The impact of antidepressant use on social functioning: reboxetine versus fluoxetine.

Depression compromises affected individuals' functional well-being and impairs their level of social and workplace performance. Improved social functioning in depressed patients may improve their work productivity. This study evaluated the differential effects of two antidepressants on social functioning outcomes for patients with major depression comparing reboxetine, a non-tricyclic, selective noradrenaline reuptake inhibitor and fluoxetine, a commonly prescribed selective serotonin reuptake inhibitor. A model using data from 284 depressed patients (138 reboxetine, 146 fluoxetine) in two 8-week clinical trials was developed to predict the percentage change over time in continuous outcome assessments as measured by a 21-item self-rating scale called the Social Adaptation Self-evaluation Scale (SASS). The percentage change from baseline SASS score was modelled as a function of both time-invariant and time-varying covariates. Results suggest that, by mid-study, the more severely ill subjects benefitted more from reboxetine treatment in terms of the outcome improvement rate and, by study-end, this effect also extended into the less severely ill population. In addition, a significant relationship was identified between the change in depression symptom severity as measured by the standard Hamilton Depression Rating Scale score and the change in social functioning per the SASS.

Who gets chemotherapy for metastatic lung cancer?

STUDY OBJECTIVES: To determine the prevalence and factors associated with chemotherapy use in elderly patients presenting with advanced lung cancer. DESIGN: A retrospective cohort study using administrative data. SETTING AND PATIENTS: We analyzed the medical bills for the 6,308 Medicare patients > 65 years old with diagnosed stage IV non-small cell lung cancer (NSCLC) in the 11 SEER (survival, epidemiology, and end results) regions between 1991 and 1993. The main outcome measure, chemotherapy administration, was identified by the relevant medical billing codes. Patient sociodemographic and disease characteristics were obtained from the SEER database and census data. RESULTS: Almost 22% of patients received chemotherapy at some time for their metastatic NSCLC. As expected, younger patients and those with fewer comorbid conditions were more likely to receive chemotherapy. However, several nonmedical factors, such as nonblack race, higher socioeconomic status, treatment in a teaching hospital, and living in the Seattle/Puget Sound or Los Angeles SEER regions, also significantly increased a patient's likelihood of receiving chemotherapy. CONCLUSION: Compared to previous reports, the prevalence of chemotherapy use for advanced NSCLC appears to be increasing. However, despite uniform health insurance coverage, there is wide variation in the utilization of palliative chemotherapy among Medicare patients, and nonmedical factors are strong predictors of whether a patient receives chemotherapy. While it is impossible to know the appropriate rate of usage, nonmedical factors should only influence a patient's likelihood of receiving treatment if they reflect patient treatment preference. Research to further clarify the costs, benefits, and patient preferences for chemotherapy in this patient population is warranted in order to minimize the effect of nonmedical biases on management decisions.

Is warfarin underused in the treatment of elderly persons with atrial fibrillation?

BACKGROUND: Several randomized clinical trials have shown that among patients with atrial fibrillation, warfarin sodium use protects against stroke. Recently, experts have voiced concern about possible underuse of warfarin by practicing physicians. Few studies, however, have quantitated the amount of warfarin underuse. METHODS: We randomly sampled 65 Medicare beneficiaries discharged alive from each of 5 small Pennsylvania hospitals between July 1, 1993, and June 30, 1994, with a discharge diagnosis code for atrial fibrillation. Trained abstractors verified that atrial fibrillation was present at some time during the hospitalization, determined the presence of contraindications to anticoagulation, and identified warfarin or aspirin use at discharge for each patient. An internist used implicit criteria to identify the reason for warfarin nonuse in patients who had none of the explicit contraindications to warfarin and did not receive it. RESULTS: Of 322 charts reviewed, 48 patients were not in atrial fibrillation during the hospitalization, 79 had contraindications to warfarin use, 21 either died or were transferred to another hospital, and 2 were admitted with a complication of warfarin. Of the 172 remaining patients, 76 (44%) underwent anticoagulation. On implicit review of the 96 patients who did not undergo anticoagulation, the internist judged that warfarin would not have been appropriate in 54. After excluding those patients, 76 (64%) of the remaining 118 patients underwent anticoagulation. Patients not receiving warfarin were slightly older (81.6 vs 78.3 years old), but this was not statistically significant after stratifying by hospital. Rates of warfarin use at the 5 hospitals varied widely (32%, 57%, 79%, 82%, 94%; P < .001, chi2 with 4 df). Patients with newly diagnosed atrial fibrillation were not more likely to undergo anticoagulation, nor were patients treated by internal medicine or cardiology specialists. CONCLUSIONS: There may be significant warfarin underuse in some hospitals. Overall, approximately one third of patients with atrial fibrillation for whom it appeared appropriate were not anticoagulated with warfarin. Although the fact that data were not available to or were missed by our review surely justifies some of the underuse, one should recall that even a small amount of underuse may affect a large number of people with this common condition.