Depressive symptoms, satisfaction with health care, and 2-year work outcomes in an employed population.

OBJECTIVE: The relationship of depressive symptoms, satisfaction with health care, and 2-year work outcomes was examined in a national cohort of employees. METHOD: A total of 6,239 employees of three corporations completed surveys on health and satisfaction with health care in 1993 and 1995. This study used bivariate and multivariate analyses to examine the relationships of depressive symptoms (a score below 43 on the Medical Outcomes Study Short-Form Health Survey mental component summary), satisfaction with a variety of dimensions of health care in 1993, and work outcomes (sick days and decreased effectiveness in the workplace) in 1995. RESULTS: The odds of missed work due to health problems in 1995 were twice as high for employees with depressive symptoms in both 1993 and 1995 as for those without depressive symptoms in either year. The odds of decreased effectiveness at work in 1995 was seven times as high. Among individuals with depressive symptoms in 1993, a report of one or more problems with clinical care in 1993 predicted a 34% increase in the odds of persistent depressive symptoms and a 66% increased odds of decreased effectiveness at work in 1995. There was a weaker association between problems with plan administration and outcomes. CONCLUSIONS: Depressive disorders in the workplace persist over time and have a major effect on work performance, most notably on "presenteeism," or reduced effectiveness in the workplace. The study's findings suggest a potentially important link between consumers' perceptions of clinical care and work outcomes in this population.

Thin < or = 1 mm level III and IV melanomas are higher risk lesions for regional failure and warrant sentinel lymph node biopsy.

BACKGROUND: Thin melanomas have become increasingly prevalent, and lesions 1 mm or less in thickness are frequently diagnosed. They are considered highly curable when treated with wide local excision alone with reported 5-year disease free survivals of 95% to 98%. However, thin Clark level III and IV melanomas may have an increased potential for metastasizing and late recurrence because of dermal lymphatics located at the interface of the papillary and reticular dermis. We have addressed this controversial area by reviewing the outcomes of patients with invasive thin (< or = 1.0 mm thick) melanomas. METHODS: We reviewed 415 invasive melanomas from 1983-1995 in the Rhode Island tumor registries which kept records of both tumor thickness and Clark levels. Sixty-eight (16.4%) of the 415 invasive melanomas were thin (< or = 1.0 mm in thickness) and were treated by wide local excision only. In situ lesions were excluded. Thirty-eight (56%) of the 68 thin melanomas were either Clark level III or IV. RESULTS: Seven (18.4%) of the 38 level III and IV thin melanomas had a recurrence at a minimum follow-up of 36 months. Median time to recurrence was 52 months, and the average measured depth of tumor thickness was 0.84 mm. Only one (3.3%) of 30 level II melanomas recurred (P < .05). CONCLUSIONS: Thin level III and IV melanomas are at increased risk for late recurrence when compared with all thin melanomas. Because there is effective adjuvant therapy with alpha interferon for patients with stage III melanoma to treat regional and systemic disease, and because sentinel lymph node biopsy (SLNB) offers minimal morbidity, we suggest using SLNB to accurately stage and treat all patients with thin melanoma that are high Clark levels that are at increased risk for metastases.

Physical health, depressive symptoms, and managed care enrollment.

OBJECTIVE: This study used a national employee survey to test the hypothesis that symptomatic individuals in general, and individuals with depressive symptoms in particular, are disproportionately enrolled in fee-for-service health care plans as compared to health maintenance organizations (HMOs). METHOD: The study analyzed data from the 1993 Employee Health Care Value Survey, a questionnaire distributed to employees of three large corporations. The sample comprised 20,283 employees covering six U.S. geographic regions and 46 health plans. The authors used logistic regression to model the association between HMO enrollment and presence of physical and depressive symptoms, measured by subscales derived from the Medical Outcomes Study 36-item Short-Form Health Survey, adjusting for health, demographic, and insurance variables. RESULTS: In unadjusted models, enrollees in fee-for-service plans had higher rates of both depressive and physical symptoms than HMO enrollees. After adjustment for age alone or for age and other potential confounders, there was no difference in physical symptoms between plan types. However, individuals with high levels of depressive symptoms were 16% less likely to be enrolled in HMOs than in fee-for-service plans after adjustment for age, other demographic variables, physical health status, and insurance characteristics. CONCLUSIONS: This study provides evidence that symptomatic individuals are more likely to be enrolled in fee-for-service plans than in HMOs. While much of the effect for physical symptoms may be explained by differences in demographic variables, particularly age, the difference in depressive symptoms appears to be independent of those variables.

