The cardiovascular event reduction tool (CERT)--a simplified cardiac risk prediction model developed from the West of Scotland Coronary Prevention Study (WOSCOPS).

The clinical decision to treat hypercholesterolemia is premised on an awareness of patient risk, and cardiac risk prediction models offer a practical means of determining such risk. However, these models are based on observational cohorts where estimates of the treatment benefit are largely inferred. The West of Scotland Coronary Prevention Study (WOSCOPS) provides an opportunity to develop a risk-benefit prediction model from the actual observed primary event reduction seen in the trial. Five-year Cox model risk estimates were derived from all WOSCOPS subjects (n = 6,595 men, aged 45 to 64 years old at baseline) using factors previously shown to be predictive of definite fatal coronary heart disease or nonfatal myocardial infarction. Model risk factors included age, diastolic blood pressure, total cholesterol/ high-density lipoprotein ratio (TC/HDL), current smoking, diabetes, family history of fatal coronary heart disease, nitrate use or angina, and treatment (placebo/ 40-mg pravastatin). All risk factors were expressed as categorical variables to facilitate risk assessment. Risk estimates were incorporated into a simple, hand-held slide rule or risk tool. Risk estimates were identified for 5-year age bands (45 to 65 years), 4 categories of TC/HDL ratio (<5.5, 5.5 to <6.5, 6.5 to <7.5, > or = 7.5), 2 levels of diastolic blood pressure (<90, > or = 90 mm Hg), from 0 to 3 additional risk factors (current smoking, diabetes, family history of premature fatal coronary heart disease, nitrate use or angina), and pravastatin treatment. Five-year risk estimates ranged from 2% in very low-risk subjects to 61% in the very high-risk subjects. Risk reduction due to pravastatin treatment averaged 31%. Thus, the Cardiovascular Event Reduction Tool (CERT) is a risk prediction model derived from the WOSCOPS trial. Its use will help physicians identify patients who will benefit from cholesterol reduction.

Interpreting excess mortality in a prevention trial for older adults.

BACKGROUND: In a randomized trial evaluating preventive services for older adults excess mortality was observed in the treatment group. We examined four explanations: unbalance of baseline characteristics, unintended effects of the intervention, consequence of an autonomy intervention (including increased number of living wills in the treatment group), and chance. We focus here on the effects of the autonomy intervention. METHODS: Preparation of living wills in the treatment and control groups was compared both at baseline and follow-up. A linear predictor of mortality was used to identify participants at high risk of dying. Charts of these 200 participants were reviewed for evidence of serious medical events and resuscitation decisions. Rates of life-sustaining treatment were compared between treatment and controls using logistic regression. RESULTS: More living wills (65%) were noted for the treatment group than control group (47%) at follow-up. Thirty-six per cent of participants were identified as having a serious medical event; of these, participants in the treatment group were over twice as likely not to receive life-sustaining treatment. CONCLUSIONS: Advance directives contributed to excess deaths, indicating the success of the autonomy intervention.

A 12-year experience with enterovesical fistulas.

OBJECTIVES: To review our experience with enterovesical fistulas in order to determine the most accurate diagnostic studies and most effective method of treatment. METHODS: A retrospective record review of 76 patients who were diagnosed and treated for enterovesical fistulas over a 12-year period was performed. Data collection focused on presenting symptoms, urinary disease process, diagnostic studies, and methods of management. RESULTS: Diverticular disease was the primary etiologic factor in the majority of patients (59%), with colonic malignancy, granulomatous bowel disease, and radiation therapy accounting for the majority of the remainder. Cystoscopy (60%) and cystography (44%) were the most sensitive diagnostic studies. There was no statistical difference in the complication rate between groups treated with single or multistage repair. CONCLUSIONS: One-stage repair of enterovesical fistulas can be safely performed when the cause is diverticular or granulomatous bowel disease. Staged repairs may be more judicious in patients with large intervening pelvic abscesses or those in whom advanced malignancy or radiation changes are present.

