Asch and colleaguesArticle developed a set of 47 clinical indicators for measuring
underuse of necessary care for 15 common medical conditions and for preventive
care among the elderly Medicare population and applied them to administrative
data. For 16 of 40 indicators, beneficiaries received the indicated care less
than two thirds of the time. African Americans, residents of poverty areas,
and residents of Health Professional Shortage Areas had significantly more
underuse compared with other beneficiaries. In an editorial, HannanArticle emphasizes
the urgent need to develop ongoing systems to measure and monitor the quality
of care in the United States.
Many countries recommend a booster dose of Haemophilus
influenzae type b (Hib) vaccine in the second year of life, but there
is little evidence indicating that a booster dose is necessary. The recommended
schedule for Hib vaccination of infants in the United Kingdom consists of
3 doses at 2, 3, and 4 months of age and no booster dose. Heath and colleagues
report that between October 1992 and March 1999, the clinical vaccine failure
rate in the United Kingdom derived from the observed number of true vaccine
failures after 3 doses of Hib conjugate vaccine was 2.2 per 100,000 vaccinees.
Clinical protection remained high until the sixth year of life despite a small
but significant decline after the first year of life and waning levels of
antibody to Hib capsular polysaccharide.
The availability of alcohol in a community may be associated with motor
vehicle crashes and violent assaults. Holder and colleagues evaluated the
effect of a community-based environmental intervention on the rate of high-risk
drinking and alcohol-related motor vehicle injuries and assaults in 3 communities.
Self-reported heavy drinking declined in the intervention communities and,
compared with matched control communities, driving after drinking crashes
decreased by 6%, nighttime injury crashes decreased by 10%, and assault injuries
observed in emergency departments declined by 43%.
Cigarette smoking has been associated with some anxiety disorders, but
whether anxiety disorders predict risk for future smoking or whether smoking
predicts risk for subsequent anxiety disorders is not known. Johnson and colleagues
assessed psychiatric disorders and smoking among 688 adolescents in 1985-1986
(mean age, 16 years) and reevaluated study participants in 1991 through 1993
at mean age 22 years. The risk for agoraphobia, generalized anxiety disorder,
and panic disorder during early adulthood was increased among adolescents
who smoked 20 cigarettes or more per day. Anxiety disorders in adolescence
were not significantly associated with cigarette smoking during early adulthood.
To study the effectiveness of noninvasive techniques of ventilatory
support, Delclaux and colleaguesArticle assigned patients with acute hypoxemic, nonhypercapnic
respiratory insufficiency to receive either oxygen therapy plus continuous
positive airway pressure (CPAP) or oxygen therapy alone. There were no significant
differences between the groups in the rate of endotracheal intubation, in-hospital
mortality, or mean intensive care unit (ICU) length of stay, but adverse events
in the ICU were significantly more common in the CPAP group. In a case-control
study among patients with acute exacerbation of chronic obstructive pulmonary
disease or hypercapnic cardiogenic pulmonary edema, Girou and colleaguesArticle found
that the incidence of nosocomial infections and pneumonia was significantly
lower among patients who were treated with noninvasive ventilation compared
with matched controls treated with mechanical ventilation. In an editorial,
KeenanArticle observes that the benefit of noninvasive positive pressure ventilation
is less consistent among patients with hypoxemic respiratory failure than
among patients with hypercarbic respiratory failure.
"Medicine is the people we meet along the way—pain, worry, or
suffering provides the excuse to meet them." From "I Have Always Been Fascinated . . . "
The continuing priority of avoiding medical error and injury was highlighted
by the recent presentation of National Patient Safety Awards to the designers
of innovative improvement programs.
Three case presentations illustrate the broad clinical spectrum of early
For your patients: A primer on mechanical ventilation.
A JAMA theme issue on end-of-life care.
This Week in JAMA. JAMA. 2000;284(18):2285. doi:10.1001/jama.284.18.2285