Patients In New York Research Articles

Human Adenovirus 14a: A New Epidemic Threat

Human Adenovirus 14a: A New Epidemic Threat

Impact of the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System on the management of patients with acute myocardial infarction complicated by cardiogenic shock

Studies suggest that the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System, which makes public the operator-specific mortality for patients undergoing coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI), may deter operators from providing revascularization to high-risk cardiac patients in New York compared to other states. We performed a retrospective analysis of 545 US patients with acute myocardial infarction and cardiogenic shock due to predominant left ventricular failure enrolled in the SHOCK Registry. Adjusting for case mix using a propensity score method, we compared the use of coronary angiography, PCI, CABG, and outcomes between 220 patients in New York and 325 in other states. New York patients were older with similar or less severe baseline characteristics. After propensity score adjustment, New York patients were less likely than non-New York patients to undergo coronary angiography (odds ratio 0.46, 95% CI 0.31-0.68, P < .001) and PCI (odds ratio 0.51, 95% CI 0.33-0.77, P = .002). Coronary artery bypass graft rates were similarly low (14.1% vs 15.1%, P = not significant), but New York patients waited significantly longer after shock onset for surgery (101.2 vs 10.3 hours, P < .001) with only 32.3% of New York patients vs 75.5% of non-New York patients (P < .001) taken for CABG within 3 days of shock onset. In our propensity-adjusted retrospective analysis, New York patients with acute myocardial infarction and cardiogenic shock were less likely to undergo coronary angiography and PCI and waited significantly longer to receive CABG than their non-New York counterparts. These findings suggest that state-required reporting to the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System may result in the reluctance to revascularize the highest-risk cardiac patients.

Veterans Health Administration Patients’ Use of the Private Sector for Coronary Revascularization In New York

We sought to quantify Veterans Health Administration (VA) patients' utilization of coronary revascularization in the private sector and to assess the potential impact of directing this care to high-performance hospitals. Using VA and New York State administrative and clinical databases, we conducted a retrospective cohort study examining residents of New York State who were enrolled in the VA and underwent either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) in 1999 or 2000 (n=6562) in either the VA or the private sector. We first calculated the proportion of revascularizations obtained in the VA and the private sector. We then identified the private sector hospitals in which these men obtained revascularizations and determined potential changes in mortality and travel burden associated with directing private sector care to high performance hospitals. VA patients in New York were much more likely to undergo revascularization in the private sector than in VA hospitals: 83% of CABGs (2341/2829) and 87% of PCIs (4054/4665) were obtained in the private sector. Private sector utilization was distributed evenly across high- and low-mortality hospitals. Directing private-sector CABG surgery to high-performance hospitals could have reduced expected mortality by 24% (from 2.3% to 1.7%) and would only increase median travel time from 21 to 30 minutes. The benefit of redirecting PCI care is minimal. For high-mortality procedures that veterans frequently obtain in the private sector, like CABG, directing care to high-performance hospitals may be an effective way to improve outcomes for veterans.

Follow-up of patients with celiac disease: Achieving compliance with treatment

Celiac disease is the only autoimmune condition for which we know the environmental trigger: gluten. Complete removal of gluten from the diet in a patient with celiac disease should result in symptomatic, serologic, and histologic remission. However, compliance with the gluten-free diet, especially in the United States, is extremely challenging. Compliance can be measured both noninvasively, by dietary history and measurement of serum antibodies, and invasively, by using endoscopic and histologic criteria. The advantages and disadvantages of these various modalities are discussed. The highest rates of compliance are reported in patients who are diagnosed as young children, whereas adolescents and those diagnosed via mass serologic screening have the most transgressions. Barriers to compliance include the poor palatability of gluten-free foods, confusing food-labeling practices, and common comorbid psychologic burdens such as anxiety and depression. Because celiac disease is a multisystemic disorder, physicians need to be aware of the potential autoimmune, nutritional, and malignant complications. An algorithm for the follow-up and management of the newly diagnosed celiac disease patient is presented, which includes regular follow-up; measurement of serum antibodies; eliciting a detailed dietary history; and examination for signs and symptoms of nutritional deficiencies, malignancy, and other autoimmune diseases. Ideally, a team approach to the follow-up of the newly diagnosed patient should include regular supervision by an interested physician, medical nutritional counseling by a registered dietician, and access to local and national support groups knowledgeable about this condition.

