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This Week in JAMA
October 16, 2002

This Week in JAMA

JAMA. 2002;288(15):1813. doi:10.1001/jama.288.15.1813
Costs of Strategies for Acute Coronary Syndromes

In the Treat Angina With Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy (TACTICS)–Thrombolysis in Myocardial Infarction (TIMI) 18 trial, patients with either unstable angina or non–ST-segment elevation myocardial infarction treated with aspirin, heparin, and a platelet glycoprotein IIb/IIIa inhibitor who were treated with an early invasive strategy (catheterization within 4-48 hours of randomization and revascularization as appropriate) had a significantly reduced rate of major cardiac events at 6 months compared with those who were treated with a conservative strategy. In this economic analysis of the TACTICS-TIMI 18 trial, Mahoney and colleaguesArticle found that initial hospitalization costs, which were significantly higher in the invasive strategy group, were largely offset by greater costs primarily for rehospitalization in the conservative strategy group during 6 months of follow-up. The estimated cost per year of life gained for the invasive strategy ranged from $8371 to $25 769. In an editorial, CohenArticle notes that the early invasive management strategy appears to be both clinically and economically advantageous for patients at higher risk of ischemic complications, but not for patients at low risk.

Certificate of Need Regulation and Quality of Care

Certificate of need regulation, which began in 1974, was designed to control health care costs by preventing unnecessary expansion of medical facilities. To examine the relationship between certificate of need regulation and quality of care, Vaughan-Sarrazin and colleagues compared risk-adjusted hospital mortality rates for coronary artery bypass graft (CABG) surgery and the proportion of patients undergoing CABG surgery in low-volume hospitals in states with and without certificate of need regulation. Risk-adjusted mortality for CABG surgery was significantly higher in states without certificate of need regulation compared with states with continuous certificate of need regulation from 1994 through 1999. Average hospital volumes for CABG surgery in states without certificate of need regulation were significantly lower than in states with regulation, and more patients in states without certificate of need regulation underwent CABG surgery in low-volume hospitals.

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Plasma Folate Levels and Risk of Spontaneous Abortion

Both folate deficiency and folic acid supplementation have been associated with increased risk of spontaneous abortion. In this population-based case-control study conducted in Sweden, where folic acid food fortification has not been introduced, George and colleagues found that risk of early spontaneous abortion was greater among women with low plasma folate levels (≤2.19 ng/mL) than among women with plasma folate levels between 2.20 and 3.95 ng/mL. Risk of spontaneous abortion was not increased among women with higher folate levels.

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Six-Year Follow-up of Programs for Children of Divorce

Wolchik and colleagues conducted a 6-year follow-up evaluation of adolescents aged 15 to 19 years who had participated in a randomized controlled trial of 2 interventions designed to prevent mental health problems in children with divorced parents. Compared with participants who received the control condition, adolescents who participated in the intervention programs had a lower rate of diagnosed mental disorders, fewer sexual partners, and less alcohol, marijuana, and other drug use.

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CLINICIAN'S CORNER

Part 1Article of this article reviews evidence about the value of various clinical applications of bone densitometry. Discussion of clinical situations presented in part 2Article addresses who should be tested with bone densitometry, what test to use, how to do follow-up testing, and how to improve screening.

A Piece of My Mind

"The most powerful therapy I have to offer my patients is me, and I have tried that prescription as much as possible." From "What Will I Do Without You?"

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Medical News & Perspectives

The next generation of experimental eye implants will use neurotransmitters to stimulate individual neurons in the retina.

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Primary Prevention of Hypertension

The new report from the National High Blood Pressure Education Program Coordinating Committee on the primary prevention of hypertension emphasizes a population-based strategy to achieve a downward shift in the distribution of blood pressure in the general population and an intensive targeted strategy to decrease blood pressure in those at high risk of developing hypertension.

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Transmission of Vaccinia Virus

Neff and coauthors review data from the 1960s on transmission of vaccinia virus from smallpox vaccinees to contacts, assess the present risk of transmission of contact vaccinia, and discuss implications for current smallpox vaccination policy.

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Chronic Illness Care in Primary Care: Innovations in Primary Care

Part 2 of a 2-part article on a chronic care model developed to improve the management of patients with chronic illness in primary care evaluates the extent to which the chronic care model improves care and whether it reduces health care costs.

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Patient Page

For your patient: Information about miscarriage.

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