A new paradigm for alcohol use in older persons.

BACKGROUND: Current paradigms for conceptualizing alcohol-related problems typically focus on persons who are abusing or dependent on alcohol. These paradigms may not apply to older drinkers whose alcohol use, regardless of consumption-level, can cause problems because of age-related changes in physiology and interactions with increased morbidity, medication use, and functional limitations. OBJECTIVE: We convened an expert panel# to develop clinical indications of harmful, hazardous, and nonhazardous drinking in persons 65 years of age and older. RESEARCH DESIGN AND SUBJECTS: Nine panelists with expertise in psychiatry, geriatrics, internal medicine, and alcohol research were provided with epidemiological data and a published explicit literature review of alcohol use in the elderly. The RAND/UCLA two-round panel method was used to develop the indications. After the second round, the authors wrote a draft statement that was circulated to the panelists whose comments were incorporated into a final document. RESULTS: Panelists agreed on 215 scenarios in which older peoples' use of alcohol either alone or in the presence of chronic medical conditions, medication use, symptoms, smoking, and functional limitations are hazardous or harmful. Panelists' ratings of risk did not differ significantly between persons aged 65 to 74 years and those aged 75 years and older. CONCLUSION: Alcohol use may be hazardous or harmful for older persons, particularly in conjunction with physical or emotional illnesses, medication use, functional limitations, smoking, and driving after drinking. When asking about alcohol use in older persons, clinicians need to be aware of these factors to assist in identifying and managing potential or actual alcohol-related problems.

Use of chiropractic services from 1985 through 1991 in the United States and Canada.

OBJECTIVES: The purpose of this paper is to describe the demographic and clinical characteristics of chiropractic patients and to document chiropractic visit rates in 6 sites in the United States and Canada. METHODS: Random samples of chiropractors from 5 US sites and 1 Canadian site were selected. A record abstraction system was developed to obtain demographic and clinical data from office charts. RESULTS: Of the 185 eligible chiropractors sampled, 131 (71%) participated. Sixty-eight percent of the selected charts showed that care was sought for low back pain, while 32% recorded care for other reasons. Spinal manipulative therapy was recorded in 83% of all charts. There was a greater than 2-fold difference in the median number of visits related to low back pain per episode of care across sites. The chiropractic visit rates in the US sites and Ontario are estimated to be 101.2 and 140.9 visits per 100 person-years, respectively. CONCLUSIONS: The chiropractic use rate in these sites is twice that of estimates made 15 years ago. The great majority of patients receive care for musculoskeletal conditions of the back and neck. The number of visits per episode varies appreciably by site.

Comparison of a generic to disease-targeted health-related quality-of-life measures for multiple sclerosis.

Evaluation of the relative contributions of generic and disease-targeted measures to assessing health-related quality of life (HRQOL) for chronic conditions is needed to help in selection of appropriate measures. We administered a generic HRQOL measure (the Short Form-36 [SF-36]), three disease-targeted supplemental scales to the SF-36, and two disease-targeted HRQOL instruments to 171 adults with multiple sclerosis. Most scales yielded adequate variability, internal consistency reliability, and test-retest reliability. The relationship between each measure and four primary "criterion" variables were assessed: overall symptom severity in the prior year; ambulation status; days unable to work or attend school in the prior month: and a rating of overall quality of life. Results indicate that the disease-targeted scales provided unique information not captured by the generic measure. We conclude that if a generic measure of HRQOL is desirable for a given study of multiple sclerosis, additional information will be gained by supplementing that measure with selected scales.

Obtaining clinical data on the appropriateness of medical care in community practice.

We sought the voluntary cooperation of a randomly selected sample of community physicians and hospitals in five states for a study of how appropriately they performed coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy. Ninety percent of 913 sampled physicians (n = 819) consented to a review of up to 20 of their 1981 Medicare patients' records. These physicians represented seven different specialties and subspecialties and performed 4988 procedures, 92% of the desired sample. Only three of 230 hospitals did not participate. We attribute our method's success primarily to the formation of a network to connect the branches of the profession, respect for office and hospital practice routine, confidentiality, and the development of carefully designed medical record abstraction systems. We conclude that, with effort, cooperative research among disparate segments of the medical community can become a reality even if the topic studied is relatively sensitive.