Now in its Third Edition, this manual is an accessible, reliable source of guidance on clinical problems that are frequently encountered in the adult ambulatory care setting. More than 90 expert contributors from every branch of clinical medicine provide practical, knowledgeable answers to the questions arising in day-to-day patient care.Coverage encompasses all organ systems, with additional sections on constitutional symptoms, psychiatric and behavioral problems, infectious diseases, women's and men's health issues, and health maintenance. Chapters are either symptom-oriented or disease-oriented, depending on the way a condition presents in practice. Each chapter focuses on the questions clinicians encounter when caring for patients, such as how often the condition occurs, its natural history, and the effectiveness of preventive and therapeutic interventions. The authors offer succinct, practical advice and also explain the rationale for their recommendations. Annotated references at the end of each chapter direct the reader to additional information.

Now in its Third Edition, this manual is an accessible, reliable source of guidance on clinical problems that are frequently encountered in the adult ambulatory care setting. More than 90 expert contributors from every branch of clinical medicine provide practical, knowledgeable answers to the questions arising in day-to-day patient care.Coverage encompasses all organ systems, with additional sections on constitutional symptoms, psychiatric and behavioral problems, infectious diseases, women's and men's health issues, and health maintenance. Chapters are either symptom-oriented or disease-oriented, depending on the way a condition presents in practice. Each chapter focuses on the questions clinicians encounter when caring for patients, such as how often the condition occurs, its natural history, and the effectiveness of preventive and therapeutic interventions. The authors offer succinct, practical advice and also explain the rationale for their recommendations. Annotated references at the end of each chapter direct the reader to additional information.

Objective: To determine the hospital cost of caring for newborn infants with congenital syphilis.

Study Population: All live-born singleton neonates with birth weight greater than 500 gm at an inner-city municipal hospital in New York City in 1989.

Methods: We compared the characteristics of 114 infants with case-compatible congenital syphilis with those of 2906 infants without syphilis. Cost estimates were based on New York State newborn diagnosis-related groups (DRG) reimbursements adjusted for length of stay, birth weight, preterm delivery, and selected maternal risk factors, including infection with the human immunodeficiency virus, cocaine use during pregnancy, and history of injected drug use.

Results: For infants with congenital syphilis, the unadjusted mean cost ($11,031) and the median cost ($4961) were more than three times larger than those for infants without syphilis (p 0.01). After adjustment, congenital syphilis was associated with an additional length of hospitalization of 7 1/2 days and an additional cost of $4690 (both p 0.01) above mean study population values (7.13 days, $3473).

Conclusions: Based on the number of reported cases (1991 to 1994), the average annual national cost of treating infants with congenital syphilis is approximately $18.4 million (1995 dollars). This estimate provides a benchmark to assess the cost-effectiveness of strategies to prevent, diagnose, and treat the disease.

