Percent Relative Reduction Research Articles

Impact of the Oncology Care Model on End‐of‐Life Care

Research ObjectiveThe Oncology Care Model (OCM) is a six‐year episode‐based alternative payment model for cancer care launched by the Centers for Medicare & Medicaid Services in July 2016. OCM includes several elements intended to improve end‐of‐life (EOL) care. We evaluated the impact of OCM on EOL care intensity, spending, and oncologist and patient experiences.Study DesignUsing 100% Medicare claims (2014–2019) we employed a Difference‐in‐Differences (DID) approach comparing changes over time in care intensity and Medicare payments at the end of life, for beneficiaries served by OCM practices and by a propensity‐score matched comparison group of non‐participating practices. We also surveyed caregivers of deceased beneficiaries about patient experiences in the last month of life, and we surveyed oncologists from OCM practices about changes in palliative and EOL care. Finally, we conducted case studies with over 40 OCM practices.Population StudiedClaims‐based analyses included 256,102 Medicare beneficiaries in OCM or comparison practices who underwent chemotherapy for cancer and died during or within 90 days of their last OCM‐defined episode. Surveys were completed by family members of 5786 deceased beneficiaries (55% OCM, 45% comparison) and by 400 oncologists working in OCM practices.Principal FindingsOCM led to fewer hospitalization in the last 30 days of life for deceased OCM versus comparison beneficiaries (DID:‐11 per 1000 beneficiaries (90%CI:‐19, −4). OCM had no impact on outpatient emergency department use in the last month of life, use of infused chemotherapy in the last two weeks of life, or on hospice use, duration, or timing.The average Medicare Part A payments during the last episode for deceased beneficiaries rose $440 less in the OCM group than in comparisons, a 2.4 percent relative reduction from the OCM baseline mean of $18,530 (p ≤ 0.05). OCM had no impact on average total episode payments, or on Medicare Part B or D payments, during deceased beneficiaries' last episodes.OCM did not affect caregivers' perceptions: survey respondents rated EOL care highly before OCM began, and there were no changes over time and no differences between OCM and comparison respondents. Roughly one third of oncologists reported enhancing access to palliative care (36%) and using new/enhanced standards or guidelines to trigger discussions about EOL goals and hospice (32%). Most oncologists (55%) reported that OCM improves quality of EOL care.ConclusionsOCM led to a small relative reduction in hospitalizations during deceased beneficiaries' last month of life and a corresponding relative decrease in Medicare Part A payments. OCM had no impact on hospice use, duration, or timing. OCM had no impact on beneficiaries' care experiences at the end of life. Oncologists reported EOL process improvements attributable to OCM.Implications for Policy or PracticeOCM emphasizes shared decision making and advance care planning to ensure that cancer beneficiaries' EOL wishes are documented and followed. The first three years of OCM suggest that these efforts led to small relative reductions in hospitalizations and Part A payments in the last month of life. The lack of impact on hospice use/timing, despite clinician‐reported EOL care process improvements, suggests ongoing areas for potential improvements.Primary Funding SourceCenters for Medicare and Medicaid Services.

An Employer-Provider Direct Payment Program Is Associated With Lower Episode Costs.

Bundled payment has shown promise in reducing medical spending while maintaining quality. However, its impact among commercially insured populations has not been well studied. We examined the impacts on episode cost and patient cost sharing of a program that applies bundled payments for orthopedic and surgical procedures in a commercially insured population. The program we studied negotiates preferred prices for selected providers that cover the procedure and all related care within a thirty-day period after the procedure and waives cost sharing for patients who receive care from these providers. After implementation, episode prices for three selected surgical procedures declined by $4,229, a 10.7percent relative reduction. Employers captured approximately 85percent of the savings, or $3,582 per episode (a 9.5percent relative decrease), and patient cost-sharing payments decreased by $498 per episode (a 27.7percent relative decrease).

