Cost-effectiveness and cost-benefit of sumatriptan in patients with migraine

OBJECTIVE

To investigate the cost-effectiveness and cost-benefit of initiating sumatriptan therapy in patients with acute migraine who were previously taking nontriptan drugs.

PATIENTS AND METHODS

This is an economic analysis of a prospective, pretest-posttest, observational 6-month outcomes study of 178 patients with a physician diagnosis of migraine who received their first prescription for sumatriptan between October 1994 and August 1996 and were members of a mixed-model managed care organization in western Pennsylvania. Migraine-related resource use data were obtained from the managed care organization's medical and pharmacy claims databases. The primary outcome measure for this economic analysis was the total disability time that patients experienced because of migraine. Patients reported time missed from work and usual nonwork activities because of migraine on self-administered questionnaires at baseline and at 3 and 6 months after initiation of sumatriptan.

RESULTS

Initiation of sumatriptan resulted in a decrease of 662 migraine-disability-days for work and 1236 migraine-disability-days for nonwork activities during the 6 months of the study (decrease from 27.8 to 17.2 days per person), totaling 1898 migraine-disability-days averted with sumatriptan therapy. Migraine-related medical costs were lower after sumatriptan was initiated ($18,351 vs $26,192), whereas migraine-related pharmacy costs were lower with prior nontriptan drug therapy ($22,209 vs $74,861). The overall net cost savings after sumatriptan was initiated in these patients was $222,332 ($1249 per patient) with a benefit-to-cost ratio of $5.67 gained for each health care dollar spent from a societal perspective. The incremental cost-effectiveness ratio was $25 for each additional migraine-disability-day averted by using sumatriptan vs nontriptan drug therapy. Sensitivity analysis showed that changes in medical costs had little effect on the ratios and that sumatriptan remained cost-beneficial across a wide range of patient wages.

CONCLUSION

This study showed that initiation of sumatriptan in patients previously receiving nontriptan therapy was cost-effective and had an economic benefit for patients, employers, and society. Sumatriptan also helped patients and physicians achieve goals recommended by the US Headache Consortium by reducing patients' disability and thus improving their ability to function at work and nonwork activities.

The racial crossover in comorbidity, disability, and mortality

This study analyzed one respondent per household who was age 70 or more at the time of the household's inclusion in Wave 1 (1993-1994) and whose survival status was determinable at Wave 2 (1995-1996) of the Survey on Asset and Health Dynamics Among the Oldest Old (AHEAD Survey). At age 76 at Wave 1, there was a racial crossover in the cumulative number of six potentially fatal diagnoses (chronic lung disease, cancer, heart disease, hypertension, diabetes, and stroke) from a higher cumulative average number for blacks to a higher average number for whites. Also, there was a racial crossover at age 86 in the cumulative average number of disabilities in the Advanced Activities of Daily Living (AADLs), from a higher average for blacks to a higher average for whites. Between Waves 1 and 2, there was a racial crossover in the odds of mortality from higher odds for blacks to higher odds for whites; this occurred at about age 81. The results are consistent with the interpretation that the racial crossover in comorbidity (but not the crossover in AADL disability) propelled the racial crossover in mortality.

Changes in resource use and outcomes for patients with migraine treated with sumatriptan: a managed care perspective

BACKGROUND

Migraine headaches result in significant patient suffering and high costs to managed care organizations and employers. Studies that evaluate patient outcomes and the financial consequences of migraine treatment are important from a clinical and an economic perspective.

METHODS

This prospective, observational study assessed the outcomes of migraineurs in a mixed model staff/ independent practice association managed care organization for patients previously diagnosed as having migraine who received their first prescription for sumatriptan. Data collected included medical as well as pharmacy claims and patient surveys to measure changes in satisfaction, health-related quality of life, workplace productivity, and nonworkplace activity after sumatriptan therapy was initiated.

RESULTS

A total of 178 patients completed the study. Results showed significant decreases in the mean number of migraine-related physician office visits, emergency department visits, and medical procedures in the 6 months after sumatriptan therapy compared with the 6 months before sumatriptan was used (P<.05). Four of the health-related quality-of-life dimensions and the physical component summary score measured by the SF-36 (which is a valid, reliable general health status instrument) showed significant improvements at 6 months compared with patients' scores before use of sumatriptan (P<.05). Health-related quality of life measured by the disease-specific instrument MSQ (Migraine-Specific Quality of Life Questionnaire-Version 1.0, 1992 Glaxo Wellcome Inc, Research Triangle Park, NC) showed significant improvement at 3 and at 6 months compared with baseline scores (P<.05). There were also improvements in patient satisfaction and significant reductions in time lost from workplace productivity and nonworkplace activity.

