Where population health misses the mark: breaking the 80/20 rule

Conventional population management theory, predicated on prevention and keeping the healthy majority healthy, fails to address the root cause of the unsustainable health care spending trajectory in the United States. The national health care agenda has been heavily influenced by the assumptions that disease prevention and the general promotion of "population health" will be sufficient to reduce health care spending to a sustainable level. However, a very small subset of the population with chronic and complex conditions account for a disproportionate share of health care spending, and unnecessary variation in the care of those chronic and complex episodes wastes 20% to 30% of the episodic spending. Health care spending follows what is known as "the 80/20 rule," with 80% of all spending being incurred by only 20% of the population. Whether a population is defined as a company, a county, or a country, the overwhelming majority of their health care spending comes from a small minority of the individuals, and the bulk of that spending is associated with either largely unavoidable and unpredictable single events or complex episodes of care. Achieving an economically sustainable health care system will require more efficient and effective delivery of those complex episodes of care.

Challenges of becoming a regional referral system: the University of Kentucky as a case study

The U.S. health care system must change because of unsustainable costs and limited access to care. Health care legislation and the recognition that health care costs must be curbed have accelerated the change process. How should academic medical centers (AMCs) respond? Teaching hospitals are a heterogeneous group, and the leaders of each must understand their institution's goals and the necessary resources to achieve them. Clinical leaders and staff at one AMC, the University of Kentucky (UK), committed to transforming the AMC into a regional referral center. To achieve this goal, UK leaders integrated the clinical enterprise, focused recruitment on advanced subspecialists, and initiated productive relationships with other providers. Attracting adequate numbers of destination patients with complex illnesses required UK to have a "market space" of five to seven million people. The resources required to effect such progress have been daunting. Relationships with providers and payers have been necessary to forge a network. These relationships have been challenging to establish and manage and have evolved over time. Most AMCs are not-for-profit public good entities that nevertheless exist in an industry driven by competition in quality and cost, and therefore scale and access to capital are paramount. AMC leaders must understand their institutions as both part of an industry and as a public good in order to adapt to the changing health care system. Although the experience of any particular AMC is inherently unique, UK's journey provides a useful case study in establishing institutional goals, outlining a strategy, and identifying required resources.

The evolution of a Department of Internal Medicine under an integrated clinical enterprise model: the University of Kentucky experience

The impact on the Department of Internal Medicine of the emergence of the University of Kentucky Healthcare Enterprise as an integrated clinical model has been enormous. In fiscal year 2004, the department was financially insolvent and on the verge of implementing plans to decrease faculty from 127 to 65. Since that time, the department has changed dramatically with a corresponding improvement in its clinical, academic, and financial activity. The department has grown to 175 faculty, with a healthy financial outlook and a shared vision with the clinical enterprise. Departmental clinical growth has been accompanied by growth in extramural research funding. The clinical growth of the department, in turn, supported the growth of the integrated clinical enterprise overall.The purpose of this article is to present a case history of the impact of transition to an integrated clinical enterprise financial model on the clinical, research, and educational functions of a department of internal medicine, and the opportunities and lessons learned from this transition. The implementation of an enterprise model allowed revival and expansion of the clinical programs of the department. This expansion did not occur at the expense of the research and educational missions of the department but, rather, was associated with improved performance in these areas. The processes which were established during the conversion to the enterprise model, which involve strategic planning, monitoring of plan implementation, recalibration of objectives, financial transparency, and accountability of leadership and faculty, may better prepare the institution to face the challenges of the rapidly changing economic environment.

An institutional process to improve inpatient glycemic control

Many institutions are evaluating their inpatient patterns of care for patients with diabetes mellitus and hyperglycemia, based upon compelling evidence that strict glycemic control improves outcomes in a variety of hospital settings. In 2005, a multidisciplinary task force was established at the University of Kentucky Chandler Medical Center in Lexington, Kentucky, to guide a process to improve the quality and safety of inpatients with hyperglycemia. This article describes the stepwise process including an examination of our procedures, adoption of standards, and establishment of common protocols and procedures. Successful implementation of the protocols was preceded by extensive educational efforts. Refinement of the protocols based on early experience and feedback from staff has resulted in improvements in glycemic parameters and less reliance on sliding scale insulin regimens.

