Jane Neff Rollins

LOS ANGELES — A practice-based, paper-and-pencil-based intervention can improve quality of care for community-based vulnerable elderly patients with dementia or incontinence, Dr. David B. Reuben reported at the annual meeting of the Society of General Internal Medicine.

The Assessing Care of the Vulnerable Elders (ACOVE-2) trial, funded by Pfizer and Rand Health, was implemented in two large group practices in California with patients aged 75 years and older who had dementia or incontinence. The intervention group included 357 patients, and the control group had 287 patients, said Dr. Reuben, director of the multicampus program in geriatric medicine and gerontology at UCLA.

Study sites included a primary care practice with 30 physicians serving 22,000 patients (67% of whom were in managed care programs) and a multispecialty practice with 100 physicians and 140,000 patients (50% in managed care programs).

The ACOVE-2 sites in the intervention group redesigned their practices to identify eligible individuals, collect data, develop structured visit notes to suggest appropriate care, provide patient education, and link patients to community resources.

The structured visit notes were filled out by the physician. For example, the visit note for preventing falls included check boxes for testing vision, gait, and balance. The dementia visit note included check boxes for long- and short-term memory, a simple math question about making change for a purchase, and a language-related question. The treatment plan section for incontinence included suggested drugs and dosages and had a place to check off recommended specialty referrals.

After the intervention, overall care patterns improved: 45% of patients at risk for falls received a specialty exam and 89% received recommendations to improve strength/gait problems, compared with 12% and 58%, respectively, before the intervention.

In addition, after the intervention, 33% of patients with incontinence received a recommendation for behavioral treatment before drug intervention, compared with 4% before the trial. However, there was no significant difference between the intervention and control groups in the management of dementia. In fact, in patients with positive screening results, the control group received cholinesterase inhibitors at higher rates than the intervention group.

The structured visit notes included check boxes to minimize the time needed to fill out each section. “If it was quick, we knew doctors would do it. If it took time, doctors wouldn't do it,” Dr. Reuben said.

“I think the most interesting and controversial aspect of patient education material was the follow-up sheet,” Dr. Reuben said. The follow-up sheet included patient instructions for treatment and a list of questions for the patient to answer as homework before the next visit. To show doctors that it did not take long to fill out the forms, small-group educational sessions—using real charts with all identifying material removed—outlined practical approaches to each of the conditions listed.

Physicians may encounter problems adapting ACOVE processes to their own practices, Dr. Reuben said. “One thing I can guarantee. If you try to do this exactly how it was done, it won't work or you won't do it. You must ask 'what can I do to tweak it?'”

More information about ACOVE, including forms and physician and patient education materials, are available at www.geronet.ucla.edu/centers/acove/index.htm

LOS ANGELES — A practice-based, paper-and-pencil-based intervention can improve quality of care for community-based vulnerable elderly patients with dementia or incontinence, Dr. David B. Reuben reported at the annual meeting of the Society of General Internal Medicine.

The Assessing Care of the Vulnerable Elders (ACOVE-2) trial, funded by Pfizer and Rand Health, was implemented in two large group practices in California with patients aged 75 years and older who had dementia or incontinence. The intervention group included 357 patients, and the control group had 287 patients, said Dr. Reuben, director of the multicampus program in geriatric medicine and gerontology at UCLA.

Study sites included a primary care practice with 30 physicians serving 22,000 patients (67% of whom were in managed care programs) and a multispecialty practice with 100 physicians and 140,000 patients (50% in managed care programs).

The ACOVE-2 sites in the intervention group redesigned their practices to identify eligible individuals, collect data, develop structured visit notes to suggest appropriate care, provide patient education, and link patients to community resources.

The structured visit notes were filled out by the physician. For example, the visit note for preventing falls included check boxes for testing vision, gait, and balance. The dementia visit note included check boxes for long- and short-term memory, a simple math question about making change for a purchase, and a language-related question. The treatment plan section for incontinence included suggested drugs and dosages and had a place to check off recommended specialty referrals.

After the intervention, overall care patterns improved: 45% of patients at risk for falls received a specialty exam and 89% received recommendations to improve strength/gait problems, compared with 12% and 58%, respectively, before the intervention.

In addition, after the intervention, 33% of patients with incontinence received a recommendation for behavioral treatment before drug intervention, compared with 4% before the trial. However, there was no significant difference between the intervention and control groups in the management of dementia. In fact, in patients with positive screening results, the control group received cholinesterase inhibitors at higher rates than the intervention group.

The structured visit notes included check boxes to minimize the time needed to fill out each section. “If it was quick, we knew doctors would do it. If it took time, doctors wouldn't do it,” Dr. Reuben said.

“I think the most interesting and controversial aspect of patient education material was the follow-up sheet,” Dr. Reuben said. The follow-up sheet included patient instructions for treatment and a list of questions for the patient to answer as homework before the next visit. To show doctors that it did not take long to fill out the forms, small-group educational sessions—using real charts with all identifying material removed—outlined practical approaches to each of the conditions listed.

Physicians may encounter problems adapting ACOVE processes to their own practices, Dr. Reuben said. “One thing I can guarantee. If you try to do this exactly how it was done, it won't work or you won't do it. You must ask 'what can I do to tweak it?'”

More information about ACOVE, including forms and physician and patient education materials, are available at www.geronet.ucla.edu/centers/acove/index.htm

LOS ANGELES — A practice-based, paper-and-pencil-based intervention can improve quality of care for community-based vulnerable elderly patients with dementia or incontinence, Dr. David B. Reuben reported at the annual meeting of the Society of General Internal Medicine.

The Assessing Care of the Vulnerable Elders (ACOVE-2) trial, funded by Pfizer and Rand Health, was implemented in two large group practices in California with patients aged 75 years and older who had dementia or incontinence. The intervention group included 357 patients, and the control group had 287 patients, said Dr. Reuben, director of the multicampus program in geriatric medicine and gerontology at UCLA.

Study sites included a primary care practice with 30 physicians serving 22,000 patients (67% of whom were in managed care programs) and a multispecialty practice with 100 physicians and 140,000 patients (50% in managed care programs).

The ACOVE-2 sites in the intervention group redesigned their practices to identify eligible individuals, collect data, develop structured visit notes to suggest appropriate care, provide patient education, and link patients to community resources.

The structured visit notes were filled out by the physician. For example, the visit note for preventing falls included check boxes for testing vision, gait, and balance. The dementia visit note included check boxes for long- and short-term memory, a simple math question about making change for a purchase, and a language-related question. The treatment plan section for incontinence included suggested drugs and dosages and had a place to check off recommended specialty referrals.

After the intervention, overall care patterns improved: 45% of patients at risk for falls received a specialty exam and 89% received recommendations to improve strength/gait problems, compared with 12% and 58%, respectively, before the intervention.

In addition, after the intervention, 33% of patients with incontinence received a recommendation for behavioral treatment before drug intervention, compared with 4% before the trial. However, there was no significant difference between the intervention and control groups in the management of dementia. In fact, in patients with positive screening results, the control group received cholinesterase inhibitors at higher rates than the intervention group.

The structured visit notes included check boxes to minimize the time needed to fill out each section. “If it was quick, we knew doctors would do it. If it took time, doctors wouldn't do it,” Dr. Reuben said.

“I think the most interesting and controversial aspect of patient education material was the follow-up sheet,” Dr. Reuben said. The follow-up sheet included patient instructions for treatment and a list of questions for the patient to answer as homework before the next visit. To show doctors that it did not take long to fill out the forms, small-group educational sessions—using real charts with all identifying material removed—outlined practical approaches to each of the conditions listed.

Physicians may encounter problems adapting ACOVE processes to their own practices, Dr. Reuben said. “One thing I can guarantee. If you try to do this exactly how it was done, it won't work or you won't do it. You must ask 'what can I do to tweak it?'”

More information about ACOVE, including forms and physician and patient education materials, are available at www.geronet.ucla.edu/centers/acove/index.htm

LOS ANGELES — End-of-life spending for Medicare beneficiaries varies widely based on geographic location, but individual patient preferences do not drive these regional variations, Dr. Amber E. Barnato reported at the annual meeting of the Society of General Internal Medicine.

For example, average per capita costs in the last 6 months of life among beneficiaries in Portland, Ore., total $9,600, compared with $2,400 in Los Angeles, said Dr. Barnato, of the University of Pittsburgh.

A previous national survey with structured vignettes asking about patient preferences for treatment found that doctors in high-intensity regions are more likely to recommend tests and refer to specialists, and are less likely to recommend hospice care (Ann. Intern. Med. 2003;138:288–98).

The investigators surveyed a national probability sample of fee-for-service Medicare beneficiaries aged 65 years or older. Potential subjects were identified from the Medicare beneficiaries database for the entire United States; a sample of 3,845 people were asked to participate in the study, and 2,515 completed the survey.

The researchers asked respondents to imagine that they had less than 1 year to live. Participants then responded to questions about their preferences for active treatment, ventilator use, and palliative care.

The mean age of respondents was 75.6 years, 42% were male, and 82% were non-Hispanic white, 7% black, and 5% Hispanic.

Overall, 44% of participants said they worried about getting too little treatment in the last year of their lives, whereas 49% worried about getting too much treatment. A total of 16% would prefer potentially life-prolonging drugs that made them feel worse all the time, while 75% would prefer palliative drugs, even if they might shorten life.