Cardiac dose reduction using deep inspiratory breath hold (DIBH) in radiation treatment of left sided breast cancer patients with breast conservation surgery and modified radical mastectomy

PurposeDeep inspiration breath hold (DIBH) reduces heart and pulmonary doses during left-sided breast radiation therapy (RT); however, there is limited information whether the reduction in doses is similar in patients with modified radical MRM (MRM) and breast conservation surgery (BCS). The primary objective was to determine whether DIBH offers greater dosimetric reduction in cardiac doses in patients with MRM as compared to BCS with secondary objectives of documenting time consumed in counseling, simulation and planning such techniques. MethodsThirty patients with diagnosis of left sided breast cancer underwent CT simulation both free breathing (FB) and DIBH. Patients were grouped into two cohorts: MRM (n = 20) and BCS (n = 10). 3D-conformal plans were developed and FB was compared to DIBH for entire group (n = 30) and each cohort using Wilcoxon signed-rank tests for continuous variables and McNemar's test for discrete variables. The percent relative reduction conferred by DIBH in mean heart (Dmean heart) and left anterior descending artery dose (LADmean and LADmax), heart V25,V10, V2 and ipsilateral DmeanLung,V20, V12 were compared between the two cohorts using Wilcox rank-sum testing. A two-tailed p-value ≤ 0.05 was considered statistically significant. Time consumed during FB and DIBH from patient counseling to planning was documented. ResultsPatients undergoing BCS had comparable boost target coverage on DIBH and FB. For the overall group (n = 30), DIBH reduced Dmean heart and LAD dose, V25, V10 and V2 doses for the heart and Ipsilateral DmeanLung, V20, V12 which was statistically significant. For individual cohorts DIBH did not significantly reduce the lung (Ipsilateral DmeanLung, V20, V12) and LAD (LADmean and LADmax) doses for BCS while significant reduction in all cardiopulmonary doses was seen in MRM cohort. Despite significant reductions with DIBH in MRM, ipsilateral lung constraint of V12 < 15% was less commonly achieved in MRM (n = 11, 55%) requiring nodal radiation as compared to BCS (n = 3, 30%). Percent reduction in all cardiac and pulmonary dosimetric parameters with DIBH was similar in the MRM cohort as compared to BCS cohort. In total 73.1 ± 2.6 min was required for FB as compared to 108.1 ± 4.1 min in DIBH. ConclusionDIBH led to significant reduction of cardiac doses in both MRM and BCS. Reduction of lung and LAD doses were significant in MRM cohort. All cardiac constraints were met with DIBH in both cohorts, lung constraints were less frequently met in MRM cohort requiring nodal radiation.

A Medicaid Alternative Payment Model Program In Oregon Led To Reduced Volume Of Imaging Services.

The patient-centered medical home model aspires to fundamentally restructure care processes, but a volume-based payment system may hinder such transformations. In 2013 Oregon's Medicaid program changed its reimbursement of traditional primary care services for selected community health centers (CHCs) from a per visit to a per patient rate. Using Oregon claims data, we analyzed the price-weighted volume of care for five service areas: traditional primary care services, including imaging, tests, and procedures; other services provided by CHCs that were carved out from the payment reform; emergency department visits; inpatient services; and other services of non-CHC providers. We further subdivided traditional primary care services using Berenson-Eggers Type of Service categories of care. We compared participating and nonparticipating CHCs in Oregon before and after the payment model was implemented. The payment reform was associated with a 42.4percent relative reduction in price-weighted traditional primary care services, driven fully by decreased use of imaging services. Other outcomes remained unaffected. Oregon's initiative could provide lessons for other states interested in using payment reform to advance the patient-centered medical home model for the Medicaid population.

Eight-year post-trial follow-up of health care and long-term care costs of tele-based health coaching.

