Cost-effectiveness of training rural providers to identify and treat patients at risk for fragility fractures.

UNLABELLED: This is a cost-effectiveness analysis of training rural providers to identify and treat osteoporosis. Results showed a slight cost savings, increase in life years, increase in treatment rates, and decrease in fracture incidence. However, the results were sensitive to small differences in effectiveness, being cost-effective in 70 % of simulations during probabilistic sensitivity analysis. INTRODUCTION: We evaluated the cost-effectiveness of training rural providers to identify and treat veterans at risk for fragility fractures relative to referring these patients to an urban medical center for specialist care. The model evaluated the impact of training on patient life years, quality-adjusted life years (QALYs), treatment rates, fracture incidence, and costs from the perspective of the Department of Veterans Affairs. METHODS: We constructed a Markov microsimulation model to compare costs and outcomes of a hypothetical cohort of veterans seen by rural providers. Parameter estimates were derived from previously published studies, and we conducted one-way and probabilistic sensitivity analyses on the parameter inputs. RESULTS: Base-case analysis showed that training resulted in no additional costs and an extra 0.083 life years (0.054 QALYs). Our model projected that as a result of training, more patients with osteoporosis would receive treatment (81.3 vs. 12.2 %), and all patients would have a lower incidence of fractures per 1,000 patient years (hip, 1.628 vs. 1.913; clinical vertebral, 0.566 vs. 1.037) when seen by a trained provider compared to an untrained provider. Results remained consistent in one-way sensitivity analysis and in probabilistic sensitivity analyses, training rural providers was cost-effective (less than $50,000/QALY) in 70 % of the simulations. CONCLUSIONS: Training rural providers to identify and treat veterans at risk for fragility fractures has a potential to be cost-effective, but the results are sensitive to small differences in effectiveness. It appears that provider education alone is not enough to make a significant difference in fragility fracture rates among veterans.

Spectral filters in low-vision correction.

Coloured filters are used to protect the lens, retina and other ocular tissues against the hazard of light damage and to improve the quality of vision mainly in cases of ocular media opacities. Four types of yellow, amber and orange filters have been designed as tinted glasses, shields and colour covering of spectacles. They were tested on 15 adult patients with partial cataract and on 80 children with congenital pathology (i.e. macular hypoplasia, albinism, aphakia after congenital cataract). The majority of the children had nystagmus. The filters with particular spectral characteristics provide reduction of light intensity in the light-damaging range by at least a factor of five. Optimal filters were selected by examination of visual acuity, contrast frequency sensitivity, glare sensitivity and subjective selection by the patients. The effects of filters were: 11-43% increase in corrected visual acuity, 27-34% increase in contrast sensitivity function (CSF) for all frequencies and a marked reduction in glare sensitivity. All patients reported subjective improvement including reduction of photophobia, eye-strain and eye discomfort. It is concluded that coloured filters are able to contribute substantially to rehabilitation of low-vision patients.

Medical patients assessment protocol: a tool for evaluating the appropriateness of utilizing hospital-stay days for acute medical patients; development, reliability and applications.

An attempt was made to formulate a tool that, when compared to the appropriateness evaluation protocol (AEP) used for evaluating the utilization of hospital services for medical patients, would be an improvement. To establish this, a four-phase project was evolved, which included: (a) taxonomy definition of medical and nonmedical reasons for acute-care hospital bed utilization for a day of care, (b) use of the preliminary protocol by trained nurses to extend the range of clinical conditions included, (c) independent review of the protocol by three senior physicians, and (d) comparative interrater reliability and feasibility study between the new instrument-the medical patients assessment protocol (MPAP) and the AEP. We found the MPAP to have a higher inter-rater reliability than the AEP (kappa = 0.94 and 0.78, respectively), to be more clinically oriented, more comprehensive, and similar to the AEP regarding the time required for investigation of cases. Therefore, we recommend the use of the MPAP for management and quality control of medical hospitalized patients.

Factors associated with nonprescription of evolving modes of therapy--a model for drug use evaluation in hospitalized medical patients.