Elderly trauma inpatients in New York state: 1994-1998.

The aging of the population in the United States has led to an increase in geriatric trauma. This study aimed to examine the characteristics and outcomes of geriatric trauma patients in New York State. Four groups of elderly trauma patients (ages 40-64, 65-74, 75-84, and 85+ years) were contrasted with younger adults ages 13 to 39 years with respect to mechanism of injury, discharge disposition, hospital length of stay, comorbidities, and type of hospital in which they were treated. Also, the independent association of each group with in-hospital mortality was investigated for patients with blunt injuries using logistic regression. There was a 17.6% increase between 1994 and 1998 in the number of traumatic injuries qualifying for the New York State Trauma Registry in the 75- to 84-year-old group and a 16.4% increase in the group ages 85 years or older, despite a decrease in traumatic injuries in other age groups. The majority of these injuries among the patients 75 years of age or older resulted from low falls (from the same level). The mortality rate rose substantially with age, from 5.1% to 5.9% to 9.4% to 12.3% to 15.8%, respectively, for the groups ages 13 to 39, 40 to 64, 65 to 74, 75 to 84, and 85 or more years. Also, fewer than 20% of the patients older than 75 years died within 1 day after admission to the hospital, as compared with 44% of the patients younger than 65 years. The groups ages 40 to 64, 65 to 74, 75 to 84, and 85 years or older were all independent (increasingly) significant predictors of mortality for all three mechanisms of injury investigated. The adjusted odds ratios for mortality relative to patients who were 13 to 39 years of age were 2.67, 8.41, 17.40, and 34.98, respectively, for the groups ages 40 to 64, 65 to 74, 75 to 84, and 85 years or older. Trauma is a serious and escalating problem for the elderly, and increasing age is a significant risk factor for patient mortality.

Do well-publicized risk-adjusted outcomes reports affect hospital volume?

Report cards on hospital performance are common but have uncertain impact. The objective of this study was to determine whether hospitals recognized as performance outliers experience volume changes after publication of a report card. Secondary objectives were to test whether favorable outliers attract more patients with related conditions, or from outside their catchment areas; and whether disadvantaged groups are less responsive to report cards. We used a time-series analysis using linear and autoregressive models. We studied patients admitted to nonfederal hospitals designated as outliers in reports on coronary bypass surgery (CABG) mortality in New York, acute myocardial infarction (AMI) mortality in California, and postdiskectomy complications in California. We studied observed versus expected hospital volume for topic and related conditions and procedures, by month/quarter after a report card, with and without stratification by age, race/ethnicity, insurance, and catchment area. Potential confounders included statewide prevalence, prereport hospital volume and market share, and unrelated volume. In California, low-mortality and high-mortality outliers did not experience changes in AMI volume after adjusting for autocorrelation. Low-complication outliers for lumbar diskectomy experienced slightly increased volume in autoregressive models. No other cohorts demonstrated consistent trends. In New York, low-mortality outliers experienced significantly increased CABG volume in the first month after publication, whereas high-mortality outliers experienced decreased volume in the second month. The strongest effects were among white patients and those with HMO coverage in California, and among white or other patients and those with Medicare in New York. Volume effects were modest, transient, and largely limited to white Medicare patients in New York.

Is geography destiny for patients in new york with myocardial infarction?