To evaluate the long-term effect of telephone health coaching on health care and long-term care (LTC) costs in type 2 diabetes (T2D) and coronary artery disease (CAD) patients. Randomized controlled trial (RCT) data were linked to Finnish national health and social care registries and electronic health records (EHR). Post-trial eight-year economic evaluation was conducted. A total of 1,535 patients (≥45years) were randomized to the intervention (n=1034) and control groups (n=501). The intervention group received monthly telephone health coaching for 12months. Usual health care and LTC were provided for both groups. Intention-to-treat analysis showed no significant change in total health and long-term care costs (intervention effect €1248 [3 percent relative reduction], CI -6347 to 2217) in the intervention compared to the control group. There were also no significant changes among subgroups of patients with T2D or CAD. Health coaching had a nonsignificant effect on health care and long-term care costs in the 8-year follow-up among patients with T2D or CAD. More research is needed to study, which patient groups, at which state of the disease trajectory of T2D and cardiovascular disease, would best benefit from health coaching.

Behavioral Health Care And Firearm Suicide: Do States With Greater Treatment Capacity Have Lower Suicide Rates?

Firearms account for most self-harm deaths, and many more Americans kill themselves with a firearm each year than are murdered with one. Mental illness is an important risk factor for firearm suicide. While the literature focuses on firearm safety, little is understood about how the supply of behavioral health treatment services can reduce firearm suicide. We evaluated whether states with greater behavioral health treatment capacity have lower firearm suicide rates, examining variation across the United States and over time. The mean adjusted firearm suicide rate rose from 6.74 per 100,000 people in 2005 to 7.89 per 100,000 in 2015-a 17.1percent increase. We found a significant independent inverse relationship between greater behavioral health treatment capacity and the firearm suicide rate. We show that across all states, on average, a 10.0percent relative increase in behavioral health workers per state was associated with a modest 1.2percent relative reduction in the adjusted firearm suicide rate. Given this finding, we discuss whether firearm control initiatives might offer a greater protective effect for reducing firearm suicide, compared to the protective effect of increasing behavioral health treatment capacity.

Oregon's Medicaid Reform And Transition To Global Budgets Were Associated With Reductions In Expenditures.

In 2012 Oregon initiated an ambitious delivery system reform, moving the majority of its Medicaid enrollees into sixteen coordinated care organizations, a type of Medicaid accountable care organization. Using claims data, we assessed measures of access, appropriateness of care, utilization, and expenditures for five service areas (evaluation and management, imaging, procedures, tests, and inpatient facility care), comparing Oregon to the neighboring state of Washington. Overall, the transformation into coordinated care organizations was associated with a 7percent relative reduction in expenditures across the sum of these services, attributable primarily to reductions in inpatient utilization. The change to coordinated care organizations also demonstrated reductions in avoidable emergency department visits and improvements in some measures of appropriateness of care, but also exhibited reductions in primary care visits, a potential area of concern. Oregon's coordinated care organizations could provide lessons for controlling health care spending for other state Medicaid programs.

Quantitative assessment of the upper airway in infants and children with subglottic stenosis.

Determine whether quantitative geometric measures and a computational fluid dynamic (CFD) model derived from medical imaging of children with subglottic stenosis (SGS) can be effective diagnostic and treatment planning tools. Retrospective chart and imaging review in a tertiary care hospital. Computed tomography scans (n = 17) of children with SGS were analyzed by geometric and CFD methods. Polysomnograms (n = 15) were also analyzed. Radiographic data were age/weight flow normalized and were compared to an atlas created from radiographically normal airways. Five geometric, seven CFD, and five polysomnography measures were analyzed. Statistical analysis utilized a two-sample t test with Bonferroni correction and area under the curve analysis. Two geometric indices (the ratio of the subglottic to midtracheal airway, the percent relative reduction of the subglottic airway) and one CFD measure (the percent relative reduction of the hydraulic diameter of the subglottic airway) were significant for determining which children with SGS received surgical intervention. Optimal cutoffs for these values were determined. Polysomnography, the respiratory effort-related arousals index, was significant only prior to Bonferroni correction for determining which children received surgical intervention. Geometric and CFD variables were sensitive at determining which patients with SGS received surgical intervention. Discrete quantitative assessment of the pediatric airway was performed, yielding preliminary data regarding possible objective thresholds for surgical versus nonsurgical treatment of disease. This study is limited by its small, retrospective, single-institution nature. Further studies to validate these findings and possibly optimize treatment threshold recommendations are warranted. 4 Laryngoscope, 126:1225-1231, 2016.