Thirteen percent of respondents would prefer mechanical ventilation if it would extend their life by 1 week, and 22% would prefer MV if it would extend life by 1 month. A large proportion of respondents thought the likelihood of returning to normal activity after being on a ventilator was high, according to Dr. Barnato.

In general, participants' concerns about preferences for end-of-life treatment were not significantly different among quintiles of the End-of-Life Expenditure Index, although in higher-intensity regions respondents were less likely to want palliative drugs that might shorten life. This exception no longer held, however, once multivariable analyses were adjusted for sociodemographic variables and health status.

A major study limitation was the nonresponse rate. It is possible that the original hypothesis was not borne out because patterns of nonresponse differed by region.

The survey showed that almost all Medicare enrollees worry that the amount of treatment they want in their last year of life will not align with what they will actually receive. When asked to choose, most participants preferred treatment that would ease pain rather than extend life.

LOS ANGELES — End-of-life spending for Medicare beneficiaries varies widely based on geographic location, but individual patient preferences do not drive these regional variations, Dr. Amber E. Barnato reported at the annual meeting of the Society of General Internal Medicine.

For example, average per capita costs in the last 6 months of life among beneficiaries in Portland, Ore., total $9,600, compared with $2,400 in Los Angeles, said Dr. Barnato, of the University of Pittsburgh.

A previous national survey with structured vignettes asking about patient preferences for treatment found that doctors in high-intensity regions are more likely to recommend tests and refer to specialists, and are less likely to recommend hospice care (Ann. Intern. Med. 2003;138:288–98).

The investigators surveyed a national probability sample of fee-for-service Medicare beneficiaries aged 65 years or older. Potential subjects were identified from the Medicare beneficiaries database for the entire United States; a sample of 3,845 people were asked to participate in the study, and 2,515 completed the survey.

The researchers asked respondents to imagine that they had less than 1 year to live. Participants then responded to questions about their preferences for active treatment, ventilator use, and palliative care.

The mean age of respondents was 75.6 years, 42% were male, and 82% were non-Hispanic white, 7% black, and 5% Hispanic.

Overall, 44% of participants said they worried about getting too little treatment in the last year of their lives, whereas 49% worried about getting too much treatment. A total of 16% would prefer potentially life-prolonging drugs that made them feel worse all the time, while 75% would prefer palliative drugs, even if they might shorten life.

Thirteen percent of respondents would prefer mechanical ventilation if it would extend their life by 1 week, and 22% would prefer MV if it would extend life by 1 month. A large proportion of respondents thought the likelihood of returning to normal activity after being on a ventilator was high, according to Dr. Barnato.

In general, participants' concerns about preferences for end-of-life treatment were not significantly different among quintiles of the End-of-Life Expenditure Index, although in higher-intensity regions respondents were less likely to want palliative drugs that might shorten life. This exception no longer held, however, once multivariable analyses were adjusted for sociodemographic variables and health status.

A major study limitation was the nonresponse rate. It is possible that the original hypothesis was not borne out because patterns of nonresponse differed by region.

The survey showed that almost all Medicare enrollees worry that the amount of treatment they want in their last year of life will not align with what they will actually receive. When asked to choose, most participants preferred treatment that would ease pain rather than extend life.

LOS ANGELES — End-of-life spending for Medicare beneficiaries varies widely based on geographic location, but individual patient preferences do not drive these regional variations, Dr. Amber E. Barnato reported at the annual meeting of the Society of General Internal Medicine.

For example, average per capita costs in the last 6 months of life among beneficiaries in Portland, Ore., total $9,600, compared with $2,400 in Los Angeles, said Dr. Barnato, of the University of Pittsburgh.

A previous national survey with structured vignettes asking about patient preferences for treatment found that doctors in high-intensity regions are more likely to recommend tests and refer to specialists, and are less likely to recommend hospice care (Ann. Intern. Med. 2003;138:288–98).

The investigators surveyed a national probability sample of fee-for-service Medicare beneficiaries aged 65 years or older. Potential subjects were identified from the Medicare beneficiaries database for the entire United States; a sample of 3,845 people were asked to participate in the study, and 2,515 completed the survey.

The researchers asked respondents to imagine that they had less than 1 year to live. Participants then responded to questions about their preferences for active treatment, ventilator use, and palliative care.

The mean age of respondents was 75.6 years, 42% were male, and 82% were non-Hispanic white, 7% black, and 5% Hispanic.

Overall, 44% of participants said they worried about getting too little treatment in the last year of their lives, whereas 49% worried about getting too much treatment. A total of 16% would prefer potentially life-prolonging drugs that made them feel worse all the time, while 75% would prefer palliative drugs, even if they might shorten life.

Thirteen percent of respondents would prefer mechanical ventilation if it would extend their life by 1 week, and 22% would prefer MV if it would extend life by 1 month. A large proportion of respondents thought the likelihood of returning to normal activity after being on a ventilator was high, according to Dr. Barnato.

In general, participants' concerns about preferences for end-of-life treatment were not significantly different among quintiles of the End-of-Life Expenditure Index, although in higher-intensity regions respondents were less likely to want palliative drugs that might shorten life. This exception no longer held, however, once multivariable analyses were adjusted for sociodemographic variables and health status.

A major study limitation was the nonresponse rate. It is possible that the original hypothesis was not borne out because patterns of nonresponse differed by region.

The survey showed that almost all Medicare enrollees worry that the amount of treatment they want in their last year of life will not align with what they will actually receive. When asked to choose, most participants preferred treatment that would ease pain rather than extend life.

LOS ANGELES — Cost is the most frequently cited barrier to adoption of electronic health records, according to two surveys presented in posters at the annual meeting of the Society of General Internal Medicine.

Although electronic health records (EHRs) appear to increase the efficiency and quality of medical care, few published studies have assessed how many ambulatory care practices in the United States currently use EHRs.

Dr. Steven Simon and his team at Harvard Medical School, Boston, conducted a survey of physicians, and Madeline McCarthy from Partners Healthcare System Inc., also in Boston, surveyed practice managers. Both studies were done in Massachusetts in 2005, and both revealed barriers to making a smooth transition from paper-based record systems to EHRs.

Overall, 23% of physicians who responded to the Harvard survey used EHRs in their practices—most of them (58%) for at least the previous 3 years. A larger proportion of multispecialty practices (35%) than primary care practices (25%) were using EHRs.

Larger practices (seven or more physicians) were more likely to adopt EHRs than were solo practices (57% vs. 15%). Hospital-based practices or those with computerized office systems were also more likely to use EHRs.

Barriers to adopting EHRs identified by survey respondents included start-up costs (75%), maintenance costs (72%), loss of productivity while learning (73%), lack of computer skills (57%), skepticism about benefits (54%), and privacy or security concerns (48%). Physicians who listed start-up costs and loss of productivity as reasons not to adopt EHRs were significantly less likely to use EHRs in their practices.

In Ms. McCarthy's study, 29% of practice managers reported using EHRs in their practices: 26% of primary-care-only and 28% of specialty-care-only practices had adopted EHRs, compared with 40% of multispecialty practices.

Practices that had computerized claims and/or billing systems, computerized scheduling systems, or computerized prescribing systems were significantly more likely to have also adopted EHRs than were practices without such systems.

Among practices in which EHRs allowed computerized retrieval of laboratory and radiology results, 88% of practices reported that a majority of their clinicians actively use these features. Also, survey responses showed that in 72% of practices with electronic decision support, the majority of clinicians actively use that feature.

The findings showed that among the practices that do not currently use EHRs, the majority plan to implement them within 3–5 years. Surprisingly, however, 37% of practices did not plan to establish EHRs in the foreseeable future. Cost was the most frequent (50%) reason given for not implementing EHRs.

Although both surveys were limited in that the study population was from a single state, they did target practices that varied widely in terms of number of physicians, specialties, hospital associations, and urban vs. rural location.

LOS ANGELES — Cost is the most frequently cited barrier to adoption of electronic health records, according to two surveys presented in posters at the annual meeting of the Society of General Internal Medicine.

Although electronic health records (EHRs) appear to increase the efficiency and quality of medical care, few published studies have assessed how many ambulatory care practices in the United States currently use EHRs.

Dr. Steven Simon and his team at Harvard Medical School, Boston, conducted a survey of physicians, and Madeline McCarthy from Partners Healthcare System Inc., also in Boston, surveyed practice managers. Both studies were done in Massachusetts in 2005, and both revealed barriers to making a smooth transition from paper-based record systems to EHRs.

Overall, 23% of physicians who responded to the Harvard survey used EHRs in their practices—most of them (58%) for at least the previous 3 years. A larger proportion of multispecialty practices (35%) than primary care practices (25%) were using EHRs.

Larger practices (seven or more physicians) were more likely to adopt EHRs than were solo practices (57% vs. 15%). Hospital-based practices or those with computerized office systems were also more likely to use EHRs.

Barriers to adopting EHRs identified by survey respondents included start-up costs (75%), maintenance costs (72%), loss of productivity while learning (73%), lack of computer skills (57%), skepticism about benefits (54%), and privacy or security concerns (48%). Physicians who listed start-up costs and loss of productivity as reasons not to adopt EHRs were significantly less likely to use EHRs in their practices.

