The Comparative Effectiveness of Monotherapy and Combination Therapies: Impact of Angiotensin Receptor Blockers on the Onset of Alzheimer's Disease.

Background: The criteria for use of Alzheimer's disease (AD) drug Leqembi recommended by the Department of Veterans Affairs (VA) include patients aged 65 years or older with mild cognitive impairment (MCI) or mild AD. Comorbidities that include hypertension, hyperlipidemia, and diabetes are common among these patients. Objectives: Our objective is to investigate the comparative effectiveness of the administration of one, two, or three medications belonging to the categories of angiotensin receptor blockers (ARBs), angiotensin-converting enzyme inhibitors (ACEIs), Beta Blockers, Statins, and Metformin, for their potential to delay the clinical onset of AD and provide a window of opportunity for therapeutic intervention. Design: Retrospective matched case-control study. Setting: Data from the Department of Veterans Affairs national corporate data warehouse. Participants: We conducted an analysis of 122,351 participants (13,611 with AD and 108,740 without AD), aged 65-89, who began at least one of the prescribed medication classes under investigation between October 1998 and April 2018. Measurements: We utilized Cox proportional hazard regressions, both with and without propensity score weighting, to estimate hazard ratios (HR) associated with the use of different medication combinations for the pre-symptomatic survival time of AD onset. Additionally, we employed a supervised machine learning algorithm (random forest) to assess the relative importance of various therapies in predicting the occurrence of AD. Result: Adding Metformin to the combination of ACEI+Beta Blocker (HR = 0.56, 95% CI (0.41, 0.77)) reduced the risk of AD onset compared to ACEI monotherapy alone (HR = 0.91, (0.85, 0.98)), Beta Blocker monotherapy (HR = 0.86, 95% CI (0.80, 0.92)), or combined ACEI+Beta Blocker (HR=0.85, 95%CI (0.77, 0.94)), when statin prescribers were used as a reference. Prescriptions of ARB alone or the combination of ARB with Beta Blocker showed an association with a lower risk of AD onset. Conclusion: Selected medications for the treatment of multiple chronic conditions among elderly individuals with hypertension, hyperlipidemia, and diabetes as monotherapy or combination therapies lengthen the pre-symptomatic period before the onset of AD.

The impact of electrical injuries on long-term outcomes: A Burn Model System National Database study.

INTRODUCTION: Electrical injuries exhibit significant acute and long-term sequelae. Amputation and neurological deficits are common in electrical injury survivors. There is a paucity of information on the long-term outcomes of this population. Therefore, this study examines the long-term outcomes of electrical injuries by comparing them to fire/flame injuries. METHODS: Data from the Burn Model System National Database collected between 1996 and 2015 was examined. Demographic and clinical characteristics for adult burn survivors with electrical and fire/flame injuries were compared. Satisfaction With Life Scale (SWLS), Short Form-12 Physical Composite Score (SF-12 PCS), Short Form-12 Mental Composite Score (SF-12 MCS), and employment status were examined at 24 months post-injury. Linear and logistic regression models were used to assess differences in outcome measures between groups, controlling for demographic and clinical variables. RESULTS: A total of 1147 adult burn survivors (111 with electrical injuries; 1036 with fire/flame injuries) were included in this study. Persons with electrical injuries were more likely to be male and injured at work (p<0.001). SF-12 PCS scores were significantly worse for survivors with electrical injuries at 24 months post-injury than survivors with fire/flame injuries (p<0.01). Those with electrical injuries were nearly half as likely to be employed at 24 months post-injury than those with fire/flame injuries (p=0.002). There were no significant differences in SWLS and SF-12 MCS between groups. CONCLUSIONS: Adult survivors with electrical injuries reported worse physical health and were less likely to be employed at 24 months post-injury compared to survivors with fire/flame injuries. A more detailed understanding of return to work barriers and work accommodations is merited for the electrical injury population. Furthermore, the results of this study should inform future resource allocation for the physical health and employment needs of this population.

Head and neck burns are associated with long-term patient-reported dissatisfaction with appearance: A Burn Model System National Database study.