The Association between High-Deductible Health Plan Transition and Contraception and Birth Rates.

To evaluate the association between employer-mandated enrollment into high-deductible health plans (HDHPs) and contraception and birth rates among reproductive-age women. Using data from 2002 to 2008, we examined 1,559 women continuously enrolled in a Massachusetts health plan for 1year before and after an employer-mandated switch from an HMO to a HDHP, compared with 2,793 matched women contemporaneously enrolled in an HMO. We used an individual-level interrupted time series with comparison series design to examine level and trend changes in clinician-provided contraceptives and a differences-in-differences design to assess annual birth rates. Employer, plan, and member characteristics were obtained from enrollment files. Contraception and childbirth information were extracted from pharmacy and medical claims. Monthly contraception rates were 19.0-24.0 percent at baseline. Level and trend changes did not differ between groups (p=.92 and p=.36, respectively). Annual birth rates declined from 57.1/1,000 to 32.7/1,000 among HDHP members and from 61.9/1,000 to 56.2/1,000 among HMO controls, a 40 percent relative reduction in odds of childbirth (odds ratio=0.60; p=.02). Women who switched to HDHPs experienced a lower birth rate, which might reflect strategies to avoid childbirth-related out-of-pocket costs under HDHPs.

Our Takeaways from the San Antonio Breast Cancer Symposium

Our Takeaways from the San Antonio Breast Cancer Symposium

Evidence Of Cost Shifting In California Hospitals

We used 1993-2001 data from private hospitals in California to investigate whether decreases in Medicare and Medicaid prices were associated with increases in prices paid for privately insured patients. We found that a 1 percent relative decrease in the average Medicare price is associated with a 0.17 percent increase in the corresponding price paid by privately insured patients; similarly, a 1 percent relative reduction in the average Medicaid price is associated with a 0.04 percent increase. These relationships imply that cost shifting from Medicare and Medicaid to private payers accounted for 12.3 percent of the total increase in private payers' prices from 1997 to 2001.

Statins and the Risk of Colorectal Cancer

Statins are inhibitors of 3- hydroxy-3-methylglutaryl coenzyme A reductase and effective lipid-lowering agents. Statins inhibit the growth of coloncancer cell lines, and secondary analyses of some, but not all, clinical trials suggest that they reduce the risk of colorectal cancer. METHODS: The Molecular Epidemiology of Colorectal Cancer study is a population-based case-control study of patients who received a diagnosis of colorectal cancer in northern Israel between 1998 and 2004 and controls matched according to age, sex, clinic, and ethnic group. We used a structured interview to determine the use of statins in the two groups and verified self-reported statin use by examining prescription records in a subgroup of patients for whom prescription records were available. RESULTS: In analyses including 1953 patients with colorectal cancer and 2015 controls, the use of statins for at least five years(vs. the nonuse of statins) was associated with a significantly reduced relative risk of colorectal cancer(odds ratio, 0.50; 95 percent confidence interval, 0.40 to 0.63). This association remained significant after adjustment for the use or nonuse of aspirin or other nonsteroidal antiinflammatory drugs; the presence or absence of physical activity, hypercholesterolemia, and a family history of colorectal cancer; ethnic group; and level of vegetable consumption(odds ratio, 0.53; 95 percent confidence interval, 0.38 to 0.74). The use of fibric-acid derivatives was not associated with a significantly reduced risk of colorectal cancer(odds ratio, 1.08; 95 percent confidence interval, 0.59 to 2.01). Self-reported statin use was confirmed for 276 of the 286 participants(96.5 percent) who reported using statins and whose records were available. CONCLUSIONS: The use of statins was associated with a 47 percent relative reduction in the risk of colorectal cancer after adjustment for other known risk factors. Because the absolute risk reduction is likely low, further investigation of the overall benefits of statins in preventing colorectal cancer is warranted.

