One in eight Americans today is over the age of 65, and the proportion will increase dramatically in the future. The aging of the population has begun to drive tax and budget decisions and the federal policy agenda, as policy makers and voters look ahead to enormous demands on the health and income security programs. Indeed, it is projected that Medicare and Social Security will constitute nearly half the federal budget in the year 2030, when one in five Americans will be over 65. In Policies for an Aging Society, Stuart H. Altman and David I. Shactman have gathered experts in public and health policy, economics, law, and management to identify the salient issues and explore realistic options. From positions ranging from liberal to conservative, the contributors take a wide view of the philosophical, economic, and programmatic aspects of the social protection programs for elderly Americans. They ask broad questions and propose integrated conceptions of how our society can best provide for the needs of its aging population.

The world of Eli Ginzberg can readily be thought of as a triptych-a career in three parts. In his early years, Ginzberg's work was dedicated to understanding the history of economics, from Adam Smith to C. Wesley Mitchell, and placing that understanding in what might well be considered economic ethnography. His studies took him on travels from Wales in the United Kingdom to California in the United States. For example, the poignant account of Welsh miners in an era of economic depression and technological change remains a landmark work. His report of a cross country trip taken in the first year of the New Deal provides insight and evaluation that can scarcely be captured in present-day writings.

The second period of his career corresponds to Ginzberg's increasing involvement in the practice of economics. He deals with issues related to manpower allocation, employment shifts, and gender and racial changes in the workforce. His writing reflects a growing concern for child welfare and education. In this period, his work increasingly focuses on federal, state and city governments, and how the public sector impacts all basic social issues. His work was sufficiently transcendent of political ideology that seven presidents sought and received his advice and participation.

After receiving all due encomiums and congratulations for intellectual work and policy research well done, Ginzberg then went on to spend the next thirty years of his life carving out a place as a preeminent economist of health, welfare services, and hospital administration. It is this portion of his life that is the subject of Eli Ginzberg: The Economist as a Public Intellectual. What is apparent in Ginzberg's work of this period is his sense of the growing interaction of all the social sciences-pure and applied-to develop a sense of the whole. The contributors to this festschrift, join together to provide a portrait of a figure whose life and work have spanned the twentieth century, and yet pointed the way to changes in the twenty-first century. Eli Ginzberg from the start possessed a strong sense of social justice and economic equality grounded in a Judaic-Christian tradition. All of these aspects come together in the writings of a person who transcends all parochialism and gives substantive content to the often-cloudy phrase, public intellectual.

The case for reduction of air pollution has been predicated primarily on the frequently observed relationship between pollution and mortality and morbidity. Because pollution control usually involves costs, a rational public policy will weigh the benefits against the costs. This study investigates another potential benefit from pollution reduction: namely, decreased use of medical care. We find a strong relationship between particulate matter and inpatient and outpatient care at ages 65-84 across 183 metropolitan statistical areas (MSAs). The relationship is statistically significant at a very high level of confidence even after the region and population size of the areas, education, real income, racial composition, use of cigarettes, and obesity are controlled for.

BACKGROUND: Patients with end-stage renal disease are known to have decreased survival after myocardial infarction, but the association of less severe renal dysfunction with survival after myocardial infarction is unknown.

OBJECTIVES: To determine how patients with renal insufficiency are treated during hospitalization for myocardial infarction and to determine the association of renal insufficiency with survival after myocardial infarction.

DESIGN: Cohort study.

SETTING: All nongovernment hospitals in the United States.

PATIENTS: 130 099 elderly patients with myocardial infarction hospitalized between April 1994 and July 1995.

MEASUREMENTS: Patients were categorized according to initial serum creatinine level: no renal insufficiency (creatinine level < 1.5 mg/dL [<132 micromol/L]; n = 82 455), mild renal insufficiency (creatinine level, 1.5 to 2.4 mg/dL [132 to 212 micromol/L]; n = 36 756), or moderate renal insufficiency (creatinine level, 2.5 to 3.9 mg/dL [221 to 345 micromol/L]; n = 10 888). Vital status up to 1 year after discharge was obtained from Social Security records.

RESULTS: Compared with patients with no renal insufficiency, patients with moderate renal insufficiency were less likely to receive aspirin, beta-blockers, thrombolytic therapy, angiography, and angioplasty during hospitalization. One-year mortality was 24% in patients with no renal insufficiency, 46% in patients with mild renal insufficiency, and 66% in patients with moderate renal insufficiency (P < 0.001). After adjustment for patient and treatment characteristics, mild (hazard ratio, 1.68 [95% CI, 1.63 to 1.73]) and moderate (hazard ratio, 2.35 [CI, 2.26 to 2.45]) renal insufficiency were associated with substantially elevated risk for death during the first month of follow-up. This increased mortality risk continued until 6 months after myocardial infarction.