Consumer surveys of health plan performance: a comparison of content and approach and a look to the future.

BACKGROUND: Escalating demand in the market-place for consumer-supplied data on health plan performance has led to a growing number of competing survey instruments. Many of them offer distinct perspectives on what concepts should be measured and how they should be measured. The principal user groups of this information-purchasers, consumers, and health plans-face an increasingly complex decision when choosing between instruments. DIALECTIC OF SURVEY DEVELOPMENT: Many of the differences between surveys arise because the three user groups apply survey results for different purposes. At the same time, a standardized instrument would provide the three user groups more information and context. A dialectic process between these two dynamics is guiding the exchange between survey developers and users and is resulting in slow if somewhat unsteady progress toward consensus on common core content across user groups. SIX CONSUMER SURVEYS: This article seeks to promote public debate on the content and approach of consumer surveys of plan performance, a task that is separate from comparative empirical testing. Six instruments are described-the Consumer Satisfaction Survey, Employee Health Care Value Survey, Health Plan Value Check, Adult Health Care Survey, Annual Member Health Care Survey-Version 1.0, and the Consumer Health Plan Value Survey. To help differentiate the instruments, several common methodologic choice points faced by each (for example, use of "not applicable" as an option) are highlighted. The alternative approaches taken by the instruments to address these choice points are discussed in terms of the arguments for and against their use. ANTICIPATING THE FUTURE: Although it is too early to predict which survey measures or approaches will figure most heavily in the eventual core instrument, it is not too early to anticipate that the critical decisions will be made on both academic (for example, psychometric and cognitive testing) and marketplace criteria. Increasingly influential will be collective user prerequisites emerging out of the interplay of the three user groups in the marketplace. Six key collective prerequisites (for example, defining common ground between the user groups) are identified, and their likely impact on the development of consumer surveys of health plan performance are described.

Toward the intelligent use of health care consumer surveys.

Consumer surveys are at a pivotal moment in health care. With demand for consumer-supplied data escalating in every sector of the industry, current opportunities for consumer surveys to demonstrate unique value in the marketplace are unparalleled. These opportunities, however, carry considerable risks, particularly with respect to performance report cards for competing health plans and providers. As investigators multiply in an area notably lacking in standardization, the chances increase that surveys will arrive at conflicting assessments of plans and providers. To resolve these inconsistencies, users will need to sharpen their understanding of the role of consumer surveys, the business and operational needs they can address, and how their results can be affected by methodology. This article discusses each of these issues with an eye toward promoting intelligent use of consumer surveys in the health care marketplace.

Maternal and fetal brain and plasma levels of cocaine and benzoylecgonine after acute or chronic maternal intravenous administration of cocaine.

The effect of repeated i.v. administration of cocaine HCl (1.5, 3 or 6 mg/kg daily) from gestational day 8 through gestational day 18 was studied on maternal and litter parameters in the pregnant female Sprague-Dawley rat. These doses of cocaine had no significant effect on maternal weight gain or nutritional intake and did not significantly affect litter size. Levels of cocaine and its metabolite benzoylecgonine in the brain and plasma of the dams and their fetuses were measured on gestational day 18 at 1, 5, 20 or 60 min after a single injection or 11 daily i.v. injections of cocaine (6 mg/kg). The shape of the time courses for cocaine differed somewhat between dams and fetuses, with fetal plasma concentrations of cocaine initially being lower than those of their dams and then by 5 min becoming equivalent to those of their dams. Although plasma concentrations of cocaine soon equilibrated between dams and fetuses, plasma concentrations of benzoylecgonine did not. Interestingly, brain concentrations of cocaine did not differ between dams and fetuses. The most remarkable finding was that the relative distribution of cocaine between brain and plasma differed after chronic vs. acute treatment, with a relative shift in the distribution of cocaine from plasma to the brain in the fetuses, and with the exception of the earliest time point measured, in the dams after repeated dosing.

The central Iowa project.

This project developed and tested a population-based survey, the HS Form, to examine health and health care in the Central Iowa community. Data from this new collection of proven sets of items were used to compare competing health plans, doctor offices, hospitals, and to develop preliminary norms of the community's insured, in two areas: system performance and health burden. The results showed that the survey: (1) was both feasible and efficient in delivering a comprehensive and generic assessment of consumers and patients; (2) revealed consistent, noteworthy differences between plans and between providers across both sets of criteria; and (3) indicated that there is substantial room for improvement in Central Iowa's health care delivery system from the public's perspective. Recommendations for next steps include: (1) following through on the June 1993 community forum (held to discuss the project's methods and results with local decision makers); (2) broadening the evaluation design to increase sample representativeness; and (3) implementing a pre/post approach to measure changes in plan and provider performance.