Statins and the Risk of Colorectal Cancer

Statins are inhibitors of 3- hydroxy-3-methylglutaryl coenzyme A reductase and effective lipid-lowering agents. Statins inhibit the growth of coloncancer cell lines, and secondary analyses of some, but not all, clinical trials suggest that they reduce the risk of colorectal cancer. METHODS: The Molecular Epidemiology of Colorectal Cancer study is a population-based case-control study of patients who received a diagnosis of colorectal cancer in northern Israel between 1998 and 2004 and controls matched according to age, sex, clinic, and ethnic group. We used a structured interview to determine the use of statins in the two groups and verified self-reported statin use by examining prescription records in a subgroup of patients for whom prescription records were available. RESULTS: In analyses including 1953 patients with colorectal cancer and 2015 controls, the use of statins for at least five years(vs. the nonuse of statins) was associated with a significantly reduced relative risk of colorectal cancer(odds ratio, 0.50; 95 percent confidence interval, 0.40 to 0.63). This association remained significant after adjustment for the use or nonuse of aspirin or other nonsteroidal antiinflammatory drugs; the presence or absence of physical activity, hypercholesterolemia, and a family history of colorectal cancer; ethnic group; and level of vegetable consumption(odds ratio, 0.53; 95 percent confidence interval, 0.38 to 0.74). The use of fibric-acid derivatives was not associated with a significantly reduced risk of colorectal cancer(odds ratio, 1.08; 95 percent confidence interval, 0.59 to 2.01). Self-reported statin use was confirmed for 276 of the 286 participants(96.5 percent) who reported using statins and whose records were available. CONCLUSIONS: The use of statins was associated with a 47 percent relative reduction in the risk of colorectal cancer after adjustment for other known risk factors. Because the absolute risk reduction is likely low, further investigation of the overall benefits of statins in preventing colorectal cancer is warranted.

Statins and the Risk of Colorectal Cancer

Statins are inhibitors of 3- hydroxy-3-methylglutaryl coenzyme A reductase and effective lipid-lowering agents. Statins inhibit the growth of coloncancer cell lines, and secondary analyses of some, but not all, clinical trials suggest that they reduce the risk of colorectal cancer. METHODS: The Molecular Epidemiology of Colorectal Cancer study is a population-based case-control study of patients who received a diagnosis of colorectal cancer in northern Israel between 1998 and 2004 and controls matched according to age, sex, clinic, and ethnic group. We used a structured interview to determine the use of statins in the two groups and verified self-reported statin use by examining prescription records in a subgroup of patients for whom prescription records were available. RESULTS: In analyses including 1953 patients with colorectal cancer and 2015 controls, the use of statins for at least five years(vs. the nonuse of statins) was associated with a significantly reduced relative risk of colorectal cancer(odds ratio, 0.50; 95 percent confidence interval, 0.40 to 0.63). This association remained significant after adjustment for the use or nonuse of aspirin or other nonsteroidal antiinflammatory drugs; the presence or absence of physical activity, hypercholesterolemia, and a family history of colorectal cancer; ethnic group; and level of vegetable consumption(odds ratio, 0.53; 95 percent confidence interval, 0.38 to 0.74). The use of fibric-acid derivatives was not associated with a significantly reduced risk of colorectal cancer(odds ratio, 1.08; 95 percent confidence interval, 0.59 to 2.01). Self-reported statin use was confirmed for 276 of the 286 participants(96.5 percent) who reported using statins and whose records were available. CONCLUSIONS: The use of statins was associated with a 47 percent relative reduction in the risk of colorectal cancer after adjustment for other known risk factors. Because the absolute risk reduction is likely low, further investigation of the overall benefits of statins in preventing colorectal cancer is warranted.

