In this review of the literature, Armour et al examine the influence of managed care financial incentives on physicians' use of resources. There is a limited amount of data on the subject, and evidence regarding the effect of explicit financial incentives and bonus payments to physicians is mixed.
In this 10-year study of 1874 injection drug users, Strathdee and colleagues found that risk factors for human immunodeficiency virus (HIV) infection were different for men and women. Among men, sharing needles, daily injection, shooting-gallery attendance, and homosexuality were the most prominent risk factors. Among women, incidence was higher in those with sexually transmitted diseases. These results show that HIV interventions for injection drug users should be sex-specific.
The impact of comorbidity on glycemic control is assessed in this article on 654 patients with type 2 diabetes mellitus. El-Kebbi et al used the Chronic Disease Score (CDS) index to rate comorbidity and found that patients with higher CDS scores were older and had lower hemoglobin A1c (HbA1c) levels. They found higher HbA1c levels in patients receiving drug therapy, patients with lower C-peptide levels, and younger patients.
This review by Attia et al summarizes data from published studies on the rate of deep vein thrombosis (DVT) and the efficacy of thromboprophylaxis among general medical-surgical, trauma, neurosurgical, and spinal cord injury patients. Low-dose, unfractionated subcutaneous heparin appears to provide adequate DVT prophylaxis in medical and surgical patients in the intensive care unit, but may be less efficacious than subcutaneous low–molecular weight heparin in those who have sustained major trauma with skeletal injury. Mechanical prophylaxis, such as graduated compression stockings or pneumatic compression devices, has not been well investigated in either of these populations, but offers some benefit among neurosurgical patients. Studies of patients with spinal cord injury are too disparate to arrive at any meaningful conclusions. Decisions about prophylaxis against DVT must balance the absolute risk of venous thromboembolism against that of hemorrhage; thus, the efficacy data established in one population do not necessarily translate into a net benefit among other individuals.
To assess clinician beliefs about the etiology, clinical course, and treatment of patients with illness attributed to service in the Gulf War, Richardson and colleagues surveyed providers from the general internal medicine and mental health clinics of 3 Veterans Affairs medical centers. Internal medicine providers were more likely to attribute health problems of Gulf War veterans to psychological causes and to recommend psychological treatment than mental health care providers. Mental health care providers were more likely to attribute the symptoms of these veterans to physical causes and to recommend biomedical treatment. The authors conclude that divergent provider beliefs may contribute to the multiple referrals experienced by Gulf War patients and others with medically unexplained symptoms.
Using a sample of claims from a commercial insurer, Laditka et al studied health care use and costs for individuals with diabetes. The diabetic population was 1.6% of the total population, but had 9.4% of costs. The greatest use of healthcare resources and cost was associated with individuals with type 1 diabetes mellitus. The hospitalization rate for this group was 8 times higher for both acute myocardial infarction and coronary artery bypass, nearly 9 times higher for cardiac catheterization, and more than 22 times higher for heart failure. For physician services, those with type 1 diabetes used over 27 times more relative value units than the general population for endocrinologists and nephrologists. These results reflect the great human toll of diabetes and highlight the importance of aggressive diabetes management, especially for those with type 1 diabetes.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2001;161(10):1260. doi:10.1001/archinte.161.10.1260