Purpose The use of coronary revascularization among patients with myocardial infarction varies by race/ethnicity and socioeconomic status. The objective of this study was to determine whether local availability of facilities might influence apparent racial disparities in revascularization and health outcomes. Methods Using Statewide Planning and Research Cooperative System data (1988–1999) from the New York State Department of Health, we determined revascularization rates among patients hospitalized with myocardial infarction in two socioeconomically disadvantaged communities in New York City (the South Bronx, which has no hospitals that have revascularization facilities, and Harlem, which has three revascularization facilities), as well as in its most advantaged community (mid-Manhattan, which has six such facilities). The rest of New York City served as reference. We measured demographic and clinical characteristics and revascularization rates in each community. Results Among patients hospitalized with myocardial infarction, the age-adjusted revascularization rates were 29.2% for whites, 12.5% for blacks, and 19.9% for Hispanics ( P <0.01). Rates were 12.0% in the South Bronx, 24.0% in Harlem, 38.4% in mid-Manhattan, and 21.2% in the rest of New York City ( P <0.05). Logistic regression analysis, adjusting for age, sex, race, insurance status, comorbidity, clinical complications, and year of admission, revealed that South Bronx patients were about 20% less likely to be revascularized than those in the rest of New York City, whereas patients living in Harlem were twice as likely to receive such treatment as residents in the rest of New York City. Among patients admitted to hospitals with cardiac revascularization facilities, lower use among South Bronx residents persisted, but after adjusting for patient characteristics, Harlem residents were significantly less likely to be revascularized than those from the rest of New York City. Conclusion Race and socioeconomic factors influence the likelihood of revascularization after myocardial infarction among residents of New York City. In addition, lack of availability of revascularization further reduces its use by residents of disadvantaged neighborhoods.

Alimentary diseases in the poor and middle class in London 1773-1815, and in New York poor 1797-1818.

Although dyspepsia has been described for thousands of years, few studies have analysed its incidence before the 19th century when peptic ulcer first became a major dyspepsia-producing disease. The incidence of alimentary disease around 1800 was examined in three private practices for the fee-paying middle class and in five public dispensaries for the poor in London, as well as in one dispensary in New York. The proportions of attendances for alimentary disorders were identical, 16%, in each of the three groups. Diarrhoea and dysentery were twice as common in the London dispensary than in private practice, presumably because of poor sanitation. Dyspepsia showed a similar incidence in the London dispensary and private practice, but was only half as common in New York. Worms were three times more common in dispensary patients in New York than in London. The incidence of diarrhoea and dyspepsia indicated no significant time trends over 43 years. None of the alimentary causes of death showed peptic ulcer at necropsy, and both haematemesis and intestinal haemorrhage were rare. Around 1800, the infrequent deaths from alimentary conditions suggested that the ulcer epidemic had not yet started. Instead, it is probable that the dyspepsia was similar to the non-ulcer dyspepsia of today.

US web site will publish list of "drug-free practitioners"

No Free Lunch, a group of US health care providers who “believe that pharmaceutical promotion should not guide clinical practice” (www.nofreelunch.org) is to publicize a list of practitioners who have pledged to be “drug company-free.” Doctors who sign up to the “drug-free practitioners list” must pledge to be “free of company money and influence in their clinical practice, teaching, and research.” They must also promise to practice medicine on the basis of the best available scientific evidence and in the best interest of their patients, rather than on the basis of “advertising gimmicks and promotional ploys.” The idea for the list came from a group of patients in New York who had been given free drug samples by their doctors. These patients began to question why they were given samples, believing that it was part of a marketing strategy by the pharmaceutical industry. In one recent study, doctors stated that they used free samples as a way of avoiding cost to patients who were uninsured ( Journal of General Internal Medicine 2000;15:478-483) [PubMed]. Theavailability of drug samples, however, led doctors to dispense andsubsequently to prescribe drugs that differed from their preferreddrug choice. The pharmaceutical industry gave $7.2 billion worth ofsamples to US doctors in 1999, and No Free Lunch believes that thiswas a deliberate marketing ploy. In addition to publishing thelist, No Free Lunch offers a “pen amnesty”program—doctors hand in their drug company pens and receive a NoFree Lunch pen in return. Doctors can also check their own“drug company dependence” by answering a special CAGEquestionnaire (www.nofreelunch.org/cage.html),a parody of the screening tool commonly used for alcohol dependence:“Have you ever prescribed Celebrex? Do you getAnnoyed by people who complain about drug lunches and freegifts? Is there a medication loGo on the pen you're using rightnow? Do you drink your morning Eye-opener out of a Lipitorcoffee mug?” Bob Goodman, the director of No Free Lunch,hopes that the group will help to change a medical culture that seestaking gifts from drug representatives as “anentitlement.”

Parakeets, canaries, finches, parrots and lung cancer: no association.