Health-related quality-of-life assessment and planning for the pharmaceutical industry.

Health-related quality of life (HRQL) represents a patient-centered approach to assessing functional status and well-being that integrates the impact of both medical treatment and disease. The pharmaceutical industry is increasingly incorporating HRQL measures into the drug development process as part of a comprehensive outcomes evaluation. HRQL measures can be used to distinguish the effects of competing treatments, demonstrate trade-offs between survival and functional status and well-being, and provide comprehensive information on the effects of treatment on patient outcomes. Two main approaches have been used to measure HRQL: psychometric-based instruments and preference-based instruments. Each approach has advantages and disadvantages for the evaluation of pharmaceuticals, and no one approach can be recommended for all studies. The selection of HRQL measures for clinical trials requires attention to the appropriateness, psychometric characteristics, and practicality of the available instruments. The comprehensive evaluation of pharmaceutical treatments requires measures of HRQL as well as safety and clinical efficacy.

Nafazatrom, an arachidonate metabolism inhibitor, decreases prolactin and GH release.

Nafazatrom, an inhibitor of arachidonate metabolism by the lipoxygenase enzymes, decreases basal prolactin and growth hormone release in a concentration-dependent manner without significantly affecting the synthesis of either hormone. It is required that nafazatrom be incubated with pituitary cells for approximately 2 h for this effect to become evident; the blockade increases in magnitude for up to 4 h. Nafazatrom blocks the increase in prolactin release caused by the releasing factors TRH and angiotensin II and the increase in prolactin and growth hormone release due to the calcium channel activator maitotoxin. These data suggest that the lipoxygenase products of arachidonate metabolism may be important mediators in basal and secretagogue-induced release of prolactin and growth hormone.

Adult day health care evaluation study: methodology and implementation. Adult Day Health Care Evaluation Development Group.

The Adult Day Health Care Evaluation Study was developed in response to a congressional mandate to study the medical efficacy and cost effectiveness of the Adult Day Health Care (ADHC) effort in the Department of Veterans Affairs (VA). Four sites providing ADHC in VA facilities are participating in an ongoing randomized controlled trial. Three years of developmental work prior to the study addressed methodological issues that were problematic in previous studies. This developmental work resulted in the methodological approaches described here: (1) a patient recruitment process that actively recruits and screens all potential candidates using empirically developed admission criteria based on predictors of nursing home placement in VA; (2) the selection and development of measures of medical efficacy that assess a wide range of patient and caregiver outcomes with sufficient sensitivity to detect small but clinically important changes; and (3) methods for detailed, accurate, and efficient measurement of utilization and costs of health care within and outside VA. These approaches may be helpful to other researchers and may advance the methodological sophistication of long-term care program evaluation.

Cost and outcomes of Medicare reimbursement for HMO preventive services.

Medicare beneficiaries enrolled in a health maintenance organization (HMO) were randomized to a preventive services benefit package for 2 years or to usual care. At 24- and 48-month follow-ups, the treatment group had completed more advance directives, participated in more exercise, and consumed less dietary fat than the control group. Unexpectedly, more deaths occurred in the treatment group. Surviving treatment-group enrollees reported higher satisfaction with health, less decline in self-rated health status, and fewer depressive symptoms than surviving control participants. Despite these changes, the intervention did not yield lower cost per quality-adjusted life year in this historically prevention-oriented HMO.

A model for reducing the cost of care in VA medical centers that offer adult day health care.

One approach to providing cost-effective adult day health care (ADHC) services is to guide both the inputs to ADHC services and the provision of other services so that substitution for institutional services can realistically take place. This approach has been used in a randomized clinical trial to evaluate the medical efficacy and cost of ADHC in the Department of Veterans Affairs (DVA). This article describes the strategies that were used to improve the cost effectiveness of ADHC during the evaluation. Cost and use estimates were developed based on the best data available from the DVA and previous research on the cost for patients' use of ADHC, nursing home, hospital, and ambulatory care. A cost workshop was attended by the ADHC managers to develop plans for controlling costs. Plans were identified that increase the likelihood that ADHC can be shown to be less costly than customary care.