Is Antibiotic Prophylaxis for Bacterial Endocarditis Cost-Effective?

Background. Antibiotic prophylaxis for bacterial endocarditis is recommended by the American Heart Association (AHA) before undergoing certain dental procedures. Whether such antibiotic prophylaxis is cost-effective is not clear. The authors’ objective is to estimate the cost-effectiveness of predental antibiotic prophylaxis in patients with underlying heart disease. Methods. The authors conducted a cost-effectiveness analysis using a Markov model to compare cost-effectiveness of 7 antibiotic regimens per AHA guidelines and a no prophylaxis strategy. The study population consisted of a hypothetical cohort of 10 million patients with either a high or moderate risk for developing endocarditis. Results. Prophylaxis for patients with moderate or high risk for endocarditis cost $88,007/quality-adjusted life years saved if clarithromycin was used. Prophylaxis with amoxicillin and ampicillin resulted in a net loss of lives. All other regimens were less cost-effective than clarithromycin. For 10 million persons, clarithromycin prophylaxis prevented 119 endocarditis cases and saved 19 lives. Conclusion. Predental antibiotic prophylaxis is cost-effective only for persons with moderate or high risk of developing endocarditis. Contrary to current recommendations, our data demonstrate that amoxicillin and ampicillin are not cost-effective and should not be considered the agents of choice. Clarithromycin should be considered the drug of choice and cephalexin as an alternative drug of choice. The current published guidelines and recommendations should be revised.

Are patients at Veterans Affairs medical centers sicker? A comparative analysis of health status and medical resource use

BACKGROUND

The Veterans Affairs (VA) health system has been criticized for being inefficient based on comparisons of VA care with non-VA care. Whether such comparisons are biased by differences between the VA patient population and the non-VA patient population is not known. Our objective is to determine if VA patients are different from non-VA patients in terms of health status and medical resource use.

METHOD

We analyzed 128,099 records from the National Health Interview Survey for the years 1993 and 1994. We compared the VA patient population with the general patient population for self report on health status, number of medical conditions, number of outpatient physician visits, number of hospital admissions, and number of hospital days each year.

RESULTS

The VA patient population had poorer health status (odds ratio [OR], 14.7; 95% confidence interval [CI], 10.7-20.2), more medical conditions (OR, 14; 95% CI, 10.5-18.7), and higher medical resource use compared with the general patient population (OR, 3.7 for 3 or more physician visits per year; OR 5.4 for 3 or more hospital admissions per year; OR, 7.7 for 21 or more days spent in a hospital per year). However, after controlling for health and sociodemographic differences, VA patients had similar resource use compared with the general patient population.

CONCLUSION

Large differences in sociodemographic status, health status, and subsequent resource use exist between the VA and the general patient population. Therefore, comparisons of VA care with non-VA care need to take these differences into account. Furthermore, health care planning and resource allocation within the VA should not be based on data extrapolated from non-VA patient populations. Arch Intern Med. 2000;160:3252-3257.

Understanding racial variation in the use of coronary revascularization procedures: the role of clinical factors

BACKGROUND

Black patients undergo coronary artery bypass grafting and percutaneous transluminal coronary angioplasty less often than white patients. It is unclear how racial differences in clinical factors contribute to this variation.

METHODS

A retrospective cohort study was performed of 666 male patients (326 blacks and 340 whites), admitted to 1 of 6 Veterans Affairs hospitals from October 1, 1989, to September 30, 1995, with acute myocardial infarction or unstable angina who underwent cardiac catheterization. The primary comparison was whether racial differences in percutaneous transluminal coronary angioplasty and coronary artery bypass grafting rates persisted after stratifying by clinical appropriateness of the procedure, measured by the appropriateness scale developed by the RAND Corporation, Santa Monica, Calif.

