Postmenopausal estrogens in prevention of osteoporosis. Benefit virtually without risk if cardiovascular effects are considered.

Postmenopausal estrogens can delay or prevent osteoporosis and decrease the frequency of fractures, but they also increase the risk of endometrial cancer. A decision analytic model was developed using a Markov process with 18 different states to estimate quality-adjusted life expectancy with and without estrogen therapy. The model considered fractures of the hip, wrist, pelvis, humerus and spine with potential outcomes of short-term morbidity, long-term disability, nursing home placement, and death. Quality adjustments were based on expert opinions. In sensitivity analyses, various risks of endometrial cancer and hysterectomy due to estrogens were examined. The effect of estrogen therapy on cardiac mortality also was considered. For a cohort of 50-year-old white women who would take estrogens for 15 years, the analysis showed a benefit of 0.47 years but 0.67 quality-adjusted years. For every five-fold increase in the relative risk of endometrial cancer, the benefit decreases by 0.07 quality years. The benefit would increase by 0.17 quality years for each 10 percent decrease in the fracture rate and 0.32 for each 10 percent decrease in cardiovascular mortality rate. Thus, estrogen therapy provides a significant gain in quality-adjusted life expectancy. In considering the efficacy of any drug, all the benefits of the drug as well as all its risks must be included. If the beneficial effect of estrogens on cardiovascular mortality is confirmed, it will overshadow all other effects. Any recommendation about postmenopausal estrogens with respect to osteoporosis that excludes their cardiovascular effects markedly underestimates the potential gains from therapy.

Realizing the potential of clinical judgment: a real-time strategy for predicting outcomes and cost for medical inpatients.

PURPOSE: We sought to determine whether illness severity and anticipated level of function, as evaluated at the time of admission, were associated with outcomes and costs of care for patients admitted to the medical service. METHODS: All 1,759 patients admitted to the medical service at a large urban academic medical center between July 1, 1997, and September 30, 1997 (excluding those admitted directly to the intensive care units or for protocol chemotherapy), were evaluated and categorized by the admitting intern by illness severity (not ill, mildly ill, moderately ill, severely ill, or moribund) and anticipated level of function at discharge (excellent, good, fair, or poor) as part of their routine sign-out process. Interns' ratings were always available within 24 to 28 hours of admission. In-hospital mortality, length of stay, cost of hospitalization, and anticipated billing revenue were evaluated. RESULTS: Patients who were more severely ill had significantly greater in-hospital mortality. For example, mortality was 1.1% (11 of 972) among those who were not ill or mildly ill, 3.6% (26 of 724) among those who were moderately ill, and 15% (9 of 60) among those who were severely ill. Illness severity (P = 0.003) and anticipated functional status (P < 0.01) were significant predictors of in-hospital mortality. Illness severity and function were also significant predictors of greater length of stay and greater costs of hospitalization (all P < 0.0001). The 389 patients who were moderately ill with fair or poor anticipated function were associated with the largest cumulative losses (about $330,000 during the 3-month period), whereas the 798 mildly ill patients with good or excellent function were associated with the largest cumulative profits ($550,000). CONCLUSION: Physicians' estimates of patients' illness severity and anticipated function at the time of discharge, as made by interns using a system designed to help them sign out to their colleagues, predict outcomes and costs of hospitalization. Such a system may be useful in developing new approaches to management strategies based on prognosis.

Improvement of outcomes after coronary artery bypass. A randomized trial comparing intraoperative high versus low mean arterial pressure.