INTRODUCTION: Burns affecting the head and neck (H&N) can lead to significant changes in appearance. It is postulated that such injuries have a negative impact on patients' social functioning, quality of life, physical health, and satisfaction with appearance, but there has been little investigation of these effects using patient reported outcome measures. This study evaluates the effect of H&N burns on long-term patient reported outcomes compared to patients who sustained burns to other areas. METHODS: Data from the National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System National Database collected between 1996 and 2015 were used to investigate differences in outcomes between those with and without H&N burns. Demographic and clinical characteristics for adult burn survivors with and without H&N burns were compared. The following patient-reported outcome measures, collected at 6, 12, and 24 months after injury, were examined: satisfaction with life (SWL), community integration questionnaire (CIQ), satisfaction with appearance (SWAP), short form-12 physical component score (SF-12 PCS), and short form-12 mental component score (SF-12 MCS). Mixed regression model analyses were used to examine the associations between H&N burns and each outcome measure, controlling for medical and demographic characteristics. RESULTS: A total of 697 adults (373 with H&N burns; 324 without H&N burns) were included in the analyses. Over 75% of H&N injuries resulted from a fire/flame burn and those with H&N burns had significantly larger burn size (p<0.001). In the mixed model regression analyses, SWAP and SF-12 MCS were significantly worse for adults with H&N burns compared to those with non-H&N burns (p<0.01). There were no significant differences between SWL, CIQ, and SF-12 PCS. CONCLUSIONS: Survivors with H&N burns demonstrated community integration, physical health, and satisfaction with life outcomes similar to those of survivors with non-H&N burns. Scores in these domains improved over time. However, survivors with H&N burns demonstrated worse satisfaction with their appearance. These results suggest that strategies to address satisfaction with appearance, such as reconstructive surgery, cognitive behavior therapy, and social skills training, are an area of need for survivors with H&N burns.

Evaluation of health services use following the initiation of risperidone long-acting therapy among schizophrenia patients in the veterans health administration.

WHAT IS KNOWN AND OBJECTIVE: The introduction of long-acting injection antipsychotic agents has been associated with better treatment persistence and better subsequent patient outcomes. However, limited empirical data are available on patient outcomes resulting from the initiation of long-acting injectable antipsychotic agents. In this study, we assessed patterns of health-care utilization following the initiation of risperidone long-acting therapy (RLAT), the first and only second generation long-acting injectable antipsychotic agent, in schizophrenia patients within the Veterans Health Administration. METHODS: Patients were identified if they initiated RLAT between 1 October 2005 and 30 September 2006, were ≥ 18 years of age at the time of initiation, and had at least four injections following the initiation. Paired t-tests and McNemar tests were used to compare patterns of health services use during 12 months pre- and post-initiation. RESULTS AND DISCUSSION: Among 924 eligible study subjects, about 94% were male with mean age of 51·1 years and as high as 60% had >3 and 29% had >5 comorbid conditions. The initiators of RLAT had an average of 17·3 (SD ± 9·7) injections within the 12 months following the initiation, with an average of 14 days between injections. Between the pre- and post-initiation periods, although the number of psychiatric-related outpatient visits increased from 24·6 to 39·1 (P < 0·001), the number of psychiatric hospitalizations decreased from 1·4 to 1·0 (P < 0·001) with an average length of stay reducing from 20 to 14 days (P < 0·001). The percentage of patients who experienced at least one or two psychiatric-related hospitalizations decreased from 68·9% to 45·7% (P < 0·001) and from 34·9% to 24·4% (P < 0·001), respectively. WHAT IS NEW AND CONCLUSION: Despite the values of RLAT in treating patients with schizophrenia, RLAT is largely underutilized in routine clinical practice. This observation highlights the importance for future research to ascertain the cost-effectiveness of initiating RLAT, especially the extent to which medication adherence influences the prescription pattern of RLAT and subsequent costs of initiating RLAT.

Survival in end stage renal disease: calcium carbonate vs. sevelamer.