Daclizumab to Prevent Rejection after Cardiac Transplantation

Daclizumab, a humanized monoclonal antibody against the interleukin-2 receptor, reduced the risk of rejection without increasing the risk of infection among renal-transplant recipients and, in a single-center trial, among cardiac-transplant recipients. We conducted a multicenter, placebo-controlled, double-blind study to confirm these results in cardiac-transplant patients. We randomly assigned 434 recipients of a first cardiac transplant treated with standard immunosuppression (cyclosporine, mycophenolate mofetil, and corticosteroids) to receive five doses of daclizumab or placebo. The primary end point was a composite of moderate or severe cellular rejection, hemodynamically significant graft dysfunction, a second transplantation, or death or loss to follow-up within six months. By six months, 104 of 218 patients in the placebo group had reached the primary end point, as compared with 77 of the 216 patients in the daclizumab group (47.7 percent vs. 35.6 percent, P=0.007), a 12.1 percent absolute risk reduction and a 25 percent relative reduction. The rate of rejection was lower in the daclizumab group than in the placebo group (41.3 percent vs. 25.5 percent). Among patients reaching the primary end point, the median time to the end point was almost three times as long in the daclizumab group as in the placebo group during the first 6 months (61 vs. 21 days) and at 1 year (96 vs. 26 days). More patients in the daclizumab group than in the placebo group died of infection (6 vs. 0) when they received concomitant cytolytic therapy. Daclizumab was efficacious as prophylaxis against acute cellular rejection after cardiac transplantation. Because of the excess risk of death, concurrent or anticipated use of cytolytic therapy with daclizumab should be avoided.

Statins and the Risk of Colorectal Cancer

Statins are inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A reductase and effective lipid-lowering agents. Statins inhibit the growth of colon-cancer cell lines, and secondary analyses of some, but not all, clinical trials suggest that they reduce the risk of colorectal cancer. The Molecular Epidemiology of Colorectal Cancer study is a population-based case-control study of patients who received a diagnosis of colorectal cancer in northern Israel between 1998 and 2004 and controls matched according to age, sex, clinic, and ethnic group. We used a structured interview to determine the use of statins in the two groups and verified self-reported statin use by examining prescription records in a subgroup of patients for whom prescription records were available. In analyses including 1953 patients with colorectal cancer and 2015 controls, the use of statins for at least five years (vs. the nonuse of statins) was associated with a significantly reduced relative risk of colorectal cancer (odds ratio, 0.50; 95 percent confidence interval, 0.40 to 0.63). This association remained significant after adjustment for the use or nonuse of aspirin or other nonsteroidal antiinflammatory drugs; the presence or absence of physical activity, hypercholesterolemia, and a family history of colorectal cancer; ethnic group; and level of vegetable consumption (odds ratio, 0.53; 95 percent confidence interval, 0.38 to 0.74). The use of fibric-acid derivatives was not associated with a significantly reduced risk of colorectal cancer (odds ratio, 1.08; 95 percent confidence interval, 0.59 to 2.01). Self-reported statin use was confirmed for 276 of the 286 participants (96.5 percent) who reported using statins and whose records were available. The use of statins was associated with a 47 percent relative reduction in the risk of colorectal cancer after adjustment for other known risk factors. Because the absolute risk reduction is likely low, further investigation of the overall benefits of statins in preventing colorectal cancer is warranted.

Intensive Lipid Lowering with Atorvastatin in Patients with Stable Coronary Disease

