Objective. To evaluate the costs and benefits of a group B streptococci screening strategy using a new, rapid polymerase chain reaction test in a hypothetical cohort of expectant mothers in the United States.

Methods. Design. Cost-benefit analysis using the human capital method. We developed a decision model to analyze the costs and benefits of a hypothetical group B streptococci screening strategy using a new, rapid polymerase chain reaction test as compared with the currently recommended group B streptococci screening guidelines-prenatal culture performed at 35 to 37 weeks or risk-factorbased strategy with subsequent intrapartum treatment of the expectant mothers with antibiotics to prevent early-onset group B streptococcal infections in their infants.

Participants. A hypothetical cohort of pregnant women and their newborns.

Interventions. Screening strategies for group B streptococci using the new polymerase chain reaction technique, the 35- to 37-week culture, or maternal risk factors.

Outcome Measures. Infant infections averted, infant deaths, infant disabilities, costs, and societal benefits of healthy infants.

Results. A screening strategy using the new polymerase chain reaction test generates a net benefit of $7 per birth when compared with the maternal risk-factor strategy. For every 1 million births, 80 700 more women would receive antibiotics, 884 fewer infants would become infected with early-onset group B streptococci, and 23 infants would be saved from death or disability. The polymerase chain reaction-based strategy generates a net benefit of $6 per birth when compared with the 35- to 37-week prenatal culture strategy and results in fewer maternal courses of antibiotics (64 080 per million births), fewer perinatal infections with early-onset group B streptococci (218/million), and a reduction in 6 infant deaths and severe infant disability per million births. The benefits hold over a wide range of assumptions regarding key factors in the analysis.

Conclusions. Although additional clinical trials are needed to establish the accuracy of this new polymerase chain reaction test, initial studies suggest that strategies using this test will be superior to the other 2 strategies. Using the rapid polymerase chain reaction test becomes less attractive as the cost of the test increases. The test's greatest strengths lie in its ability to identify women and infants at risk at the time of labor, thereby decreasing the number of false-positives and false-negatives seen with the other 2 strategies and allowing for more accurate and effective intrapartum prophylaxis.

The ethical case for the social insurance model will be strengthened as people realize that most health problems have at least in part a genetic basis. The efficiency case will benefit from recognition that employment-based insurance has high administrative costs but provides no advantages to society as a whole. The desire to exert more direct control over rising expenditures will provide an additional reason to introduce some form of national health insurance.

The timing of such a change, however, will depend largely on factors external to health care. Major changes in health policy are political acts undertaken for political purposes. This was true when Bismarck introduced national health insurance to the new German state in the 19th century. It was true when England adopted national health insurance after World War II; and it will be true in the United States as well. National health insurance will probably come to the United States after a major change in the political climate, the kind of change that often accompanies a war, a depression, or large scale civil unrest. Until then, the major effect of the new plans will be to make young and healthy workers better off at the expense of their older, sicker colleagues.

OBJECTIVE: To investigate recent national trends in nonsteroidal antiinflammatory drug (NSAID) and acetaminophen use for osteoarthritis (OA).

METHODS: Using data from the 1989-98 National Ambulatory Medical Care Survey, a representative sample of US office based physician visits, we assessed 4471 visits by patients 45 years or older with a diagnosis of OA. We examined cross sectional and longitudinal patterns of OA pharmacotherapy. The independent effects of patient and physician characteristics on NSAID and acetaminophen use were examined using multiple logistic regression analysis.

RESULTS: Pharmacological treatment for OA (either NSAID, acetaminophen, or both) has steadily decreased from 49% of visits (1989-91) to 46% (1992-94) to 40% (1995-98) (p = 0.001). Reduced NSAID use over this time period (46% to 33%; p = 0.001) was partially offset by a modest increase in acetaminophen use (5% to 10%; p = 0.001). Among individual NSAID, ibuprofen (5.7% of OA visits), nabumetone (4.9%), naproxen (4.6%), and aspirin (4.4%) were the most frequently reported in 1995-98. For patient visits in 1995-98, 45 to 59-year-olds (38%) received NSAID more often than 60 to 74-year-olds (34%) or patients older than 75 (28%; p = 0.029). Other possible predictors of OA therapy included patient race and physician specialty.

CONCLUSION: The decline in the use of NSAID from 1989 to 1998, especially among elderly patients, and the frequent selection of safer medications may reflect awareness of the literature citing the risks of nonsteroidals for OA. However, variations in prescribing patterns among different patient populations and the modest use of acetaminophen, despite evidence supporting its efficacy, suggest that better assimilation of the literature into medical practice is needed to optimize OA therapy.

PURPOSE: To determine if greater managed care market share is associated with greater use of recommended therapies for fee-for-service patients with acute myocardial infarction.