BACKGROUND AND OBJECTIVE: There is concern regarding long-term excess calcium intake in end-stage renal disease populations. Because calcium carbonate is an over-the-counter (OTC) medication, few studies have been able to track its use. The Veterans Health Administration (VA) tracks national pharmacy data for both OTC and prescription drugs. We thus compared survival in incident dialysis patients on sevelamer and calcium carbonate phosphate binders. METHODS: This was a retrospective cohort study of veterans initiating haemodialysis using existing VA databases. Patients were divided into calcium only (n = 769) and sevelamer only (n = 608) groups, then followed for up to 2 years until FY03 end. Survival was modelled using Cox regression adjusting for age, gender, race, marital status, service-connected disability, region, diabetes, hypertension and Charlson index. Stability of findings was examined using propensity score analysis. RESULTS: Sevelamer only vs. calcium only subjects were younger (respective mean ages 59.6 and 63.0, P < 0.001) with fewer comorbidities (Charlson index 3.8 and 4.5, P < 0.001). By study end, 24% of sevelamer and 30% of calcium subjects had died. Comparing sevelamer to calcium, the unadjusted hazard ratio for death was 0.62 (95% CI 0.50-0.76); the adjusted hazard ratio was 0.67 (CI 0.54-0.84). Propensity score analysis revealed similar results, with a hazard ratio of 0.65 (CI 0.54-0.80). CONCLUSIONS: In a national incident dialysis cohort, sevelamer treatment was associated with improved survival compared with calcium carbonate. Further research should investigate whether the worse survival with calcium is a long-term consequence of increased calcium accumulation.

Treatment persistence: a comparison among patients with schizophrenia who were initiated on atypical antipsychotic agents.

BACKGROUND: Although clinical trials have demonstrated the efficacy of atypical antipsychotic agents in reducing symptoms of schizophrenia, the likelihood of sustaining control of schizophrenic symptoms may depend on treatment persistence. OBJECTIVE: In this study, we compared treatment persistence between patients who were initiated on risperidone or olanzapine, the two most widely prescribed atypical antipsychotic agents. METHOD: We identified patients with schizophrenia by ICD-9-CM codes (> or =1 inpatient or > or =2 outpatient ICD-9-CM codes > or =7 days apart) between 1 July 1998 and 30 June 1999. We further selected those who were prescribed the target drug during 1 April 1999 through 31 March 2000 provided that they were not on any antipsychotic agents during the prior 6 months. Using event history analysis, we compared the treatment persistence in terms of hazard ratio between olanzapine and risperidone initiators, adjusting for patient's sociodemographic and clinical characteristics. RESULTS: Following the initiation of the target drug, more patients switched from risperidone to olanzapine than vice versa. However, among patients with schizophrenia who had comorbid diabetes, there were more patients who made a switch from olanzapine to risperidone; whereas among those who used anxiolytics, there were more patients who switched from risperidone to olanzapine. Finally, olanzapine initiators had decreased hazards of discontinuation by 14% (unadjusted; P < 0.001) and 12% (adjusted; P = 0.002), respectively, than risperidone initiators. CONCLUSIONS: Compared with risperidone, olanzapine seems to be better tolerated by patients as indicated by better treatment persistence. As such, initiation of olanzapine may increase the likelihood of sustaining control of symptoms of schizophrenia. Future research needs to provide a more comprehensive assessment of treatment persistence by considering other antipsychotic agents in the study and developing models to assess treatment persistence and switching as two interdependent competing risks.

Initiation of atypical antipsychotic agents and health outcomes in patients with schizophrenia.

BACKGROUND: Although pharmacological treatments are available for patients with schizophrenia, there is a lack of systematic and comprehensive evaluation of health outcomes following the initiation of atypical antipsychotic agents. OBJECTIVE: To assess the effects of the initiation of olanzapine or risperidone, the two most widely prescribed atypical antipsychotics, on patients' health outcomes, as measured by changes in patient clinical characteristics between 6 months prior to and post-initiation. METHOD: We identified patients with schizophrenia by >1 inpatient or > or = 2 outpatient ICD-9-CM codes (> or = 7 days apart) between 1 July 1998 and 30 June 1999, and those who were initiated on olanzepine or risperidone during the period 1 April 1999 to 31 March 2000 inclusive. We then subdivided these patients into three groups: (i) those who were not on olanzapine or risperidone, (ii) those who were not on any atypical agents, and (iii) those who were not on any antipsychotic agents, for 6 months prior to being issued with the new prescription. Using test of means or chi-square tests, we examined whether the initiation of olanzapine or risperidone is related to different changes in patient clinical indicators, such as number of drugs for psychiatric conditions, use of psychiatric services, and use of non-psychiatric services. RESULTS: Between pre- and post-initiation, olanzapine initiators had a greater decrease in the number of psychiatric hospitalizations and use of psychotropic agents, whereas risperidone initiators had a greater reduction in the number of non-psychiatric hospitalizations. The initiation of olanzapine and risperidone appear to be associated with different patient health outcomes. Compared with olanzapine initiators, risperidone initiators had a greater increase in the use of treatments related to mental health, but had greater decrease in the use of treatments related to physical health. CONCLUSION: Despite olanzapine and risperidone being often perceived as similar antipsychotic agents, our results suggest that the clinical outcomes associated with their use are different. Outcome data from routine clinical practice are required to provide a more comprehensive assessment of these drugs.