Methods of determining the cost of health care in the Department of Veterans Affairs medical centers and other non-priced settings.

Cost is increasingly important in the evaluation of health care. Though charges are often used as a proxy for cost, some health care systems such as the Veterans Administration do little or no billing. This article describes, presents examples of, and evaluates four options for determining the cost of care within the Department of Veterans Affairs: measuring input costs, the Department's cost accounting system, the reimbursement system, and use of charges from a surrogate health care facility. Each approach is evaluated for accuracy, ability to compare the costs of different treatments, and effort required to estimate cost.

A cost evaluation of a hospital-based perinatal case management program.

A procedure to determine the costs of nursing care delivery for comparative analysis between a conventional hospital obstetrical nursing care delivery model and a redesigned hospital-based perinatal case management model of nursing care delivery is described.

The implications for information system design of how health care costs are determined.

As the costs of health care assume increasing importance in national health policy, information systems will be required to supply better information about how costs are generated and how resources are distributed. Costs, as determined by accounting systems, often are inadequate for policy analysis because they represent resources consumed (expenditures) to produce given outputs but do not measure forgone alternative uses of the resources (opportunity costs). To accommodate cost studies at the program level and the system level, relational information systems must be developed that allow costs to be summed across individuals to determine an organization's costs, across providers to determine an individual patient's costs, and across both to determine system and population costs. Program level studies require that cost variables be grouped into variable costs that are tied to changes in volume of output and fixed costs that are allocated rationally. Data sources for program-level analyses are organizational financial statements, cost center accounting records, Medicare cost reports, American Hospital Association surveys, and the Department of Veterans Affairs (VA) cost distribution files. System-level studies are performed to predict future costs and to compare costs of alternative modes of treatment. System-level analyses aggregate all costs associated with individuals to produce population-based costs. Data sources for system-level analyses include insurance claims;n Medicare files; hospital billing records; and VA inpatient, outpatient, and management databases. Future cost studies will require the assessment of costs from all providers, regardless of organizational membership status, for all individuals in defined populations.

Hospital survival in a competitive environment: the competitive constituency model.

Organizational theory is extended to develop a method for administrators to assess hospital effectiveness in a competitive environment. First, the literature pertaining to organizational effectiveness and survival is synthesized to show the lack of consideration for the effects of competition. Second, the article integrates the effects of competition on organizational effectiveness through a competitive constituency model. A step-by-step procedure is proposed to apply the theory in an organizational setting. The model explicitly addresses differences in power relations between hospitals, their competition, and their stakeholders. The relative nature of effectiveness is explored by comparing the hospital to its competition using criteria developed through specific goals of stakeholders. The distinction between managerial and organizational effectiveness constructs is clarified. Finally, the practical application of this model is demonstrated by assessing the effectiveness of a hospital in the competitive environment of Seattle, Washington, where two hospitals have recently closed.

The development and evaluation of hospital performance measures for policy analysis.

The purpose of this study was to develop and evaluate hospital performance measures to include aspects of hospital behavior beyond the traditional use of hospital profit margins for policy analysis. A number of measures have been used in the literature that are purported to reflect a variety of hospital behaviors. The reliability and validity of these and new measures were assessed using descriptive statistics and factor analysis on a sample of hospitals for a 3-year period. The sample consisted of all hospitals for which there were Medicare Cost Report and balance sheet data during the federal fiscal years 1987 through 1989. Using a subset of three hospital groups, 33 measures were evaluated, from which five were selected to represent the critical aspects of hospital performance important for policy analysis. The measures are: TEM, a new technical efficiency measure using data envelopment analysis techniques; the current ratio, depicting short-term financial performance; the ratio of longterm debt-to-net fixed assets, representing long-term viability; total margin, portraying profitability; and Medicare margin, characterizing Medicare's contribution to hospital financial position. Each represents different aspects of hospital efficiency and financially viability.