OBJECTIVE: To measure the rate of inappropriate underuse of drug therapy among hospitalized patients and to identify factors associated with nonprescription of two effective modes of therapy. DESIGN: A survey was conducted by retrospective chart extraction to measure the rates of nonprescription of two therapeutic modalities--aspirin and angiotensin converting enzyme inhibitors. Stepwise logistic regression was used to determine which factors were significantly associated with nonprescription of either drug. SETTING: Two internal medicine departments in a major community and referral hospital in Israel. PATIENTS: Those who were hospitalized through 1990 with a diagnosis on their discharge sheet of angina pectoris or congestive heart failure. A random sample selection was made to define the study population. RESULTS: The rates of nonprescription among patients in whom there are no drug contraindications were 54% (95% CI 47-62) for aspirin and 34% (95% CI 27-41) for angiotensin converting enzyme inhibitors. Three variables correlated independently with nonprescription of both drugs: hospitalization in ward B, nonuse of the drug prior to hospitalization, and secondary priority of the diagnosis angina pectoris or congestive heart failure on discharge sheet. CONCLUSIONS: Nonprescription of essential drugs is a common phenomenon that varies significantly among physicians. Inconsistency in application of knowledge to clinical practice, as well as a diversity of approaches toward interpretations of clinical study results, significantly influences the prescription rates of evolving modes of therapy.

Colonoscopy in patients aged 80 years or older and its contribution to the evaluation of rectal bleeding.

Colonoscopies performed in patients aged 80 years or older at the Sheba Medical Center were analysed according to the primary indication for the procedure: 101 colonoscopies were performed because of rectal bleeding of at least 2 months duration, and 335 for all other indications. Carcinoma of the large bowel was found in 29 (28.7%) bleeders, with the rectum being the most frequently involved site (12 patients). Among the non-bleeders, the prevalence of cancer was significantly lower (33 cases, 9.8%; P less than 0.001), and rectal carcinoma was less common (five patients, P = 0.04), but proximal tumours were more frequent. Of patients with cancer who had operations, the majority (72%) had a tumour confined to the bowel wall (Dukes A or B). The rate of adenomas was similar for both groups (34% vs 29%). The non-bleeders complained more frequently of abdominal pain or a change in bowel habits as compared to the bleeders, but both groups had similar rates for anaemia and weight loss. In all, 47% of these octogenarians with cancer, and 26% with adenomas were referred for colonoscopy because of rectal bleeding. This procedure was found to be safe in old age, as we recorded only four (0.9%) non-fatal complications among our series, a similar figure to the overall incidence of complications at our Institute. In conclusion, our data indicate that rectal bleeding in octogenarians warrants a complete colonic investigation, preferably by total colonoscopy.

Colonoscopy without prior preparation in mild to moderate active ulcerative colitis.

We evaluated the effect of different types of preparations on the diagnostic yield of colonoscopy (total or limited) in mild to moderate active ulcerative colitis. Our ability to determine the extent of disease and see the mucosa beyond the inflamed areas was assessed in patients receiving no preparation (group A, 72 examinations) and those receiving diphosphosoda enemas (group B, 181 examinations). There were three failures in group A and 11 in group B. In the majority of patients (71% of group A, 83% of group B) the scope could be passed under optimal viewing conditions at least one segment beyond the involved area. In group A the cecum was reached in 16% of the procedures and in group B in 18%. We conclude that in mild to moderate active ulcerative colitis, colonoscopy can be performed without preparation, and still achieve the same results as with preparatory enemas.

Optimizing selection of in vitro tests for diagnosing thyroid disorders.

The optimal utilization of the thyroid related radioimmunoassays T3, T4, and TSH-RIA is derived from analysing the clinical and laboratory data for 974 patients with functional thyroid disorders. A statistical computer analysis of the contribution of each of the three tests, and in combination, to the final diagnoses of hypothyroid, euthyroid, and hyper thyroid states was designed. The best contributing test for hypothyroidism and euthyroidism was TSH-RIA (98.5 and 93%, respectively). T4/T3 + TSH-RIAs were the optimal dual combination for diagnosing euthyroidism (98.0%). For diagnosing hyperthyroidism T4-RIA was the best single test (82.5%) followed by T3 + T4 as an optimal dual combination (95%). Using all three tests was of no significant additional value over dual combinations. It is concluded that the work and cost of randomly performing three tests routinely is not justified without clinical basis. An algorithm is proposed to guide thyroid studies based on computer analyses of the above-mentioned single or dual-test combinations to establish accurate diagnosis at the lowest laboratory cost.

Left-ventricular exercise echocardiographic abnormalities in patients with sarcoidosis without ischemic heart disease.