Patient characteristics and prescription patterns of atypical antipsychotics among patients with schizophrenia.

BACKGROUND: Schizophrenia, one of the leading causes of disability, contributes substantially to the use of medical and mental health services. The treatment of schizophrenia is therefore particularly important to reduce deficits across a large number of neurocognitive domains. OBJECTIVE: To describe the prescription (e.g. initiation and switching) patterns of atypical antipsychotic agents and examine the extent to which patient sociodemographic and clinical characteristics are associated with the prescription patterns of atypical antipsychotics among patients with schizophrenia. METHODS: Using unique data sources from the Veterans Health Administration (VA), the study identified 89 107 patients with schizophrenia based on at least one inpatient or more than or equal to two outpatients' ICD-9-CM codes (> or =7 days apart). We defined a prior 6-month (1/1/99 to 6/30/99) and a post 6-month (7/1/99 to 12/31/99) period to describe patterns of initiation and switching of atypical antipsychotics. RESULTS: Only a small number of patients were on clozapine (1.8%) and quetiapine (1.4%). More patients were prescribed olanzapine (23%) than risperidone (20%) (P < 0.001). Compared with patients who were on risperidone, those who were on olanzapine were younger (P < 0.001), more likely Hispanic (P < 0.001), more likely married (P < 0.05), had more service-connected disability (P < 0.001), had fewer numbers of physical comorbidities (P < 0.001), and a lower body mass index (BMI) (P < 0.05). CONCLUSION: Olanzapine and risperidone appear to be prescribed to patients with different sociodemographic and clinical characteristics. Future research needs to explore the reasons for those differences.

Identifying patient and physician characteristics that affect compliance with antihypertensive medications.

BACKGROUND: Compliance with antihypertensive medications is essential to the clinical management of hypertension. Poor compliance with antihypertensive medications has often been associated with treatment failure and disease progression. OBJECTIVE: To identify patient and prescriber characteristics that may influence compliance with antihypertensive medications. METHOD: We used pharmacy records within the Veterans Health Administration, a database which included 1292 patients and 656 physicians over a 2-year time period from April 1, 1996, to April 1, 1998. The level of compliance with antihypertensive medications was assessed using a measure developed for this purpose within the Administration. Three separate ordinary least squares regression models were conducted to ascertain the effects of patient and physician characteristics on compliance. RESULTS: Despite the importance of compliance in the clinical management of hypertension, poor compliance with antihypertensive drug treatment was still widespread. Patients who were younger and less active in their treatment decisions tended to be less compliant (P < 0.05 and 0.05, respectively). Health care providers who were older, residents in speciality care, and physicians (as compared with non-physicians) had patients who were also less likely to be compliant (P < 0.01, 0.01, and 0.05, respectively). CONCLUSION: These findings suggest that in order to increase the effectiveness of medical care for hypertension, it is important to improve compliance with antihypertensive agents.

A multicenter two by two factorial trial of cognitive behavioral therapy and aerobic exercise for Gulf War veterans' illnesses: design of a veterans affairs cooperative study (CSP #470).

