DESIGN AND SETTING

Structured patient interview at a staff-model health maintenance organization (HMO), an internal medicine group practice at a private teaching hospital, and an AIDS clinic at a public hospital.

PATIENTS

289 persons with AIDS.

MAIN RESULTS

Only 38% of patients had discussed their preferences for resuscitation with their physician. Using logistic regression, we found that patients were less likely to have discussed resuscitation with their physician if they were nonwhite (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.24 to 0.99), had never been hospitalized (OR, 0.52; 95% CI, 0.27 to 0.99), or were cared for in the HMO (OR, 0.44 relative to the private teaching hospital; 95% CI, 0.23 to 0.82). Patients were more likely to have discussed their preferences if they were not currently taking zidovudine (OR, 1.76; 95% CI, 1.02 to 3.03) and if they had decided to defer life-sustaining therapy (OR, 2.30; 95% CI, 1.35 to 3.91). Among nonwhites, those with a nonwhite physician were more likely to have discussed resuscitation (OR, 4.38; 95% CI, 1.13 to 16.93). Of patients who had not discussed their preferences for life-sustaining care, 72% wanted to do so. Patient desire for discussion of this issue did not vary by race, severity of illness, hospitalization status, use of zidovudine, or site of care.

CONCLUSIONS

A majority of persons with AIDS in this study had not discussed their preferences for life-sustaining care with their physician, despite the desire to do so. Interventions to improve patient-physician communication about resuscitation for nonwhites and other groups at risk of inadequate discussion might lead to clinical decisions that are more consistent with patient preferences.

The effect of providing health coverage to poor uninsured pregnant women in Massachusetts

OBJECTIVES

There has been substantial policy interest in whether the provision of health coverage to poor uninsured pregnant women affects access to prenatal care and birth outcomes. We therefore examined whether the statewide provision of health coverage to uninsured low-income pregnant women affects access to prenatal care and infant birth outcomes.

DESIGN

Natural experiment.

PATIENTS

All in-hospital, single-gestation live births in 1984 (N = 57,257) and 1987 (N = 64,346).

INTERVENTION

In 1985, Massachusetts instituted Healthy Start, a program providing health coverage to uninsured pregnant women with incomes below 185% of the federal poverty level.

MAIN OUTCOME MEASURES

Rates of satisfactory prenatal care, care initiated before the third trimester, and adverse infant outcome for uninsured women and for two concurrent control groups, women with Medicaid, and women with private insurance. We calculated the difference in rates between the uninsured and each concurrent control. To assess the effect of the program, we examined the change in these interpayer differences in rates between 1984 and 1987.

MAIN RESULTS

Between 1984 and 1987, the rate of satisfactory prenatal care declined from 96.4% to 93.8% for all women in Massachusetts (P < .001). There was no statewide change in the overall incidence of adverse birth outcome (6.6% in both years). In 1984, uninsured women were less likely than privately insured women to receive satisfactory prenatal care (90.5% and 98.1%, respectively; interpayer difference, -7.6%) and to initiate care before the third trimester (94.2% and 99.1%; interpayer difference, -4.9%), and were more likely to suffer an adverse birth outcome (7.1% and 5.8%; interpayer difference, 1.3%). Between 1984 and 1987, there were no statistically significant changes in the interpayer differences in rates for any of the outcome measures relative to either control group.

CONCLUSIONS

Our findings suggest that access to prenatal care may have declined for all women in Massachusetts between 1984 and 1987. In the setting of this statewide decline in access, the expansion of health coverage to uninsured low-income pregnant women was not associated with an improvement in access to prenatal care or birth outcomes.

Risk factors for stroke in patients with nonrheumatic atrial fibrillation: a case-control study

PURPOSE

Randomized controlled trials have demonstrated that anticoagulant therapy is very effective at preventing stroke among patients with nonrheumatic atrial fibrillation. However, these trials have reported too few strokes for powerful risk factor analysis. Observational studies may provide additional information. The purpose of this study was to identify risk factors in a larger number of patients with stroke and nonrheumatic atrial fibrillation, using case-control methodology.