CONCLUSION

In the 6 months after sumatriptan therapy was initiated, health care resource use and time lost from workplace productivity and nonworkplace activity were reduced, while health-related quality of life and patient satisfaction scores improved for the managed care migraineurs enrolled in this study.

The impact of clinical guidelines on practice patterns: doing more versus doing less

This study examined the determinants of compliance with clinical guidelines for glucocyte colony-stimulating factor (GCSF), a biotechnology product designed to reduce postchemotherapy infections. The pattern of compliance did change over time. After the guidelines were disseminated, appropriate use of GCSF increased. However, inappropriate use also increased. Patients who were younger and had an attending physician who was an oncologist or hematologist were more likely to receive GCSF whether they met the guideline criteria or not. Our findings suggest that older patients may be treated less aggressively than others and that physicians who are the most knowledgeable about guidelines may feel the most qualified to override the guidelines when they believe they do not apply. Our findings also demonstrate that it is easier to encourage physicians to do more for patients rather than less.

Estrogen and calcium supplement use among Japanese-American women: effects upon bone loss when used singly and in combination

We examined the effects of estrogen and calcium supplementation upon bone loss among a cohort of Japanese-American women. The women averaged 64 years of age (age range 45-81) and 14 years postmenopause at their initial examination in 1981. They returned at 1-3-year intervals for subsequent examinations, most recently in 1992-1994. At each examination, bone mass was measured at the calcaneus and distal and proximal radius. The women had low average dietary calcium intakes (median intake 384 mg/day). Women taking calcium supplements reported a median supplement intake of 355 mg/day; over 75% of the women taking estrogen took the equivalent of 0.6 mg/day or more of conjugated estrogens. Women taking estrogen had uniformly slower bone loss at all three sites. Compared to women not taking estrogen, whose bone loss averaged about 1% per year, women taking estrogen had 0.75-0.85% per year decreased bone loss at the three bone sites. By contrast, women who stopped estrogen had greater than average loss rates (0.35-0.65% per year greater). Calcium supplementation also reduced bone loss, but to a lesser extent than estrogen: bone loss decreased 0.25% per year at the radius sites, but was not slowed at the calcaneus. The calcaneus is more trabecular than the radius sites, which may explain the lack of response. We also examined combined estrogen and calcium supplement use.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative evaluation of the safety and efficacy of HMG-CoA reductase inhibitor monotherapy in the treatment of primary hypercholesterolemia

OBJECTIVE

To evaluate the comparative efficacy and safety of the 4 currently available hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors, fluvastatin, lovastatin, pravastatin, and simvastatin, in the treatment of primary hypercholesterolemia.

DATA SOURCES

English-language clinical studies, abstracts, and review articles identified from MEDLINE searches and bibliographies of identified articles. Unpublished data were obtained from the Food and Drug Administration in accordance with the Freedom of Information Act.

STUDY SELECTION

Placebo-controlled and comparative studies of HMG-CoA reductase inhibitor monotherapy in the treatment of primary hypercholesterolemia.

DATA EXTRACTION

Pertinent studies were selected and the data were synthesized into a review format.

DATA SYNTHESIS

The chemistry, pharmacology, and pharmacokinetics of the 4 HMG-CoA reductase inhibitors are reviewed. Clinical trials evaluating the hypocholesterolemic efficacy of the HMG-CoA reductase inhibitors are examined, and results on the comparative efficacy and safety of these agents are summarized. On a milligram-per-milligram basis, simvastatin is twice as potent as lovastatin and pravastatin. The hypocholesterolemic effects of fluvastatin appear to be approximately 30% less than that of lovastatin. In posttransplant patients receiving cyclosporine, safety has been documented for low doses of lovastatin and simvastatin, but when a higher dosage of an HMG-CoA reductase inhibitor is warranted, pravastatin should be considered the drug of choice because of a lower incidence of myopathy. Relevant data on the incidence of adverse effects are presented. Pertinent outcomes data from clinical trials evaluating the effect of HMG-CoA reductase inhibitors on atherosclerosis regression and coronary mortality, as well as published economic analyses of cholesterol-lowering agents, are summarized. Recommendations on the selection of an HMG-CoA reductase inhibitor in various clinical situations are provided.

CONCLUSIONS

The literature supports the comparable safety and tolerability of all 4 currently available HMG-CoA reductase inhibitors. Therefore, the choice of an HMG-CoA reductase inhibitor should depend on the extent of cholesterol lowering needed to meet the recommended treatment goal established by the National Cholesterol Education Program. Direct comparative studies are needed to confirm the relative, long-term cost-effectiveness of the various HMG-CoA reductase inhibitors in the treatment of primary hypercholesterolemia.