We performed postexercise two-dimensional echocardiography in 21 patients with sarcoidosis but no signs of ischemic heart disease and in 24 normal control subjects. This was done to assess global and regional left-ventricular (LV) function and to try to identify the presence of occult myocardial involvement among sarcoidosis patients. All 21 sarcoidosis patients had a normal resting left-ventricular ejection fraction (LVEF) and echocardiogram. An abnormal LV response to exercise was detected in 10 sarcoidosis patients in the form of a significant decrease in mean LVEF with exercise without concomitant clinical and ECG evidence of myocardial ischemia. Seven of these 10 patients were found to have a pathological increase in LV and systolic volume with exercise, although it did not achieve statistical significance. In addition, markedly abnormal regional septal wall motion was noted in two of these patients. In the remaining 11 sarcoidosis patients, mean LVEF increased significantly with exercise. This is the normal ejection fraction response to stress. These 11 patients also showed that LV end-systolic volume decreased with exercise; the decrease was from 40.8 to 27.9 ml (P = 0.0004). In the control group, the mean LVEF increased from 69.5 +/- 7.2 at rest to 78.5 +/- 7.6 with exercise (P less than 10(-6)). We conclude that postexercise echocardiography is a noninvasive, simple, and safe method to detect and to follow the course of possible occult myocardial sarcoidosis.

Colorectal adenomatous polyps and carcinoma in Ashkenazi and non-Ashkenazi Jews in Israel.

In Israel, the incidence of colorectal cancer among European-American-born Jews is approximately 2.5 times that of African-Asian-born Jews. To determine the risk of all colorectal tumors for the two ethnic groups, 335 patients with colorectal adenomatous polyps and 295 with colorectal cancer, diagnosed between 1980-1984 at the Sheba Medical Center, were compared to the 35,094 persons attending the outpatient clinics at the same hospital, during September and October 1984. Ashkenazi patients (European-American-born) had a 2.5-fold risk (95% confidence interval 1.9-3.3) of colorectal polyps compared to non-Ashkenazi patients (African-Asian-born). The risk was similar for males (odds ratios [OR] = 2.3) and females (OR = 2.8). Ashkenazis also had a significantly enhanced risk of carcinoma: OR = 3.1; 95% confidence interval 2.2-4.3. The risk ratio was slightly higher for males (OR = 3.5) than females (OR = 2.7). Age-specific analyses demonstrated an elevated risk of both malignant and benign neoplasms among Ashkenazi patients at all ages at diagnosis. Among the polyp patients, the highest risk ratio was for patients between 30 and 49 years old, while among the cancer patients the risk was highest in the group of 60-69-year-olds. The distribution by size of polyps, number of polyps, as well as polyp subsite, was similar for Ashkenazi and non-Ashkenazi patients; however non-Ashkenazis tended to have slightly more right-sided colon cancer.

Pressure/volume ratio and pressure/volume ratio exercise quotient: an echocardiographic comparative study of left ventricular function indicators.

Noninvasive evaluation of left ventricular function (LVF) has been performed with two-dimensional echocardiography (TDE). Ejection fraction (EF), end systolic volume index (ESVI) and systolic blood pressure/end systolic volume index ratio (PVR)--an indicator which is independent of preload and afterload changes in a wide physiologic range--were assessed at rest and after exercise. Twenty-seven postmyocardial infarction (MI) patients were compared to 27 normal controls in an attempt to examine the above parameters of LVF in each group, measured by TDE. Correlation of TDE EF with radionuclide angiography EF proved the reliability of TDE. Rest and postexercise values of EF and PVR showed highly significant differences between the two groups. Using ESVI, a relatively lesser significant difference was found. PVR values at rest were 4.86 mm Hg/ml/m2 in the study group and 9.51 in the control group. These values increased to 5.34 and 15.15, respectively, after exercise. The ratio of PVR after exercise to PVR at rest, expressed as percentage change (PVREQ), seemed to be an additional tool in separating between both groups. This indicator merges pressure, volume, and the influence of exercise on both; a PVREQ of at least 145% correlated well with absence of MI in most of our patients.

The effect of epidural analgesia on maternal thermoregulation in labor.

Core and peripheral body temperatures were recorded in 24 parturients in labor with epidural analgesia and in 9 control parturients without analgesia. Shivering occurred in 11 (46%) of the women with epidural analgesia and in one parturient without analgesia. Twelve patients (50%) showed increase in leg and chest temperatures after injection of bupivacaine 0.35% into the epidural space. Lumbar epidural analgesia may produce shivering and temporary temperature changes in the periphery. Core temperature is not significantly altered.