OBJECTIVES: The authors sought to develop a conceptual framework for evaluating whether existing information technologies and decision support systems (IT/DSSs) would assist the key decisions faced by clinicians and public health officials preparing for and responding to bioterrorism.

METHODS: They reviewed reports of natural and bioterrorism related infectious outbreaks, bioterrorism preparedness exercises, and advice from experts to identify the key decisions, tasks, and information needs of clinicians and public health officials during a bioterrorism response. The authors used task decomposition to identify the subtasks and data requirements of IT/DSSs designed to facilitate a bioterrorism response. They used the results of the task decomposition to develop evaluation criteria for IT/DSSs for bioterrorism preparedness. They then applied these evaluation criteria to 341 reports of 217 existing IT/DSSs that could be used to support a bioterrorism response. Main Results: In response to bioterrorism, clinicians must make decisions in 4 critical domains (diagnosis, management, prevention, and reporting to public health), and public health officials must make decisions in 4 other domains (interpretation of bioterrorism surveillance data, outbreak investigation, outbreak control, and communication). The time horizons and utility functions for these decisions differ. From the task decomposition, the authors identified critical subtasks for each of the 8 decisions. For example, interpretation of diagnostic tests is an important subtask of diagnostic decision making that requires an understanding of the tests' sensitivity and specificity. Therefore, an evaluation criterion applied to reports of diagnostic IT/DSSs for bioterrorism asked whether the reports described the systems' sensitivity and specificity. Of the 217 existing IT/DSSs that could be used to respond to bioterrorism, 79 studies evaluated 58 systems for at least 1 performance metric.

CONCLUSIONS: The authors identified 8 key decisions that clinicians and public health officials must make in response to bioterrorism. When applying the evaluation system to 217 currently available IT/DSSs that could potentially support the decisions of clinicians and public health officials, the authors found that the literature provides little information about the accuracy of these systems.

When teaching my students about what goes into a good doctor-patient interaction, I tell them about the studies that show how quickly doctors interrupt their patients. Male physicians especially, I tell them, are notorious for stopping the patient mid-sentence to redirect the discussion. In one study that I came across, female primary care physicians waited an average of 3 minutes before interrupting the patient to redirect the discussion toward issues more relevant to diagnosis. Male physicians waited an average of 47 seconds.

How long do I wait, I wondered? I decided to try an experiment. I would let my next patient talk as long as he or she needed to explain his or her reason for seeing me. I would watch the clock and see how long a patient might naturally take to explain the presenting complaint. I would hold my tongue.

The patient was in her 70s and greeted me with a smile when I stepped behind the curtain to be with her. "Hello, I'm Dr. Barr. What's the problem that brings you in today?"

She began to describe the past several weeks of her life. As I recall, it had to do with a coworker noticing something, talking with her sister on the phone, and her reluctance to see doctors. The word "cough" surfaced for a second, then quickly became submerged again. Looking at the medicines on the shelf at the drug store and not knowing which to choose. ... Needing to dress warmly ... (Wasn't this weather we'd been having nasty?) ... Sometimes she had trouble sleeping ...

The nurse poked her head through the curtain and silently tapped her watch. The waiting room of our urgent care center was full, and things were starting to back up. I wouldn't budge, though - I turned back to the patient and nodded. However long it took, I would wait for the patient to stop of her own accord. I wouldn't butt in.

It was the cough that was keeping her awake. ... She always got colds more easily than other people. ... Her sister was just a worrier. ... She finally had agreed to come in to see a doctor, just to reassure her friends and family.

Twenty-two minutes, from start to finish. The nurses were never going to forgive me.

The lungs had left-sided rales. The fever was mild, but the white count suggested infection. The chest radiograph showed a large infiltrate on the left and what I feared was a mass. I called the pulmonary specialist across the street and asked if he could squeeze the patient in this afternoon. He did, only to confirm the worst. It appeared the patient had a tumor causing the infiltrate, and there probably were enlarged hilar nodes as well. She probably had lung cancer, and it was probably in an advanced stage. She needed antibiotics right away to get the infection under control, after which further testing would be arranged.