Educational inequality in adult mortality: an assessment with death certificate data from Michigan

Education was added to the U.S. Standard Certificate of Death in 1989. The current study uses Michigan's 1989-1991 death certificates, together with the 1990 Census, to evaluate the quality of data on education from death certificates and to examine educational differences in mortality rates. With log-rates modeling, we systematically analyze the variability in educational differences in mortality by race and sex across the adult life cycle. The relative differences in mortality rates between educational levels decline with age at the same pace for all sex and race categories. Women gain a slightly greater reduction in mortality than men by reaching the secondary-education level, but a modestly smaller reduction by advancing beyond it. Blacks show a reduction in predicted mortality rates comparable to whites' by moving from the secondary to the postsecondary level of education but experience less reduction than whites by moving from the primary to the secondary level. Thus, the secular decline in mortality rates that generally accompanies historical improvements in education might actually be associated with an increase in the relative differences between blacks' and whites' mortality. We discuss limitations of the data and directions for future research.

Changes in dimensions and mechanical properties of bone in chicks fed high levels of niacin

Tibia dimensions and mechanical properties were determined in White Leghorn cockerels that had been fed from 0.1 to 2.0% niacin as a supplement to standard poultry diets. Four experiments of from 20 to 38 days were conducted. No significant differences due to niacin were found in weight gain, feed consumed or feed:gain ratios. Decreases in the exterior (P < 0.009) and interior (P < 0.015) diameters of the major axes of the tibiae were found at 0.75-2.0% niacin. Exterior (P < 0.005) and interior (P < 0.001) diameters of the minor axes of the tibia were decreased at levels of 0.75 and 1%. Changes occurred in lateral wall thickness of chicks fed 0.75% niacin for 20 days (P < 0.004) and 38 days (P < 0.023) and in anterior wall thickness of 6-month-old chickens fed 1.0% niacin for 28 days (P < 0.001). Ultimate force was decreased in young chicks fed 1.0 and 1.5% niacin (P < 0.014) and 6-month-old White Leghorn chickens fed 1.0% niacin (P < 0.004). The addition of high levels of niacin to chick rations resulted in changes in dimensions, bone strength and susceptibility to fracture.

Cost accounting supports clinical evaluations

This article describes how a hospital cost accounting system was used to evaluate the financial impact of the use of a new and expensive drug at a 700-bed academic medical center.

Intraosseous extravasation complication reports

We report two cases of severe complications from intraosseous infusions. One child was a sudden infant death syndrome patient who developed severe tissue necrosis after intraosseous placement. The second child was a near drowning who developed a compartment syndrome requiring fasciotomy. Extravasation is a potentially major complication that resulted in these limb-threatening events. Intraosseous infusion remains an important resuscitation modality, but great care must be taken to avoid these results. Strategies for avoiding extravasation are discussed.

Spectral sensitivities of the human cones

Transient chromatic adaptation produced by an abrupt change of background color permits an easier and closer approach to cone isolation than does steady-state adaptation. Using this technique, we measured middle-wave-sensitive (M)-cone spectral sensitivities in 11 normals and 2 protanopes and long-wavelength-sensitive (L-) cone spectral sensitivities in 12 normals and 4 deuteranopes. Although there is great individual variation in the adapting intensity required for effective isolation, there is little variation in the shape of the M- and L-cone spectral-sensitivity functions across subjects. At middle and long wavelengths, our mean spectral sensitivities agree extremely well with dichromatic spectral sensitivities and with the M- and L-cone fundamentals of Smith and Pokorny [Vision Res. 15, 161 (1975)] and of Vos and Walraven [Vision Res. 11, 799 (1971)], both of which are based on the CIE (Judd-revised) 2 degrees color-matching functions (CMF's). But the agreement with the M-cone fundamentals of Estévez [Ph.D. dissertation, Amsterdam University (1979)] and of Vos et al. [Vision Res. 30, 936 (1990)], which are based on the Stiles-Burch 2 degrees CMF's, is poor. Using our spectral-sensitivity data, tritanopic color-matching data, and Stile's pi 3, we derive new sets of cone fundamentals. The consistency of the proposed fundamentals based on either the Stiles-Burch 2 degrees CMF's or the CIE 10 degrees large-field CMF's with each other, with protanopic and deuteranopic spectral sensitivities, with tritanopic color-matching data, and with short-wavelength-sensitive (S-) cone spectral-sensitivity data suggests that they are to be preferred over fundamentals based on the CIE 2 degrees CMF's.