In Ms. McCarthy's study, 29% of practice managers reported using EHRs in their practices: 26% of primary-care-only and 28% of specialty-care-only practices had adopted EHRs, compared with 40% of multispecialty practices.

Practices that had computerized claims and/or billing systems, computerized scheduling systems, or computerized prescribing systems were significantly more likely to have also adopted EHRs than were practices without such systems.

Among practices in which EHRs allowed computerized retrieval of laboratory and radiology results, 88% of practices reported that a majority of their clinicians actively use these features. Also, survey responses showed that in 72% of practices with electronic decision support, the majority of clinicians actively use that feature.

The findings showed that among the practices that do not currently use EHRs, the majority plan to implement them within 3–5 years. Surprisingly, however, 37% of practices did not plan to establish EHRs in the foreseeable future. Cost was the most frequent (50%) reason given for not implementing EHRs.

Although both surveys were limited in that the study population was from a single state, they did target practices that varied widely in terms of number of physicians, specialties, hospital associations, and urban vs. rural location.

LOS ANGELES — Cost is the most frequently cited barrier to adoption of electronic health records, according to two surveys presented in posters at the annual meeting of the Society of General Internal Medicine.

Although electronic health records (EHRs) appear to increase the efficiency and quality of medical care, few published studies have assessed how many ambulatory care practices in the United States currently use EHRs.

Dr. Steven Simon and his team at Harvard Medical School, Boston, conducted a survey of physicians, and Madeline McCarthy from Partners Healthcare System Inc., also in Boston, surveyed practice managers. Both studies were done in Massachusetts in 2005, and both revealed barriers to making a smooth transition from paper-based record systems to EHRs.

Overall, 23% of physicians who responded to the Harvard survey used EHRs in their practices—most of them (58%) for at least the previous 3 years. A larger proportion of multispecialty practices (35%) than primary care practices (25%) were using EHRs.

Larger practices (seven or more physicians) were more likely to adopt EHRs than were solo practices (57% vs. 15%). Hospital-based practices or those with computerized office systems were also more likely to use EHRs.

Barriers to adopting EHRs identified by survey respondents included start-up costs (75%), maintenance costs (72%), loss of productivity while learning (73%), lack of computer skills (57%), skepticism about benefits (54%), and privacy or security concerns (48%). Physicians who listed start-up costs and loss of productivity as reasons not to adopt EHRs were significantly less likely to use EHRs in their practices.

In Ms. McCarthy's study, 29% of practice managers reported using EHRs in their practices: 26% of primary-care-only and 28% of specialty-care-only practices had adopted EHRs, compared with 40% of multispecialty practices.

Practices that had computerized claims and/or billing systems, computerized scheduling systems, or computerized prescribing systems were significantly more likely to have also adopted EHRs than were practices without such systems.

Among practices in which EHRs allowed computerized retrieval of laboratory and radiology results, 88% of practices reported that a majority of their clinicians actively use these features. Also, survey responses showed that in 72% of practices with electronic decision support, the majority of clinicians actively use that feature.

The findings showed that among the practices that do not currently use EHRs, the majority plan to implement them within 3–5 years. Surprisingly, however, 37% of practices did not plan to establish EHRs in the foreseeable future. Cost was the most frequent (50%) reason given for not implementing EHRs.

Although both surveys were limited in that the study population was from a single state, they did target practices that varied widely in terms of number of physicians, specialties, hospital associations, and urban vs. rural location.

LOS ANGELES — Long-term ACE inhibitor therapy was associated with a 21% decreased risk of colorectal cancer in a cohort of hypertensive patients over age 50, Dr. George Makar reported at the annual Digestive Disease Week.

“The benefit of ACE inhibitors is most pronounced with 5 years of exposure,” said Dr. Makar, of the gastroenterology division, University of Pennsylvania School of Medicine, Philadelphia. The protective effect was greater (75%) in people with diabetes than in nondiabetics, he noted.

Dr. Makar and his colleagues conducted a nested, case-control cohort study of hypertensive patients older than 50 years, some of whom were receiving long-term ACE inhibitor therapy. Using the General Practice Research Database (United Kingdom), they identified 1,988 subjects with a new diagnosis of colorectal cancer; each case was matched to up to 10 controls (total of 18,131) based on age, sex, calendar year, and duration of follow-up. Patients were excluded if they developed colorectal cancer within 1 year of their diagnosis of hypertension or if cases had received ACE inhibitor therapy before their cancer diagnosis for less than 1 year.

ACE inhibitor therapy of more than 3 years' duration was associated with a significant reduction in colorectal cancer risk (OR 0.79); the analysis was adjusted for duration of hypertension follow-up and number of physician visits within 1 year of the index trial visit. The investigators found a significant duration-response effect among patients with diabetes (adjusted OR 0.27). There was no significant difference between users and nonusers of aspirin or NSAIDs.

Limitations of the study included incomplete data on obesity and tobacco exposure. Also, no data were collected on potential confounders such as family history and use of over-the-counter NSAIDs and dietary supplements.

LOS ANGELES — Long-term ACE inhibitor therapy was associated with a 21% decreased risk of colorectal cancer in a cohort of hypertensive patients over age 50, Dr. George Makar reported at the annual Digestive Disease Week.

“The benefit of ACE inhibitors is most pronounced with 5 years of exposure,” said Dr. Makar, of the gastroenterology division, University of Pennsylvania School of Medicine, Philadelphia. The protective effect was greater (75%) in people with diabetes than in nondiabetics, he noted.

Dr. Makar and his colleagues conducted a nested, case-control cohort study of hypertensive patients older than 50 years, some of whom were receiving long-term ACE inhibitor therapy. Using the General Practice Research Database (United Kingdom), they identified 1,988 subjects with a new diagnosis of colorectal cancer; each case was matched to up to 10 controls (total of 18,131) based on age, sex, calendar year, and duration of follow-up. Patients were excluded if they developed colorectal cancer within 1 year of their diagnosis of hypertension or if cases had received ACE inhibitor therapy before their cancer diagnosis for less than 1 year.

ACE inhibitor therapy of more than 3 years' duration was associated with a significant reduction in colorectal cancer risk (OR 0.79); the analysis was adjusted for duration of hypertension follow-up and number of physician visits within 1 year of the index trial visit. The investigators found a significant duration-response effect among patients with diabetes (adjusted OR 0.27). There was no significant difference between users and nonusers of aspirin or NSAIDs.

Limitations of the study included incomplete data on obesity and tobacco exposure. Also, no data were collected on potential confounders such as family history and use of over-the-counter NSAIDs and dietary supplements.

LOS ANGELES — Long-term ACE inhibitor therapy was associated with a 21% decreased risk of colorectal cancer in a cohort of hypertensive patients over age 50, Dr. George Makar reported at the annual Digestive Disease Week.

“The benefit of ACE inhibitors is most pronounced with 5 years of exposure,” said Dr. Makar, of the gastroenterology division, University of Pennsylvania School of Medicine, Philadelphia. The protective effect was greater (75%) in people with diabetes than in nondiabetics, he noted.

Dr. Makar and his colleagues conducted a nested, case-control cohort study of hypertensive patients older than 50 years, some of whom were receiving long-term ACE inhibitor therapy. Using the General Practice Research Database (United Kingdom), they identified 1,988 subjects with a new diagnosis of colorectal cancer; each case was matched to up to 10 controls (total of 18,131) based on age, sex, calendar year, and duration of follow-up. Patients were excluded if they developed colorectal cancer within 1 year of their diagnosis of hypertension or if cases had received ACE inhibitor therapy before their cancer diagnosis for less than 1 year.

ACE inhibitor therapy of more than 3 years' duration was associated with a significant reduction in colorectal cancer risk (OR 0.79); the analysis was adjusted for duration of hypertension follow-up and number of physician visits within 1 year of the index trial visit. The investigators found a significant duration-response effect among patients with diabetes (adjusted OR 0.27). There was no significant difference between users and nonusers of aspirin or NSAIDs.

Limitations of the study included incomplete data on obesity and tobacco exposure. Also, no data were collected on potential confounders such as family history and use of over-the-counter NSAIDs and dietary supplements.

LOS ANGELES — Establishment of a screening program using virtual colonoscopy did not lead to a decrease in the number of standard optical colonoscopies performed within 14 months of its introduction, Dr. Darren C. Schwartz reported at the annual Digestive Disease Week.

Only a small proportion of patients who underwent virtual colonoscopy were subsequently referred for optical colonoscopy with polypectomy, said Dr. Schwartz, a fellow at the University of Wisconsin, Madison.

Contrary to the researchers' initial hypothesis, there was no observable shift in the purpose of optical colonoscopy referrals from screening to therapeutic interventions such as polypectomy.

Dr. Schwartz and his colleagues measured the impact of primary screening virtual colonoscopy on the demand for optical colonoscopy at the University of Wisconsin Medical Center. This project was feasible because in 2004, third-party payers in Wisconsin agreed to pay for primary screening virtual colonoscopy for patients at average risk for colorectal cancer.

All optical colonoscopy procedures were performed by 10 university attending gastroenterologists, and all virtual colonoscopy procedures were performed by three attending radiologists at the same university-based endoscopy unit.