CONCLUSIONS: Renal insufficiency was an independent risk factor for death in elderly patients after myocardial infarction. Targeted interventions may be needed to improve treatment for this high-risk population.

An extensive literature documents a high prevalence of errors in clinical diagnosis discovered at autopsy. Multiple studies have suggested no significant decrease in these errors over time. Despite these findings, autopsies have dramatically decreased in frequency in the United States and many other countries.

In 1994, the last year for which national U.S. data exist, the autopsy rate for all non-forensic deaths fell below 6 percent. The marked decline in autopsy rates from previous rates of 40-50 percent undoubtedly reflects various factors, including reimbursement issues, the attitudes of clinicians regarding the utility of autopsies in the setting of other diagnostic advances, and general unfamiliarity with the autopsy and techniques for requesting it, especially among physicians-in-training.

The autopsy is valuable for its role in undergraduate and graduate medical education, the identification and characterization of new diseases, and contributions to the understanding of disease pathogenesis. Although extensive, these benefits are difficult to quantify. This systematic review studied the more easily quantifiable benefits of the autopsy as a tool in performance measurement and improvement. Such benefits largely relate to the role of the autopsy in detecting errors in clinical diagnosis and unsuspected complications of treatment.

It is hoped that characterizing the extent to which the autopsy provides data relevant to clinical performance measurement and improvement will help inform strategies for preserving the benefits of routinely obtained autopsies and for considering its wider use as an instrument for quality improvement.

This report does not attempt to address the roles of the autopsy in medical education; furthering medical research; quality control within pathology; verification, second-opinion consultations, and legal documentation of findings; the bereavement process for surviving family members; or other benefits that are described in many of the sources listed in the bibliography (Appendix F). In addition to being difficult to quantify, these benefits apply primarily to teaching hospitals. To address the role of the autopsy as an outcome measure and tool for quality improvement, the report focuses on benefits likely to apply to all hospitals, such as the detection of important diagnostic errors and related quality problems.

Survival of patients who sustain a ventricular arrhythmia is poor but slowly improving due to in-hospital use of medications and ICDs. However, this more intensive hospital treatment has been accompanied by increased hospital expenditures, finds this study. The researchers analyzed Medicare databases from 1985 to 1995 to identify elderly patients hospitalized with ventricular arrhythmias (index admission). They created a longitudinal patient profile by linking the index hospital admission with all earlier and subsequent admissions and with death records.

During this time, about 85,000 elderly patients went to U.S. emergency departments (EDs) with ventricular arrhythmias each year. Only about 20,000 of these patients lived to be admitted to the hospital from the ED, and then about 14 percent died within the first day. From 1987 to 1995, the demographic and clinical characteristics of patients and the use of coronary angioplasty and bypass graft surgery for these patients were largely unchanged. However, the use of electrophysiology studies (EPS) grew from 3 to 22 percent and use of ICDs increased from 1 to 13 percent. A growing number of patients survived, particularly in the medium term, with 1-year survival rates increasing from 53 percent in 1987 to 58 percent in 1994, or half a percentage point each year.

At the same time, hospital expenditures rose 8 percent per year, primarily because of the increased use of EPS and ICD procedures. By 1993, Medicare was reimbursing hospitals an average of $15,627 for care for each patient during the year after admission for ventricular tachycardia/fibrillation. During the subsequent year, another $14,739 on average was spent for these patients. The increased intensity of care for these patients led to a rise in the average expenditure per patient of about $1,000 per year (in 1993 dollars) from 1987 to 1995.

The use of coronary angiography and revascularization is lower than expected among black patients. It is uncertain whether use of other cardiac procedures also varies according to race and ethnicity and whether outcomes are affected.

Methods

We analyzed discharge abstracts from all nonfederal hospitals in California of patients hospitalized for a primary diagnosis of ventricular tachycardia or ventricular fibrillation between 1992 and 1994. We compared mortality rates and use of electrophysiologic study (EPS) and implantable cardioverter-defibrillator (ICD) procedures according to the race and ethnicity of the patient.

Results

Among 8713 patients admitted with ventricular tachycardia or ventricular fibrillation, 29% (n  2508) had a subsequent EPS procedure, and 9% (n  818) had an ICD implanted. After controlling for potential confounding factors, we found that black patients were significantly less likely than white patients to undergo EPS (odds ratio 0.72, CI 0.56-0.92) or ICD implantation (odds ratio 0.39, CI 0.25-0.60). Blacks discharged alive from the initial hospital admission had higher mortality rates over the next year than white patients, even after controlling for multiple confounding risk factors (risk ratio 1.18, CI 1.03-1.36). The use of EPS and ICD procedures was also significantly affected by several other factors, most notably by on-site procedure availability but also by age, sex, and insurance status.

Conclusions

In a large population of patients hospitalized for ventricular arrhythmia, blacks had significantly lower rates of utilization for EPS and ICD procedures and higher subsequent mortality rates.