Previous trials have demonstrated that lowering low-density lipoprotein (LDL) cholesterol levels below currently recommended levels is beneficial in patients with acute coronary syndromes. We prospectively assessed the efficacy and safety of lowering LDL cholesterol levels below 100 mg per deciliter (2.6 mmol per liter) in patients with stable coronary heart disease (CHD). A total of 10,001 patients with clinically evident CHD and LDL cholesterol levels of less than 130 mg per deciliter (3.4 mmol per liter) were randomly assigned to double-blind therapy and received either 10 mg or 80 mg of atorvastatin per day. Patients were followed for a median of 4.9 years. The primary end point was the occurrence of a first major cardiovascular event, defined as death from CHD, nonfatal non-procedure-related myocardial infarction, resuscitation after cardiac arrest, or fatal or nonfatal stroke. The mean LDL cholesterol levels were 77 mg per deciliter (2.0 mmol per liter) during treatment with 80 mg of atorvastatin and 101 mg per deciliter (2.6 mmol per liter) during treatment with 10 mg of atorvastatin. The incidence of persistent elevations in liver aminotransferase levels was 0.2 percent in the group given 10 mg of atorvastatin and 1.2 percent in the group given 80 mg of atorvastatin (P<0.001). A primary event occurred in 434 patients (8.7 percent) receiving 80 mg of atorvastatin, as compared with 548 patients (10.9 percent) receiving 10 mg of atorvastatin, representing an absolute reduction in the rate of major cardiovascular events of 2.2 percent and a 22 percent relative reduction in risk (hazard ratio, 0.78; 95 percent confidence interval, 0.69 to 0.89; P<0.001). There was no difference between the two treatment groups in overall mortality. Intensive lipid-lowering therapy with 80 mg of atorvastatin per day in patients with stable CHD provides significant clinical benefit beyond that afforded by treatment with 10 mg of atorvastatin per day. This occurred with a greater incidence of elevated aminotransferase levels.

ERRATA

The Journal has been notified by Dr. Barry M. Farr of an error that occurred in typesetting the recently published article by Jernigan et al. (1) on effectiveness of contact isolation during a hospital outbreak of methicillin-resistant Staphylococcus aureus (MRSA). The error occurred in the first paragraph of the discussion on page 502. A reference is missing from the sentence that reads, “The only controlled study of types of isolation for MRSA compared strict isolation with modified contact isolation and failed to detect a significant difference in rate of transmission, but the study included only 20 cases and had only 23 percent power to detect a 50 percent relative reduction in rate.” The reference that should have been cited at the end of this sentence is reference 27 in the original reference list of Jemigan et al. (1), i.e., Ribner et al. (2).

ERRATA

The Journal has been notified by Dr. Barry M. Farr of an error that occurred in typesetting the recently published article by Jernigan et al. (1) on effectiveness of contact isolation during a hospital outbreak of methicillin-resistant Staphylococcus aureus (MRSA). The error occurred in the first paragraph of the discussion on page 502. A reference is missing from the sentence that reads, “The only controlled study of types of isolation for MRSA compared strict isolation with modified contact isolation and failed to detect a significant difference in rate of transmission, but the study included only 20 cases and had only 23 percent power to detect a 50 percent relative reduction in rate.” The reference that should have been cited at the end of this sentence is reference 27 in the original reference list of Jemigan et al. (1), i.e., Ribner et al. (2).

Costs and effectiveness of routine therapy with long-term beta-adrenergic antagonists after acute myocardial infarction.

We analyzed the costs and effectiveness of routine therapy with beta-adrenergic antagonists in patients who survived an acute myocardial infarction. On the basis of data pooled from the literature, this form of therapy resulted in a 25 percent relative reduction annually in the mortality rate for years 1 to 3 and a 7 percent relative reduction for years 4 to 6 after a myocardial infarction. The estimated cost of six years of routine beta-adrenergic-antagonist therapy to save an additional year of life was $23,400 in low-risk patients, $5,900 in medium-risk patients, and $3,600 in high-risk patients, assuming that the entire benefit of earlier treatment is lost immediately after six years. Under a more likely assumption--that the benefit of six years of treatment wears off gradually over the subsequent nine years--the estimated cost of therapy per year of life saved would be $13,000 in low-risk patients, $3,600 in medium-risk patients, and $2,400 in high-risk patients. As compared with coronary-artery bypass grafting and the medical treatment of hypertension, routine beta-adrenergic-antagonist therapy has a relatively favorable cost-effectiveness ratio.