The investigators collected virtual colonoscopy and optical colonoscopy referral data and information about the number and type of procedures prospectively. The relevant time periods were the 3 months before the introduction of screening virtual colonoscopy (T1), the period from 3 months before to 5 months after virtual colonoscopy became available (T2), and the 14-month period after introduction of virtual colonoscopy (T3).

The investigators also looked at the period 6–14 months after virtual colonoscopy screening was initiated (T4) because they thought there would be an initial increase in virtual colonoscopy productivity during the first 6 months, followed by a “steady state” level of productivity.

End points included monthly referrals for virtual colonoscopy and optical colonoscopy, monthly number of virtual colonoscopies actually performed, and monthly numbers of screening optical colonoscopies, total optical colonoscopies, and optical colonoscopies with polypectomy.

Monthly referrals for screening optical colonoscopy fell from a mean of 255 (T1) to 218 (T3) after institution of virtual colonoscopy screening, but this decrease was not significant. The total number of optical colonoscopies and the number of screening optical colonoscopies actually performed per month also did not change significantly. The mean percentage of optical colonoscopies with polypectomy remained essentially constant during all study periods, ranging from 40.5% for T2 to 42.9% for T4.

Of the patients who had screening virtual colonoscopies during study period T4 (mean of 120 per month), 15.1% had polyps detected and 7.0% (8.4 per month) were referred for optical colonoscopy with polypectomy. In addition, 136 patients initially referred for optical colonoscopy subsequently opted for virtual colonoscopy between T2 and T4.

Dr. Schwartz reported no relevant financial relationships.

LOS ANGELES — Establishment of a screening program using virtual colonoscopy did not lead to a decrease in the number of standard optical colonoscopies performed within 14 months of its introduction, Dr. Darren C. Schwartz reported at the annual Digestive Disease Week.

Only a small proportion of patients who underwent virtual colonoscopy were subsequently referred for optical colonoscopy with polypectomy, said Dr. Schwartz, a fellow at the University of Wisconsin, Madison.

Contrary to the researchers' initial hypothesis, there was no observable shift in the purpose of optical colonoscopy referrals from screening to therapeutic interventions such as polypectomy.

Dr. Schwartz and his colleagues measured the impact of primary screening virtual colonoscopy on the demand for optical colonoscopy at the University of Wisconsin Medical Center. This project was feasible because in 2004, third-party payers in Wisconsin agreed to pay for primary screening virtual colonoscopy for patients at average risk for colorectal cancer.

All optical colonoscopy procedures were performed by 10 university attending gastroenterologists, and all virtual colonoscopy procedures were performed by three attending radiologists at the same university-based endoscopy unit.

The investigators collected virtual colonoscopy and optical colonoscopy referral data and information about the number and type of procedures prospectively. The relevant time periods were the 3 months before the introduction of screening virtual colonoscopy (T1), the period from 3 months before to 5 months after virtual colonoscopy became available (T2), and the 14-month period after introduction of virtual colonoscopy (T3).

The investigators also looked at the period 6–14 months after virtual colonoscopy screening was initiated (T4) because they thought there would be an initial increase in virtual colonoscopy productivity during the first 6 months, followed by a “steady state” level of productivity.

End points included monthly referrals for virtual colonoscopy and optical colonoscopy, monthly number of virtual colonoscopies actually performed, and monthly numbers of screening optical colonoscopies, total optical colonoscopies, and optical colonoscopies with polypectomy.

Monthly referrals for screening optical colonoscopy fell from a mean of 255 (T1) to 218 (T3) after institution of virtual colonoscopy screening, but this decrease was not significant. The total number of optical colonoscopies and the number of screening optical colonoscopies actually performed per month also did not change significantly. The mean percentage of optical colonoscopies with polypectomy remained essentially constant during all study periods, ranging from 40.5% for T2 to 42.9% for T4.

Of the patients who had screening virtual colonoscopies during study period T4 (mean of 120 per month), 15.1% had polyps detected and 7.0% (8.4 per month) were referred for optical colonoscopy with polypectomy. In addition, 136 patients initially referred for optical colonoscopy subsequently opted for virtual colonoscopy between T2 and T4.

Dr. Schwartz reported no relevant financial relationships.

LOS ANGELES — Establishment of a screening program using virtual colonoscopy did not lead to a decrease in the number of standard optical colonoscopies performed within 14 months of its introduction, Dr. Darren C. Schwartz reported at the annual Digestive Disease Week.

Only a small proportion of patients who underwent virtual colonoscopy were subsequently referred for optical colonoscopy with polypectomy, said Dr. Schwartz, a fellow at the University of Wisconsin, Madison.

Contrary to the researchers' initial hypothesis, there was no observable shift in the purpose of optical colonoscopy referrals from screening to therapeutic interventions such as polypectomy.

Dr. Schwartz and his colleagues measured the impact of primary screening virtual colonoscopy on the demand for optical colonoscopy at the University of Wisconsin Medical Center. This project was feasible because in 2004, third-party payers in Wisconsin agreed to pay for primary screening virtual colonoscopy for patients at average risk for colorectal cancer.

All optical colonoscopy procedures were performed by 10 university attending gastroenterologists, and all virtual colonoscopy procedures were performed by three attending radiologists at the same university-based endoscopy unit.

The investigators collected virtual colonoscopy and optical colonoscopy referral data and information about the number and type of procedures prospectively. The relevant time periods were the 3 months before the introduction of screening virtual colonoscopy (T1), the period from 3 months before to 5 months after virtual colonoscopy became available (T2), and the 14-month period after introduction of virtual colonoscopy (T3).

The investigators also looked at the period 6–14 months after virtual colonoscopy screening was initiated (T4) because they thought there would be an initial increase in virtual colonoscopy productivity during the first 6 months, followed by a “steady state” level of productivity.

End points included monthly referrals for virtual colonoscopy and optical colonoscopy, monthly number of virtual colonoscopies actually performed, and monthly numbers of screening optical colonoscopies, total optical colonoscopies, and optical colonoscopies with polypectomy.

Monthly referrals for screening optical colonoscopy fell from a mean of 255 (T1) to 218 (T3) after institution of virtual colonoscopy screening, but this decrease was not significant. The total number of optical colonoscopies and the number of screening optical colonoscopies actually performed per month also did not change significantly. The mean percentage of optical colonoscopies with polypectomy remained essentially constant during all study periods, ranging from 40.5% for T2 to 42.9% for T4.

Of the patients who had screening virtual colonoscopies during study period T4 (mean of 120 per month), 15.1% had polyps detected and 7.0% (8.4 per month) were referred for optical colonoscopy with polypectomy. In addition, 136 patients initially referred for optical colonoscopy subsequently opted for virtual colonoscopy between T2 and T4.

Dr. Schwartz reported no relevant financial relationships.

LOS ANGELES — Nearly one in nine patients admitted with an acute myocardial infarction were seen shortly before their MI in the primary care setting with symptoms suggestive of acute cardiac ischemia Dr. Thomas D. Sequist reported at the annual meeting of the Society of General Internal Medicine.

“We know from our own experience in Boston that missed diagnosis of MI in this setting is a rising source of malpractice claims,” said Dr. Sequist of Brigham and Women's Hospital, Boston.

The investigators identified 966 admissions for acute MI, of whom 106 (11%) had complained of symptoms typical of potential heart disease at their last outpatient visit. During the outpatient visit prior to the MI, chest pain and dyspnea accounted for more than three-quarters of all chief complaints. Other complaints included thoracic or epigastric pain, dizziness, weakness, or nausea.

This population-based case-control study used billing claims to identify admissions for acute MI from 2000 to 2004 among patients with no prior history of coronary heart disease (CHD). The 318 control patients were matched to cases on chief complaint and date of outpatient visit, but had no diagnosis of MI within the next 30 days.

Compared with controls, cases were older and were more likely to be male and to have diabetes or dyslipidemia. Approximately 50% of both cases and controls received an electrocardiogram (ECG). Not surprisingly, among those who had an ECG, the rates of normal results were much lower in cases than controls. Despite having symptoms of possible CHD, few study participants in both groups received cardiac medications (aspirin, 11%; beta-blockers, 7%). “There was a significant opportunity for more aggressive evaluation and treatment of these symptomatic patients,” Dr. Sequist said.

The Framingham Risk Score (FRS) predicts risk for developing CHD using information about coronary risk factors readily available in the outpatient setting, and may be used with asymptomatic individuals. In contrast, the Diamond and Forrester Probability (DFP) and the Goldman Prediction Tool (GPT), which calculate risk scores that predict either CHD or MI, can only be used with individuals who have chest pain.

Cases had a nearly 20-fold greater likelihood of having a FRS greater than or equal to 10%, compared with controls (odds ratio, 19.5). Among patients whose FRS was greater than or equal to 10%, more than 30% were diagnosed with angina. Higher DFP and GPT scores were also associated with MI (odds ratio of 8.3 with a DFP score of 10% or more, and OR of 12.1 with a GPT greater than 7%). However, the FRS had the best sensitivity (85%) and specificity (75%) combination in those individuals at moderate risk.

“This study documents the very substantial role of primary care clinicians in the early evaluation of acute cardiac ischemia,” Dr. Sequist said.

LOS ANGELES — Nearly one in nine patients admitted with an acute myocardial infarction were seen shortly before their MI in the primary care setting with symptoms suggestive of acute cardiac ischemia Dr. Thomas D. Sequist reported at the annual meeting of the Society of General Internal Medicine.