Venomous bites to the external genitalia: an unusual cause of acute scrotum.

The acute scrotum generates a long list of differential diagnoses. An unusual etiology includes insect envenomation, which typically is an acute process with rapid onset of symptomatologies. Two patients with genital envenomation are reported. We review the reported cases at our institution with all types of bites and stings. Symptoms of pain and pruritus, and signs of ecchymosis and edema preceding exfoliating dermatitis were evident in both cases. Mild analgesics and antihistamines promoted resolution in each instance.

Comparison of utilization and cost among contract adult day health care, VA adult day health care, and customary care.

The contract ADHC evaluation compared the utilization and costs of patients assigned to contract ADHC with patients assigned to VA-ADHC care or customary care in the VA-ADHC evaluation. The ADHC costs per patient day were lower on average in the contract sites than in the VA-ADHC sites, although they were similar to the costs at 2 of the 4 VA-ADHCs. The contract site patients received significantly more days of ADHC care, offsetting their lower cost per day. Contract site patients had significantly fewer VA clinic visits and VA nursing home admissions than did patients in the VA-ADHC or customary care groups. Patients at the contract sites also had significantly fewer days of nursing home care than did the customary care group patients. Propensity scores based on intake characteristics were used to adjust for initial differences between the patients in the 2 evaluations. After adjustments, the total cost of care for contract ADHC patients was found to be significantly higher than the cost for customary care patients, but no significant difference was found between contract ADHC patients and VA-ADHC patients.

Financial management of posthospital care programs.

In this article the model estimates differences in utilization and subsequent costs of inpatient acute care, nursing home, and clinic visits as a result of patients using a posthospital care program. These estimates are compared to actual costs showing the model's robustness. The model is developed to aid in both the evaluation and the management of hospital-based postdischarge programs.

A description of the content of army family practice.

BACKGROUND: For decisions about residency curricula and downsizing the US Army medical corps, decision makers must know the practice content of the various specialties. Little is known about the content of Army family practice. The purpose of our study was to describe the content of Army family practice. METHODS: We analyzed a random sample of 28,849 family practice encounters from the US Army Ambulatory Care Data Base Study. Variables included patient demographics, diagnoses, visit duration, procedures, and medical facility. Patient age and visit duration were compared using analysis of variance; facility profiles were compared by age category and sex of patients, family member position, and procedure frequency using chi-square analysis. Diagnostic content of the facilities was compared by both chi-square and Kendall's tau B tests. RESULTS: The typical patient was a 26-year-old woman. The 25 most frequent diagnoses accounted for three-fourths of all encounters, with variation by patient age. The majority of visits did not include a procedure, but procedure frequency varied by patient age and diagnostic certainty. Mean visit duration was 16.4 minutes and varied by age. There were differences among the sites for all variables. CONCLUSIONS: Army family physicians see patients of all ages, of whom more are the family members of soldiers than the soldiers themselves; they frequently do procedures and are usually certain of their diagnoses, which include a broad spectrum of illnesses. Army family physicians are flexible, adapt to local patient and environmental needs, and are uniquely qualified to form the basis of Army medicine.

A comparison of the content of army family practice with nonfederal family practice.

BACKGROUND: To assist with planning for education and practice, family physicians should know the practice content of their practices. The present study compared the content of nonfederal family practice with Army family practice to explore their differences. METHODS: This was a secondary analysis that compared the similar variables within two national data sets: The National Ambulatory Medical Care Survey and the Army's Ambulatory Care Data Base. RESULTS: Army patients were younger and more likely to be female than were nonfederal patients. Army family physicians spent more time with patients in all groups than did nonfederal family physicians. While 12 of the top 20 diagnosis clusters of each sector were the same, there were differences found in the percentages of total visits contained within the top 20 clusters. CONCLUSIONS: Both nonfederal and Army family practice have a wide variation in patients and diagnoses. The two sectors are different in patient age and the frequency of different diagnoses. Knowledge of these differences can assist with planning.