RESULTS

Whites more often than blacks underwent a revascularization procedure (47% vs 28%). There was substantial variation in black-white odds ratios within different appropriateness categories. Blacks were significantly less likely to undergo percutaneous transluminal coronary angioplasty (odds ratio, 0.30; 95% confidence interval, 0.14-0.63 [P<.01]) when the indication was rated "equivocal." Similarly, blacks were less likely to undergo coronary artery bypass grafting (odds ratio, 0.44; 95% confidence interval, 0.23-0.86 [P<.01]) when only coronary artery bypass grafting was indicated as "appropriate and necessary." Differences in comorbidity or use of cigarettes or alcohol did not explain these variations. Using administrative data from the Veterans Health Administration, we found no differences in 1-year (5.2% vs 7.4%) and 5-year (23.3% vs 26.2%) mortality for blacks vs whites.

CONCLUSION

Among patients with acute myocardial infarction or unstable angina, variation in clinical factors using RAND appropriateness criteria for procedures explained some, but not all, racial differences in coronary revascularization use.

Screening for problem drinking: impact on physician behavior and patient drinking habits

OBJECTIVE

To assess the effect of a screen for problem drinking on medical residents and their patients.

DESIGN

Descriptive cohort study.

SETTING

Veterans Affairs Medical Clinic.

PATIENTS

Patients were screened 2 weeks before a scheduled visit (n = 714). Physicians were informed if their patients scored positive.

MEASUREMENTS AND MAIN RESULTS

Physician discussion of alcohol use was documented through patient interview and chart review. Self-reported alcohol consumption was recorded. Of 236 current drinkers, 28% were positive for problem drinking by the Alcohol Use Disorders Identification Test (AUDIT). Of 58 positive patients contacted at 1 month, 78% recalled a discussion about alcohol use, 58% were advised to decrease drinking, and 9% were referred for treatment. In 57 positive patient charts, alcohol use was noted in 33 (58%), and a recommendation in 14 (25%). Newly identified patients had fewer notations than patients with prior alcohol problems. Overall, 6-month alcohol consumption decreased in both AUDIT-positive and AUDIT-negative patients. The proportion of positive patients who consumed more than 16 drinks per week (problem drinking) decreased from 58% to 49%. Problem drinking at 6 months was independent of physician discussion or chart notation.

CONCLUSIONS

Resident physicians discussed alcohol use in a majority of patients who screened positive for alcohol problems but less often offered specific advice or treatment. Furthermore, residents were less likely to note concerns about alcohol use in charts of patients newly identified. Finally, a screen for alcohol abuse may influence patient consumption.

Appropriateness of imaging procedure requests: do radiologists agree?

OBJECTIVE

We explored the agreement among radiologists in their evaluation of the appropriateness of individual requests for imaging procedures.

MATERIALS AND METHODS

We reviewed 318 noninterventional CT, sonographic, MR imaging, and nuclear medicine procedures ordered at a general internal medicine clinic during 8 months in 1995. Five subspecialty radiologists used data from the radiology request from and clinic notes to independently rate the appropriateness of each requested imaging procedure on a four-point scale. The radiologists were unaware of the results achieved by each procedure. Each case was reviewed by at least three radiologists, of whom at least one had relevant subspecialty expertise. Agreement among radiologists was analyzed using Cohen's kappa statistic and weighted kappa statistics and Cronbach's alpha statistic.

RESULTS

Nonchance agreement (kappa) was .19 +/- .05; weighted kappa was .24 +/- .05. Interrater agreement was significantly greater than that expected from chance alone (p < .01). The composite score, defined as the average of the radiologists' scores for each case, showed moderate reliability, as evidenced by a value for Cronbach's alpha of 70.

CONCLUSION

In the absence of explicit criteria, we found modest but statistically significant agreement among radiologists about the appropriateness of individual requests for imaging procedures. The disagreement among radiologists highlights the importance of developing well-reasoned, explicit criteria by which to judge the appropriateness of diagnostic radiology procedures. Further study is needed to elucidate the relationship between appropriateness and actual patient outcomes.

Outpatient internal medicine preoperative evaluation: a randomized clinical trial

The purpose of this study was to evaluate the effect on resource use of a program outpatient internal medicine preoperative evaluation in a two arm parallel design randomized clinical trial. In a tertiary care teaching Veterans Affairs hospital, 355 patients (179 inpatient arm, 176 outpatient arm)(mean age 65.5 years) were referred for internal medicine preoperative evaluation before elective surgery. Outpatient internist preoperative evaluation was performed 2 to 3 weeks before admission for surgery in the experimental arm with preoperative laboratory and radiology testing performed during the visit. The control arm was admitted for surgery without outpatient evaluation. The main outcome measure was the length of stay. Preoperative length of stay was significantly reduced from 2.9 days in the inpatient arm to 1.6 days in the outpatient arm (P < 0.001, 95% confidence interval of the difference, -0.8 to -1.8 days). Postoperative length of stay in the outpatient arm (3.6 days) was slightly but not significantly longer than the inpatient arm (3.0 days) (95% confidence interval of the increase, -0.6 to 1.8 days). Total length of stay showed no significant difference between the outpatient (5.5 days) and inpatient (6.0 days) arms (95% confidence interval of the difference, -2.0 to 1.1 days). Unnecessary admissions, defined as patients admitted who were admitted but did not undergo surgery, were decreased significantly comparing the inpatient arm (12.3%) to the outpatient arm (5.7%) (95% confidence interval of the difference, 0.5% to 12.7%). Measures of resource use showed no difference between arms including laboratory tests (95% C.I. of the difference, -3.0 to 6.8 tests), imaging tests (95% C.I. of the difference, -0.5 to 0.8 tests) were administered. A significant increase in the use of consultants between the outpatient arm (1.3 consultations) and inpatient arm (0.9 consultations) was discovered (95% C.I. of the difference, 0.2 to 0.6). Patients health status after discharge and satisfaction with care were not different between the two arms of the investigation. A program of outpatient internal medicine preoperative evaluation significantly reduced preoperative length of stay with a lesser effect on total length of stay. Unnecessary admission of patients for elective surgery were reduced by this program.

Racial differences in the use of invasive cardiovascular procedures in the Department of Veterans Affairs medical system

BACKGROUND

Previous studies have found racial differences in the use of invasive cardiovascular procedures, which may be due in part to the greater financial incentives to perform such procedures in white patients. In Department of Veterans Affairs hospitals, direct financial incentives affecting use of the procedures are minimized for both patients and physicians.

METHODS

We conducted a retrospective analysis of the use of cardiovascular procedures among black and white male veterans discharged from Veterans Affairs hospitals with primary diagnoses of cardiovascular disease or chest pain during fiscal years 1987 through 1991. We used coded discharge data to determine whether cardiac catheterization, percutaneous transluminal coronary angioplasty, or coronary artery bypass grafting was performed during or immediately after such admissions. We used logistic-regression analysis to adjust for the primary discharge diagnosis, the presence of coexisting conditions, age, marital status, type of eligibility to receive care at Veterans Affairs hospitals, geographic region, and whether the hospital was equipped to perform bypass surgery. We classified the primary diagnosis as myocardial infarction, unstable angina, angina, chronic ischemia, chest pain, or "other" cardiovascular diagnosis.

RESULTS

After we adjusted for all the potential confounders, we found that white veterans were more likely than black veterans to undergo cardiac catheterization (odds ratio, 1.38; 95 percent confidence interval, 1.34 to 1.42), angioplasty (odds ratio, 1.50; 95 percent confidence interval, 1.38 to 1.64), and coronary artery bypass surgery (odds ratio, 2.22; 95 percent confidence interval, 2.09 to 2.36).

CONCLUSIONS

Even when financial incentives are absent, whites are more likely than blacks to undergo invasive cardiac procedures. These findings suggest that social or clinical factors affect the use of these procedures in blacks and whites.

Effects of a night float system on housestaff neuropsychologic function

To examine the effect of a night float call system (NFS), a battery of neuropsychologic tests was administered to housestaff after call during an overnight call system (ONCS), and the results were compared with the results obtained during a NFS. Although NFS housestaff were less sleep-deprived, results of tests of psychomotor function were not different. Importantly, both groups had high depression, hostility, and anxiety scores. NFS housestaff had small but significantly lower depression scores, which, if not due to time of year, may represent a positive effect of the NFS. Future investigation should be directed at clarifying the aspects of residency training that adversely affect housestaff mood.

The effect of fish oil supplements on blood pressure

We conducted a double-blind, placebo-controlled crossover study to determine the effects of fish oil supplementation on blood pressure in middle-aged men. Subjects were randomly assigned to consume either 20 g of fish oil or safflower oil for 12 weeks and then consume the other oil for an additional 12 weeks after a 4-week washout period. We found no significant changes from the pretreatment value in systolic or diastolic blood pressure with the use of fish oil supplements. In addition, there were no significant differences in the posttreatment blood pressures comparing the fish and safflower oil phases of the study.

Influenza vaccination. Knowledge, attitudes, and behavior among high-risk outpatients

The Minneapolis and Pittsburgh Veterans Affairs Medical Centers conduct virtually identical institution-wide influenza vaccination programs that include annual educational and publicity mailings to all outpatients. Despite these efforts, 40% to 50% of high-risk outpatients at both centers fail to receive influenza vaccine each year. To assess differences between high-risk vaccine recipients and nonrecipients, a self-administered questionnaire was mailed to 500 randomly selected outpatients from each site. The questionnaire asked about risk factors, vaccination status, and knowledge and attitudes regarding influenza and "flu shots." Patient risk characteristics and vaccination rates in Minneapolis and Pittsburgh were similar with 75.6% and 76.3% reporting high-risk conditions and 65.6% and 56.1% of high-risk respondents reporting influenza vaccination, respectively. High-risk vaccine recipients and nonrecipients had similar knowledge but different attitudes about influenza and "flu shots." Using stepwise logistic regression, factors positively associated with vaccination behavior were: intention to follow physician or nurse recommendations for "flu shots" (odds ratio [OR] = 7.09); previous vaccination behavior (OR = 6.36); and physician or nurse recommendations for a "flu shot" (OR = 4.29). Factors negatively associated with vaccination behavior were difficulty in coming to the medical center (OR = 0.42) and previous side effects from the vaccine (OR = 0.19). These findings suggest areas in need of additional emphasis if influenza vaccination rates are to be improved.

Preoperative screening: value of previous tests

OBJECTIVE

To determine the frequency of tests done in the year before elective surgery that might substitute for preoperative screening tests and to determine the frequency of test results that change from a normal value to a value likely to alter perioperative management.

DESIGN

Retrospective cohort analysis of computerized laboratory data (complete blood count, sodium, potassium, and creatinine levels, prothrombin time, and partial thromboplastin time).

SETTING

Urban tertiary care Veterans Affairs Hospital.

PATIENTS

Consecutive sample of 1109 patients who had elective surgery in 1988.

MEASUREMENTS AND MAIN RESULTS

At admission, 7549 preoperative tests were done, 47% of which duplicated tests performed in the previous year. Of 3096 previous results that were normal as defined by hospital reference range and done closest to the time of but before admission (median interval, 2 months), 13 (0.4%; 95% CI, 0.2% to 0.7%), repeat values were outside a range considered acceptable for surgery. Most of the abnormalities were predictable from the patient's history, and most were not noted in the medical record. Of 461 previous tests that were abnormal, 78 (17%; CI, 13% to 20%) repeat values at admission were outside a range considered acceptable for surgery (P less than 0.001, frequency of clinically important abnormalities of patients with normal previous results with those with abnormal previous results).

