Physician perceptions of a national formulary.

OBJECTIVE: To assess the perceptions of US Department of Veterans Affairs (VA) physicians regarding effects of a National Formulary (NF) on patient care, access to drugs, physician workload, and resident training approximately 1 year after it was implemented. STUDY DESIGN: Cross-sectional survey. METHODS: A questionnaire was sent to attending physicians working within the VA healthcare system. Participants included general internists (n = 2824), neurologists (n = 238), psychiatrists (n = 997), general surgeons (n = 429), and urologists (n = 152). The response rate was 45%. RESULTS: Most physicians (63%) thought that they could prescribe needed drugs; 65% agreed that patients could obtain needed nonformulary drugs. One third disagreed that access to prescription pharmaceuticals had increased; 29% stated the NF impinged on providing quality care to their own patients, and 21% thought it did so to patients from other VA facilities. Thirty eight percent of physicians perceived the NF to be more restrictive than private sector formularies; 16% thought that the NF diminished the ability to train residents for managed care. Forty percent thought that the NF added to workload. Generalists more often perceived that the NF improved their ability to provide care compared with neurologists (27% vs 18%, P = .046), psychiatrists (27% vs 22%, P = .027), and internal medicine subspecialists (27% vs 18%, P = .001). Physicians with more clinic time were more likely to perceive that the NF increased workload. CONCLUSION: Although differences of opinions among physicians were noted, most responding VA physicians did not perceive that the NF adversely affected patient care, access to pharmaceuticals, physician workload, or resident training.

Understanding racial variation in the use of coronary revascularization procedures: the role of clinical factors.

BACKGROUND: Black patients undergo coronary artery bypass grafting and percutaneous transluminal coronary angioplasty less often than white patients. It is unclear how racial differences in clinical factors contribute to this variation. METHODS: A retrospective cohort study was performed of 666 male patients (326 blacks and 340 whites), admitted to 1 of 6 Veterans Affairs hospitals from October 1, 1989, to September 30, 1995, with acute myocardial infarction or unstable angina who underwent cardiac catheterization. The primary comparison was whether racial differences in percutaneous transluminal coronary angioplasty and coronary artery bypass grafting rates persisted after stratifying by clinical appropriateness of the procedure, measured by the appropriateness scale developed by the RAND Corporation, Santa Monica, Calif. RESULTS: Whites more often than blacks underwent a revascularization procedure (47% vs 28%). There was substantial variation in black-white odds ratios within different appropriateness categories. Blacks were significantly less likely to undergo percutaneous transluminal coronary angioplasty (odds ratio, 0.30; 95% confidence interval, 0.14-0.63 [P<.01]) when the indication was rated "equivocal." Similarly, blacks were less likely to undergo coronary artery bypass grafting (odds ratio, 0.44; 95% confidence interval, 0.23-0.86 [P<.01]) when only coronary artery bypass grafting was indicated as "appropriate and necessary." Differences in comorbidity or use of cigarettes or alcohol did not explain these variations. Using administrative data from the Veterans Health Administration, we found no differences in 1-year (5.2% vs 7.4%) and 5-year (23.3% vs 26.2%) mortality for blacks vs whites. CONCLUSION: Among patients with acute myocardial infarction or unstable angina, variation in clinical factors using RAND appropriateness criteria for procedures explained some, but not all, racial differences in coronary revascularization use.

Therapeutic substitution of cimetidine for nizatidine was not associated with an increase in healthcare utilization.

OBJECTIVE: To examine changes in healthcare utilization resulting from a formulary switch to cimetidine from nizatidine at the Veterans Affairs Pittsburgh Healthcare System. STUDY DESIGN: A retrospective analysis of administrative and clinical data 6 months before and 6 months after the therapeutic substitution. METHODS: The 704 patients who were switched from nizatidine to cimetidine were included in the study. Administrative data included total and primary care clinic visits, emergency room visits, gastrointestinal (GI)-related radiological studies, and GI endoscopic procedures. Discharge summaries were examined, and rates of total and GI-related hospitalizations were calculated. RESULTS: There was no evidence of increased utilization of healthcare resources during the 6 months after the formulary switch. Estimated monthly pharmaceutical savings for the Veterans Affairs Pittsburgh Healthcare System were $7260. CONCLUSIONS: A formulary switch from nizatidine to cimetidine can be accomplished at significant pharmaceutical cost savings, and this retrospective study suggests that this can be done without increasing other aspects of healthcare resource utilization.