The relationship between pet bird keeping and lung cancer according to exposure to tobacco smoking was investigated in a case-control study in hospitals of New York City and Washington, DC, USA. Newly diagnosed lung cancer cases (n = 887) aged 40-79 years were compared with 1350 controls with diseases not related to smoking, of the same age, gender and date of admission as the cases. The prevalence of pet bird keeping was 12.5% in men and 19.1% in women. There was no association between ever keeping a pet bird and lung cancer in never smokers (men adjusted odds ratio (OR) = 0.70, 95% confidence interval (CI) 0.15-3.17; women, 1.32, 95% CI 0.65-2.70), or in smokers and non-smokers combined, after adjustment for ever smoking (men: 1.28, 95% CI 0.88-1.86; women: 1.17, 95% CI 0.83-1.64; all: 1.21, 95% CI 0.95-1.56). Risk did not increase in relation to duration of pet bird keeping. Cases and controls kept similar types of birds. There was a tenfold increase of lung cancer risk associated with smoking among non-bird keepers (adjusted OR = 9.15). There was no indication of a synergism, either additive or multiplicative, between smoking and pet bird keeping with respect to lung cancer risk. Either alone or in conjunction with smoking, keeping parakeets, canaries, finches or parrots is not a risk factor for lung cancer among hospital patients in New York and in Washington, DC.

A Continuing Survey of Drug-Resistant Tuberculosis, New York City, April 1994

A 1991 survey showed high levels of drug resistance among tuberculosis patients in New York, NY. As a result, the tuberculosis control program was strengthened, including expanded use of directly observed therapy and improved infection control. We collected isolates from every patient in New York City with a positive culture for Mycobacterium tuberculosis during April 1994; results were compared with those in the April 1991 survey. From 1991 to 1994, the number of patients decreased from 466 to 332 patients. The percentage with isolates resistant to 1 or more antituberculosis drugs decreased from 33% to 24% (P < .01); with isolates resistant to at least isoniazid decreased from 26% to 18% (P < .05); and with isolates resistant to both isoniazid and rifampin decreased from 19% to 13% (P < .05). The number of patients with isolates resistant to both isoniazid and rifampin decreased by more than 50%. Among never previously treated patients, the percentage with resistance to 1 or more drugs decreased from 22% in 1991 to 13% in 1994 (P < .05). The number of patients with consistently positive culture results for more than 4 months decreased from 130 to 44. A history of antituberculosis treatment was the strongest predictor of drug resistance (odds ratio = 3.1; P < .001). Human immunodeficiency virus infection was associated with drug resistance among patients who never had been treated for tuberculosis. Drug-resistant tuberculosis declined significantly in New York City from 1991 to 1994. Measures to control and prevent tuberculosis were associated with a 29% decrease in the proportion of drug resistance and a 52% decrease in the number of patients with multidrug-resistant tuberculosis.

The Impact of Legislation Requiring DNR Orders: New York State Compared with Neighboring States

Decisions to place limitations on the care of patients are complex, and they often involve physicians, other medical professionals, patients, or a surrogate decision-maker, family members, and others. In 1988, the Joint Commission on Accreditation of Health Care Organizations (JCAHO) and the New York State government adopted two different approaches to this complex issue of do-not-resuscitate (DNR) orders: one involved professional self-regulation, whereas the other mandated a standardized procedure requiring completion of legal documents. This study examines the impact of these two different approaches to writing of DNR orders for adult intensive care unit (ICU) patients on utilization and resulting length of stay. The study used three data bases. One is from a larger study designed to update the Mortality Probability Model (MPM), a measure of severity of illness for ICU patients. This data base includes consecutive admissions to the adult ICUs of four hospitals in the northeastern United States. The second is a similar data base from the European-North American Study of Severity Systems (ENAS), and it includes 20 hospitals. The third data base, a 1991 national survey of ICUs by the Society of Critical Care Medicine (SCCM), lists characteristics of patients in ICUs in the United States on a specific day. Logistic regression was used to analyze the first two data bases; the percentage of patients in New York with DNR orders was calculated for each of the three data bases and compared with patients in neighboring states. Length of ICU and hospital stay was measured in the first two data sets. In the MPM data, 14.4% of medical patients in New York had a DNR order written at the time of ICU discharge, compared with 198% of medical patients in Massachusetts; and 4.3% of New York surgical patients had a DNR order written at the time of ICU discharge, compared with 8.3% of surgical patients in Massachusetts. In the ENAS data, 7.4% of New York nonoperative patients has a DNR order in place within 24 hours, compared with 8.4% of such patients in the other states; and 1.0% of New York operative patients had DNR orders, compared with 3–5% of operative patients from other states. Logistic regression revealed that a New York patient was less likely to have a DNR order written than a patient located in one of the other states studied. Data from the SCCM survey demonstrated that the New York percentage of patients with “no CPR” orders was 5.50%, compared with a percentage of 6.87% in other states. With few exceptions, these differences between New York and surrounding states did not have an impact on hospital length of stay. During the period studied following implementation of New York's DNR Law, utilization of DNR orders in New York State was significantly lower than neighboring states. This decreased utilization, however, did not effect hospital utilization as measured through length of stay and ICU admissions.