BACKGROUND: The objective of this randomized clinical trial of elective coronary artery bypass grafting was to investigate whether intraoperative mean arterial pressure below autoregulatory limits of the coronary and cerebral circulations was a principal determinant of postoperative complications. The trial compared the impact of two strategies of hemodynamic management during cardiopulmonary bypass on outcome. Patients were randomized to a low mean arterial pressure of 50 to 60 mm Hg or a high mean arterial pressure of 80 to 100 mm Hg during cardiopulmonary bypass. METHODS: A total of 248 patients undergoing primary, nonemergency coronary bypass were randomized to either low (n = 124) or high (n = 124) mean arterial pressure during cardiopulmonary bypass. The impact of the mean arterial pressure strategies on the following outcomes was assessed: mortality, cardiac morbidity, neurologic morbidity, cognitive deterioration, and changes in quality of life. All patients were observed prospectively to 6 months after the operation. RESULTS: The overall incidence of combined cardiac and neurologic complications was significantly lower in the high pressure group at 4.8% than in the low pressure group at 12.9% (p = 0.026). For each of the individual outcomes, the trend favored the high pressure group. At 6 months after coronary bypass for the high and low pressure groups, respectively, total mortality rate was 1.6% versus 4.0%, stroke rate 2.4% versus 7.2%, and cardiac complication rate 2.4% versus 4.8%. Cognitive and functional status outcomes did not differ between the groups. CONCLUSION: Higher mean arterial pressures during cardiopulmonary bypass can be achieved in a technically safe manner and effectively improve outcomes after coronary bypass.

Geographic variations in the rates of elective total hip and knee arthroplasties among Medicare beneficiaries in the United States.

We analyzed the variations in the rates of elective total hip and total knee arthroplasties for 1988 in the United States to determine whether the rates correlated with the numbers of surgeons. There were 56,204 total hip arthroplasties and 68,491 total knee arthroplasties, performed in the home states of the patients among all of the Medicare beneficiaries. Medicare beneficiaries include most people who are more than sixty-five years old in the United States and a small proportion of younger people who are eligible for Medicare for other reasons. Seventy-nine per cent of the patients who had had a total hip arthroplasty and 89 per cent of those who had had a total knee arthroplasty had been managed with the operation because of osteoarthrosis. Both operations were most common in the seventy to seventy-four-year age-group. We calculated the rate of operations per 100 beneficiaries for each state and age-adjusted the results. Across all of the states, bilateral procedures constituted 1.6 per cent of the total hip arthroplasties and 4.8 per cent of the total knee arthroplasties. The in-hospital rates of mortality were 0.72 per cent for total hip arthroplasties and 0.45 per cent for total knee arthroplasties. The destinations after discharge from the hospital were similar for the two groups of patients, with more than 65 per cent of the patients being discharged directly to their homes. There were no significant differences among states in terms of the length of stay in the hospital or reimbursement of the hospital.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of clinical performance of primary care and traditional internal medicine residents.

OBJECTIVE: To compare primary care and traditional Internal Medicine residents in their adherence to preventive medicine guidelines, performance in the management of chronic diseases, and utilization of resources. DESIGN: Prospective cohort study. SETTING: Urban Internal Medicine residency program. PARTICIPANTS: Sixteen primary care and 137 traditional Internal Medicine residents who took care of 6,307 patients (a total of 21,002 patient visits in a 1-year period). MEASUREMENTS: Adherence to preventive medicine guidelines for the screening of breast cancer, cervical cancer, hypercholesterolemia, and colon cancer; admission rates among patients with asthma, chronic pulmonary disease, and diabetes mellitus; four items in the management of diabetes; and resource utilization including the costs for laboratory and radiology tests and number of consultations. RESULTS: Primary care residents, as compared with traditional residents, adhered to preventive medicine guidelines for a greater proportion of their patients for the following: breast cancer among women aged 52 to 75 years (61% vs. 54%, respectively, P = 0.05); cholesterol screening among patients aged 20 to 64 years (39% vs. 33%, P = 0.007); colon cancer among patients older than 50 years (49% vs. 31%, P = 0.001); and cervical cancer among women aged 20 to 64 years (36% vs. 31%, P = 0.03). There were no differences in hospital admission rates for patients with diabetes or asthma. Total ambulatory care costs for tests, procedures, consults, and office visits were greater for patients of primary care residents ($1,045 vs. $899, P = 0.0001), although total costs per primary care visit were similar between the two patient groups. CONCLUSIONS: Primary care residents more closely adhered to preventive medicine guidelines but were similar to traditional residents in their management of chronic diseases. Patients of primary care residents had greater ambulatory care costs that were not entirely attributable to greater adherence to preventive medicine guidelines.

Cost-effectiveness of splenectomy versus intravenous gamma globulin in treatment of chronic immune thrombocytopenic purpura in childhood.