Hepatitis, hyperglycemia, pleural effusion, eosinophilia, hematuria and proteinuria occurring early in clozapine treatment.

This report describes a 48-year-old caucasian male with schizophrenia who developed hepatitis, hyperglycemia, pleural effusion, eosinophilia, hematuria and proteinuria early in clozapine treatment which resolved on drug discontinuation. The literature on similar cases is reviewed.

Do patient preferences contribute to racial differences in cardiovascular procedure use?

OBJECTIVE: To determine whether patient preferences for the use of coronary revascularization procedures differ between white and black Americans. DESIGN: Cross-sectional survey. SETTING: Tertiary care Department of Veterans Affairs hospital. PATIENTS: Outpatients with and without known coronary artery disease were interviewed while awaiting appointments (n = 272). Inpatients awaiting catheterization were approached the day before the scheduled procedure (n = 80). Overall, 118 blacks and 234 whites were included in the study. MEASUREMENTS AND MAIN RESULTS: Patient responses to questions regarding (1) willingness to undergo angioplasty or coronary artery bypass surgery if recommended by their physician and (2) whether they would elect bypass surgery if they were in either of two hypothetical scenarios, one in which bypass surgery would improve symptoms but not survival and one in which it would improve both symptoms and survival. Blacks were less likely to say they would undergo revascularization procedures than whites. However, questions dealing with familiarity with the procedure were much stronger predictors of a positive attitude toward the procedure use. Patients who were not working or over 65 years of age were also less interested in procedure use. In multivariable analysis race was not a significant predictor of attitudes toward revascularization except for angioplasty recommended by their physician. CONCLUSIONS: Racial differences in revascularization rates may be due in part to differences in patient preferences. However, preferences were more closely related to questions assessing various aspects of familiarity with the procedure. Patients of all races may benefit from improved communication regarding proposed revascularization. Further research should address this issue in patients contemplating actual revascularization.

Brain abscess caused by Schizophyllum commune: an emerging basidiomycete pathogen.

Despite the worldwide distribution and prevalence of Schizophyllum commune, an emerging basidiomycetous pathogen, human infections occur only rarely. We describe the first well-documented pulmonary infection caused by S. commune which disseminated to the brain of a 58-year-old patient undergoing empiric corticosteroid therapy. Magnetic resonance imaging scans revealed ring-enhancing masses. Histologic examination of biopsy tissue from lungs and brain showed hyaline, septate, branched hyphae with clamp connections. Cultures of the lung tissue grew S. commune, which produced numerous, characteristic flabelliform and medusoid fruiting bodies on Czapek's agar. The isolate was susceptible to amphotericin B (MIC, < 0.03 microgram/ml) and fluconazole (MIC, 8 micrograms/ml). Despite treatment with antifungal and antibacterial agents, the patient developed progressive pulmonary failure and bacterial sepsis and died.

Racial differences in the use of invasive cardiovascular procedures in the Department of Veterans Affairs medical system.

BACKGROUND: Previous studies have found racial differences in the use of invasive cardiovascular procedures, which may be due in part to the greater financial incentives to perform such procedures in white patients. In Department of Veterans Affairs hospitals, direct financial incentives affecting use of the procedures are minimized for both patients and physicians. METHODS: We conducted a retrospective analysis of the use of cardiovascular procedures among black and white male veterans discharged from Veterans Affairs hospitals with primary diagnoses of cardiovascular disease or chest pain during fiscal years 1987 through 1991. We used coded discharge data to determine whether cardiac catheterization, percutaneous transluminal coronary angioplasty, or coronary artery bypass grafting was performed during or immediately after such admissions. We used logistic-regression analysis to adjust for the primary discharge diagnosis, the presence of coexisting conditions, age, marital status, type of eligibility to receive care at Veterans Affairs hospitals, geographic region, and whether the hospital was equipped to perform bypass surgery. We classified the primary diagnosis as myocardial infarction, unstable angina, angina, chronic ischemia, chest pain, or "other" cardiovascular diagnosis. RESULTS: After we adjusted for all the potential confounders, we found that white veterans were more likely than black veterans to undergo cardiac catheterization (odds ratio, 1.38; 95 percent confidence interval, 1.34 to 1.42), angioplasty (odds ratio, 1.50; 95 percent confidence interval, 1.38 to 1.64), and coronary artery bypass surgery (odds ratio, 2.22; 95 percent confidence interval, 2.09 to 2.36). CONCLUSIONS: Even when financial incentives are absent, whites are more likely than blacks to undergo invasive cardiac procedures. These findings suggest that social or clinical factors affect the use of these procedures in blacks and whites.