SUBJECTS AND METHODS: We examined the care of 112,900 fee-for-service Medicare beneficiaries aged > or = 65 years who resided in one of 320 metropolitan statistical areas and who were admitted with an acute myocardial infarction between February 1994 through July 1995. Use of recommended medical treatments and 30-day survival were determined for areas with low (<10%), medium (10% to 30%), and high (>30%) managed care market share.

RESULTS: After adjustment for severity of illness, teaching status of the admission hospital, and area characteristics, areas with high levels of managed care had greater use of beta-blockers (relative risk [RR] for greater use = 1.18; 95% confidence interval [CI]: 1.06 to 1.29) and aspirin at discharge (RR = 1.05; 95% CI: 1.02 to 1.07), but less appropriate coronary angiography (RR = 0.93; 95% CI: 0.86 to 1.01) and reperfusion (RR = 0.95; 95% CI: 0.85 to 1.03) when compared with areas with low levels of managed care.

CONCLUSIONS: Medicare beneficiaries with fee-for-service insurance who resided in areas with high managed care activity were more likely to have received appropriate treatment with beta-blockers and aspirin, and less likely to have undergone coronary angiography following admission for myocardial infarction. Thus, the effects of managed care may not be limited to managed care enrollees.

Objective: To examine the prevalence of overweight concerns and body dissatisfaction among third-grade girls and boys and the influences of ethnicity and socioeconomic status (SES).

Study Design: Nine hundred sixty-nine children (mean age, 8.5 years) attending 13 northern California public elementary schools completed assessments of overweight concerns, body dissatisfaction, and desired shape, height, and weight.

Results: The sample was 44% white, 21% Latino, 19% non-Filipino Asian American, 8% Filipino, and 5% African American. Twenty-six percent of boys and 35% of girls reported wanting to lose weight, and 17% of boys and 24% of girls reported dieting to lose weight. Among girls, Latinas and African Americans reported significantly more overweight concerns than Asian Americans and Filipinas, and Latinas reported significantly more overweight concerns than whites. White and Latina girls also reported greater body dissatisfaction than Asian American girls. Some differences persisted even after controlling for actual body fatness. Higher SES African American girls reported significantly more overweight concerns than lower SES African American girls, but higher SES white girls reported less overweight concerns than lower SES white girls.

Conclusion: Overweight concerns and body dissatisfaction are highly prevalent among third-grade girls and boys, across ethnicity and SES. Young Latina and African American girls manifest equivalent or higher levels of disordered eating attitudes and behaviors as white and Asian American girls.

Objective: Identifying parental behaviors that influence childhood obesity is critical for the development of effective prevention and treatment programs. Findings from a prior laboratory study suggest that parents who impose control over their children's eating may interfere with their children's ability to regulate intake, potentially resulting in overweight. These findings have been widely endorsed; however, the direct relationship between parental control of children's intake and their children's degree of overweight has not been shown in a generalized sample.

Research Methods and Procedures: This study surveyed 792 third-grade children with diverse ethnic and socioeconomic backgrounds from 13 public elementary schools. Parental control over children's intake was assessed through telephone interviews using a state-of-the-art instrument, and children were measured for height, weight, and triceps skinfold thickness.

Results: Counter to the hypothesis, parental control over children's intake was inversely associated with overweight in girls, as measured by body mass index, r = -0.12, p 0.05, and triceps skinfolds, r = -0.11, p 0.05. This weak relationship became only marginally significant when controlling for parents' perceptions of their own weight, level of household education, and children's age. No relationship between parental control of children's intake and their children's degree of overweight was found in boys.

Discussion: Previous observations of the influence of parental control over children's intake in middle-class white families did not generalize to 8- to 9-year-olds in families with diverse socioeconomic and ethnic backgrounds. The present findings reveal a more complex relationship between parental behaviors and children's weight status.

Previous attempts to reduce the effects of television advertising on children's purchase requests have had little success. Therefore, we tested the effects of a classroom intervention to reduce television, videotape, and video game use on children's toy purchase requests, in a school-based randomized controlled trial. Third- and fourth-grade children (mean age, 8.9 years) in two sociodemographically and scholastically matched public elementary schools were eligible to participate. Children in one randomly selected elementary school received an 18-lesson, 6-month classroom curriculum to reduce television, videotape, and video game use. In both schools, in September (before intervention) and April (after intervention) of a single school year, children and parents reported children's prior week's purchase requests for toys seen on television. After intervention, children in the intervention school were significantly less likely to report toy purchase requests than children in the control school, with adjusting for baseline purchase requests, gender, and age (odds ratio, 0.29; 95% confidence interval, 0.12-0.69). Among intervention school children, reductions in self-reported purchase requests were also associated with reductions in television viewing. There was no significant difference between schools in parent reports of children's requests for toy purchases. These findings suggest that reducing television viewing is a promising approach to reducing the influences of advertising on children's behavior.