Infusions of intravenous gamma-globulin (IVGG) are an effective, nontoxic therapy for chronic idiopathic thrombocytopenic purpura (ITP) that would be more widely accepted if the therapeutic agent were not so expensive. The costs and outcomes of managing such children with splenectomy and IVGG were modeled with Markov processes. Children unresponsive to one treatment were considered to have received the alternative. The model accounted for spontaneous remissions, therapeutic responses, traumatic events, episodes of sepsis, and operative deaths. For a 10-year-old child with chronic ITP, the strategy of initial treatment with splenectomy had associated costs of $17,000 and a 97.9% ten-year survival rate, whereas the strategy of initial treatment with IVGG had associated costs of $21,000 but a 98.6% survival rate. Each additional life saved by employing the IVGG strategy cost $540,000, or $8,000 per year for a life expectancy of 70 years. Sensitivity analyses demonstrated that for older children the IVGG strategy continued to result in improved survival rates but was more costly than the splenectomy strategy. For younger children, the IVGG strategy dominated, with improved survival rates and lower costs.

Breast cancer screening for elderly women with and without comorbid conditions. A decision analysis model.

OBJECTIVE: To determine whether breast cancer screening extends life for women aged 65 years or more with and without comorbid medical conditions. SETTING: A provider-patient encounter. DESIGN: A decision analysis of the utility of screening for breast cancer. MEASUREMENTS: Clinical examination and mammography among four groups of women aged 65 to 85 or more years: average health, mild hypertension, congestive heart failure, and average-health black women. The effects of screening were estimated using the best quality data available. RESULTS: Screening saved life at all ages among patients studied. Savings were highest for black women and decreased with increasing age and comorbidity. Screening all average-health women aged 65 or more saved 67,912 years of life. For women who had cancer, screening extended life by 617 days for average-health women between 65 and 69 years of age and 178 days for those aged 85 years or more. Perioperative mortality and test characteristics had little effect on the results. The risks equaled the benefits of screening only when operative mortality was between 27% and 62%. The marginal costs of screening during a routine office visit were $138 and increased with advancing age and decreasing test specificity. Benefits persisted after adjustment for changes in long-term quality of life; however, for women aged 85 years and older (with and without comorbidities), the short-term morbidity of anxiety or discomfort associated with screening may have outweighed the benefits. CONCLUSION: No inherent reason exists to impose an upper-age limit for breast cancer screening; however, more data are needed on women's preferences for screening strategies.

Diagnostic test restraint and the specialty consultation.

OBJECT: To assess the effect consultants had on the diagnostic process in the management of patients admitted to the medical service of a university hospital. DESIGN: Cohort study utilizing prospective evaluation by residents, retrospective chart review, and direct communication with the patient, a family member, or the patient's physician one year after admission to the hospital. SETTING: The medical inpatient service of an urban university hospital. PATIENTS: The 580 patients admitted to the medical service during one month in 1984 for whom complete data were available. MAIN RESULTS: Sixty-three percent of the patients had consultations. Seventy percent (198/284) of the patients admitted by generalists had consultations, while 57% (170/296) of the patients admitted by subspecialists had consultations. Of the 1,422 major diagnostic tests performed on these patients, 504 (35%) were first recommended by consultants, and the consultants recommended cancellation of only ten major diagnostic tests. Patients who were seen by consultants had a length of stay that was more than double that of patients not seen by consultants. Consultation was associated with prolonged stay when patients were stratified by important clinical variables and remained an important independent factor in a multivariate model. The prolongation of hospitalization was principally due to delays in scheduling and interpreting sophisticated tests recommended by the consultants. When stratified into prognostically similar clinical groupings, there was no significant difference in in-hospital mortality between patients seen and those not seen by a consultant. CONCLUSION: Efforts to foster diagnostic restraint in the management of hospitalized patients should be broadened to include attention to the specialty consultation process.

Diagnosis, treatment, comorbidity, and resource utilization of depressed patients in a general medical practice.