Chronic Pneumocystis carinii infection of the liver. A case report and review of the literature.

Pneumocystis carinii infection of the liver is being reported with increasing frequency in patients with acquired immune deficiency syndrome (AIDS). The clinical picture typically resembles hepatitis. We report such an occurrence in a patient with persistent elevation of alkaline phosphatase and gamma-glutamyl transpeptidase with relatively normal transaminases who was found to have P. carinii on antemortem liver biopsy. The differential diagnosis of abnormal alkaline phosphatase and gamma-glutamyl transpeptidase in patients with AIDS should include P. carinii.

Profound papilledema due to cryptococcal meningitis in acquired immunodeficiency syndrome: successful treatment with fluconazole.

Although cryptococcal meningitis is a frequent infection in patients with AIDS, papilledema is rarely reported. We have reported a case of profound papilledema associated with cryptococcal meningitis in a patient with AIDS. After treatment failure with amphotericin B, the patient was successfully treated with fluconazole, and the papilledema resolved.

Pericardial effusion and tamponade due to Kaposi's sarcoma in acquired immunodeficiency syndrome.

We describe a 29-year-old homosexual man with acquired immunodeficiency syndrome who developed pericardial effusion and tamponade. Pericardiocentesis resulted in clinical improvement. All diagnostic tests on pericardial fluid were negative. At autopsy, extensive plaques and nodules of Kaposi's sarcoma were found studding the epicardium, and no other cause of effusion was found. To our knowledge there has been no previous case of Kaposi's sarcoma associated with pericardial effusion and tamponade reported in patients with AIDS. Kaposi's sarcoma should be considered in the differential diagnosis of pericardial effusion in these patients.

Cartilage metabolism during growth retardation following irradiation of the head of the neonatal rat.

The heads of 2-day-old male and female rats were irradiated with a single dose of 600 rads X irradiation, a dose which is known to stunt body weight, tibial length, and tail length, in order to ascertain its effects on synthesis by cartilage of sulfated proteoglycans, DNA, chondroprotein, and collagen as determined by utilization of [35S]sulfate, [Me-3H]thymidine, [1-14C]leucine, and [3,4-3H]proline, respectively. Data have been collected at 20-21, 23, 41-45, and 70-71 days of age. In comparison to controls, growth in body weight, tibial length, and tail length was significantly retarded in irradiated rats of both sexes. Although slow catch-up growth was observed with respect to tail length in both sexes and tibial length in females, a significant deficit in body weight in irradiated rats in both sexes remained at 70-71 days. Cartilage metabolism as evidenced by incorporation of the labeled substances showed no significant disturbance just prior to weaning (20-21 days) or after completion of the principal growth surge (70-71 days). Reduced sulfate and thymidine incorporation attributable to a brief period of undernutrition associated with weaning occurred in head-irradiated rats immediately following weaning (23 days). Increased isotope incorporation occurred at 41-45 days of age in cartilage of irradiated rats incubated with labeled sulfate, leucine, and proline; it did not increase with labeled thymidine. We conclude that neonatal head irradiation slows the rate of growth through the age of most rapid postnatal growth in normal rats. The pattern of cartilage metabolism during this time can be the result either of stimulation by a factor other than somatomedin, or selective inhibition of cartilage thymidine incorporation acting in combination with somatomedin.