OBJECTIVE: To compare the probability of cancer in a solitary pulmonary nodule using standard criteria with Bayesian analysis and result of 2- [F-18] fluoro-2-deoxy-D-glucose-positron emission tomographic (FDG-PET) scan.

SETTING: A university hospital and a teaching Veteran Affairs Medical Center.

METHODS: Retrospective analysis of 52 patients who had undergone both CT scan of the chest and a FDG-PET scan for evaluation of a solitary pulmonary nodule. FDG-PET scan was classified as abnormal or normal. Utilizing Bayesian analysis, the probability of cancer using "standard criteria" available in the literature, based on patient's age, history of previous malignancy, smoking history, size and edge of nodule, and presence or absence of calcification were calculated and compared to the probability of cancer based on an abnormal or normal FDG-PET scan. Histologic study of the nodules was the gold standard.

RESULTS: The likelihood ratios for malignancy in a solitary pulmonary nodule with an abnormal FDG-PET scan was 7.11 (95% confidence interval [CI], 6.36 to 7.96), suggesting a high probability for malignancy, and 0.06 (95% CI, 0.05 to 0.07) when the PET scan was normal, suggesting a high probability for benign nodule. FDG-PET scan as a single test alone was more accurate than the standard criteria and standard criteria plus PET scan in correctly classifying nodules as malignant or benign.

CONCLUSION: FDG-PET scan as a single test was a better predictor of malignancy in solitary pulmonary nodules than the standard criteria using Bayesian analysis. FDG-PET scan can be a useful adjunct test in the evaluation of solitary pulmonary nodules.

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.

Does government spend too little or too much on child care? How can education dollars be spent more efficiently? Should government's role in medical care increase or decrease? In this volume, social scientists, lawyers, and a physician explore the political, social, and economic forces that shape policies affecting human services.

Four in-depth studies of human-service sectors - child care, education, medical care, and long-term care for the elderly - are followed by six cross-sector studies that stimulate new ways of thinking about human services through the application of economic theory, institutional analysis, and the history of social policy.

This timely study sheds important light on the tension between individual and social responsibility, and will appeal to economists and other social scientists and policymakers concerned with social policy issues.

Managed competition in health care is an idea that has evolved over two decades of research and refinement. It is defined as a purchasing strategy to obtain maximum value for consumers and employers, using rules for competition derived from microeconomic principles. A sponsor (either an employer, a governmental entity, or a purchasing cooperative), acting on behalf of a large group of subscribers, structures and adjusts the market to overcome attempts by insurers to avoid price competition. The sponsor establishes rules of equity, selects participating plans, manages the enrollment process, creates price-elastic demand, and manages risk selection. Managed competition is based on comprehensive care organizations that integrate financing and delivery. Prospects for its success are based on the success and potential of a number of high-quality, cost-effective, organized systems of care already in existence, especially prepaid group practices. As it is outlined here, managed competition as a means to reform the U.S. health care system is compatible with Americans' preferences for pluralism, individual choice and responsibility, and universal coverage.