Improving medical care for West Virginia seniors.

Using data published by the Health Care Financing Administration (HCFA), supplemented with information obtained from West Virginia Medicare claims data and Medicare hospital records, we compared the performance of West Virginia physicians and hospitals on 22 quality of care indicators for six common conditions. The conditions are myocardial infarction, congestive heart failure, atrial fibrillation, stroke, breast cancer screening and pneumonia. Quality indicator performance for most indicators in West Virginia from 1997-98 was lower than the average of the 19 states with data collected at the same time. For some indicators, such as early use of beta blockers following myocardial infarction (52.7%), administration of influenza vaccine (58.2%), and warfarin prescription to atrial fibrillation patients (45.1%), the state's care ranked near the bottom. However, quality scores varied widely among West Virginia health care providers, suggesting that statewide improvement in care is feasible. Ongoing efforts among physicians, hospitals and the peer review organization are aimed at achieving such improvement.

Influenza immunization and mortality among diabetic Medicare beneficiaries in West Virginia.

This study estimated the increased risk of death among Medicare beneficiaries with diabetes in West Virginia who do not receive influenza beneficiaries with diabetes. Medicare beneficiaries with diabetes who did not have claims for influenza vaccination had approximately a 1.7-fold risk of death during a subsequent influenza season, compared with those with a vaccination. This risk was observed in all age and sex subgroups, and was changed very little by adjustment for comorbidity. The adjusted odds ratio for death in the vaccinated group (compared with the unvaccinated group) during the 1996-97 influenza season was 0.639 (95% confidence interval 0.565-0.722); in 1997-98 it was 0.601 (95% confidence interval 0.527-0.687). West Virginia Medicare beneficiaries with diabetes are at a significantly increased risk of death during an influenza season if they do not have prior claims for influenza vaccination.

A ten-year review of the validity and clinical utility of depression screening.

OBJECTIVE: Use of depression screening instruments in primary care is controversial. The authors reviewed research studies published since the development of national practice guidelines to determine whether new evidence might favor screening. The review focused on evidence-related validity and clinical utility of depression screening instruments. METHODS: Silver Platter MEDLINE was searched for English-language studies of depression screening instruments published between 1986 and 1995. Studies were classified by type--reviews of studies, outcome studies, validation studies. RESULTS AND CONCLUSIONS: Fifty-nine studies met criteria for review. Validation studies were the most frequent type (39 studies) and were subclassified according to population, type of comparison, and analytical method. These studies documented the validity of screening instruments compared with formal criteria and demonstrated consistently better performance for systematic approaches compared with clinical impressions. Thirteen studies were reviews; those reviewing evidence for effectiveness disagreed in their conclusions. Only seven outcome studies related to depression screening instruments were found, and none showed measurable benefit in a screened population. Several studies showed that very brief instruments performed about as well as longer, well-validated questionnaires for screening in general populations.

A preliminary comparison between local public health units in the Canadian Province of Ontario and in the United States.

This comparison between public health departments in the United States and in the Canadian Province of Ontario addresses the funding and staffing and the size and program content of local health departments after Canada's national health reform provided universal access to personal health services. Ontario's local health departments are required to provide a uniform set of public health services. In the United States, there is substantial variation among jurisdictions in kinds and amounts of services delivered. Ontario health units have staff sizes and budget levels that increase in proportion to population served, like those in the United States. But in Ontario, per capita expenditures increase with decreasing population, while the reverse is true in the United States. This anomaly may be attributed to lack of critical staff or elimination of key programs in small U.S. departments. Medical care of indigents probably accounts for the increased per capita costs seen in very large U.S. health departments. An estimated price for uniform public health services meeting the Ontario requirements in all U.S. jurisdictions as they were organized in 1989 is $5.8 billion per annum (not adjusted for inflation). If smaller health departments were consolidated, a savings of more than $1 billion could be realized. Even with this reorganization, average expenditures in smaller U.S. health departments would need to be doubled, and staff sizes increased by about 50 percent to meet Ontario's uniform public health program standards.

Continuing outbreak of hepatitis A linked with intravenous drug abuse in Multnomah County.

A communitywide outbreak of hepatitis A occurred in Portland, OR, from 1983 through 1986. At the peak of the outbreak, the age- and sex-specific annual incidence rate approached 400 cases per 100,000 population among men ages 25 to 34, the highest risk group. The community incidence rate was nearly 10 times the relevant national incidence rate. A review of the records concerning cases of hepatitis A reported in the last 6 months of 1985 revealed that about half the number of young adults whose cases were investigated during that time reported a history of intravenous (IV) drug use--a proportion about 50 times greater than expected among persons in that age range. A simultaneous epidemic of overdose deaths from heroin and a concomitant increase in hepatitis B incidence rates led to the suspicion that this was a drug-abuse-associated epidemic of hepatitis among new IV drug users. Control of this outbreak was difficult because the population most at risk was distrustful of public health officials. Increased surveillance in food service establishments and schools might have prevented outbreaks from a common source in the general population; however, an increase of sporadic cases in the nondrug-using population clearly occurred.