Physician use of information technology in ambulatory medicine: an overview.

Physicians practicing ambulatory medicine have never had more opportunities to use information technology to help them in their everyday practice. In parallel, evolving health care industry dynamics are increasing the need for clinical computer applications, which help improve the quality, efficiency, and the cost-effectiveness of patient care. This article examines: (1) the information needs of practicing physicians, (2) current and emerging technologies that can improve clinical decision making at the point of care, and (3) the impact of these technologies on clinical quality, medical costs, and physician practice efficiency. The article uses patient case scenarios to illustrate the emerging role of information technology in patient care.

Cost-effectiveness of misoprostol for prophylaxis against nonsteroidal anti-inflammatory drug-induced gastrointestinal tract bleeding.

Patients who take nonsteroidal anti-inflammatory drugs (NSAIDs) are at increased risk of upper gastrointestinal tract bleeding, which may be prevented with prophylactic prescription of misoprostol. Using data from the literature, we estimated rates of gastrointestinal tract bleeding in NSAID users, direct medical costs, years of life lost, and cost-effectiveness of a 1-year course of misoprostol in three clinical populations of NSAID users: all users, users aged 60 years or older, and users with rheumatoid arthritis. The incremental cost-effectiveness ratios for misoprostol as primary prevention were $667,400 per year of life saved for all NSAID users; $186,700 per year of life saved for users aged 60 years or older; and $95,600 per year of life saved for users with rheumatoid arthritis. Misoprostol as secondary prevention for those who continued to take NSAIDs despite having had an episode of gastrointestinal tract bleeding in the previous year was associated with incremental cost-effectiveness ratios less than $40,000 per year of life saved in all patient groups. We conclude that misoprostol is costly as primary prevention for NSAID-induced gastrointestinal tract bleeding in the groups examined but may be cost-effective as secondary prevention in patients with a proved history of gastrointestinal tract bleeding.

Long-term cost-effectiveness of various initial monotherapies for mild to moderate hypertension.

To evaluate the comparative efficacy and cost-effectiveness of various antihypertensive medications in persons aged 35 through 64 years with diastolic blood pressure of 95 mm Hg or greater and no known coronary heart disease, we used the Coronary Heart Disease Policy Model, which is a computer simulation of overall mortality as well as the mortality, morbidity, and cost of coronary heart disease in the US population. From the pooled literature, we estimated the antihypertensive and total cholesterol effects of various antihypertensive regimens. For 20 years of simulated therapy from 1990 through 2010, the cost per year of life saved was projected to be $10,900 for propranolol hydrochloride; $16,400 for hydrochlorothiazide; $31,600 for nifedipine; $61,900 for prazosin hydrochloride; and $72,100 for captopril. Doubling the cholesterol effects of the agents under study did not significantly change their effectiveness because, in general, lowering diastolic blood pressure by 1 mm Hg was equivalent to lowering the cholesterol level by 6%. Although any projection requires multiple estimates, each of which may be open to debate, propranolol appears to be the preferred initial option under most of a variety of alternative assumptions.

Calcium-channel blockers and the hepatorenal syndrome.

It is suggested that calcium-channel blockers may be the agents of choice for treating the renal dysfunction associated with the hepatorenal syndrome because these agents may be effective in reversing the episodic renal vasospasm which characterizes this disorder.

The effect of the cold pressor test on vasopressin secretion in man.

Stress has been thought to induce the release of arginine vasopressin (AVP). We evaluated this claim by studying the effects of a modified cold pressor test on plasma AVP, plasma cortisol, blood pressure, pulse rate, and a number of variables known to affect AVP secretion. In a cross-over study design, test and control values were obtained in seven male subjects. The pressor test was found to induce painful stress as evidenced by subjective reports and the objective findings of increased mean arterial pressure (13.9 +/- 3.1 mm Hg; p less than 0.004), pulse rate (9.2 +/- 2.8 beats/min; p less than 0.02), and plasma cortisol (3.5 +/- 0.8 micrograms/dl; p less than 0.005). In contrast, there were no significant changes in plasma AVP that could be attributed to the cold pressor test. There also were no changes in plasma osmolality, measured plasma solutes, hematocrit or body temperature. An unexpected finding was a premonitory drop in plasma AVP occurring just prior to the pressor test (2.5 +/- 2.0 pg/ml; p less than 0.04) and at the comparable time point in the control study (3.1 +/- 1.2 pg/ml; p less than 0.001). There were no changes in any of the other measured variables which could account for this drop. We conclude that the cold pressor test is not a stimulus to AVP release and that anticipation of stress may inhibit secretion of this hormone.