The patient came back to our center for the antibiotics. The specialist had told her what he had found and had given her an indication of the grave prognosis she faced. I stepped back into the patient's space and said with sadness, "This hasn't been a very good day for you, has it?"

She looked at me for a moment with an unmistakable smile on her face. She reached out her hand and patted me on the wrist.

"Oh, don't worry about all that. I've had a good life. But I just wanted you to know - this is the best doctor visit I've ever had. You're the only one who ever listened."

We evaluated the usefulness of detection systems and diagnostic decision support systems for bioterrorism response. We performed a systematic review by searching relevant databases (e.g., MEDLINE) and Web sites for reports of detection systems and diagnostic decision support systems that could be used during bioterrorism responses. We reviewed over 24,000 citations and identified 55 detection systems and 23 diagnostic decision support systems. Only 35 systems have been evaluated: 4 reported both sensitivity and specificity, 13 were compared to a reference standard, and 31 were evaluated for their timeliness. Most evaluations of detection systems and some evaluations of diagnostic systems for bioterrorism responses are critically deficient. Because false-positive and false-negative rates are unknown for most systems, decision making on the basis of these systems is seriously compromised. We describe a framework for the design of future evaluations of such systems.

This compendium of articles provides a clear view of the factors affecting the health of Americans and the role of public health, medical care, and the community in ensuring the nation's health. The Seventh Edition continues the emphasis of earlier editions on the health of the population, the determinants of health, women's health, long term care, and the precarious set of circumstances faced by the nation's public health and health care systems as we begin the 21st century.

New issues, particularly related to bioterrorism and community health are addressed in this edition. This volume also includes coverage of tobacco, immunizations, HIV/AIDS, environmental health, dietary guidelines, physical activity, and food safety. In addition, a major new feature is an article on community problem solving, emphasizing a multidisciplinary approach to collaborative practice and research to improve community health.

Using data from the National Health and Nutrition Examination Survey, we examine the relationship between nutritional status, poverty, and food insecurity for household members of various ages. Our most striking result is that, while poverty is predictive of poor nutrition among preschool children, food insecurity does not provide any additional predictive power for this age group. Among school age children, neither poverty nor food insecurity is associated with nutritional outcomes, while among adults and the elderly, both food insecurity and poverty are predictive. These results suggest that researchers should be cautious about assuming connections between food insecurity and nutritional outcomes, particularly among children.

OBJECTIVE: Positron emission tomography (PET) is a high-cost imaging tool primarily used in oncology, cardiology, and neuropsychiatry. Accurate estimates of the cost of PET are needed to assess its cost effectiveness and determine the appropriate role for this modality in clinical applications. We performed a survey-based cost analysis of PET with FDG by estimating direct, indirect, and capital costs from eight PET centers. A breakdown of the operational budget of PET centers and FDG-compounding facilities is presented along with the costs per scan. Differences in costs between sites that purchase FDG and those that manufacture FDG are also examined. MATERIALS AND METHODS: We sent surveys to managers of eight Veterans Affairs and two non-Veterans Affairs PET scanning and FDG-compounding facilities. The survey included questions about service volume and the direct costs of equipment, personnel, space, supplies, and repairs needed for FDG compounding and PET scanning and interpretation. We estimated the indirect costs associated with FDG compounding, PET scanning, and PET interpretation. RESULTS: Of the eight sites that responded to our survey, three sites manufacture FDG on-site, three sites purchase FDG, and two sites do both. The total mean cost per scan using manufactured FDG is 1885 US dollars, and it is 1898 US dollars using purchased FDG. CONCLUSION: PET is expensive. The cost is similar when FDG is manufactured or purchased. Because both PET and cyclotron facilities have high fixed costs, increasing the number of scans obtained and the number of FDG doses manufactured may lead to a decrease in unit costs.

Background: In recent years, there has been significant controversy over how institutional review board (IRB) procedures are structured, administered, and balanced against other concerns (for example, the feasibility of multicenter research). Formal economic analysis has been largely absent in these debates. With hospitals and research facilities under budgetary pressures, it is essential that cost-effective IRB systems be developed.

Objective: To estimate the cost of IRB procedures in an eight-site observational substance abuse treatment study.