The Department of Veterans Affairs (VA) Cooperative Studies Program (CSP) Study #470 is a 2 x 2 factorial trial designed to evaluate the hypothesis that both cognitive behavioral therapy (CBT) and aerobic exercise will significantly improve physical function in participants with Gulf War veterans' illnesses (GWVI), and that adding CBT to aerobic exercise will provide further incremental benefit. One thousand three hundred fifty-six veterans will be randomized to one of four treatment arms: CBT plus aerobic exercise plus usual and customary care, aerobic exercise plus usual and customary care, CBT plus usual and customary care, or usual and customary care alone. The study duration is 2.5 years with 1.5 years of intake and 1 year of follow-up. The primary outcome measure is the proportion of veterans improved more than seven units on the physical component summary (PCS) scale of the Short Form Health Survey for Veterans (SF-36V) measured 12 months after randomization. This generic quality-of-life measure was chosen because there is no disease-specific measure for GWVI and the symptoms of GWVI span a wide range of physical manifestations that are related to the domains covered by the PCS scale. Sample size was determined to detect all six pairwise comparisons between the four treatment arms with 90% power and a Bonferroni adjustment for an overall type I error of 0.05 or 0.05/6 = 0.0083. CSP #470 was initiated in May 1999 in 18 VA and two Department of Defense medical centers. To date this represents the largest randomized trial designed to evaluate treatments for individuals with unexplained physical symptoms. This paper will focus on the rationale and unique features of the study design. Control Clin Trials 2001;22:310-332

Health status in VA patients: results from the Veterans Health Study.

Recently, the Veterans Administration (VA) Under Secretary for Health has designated functional status as one of the domains of value for the system, given its increasing importance for clinical care. The Veterans Health Study (VHS) was designed to assist the VA in monitoring outcomes and measuring the case mix of patients who use the VA. The Veterans SF-36 (short form functional status assessment for veterans) was administered to 2425 veterans receiving ambulatory care. Measures of the Veterans SF-36 were strongly correlated with sociodemographics and morbidities of the veterans. Young veterans had poorer mental health status than older veterans. Veterans who used ambulatory care in the VHS reported lower levels of health status, reflecting more disease than a non-VA civilian population. These measures of health are important indicators of the disease burden or case mix of the patients and are pertinent to health systems such as the VA for resource allocation decisions and as outcomes of care.

Functional status outcomes for assessment of quality in long-term care.

OBJECTIVE: Although decline in functional status has been recommended as a quality indicator in long-term care, studies examining its use provide no consensus on which definition of functional status outcome is the most appropriate to use for quality assessment. We examined whether different definitions of decline in functional status affect judgments of quality of care provided in Department of Veterans Affairs (VA) long-term care facilities. METHODS: Six measures of functional status outcome that are prominent in the literature were considered. The sample consisted of 15 409 individuals who resided in VA long-term care facilities at any time from 4/1/95 to 10/1/95. Activities of daily living variables were used to generate measures of functional status. Differences between residents' baseline and semi-annual assessments were considered and facility performance using the various definitions of functional status were described. RESULTS: The percentage of residents seen as declining in functional status ranged from 7.7% to 31.5%, depending upon the definition applied. The definition of functional status also affected rankings, z-scores, and 'outlier' status for facilities. CONCLUSION: Judgments of facility performance are sensitive to how outcome measures are defined. Careful selection of an appropriate definition of functional status outcome is needed when assessing quality in long-term care.

Symptom severity of osteoarthritis of the knee: a patient-based measure developed in the veterans health study.

BACKGROUND: Our objective was to develop a patient-based measure of the severity of osteoarthritis of the knee, focusing on symptomatology, that may be used in conjunction with measures of health-related quality of life in monitoring the health status of outpatients. METHODS: We surveyed a random sample of male outpatients at Boston-area Veterans Affairs medical centers who were identified as having osteoarthritis of the knee according to a three-question screen. Structured interviews included 12 items covering five domains of symptoms (global severity, 4 items; pain with activity, 3 items; pain at rest, 2 items; impaired mobility, 2 items; and sensations of crepitus, 1 item), which were derived from clinical texts, consensus statements, and previously developed severity indices. Interviews also included a detailed medical history. Health-related quality of life was measured by the Medical Outcomes Study Health Status Survey (SF-36). Factor analysis and evaluation of multiattribute scales were used to evaluate the structural relationships between and within the five domains of symptoms. RESULTS: We identified 415 of the 1770 screened outpatients as having osteoarthritis of the knee. Internal consistencies of the five domains ranged from .50 to .72, with substantial convergence between domains. The 12 items comprise a summary index with high internal consistency (alpha = .88). Overall severity, defined as the mean of the 12 items after standardization, was moderately correlated with the SF-36 component summaries: r = -.48 for physical; r = -.30 for mental. CONCLUSIONS: Our measure provides a reliable index that represents symptomatic severity of osteoarthritis of the knee, which may be useful in comparing patient groups and assessing health outcomes; subscales may help characterize temporal changes, including responses to treatment.

