Understanding the guidelines for treating HIV disease.

In 1996 a panel of experts convened by the International AIDS Society-USA issued new guidelines for treating human immunodeficiency virus (HIV) infection, which have recently been updated. Quantitative plasma HIV-1 RNA concentration (viral load) and CD4+ lymphocyte levels are used to monitor disease progression, determine the need to initiate antiretroviral treatment, monitor effectiveness of treatment and evaluate the need to change medications. Multi-drug therapy with nucleoside analogs, nonnucleoside reverse transcriptase inhibitors and protease inhibitors can result in measurable improvement in clinical outcome in HIV-1 infected patients.

A cost-benefit analysis of colposcopy for cervical squamous intraepithelial lesions found on Papanicolaou smear.

BACKGROUND: We performed a cost-benefit analysis of a protocol for studying patients with squamous intraepithelial lesions (SIL) on Papanicolaou smears to determine whether it compared favorably with resources spent on other health programs for screening and treatment. METHODS: During a 3-year period, 424 patients with dysplastic Papanicolaou smears were examined, studied by biopsy, and treated. We calculated costs based on a model protocol and derived a cost per year of life saved for preventing death from invasive cervical carcinoma. A sensitivity analysis was performed on selected assumptions of the analysis. RESULTS: The marginal, or incremental, cost of colposcopic evaluation and treatment of Papanicolaou smears with low-grade SIL, high-grade SIL (moderate), and high-grade SIL (severe), depending on assumptions, ranged from $406 to $5746, $160 to $2263, and $85 to $1197 per year of life saved, respectively. Depending on the assumption of the rate of Papanicolaou smears with SIL in the screened population being 1.8%, 5.1%, or 11.5%, the estimated total cost of screening and treating the referral base was $1.3 million, $538,126, and $307,037, respectively. This results in the average cost per year of life saved to screen and treat low-grade SIL, high-grade SIL (moderate), and high-grade SIL (severe) to be $1105 to $68,909, $375 to $21,673, and $177 to $8831, respectively. CONCLUSIONS: Both marginal cost and average screening costs of evaluating and treating abnormal Papanicolaou smears by the protocol described in this article compare favorably with costs per year of life saved for other health care screening and treatment strategies for many assumptions. The marginal cost to perform colposcopy on patients with a Papanicolaou smear with low-grade SIL is so low that it is relatively a very effective strategy.

An epidemiological approach to quality assurance in the hospital.

This article discusses epidemiological methodology: comparing rates, confounding, the use of confidence intervals, Bayes' theorem, and occurrence screening. An appreciation of the limits of epidemiological methods will provide the manager with realistic expectations of the quality assurance process.

Primary causes of medical instability of Medicare patients at discharge 1990-1991.

BACKGROUND: HCFA-sponsored Peer Review Organizations nationwide have been criticized by organized medicine, Medicare beneficiaries and interested Congressional parties for being punitive without exploiting educational opportunities garnered through their massive data collection capabilities. Until now this data has been poorly analyzed and has not been adequately utilized as a positive motivational tool. METHODS: HCFA has developed, with the cooperation of the medical community, six generic screens for Peer Review Organizations to utilize when evaluating quality care provided Medicare beneficiaries in an acute care setting. Through the sheer volume of cases seen, significant inpatient information can be obtained that cannot be duplicated in any other epidemiological endeavor. Line item discrepancies can be further studied through small-area-analysis to determine "who" as well as "what" may be the problem. RESULTS: By compiling and reviewing data in a systematic manner over two years (1990-1991), the Alabama Quality Assurance Foundation (AQAF) has singled out problems with patient medical stability at discharge as the predominant concern for care providers and reviewers alike. CONCLUSIONS: Having determined the primary problem in rendering quality care in a Prospective Payment System to Medicare beneficiaries lies in premature discharges, subsequent small-area-analysis further narrows the focus of concerned individuals. Hopefully, practitioners and providers alike will act on their own initiative in correcting this problem. Follow-up review will be utilized to assure this self-corrective action.

Drug testing in the workplace. What primary care physicians need to know.

As drug testing in the workplace becomes more common, primary care physicians need to be more informed about social and technical issues involved. How are laboratory results of urinalysis interpreted? What are the primary care physician's responsibilities to the patients being tested and their employers? In this article, Drs Everett and Linder discuss current drug testing procedures, guidelines, and interpretation of results.

Epidemiologic observations of operating room infections resulting from variations in ventilation and temperature.

Over a period of years the ventilation system of a community hospital progressively deteriorated until it no longer met regulatory guidelines. The hospital, a publicly funded military facility, requested funding to repair the ventilation system, but funds were not forthcoming because of budget austerity. When an increase in infections was documented, high-risk operations were curtailed and funding was expedited. With the new improved ventilation system the operating rooms once again met regulatory guidelines and infections returned to baseline rates. Throughout the period infections remained below recognized national levels.

Experience with colposcopy in a family practice center.

The experience of a family practice center that performed colposcopy for one year was reviewed to provide insight into the appropriateness of this procedure to a family practice clinic. Almost three thousand Papanicolaou smears were performed, which prompted 97 colposcopy clinic appointments involving 68 patients. Dysplastic Pap smears accounted for 1.82% of the total. Atypical Pap smears occurred in 3.91% of the tests, and 16.1% of a sample of these demonstrated dysplasia. Controversy concerning the atypical Pap smear is discussed. The colposcopy service was convenient for the patients and was at least revenue neutral while providing a new professional opportunity for selected family practitioners. A referral base of at least 1,000 Pap smears might justify a colposcopy program, depending on referral strategies.

