This study examined factors affecting medical service use among HIV-infected persons with a substance abuse disorder. The sample comprised 190 participants enrolled in a randomized trial of a case management intervention. Participants were interviewed about their backgrounds, housing status, income, alcohol and drug use problems, health status and depressive symptoms at study entry. Electronic medical records were used to assess medical service use. Poisson regression models were tested to determine the effects of need, enabling and predisposing factors on the dependent variables of emergency department visits, inpatient admissions and ambulatory care visits. During a two-year period, 71% were treated in the emergency department, 64% had been hospitalized and the sample averaged 12.9 ambulatory care visits. Homelessness was associated with higher utilization of emergency department and inpatient services; drug use severity was associated with higher inpatient and ambulatory care service use; and alcohol use severity was associated with greater use of emergency medical services. Homelessness and substance abuse exacerbate the health care needs of HIV-infected persons and result in increased use of emergency department and inpatient services. Interventions are needed that target HIV-infected persons with substance abuse disorders, particularly those that increase entry and retention in outpatient health care and thus decrease reliance on acute hospital-based services.

Kernicterus, thought to be due to severe hyperbilirubinemia, is an uncommon disorder with tragic consequences, especially when it affects healthy term and near-term infants. Early identification, prevention and treatment of severe hyperbilirubinemia should make kernicterus a preventable disease. However, national epidemiologic data are needed to monitor any preventive strategies. Recommendations are provided to obtain prospective data on the prevalence and incidence of severe hyperbilirubinemia and associate mortality and neurologic injury using standardized definitions, explore the clinical characteristics and root causes of kernicterus in children identified in the Kernicterus Pilot Registry, identify and test an indicator for population surveillance, validating systems-based approaches to the management of newborn jaundice, and explore the feasibility of using biologic or genetic markers to identify infants at risk for hyperbilirubinemia. Increased knowledge about the incidence and consequences of severe hyperbilirubinemia is essential to the planning, implementation and assessment of interventions to ensure that infants discharged as healthy from their birth hospitals have a safer transition to home, avoiding morbidity due to hyperbilirubinemia and other disorders.At a recent NIHCD-sponsored conference, key questions were raised about kernicterus and the need for additional strategies for its prevention. These questions and an approach to their answers form the basis of this report.

Background: Improving asthma knowledge and self-management is a common focus of asthma educational programs, but most programs have had little influence on morbidity outcomes. We developed a novel multiple-component intervention that included the use of an asthma education video game intended to promote adoption of asthma self-management behaviors and appropriate asthma care.

Objective: To determine the effectiveness of an asthma education video game in reducing morbidity among high-risk, school-aged children with asthma.

Methods: We enrolled 119 children aged 5 to 12 years from low-income, urban areas in and around San Francisco, CA, and San Jose, CA. Children with moderate-to-severe asthma and parental reports of significant asthma health care utilization were randomized to participate in the disease management intervention or to receive their usual care (control group). Patients were evaluated for clinical and quality-of-life outcomes at weeks 8, 32, and 52 of the study.

Results: Compared with controls, the intervention group had significant improvements in the physical domain (P = .04 and P = .01 at 32 and 52 weeks, respectively) and social activity domain (P = .02 and P = .05 at 32 and 52 weeks, respectively) of asthma quality of life on the Child Health Survey for Asthma and child (P = .02 at 8 weeks) and parent (P = .04 and .004 at 32 and 52 weeks, respectively) asthma self-management knowledge. There were no significant differences between groups on clinical outcome variables.

Conclusions: A multicomponent educational, behavioral, and medical intervention targeted at high-risk, inner-city children with asthma can improve asthma knowledge and quality of life.

The traditional focus of disability research has been on the elderly, with good reason. Chronic disability is much more prevalent among the elderly, and it has a more direct impact on the demand for medical care. It is also important to understand trends in disability among the young, however, particularly if these trends diverge from those among the elderly. These trends could have serious implications for future health care spending because more disability at younger ages almost certainly translates into more disability among tomorrow's elderly, and disability is a key predictor of health care spending. Using data from the Medicare Current Beneficiary Survey (MCBS) and the National Health Interview Study (NHIS), we forecast that per-capita Medicare costs will decline for the next fifteen to twenty years, in accordance with recent projections of declining disability among the elderly. By 2020, however, the trend reverses. Per-capita costs begin to rise due to growth in disability among the younger elderly. Total costs may well remain relatively flat until 2010 and then begin to rise because per-capita costs will cease to decline rapidly enough to offset the influx of new elderly people. Overall, cost forecasts for the elderly that incorporate information about disability among today's younger generations yield more pessimistic scenarios than those based solely on elderly data sets, and this information should be incorporated into official Medicare forecasts.