Dietary aluminum chloride reduces the amount of intestinal calbindin D-28K in chicks fed low calcium or low phosphorus diets

The mechanism of aluminum (Al) toxicity may involve disturbances in calcium (Ca) metabolism. Aluminum compounds have been reported to reduce vitamin D-dependent Ca absorption in chicks, rats and humans. To investigate the mechanism by which Al reduces Ca absorption, we studied the effect of dietary aluminum chloride (AlCl3) on the relative amounts of intestinal calbindin D-28K in chicks fed diets varying in Ca and phosphorus concentration. AlCl3 was added so that Al constituted 0, 0.15 or 0.3 g/100 g of diets that were either adequate, low in Ca, low in P, or contained supplemental P. Diets were fed for 2 wk. Intestinal calbindin D-28K levels were assayed using SDS-PAGE and 45Ca binding to Western blots. Added dietary Al greatly reduced the amount of intestinal calbindin in chicks fed adequate diets, low Ca diets, or low P diets. When diets with supplemental P were fed, little calbindin was evident with or without added Al. Tibia ash, body weight and food intake were also reduced (P < 0.05) by added Al. These results indicate that dietary AlCl3 inhibits vitamin D-dependent Ca absorption by reducing the amount of intestinal calbindin D-28K. Aluminum, therefore, may interfere with the body's ability to regulate intestinal calbindin D-28K levels. This could have implications for other tissues that contain substantial levels of calbindin D-28K.

Does women's literacy affect desired fertility and contraceptive use in rural-urban Pakistan?

The 1984-85 Pakistan Contraceptive Prevalence Survey showed that urban wives had more than twice the literacy rate of rural wives. The present study explored the relationship of the rural-urban gap in female literacy to differences in contraceptive use. In rural areas, literacy did not increase women's perceptions of having reached a 'sufficient' number of living children, although the opposite was true for urban areas. Yet rural women with an 'insufficient' number of living children were more likely to use contraception if they were literate, as did their urban counterparts. Thus, raising the literacy rate in rural Pakistan would not narrow the rural-urban gap in contraception to cease childbearing but would narrow the rural-urban gap in contraception used to space wanted births further apart. Recommendations for government policy are made.

Ondansetron: costs and resource utilisation in a US teaching hospital setting

A retrospective pharmacoeconomic analysis was conducted to compare lengths of hospital stay for, and usage of hospital resources by, patients (850 admissions) who received either ondansetron or standard antiemetic therapy during hospital admissions for cancer chemotherapy. Average hospital costs for patients admitted to a 720 bed academic medical centre for maintenance chemotherapy between October 1990 and September 1991 were analysed using the hospital's online computerised clinical financial management system. A separate prospective time-and-motion study was used to evaluate specific costs of nursing care associated with episodes of severe nausea and vomiting. In addition, patient perception of quality of life and satisfaction with therapy were evaluated for 27 chemotherapy patients using quality-of-life measurements on the Functional Living Index-Cancer (FLIC) scale. The results of these studies showed that the average length of hospital stay was shorter for patients who received ondansetron rather than standard antiemetic therapy, but that average hospital costs were not significantly different. The reduced hospitalisation costs offset the higher acquisition cost of ondansetron. Mean quality-of-life scores decreased significantly after chemotherapy for patients receiving either ondansetron or standard therapy, but the changes in scores were not strongly associated with the antiemetic agents used or with any of the clinical or demographic variables measured in this study.

Evaluating the cost containment potential of clinical guidelines

New expensive biotechnology products create financial as well as clinical dilemmas for hospitals. Clinical guidelines that govern the use of these new products are often viewed as the best response to these dilemmas. This article describes a prospective analysis of the impact of one new drug and the guidelines developed to control its use. A simple model of clinical decision making is used to evaluate alternative scenarios. The analysis illustrates the importance of evaluating the cost containment potential of clinical guidelines before they are implemented.

Hindu and Christian fertility in India: a test of three hypotheses

Three hypotheses interpret differences in human fertility among religious groups. The Particularistic Theology Hypothesis stresses the pronatalist influence of doctrines forbidding artificial contraception and emphasizing the importance of sons, while the Characteristics Hypothesis focuses on the antinatalist effect of urban residence, higher education, and late age at marriage. But the Minority Status Hypothesis argues that such antinatalist effects may be stronger for a minority than a majority, since better-educated, late-marrying urbanites have greater chances for upward mobility. Minority groups with these advantages may have much lower fertility than similar people in the majority group if antinatalism is seen as a way to counter prejudice and move up. I tested these three hypotheses with data from the 1981 Census of India, from which I calculated mean numbers of children ever born per wife aged 35-44. I standardized the mean for differences between Hindu and Christian women by urban residence, education, age, and length of marriage. The standardized fertility rates of Hindus and Christians were similar in 25 states/union territories. Only in Meghalaya, Mizoram, and Nagaland did the Hindu religious minority have a lower standardized birth rate than the Christian majority; but the Muslim minority had one like the Christians'. This pattern was most consistent with the Characteristics Hypothesis.