PATIENTS AND METHODS

We identified all patients discharged from one hospital over an 8-year period who met our case definition of nonrheumatic atrial fibrillation and ischemic stroke (n = 134), and compared them with contemporaneous control subjects who were discharged with nonrheumatic atrial fibrillation without stroke (n = 131).

RESULTS

Cases and controls were similar in terms of duration of atrial fibrillation; proportion with paroxysmal atrial fibrillation; percentage with a past medical history of angina, myocardial infarction, congestive heart failure, diabetes, or smoking; and mean left atrial size. In contrast, cases were significantly older than controls (78.5 versus 74.8 years, p = 0.002) and more likely to have a history of hypertension (55% versus 38%, p = 0.0093). The relative odds for stroke was 1.91 for patients with hypertension, 1.73 for patients older than 75 years, and 3.26 for patients with both factors.

CONCLUSIONS

Our analysis suggests that age and hypertension should be considered when deciding upon long-term anticoagulant therapy to prevent stroke in patients with nonrheumatic atrial fibrillation.

Sensitivity of treponemal tests for detecting prior treated syphilis during human immunodeficiency virus infection

To evaluate the sensitivity of treponemal tests as a marker of prior syphilis in individuals with human immunodeficiency virus (HIV) infection, the syphilis serology of 109 homosexual men with a documented history of treated syphilis was compared with records of prior results and confirmed on stored serum samples. None of the HIV-seronegative individuals lost reactivity to a treponemal test, whereas 7% of the seropositive asymptomatic individuals and 38% of those with symptomatic HIV infection had loss of reactivity. Symptomatic HIV infection was associated with loss of reactivity, as a T4 lymphocyte count less than 200 X 10(6)/1, a T4-to-T8 ratio less than 0.6, a single prior episode of syphilis, and a low VDRL titer at the time of the last documented episode of syphilis. Although no conclusions can be drawn about the sensitivity of treponemal tests in patients with active syphilis and HIV infection, these data suggest that treponemal tests may not identify those previously infected with Treponema pallidum.

Cisplatin and fluorouracil as neoadjuvant therapy in head and neck cancer. A preliminary report

A randomized, prospective trial utilizing cisplatin and fluorouracil as neoadjuvant chemotherapy in the treatment of advanced squamous cell carcinomas of the upper aerodigestive tract was initiated in January 1983. Sixty patients were stratified by site (oral cavity, 19; larynx, 14; hypopharynx, 14; oropharynx, 11; nasopharynx, one; and paranasal sinuses, one) and by stage (III, 19; IV, 41), and then randomized to receive either standard treatment (defined as preoperative irradiation followed by radical excision or irradiation alone) or adjuvant chemotherapy followed by standard treatment. An additional three patients were entered into the study, but withdrew. Chemotherapy consisted of three cycles for those patients in whom an objective tumor response was observed; nonresponders received standard treatment. Response to chemotherapy was complete in five and partial (greater than 50%) in 18 patients, for an overall response rate of 85%. The follow-up for surviving patients was a minimum of 24 months and a maximum of 44 months. Survival was compared for patients in both treatment groups according to the method of Lee and Desu. Despite excellent tumor response, actuarial survival was 70% in the standard treatment group as opposed to 56% in the experimental group. It was therefore evident that the high response rates reported in previous pilot studies do not necessarily result in improved survival in these cancers.

The effects of delay in standard treatment due to induction chemotherapy in two randomized prospective studies