“We know from our own experience in Boston that missed diagnosis of MI in this setting is a rising source of malpractice claims,” said Dr. Sequist of Brigham and Women's Hospital, Boston.

The investigators identified 966 admissions for acute MI, of whom 106 (11%) had complained of symptoms typical of potential heart disease at their last outpatient visit. During the outpatient visit prior to the MI, chest pain and dyspnea accounted for more than three-quarters of all chief complaints. Other complaints included thoracic or epigastric pain, dizziness, weakness, or nausea.

This population-based case-control study used billing claims to identify admissions for acute MI from 2000 to 2004 among patients with no prior history of coronary heart disease (CHD). The 318 control patients were matched to cases on chief complaint and date of outpatient visit, but had no diagnosis of MI within the next 30 days.

Compared with controls, cases were older and were more likely to be male and to have diabetes or dyslipidemia. Approximately 50% of both cases and controls received an electrocardiogram (ECG). Not surprisingly, among those who had an ECG, the rates of normal results were much lower in cases than controls. Despite having symptoms of possible CHD, few study participants in both groups received cardiac medications (aspirin, 11%; beta-blockers, 7%). “There was a significant opportunity for more aggressive evaluation and treatment of these symptomatic patients,” Dr. Sequist said.

The Framingham Risk Score (FRS) predicts risk for developing CHD using information about coronary risk factors readily available in the outpatient setting, and may be used with asymptomatic individuals. In contrast, the Diamond and Forrester Probability (DFP) and the Goldman Prediction Tool (GPT), which calculate risk scores that predict either CHD or MI, can only be used with individuals who have chest pain.

Cases had a nearly 20-fold greater likelihood of having a FRS greater than or equal to 10%, compared with controls (odds ratio, 19.5). Among patients whose FRS was greater than or equal to 10%, more than 30% were diagnosed with angina. Higher DFP and GPT scores were also associated with MI (odds ratio of 8.3 with a DFP score of 10% or more, and OR of 12.1 with a GPT greater than 7%). However, the FRS had the best sensitivity (85%) and specificity (75%) combination in those individuals at moderate risk.

“This study documents the very substantial role of primary care clinicians in the early evaluation of acute cardiac ischemia,” Dr. Sequist said.

LOS ANGELES — Nearly one in nine patients admitted with an acute myocardial infarction were seen shortly before their MI in the primary care setting with symptoms suggestive of acute cardiac ischemia Dr. Thomas D. Sequist reported at the annual meeting of the Society of General Internal Medicine.

“We know from our own experience in Boston that missed diagnosis of MI in this setting is a rising source of malpractice claims,” said Dr. Sequist of Brigham and Women's Hospital, Boston.

The investigators identified 966 admissions for acute MI, of whom 106 (11%) had complained of symptoms typical of potential heart disease at their last outpatient visit. During the outpatient visit prior to the MI, chest pain and dyspnea accounted for more than three-quarters of all chief complaints. Other complaints included thoracic or epigastric pain, dizziness, weakness, or nausea.

This population-based case-control study used billing claims to identify admissions for acute MI from 2000 to 2004 among patients with no prior history of coronary heart disease (CHD). The 318 control patients were matched to cases on chief complaint and date of outpatient visit, but had no diagnosis of MI within the next 30 days.

Compared with controls, cases were older and were more likely to be male and to have diabetes or dyslipidemia. Approximately 50% of both cases and controls received an electrocardiogram (ECG). Not surprisingly, among those who had an ECG, the rates of normal results were much lower in cases than controls. Despite having symptoms of possible CHD, few study participants in both groups received cardiac medications (aspirin, 11%; beta-blockers, 7%). “There was a significant opportunity for more aggressive evaluation and treatment of these symptomatic patients,” Dr. Sequist said.

The Framingham Risk Score (FRS) predicts risk for developing CHD using information about coronary risk factors readily available in the outpatient setting, and may be used with asymptomatic individuals. In contrast, the Diamond and Forrester Probability (DFP) and the Goldman Prediction Tool (GPT), which calculate risk scores that predict either CHD or MI, can only be used with individuals who have chest pain.

Cases had a nearly 20-fold greater likelihood of having a FRS greater than or equal to 10%, compared with controls (odds ratio, 19.5). Among patients whose FRS was greater than or equal to 10%, more than 30% were diagnosed with angina. Higher DFP and GPT scores were also associated with MI (odds ratio of 8.3 with a DFP score of 10% or more, and OR of 12.1 with a GPT greater than 7%). However, the FRS had the best sensitivity (85%) and specificity (75%) combination in those individuals at moderate risk.

“This study documents the very substantial role of primary care clinicians in the early evaluation of acute cardiac ischemia,” Dr. Sequist said.

LOS ANGELES — An attenuated herpes zoster virus vaccine effectively prevents herpes zoster and postherpetic neuralgia, according to a presentation by Dr. Samuel Cykert at the annual meeting of the Society of General Internal Medicine.

The vaccine (Zostavax, Merck & Co.), which was licensed for use in people age 60 years and older by the Food and Drug Administration in late May, is administered as a single injection. The lifetime risk of symptomatic shingles is estimated at 2 in every 10 people, the FDA noted in a statement announcing the licensure of the vaccine.

The vaccine's cost-effectiveness is dependent on the price of the vaccine and the age of the patients being vaccinated, said Dr. Cykert of the University of North Carolina at Chapel Hill.

The incidence of shingles nearly triples between the ages of 60 and 75 years, he added.

Prednisone and the prescription antivirals that are currently used to shorten symptom duration are not effective in preventing postherpetic neuralgia (PHN), Dr. Cykert said.

In the Shingles Prevention Study, more than 38,000 adults (median age, 69 years) were randomized to receive the live attenuated varicella-zoster virus vaccine, or placebo. The subjects were followed for an average of 3 years to determine whether they developed shingles, and if so, to assess the duration of the pain.

The vaccine reduced the occurrence of shingles by about 50% in participants aged 60 years and older, and by 64% in those aged 60–69 years. In those participants who received the vaccine but who still developed shingles, pain duration was reduced slightly, according to the FDA statement.

The most frequently reported side effects in subjects who received Zostavax were itching, headache, and redness, swelling, and pain at the injection site. Significant adverse events were not found to be more common among participants in the vaccine group, compared with those in the placebo group, the FDA noted.

The primary goals of Dr. Cykert's pharmacoeconomic study were to define the circumstances under which the vaccine would be considered cost effective, using the criterion of $50,000 per quality-adjusted life year (QALY) gained.

The analysis estimated the cost-effectiveness of the vaccine by calculating the savings expected from prevention of herpes zoster (including reductions in treatment and in loss of work time for those younger than age 65) and subtracting that from the cost of the vaccine, Dr. Cykert expained.

“Our strategy of targeting 65-year-olds would create the best bang for the buck,” he said, because of the high incidence of shingles and the responsiveness to the vaccine at that age.

Among a cohort of 65-year-olds, the cost-effectiveness would be $57,840 per QALY. For all age groups combined, however, when the base model was run assuming lifetime vaccine efficacy, the cost per QALY would be $92,900. When the duration of vaccine efficacy was limited to 10 years, the base cost per QALY for all age groups would increase to $97,600, the analysis showed.

If the cost of the vaccine in the base model is reduced to $313 per unit, the cost meets the $50,000 per QALY cutoff. For the age-65 model, a vaccine price of $452 meets the same cutoff.

If the vaccine could be sold for $100 per dose, the vaccination strategy for 65-year-olds would actually save money, Dr. Cykert said.

According to Dr. Cykert, however, if the vaccine price remains high, other health care priorities would be likely to take precedence over a vaccine that does not actually save lives.

In contrast, if the vaccine is priced “responsibly,” he said, many older adults at risk of shingles are likely to benefit from an improved quality of life.

LOS ANGELES — An attenuated herpes zoster virus vaccine effectively prevents herpes zoster and postherpetic neuralgia, according to a presentation by Dr. Samuel Cykert at the annual meeting of the Society of General Internal Medicine.

The vaccine (Zostavax, Merck & Co.), which was licensed for use in people age 60 years and older by the Food and Drug Administration in late May, is administered as a single injection. The lifetime risk of symptomatic shingles is estimated at 2 in every 10 people, the FDA noted in a statement announcing the licensure of the vaccine.

The vaccine's cost-effectiveness is dependent on the price of the vaccine and the age of the patients being vaccinated, said Dr. Cykert of the University of North Carolina at Chapel Hill.

The incidence of shingles nearly triples between the ages of 60 and 75 years, he added.

Prednisone and the prescription antivirals that are currently used to shorten symptom duration are not effective in preventing postherpetic neuralgia (PHN), Dr. Cykert said.

In the Shingles Prevention Study, more than 38,000 adults (median age, 69 years) were randomized to receive the live attenuated varicella-zoster virus vaccine, or placebo. The subjects were followed for an average of 3 years to determine whether they developed shingles, and if so, to assess the duration of the pain.

The vaccine reduced the occurrence of shingles by about 50% in participants aged 60 years and older, and by 64% in those aged 60–69 years. In those participants who received the vaccine but who still developed shingles, pain duration was reduced slightly, according to the FDA statement.

The most frequently reported side effects in subjects who received Zostavax were itching, headache, and redness, swelling, and pain at the injection site. Significant adverse events were not found to be more common among participants in the vaccine group, compared with those in the placebo group, the FDA noted.