The Employee Health Care Value Survey: round one.

In a groundbreaking arrangement, a consortium of large employers--the Xerox, GTE, and Digital Equipment Corporations--launched the Employee Health Care Value Survey during fall 1993. Completed by 24,306 employees, this survey was used to develop comparable methods for assessing corporate health care benefit strategies. It also enabled fair comparisons of thirty-two health plans across the country on more than sixty criteria. Variation in performance among plans was substantial, with managed care plans--particularly prepaid group practices and individual practice associations (IPAs)--recording the most favorable rankings on disenrollment, overall satisfaction, and other measures of "bottom-line performance." Variation in enrollees' health among plans was more modest, with indemnity enrollees posing a somewhat greater illness burden to their plans than enrollees of other plan types. The employers and evaluated health plans are now using the results for multiple purposes, including quality improvement initiatives, employee-based plan performance reports, employee contribution strategies, and health promotion programs.

Role of cigarette use in hyponatremia in schizophrenic patients.

Urine volume and osmolality were studied in two schizophrenic patients with hyponatremia and six normal subjects after they smoked or ingested cigarettes. The results suggest that cigarette use may contribute to the development of hyponatremia by impairing water excretion.

Paraquat poisoning.

The authors present a review of the toxicology, pathophysiology, and treatment of paraquat, a potent herbicide.

Indomethacin in the treatment of lithium-induced nephrogenic diabetes insipidus.

Nephrogenic diabetes insipidus (NDI) is a frequent complication in patients receiving long-term lithium therapy. Both thiazide diuretics and amiloride may reduce the polyuria, but the use of each is associated with problems. We report the results of a clinical trial using the nonsteroidal anti-inflammatory drug indomethacin to treat a patient with well-documented lithium-induced NDI that persisted following cessation of lithium treatment. The administration of a single dose of indomethacin resulted in a dramatic decrease in urine volume and increase in urine osmolality that persisted for several hours, and was independent of renal hemodynamic changes. Subsequently, the patient experienced a sustained, favorable effect on her polyuria during long-term (3 months) indomethacin therapy without a deleterious effect on her renal function. Indomethacin may be a useful therapeutic tool for the amelioration of lithium-induced NDI.

Consumers and choice: cost containment strategies for health care provision.

Consumer responses to three cost containment strategies for providing health care are examined. The data come from a random sample of 365 Los Angeles adults interviewed by telephone. It is found that aggregate sample responses are negative toward two strategies (labelled preferred provider and health planning) and positive toward the third (labelled self care). Furthermore, it is found that demographic characteristics that predict approval of one strategy predict disapproval of other strategies. These findings, coupled with models assessing how and why segments of consumers respond as they do, suggest that no one strategy is likely to appeal to all consumers. Implications for the implementation of health care delivery systems inspired by containment strategies are discussed in the context of recent events in California.

Internal thoracic vein cannulation as a complication of central venous catheterization.

Central venous catheterization is utilized in resuscitation and evaluation of the severely ill patient. It is also employed for total parenteral nutrition. The list of potential complications is extensive and includes catheter malposition, with its attendant morbidity, as the most frequent complication. Inaccurate venous pressure measurements and mediastinal phlebitis have been cited as natural sequelae of inadvertent catheterization of the internal thoracic (mammary) vein (ITV). The histories of four patients who had ITV cannulation are analyzed as to indications for central venous catheterizations, site of insertion, time of delayed recognition, and attendant complications. In addition, the records of 150 consecutive patients who underwent central venous line placement were reviewed to determine the number of lines placed (242), the number and percentage of postcatheterization chest films obtained with standard posterior-anterior (P-A) and lateral technique (70, 29%), the number and incidence of catheterization-associated complications (78, 32%), and the number and incidence of ITV cannulation (5, 2%). No untoward results were seen as a result of this complication in the nine patients discovered, although the potential for morbidity was present. Subtle changes on portable chest films and standard technique P-A and lateral films remain the best protection against complications associated with ITV cannulation.

The response of willow grouse chicks to auditory stimuli 3. Recognition of the incubating hen's voice.

Willow grouse chicks were removed from the nests of captive hens, either at hatching or less than 24 hours later. They were tested for their ability to discriminate, and preference for, the voice of the hen which had incubated them, and the voice of another hen grouse. The chicks removed at hatching approached and tried to nestle under the loudspeaker playing the calls of their own hens. The chicks which had remained with their hens and been brooded by them were indifferent to the recording of their voices, but tended to avoid the voice of the unknown hen.