It is often suggested that tumors will respond to induction chemotherapy and result in improved survival for patients with squamous cell carcinoma of the head and neck. Two regimens of induction chemotherapy were studied in separate randomized, prospective trials over the last 6 years. Eighty-three patients with advanced disease were entered into the first study (43/chemotherapy; 40/control), and 60 into the second (27/chemotherapy; 33/control). Patient randomization was stratified by stage (III/IV) and site (oral cavity, oropharynx, nasopharynx, hypopharynx, larynx, paranasal sinuses). The first study utilized bleomycin, Cytoxan, methotrexate and 5-fluorouracil in two cycles (one cycle if no tumor response), followed by standard treatment which consisted of combined irradiation and surgery or, in some instances, primary irradiation alone. The second study utilized cisplatin and 5-fluorouracil in three cycles prior to standard treatment. An objective tumor response to chemotherapy was observed in 68% in the first study and 85% in the second. The patient survival in both studies (at 24 months in the first; at 19 in the second) was better in the control than that in the experimental groups (43% to 31%; 69% to 46%). In the second study, the average length of delay of standard treatment was longer than in the first study (95 days vs. 66 days; P less than .02). Results combining the P-values of both studies indicate that the relative risk of having persistent disease was 2.9 times greater for patients who received chemotherapy. While toxicity to chemotherapy was not a factor in survival, the number of patients who withdrew from the studies and those who did not comply with treatment were greater in the chemotherapy groups. Except for new drug regimens of exceptional promise, it is recommended that future studies be designed so that chemotherapy is given concurrent with, or following the completion of standard treatment.

Dosimetric comparison of the Fletcher family of gynecologic colpostats 1950-1980

The Fletcher gynecologic applicator was developed for irradiation of carcinoma of the uterine cervix in the early 1950's. Since that time, numerous modifications and changes have been made in the colpostat construction and in the location of the shields that provide a reduced dose to the bladder trigone anteriorly and to the rectal wall posteriorly. The original applicators include the preload radium double colpostat and the preload radium single colpostat. In the 1960's, afterloading colpostats were manufactured as the Fletcher-Suit and the Fletcher-Green devices. With the introduction of the Delclos mini-colpostat, a new generation of applicators followed in the 1970's. The Fletcher-Suit-Delclos colpostat recently manufactured by two companies can be used as a mini-colpostat. By adding a shield-containing cap, these applicators function as the original Fletcher colpostat. With the development of new applicators over the past 30 years, numerous changes in the position of the shields and, therefore, the dose transmitted to the surrounding tissues have been made. This paper describes dosimetric evaluation of all of these applicators and the various changes that have occurred through the generations of Fletcher colpostats in an attempt to provide information for radiation therapists and gynecologists who are using these instruments in their clinical practice.

Nafazatrom: in-vitro assessment of radiation and drug activity against animal and human cell lines

The B-16 melanoma animal cell line and HEC-1A human endometrial cell line treated with Nafazatrom (NFZ) (5 mu/ml) and varying doses of ionizing radiation show a dose response curve of increased colony inhibition with increasing radiation dose. The B-16 line consistently demonstrated enhanced colony inhibition when NFZ was added prior to radiation. This colony inhibition by NFZ was not seen in the HEC-1A cell line. No adverse effect, i.e., increased tumor colony growth, was evident when NFZ and radiation were combined. This study suggests that ionizing radiation can be combined with NFZ without adverse effect on the cell killing effects of either modality.

Experimental evaluation of a posterior drainage system

We have evaluated an experimental artificial shunt to drain intraocular fluid into the retrobulbar space. The device consists of a hollow needle for insertion into the eye, a slit valve to regulate the drainage pressure, and a dome-shaped outflow system. The device was inserted through the sclera, choroid, and retina into the eyes of cynomolgus monkeys. The system was tolerated without producing retinal detachment. A localized foreign body reaction occurred in the retina, choroid, and sclera adjacent to the device. The intraocular pressure was lowered until fibrous encapsulation of the outflow system occurred.

Fletcher-Suit-Delclos gynecologic applicator: evaluation of a new instrument

A new instrument has been added to the Fletcher-Suit-Delclos group of gynecologic applicators. The colpostats can be used as mini-ovoids, but by adding a shielded cap, the instrument has the configuration of the original preload Fletcher colpostat. Dosimetric studies show that this applicator produced transmission ratios (the fraction of radiation transmitted through the tungsten shield) and isodose curves similar to the bladder trigone and anterior rectal wall of 10-25%. With the shield-containing cap removed, the mini-ovoid provides little reduction in dose to those areas and should be used with caution.