Health-related quality of life in patients served by the Department of Veterans Affairs: results from the Veterans Health Study.

BACKGROUND: The Department of Veterans Affairs Health Care System (VA) is the largest integrated single payer system in the United States. To date, there has been no systematic measurement of health status in the VA. The Veterans Health Study has developed methods to assess patient-based health status in ambulatory populations. OBJECTIVES: To describe the health status of veterans and examine the relationships between their health-related quality of life, age, comorbidity, and socioeconomic and service-connected disability status. METHODS: Participants in the Veterans Health Study, a 2-year longitudinal study, were recruited from a representative sample of patients receiving ambulatory care at 4 VA facilities in the New England region. The Veterans Health Study patients received questionnaires of health status, including the Medical Outcomes Study Short Form 36-Item Health Survey; and a health examination, clinical assessments, and medical history taking. Sixteen hundred sixty-seven patients for whom we conducted baseline assessments are described. RESULTS: The VA outpatients had poor health status scores across all measures of the Medical Outcomes Study Short Form 36-Item Health Survey compared with scores in non-VA populations (at least 50% of 1 SD worse). Striking differences also were found with the sample stratified by age group (20-49 years, 50-64 years, and 65-90 years). For 7 of the 8 scales (role limitations due to physical problems, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems, and mental health), scores were considerably lower among the younger patients; for the eighth scale (physical function), scores of the young veterans (aged 20-49 years) were almost comparable with the levels in the old veterans (>65 years). The mental health scores of young veterans were substantially worse than all other age groups (P<.001) and scores of screening measures for depression were significantly higher in the youngest age group (51%) compared with the oldest age groups (33% and 16%) (P<.001). CONCLUSIONS: The VA outpatients have substantially worse health status than non-VA populations. Mental health differences between the young and old veterans who use the VA health care system are sharply contrasting; the young veterans are sicker, suggesting substantially higher resource needs. Mental health differences may explain much of the worse health-related quality of life in young veterans. As health care systems continue to undergo a radical transformation, the Department of Veterans Affairs should focus on the provision of mental health services for its younger veteran.

A telecommunications system for monitoring and counseling patients with hypertension. Impact on medication adherence and blood pressure control.

This study was conducted to evaluate the effect of automated telephone patient monitoring and counseling on patient adherence to antihypertensive medications and on blood pressure control. A randomized controlled trial was conducted in 29 greater Boston communities. The study subjects were 267 patients recruited from community sites who were >or= 60 years of age, on antihypertensive medication, with a systolic blood pressure (SBP) of >or= 160 mm Hg and/or a diastolic blood pressure (DBP) of >or= 90 mm Hg. The study compared subjects who received usual medical care with those who used a computer-controlled telephone system in addition to their usual medical care during a period of 6 months. Weekly, subjects in the telephone group reported self-measured blood pressures, knowledge and adherence to antihypertensive medication regimens, and medication side-effects. This information was sent to their physicians regularly. The main study outcome measures were change in antihypertensive medication adherence, SBP and DBP during 6 months, satisfaction of patient users, perceived utility for physicians, and cost-effectiveness. The mean age of the study population was 76.0 years; 77% were women; 11% were black. Mean antihypertensive medication adherence improved 17.7% for telephone system users and 11.7% for controls (P = .03). Mean DBP decreased 5.2 mm Hg in users compared to 0.8 mm Hg in controls (P = .02). Among nonadherent subjects, mean DBP decreased 6.0 mm Hg for telephone users, but increased 2.8 mm Hg for controls (P = .01). For telephone system users, mean DBP decreased more if their medication adherence improved (P = .03). The majority of telephone system users were satisfied with the system. Most physicians integrated it into their practices. The system was cost-effective, especially for nonadherent patient users. Therefore, weekly use of an automated telephone system improved medication adherence and blood pressure control in hypertension patients. This system can be used to monitor patients with hypertension or with other chronic diseases, and is likely to improve health outcomes and reduce health services utilization and costs.