The third edition has 120 new articles, among them Artificial nutrition and hydration, Bioterrorism, Cloning, Cybernetics, Dementia, Managed care, and Nanotechnology. Some 200 articles have been extensively revised, and 100 additional articles have new bibliographies. The alphabetical entries address a wide range of topics that raise difficult and important questions. Abortion, genetic screening, female genital mutilation, the right to die, health issues of immigration, and corporate responsibility are but a few. The contributors discuss the issues from many points of view. The abortion article includes sections covering medical perspectives, contemporary ethical and legal aspects, and Jewish, Catholic, Protestant, and Islamic religious perspectives. There are also articles about bioethics in Buddhism, eugenics, health policy, women as health-care professionals, whistle-blowing in health care, and veterinary ethics. All of the articles are signed, and all have bibliographies. Ample cross-references help readers find related useful material. A list of all the articles and a topical outline appear in volume 1. A series of appendixes offers codes, oaths, and directives related to bioethics; additional resources; key legal cases; and an annotated bibliography of literary works that have a medical component. A detailed index helps users find material that may be scattered over numerous entries, such as information about surrogate motherhood.

We all have a stake in the size of the physician workforce. With too few physicians, access to care will be compromised; with too many, there will be strong pressures to overconsume health services. Increasing the production of U.S.-trained physicians by expanding physical resources of medical schools and creating new residency and fellowship positions will be costly and will have delayed, long-lasting effects on the supply of physicians' services. According to those who believe that physicians increase the demand for their own services, every additional physician would generate added health care costs for the length of a career, which now averages about 30 years. These increased expenditures would dwarf the short-term costs of expanding our capacity to train physicians.

Because new graduates are a small fraction of the total physician workforce, the supply of physicians would change little in the short run, even if it were possible to expand the number of training positions instantly. In an article in this issue (1), Richard Cooper forcefully argues that this delay is an important reason to take immediate action to increase the production of physicians. He projects that the United States will have 200 000 fewer physicians than we need in 2020. We agree that demographic and economic trends could increase the demand for physician services in the coming years, but we also believe that his forecast contains far too many uncertainties to serve as the basis for taking immediate action. We think that Cooper's analysis does not take account of important factors that could change the need for large increases in physician supply. In this commentary, we discuss the potential roles of a healthier aging population, changes in government policy, new technology, physician-induced demand for health care, and changes in the price of health care.

We conducted a cross-sectional survey of 210 patients who came to a free medical clinic for health care over an 8-month period. We (1) measured their satisfaction with care, (2) determined the frequency of missed opportunities for providing health education and social work consultation, and (3) assessed whether patient-specific factors drive the frequency of these missed opportunities. Of the 210 patients surveyed, a total of 168 (80.0%) completed the entire survey. The mean satisfaction rating was high (4.6 on a scale of 1 to 5). A significant number of missed opportunities occurred, with only 28% of patients receiving patient education material, and 32% of patients visiting the social worker. No particular patient groups emerged as most susceptible to these missed opportunities. This study shows both the high degree of patient satisfaction at this free clinic and the many opportunities for improving patient education and social services. Adding health education and social work consultation to the patient encounter could improve the health of these patients.

Variation in use of health care is ubiquitous in the United States. It is attributable to exogenous differences in supply of medical resources; to identified and unidentified economic, social, and cultural factors; and to the idiosyncratic beliefs of physicians. It is perpetuated by the parochial character of much clinical practice. Patients in high-intensity areas do not appear to have better health outcomes: Much care is "flat of the curve." A more robust scientific foundation for clinical decisions could help to reduce variations, but major reform of health care financing is probably necessary to achieve substantial improvement in the organization and delivery of care.

This issue of CHP/PCOR's quarterly newsletter covers news and developments from the summer 2004 quarter. It features articles about: