Direct medical costs attributable to osteoporotic fractures

Osteoporotic fractures are a major cause of morbidity in the elderly, the most rapidly growing segment of our population. We characterized the incremental direct medical costs following such fractures in a population-based cohort of men and women in Olmsted County, Minnesota. Cases included all County residents 50 years of age and older with an incident fracture due to minimal or moderate trauma between January 1, 1989 and January 1, 1992. For each case, a control of the same age (+/- 1 year) and sex who was attended in the local medical system in the same year was identified. Total incremental costs (cases - controls) in the year after fracture were estimated. Unit costs for each health service/procedure were obtained through the Mayo Cost Data Warehouse, which provides a standardized, inflation-adjusted estimate reflecting the national average cost of providing the service. Regression analysis was used to identify factors associated with incremental costs. There were 1263 case/control pairs; their average age was 73.8 years and 78% were female. Median total direct medical costs were $761 and $625, respectively, for cases and nonfracture controls in the year prior to fracture, and $3884 and $712, respectively, in the year following fracture. The highest median incremental costs were for distal femur ($11756) and hip fractures ($11241), whereas the lowest were for rib fractures ($213). Although hip fractures resulted in more incremental cost than any other fracture type, this amounted to only 37% of the total incremental cost of all moderate-trauma fractures combined. Regression analyses revealed that age, prior year costs and type of fracture were significant predictors of incremental costs (p<0.03 for all comparisons). The incremental costs of osteoporotic fractures are therefore substantial. Whereas hip fractures contributed disproportionately, they accounted for only one-third of the total incremental cost of fractures in our cohort. The use of incremental costs in economic analyses will provide a more accurate reflection of the true cost-effectiveness of osteoporosis prevention.

A frequently used patient and physician-directed educational intervention does nothing to improve primary care of prostate conditions

OBJECTIVES

To measure the impact of an educational intervention directed at both patients and their primary care physicians about prostate-related conditions.

METHODS

We used a randomized, control design for 50 physicians in 33 rural primary care practices from New England and Arkansas and a probability sample of 2402 of their male patients. For the physicians, we mailed two newsletters, conducted two face-to-face research staff visits, and provided printed educational manuals about the management of prostate conditions. For the patients, mailed educational pamphlets were targeted to the baseline symptom levels. After 18 months, 87% of patients and 92% of physicians completed a final survey. The patient survey measured health status, urinary symptoms and bother, treatments received, and prostate-related knowledge. The final physician survey asked them about their management of common prostate conditions.

RESULTS

Before randomization, most men (59%) said they knew little or nothing about prostate problems that affect urination, and 63% also reported "little" or "no" knowledge about prostate-specific antigen testing. Eighteen months later, we observed no differences between the intervention and control patients in the measures of health status, urinary symptoms and bother, treatments received, and prostate-related knowledge. The intervention, physicians' knowledge, and self-reported practices for managing common prostate conditions were no better than the control physicians'.

CONCLUSIONS

This commonly used education strategy had no measurable impact on prostate-related care.

Primary care pediatricians' roles and perceived responsibilities in the identification and management of depression in children and adolescents

OBJECTIVE

To describe primary care pediatricians' 1) approach to the identification and management of childhood and adolescent depression and 2) perception of their skills, responsibilities, and barriers in recognizing and managing depression in children and adolescents.

DESIGN AND METHODS

National cross-sectional survey of randomly selected primary care pediatricians that assessed the management of recalled last case of child or adolescent depression, attitudes, limitations to care from barriers and skills, and willingness to implement new educational or intervention strategies to improve care.

RESULTS

There were 280 completed surveys about child and adolescent depression (63% response rate). Pediatricians overwhelmingly reported it was their responsibility to recognize depression in both children and adolescents (90%) but were unlikely to feel responsible for treating children or adolescents (26%-27%). Those with most of their practice in capitated managed care were less likely to feel responsible for recognizing depression in either children or adolescents. Forty-six percent of pediatricians lacked confidence in their skills to recognize depression in children, and few of them (10%-14%) had confidence in their skills in different aspects of treatment with children or adolescents. Diagnostic, assessment, and management details for their last recalled case of depression in a child or adolescent were provided by 248 of these pediatricians. In addition to referring 78%-79% of the cases to mental health care professionals, 77% of pediatricians provided a wide range of brief interventions. Only 19%-20% prescribed medication. Major factors cited that limited their diagnosis or management were time (56%-68%) and training or knowledge of issues (38%-56%). Fewer pediatricians noted limitations due to insurer or financial issues (8%-39%) or patient issues (19%-31%). The 35% of pediatricians who were motivated to change their recognition and management of suspected depression were significantly more interested in implementing in the future a variety of new strategies to improve care.

CONCLUSION

Primary care pediatricians felt responsible for recognizing but not for treating child and adolescent depression. Although the lack of confidence and lack of knowledge and/or skills and time issues are major barriers that limit pediatricians in their treatment of childhood and adolescent depression, pediatricians varied in their readiness to change, with some being more willing to implement new strategies to care for depression. Educational and practice interventions need to focus on how to assist all pediatricians in diagnosis and to prepare these motivated pediatricians to manage depression in primary care settings.

Transurethral resection of the prostate among medicare beneficiaries: 1984 to 1997. For the Patient Outcomes Research Team for Prostatic Diseases

PURPOSE

We examine the epidemiology and associated risks of transurethral resection of the prostate among Medicare beneficiaries for the period 1984 to 1997.

MATERIALS AND METHODS

We used hospital claims for transurethral resection of the prostate from a 20% national sample of Medicare beneficiaries for the period 1991 to 1997. Risk of mortality and reoperation were evaluated using life table methods and compared to those for the period 1984 to 1990. We also examined the association between surgical volume and adverse outcomes following resection using unique urologist identifier codes from the 1997 part B Medicare claims.

RESULTS

Compared to 1984 to 1990, age adjusted rates of transurethral resection for benign prostatic hyperplasia (BPH) during 1991 to 1997 declined by approximately 50% for white (14.6 to 6.72/1,000) and 40% for black (11.8 to 6.58/1,000) men. Of the men who underwent resection for BPH during the recent period 53% were 75 years old or older but 30-day mortality in men 70 years old or older was significantly lower than that in 1984 to 1990. Since 1987 the 5-year risk for reoperation following transurethral resection for BPH has remained 5%. For resection performed in 1997 we observed no statistically significant association between urologist surgical volume and risks of reoperation or 30-day mortality.

CONCLUSIONS

Compared to the peak period of its use in the 1980s, older men are now undergoing transurethral resection of the prostate. Nevertheless, outcomes for men 65 years old or older continue to be good.

Respiratory responses to sudden pressure venting during stop consonant production

Twenty healthy adults, age range 20-55 years, participated in a study to assess the responses of the upper airway to sudden, unanticipated pressure venting during speech production. A computer was used to open or close a valve in a random fashion during one of two productions of the word 'hamper'. The SAR System (Microtronics Corp., Chapel Hill, N.C., USA) was used to collect and monitor respiratory variables associated with speech production. Results indicated no significant changes in duration between vented and unvented conditions. Although intraoral pressure was reduced under vented conditions, the magnitude was sufficient for sound generation. Respiratory effort increased when the airway was suddenly vented, suggesting a compensatory response to experimental perturbation. However, the response contrasted somewhat from what has been observed in patients with velopharyngeal inadequacy, indicating that the strategy used may be different.

Respiratory-related evoked potential elicited by expiratory occlusion

Respiratory-related evoked potentials (RREPs) have been elicited by inspiratory loads in adults and children. The RREP was recorded over the somatosensory region of the cerebral cortex. It was hypothesized that a RREP could be recorded by using expiratory occlusion. Electroencephalographic activity was recorded in adults from 14 scalp locations, referenced to the linked earlobes. The occlusion was presented as an interruption of expiration. Epochs of electroencephalographic activity and mouth pressure were recorded for each expiratory occlusion presentation. There were two occlusion trials and a control trial of 100 presentations each. The epochs in each trial were averaged and examined for the presence of short-latency, occlusion-related peaks. RREP peaks were observed bilaterally with expiratory occlusion and were absent in control unoccluded averages. A positive peak, P(34), was observed at central and postcentral sites. A negative peak, N(53), was observed at frontal and central sites. A second positive peak, P(95), was observed at frontal and central sites. These results demonstrate that expiratory occlusion elicits a RREP. This suggests that expiratory occlusion-related sensory information activates the cerebral cortex similar to that for inspiratory loads.

Motor innervation of the cricopharyngeus muscle by the recurrent laryngeal nerve

Patients with recurrent laryngeal nerve (RLN) paresis demonstrate impaired function of laryngeal muscles and swallowing. The cricopharyngeus muscle (CPM) is a major component of the upper esophageal sphincter. It was hypothesized that the RLN innervates this muscle. A nerve branch leading from the RLN to the CPM was found in adult sheep by anatomic dissection. Electrical stimulation of the RLN elicited a muscle action potential recorded by electrodes placed in the ipsilateral CPM. Swallowing was investigated by mechanical stimulation of oropharynx pre- and postsectioning of the RLN. Severing of the RLN resulted in a loss of the early phases of swallow-related CPM electromyographic activity; however, late-phase CPM electromyographic activity persisted. The RLN provides motor innervation of the CPM, which also has innervation from the pharyngeal plexus.

Attention and anosognosia: the case of a jargonaphasic patient with unawareness of language deficit

Some patients with aphasia lack awareness of the language errors they make. We describe a man with undifferentiated jargonaphasia and preserved auditory comprehension who was unaware of his speech production errors when he had to both speak and listen simultaneously. However, when listening to a recording of his speech, he could detect the speech errors he had made. We attribute this patient's unawareness of his speech production errors to a reduced attentional capacity for simultaneous linguistic tasks.