We present four findings. First, physicians from states enacting liability reforms that directly reduce malpractice pressure experience lower growth over time in malpractice claims rates and in real malpractice insurance premiums. Second, physicians from reforming states report significant relative declines in the perceived impact of malpractice pressure on practice patterns. Third, individual physicians' personal experiences with the malpractice system are a key determinant of the perceived importance of defensive medicine: Physicians who have had a malpractice claim filed against them, particularly a recent claim, are more likely to report changes in practices as a result of malpractice pressure than physicians who have not. Fourth, the impact of individual physicians' claims experience on perceptions is smaller in reforming than in nonreforming states. Taken together, these results suggest that reforms in law affect physicians' attitudes, both by reducing the probability of an encounter with the liability system, and by changing the nature of the experience of being sued for those physicians who defend against malpractice claims. These results validate our previous research by illustrating how reforms change physician incentives. Our 1996 study showed that reforms changed physician behavior, but stopped short of investigating the mechanism by which reforms altered medical practices.57 Our current results, however, indicate that mechanisms commonly cited by physicians in anecdotal reports namely the frequency and severity of malpractice claims may play an important role in fostering defensive medical practices. Reforms appear to affect practices particularly through their impact on the attitudes of physicians who experience lawsuits. In this paper, we did not explicitly model why attitudes of physicians who are sued in states with reforms are less dramatically affected [*pg 106] than attitudes of physicians in states without reforms.58 However, the differences we find here suggest that malpractice claims are less onerous in states with reforms, providing a foundation for their differential impact on physician attitudes. In addition, our results suggest that physician surveys do relate to actual behavior. The fact that state-level reforms both reduce measures of malpractice pressure and reduce physician perceptions of the impact of malpractice pressure suggest that survey methods provide valid measures of defensive practices. Nonetheless, further investigation of the extent of the validity of survey methods will be a fruitful topic of further research. Because the format of the 1984 and 1993 questions regarding the impact of malpractice pressure on practice patterns were not comparable,59 we needed to assume that impact of the change in the questions' terms was uncorrelated with physicians' personal characteristics and uncorrelated with geographic area in order to identify the impact of law reforms on relative changes in the rates of reported malpractice-pressure-induced changes in behavior. Future research might investigate the validity of our assumption, or might seek to replicate our results with comparable survey questions. In addition, our results suggest that physician surveys do, in part, measure negative feelings about the malpractice system, or unobserved differences across physicians, rather than the targeted issue of the impact of malpractice pressure on perceptions and practice patterns. Malpractice claims history has a strong positive correlation with perceived changes in malpractice-pressure-induced changes in practices, and more recent history is more strongly correlated with perceived changes than is less recent history. Future research might investigate the extent to which these findings represent actual changes in practices, rather than the well-studied problem of response bias.

A population-based probability sample of elderly individuals (n = 426), who were originally studied between 1981 and 1986 (mean age at initial study was 72.5 years), were followed for mortality. Those with > or = 30 respiratory disturbances per hour of sleep had significantly shorter survival (p = 0.0034), but the respiratory disturbance index (RDI) was not an independent predictor of death. When Cox proportional hazards analysis was done, only age (the strongest predictor), cardiovascular disease and pulmonary disease were independent predictors of death. It may be that factors that are secondary to or associated with sleep-disordered breathing (SDB), such as cardiovascular or pulmonary disease, predispose these elderly to death.

This volume presents innovative research on issues of importance to the well-being of older persons: labor market behavior, health care, housing and living arrangements, and saving and wealth.

Specific topics include the effect of labor market rigidities on the employment of older workers; the effect on retirement of the availability of continuation coverage benefits; and the influence of the prospective payment system (PPS) on rising Medicare costs. Also considered are the effects of health and wealth on living arrangement decisions; the incentive effects of employer-provided pension plans; the degree of substitution between 401(k) plans and other employer-provided retirement saving arrangements; and the extent to which housing wealth determines how much the elderly save and consume.

Two final studies use simulations that describe the implications of stylized economic models of behavior among the elderly. This timely volume will be of interest to anyone concerned with the economics of aging.

Urinary incontinence affects 10 million elderly and is estimated to cost more than $10 billion annually. Treatments for this conditions vary widely in efficacy and cost. Using the Agency for Health Care Policy and Research urinary incontinence guideline, we calculated expected costs for three recommended treatments for stress urinary incontinence in elderly women: (1) behavioral therapy, (2) pharmacologic therapy, and (3) surgical therapy. We constructed decision trees for each treatment option and incorporated treatment efficacy rates stated in the guideline. Costs were determined from the literature.

Using a Markov cohort simulation, 10-year expected costs per patient, in 1994 dollars, were lowest for surgical therapies and were highest for behavioral therapy (needle suspension surgery, $25,388; phenlypropanolamine and estrogen, $62,021; and behavioral therapy, $68,924). All treatment strategies were less costly than that of untreated incontinence ($86,726). Sensitivity analysis revealed that the results were highly affected by the likelihood of the patient's entering a nursing home, the cost of nursing home care, and the long-term relapse rate after surgery.

In conclusion, on the basis of data from the urinary incontinence guideline, early surgical intervention is the least costly treatment for chronic stress incontinence in elderly women. Because the long-term effectiveness of most incontinence surgeries is uncertain, additional studies are necessary to substantiate these findings.