The primary goals of Dr. Cykert's pharmacoeconomic study were to define the circumstances under which the vaccine would be considered cost effective, using the criterion of $50,000 per quality-adjusted life year (QALY) gained.

The analysis estimated the cost-effectiveness of the vaccine by calculating the savings expected from prevention of herpes zoster (including reductions in treatment and in loss of work time for those younger than age 65) and subtracting that from the cost of the vaccine, Dr. Cykert expained.

“Our strategy of targeting 65-year-olds would create the best bang for the buck,” he said, because of the high incidence of shingles and the responsiveness to the vaccine at that age.

Among a cohort of 65-year-olds, the cost-effectiveness would be $57,840 per QALY. For all age groups combined, however, when the base model was run assuming lifetime vaccine efficacy, the cost per QALY would be $92,900. When the duration of vaccine efficacy was limited to 10 years, the base cost per QALY for all age groups would increase to $97,600, the analysis showed.

If the cost of the vaccine in the base model is reduced to $313 per unit, the cost meets the $50,000 per QALY cutoff. For the age-65 model, a vaccine price of $452 meets the same cutoff.

If the vaccine could be sold for $100 per dose, the vaccination strategy for 65-year-olds would actually save money, Dr. Cykert said.

According to Dr. Cykert, however, if the vaccine price remains high, other health care priorities would be likely to take precedence over a vaccine that does not actually save lives.

In contrast, if the vaccine is priced “responsibly,” he said, many older adults at risk of shingles are likely to benefit from an improved quality of life.

LOS ANGELES — An attenuated herpes zoster virus vaccine effectively prevents herpes zoster and postherpetic neuralgia, according to a presentation by Dr. Samuel Cykert at the annual meeting of the Society of General Internal Medicine.

The vaccine (Zostavax, Merck & Co.), which was licensed for use in people age 60 years and older by the Food and Drug Administration in late May, is administered as a single injection. The lifetime risk of symptomatic shingles is estimated at 2 in every 10 people, the FDA noted in a statement announcing the licensure of the vaccine.

The vaccine's cost-effectiveness is dependent on the price of the vaccine and the age of the patients being vaccinated, said Dr. Cykert of the University of North Carolina at Chapel Hill.

The incidence of shingles nearly triples between the ages of 60 and 75 years, he added.

Prednisone and the prescription antivirals that are currently used to shorten symptom duration are not effective in preventing postherpetic neuralgia (PHN), Dr. Cykert said.

In the Shingles Prevention Study, more than 38,000 adults (median age, 69 years) were randomized to receive the live attenuated varicella-zoster virus vaccine, or placebo. The subjects were followed for an average of 3 years to determine whether they developed shingles, and if so, to assess the duration of the pain.

The vaccine reduced the occurrence of shingles by about 50% in participants aged 60 years and older, and by 64% in those aged 60–69 years. In those participants who received the vaccine but who still developed shingles, pain duration was reduced slightly, according to the FDA statement.

The most frequently reported side effects in subjects who received Zostavax were itching, headache, and redness, swelling, and pain at the injection site. Significant adverse events were not found to be more common among participants in the vaccine group, compared with those in the placebo group, the FDA noted.

The primary goals of Dr. Cykert's pharmacoeconomic study were to define the circumstances under which the vaccine would be considered cost effective, using the criterion of $50,000 per quality-adjusted life year (QALY) gained.

The analysis estimated the cost-effectiveness of the vaccine by calculating the savings expected from prevention of herpes zoster (including reductions in treatment and in loss of work time for those younger than age 65) and subtracting that from the cost of the vaccine, Dr. Cykert expained.

“Our strategy of targeting 65-year-olds would create the best bang for the buck,” he said, because of the high incidence of shingles and the responsiveness to the vaccine at that age.

Among a cohort of 65-year-olds, the cost-effectiveness would be $57,840 per QALY. For all age groups combined, however, when the base model was run assuming lifetime vaccine efficacy, the cost per QALY would be $92,900. When the duration of vaccine efficacy was limited to 10 years, the base cost per QALY for all age groups would increase to $97,600, the analysis showed.

If the cost of the vaccine in the base model is reduced to $313 per unit, the cost meets the $50,000 per QALY cutoff. For the age-65 model, a vaccine price of $452 meets the same cutoff.

If the vaccine could be sold for $100 per dose, the vaccination strategy for 65-year-olds would actually save money, Dr. Cykert said.

According to Dr. Cykert, however, if the vaccine price remains high, other health care priorities would be likely to take precedence over a vaccine that does not actually save lives.

In contrast, if the vaccine is priced “responsibly,” he said, many older adults at risk of shingles are likely to benefit from an improved quality of life.

LOS ANGELES — Older African Americans distrust clinical research significantly more than do older whites, according to results of a mail survey presented by Dr. Raegan W. Durant at the annual meeting of the Society of General Internal Medicine.

The study was designed to determine whether African Americans' distrust of clinical research arises from attitudes toward physicians and the health care system in general, or from their relationships with individual physicians.

The investigators conducted a mail survey of 3,000 community-dwelling whites and African Americans over the age of 50 years in the greater Boston area, said Dr. Durant of Beth Israel Deaconess Medical Center, Boston. Participants answered seven previously validated questions from a distrust index that measured attitudes about clinical research.

Societal distrust was defined as negative historical and cultural perceptions of physicians and clinical research in general. Interpersonal distrust was defined as negative perceptions of research based on one's relationship with an individual physician. Overall, distrust was defined as five or more distrustful responses to the seven questions.

Individuals' trust in the primary care provider (PCP) was measured with the eight-item trust subscale from the Primary Care Assessment Survey. Responses were grouped into quartiles. Independent variables included race, gender, age, education level, type of insurance, knowledge of the Tuskegee Syphilis Experiment, and personal experiences with discrimination in health care. Bivariate and multivariate analyses examined the associations among these factors and responses to the distrust index.

The analyses included 498 whites and 329 African Americans. White participants were significantly older and better educated. African American participants were significantly more likely than whites to have experienced discrimination in health care (43% vs. 15%, respectively).

A large percentage of both whites (59%) and African Americans (49%) had participated previously in a clinical trial. African Americans were more likely than whites to believe that health care providers might use them as “guinea pigs” without permission (54% vs. 28%) or to think that physicians prescribe medications to experiment on people without permission (58% vs. 41%). There was no significant difference between whites and African Americans in the percentage that believed that their physicians had ever treated them as part of an experiment without their giving permission (2.9% vs. 1.6%, respectively). Interpersonal distrust did not differ significantly between African Americans and whites.

In a multivariate model, African Americans and respondents with the least trust in their PCPs were more likely to think that they might be used as “guinea pigs” without permission (odds ratios, 2.7 and 2.8, respectively). African American race and being in the lowest quartile of trust in one's PCP were also associated with having concerns about experimental use of prescription medications (odds ratios, 1.9 and 1.8, respectively).

Neither familiarity with the Tuskegee Syphilis Experiment nor experience with discrimination in health care was found to be significantly related to concerns about unwanted experimentation in multivariate models.

Because this study population was well educated overall and a large percentage had previous clinical trial experience, the results may not be representative of other populations. There may also have been some selection bias, as more whites (65%) responded to the survey than did African Americans (44%).

“This [distrust] is a real dilemma,” Dr. Durant said. “We may not ever be able to impact society.” Societal distrust in clinical research among minorities may hamper future research in many therapeutic areas.

LOS ANGELES — Older African Americans distrust clinical research significantly more than do older whites, according to results of a mail survey presented by Dr. Raegan W. Durant at the annual meeting of the Society of General Internal Medicine.

The study was designed to determine whether African Americans' distrust of clinical research arises from attitudes toward physicians and the health care system in general, or from their relationships with individual physicians.

The investigators conducted a mail survey of 3,000 community-dwelling whites and African Americans over the age of 50 years in the greater Boston area, said Dr. Durant of Beth Israel Deaconess Medical Center, Boston. Participants answered seven previously validated questions from a distrust index that measured attitudes about clinical research.

Societal distrust was defined as negative historical and cultural perceptions of physicians and clinical research in general. Interpersonal distrust was defined as negative perceptions of research based on one's relationship with an individual physician. Overall, distrust was defined as five or more distrustful responses to the seven questions.

Individuals' trust in the primary care provider (PCP) was measured with the eight-item trust subscale from the Primary Care Assessment Survey. Responses were grouped into quartiles. Independent variables included race, gender, age, education level, type of insurance, knowledge of the Tuskegee Syphilis Experiment, and personal experiences with discrimination in health care. Bivariate and multivariate analyses examined the associations among these factors and responses to the distrust index.

The analyses included 498 whites and 329 African Americans. White participants were significantly older and better educated. African American participants were significantly more likely than whites to have experienced discrimination in health care (43% vs. 15%, respectively).

A large percentage of both whites (59%) and African Americans (49%) had participated previously in a clinical trial. African Americans were more likely than whites to believe that health care providers might use them as “guinea pigs” without permission (54% vs. 28%) or to think that physicians prescribe medications to experiment on people without permission (58% vs. 41%). There was no significant difference between whites and African Americans in the percentage that believed that their physicians had ever treated them as part of an experiment without their giving permission (2.9% vs. 1.6%, respectively). Interpersonal distrust did not differ significantly between African Americans and whites.