Methods and Findings: We estimated the cost of each IRB "action" (initial reviews, continuing reviews, amendments, and adverse event reports) at each project site using a method that has been described in detail elsewhere. In brief, a national administrative database on IRBs was consulted to determine the estimated total cost of operating IRBs of various sizes. These total costs comprised personnel, space, supplies, and training. Dividing these total costs by the total number of actions conducted per year by an IRB yielded a cost per action. When these data were used as a reference point, each of the eight IRBs in our study was estimated to have a cost per action equal to that of IRBs of a comparable size in the national database.

All study procedures for the substance abuse treatment study were approved by our local university IRB. Nevertheless, the IRBs at each of the eight participating medical centers elected to conduct an independent, full-board review of the research protocol. The focus of our economic study was the costs of these "supplemental" IRB actions. In other words, how much money was expended on further reviewing the study after the home IRB had approved the project?

Expenditures for the supplemental IRB activities were estimated at $56 191 in 2001 dollars. This consumed 16.8% of the total research grant budget for all activities (recruiting sites, enrolling and interviewing participants, analyzing data) over the same period. Most of these costs ($29 824) reflected the IRBs' expenditures for 70 supplemental actions. Coordinating center personnel, space, and supply costs made up the second largest expense, at $16 951. The additional effort for the investigators at the eight participating sites totaled $9416.

Discussion: The high costs of IRBs were driven by several factors. First, our home IRB and committees at local sites frequently disagreed on the formatting of consent procedures and patient survey forms, and all expected final say on study implementation. This resulted in consent forms and patient survey instruments being reviewed and re-reviewed many times. Second, participating institutions required review both by hospital and affiliated university IRBs. We believe this redundancy was due to fear generated by recent high-profile cases in which research institutions were penalized for human subjects violations. Third, our coordinating center was often not allowed to directly contact IRB staff at the participating sites, nor would the nine IRBs involved (including our home IRB) communicate with each other. Coordinating center staff thus spent long periods translating and retransmitting information to IRB staff and local investigators scattered throughout the country, which slowed and sometimes garbled communication.

Conclusion: These extensive IRB procedures had no discernible impact on human subjects protection. The essential procedures of the study never changed substantially, despite exchanges of over 15 000 pages of material among the nine sites. In addition, as an empirical matter, no adverse incidents occurred among the participants. Researchers and policymakers should weigh the cost and benefits of multisite review for minimal-risk studies, such as observational health services research. The National Cancer Institute's centralized IRB for multisite phase III trials is an intriguing model. Other systems exist, although none has explicitly discussed minimal-risk studies. If costs such as those identified in this project continue to grow without consideration of the benefits of facilitating scientific projects, we worry that future research may be unjustly affected.

INTRODUCTION: Many surgical suites allocate operating room (OR) block time to individual surgeons. If block time is allocated to services/groups and yet the same surgeon invariably operates on the same weekday, for all practical purposes block time is being allocated to individual surgeons. Organizational conflict occurs when a surgeon with a relatively low OR utilization has his or her allocated block time reduced. The authors studied potential limitations affecting whether a facility can accurately estimate the average block time utilizations of individual surgeons performing low volumes of cases. METHODS: Discrete-event computer simulation. RESULTS: Neither 3 months nor 1 yr of historical data were enough to be able to identify surgeons who had persistently low average OR utilizations. For example, with 3 months of data, the widths of the 95% CIs for average OR utilization exceeded 10% for surgeons who had average raw utilizations of 83% or less. If during a 3-month period a surgeon's measured adjusted utilization is 65%, there is a 95% chance that the surgeon's average adjusted utilization is as low as 38% or as high as 83%. If two surgeons have measured adjusted utilizations of 65% and 80%, respectively, there is a 16% chance that they have the same average adjusted utilization. Average OR utilization can be estimated more precisely for surgeons performing more cases each week. CONCLUSIONS: Average OR utilization probably cannot be estimated precisely for low-volume surgeons based on 3 months or 1 yr of historical OR utilization data. The authors recommend that at surgical suites trying to allocate OR time to individual low-volume surgeons, OR allocations be based on criteria other than only OR utilization (e.g., based on OR efficiency).