OBJECTIVE: Late-night salivary cortisol (LNSC) is reportedly highly accurate for the diagnosis of Cushing's syndrome (CS). However, diagnostic thresholds for abnormal results are based on healthy, young populations and limited data are available on its use in elderly populations with chronic medical conditions. The purpose of this study was to evaluate LNSC levels in elderly male veterans with and without diabetes.

DESIGN: Prospective evaluation of LNSC levels in male veterans.

PATIENTS: One hundred and fifty-four participants with type 2 diabetes and 52 participants without diabetes. MEASUREMENTS: Participants underwent outpatient LNSC (2300 h) testing. Participants with elevated LNSC (> or = 4.3 nmol/l) underwent secondary testing, including 24-h urine free cortisol (24UFC, > 60 microg/day) and dexamethasone suppression testing (DST, serum cortisol > 50 nmol/l). Participants with positive secondary testing had a morning ACTH level analysed and either pituitary or adrenal imaging performed.

RESULTS: One hundred and forty-one diabetics and 46 controls (mean age 61 years) returned samples (91% overall). Average LNSC levels (nmol/l) in diabetics were significantly higher than in nondiabetics [median (interquartile range): 2.6 (1.8-4.1) vs. 1.6 (1.0-2.0)] and in those aged > or = 60 compared to 60 [2.7 (2.0-4.3) vs. 1.9 (1.4-2.9)] (P 0.001 for both). Thirty-one participants required secondary testing. Seventy-nine per cent of participants who underwent secondary testing had normal 24UFC and DST. No cases of CS have been diagnosed to date. Increasing age [odds ratio (OR) 2.0 per decade], current diabetes mellitus (OR 4.4), and elevated blood pressure (OR 1.3 per 10 mmHg increase in systolic blood pressure) were associated with abnormal LNSC results (P 0.05 for each).

CONCLUSIONS: LNSC has been shown to be sensitive and specific in diagnosing CS in certain high-risk populations, primarily the young and middle-aged. The development of age- and comorbidity-adjusted thresholds may be warranted for LNSC testing in elderly subjects and in those with significant comorbidity.

This issue of CHP/PCOR's quarterly newsletter covers developments from the spring 2005 quarter. It includes articles about:

• research on HIV/AIDS in Russia -- presented in May at an international conference -- which shows that in order to contain the country's rapidly expanding HIV/AIDS epidemic, Russia must aggressively treat HIV-positive injection drug users;
• a CHP/PCOR-hosted discussion session with Edward Sondik, director of the National Center for Health Statistics;
• an ongoing CHP/PCOR study that examines older adults' preferences about health states in which they would need help with basic tasks like bathing or eating;
• a panel discussion on "International Responses to Infectious Diseases," led by CHP/PCOR at the Stanford Institute for International Studies' first annual conference, featuring the World Health Organization's chief of infectious diseases;
• a widely publicized study by CHP/PCOR researchers which found that obese workers are paid less than non-obese workers in similar jobs, but only when they have employer-sponsored health insurance -- a finding suggesting that the wage gap is due to obese workers' higher medical costs, rather than outright prejudice; and
• an update on the Center on Advancing Decision Making for Aging, including two new seed projects and a lecture given by economics and psychology professor George Loewenstein.

Background: The current national measure set for the quality of health care underrepresents the spectrum of outpatient care and makes limited use of readily available national ambulatory care survey data.

Methods:We examined 23 outpatient quality indicators in 1992 and again in 2002 to measure overall performance and racial/ethnic disparities in outpatient care in the United States. The National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey yielded information about ambulatory services provided in private physician offices and hospital outpatient departments, respectively. Quality indicator performance was defined as the percentage of applicable visits receiving appropriate care.

Results: In 2002, mean performance was 50% or more of applicable visits for 12 quality indicators, 7 of which were in the areas of appropriate antibiotic use and avoiding unnecessary routine screening. The performance of the remaining 11 indicators ranged from 15% to 42%. Overall, changes between 1992 and 2002 were modest, with significant improvements in 6 indicators: treatment of depression (47% vs 83%), statin use for hyperlipidemia (10% vs 37%), inhaled corticosteroid use for asthma in adults (25% vs 42%) and children (11% vs 36%), avoiding routine urinalysis during general medical examinations (63% vs 73%), and avoiding inappropriate medications in the elderly (92% vs 95%). After adjusting for potential confounders, race/ethnicity did not seem to affect quality indicator performance, except for greater angiotensin-converting enzyme inhibitor use for congestive health failure among blacks and less unnecessary antibiotic use for uncomplicated upper respiratory tract infections among whites.

Conclusions: Measurable quality deficits and modest improvements across time call for greater adherence to evidence-based medicine in US ambulatory settings. Although significant racial disparities have been described in a variety of settings, we observed that similar, although less than optimal, care is being provided on a per-visit basis regardless of patient racial/ethnic background.

Background: Low rates of technology utilization in hospitals with high proportions of black inpatients may be a remediable cause of healthcare disparities.

Objectives: Our objective was to determine how differences in technology utilization among hospitals contributed to racial disparity and if temporal reduction in hospital procedure rate variation resulted in decreased racial disparity for these technologies.

Methods: We identified 2,348,952 elderly Medicare beneficiaries potentially eligible for 1 of 5 emerging medical technologies from 1989-2000 and determined if these patients had received the indicated procedure within 90 days of their qualifying hospital admission. Initial multivariate regression models adjusted for age, race, sex, admission year, clinical comorbidity, community levels of education and income, and academic/urban hospital admission. The inpatient racial composition of each patient's admitting hospital and time-race interactions were added as covariates to subsequent models.

Results: Blacks had significantly lower adjusted rates (P 0.001) compared with whites for tissue replacement of the aortic valve, internal mammary artery coronary bypass grafting, dual-chambered pacemaker implantation, and lumbar spinal fusion. Hospitals with > 20% black inpatients were less likely to perform these procedures on both white and black patients than hospitals with 9% black inpatients, and racial disparity was greater in hospitals with larger black populations. There were no temporal reductions in racial disparities.

Conclusions: Blacks may be disadvantaged in access to new procedures by receiving care at hospitals that have both lower procedure rates and greater racial disparity. Policies designed to ameliorate racial disparities in health care must address hospital variation in the provision of care.