In a multivariate model, African Americans and respondents with the least trust in their PCPs were more likely to think that they might be used as “guinea pigs” without permission (odds ratios, 2.7 and 2.8, respectively). African American race and being in the lowest quartile of trust in one's PCP were also associated with having concerns about experimental use of prescription medications (odds ratios, 1.9 and 1.8, respectively).

Neither familiarity with the Tuskegee Syphilis Experiment nor experience with discrimination in health care was found to be significantly related to concerns about unwanted experimentation in multivariate models.

Because this study population was well educated overall and a large percentage had previous clinical trial experience, the results may not be representative of other populations. There may also have been some selection bias, as more whites (65%) responded to the survey than did African Americans (44%).

“This [distrust] is a real dilemma,” Dr. Durant said. “We may not ever be able to impact society.” Societal distrust in clinical research among minorities may hamper future research in many therapeutic areas.

LOS ANGELES — Older African Americans distrust clinical research significantly more than do older whites, according to results of a mail survey presented by Dr. Raegan W. Durant at the annual meeting of the Society of General Internal Medicine.

The study was designed to determine whether African Americans' distrust of clinical research arises from attitudes toward physicians and the health care system in general, or from their relationships with individual physicians.

The investigators conducted a mail survey of 3,000 community-dwelling whites and African Americans over the age of 50 years in the greater Boston area, said Dr. Durant of Beth Israel Deaconess Medical Center, Boston. Participants answered seven previously validated questions from a distrust index that measured attitudes about clinical research.

Societal distrust was defined as negative historical and cultural perceptions of physicians and clinical research in general. Interpersonal distrust was defined as negative perceptions of research based on one's relationship with an individual physician. Overall, distrust was defined as five or more distrustful responses to the seven questions.

Individuals' trust in the primary care provider (PCP) was measured with the eight-item trust subscale from the Primary Care Assessment Survey. Responses were grouped into quartiles. Independent variables included race, gender, age, education level, type of insurance, knowledge of the Tuskegee Syphilis Experiment, and personal experiences with discrimination in health care. Bivariate and multivariate analyses examined the associations among these factors and responses to the distrust index.

The analyses included 498 whites and 329 African Americans. White participants were significantly older and better educated. African American participants were significantly more likely than whites to have experienced discrimination in health care (43% vs. 15%, respectively).

A large percentage of both whites (59%) and African Americans (49%) had participated previously in a clinical trial. African Americans were more likely than whites to believe that health care providers might use them as “guinea pigs” without permission (54% vs. 28%) or to think that physicians prescribe medications to experiment on people without permission (58% vs. 41%). There was no significant difference between whites and African Americans in the percentage that believed that their physicians had ever treated them as part of an experiment without their giving permission (2.9% vs. 1.6%, respectively). Interpersonal distrust did not differ significantly between African Americans and whites.

In a multivariate model, African Americans and respondents with the least trust in their PCPs were more likely to think that they might be used as “guinea pigs” without permission (odds ratios, 2.7 and 2.8, respectively). African American race and being in the lowest quartile of trust in one's PCP were also associated with having concerns about experimental use of prescription medications (odds ratios, 1.9 and 1.8, respectively).

Neither familiarity with the Tuskegee Syphilis Experiment nor experience with discrimination in health care was found to be significantly related to concerns about unwanted experimentation in multivariate models.

Because this study population was well educated overall and a large percentage had previous clinical trial experience, the results may not be representative of other populations. There may also have been some selection bias, as more whites (65%) responded to the survey than did African Americans (44%).

“This [distrust] is a real dilemma,” Dr. Durant said. “We may not ever be able to impact society.” Societal distrust in clinical research among minorities may hamper future research in many therapeutic areas.

LOS ANGELES — Cost is the most frequently cited barrier to adoption of electronic health records, according to two surveys presented in posters at the annual meeting of the Society of General Internal Medicine.

Although electronic health records (EHRs) appear to increase the efficiency and quality of medical care, few published studies have assessed how many ambulatory care practices currently use EHRs.

Dr. Steven Simon and his team at Harvard Medical School, Boston, conducted a survey of physicians, and Madeline McCarthy from Partners Healthcare System Inc., also in Boston, surveyed practice managers. Both studies were done in Massachusetts in 2005.

Overall, 23% of physicians who responded to the Harvard survey used EHRs in their practices—most of them (58%) for at least the previous 3 years. A larger proportion of multispecialty (35%) than primary care practices (25%) used EHRs.

Larger practices (seven or more physicians) were more likely to adopt EHRs than were solo practices (57% vs. 15%). Hospital-based practices or those with computerized office systems were also more likely to use EHRs.

Barriers to adopting EHRs identified by survey respondents included start-up costs (75%), maintenance costs (72%), loss of productivity while learning (73%), lack of computer skills (57%), skepticism about benefits (54%), and privacy or security concerns (48%). Physicians who listed start-up costs and loss of productivity as reasons not to adopt EHRs were significantly less likely to use EHRs in their practices.

In Ms. McCarthy's study, 29% of practice managers reported using EHRs in their practices: 26% of primary-care-only and 28% of specialty-care-only practices had adopted EHRs, compared with 40% of multispecialty practices. In this study as well, small practices were significantly less likely to have EHRs than were practices with more than seven physicians.

Practices that had computerized claims and/or billing systems, computerized scheduling systems, or computerized prescribing systems were significantly more likely to have also adopted EHRs than were practices without such systems.

Among practices in which EHRs allowed computerized retrieval of laboratory and radiology results, 88% of practices reported that a majority of their clinicians actively use these features, and in 72% of practices with electronic decision support, the majority of clinicians actively used that feature.

The findings showed that among the practices that do not currently use EHRs, the majority plan to implement them within 3–5 years. Surprisingly, 37% of practices did not plan to establish EHRs in the foreseeable future. Cost was the most frequent (50%) reason given for not implementing EHRs.

LOS ANGELES — Cost is the most frequently cited barrier to adoption of electronic health records, according to two surveys presented in posters at the annual meeting of the Society of General Internal Medicine.

Although electronic health records (EHRs) appear to increase the efficiency and quality of medical care, few published studies have assessed how many ambulatory care practices currently use EHRs.

Dr. Steven Simon and his team at Harvard Medical School, Boston, conducted a survey of physicians, and Madeline McCarthy from Partners Healthcare System Inc., also in Boston, surveyed practice managers. Both studies were done in Massachusetts in 2005.

Overall, 23% of physicians who responded to the Harvard survey used EHRs in their practices—most of them (58%) for at least the previous 3 years. A larger proportion of multispecialty (35%) than primary care practices (25%) used EHRs.

Larger practices (seven or more physicians) were more likely to adopt EHRs than were solo practices (57% vs. 15%). Hospital-based practices or those with computerized office systems were also more likely to use EHRs.

Barriers to adopting EHRs identified by survey respondents included start-up costs (75%), maintenance costs (72%), loss of productivity while learning (73%), lack of computer skills (57%), skepticism about benefits (54%), and privacy or security concerns (48%). Physicians who listed start-up costs and loss of productivity as reasons not to adopt EHRs were significantly less likely to use EHRs in their practices.

In Ms. McCarthy's study, 29% of practice managers reported using EHRs in their practices: 26% of primary-care-only and 28% of specialty-care-only practices had adopted EHRs, compared with 40% of multispecialty practices. In this study as well, small practices were significantly less likely to have EHRs than were practices with more than seven physicians.

Practices that had computerized claims and/or billing systems, computerized scheduling systems, or computerized prescribing systems were significantly more likely to have also adopted EHRs than were practices without such systems.

Among practices in which EHRs allowed computerized retrieval of laboratory and radiology results, 88% of practices reported that a majority of their clinicians actively use these features, and in 72% of practices with electronic decision support, the majority of clinicians actively used that feature.

The findings showed that among the practices that do not currently use EHRs, the majority plan to implement them within 3–5 years. Surprisingly, 37% of practices did not plan to establish EHRs in the foreseeable future. Cost was the most frequent (50%) reason given for not implementing EHRs.

LOS ANGELES — Cost is the most frequently cited barrier to adoption of electronic health records, according to two surveys presented in posters at the annual meeting of the Society of General Internal Medicine.

Although electronic health records (EHRs) appear to increase the efficiency and quality of medical care, few published studies have assessed how many ambulatory care practices currently use EHRs.

Dr. Steven Simon and his team at Harvard Medical School, Boston, conducted a survey of physicians, and Madeline McCarthy from Partners Healthcare System Inc., also in Boston, surveyed practice managers. Both studies were done in Massachusetts in 2005.

Overall, 23% of physicians who responded to the Harvard survey used EHRs in their practices—most of them (58%) for at least the previous 3 years. A larger proportion of multispecialty (35%) than primary care practices (25%) used EHRs.

Larger practices (seven or more physicians) were more likely to adopt EHRs than were solo practices (57% vs. 15%). Hospital-based practices or those with computerized office systems were also more likely to use EHRs.

Barriers to adopting EHRs identified by survey respondents included start-up costs (75%), maintenance costs (72%), loss of productivity while learning (73%), lack of computer skills (57%), skepticism about benefits (54%), and privacy or security concerns (48%). Physicians who listed start-up costs and loss of productivity as reasons not to adopt EHRs were significantly less likely to use EHRs in their practices.