Newspaper reporting of the medical literature.

OBJECTIVE: To examine whether the media are providing information to the public about important medical advances in a timely manner and whether the degree of importance is associated with other aspects of newspaper reporting (presence, extent, and prominence). DESIGN: The authors explored the amount, extent, prominence, and timeliness of newspaper coverage received by New England Journal of Medicine and JAMA articles published in 1988, by searching ten leading U.S. newspapers. The journal articles were independently rated based on the public's need to know the medical information contained in the article. The intraclass reliability coefficient for this need-to-know importance score was 0.77. MEASUREMENTS AND MAIN RESULTS: Overall, 35% of the journal articles received newspaper coverage (276/786). The articles were frequently covered by more than one newspaper [extensive coverage (161/276, 58%)] and often appeared on the front page [prominent coverage (42/276, 15%)]. Articles considered most important to the public (92/786, 12%) received more extensive and prominent coverage than did less important articles (p < 0.01). More than three fourths of the newspaper stories appeared within two days of the journal article's issue date. Stories about the most important articles appeared sooner than did those about the less important articles (p < 0.0001). CONCLUSIONS: Articles reported in two prominent medical journals are often viewed as being important to the public, and these articles are receiving newspaper coverage that is extensive, prominent, and timely. This is particularly true for those articles considered most important to the public.

Comparing the status of women and men in academic medicine.

OBJECTIVE: To explore the status and academic productivity of women compared with men in academic internal medicine. DESIGN: Mail survey done in 1986. SETTING: A total of 107 major teaching hospitals in the United States. PARTICIPANTS: Full-time (1693 of 2510) faculty in cardiology, rheumatology, and general internal medicine; 67% of eligible men and 70% of eligible women. MEASUREMENTS: Academic productivity defined as research grants awarded, abstracts accepted, and papers published in refereed journals; academic advancement as determined by academic rank and tenure status; and monetary compensation. RESULTS: Women entered academic medicine with shorter periods of fellowship training and were less likely to be members in the Alpha Omega Alpha honor society, but they had job descriptions similar to those of men, with similar allocation of work between research, clinical, and teaching activities. After adjustment, women and men were similar in the numbers of research grants funded as principal investigator (1.9 compared with 2.0), abstracts accepted (6.8 compared with 6.1), and papers published in refereed journals (28.8 compared with 29.2; all with P > 0.20). Women were as likely as men to have tenure, but they had lower academic rank (full or associate professor; 33% compared with 47%, P < 0.001) and received less compensation ($72,000 compared with $79,600 annually; P < 0.001). CONCLUSION: Although women do similar professional tasks and achieve similar levels of academic productivity, they receive fewer rewards for their work, both in academic rank and monetary compensation.

Geriatrics training in physical medicine and rehabilitation.

A survey was conducted to determine the level of training in geriatrics in physical medicine and rehabilitation (PM&R) residency training programs. Questionnaires were sent to 76 accredited programs in 1989 with a 63% (48/76) response rate. Results show that 49% of patients cared for by PM&R residents in inpatient settings are 65 years of age or older, and 42% of patients cared for in ambulatory settings are in the same age group. Of PM&R programs, 30% have physician faculty who are geriatric "specialists." PM&R residents have a significant exposure to elderly patients in the consultation role. Less exposure to elderly patients occurs in distinct geriatric rehabilitation and geriatric medicine programs or units. Among 10 medical specialties, PM&R programs compare well in terms of teaching about the topics and the personnel that are important in geriatrics. This is due in part to an obvious overlap between the content of rehabilitation medicine and that of geriatrics. Furthermore, there is moderate interest in PM&R in developing fellowship training in geriatric rehabilitation. The need for more academic faculty who are geriatric "specialists," as well as the need for increasing PM&R exposure to distinctly geriatric settings as a part of training, is apparent.