Effects of dietary aluminum and niacin on chick tibiae

Effects of dietary aluminum chloride and niacin on bone mineral content and bone structural measurements were studied using young male Leghorn chicks. Standard chick rations containing .8% Ca and .4 or .5% available P were fed as control diets in three experiments. Experimental diets contained .05, .1, or .3% Al, or 1.0 or 1.5% niacin, or both and were fed for 2 wk. Tibia weights were decreased by 1.5% niacin, .3% Al, and by .1% Al plus 1.5% niacin (P less than .05). Breaking strength of tibiae was decreased (P less than .05) by 1.5% niacin, .1% Al, and .1% Al plus 1.5% niacin. Ultimate stress, which is force per unit area, was decreased by .3% Al and .05% Al plus 1.5% niacin (P less than .05). Niacin had no significant effect on bone mineral content. In Experiment 3, .3% Al decreased P, Ca, Mg, and Zn content of the tibiae (P less than .05). These findings indicate that feeding high levels of supplemental niacin results in decreased bone strength in chicks with no change in mineral content of the tibiae. Aluminum fed at levels of .3% of the diet causes a decrease in bone strength with concomitant changes in bone mineral content.

P & T Committee response to evolving technologies: preparing for the launch of high-tech, high-cost products. Roundtable discussion

P & T Committees are entering an exciting era in which the introduction of biotechnology-derived pharmaceuticals is providing life-saving opportunities for conditions for which there was little or no hope for a cure. The P & T Committee at Thomas Jefferson University Hospital has anticipated the challenge that these novel therapeutics present, and has already positioned itself for the pending approval of the first therapeutic human monoclonal antibody. Nebacumab (HA-1A, formerly known as Centoxin; by Centocor) will be used for the treatment of gram-negative sepsis. Although this antiendotoxin has a good side effect profile, its use also carries a high price tag. This will raise several difficult ethical issues once the product is introduced. In this exclusive Hospital Formulary roundtable, members of Thomas Jefferson's P & T Committee and Technology Assessment Subcommittee provide their insights for responsibly managing a high-tech, high-cost product such as nebacumab.

Effect of son mortality on contraceptive practice in Bangladesh

This study based on the 1975-76 Bangladesh Fertility Survey showed that the mortality of sons, and not daughters, was associated with a lower rate of female contraceptive initiation of use and a higher rate of discontinuation.

Matriarchy, polyandry, and fertility amongst the Mosuos in China

A survey of 232 households of the Mosuo minority group in Yunnan Province, People's Republic of China, suggested that polyandrous matriarchy did not raise the birth rate per household, but lowered the community birth rate by restricting many women's chances of marrying. The results imply that tolerance by the national government of polyandry within certain minority groups (e.g. Mosuos and Tibetans) will not prevent but may aid the attainment of zero population growth by China in the twenty-first century.

Clinical features of misdiagnosed appendicitis in children

STUDY OBJECTIVE

To compare clinical features of children with misdiagnosed appendicitis with those of children with appendicitis initially diagnosed correctly.

DESIGN

Retrospective review of hospital, emergency department, and clinic records.

SETTING

University medical center with annual ED census of 40,000 patients.

PARTICIPANTS

Children less than 13 years old admitted between May 1, 1979, and April 30, 1989, with a discharge diagnosis of appendicitis.

MEASUREMENTS

Records were reviewed for historical, physical examination, laboratory, and pathologic features for all patients on their initial presentation to a physician and on final presentation during which the correct diagnosis was made. Using chi 2 analysis and Student's test, clinical features of misdiagnosed patients and patients diagnosed correctly were compared.

RESULTS

One hundred eighty-one cases were identified with 50 initially misdiagnosed. On initial presentation, misdiagnosed patients were younger and more likely to have vomiting before pain onset, constipation, diarrhea, dysuria, and signs and symptoms of upper respiratory infections. Misdiagnosed cases were less likely to have right lower quadrant tenderness and documentation of bowel sounds, peritoneal signs, and rectal examinations. On final presentation, misdiagnosed patients were more likely to have pain duration of more than two days, temperature of more than 38.3 C, and to appear lethargic and irritable (P less than .05 for all measurements).

CONCLUSION

Clinical features of children with misdiagnosed appendicitis differ from those of children with appendicitis initially diagnosed correctly.