OBJECTIVE: The objective of the study was to determine the effect of depression on the utilization of health care resources, after adjusting for age and comorbidity from data obtained on routine clinical practice. METHOD: The study is an observational cohort of 15,186 patients followed over a one-year period beginning December 1993. Comprehensive demographic, clinical, and utilization data were available from the computerized medical information system generated database of a general internal medicine practice in an urban academic medical center. RESULTS: Four point seven percent of patients carried a provider-coded diagnosis of depression. With regards to utilization of health care resources, even after controlling for age and comorbidity, depressed patients had more primary care visits (5.3 vs. 2.9 visits, p < .001), higher rates of referral to specialists (1.1 vs. 0.5, p < .002), and radiologic tests (0.9 vs. 0.4 tests, p < .001). They had higher total outpatient charges ($1,324 vs. $701, p < .001) and total charges ($2,808 vs. $1,891, p < .001). Depressed patients also had longer length of stay when hospitalized (14.1 vs. 9.5 days, p < .002). CONCLUSIONS: Patients diagnosed as depressed had significantly higher resource utilization of all types, even after controlling for the higher burden of comorbid medical illness associated with depression.

Depression and service utilization in elderly primary care patients.

The authors analyzed the relationship between a provider's diagnosis of depression and health services utilization among all elderly patients (N=3,481) seen in a primary care practice over 12 months. Of patients with a diagnosis of depression, 29.7% were given an antidepressant. Depressed patients had increased outpatient resource utilization, including frequency of appointments, number of laboratory tests, X-rays and scans, and consultations. This association remained significant after controlling for comorbidity. On average, patients who were depressed had two more appointments per year. No difference in total cost of hospitalization was observed between the two groups. This study also demonstrated a higher incidence of nonspecific medical complaints in depressed vs. non-depressed elderly primary care patients, and all such nonspecific symptoms were associated with increased total ambulatory costs, tests and consultations. The somatic presentation of depression may contribute to the increased services utilization.

Computerized data collection in the operating room during coronary artery bypass surgery: a comparison to the hand-written anesthesia record.

OBJECTIVE: To investigate variability between hand-written and computerized anesthesia records and evaluate any associated bias. DESIGN AND MEASUREMENTS: A computer system that was used to collect intraoperative data for a study of hemodynamic management during coronary artery bypass graft surgery is described. The system collected and recorded hemodynamic data automatically downloaded from the anesthesia monitor as well as surgical events and drug administration data entered through menu options. The system then combined, summarized, and graphed the data as well as formatted it for export to a commercially available database program. In a sample of 14 patients, blood pressure data collected by the computer system was compared with the blood pressure data charted in the hand-written anesthesia record. MAIN RESULTS: Although general linear models controlling for within-patient variation and randomization assignment for mean arterial pressure range on cardiopulmonary bypass showed a significant relationship; low R2 values indicated that much of the variability could not be explained and that there was, therefore, poor agreement between the two records. Furthermore, a systematic bias in the hand-written anesthesia record was found when the computer system record was compared with the hand-written record and to the difference of the two records, so that extremes seen in the computer system record tended to be minimized in the hand-written anesthesia record. CONCLUSIONS: Because of the lack of explained variability between the computer system and hand-written anesthesia records and the bias in the hand-written anesthesia record, the hand-written anesthesia record should not be relied on as a source of accurate data for research purposes.

An organizational model for developing multidisciplinary clinical research in the academic medical center.

OBJECTIVE: To assess the impact of a new organizational model designed to stimulate multidisciplinary clinical research. METHODS: We conducted a prospective, 3 1/2-year followup of a research training program for residents, fellows, faculty, nurses, and allied health professionals in rheumatology and orthopedic surgery. Program components included a multidisciplinary clinical research conference, a clinical research methods curriculum, consultations, a patient registry, and regular meetings of a Research Methodology Core group. Measures included participation in each program component and the number of new investigators who developed funded clinical research projects. RESULTS: The multidisciplinary clinical research conference was attended by 369 new health professionals; 218 professionals participated in at least one of the courses; and 280 consultations were provided to 108 professionals. Thirteen new investigators developed 17 new grant proposals, of which 14 were externally funded. Investigators who successfully procured funding for new projects demonstrated significantly more participation in program components compared with those who did not (P < 0.001 overall). CONCLUSION: Participation in the program was significantly correlated with the development of new prospective patient-based studies. We conclude that our model has the potential to foster such research in other settings.