The quality improvement-research divide and the need for external oversight.

Historically, quality assurance studies have received scant ethical attention. The advent of information systems capable of supporting research-grade continuous quality improvement projects demands that we clearly define how these projects differ from research and when they require external review. The ethical obligation for the performance of quality assurance projects, with its emphasis on identifiable immediate action for a served population, is a critical distinction. The obligation to perform continuous quality improvement is a deliverable of the social contract entered into implicitly by patients and health care providers and systems. In this article, the authors review the ethical framework that requires these studies, evaluate the differences between quality assurance studies and classic research, and propose criteria for requiring external review.

The pharmacoeconomic impact of antimicrobial therapy for peptic ulcer disease in a large urban jail.

PURPOSE: To determine the pharmacoeconomic impact of antimicrobial treatment of peptic ulcer disease (PUD) in a large urban jail. PATIENTS AND METHODS: Retrospective comparison of PUD-related pharmacy and laboratory expenditures over a 2-year period before and after the institution of a PUD treatment protocol with the priority of Helicobacter pylori eradication for inmates in Rikers Island Correctional Facility. RESULTS: After the protocol was adopted, total pharmacy-related and laboratory-related expenses for PUD care decreased by 40.2%, and expenditures for ranitidine declined by 52.2%. There was an increase in spending for antimicrobial agents and H. pylori antibody testing, but this was insignificant compared to the savings generated by decreased ranitidine usage. Annual savings in our facility as a result of this intervention were $123,449. CONCLUSIONS: Modern therapeutic strategies for PUD aimed at eradicating H. pylori can result in significant savings in the institutional setting; these savings are largely attributable to the decreased usage of histamine-2 receptor antagonists.

Rates of and risk factors for trichomoniasis among pregnant inmates in New York City.

BACKGROUND: Trichomonas vaginalis is a common pathogen that is associated with adverse pregnancy outcomes and may serve as a cofactor in human immunodeficiency virus (HIV) transmission. GOAL: To define the epidemiology of trichomoniasis in a population of newly incarcerated pregnant women in New York City. STUDY DESIGN: Prospective study of 213 pregnant prisoners attending prenatal clinic. Patients participated in an interview regarding sexual and drug-related behaviors, and underwent direct culture for T. vaginalis in addition to routine testing for syphilis, gonorrhea, and chlamydia. RESULTS: The prevalence of trichomoniasis was 46.9%. On univariate analysis, there was a significant association between trichomoniasis and older age, crack use, prostitution, known HIV infection, and positive serological test for syphilis. Multivariate analysis showed a significant association of trichomoniasis with crack use and positive serological test for syphilis. CONCLUSION: Trichomoniasis is highly prevalent in pregnant prisoners in New York City. The extent of disease observed may justify a formal program of testing and treatment and emphasizes the urgent need for harm reduction education and expanded HIV counseling and testing services in this high-risk population.

Human immunodeficiency virus infection care is unavailable to inmates on release from jail.

BACKGROUND: The human immunodeficiency virus (HIV) seroprevalence in urban jails is higher than that in the general community. METHODS: We interviewed a cohort of HIV-infected inmates in a jail in New York, NY, during incarceration and after release to assess the accessibility of medical and social services. RESULTS Of the 170 inmates who were interviewed and released into the community, 40 (24%) came to a follow-up interview. Of the 40, 25 (62%) had not received an appointment with an infectious disease clinic by the time of the new interview. Only eight (27%) of the 32 who received zidovudine in jail obtained zidovudine; and only one of the 13 who received isoniazid prophylaxis in jail obtained isoniazid prophylaxis. Twenty (65%) had applied for but not yet received Medicaid. CONCLUSION: Inmates infected with HIV may encounter difficulties obtaining medical care and social services on release into the community, which can potentially lead to active infectious tuberculosis. Family physicians may encounter HIV-positive patients who are newly released from jail and who need follow-up medical care, and they must help address the needs of HIV-positive, formerly incarcerated people.

Anergy compromises screening for tuberculosis in high-risk populations.