Ketamine sedation for pediatric procedures: Part 2, Review and implications

Ketamine produces rapid and consistent pediatric sedation with a predictable onset and recovery time. A wide margin of safety is afforded without the respiratory and cardiovascular depression commonly seen with alternative agents. The efficacy of ketamine is well established in anesthesia and dentistry and has extensive applications in other specialties. Ketamine sedation facilitates superior technical and cosmetic results while minimizing emotional trauma to distraught children. The much-feared complications of aspiration and laryngospasm are extremely rare when ketamine is used with proper precautions. Ketamine deserves increased use in the ED, and we advocate additional clinical investigation in this setting.

Ketamine sedation for pediatric procedures: Part 1, A prospective series

Emergency physicians frequently perform painful but necessary procedures on frightened children. We conducted a prospective, uncontrolled clinical trial of ketamine sedation (4 mg/kg IM) to facilitate a variety of procedures in 108 children aged 14 months to 13 years. Acceptable conditions were achieved with a single injection in 97% of the patients, and adjunctive restraint or local anesthesia was not required in 86%. Full sedation was produced within five minutes in 83%. Mean duration from injection to dischargeable recovery was 82 minutes (range, 30 to 175 minutes). One 18-month-old child vomited shortly after injection and experienced transient laryngospasm with cyanosis; intubation was not required, and there were no adverse sequelae. Airway patency and independent respirations were fully maintained in all other patients; no hemodynamic instability occurred at any time. There were no other clinically significant complications. Emesis well into the recovery phase was noted in 6% of the patients. Nightmares were not observed. Response from parents and physicians was strongly positive. Ketamine can be effectively used by emergency physicians to facilitate procedural sedation, yet equipment and expertise for advanced airway management are mandatory due to the rare occurrence of laryngospasm.

Son preference and child replacement in Bangladesh: a new look at the child survival hypothesis

Birth history data from women in the 1975-76 Bangladesh Fertility Survey were used to search for intentions to replace dead children. The median intervals between successive births of orders (i) and (i + 1) were not shorter when some siblings of orders below (i) had died. Nor was the median duration between the death of a child and the first posthumous birth shorter when the dead child was a boy or when it was survived by fewer than two brothers. The median intervals were generally shorter when the mother lived in an urban rather than a rural area but this difference was attributable only to the shorter duration of breast-feeding by urban women. These results disputed the notions that the timing of births was deliberately quicker to replace a dead child, that attempts at replacement were sex-selective, or that child replacement intentions were stronger in urban than in rural populations.

Polygamy and fertility in Somalia

The 1983 Somali Family Health Survey showed that polygamy and monogamy selected women with different social characteristics. Wives in polygamous unions were prone to be younger at first martial cohabitation and to have previous marital disruptions. Since a young age at first cohabitation and number of previous marriages have opposite effects on the cumulative fertility rate of women, the difference in this rate between wives in polygamous and monogamous unions vanished when both factors were controlled in a multivariate analysis.

Nutrient misclassification: bias in the odds ratio and loss of power in the Mantel test for trend

The effect of misclassification by one-, two-, or seven-day food records on the apparent magnitude of results was quantified for two hypothetical models of association of diet with disease. For each of 106 women, classification to quintiles of intake was calculated from 37 to 72 one-day records and compared to classification by one- to seven-day records. In analyses based on few records per subject, odds ratios were biased toward unity and results from models differing in strength of association of diet with disease were more similar. Loss of power in a test for trend was especially important for associations of the magnitude probable for diet and disease relationships (odds ratios of 3.00 or less) and for samples of 100 cases and 100 controls or fewer. The measurement error associated with diet measures currently in use can obscure relatively strong associations even without biased or confounded measures.

Misclassification of nutrient intake of individuals and groups using one-, two-, three-, and seven-day food records

In this study, 6,844 food records were collected during three years (1979-1982) from 106 volunteer Wisconsin women, aged 35-65 years. Subjects recorded all intake of food, and vitamin/mineral supplements on a structured, precoded form. One-, two-, three-, and seven-day records were compared with usual intake of calcium, kilocalories, vitamin A, and vitamin C. Usual intake was calculated using 37-72 food records per subject. Estimates of group means from a small number of records were not significantly different from mean usual intake (p greater than 0.05). Correlations with usual intake ranged from 0.43-0.64 and from 0.71-0.90 for the one day and the seven-day estimates, respectively. For the one-day record, 43-67% of subjects were correctly classified to the extreme quintiles of intake, 52-76% for the seven-day record. Classification was least good for vitamin A, better for other nutrients with lower intraindividual variance. However, overall agreement with usual classification of assignment to quintiles even with the seven-day record was less than 55% for all four nutrients. Effects at extremes of intake might be more easily analyzed than dose-response relations.