CONCLUSIONS

Physicians evaluating patients preoperatively could safely substitute the previous test results analyzed in this study for preoperative screening tests if the previous tests are normal and no obvious indication for retesting is present.

Post-call transfer of resident responsibility: its effect on patient care

OBJECTIVE

To determine whether transferring the care of patients to another senior resident the day after admission to the hospital adversely affects the efficiency and quality of care.

DESIGN

Retrospective analysis of a natural experiment.

SETTING

The general medical service of the Minneapolis Veterans Affairs Medical Center, a major tertiary teaching hospital of the University of Minnesota internal medicine residency program.

PATIENTS/PARTICIPANTS

Subjects were all the patients admitted to the medicine service from 5:00 PM to 6:00 AM over an eight-month period.

INTERVENTION

After 5:00 PM, half of the patients were admitted to the hospital by a cross-covering senior resident (CC group of patients), and their care was transferred to a different senior resident the following day. The other patients were initially evaluated by the primary senior resident (PE group of patients). Assignment to the different services was a random, sequential process.

MEASUREMENTS AND MAIN RESULTS

The CC group had significantly more laboratory tests performed during their hospital stay than did the PE group of patients (44 vs. 32, p = 0.01), even when adjusted for length of stay. Using multiple linear regression to adjust for other clinical parameters including length of stay, DRG weight, and number of consults, the authors found that being a CC subject was a significant predictor of the number of laboratory tests obtained (p = 0.01). Furthermore, the median length of stay in the CC group (n = 74) was longer than that in the PE group (n = 72) (eight days vs. six days); this was of borderline statistical significance, using a two-sample median test (p = 0.06).

CONCLUSION

Patients transferred to a different resident the day after admission had more laboratory tests performed and longer inpatient stays.

Teaching status and resource use for patients with acute myocardial infarction: a new look at the indirect costs of graduate medical education

To investigate whether the process of graduate medical education increases costs in teaching hospitals by causing longer lengths of stay and greater resource use, we compared lengths of stay, hospital charges, and the use of cardiovascular procedures for patients with acute myocardial infarction admitted to the teaching and nonteaching services of a university-affiliated community hospital. After adjusting for severity of illness and demographic characteristics, patients on the teaching services had a mean length of stay that was shorter by 0.6 days (p = 0.04) and mean charges that were $2,060 lower (p = 0.15) than for patients on the nonteaching service. Patients on the teaching service also had 15 percent (95% CI: -26, -4) fewer cardiac catheterizations and 9 percent (-18, 0) fewer procedures for myocardial revascularization (angioplasty or cardiac bypass surgery). These findings suggest that graduate medical education per se may not directly increase the use of health care resources and that the cost differences between teaching and nonteaching hospitals may be largely a consequence of other factors. These factors may include epiphenomena of teaching such as a specialized organizational structure, specialized patient care services, and continuing medical education for the nursing and medical staffs. They may also include factors not related to teaching such as differences in patients' severity of illness and sociodemographic characteristics.

Achieving the national health objective for influenza immunization: success of an institution-wide vaccination program

PURPOSE

To enhance influenza vaccination rates for high-risk outpatients at the Department of Veterans Affairs Medical Center (VAMC) in Minneapolis, Minnesota, an institution-wide immunization program was implemented during 1987.

PATIENTS AND METHODS

The program consisted of: (1) a hospital policy allowing nurses to vaccinate without a signed physician's order; (2) stamped reminders on all clinic progress notes; (3) a 2-week walk-in flu shot clinic; (4) influenza vaccination "stations" in the busiest clinic areas; and (5) a mailing to all outpatients. Risk characteristics and vaccination rates for patients were estimated from a validated self-administered postcard questionnaire mailed to 500 randomly selected outpatients. For comparison, 500 patients were surveyed from each of three other Midwestern VAMCs without similar programs.

RESULTS

Overall, 70.6% of Minneapolis patients were high-risk and 58.3% of them were vaccinated. In contrast, 69.9% of patients at the comparison medical centers were high-risk, but only 29.9% of them were vaccinated.

CONCLUSION

The Minneapolis VAMC influenza vaccination program was highly successful and may serve as a useful model for achieving the national health objective for influenza immunization.

Deciding to restrain medical patients

To determine when and why patients are placed in mechanical restraints, we surveyed the nurse and physician caring for each of 102 restrained patients from the general medical floors of an acute-care hospital. Ninety-three percent of the questionnaires were completed. Nursing questionnaires indicated that over half of patients were restrained during the evening shift. Nurses initiated the use of restraints in 75% of cases. Fifteen percent of the patients' physicians were unaware that the patient had been restrained. In the majority of cases, the nurse and physician believed that restraint was the best alternative for managing the patient although more physicians (11%) than nurses (2%) thought an alternative intervention would be better (P less than .02). As a group, physicians and nurses restrained patients for similar reasons, most often to prevent falls from bed (69%) or to protect medical devices (36%). However, there was poor agreement between the nurse and physician as to the reason for restraint in an individual patient (kappa statistic range from .02 to .43). These findings suggest that nurse and physician communication regarding restraint is poor. We recommend that acute-care hospitals adopt policies to promote communication between nurses and physicians concerning restraints to ensure that use of this potentially hazardous intervention is used only when necessary.

Frequency of adverse reactions after influenza vaccination

PURPOSE

Although concern about side effects constitutes a major deterrent to patient compliance with recommendations for influenza vaccination, there is a paucity of data about the frequency of adverse reactions to newer trivalent vaccines. Our aim was to determine the frequency of adverse reactions to influenza vaccine in older, chronically ill persons, many of whom are at high risk for influenza-related morbidity.

PATIENTS AND METHODS

We conducted a telephone survey of 40% of the patients who were vaccinated at a walk-in flu shot clinic. The subjects were randomly assigned to two groups. To determine postvaccine symptom rates, Group I was interviewed seven days after vaccination. Group II was interviewed 21 days after vaccination in order to control for baseline symptom rates. Both groups were queried about fever, disability, and flu-like illness in the week preceding the interview.

RESULTS

Of 816 patients selected, 650 (79.6%) completed the interview. The mean age of the subjects was 63, and more than two thirds were at risk for influenza-related morbidity. The frequencies of self-reported fever (5.3% versus 5.1%, p = 0.91) and disability (10.4% versus 9.3%, p = 0.65) were similar in the two groups. However, a significantly higher proportion of Group I subjects reported a flu-like illness compared to the Group II subjects (14.2% versus 8.7%, p = 0.03). Although Group I subjects were more likely to report flu-like illness within two days of vaccination compared to a similar time interval for Group II subjects, there was no corresponding clustering of disability after vaccination.

CONCLUSION

We conclude that the overall frequency of symptoms in both groups was low; however, the absolute risk of a flu-like illness was 5.5% higher during the first week following influenza vaccination when compared with the third week after the injection. These symptoms did not result in a decreased ability to perform usual daily activities.

Fish oil supplementation does not lower plasma cholesterol in men with hypercholesterolemia. Results of a randomized, placebo-controlled crossover study

STUDY OBJECTIVE

To determine the effects of fish oil supplementation on plasma cholesterol in middle-aged men with isolated hypercholesterolemia.

DESIGN

Randomized double-blind placebo-controlled (safflower oil) two-period crossover trial with 12-week treatment periods.

SETTING

Outpatient general medicine clinic at a university-affiliated Veterans Affairs hospital.

PATIENTS

Thirty-eight men with plasma cholesterol between 5.68 and 7.76 mmol/L (220 to 300 mg/dL), triglyceride levels less than 3.39 mmol/L (300 mg/dL), and free of coexisting diseases.