In Ms. McCarthy's study, 29% of practice managers reported using EHRs in their practices: 26% of primary-care-only and 28% of specialty-care-only practices had adopted EHRs, compared with 40% of multispecialty practices. In this study as well, small practices were significantly less likely to have EHRs than were practices with more than seven physicians.

Practices that had computerized claims and/or billing systems, computerized scheduling systems, or computerized prescribing systems were significantly more likely to have also adopted EHRs than were practices without such systems.

Among practices in which EHRs allowed computerized retrieval of laboratory and radiology results, 88% of practices reported that a majority of their clinicians actively use these features, and in 72% of practices with electronic decision support, the majority of clinicians actively used that feature.

The findings showed that among the practices that do not currently use EHRs, the majority plan to implement them within 3–5 years. Surprisingly, 37% of practices did not plan to establish EHRs in the foreseeable future. Cost was the most frequent (50%) reason given for not implementing EHRs.

LOS ANGELES — Older African Americans distrust clinical research significantly more than do older whites, according to results of a mail survey presented by Dr. Raegan W. Durant at the annual meeting of the Society of General Internal Medicine.

The study was designed to determine whether African Americans' distrust of clinical research arises from attitudes toward physicians and the health care system in general, or from their relationships with individual physicians.

The investigators conducted a mail survey of 3,000 community-dwelling whites and African Americans over the age of 50 years in the greater Boston area, said Dr. Durant of Beth Israel Deaconess Medical Center, Boston. Participants answered seven previously validated questions from a distrust index that measured attitudes about clinical research.

Societal distrust was defined as negative historical and cultural perceptions of physicians and clinical research in general. Interpersonal distrust was defined as negative perceptions of research based on one's relationship with an individual physician. Overall, distrust was defined as five or more distrustful responses to the seven questions.

Individuals' trust in the primary care provider (PCP) was measured with the eight-item trust subscale from the Primary Care Assessment Survey. Responses were grouped into quartiles. Independent variables included race, gender, age, education level, type of insurance, knowledge of the Tuskegee Syphilis Experiment, and personal experiences with discrimination in health care. Bivariate and multivariate analyses examined the associations among these factors and responses to the distrust index.

The analyses included 498 whites and 329 African Americans. White participants were significantly older and better educated. African American participants were significantly more likely than whites to have experienced discrimination in health care (43% vs. 15%, respectively).

Interestingly, a large percentage of both whites (59%) and African Americans (49%) had participated previously in a clinical trial. African Americans were more likely than whites to believe that health care providers might use them as “guinea pigs” without permission (54% vs. 28%) or to think that physicians prescribe medications to experiment on people without permission (58% vs. 41%). There was no significant difference between whites and African Americans in the percentage that believed that their physicians had ever treated them as part of an experiment without their giving permission (2.9% vs. 1.6%, respectively). Interpersonal distrust did not differ significantly between African Americans and whites.

In a multivariate model, African Americans and respondents with the least trust in their PCPs were more likely to think that they might be used as “guinea pigs” without permission (odds ratios, 2.7 and 2.8, respectively). African American race and being in the lowest quartile of trust in one's PCP were also associated with having concerns about experimental use of prescription medications (odds ratios, 1.9 and 1.8, respectively).

Neither familiarity with the Tuskegee Syphilis Experiment nor experience with discrimination in health care was significantly related to concerns about unwanted experimentation in multivariate models.

Because this study population was well educated overall and a large percentage had previous clinical trial experience, the results may not be representative of other populations. There may also have been some selection bias, as more whites (65%) responded to the survey than did African Americans (44%).

“This [distrust] is a real dilemma,” Dr. Durant said. “We may not ever be able to impact society.” Societal distrust in clinical research among minorities may hamper future research in many therapeutic areas.

LOS ANGELES — Older African Americans distrust clinical research significantly more than do older whites, according to results of a mail survey presented by Dr. Raegan W. Durant at the annual meeting of the Society of General Internal Medicine.

The study was designed to determine whether African Americans' distrust of clinical research arises from attitudes toward physicians and the health care system in general, or from their relationships with individual physicians.

The investigators conducted a mail survey of 3,000 community-dwelling whites and African Americans over the age of 50 years in the greater Boston area, said Dr. Durant of Beth Israel Deaconess Medical Center, Boston. Participants answered seven previously validated questions from a distrust index that measured attitudes about clinical research.

Societal distrust was defined as negative historical and cultural perceptions of physicians and clinical research in general. Interpersonal distrust was defined as negative perceptions of research based on one's relationship with an individual physician. Overall, distrust was defined as five or more distrustful responses to the seven questions.

Individuals' trust in the primary care provider (PCP) was measured with the eight-item trust subscale from the Primary Care Assessment Survey. Responses were grouped into quartiles. Independent variables included race, gender, age, education level, type of insurance, knowledge of the Tuskegee Syphilis Experiment, and personal experiences with discrimination in health care. Bivariate and multivariate analyses examined the associations among these factors and responses to the distrust index.

The analyses included 498 whites and 329 African Americans. White participants were significantly older and better educated. African American participants were significantly more likely than whites to have experienced discrimination in health care (43% vs. 15%, respectively).

Interestingly, a large percentage of both whites (59%) and African Americans (49%) had participated previously in a clinical trial. African Americans were more likely than whites to believe that health care providers might use them as “guinea pigs” without permission (54% vs. 28%) or to think that physicians prescribe medications to experiment on people without permission (58% vs. 41%). There was no significant difference between whites and African Americans in the percentage that believed that their physicians had ever treated them as part of an experiment without their giving permission (2.9% vs. 1.6%, respectively). Interpersonal distrust did not differ significantly between African Americans and whites.

In a multivariate model, African Americans and respondents with the least trust in their PCPs were more likely to think that they might be used as “guinea pigs” without permission (odds ratios, 2.7 and 2.8, respectively). African American race and being in the lowest quartile of trust in one's PCP were also associated with having concerns about experimental use of prescription medications (odds ratios, 1.9 and 1.8, respectively).

Neither familiarity with the Tuskegee Syphilis Experiment nor experience with discrimination in health care was significantly related to concerns about unwanted experimentation in multivariate models.

Because this study population was well educated overall and a large percentage had previous clinical trial experience, the results may not be representative of other populations. There may also have been some selection bias, as more whites (65%) responded to the survey than did African Americans (44%).

“This [distrust] is a real dilemma,” Dr. Durant said. “We may not ever be able to impact society.” Societal distrust in clinical research among minorities may hamper future research in many therapeutic areas.

LOS ANGELES — Older African Americans distrust clinical research significantly more than do older whites, according to results of a mail survey presented by Dr. Raegan W. Durant at the annual meeting of the Society of General Internal Medicine.

The study was designed to determine whether African Americans' distrust of clinical research arises from attitudes toward physicians and the health care system in general, or from their relationships with individual physicians.

The investigators conducted a mail survey of 3,000 community-dwelling whites and African Americans over the age of 50 years in the greater Boston area, said Dr. Durant of Beth Israel Deaconess Medical Center, Boston. Participants answered seven previously validated questions from a distrust index that measured attitudes about clinical research.

Societal distrust was defined as negative historical and cultural perceptions of physicians and clinical research in general. Interpersonal distrust was defined as negative perceptions of research based on one's relationship with an individual physician. Overall, distrust was defined as five or more distrustful responses to the seven questions.

Individuals' trust in the primary care provider (PCP) was measured with the eight-item trust subscale from the Primary Care Assessment Survey. Responses were grouped into quartiles. Independent variables included race, gender, age, education level, type of insurance, knowledge of the Tuskegee Syphilis Experiment, and personal experiences with discrimination in health care. Bivariate and multivariate analyses examined the associations among these factors and responses to the distrust index.

The analyses included 498 whites and 329 African Americans. White participants were significantly older and better educated. African American participants were significantly more likely than whites to have experienced discrimination in health care (43% vs. 15%, respectively).

Interestingly, a large percentage of both whites (59%) and African Americans (49%) had participated previously in a clinical trial. African Americans were more likely than whites to believe that health care providers might use them as “guinea pigs” without permission (54% vs. 28%) or to think that physicians prescribe medications to experiment on people without permission (58% vs. 41%). There was no significant difference between whites and African Americans in the percentage that believed that their physicians had ever treated them as part of an experiment without their giving permission (2.9% vs. 1.6%, respectively). Interpersonal distrust did not differ significantly between African Americans and whites.

In a multivariate model, African Americans and respondents with the least trust in their PCPs were more likely to think that they might be used as “guinea pigs” without permission (odds ratios, 2.7 and 2.8, respectively). African American race and being in the lowest quartile of trust in one's PCP were also associated with having concerns about experimental use of prescription medications (odds ratios, 1.9 and 1.8, respectively).

Neither familiarity with the Tuskegee Syphilis Experiment nor experience with discrimination in health care was significantly related to concerns about unwanted experimentation in multivariate models.

Because this study population was well educated overall and a large percentage had previous clinical trial experience, the results may not be representative of other populations. There may also have been some selection bias, as more whites (65%) responded to the survey than did African Americans (44%).

“This [distrust] is a real dilemma,” Dr. Durant said. “We may not ever be able to impact society.” Societal distrust in clinical research among minorities may hamper future research in many therapeutic areas.