Racial and gender variation in use of diagnostic colonic procedures in the Michigan Medicare population.

BACKGROUND: There is accumulating evidence that screening programs can alter the natural history of colorectal cancer, a significant cause of mortality and morbidity in the US. Understanding how the technology to diagnose colonic diseases is utilized in the population provides insight into both the access and processes of care. METHOD: Using Medicare Part B billing files from the state of Michigan from 1986 to 1989 we identified all procedures used to diagnose colorectal disease. We utilized the Medicare Beneficiary File and the Area Resource File to identify beneficiary-specific and community-sociodemographic characteristics. The beneficiary and sociodemographic characteristics were, then, used in multiple regression analyses to identify their association with procedure utilization. RESULTS: Sigmoidoscopic use declined dramatically with the increasing age cohorts of Medicare beneficiaries. Urban areas and communities with higher education levels had more sigmoidoscopic use. Among procedures used to examine the entire colon, isolated barium enema was used more frequently in African Americans, the elderly, and females. The combination of barium enema and sigmoidoscopy was used more frequently among females and the newest technology, colonoscopy, was used most frequently among White males. CONCLUSION: The existence of race, gender, and socioeconomic disparities in the use of colorectal technologies in a group of patients with near-universal insurance coverage demonstrates the necessity of understanding the reason(s) for these observed differences to improve access to appropriate technologies to all segments in our society.

The epidemiology of co-occurring addictive and mental disorders: implications for prevention and service utilization.

General population data from the National Comorbidity Survey are presented on co-occurring DSM-III-R addictive and mental disorders. Co-occurrence is highly prevalent in the general population and usually due to the association of a primary mental disorder with a secondary addictive disorder. It is associated with a significantly increased probability of treatment, although the finding that fewer than half of cases with 12-month co-occurrence received any treatment in the year prior to interview suggests the need for greater outreach efforts.

Sleep apnea and panic attacks.

A survey of 301 sleep apnea patients demonstrated that obstructive sleep apnea may cause nocturnal panic attack symptoms. Sleep apnea should be considered in the differential diagnosis of nocturnal panic disorder.

The use of physical restraint in patients with cerebral contusion.

Behavioral problems resulting in the use of physical restraint is a clinical problem seen in the acute phase of recovery from cerebral contusion. However, little is known about the frequency of physical restraint, factors that might predispose to its use, the pattern of adjunctive psychotropic drugs used or the outcome for patients needing this form of management. In order to examine these issues, a retrospective study of all patients (N = 34) admitted with cerebral contusion to a neurosurgical service over a one-year period was undertaken. Physical restraint was used in twelve patients (35%) for an average length of 4.3 days. The use of physical restraint was associated with presumptive evidence of alcohol abuse or dependence but not with level of consciousness on admission. Restrained patients were frequently prescribed psychotropic drugs during hospitalization. Patients requiring physical restraint stayed in hospital nearly twice as long as those not needing restraint. Close attention to the identification and treatment of alcohol problems and their complications in this population may reduce the need for physical restraint and shorten length of hospital stay.

Accidents among schizophrenic outpatients.

A preliminary comparison of traffic, home, and work accident incidence was performed among 103 outpatient schizophrenic patients and an age matched sample of 123 controls. The number of motor vehicle drivers among schizophrenic outpatients was far less than among controls (70 of 103 versus 122 of 123; P = .00001). Among those who did drive, schizophrenic patients drove far less than controls (19 of 70 patients driving greater than or equal to 5,000 miles per year versus 81 of 122 controls; P = .0001). Patients also reported more accidents per miles driven than did controls, consistent with previous studies. Older patients reported more home accidents than did younger patients (five of eight for those over 55 years versus four of 95 for those less than 55; P = .0007); no similar effect was observed among controls. Schizophrenic outpatients may be at greater risk of motor vehicle accidents per miles driven than age matched controls; elderly patients may be at higher risk of home accidents as well.

Social phobia secondary to pathological sweating.

An individual with agenesis of the corpus callosum associated with recurrent severe sweating and hypothermia developed a social phobia. Phobias may be adaptations to real and potentially dangerous physiological events.

Continuing in treatment as a form of selection bias.

Panic patients who continued treatment (N = 12) did not have symptom scores significantly different from those of patients who declined or discontinued treatment (N = 12) but they did have lower pretreatment MHPG levels. Continuing in treatment may itself cause selection bias for biochemical variables under study.

Low MHPG and continuing treatment in panic disorder.

1. The paper presents a naturalistic study of 3-Methoxy-4-hydroxyphenylglycol and treatment response in panic disorder. 2. Twenty-eight patients unmedicated for at least one month were entered in a study of MHPG in panic disorder, and given the option of continuing or not continuing treatment. 3. At baseline and on average follow-up 6.8 months later, patients continuing in treatment had significantly lower MHPG than those who did not. 4. At baseline, the two groups of patients did not differ significantly as to number of panic attacks, Zung anxiety scale, and Beck and Hamilton Depression scales. 5. Treated patients did better on all clinical measures at follow-up. 6. Low MHPG may be related to persistence in seeking treatment for panic disorder, and perhaps to treatment response.

Patients with panic attacks and abnormal EEG results.

The authors describe a series of patients who presented with atypical panic attacks involving hostility, irritability, severe derealization, and social withdrawal. None had clear temporal lobe epilepsy but most had temporal EEG abnormalities. Although their response to treatment was unpredictable, some did well with carbamazepine or alprazolam.

Informed consent as a form of volunteer bias.

Two nontreatment studies of tardive dyskinesia were examined to see if giving or refusing informed consent might bias results. Three prominent psychiatric journals were also reviewed to determine whether the outcome of informed consent procedures was sufficiently well described to permit evaluation of potential bias. The nontreatment studies suggested that the bias created by requiring informed consent may cause both false-positive and false-negative findings. The literature review showed that treatment studies have generally ignored the potential impact of these biases on results. Accurate interpretation of research reports, particularly clinical trials, demands that more attention be given to the process of obtaining and reporting informed consent.

Beta, or type II error in psychiatric controlled clinical trials.

Fifty-two reportedly "negative" psychiatric controlled clinical trials from 1980-1984 were re-examined to note if large enough samples had been studied to give a high probability (greater than 0.90) of detecting a 20% or 50% improvement in therapeutic response, defined as a reduction in the non-response rate. Forty-four of the trials had a larger than 10% risk of missing a true 20% difference in non-response rates, and with the same risk, 25 of the trials could have missed a 50% difference between treatments. Based on estimates of 90% confidence intervals, a potential 20% difference was possible for 47, and 30 had a potential true difference of 50% in non-response rates between experimental and control conditions. Far more reports describing "non-significant" studies could not be re-examined, due to lack of reporting part or all of the relevant results. The possibility of missing considerable therapeutic improvement, or important clinical differences, because of small sample size demands more concern in psychiatry.