Origin and Interstate Spread of a New York City Multidrug-Resistant Mycobacterium tuberculosis Clone Family

<h3>Objective.</h3> —To determine whether isolates of<i>Mycobacterium tuberculosis</i>from New York and elsewhere that are resistant to four or more primary antimicrobial agents and responsible for widespread disease in the 1990s represent a newly emerged clone or a heterogeneous array of unrelated organisms. <h3>Setting.</h3> —New York City area and selected locations in the United States. <h3>Patients.</h3> —<i>M tuberculosis</i>isolates from 1953 patients in New York and multidrug-resistant isolates from six patients from other US communities. <h3>Design.</h3> —Convenience sample of all<i>M tuberculosis</i>strains (<i>M tuberculosis</i>isolates resistant to rifampin, streptomycin, isoniazid, and ethambutol, and sometimes ethionamide, kanamycin, capreomycin, or ciprofloxacin) submitted to the Public Health Research Institute Tuberculosis Center since 1991 and samples submitted to the Centers for Disease Control and Prevention from throughout the United States. The samples submitted were representative of the New York City strains of<i>M tuberculosis</i>. <h3>Main Outcome Measure.</h3> —Characterization of resistant<i>M tuberculosis</i>strains studied by IS<i>61 10</i>and polymorphic GC-rich repetitive sequence (PGRS) hybridization patterns, multiplex polymerase chain reaction (PCR) analysis, and automated DNA sequencing of genes containing mutations associated with resistance to rifampin (<i>rpoB</i>), isoniazid (<i>katG</i>and<i>inhA</i>locus), and streptomycin (<i>strA</i>and<i>rrs</i>). <h3>Results.</h3> —Multidrung-resistant<i>M tuberculosis</i>isolates were recovered from 253 New York City patients and had the same or closely allied IS<i>6110</i>and PGRS patterns, multiplex PCR type, and gene mutations associated with resistance to rifampin, isoniazid, and streptomycin. Isolates with these same molecular characteristics were recovered from patients in Florida and Nevada, health care workers in Atlanta, Ga, and Miami, Fla, and an individual who recently moved from New York City to Denver, Colo, and caused disease or skin test conversion in at least 12 people in a nursing home environment. <h3>Conclusions.</h3> —The results document the molecular origin and spread of progeny of a closely related family of multidrug-resistant<i>M tuberculosis</i>strains that have recently shared a common ancestor and undergone clonal expansion. The multidrug-resistant phenotype in these organisms arose by sequential acquisition of resistance-conferring mutations in several genes, most likely as a consequence of antibiotic selection of randomly occurring mutants in concert with inadequately treated infections. Dissemination of these difficult-to-treat bacteria throughout New York City and to at least four additional US cities has adverse implications for tuberculosis control in the 21st century. (<i>JAMA</i>. 1996;275:452-457)

Multidrug-resistant tuberculosis in patients without HIV infection.