INTERVENTIONS

Fish oil and placebo (safflower oil) supplementation. After basal measurements and a 4-week lead-in period, twenty 1-g capsules of either fish oil or placebo oil were provided for 12 weeks (period 1). After a 4-week washout phase participants then received the other oil for an additional 12 weeks (period 2).

MEASUREMENTS AND MAIN RESULTS

Blood was drawn at the beginning and end of each study period and analyzed for levels of total cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, apolipoprotein A1, and apolipoprotein B. Low-density lipoprotein (LDL) cholesterol was calculated using the Friedewald equation. Total and LDL cholesterol increased from the before treatment values by 4.8% and 9.1%, respectively, after ingestion of fish oil. Compared with placebo, LDL cholesterol was significantly higher (4.5 compared with 4.1 mmol/L, P = 0.01) and triglycerides lower (1.3 compared with 1.8 mmol/L, P = 0.01) after fish oil. Total and HDL cholesterol and apolipoprotein A1 and B levels did not differ.

CONCLUSIONS

Fish oil supplements do not lower plasma cholesterol levels in middle-aged men with hypercholesterolemia without elevated triglycerides. They should not be recommended as a method to lower plasma cholesterol in these patients.

Mechanical restraints on the medical wards: are protective devices safe?

We prospectively identified 102 mechanically restrained hospital patients and determined their hospital course. The cohort was elderly, cognitively impaired with multiple chronic diseases. The in-hospital mortality was 21 percent. Nosocomial infection developed in 12 percent and new pressure sores in 22 percent. Prolonged use of restraints (greater than 4 days) was the strongest independent predictor of nosocomial infection (relative risk 1.8, 95% CI = 1.2, 2.8) and new pressure sores (RR 1.4, 95% CI = 1.1, 1.8) as determined by multiple logistic regression analysis. Patients placed in mechanical restraints for longer than four days experience frequent morbid events and should be monitored carefully.

Organizational strategies to improve influenza vaccine delivery. A standing order in a general medicine clinic

Educational programs designed to modify physician compliance with influenza vaccination guidelines have yielded only modest improvement. We examined the impact of a standing order on the influenza vaccination rate in a general medicine clinic (GMC). The standing order gave GMC nurses the responsibility to identify and vaccinate high-risk elderly patients. The vaccine order rate in GMC patients seen during the one-month study period in 1986 (n = 97) was compared with the rate in GMC patients from a similar period in 1984 (n = 77) and with the rate in patients seen in three subspecialty clinics during the 1986 study period (n = 106). Comparison patients were vaccinated only by specific physician order. Following the intervention, 79 (81%) of 1986 GMC study patients had vaccination orders, vs 20 (28%) of the 1984 GMC comparison group and 31 (29%) of the 1986 subspecialty clinic comparison group. A simple organizational change consisting of a standing order profoundly improved compliance with vaccination guidelines.

Acute oligoarthritis associated with Clostridium difficile pseudomembranous colitis

The abrupt onset of a sterile inflammatory oligoarthritis developed in a patient with active Clostridium difficile pseudomembranous colitis. The arthritis affected a hip and a knee. Leukocyte counts of synovial fluid obtained from the patient's left hip and knee were elevated. He was haplotyped as HLA-B27 antigen-positive. The colitis and arthritis promptly abated after treatment with oral vancomycin hydrochloride. Three other cases of arthritis associated with antibiotic-induced colitis were reviewed. It seems as if treatment of the colitis leads to resolution of the arthritis.

Asymptomatic ventricular ectopy. To treat or not to treat?

Ventricular ectopy that is bothersome to the patient warrants treatment, but the asymptomatic cases present the physician with a dilemma of whether or not treatment is justified. In patients free of organic heart disease, antiarrhythmic therapy does not appear to be necessary. Post myocardial infarction (MI) patients should be considered for beta-blocker therapy regardless of the presence of ventricular ectopy. In the post-MI patient with risk factors for sudden death, treatment of complex dysrhythmia may be warranted, despite the lack of documented benefit.