Relationships between usual nutrient intake and bone-mineral content of women 35-65 years of age: longitudinal and cross-sectional analysis

In a 4-yr clinical trial, effect on single-photon absorptiometric measurements of arm bones of usual intakes of energy and 14 nutrients plus vitamin-mineral supplements was studied in 99 women, aged 35-65, randomly assigned to placebo (NS) or calcium-supplemented (1.5 g)(S) groups. Cross-sectional analysis of initial bone measurements showed vitamin C (r = 0.313, p less than 0.05) and niacin (r = 0.353, p less than 0.01) correlated with ulna in postmenopausal subjects (n = 67). Longitudinal analysis of bone-change rates of postmenopausal subjects (NS + S) showed higher calcium intakes associated with lower loss rates of humerus bone-mineral content (BMC) (r = 0.360, p less than 0.01). In postmenopausal NS but not S subjects, energy, protein, calcium, phosphorus, zinc, and folate correlate significantly with change in radius BMC; high levels of intake correlated with slower loss (p less than 0.05). Several nutrients besides calcium are related to bone loss in women.

Effects on blood pressure of calcium supplementation of women

The relationship between dietary and supplemental (1.5 g/d) calcium intake and blood pressure was examined in 81 normotensive and 34 medicated hypertensive women between the ages of 35 and 65 years who completed a 4-yr clinical trial to assess age-associated bone loss in women. Calcium intakes were monitored during the entire study. Resting blood pressures and systolic blood pressure response (SBPR) to a stress test were recorded three times during the study. At the end of the study there was no relationship between systolic or diastolic blood pressure or SBPR and total calcium intake in normotensive women (n = 81). In the medicated hypertensive group (n = 34) there was a 13 mm Hg decrease in systolic pressure of supplemented women (n = 18) and a 7 mm Hg increase in unsupplemented women (n = 16) over the 4 yr (p less than .02).

Effects of intraindividual and interindividual variation in repeated dietary records

In this study 5,115 daily diet records were collected from 151 women on two randomly selected days per sampling month (29 days) over a two-year period. Yearly estimates of the ratios of intraindividual (sigma w2) and interindividual (sigma b2) variance components were calculated for dietary intake of 15 nutrients and for dietary intake + vitamin/mineral supplements. From one year to the next, corresponding ratios of sigma w2/sigma b2 were nearly identical. Intraindividual variation in dietary intake of all 15 nutrients was greater than interindividual variation (sigma w2/sigma b2 greater than 1). Variance component ratios for highly supplemented nutrients such as iron, vitamin C and B vitamins were less than one (sigma w2/sigma b2 less than 1). Using the ratios of sigma w2/sigma b2, it was calculated that between six and 99 repeated records measuring dietary intake and between two and 31 records measuring total intake may be needed per individual to ensure that the estimate of the population correlation (rho DF) between an individual's "usual" dietary intake or total intake of a dietary risk factor and an individual's mean or usual level of a physiologic risk factor was within 10% of the true population correlation coefficient (rho xy). It was also found that twice as many dietary records per individual were required to estimate the population slope (beta xy) within 10%. These results have serious implications for the design and analysis of prospective nutritional studies.

Housing quality and child mortality in the rural Philippines

This study investigated factors influencing child survival to age 5 years for a rural farm sample in Iloilo Province, Philippines. Children from better quality housing were more likely to live to age 5 than were children from worse quality housing. The life expectancy at birth, indirectly estimated by the Brass method, was 63·4 years for children from worse quality housing and 69·9 years for children from better quality housing. The implications are explored.

A two-year dietary survey of middle-aged women: repeated dietary records as a measure of usual intake

A two-year survey of the dietary consumption and supplement use patterns of adult women was conducted at the University of Wisconsin-Madison. Participants were asked to record their diet on two randomly selected days per month over a two-year period. Each subject filled out an average of 19 records a year, for an overall 71% return rate. Because of the sampling design, it was possible to estimate each woman's "usual" or average daily dietary and total intake (diet plus supplements) of 15 nutrients. Many women were consuming usual amounts of energy, calcium, iron, magnesium, vitamin B-6, and, especially, zinc and total folate that were 30% to 50% below recommended levels. It was also found that the women generally took vitamin/mineral supplements for nutrients already adequately supplied in the diet. Low nutrient intakes may have been due, in part, to underreporting of food intakes.