Investigations of outbreaks of multidrug-resistant tuberculosis have found low rates of treatment response and very high mortality, and they have mainly involved patients with advanced human immunodeficiency virus (HIV) infection. For patients without HIV infection, one study reported an overall rate of response to treatment of 56 percent, and the mortality from tuberculosis was 22 percent. We investigated treatment response and mortality rates in 26 HIV-negative patients in New York with multidrug-resistant tuberculosis. We obtained detailed data from seven teaching hospitals in New York City on patients with multidrug-resistant tuberculosis--defined as tuberculosis resistant at least to isoniazid and rifampin--who were HIV-negative on serologic testing. Lengths of times from diagnosis to the initiation of appropriate therapy and from the initiation of appropriate therapy to conversion to negative cultures were assessed. Therapeutic responses were evaluated by both microbiologic and clinical criteria. Between March 1991 and September 1994, 26 HIV-negative patients were identified and treated. Of the 25 patients for whom adequate data were available for analysis, 24 (96 percent) had clinical responses; all 17 patients for whom data on microbiologic response were available had such a response. The median times from diagnosis to the initiation of appropriate therapy and from the initiation of therapy to culture conversion were 44 days (range, 0 to 181) and 69 days (range, 2 to 705), respectively. Side effects requiring the discontinuation of medication occurred in 4 of 23 patients (17 percent) who were treated with second-line antituberculosis medications. The median follow-up for the 23 patients who responded and who received appropriate therapy was 91 weeks (range, 41 to 225). In this report from New York City, HIV-negative patients with multidrug-resistant tuberculosis, contrary to previous reports, responded well to appropriate chemotherapy, both clinically and microbiologically.

Comparison of the appropriateness of coronary angiography and coronary artery bypass graft surgery between Canada and New York State

<h3>Objective.</h3> —To compare the appropriateness of coronary angiography and coronary artery bypass graft (CABG) use between the United States and Canada. <h3>Design.</h3> —Retrospective randomized medical record review. <h3>Setting.</h3> —All hospitals performing coronary angiography and/or CABG surgery in two Canadian provinces (Ontario and British Columbia); in New York State, 15 randomly selected hospitals that provide coronary angiography and 15 randomly selected hospitals that provide CABG surgery. <h3>Patients.</h3> —All patients were randomly selected. For coronary angiography, 533 patients in Canada and 1333 patients in New York were selected; for CABG, 556 patients in Canada and 1336 patients in New York were selected. <h3>Main Outcome Measures.</h3> —Percentage of patients in each country who had coronary angiography or CABG for necessary, appropriate, uncertain, or inappropriate indications as rated by criteria developed separately in each country and the complications of those procedures. <h3>Results.</h3> —For coronary angiography, 9% of Canadian cases and 10% of New York cases were rated inappropriate using Canadian criteria compared with 5% and 4%, respectively, using US criteria. For CABG, 4% of Canadian cases and 6% of New York cases were rated inappropriate by Canadian criteria compared with 3% and 2%, respectively, using US criteria. A lower proportion of procedures were performed on persons aged 75 years or older in Canada than in New York for both coronary angiography (5% vs 11%;<i>P</i>&lt;.001) and CABG (6% vs 14%;<i>P</i>&lt;.001). Women were also represented in lower proportions among angiography cases in Canada than in New York (28% vs 35%;<i>P</i>=.023). Canadian patients with left main coronary disease waited significantly longer between angiography and CABG than did New York patients (<i>P</i>&lt;.0001). <h3>Conclusions.</h3> —Rates of inappropriate use of cardiac procedures were low in Canada and New York, which suggests that the regionalization of cardiac procedures that characterizes both health care systems contributes to better clinical decision making. Differences in the use of cardiac procedures among the elderly in the two countries merits further comparative examination. (<i>JAMA</i>. 1994;272:934-940)

Comparison of the Appropriateness of Coronary Angiography and Coronary Artery Bypass Graft Surgery Between Canada and New York State