Anergy may occur in groups at high risk for tuberculosis, compromising tuberculin skin testing. Within New York City's correctional system, anergy prevalence was 25% among opiate users referred to detoxification programs and 3% in the general population. Correlates of anergy were recent weight loss and needle sharing. The high prevalence of anergy among opiate users compromises the utility of tuberculosis screening and suggests the need for routine chest x-rays to detect pulmonary tuberculosis in some high-risk-populations.

Abnormal chest x-rays in intravenous drug users: implications for tuberculosis screening programs.

OBJECTIVES: The purpose of the study was to (1) determine the prevalence of significant abnormalities in routine chest x-rays used to screen for pulmonary tuberculosis in intravenous drug users and (2) evaluate the ability of the purified protein derivative skin test to identify persons with such abnormalities. METHODS: We conducted a cross-sectional screening study on 1314 persons admitted to an opiate detoxification unit in an urban jail. Purified protein derivative tuberculin reactivity and the prevalence of abnormalities consistent with tuberculosis on screening chest x-rays were evaluated. The chest x-ray was obtained independent of the skin test. RESULTS: The chest x-rays of 73 of the inmates (5.6%) showed abnormalities consistent with tuberculosis. Tuberculin skin testing missed 17 of 26 chest x-rays (65%) with significant infiltrates. CONCLUSIONS: Purified protein derivative screening is insensitive to chest x-ray abnormalities that require additional diagnostic evaluation for tuberculosis. Routine chest studies should be performed on all intravenous drug users admitted to congregate housing settings.

Association of tuberculosis infection with increased time in or admission to the New York City jail system.

OBJECTIVE: To establish the association between time spent in jail or number of jail admissions and development of tuberculosis in a cohort of inmates incarcerated without evidence of tuberculosis infection on entry. DESIGN: Nested case-control design within a prospective cohort. A cohort of 2636 tuberculin skin test-negative inmates incarcerated in 1985 was matched against the Tuberculosis Registry of New York City. Each case of tuberculosis reported prior to May 15, 1992, was assigned to three randomly selected controls from the cohort. We determined time spent in jail by reviewing the computer records of the New York City Inmate Information System. Conditional logistic regression modeling was performed to establish the association of jail time with the development of tuberculosis. SETTING: New York City Jail. RESULTS: Sixty inmates developed tuberculosis by May 15, 1992. Eighty-five percent of these had pulmonary tuberculosis. Univariate analysis identified the number of jail admissions (P = .02), age greater than or equal to 30 years (P = .001), and assignment to a methadone detoxification unit (P = .001) as significant in predicting tuberculosis. Multivariate modeling identified these same variables and jail time as significant. One year of jail time increased the odds of tuberculosis to 2.2 (95% confidence interval, 1.1 to 4.4). CONCLUSION: The demonstrated association between jail time or jail admissions and development of tuberculosis suggests that the New York City jail system may be an important amplification point in the ongoing tuberculosis epidemic, deserving significant public health attention.

Role of candida in pathogenesis of antibiotic-associated diarrhoea in elderly inpatients.

The part that candida plays in antibiotic-associated diarrhoea was investigated in 24 elderly inpatients (mean age 74 years) who tested negative for Clostridium difficile toxin and other intestinal pathogens. 7 had intestinal overgrowth of Candida species (greater than or equal to 10(5) cfu/ml). None of the 24 matched, antibiotic-treated controls without diarrhoea had candida overgrowth. All 5 patients with diarrhoea and candida overgrowth treated with oral nystatin responded with resolution of diarrhoea and lowering of faecal counts to less than 10(4) cfu/ml within 7 days of start of antifungal therapy despite continuation of antibacterial therapy. In the other 2 patients with candida overgrowth, the diarrhoea subsided spontaneously and faecal candida counts returned to normal (less than 10(4) cfu/ml) after antibacterial agents were withdrawn. In patients without candida overgrowth, diarrhoea persisted until antibiotics were withdrawn, at a mean of 16 days after study entry.