Nutritive value of food served calculated from food purchased in 14 nursing homes

A three-day average of the nutritive value of pounds of food served indicated that none of the 14 nursing homes surveyed served a selection of foods which supplied recommended amounts of vitamin B6 and folacin when compared with the Recommended Dietary Allowances. Suggestions for limiting kilocalories, while providing adequate sources of other nutrients to residents, include: decreasing high caloric-low nutrient foods and total pounds of meat, increasing the proportion of fish and poultry in relation to red meats, and increasing pounds of leafy vegetables, bananas, and dry cereals.

Serum albumin and gamma globulin in Trypanosoma cruzi infections

This paper examines the association between serum protein levels and infection with Trypanosoma cruzi in a region of Central Brazil. 148 people 6 to 78 years of age, were included in this study. There were no statistically significant difference in albumin levels between those with positive T. cruzi serology (2.94 +/- 0.74 g/100 ml) and those with negative serology (3.04 +/- 0.61 g/100 ml). Thus the null hypothesis of no association between infection with T. cruzi and serum albumin is accepted. Gamma-globulin levels were elevated in both groups and were significantly greater (p less than 0.05) in the group with positive T. cruzi serology (1.91 +/- 0.41 g/100 ml) than in the group with negative serology (1.75 +/- 0.41 g/100 ml). The serum albumin levels suggest that malnutrition (either associated with low protein intake or increased loss due to hookworm) is a major problem and unlikely to change if T. cruzi transmission was controlled.

Religious differentials in reproduction: the effects of sectarian education

College-educated Catholic women in the 1976 National Survey of Family Growth had higher actual and expected fertility than did college-educated Protestants. Moreover, Catholic colleges or universities had a pronatalist effect on alumnae. Thus, a significant part of the higher Catholic than Protestant cumulative fertility among college-educated women arose from the greater propensity of such Catholics to attend sectarian schools and colleges. The implications are explored.

A dietary survey of 14 Wisconsin nursing homes

The nutrient content of meals planned for and consumed by residents of 14 Wisconsin nursing homes was determined. Menus were low in energy, niacin, magnesium, zinc, vitamin B6, and total folate. Intakes of those nutrients and nine others were also low for a large proportion of the population. Approximately 30 percent of the men and women consumed fewer than 1,200 kcal. It is recommended that nursing homes should; (a) use a food plan which meets the nutrient needs for a broad range of energy intakes and (b) periodically monitor dietary patterns to detect those residents who consume inadequate diets.

Variables affecting productivity in food service systems of nursing homes

Data were collected in food service systems of 14 nursing homes to measure and correlate 16 variables hypothesized to affect quantitative productivity, defined as minutes per meal equivalent. Analysis of data showed that as two variables--ratio of the number of employees to full-time equivalent positions and total labor hours--increased, minutes per meal equivalent increased; thus quantitative productivity decreased. As four variables--turnover of full-time employees and of all employees, ratio of number of residents to full-time equivalent worker, and total meal equivalents served--increased, minutes per meal equivalent decreased; thus quantitative productivity increased.

Dietary analysis with programmable calculator: a simplified method

The use and applications of programmable calculator in dietary analysis are presented. Results which approximate those of large computers can be obtained with considerably less time, money, and data manipulation. Program flexibility allows operators to determine the number of foods and nutrients to be analyzed. Input, data checking, and results of total nutrient consumption are achieved within minutes. The dietary analysis described in this article is well suited for small hospitals and clinics, for teaching purposes and dietary surveys and for use by non-nutritionists who have a one-time or regular need to incorporate dietary information into their work.

Productivity in foodservice systems in fourteen nursing homes

Activity sampling was used to determine the time foodservice personnel spent in work and delay activities in fourteen non-governmental skilled nursing facilities with bed capacities ranging from 81 to 120 and an occupancy rate above 80 per cent. Mean total minutes per meal equivalent (during three days of study) ranged from 7.13 to 18.95, with a mean of 11.25. Analysis of variance indicated significant differences (p < 0.01) in total minutes per meal equivalent and in direct, indirect, and delay time among the fourteen homes; no statistically significant differences were found among days.

A short method to ensure nutritional adequacy of food served in nursing homes. II. Development of a model food plan

A model food plan was developed to serve as a short method to ensure nutritional adequacy of food served to nursing home residents. Criteria were that the food plan provide 100 per cent of 1974 Recommended Dietary Allowances (RDAs) for fourteen nutrients without exceeding 110 per cent of allowances for calories. To meet the criteria, an increase in pounds of meat, fish, and poultry; dried beans, peas, and nuts; green leafy vegatables; bananas; and dry cereals over actual food issues was required. The model plan is presented in the form of pounds of food, per sixteen food groups, required for 100 persons, per day.