To compare the appropriateness of coronary angiography and coronary artery bypass graft (CABG) use between the United States and Canada. Retrospective randomized medical record review. All hospitals performing coronary angiography and/or CABG surgery in two Canadian provinces (Ontario and British Columbia); in New York State, 15 randomly selected hospitals that provide coronary angiography and 15 randomly selected hospitals that provide CABG surgery. All patients were randomly selected. For coronary angiography, 533 patients in Canada and 1333 patients in New York were selected; for CABG, 556 patients in Canada and 1336 patients in New York were selected. Percentage of patients in each country who had coronary angiography or CABG for necessary, appropriate, uncertain, or inappropriate indications as rated by criteria developed separately in each country and the complications of those procedures. For coronary angiography, 9% of Canadian cases and 10% of New York cases were rated inappropriate using Canadian criteria compared with 5% and 4%, respectively, using US criteria. For CABG, 4% of Canadian cases and 6% of New York cases were rated inappropriate by Canadian criteria compared with 3% and 2%, respectively, using US criteria. A lower proportion of procedures were performed on persons aged 75 years or older in Canada than in New York for both coronary angiography (5% vs 11%; P < .001) and CABG (6% vs 14%; P < .001). Women were also represented in lower proportions among angiography cases in Canada than in New York (28% vs 35%; P = .023). Canadian patients with left main coronary disease waited significantly longer between angiography and CABG than did New York patients (P < .0001). Rates of inappropriate use of cardiac procedures were low in Canada and New York, which suggests that the regionalization of cardiac procedures that characterizes both health care systems contributes to better clinical decision making. Differences in the use of cardiac procedures among the elderly in the two countries merits further comparative examination.

Care of Diabetic Patients by Optometrists in New York State

This study was undertaken to learn about the involvement of optometrists in the eye care of diabetic patients in New York and to collect baseline data for planning intervention programs in diabetic eye disease. This study was conducted by a mail survey being sent to all optometrists in New York whom we could identify through state sources (n = 2270). Three follow-up mailings were conducted. Eighty-six percent who received our mailing responded, 87% of whom reported that they see diabetic patients. Analysis was confined to this 87%. Routine retinal examinations were provided by 68% of the respondents who see diabetic patients, 62% of whom dilate the pupils. Sixty-eight percent who see diabetic patients diagnose retinopathy solely by their own examination, and 60% of these dilate. Follow-up of retinopathy was provided by 15% of optometrists who see diabetic patients, 90% of whom dilate the pupils of their diabetic patients. Twenty-five percent of respondents who see diabetic patients refer them to an ophthalmologist for diagnosis of retinopathy, and 67% refer all retinopathy patients to an ophthalmologist for follow-up. Although 91% of respondents recommended eye examinations at least annually for diabetic patients, only 68% specifically recommended annual examinations through dilated pupils. Those who dilate were significantly more likely to recommend annual dilated examinations than those who do not dilate, regardless of practice setting. These findings indicate that optometrists as a group see many diabetic patients. Intervention strategies should include increased emphasis on the use of dilation when examining diabetic patients and annual dilated retinal examinations.

Pathways to the hospital for the geriatric psychiatric patient in New York and London.

This communication examines the pathways of geriatric psychiatric patients in New York and London from the time of onset of a psychiatric episode to hospitalization. Informants of 50 patients in each city were interviewed with a semi-structured interview covering the events and the patient's activities prior to hospitalization. The results show that the time from the onset of the episode to hospitalization is significantly shorter in London than it is in New York. The major portion of this difference is accounted for by the longer time spent London the doctor is significantly more involved in New York between episode onset and initial medical contact. In the decision to hospitalize. In New York the main reason for hospitalization is harmful behavior, while in London it is psychiatric symptoms.

The Usefulness of a Psychological Test Battery

This paper discusses the usefulness of a battery of psychological tests administered to a group of psychiatric geriatric patients in New York and London, as an assessment of cognitive impairment. Two of the tests, the Paired Associate Learning Test, and the Digit Copying Test, were highly related to the diagnosis of organic brain syndrome or functional disorder made independently by a psychiatrist in a clinical interview. Prognostic predictions in disagreement cases were no better or no worse by psychiatric diagnosis than by psychological tests. Compared to a simple clinical test of disorientation derived from the psychiatric interview, psychological tests were more highly correlated to independent measures of patients' self-care capacity and duration of hospitalization, but equally related to psychiatric diagnosis. The verbal subtest proved to be the more useful of the psychological tests given. The logistics and difficulties of administering psychological tests to this specialized population are discussed, e.g. patients' physical limitations, communication problems; as well as efforts in this study to minimize these problems.

The post-transfer fate of relocated mental patients in New York.

The post-transfer fate of relocated mental patients in New York.