Determining risk of heart disease and obesity with a hand-held programmable calculator.

Two sets of programs are presented which aid the practicing flight surgeon to quickly assess risk of cardiovascular disease or calculate percent body fat. Risk of cardiovascular disease is easily computed using the Framingham Risk Equation and relating it to the average risk and minimal risk of a patient the same age. A "cardiovascular age" is also computed. Body composition determinations can be done quickly using only circumference measurements and recognized military formulas. Confidence intervals about the estimate and U.S. Air Force maximum allowable weights are computed. For males a maximum weight for health is computed. The programs presented were written for a simple, hand-held calculator. The calculator was selected because it is portable, inexpensive, can be used in a small clinic anywhere in the world, and requires no computer expertise, bringing sophisticated research statistical methods to the everyday clinical practice of aerospace medicine.

Screening for mitral valve prolapse: an analysis of benefits and costs in the U.S. Air Force.

Using the techniques of decision analysis, several possible mitral valve prolapse screening strategies for U.S. Air Force aircrew candidates are evaluated. Available clinical and epidemiological data are organized so that the relative merits of various strategies can be assessed by decision makers. The most efficient strategy is to screen pilot candidates with Quetelet's index (weight in kilograms/height in meters squared) and then eliminate those with an index at or below 15 who have an echocardiogram positive for mitral valve prolapse. The next most efficient strategy is to do echocardiograms on candidates with a heart murmur or click. Screening all candidates with an echocardiogram is much less efficient. Screening fighter pilot candidates only is a very inefficient strategy. Available data do not make a very convincing case for any screening program. Concerned and informed physicians will continue to have honest disagreements about screening for mitral valve prolapse in aircrew members.

Screening for gestational diabetes: an analysis of health benefits and costs.

The current recommendation to screen all pregnant mothers for diabetes at 28 weeks of gestation is examined using known epidemiological evidence in a cost-benefit analysis. The available data indicate that the potential decrease in the perinatal mortality rate would be the most cost-efficient potential health outcome of a gestational diabetes screening policy. A decrease in macrosomia and cesarean sections would be additional potential benefits, but at a cost so great that it is not an important factor in making a decision to screen for gestational diabetes. Since it is unlikely that a study can be done that would ethically demonstrate the effectiveness of universal screening in decreasing the perinatal mortality rate, further research should perhaps focus on decreasing the cost of screening, as the available data do not clearly demonstrate a favorable cost-benefit ratio in universal screening for gestational diabetes.

Spontaneous pneumothorax: an analysis of pleurectomy vs. conservative therapy in United States Air Force fliers.

Spontaneous pneumothorax is infrequently diagnosed in aircrew personnel, but the aeromedical disposition of such cases provokes spirited controversy. Using the technique of decision analysis, epidemiological information is analyzed so that consequences of conservative vs. operative management can be appreciated. Data do not support a dogmatic approach to spontaneous pneumothorax. Flight surgeons will need to continue to make their recommendations on aeromedical disposition considering the patient, flight duties, and operational environment.

Hepatitis B prevention strategies: a benefit-cost analysis of immune serum globulin, hepatitis B immune globulin, and hepatitis B vaccine in the military.

The new hepatitis B vaccine is an effective method of preventing hepatitis B infection. However, its expense could contribute greatly to health care costs, with little marginal benefit if it is used indiscriminately. This study analyzes the relative risk of hepatitis among various health care workers to determine the relative merits of a vaccine strategy. It was found that the average cost of a hepatitis B vaccine in health care facilities is greatly reduced the closer the worker is to a dialysis unit. This might justify not using the vaccine at all in health care workers at facilities without dialysis. Analyzing the marginal cost of immune serum globulin (ISG) versus hepatitis B immune globulin (HBIG) and hepatitis B vaccine in a needle-stick protocol, it was determined that the increased protection provided by HBIG and hepatitis B vaccine comes at a cost that would be considered prohibitive by many prudent decision-makers. A separate analysis of the use of hepatitis B vaccine versus ISG in troops assigned to Korea found that most decision-makers might think the cost of hepatitis B vaccine prohibitive, with the benefits mostly speculative and unproved. Data are not available that would allow a benefit-cost analysis of hepatitis B vaccine in most dental personnel.(ABSTRACT TRUNCATED AT 250 WORDS)

The aerospace screening electroencephalogram: an analysis of benefits and costs in the U.S. Air Force.

Using the techniques of decision analysis, three possible EEG screening strategies for U.S. Air Force pilots are evaluated. Available clinical and epidemiological data are organized so that the relative merits of the three strategies can be assessed by decision makers. The optimal strategy is found to be screening fighter pilot candidates only. Screening all pilot candidates is less "cost-effective" and using the EEG as a routine screening test in evaluating combat-qualified pilots for nonneurological conditions is the least effective strategy. Needs for further research and unanswered questions are discussed.

Follow-up of 14 abnormal electroencephalograms in asymptomatic U.S. Air Force Academy cadets.

The electroencephalogram (EEG) has been used as a screening test for certain military occupations in the past. This is a 10-15 year follow-up study of 14 U.S. Air Force Academy cadets who were classified as having abnormal disqualifying EEGs with spikes or spike-waves and/or focal spikes drawn from 2,947 asymptomatic U.S. Air Force Academy cadets screened from 1965-69. None of these 14 subjects developed a seizure disorder. The military value of the screening EEG is discussed.