Design and implementation of a multicriteria medical decision support system for diagnosis and treatment

Health care providers face the problem of trying to make decisions with inadequate information and also with an overload of (often contradictory) information. Physicians often choose treatment long before they know which disease is present. Indeed, uncertainty is intrinsic to the practice of medicine. Decision analysis can help physicians structure and work through a medical decision problem, and can provide reassurance that decisions are rational and consistent with the beliefs and preferences of other physicians and patients. ^ The primary purpose of this research project is to develop the theory, methods, techniques and tools necessary for designing and implementing a system to support solving medical decision problems. A case study involving “abdominal pain” serves as a prototype for implementing the system. The research, however, focuses on a generic class of problems and aims at covering theoretical as well as practical aspects of the system developed. ^ The main contributions of this research are: (1) bridging the gap between the statistical approach and the knowledge-based (expert) approach to medical decision making; (2) linking a collection of methods, techniques and tools together to allow for the design of a medical decision support system, based on a framework that involves the Analytic Network Process (ANP), the generalization of the Analytic Hierarchy Process (AHP) to dependence and feedback, for problems involving diagnosis and treatment; (3) enhancing the representation and manipulation of uncertainty in the ANP framework by incorporating group consensus weights; and (4) developing a computer program to assist in the implementation of the system. ^

EXPRESSION AND IMMUNOLOGICAL CHARACTERIZATION OF HERV-K TRANSMEMBRANE ENVELOPE PROTEIN IN HUMAN BREAST CANCER

The human endogenous retrovirus K (HERV-K) env gene encodes envelope protein comprising surface (SU) and transmembrane (TM) domains. Having shown the exclusive expression of SU in human breast cancer and the stimulation of SU-specific immune responses in patients with breast cancer, our research here confirmed and extended the data by investigating the expression of HERV-K TM envelope domain and the induction of specific immune responses against TM in breast cancer patients. We found HERV-K TM mRNA and protein expression only in human breast cancer cells but not in normal controls. The specific immune responses against TM domain were induced in mice determined by enzyme-linked immunosorbent assay (ELISA) and IFN-γ enzyme-linked immunosorbent spot (ELISPOT) assay. Furthermore, ELISA detected higher titers of anti-HERV-K TM Env IgG antibodies in sera of breast cancer patients. In addition, the magnitude of the anti-HERV TM B cell response was correlated with the disease stage. Peripheral blood mononuclear cells (PBMCs) before and after in vitro stimulation (IVS) with HERV-K TM from patients with breast cancer as well as healthy controls were tested for T cell responses against HERV-K TM domain by ELISPOT assay. Breast cancer patients (n=21) had stronger HERV-K TM-specific cellular responses than healthy controls (n=12) (P < 0.05). These findings suggest, for the first time, that HERV-K TM expression was enhanced in human breast cancer cells and was able to induce specific B cell and T cell immune responses in breast cancer patients. This study provides support for HERV-K TM as a promising source of antigen for anti-tumor immunotherapy, prevention, diagnosis, and prognosis.

CYTOGENETIC AND DNA CONTENT ANALYSIS IN MULTIPLE MYELOMA

In this dissertation, the cytogenetic characteristics of bone marrow cells from 41 multiple myeloma patients were investigated. These cytogenetic data were correlated with the total DNA content as measured by flow cytometry. Both the cytogenetic information and DNA content were then correlated with clinical data to determine if diagnosis and prognosis of multiple myeloma could be improved.^ One hundred percent of the patients demonstrated abnormal chromosome numbers per metaphase. The average chromosome number per metaphase ranged from 42 to 49.9, with a mean of 44.99. The percent hypodiploidy ranged from 0-100% and the percent hyperdiploidy from 0-53%. Detailed cytogenetic analyses were very difficult to perform because of the paucity of mitotic figures and the poor chromosome morphology. Thus, detailed chromosome banding analysis on these patients was impossible.^ Thirty seven percent of the patients had normal total DNA content, whereas 63% had abnormal amounts of DNA (one patient with less than normal amounts and 25 patients with greater than normal amounts of DNA).^ Several clinical parameters were used in the statistical analyses: tumor burden, patient status at biopsy, patient response status, past therapy, type of treatment and percent plasma cells. Only among these clinical parameters were any statistically significant correlations found: pretreatment tumor burden versus patient response, patient biopsy status versus patient response and past therapy versus patient response.^ No correlations were found between percent hypodiploid, diploid, hyperdiploid or DNA content, and the patient response status, nor were any found between those patients with: (a) normal plasma cells, low pretreatment tumor mass burden and more than 50% of the analyzed metaphases with 46 chromosomes; (b) normal amounts of DNA, low pretreatment tumor mass burden and more than 50% of the metaphases with 46 chromosomes; (c) normal amounts of DNA and normal quantities of plasma cells; (d) abnormal amounts of DNA, abnormal amounts of plasma cells, high pretreatment tumor mass burden and less than 50% of the metaphases with 46 chromosomes.^ Technical drawbacks of both cytogenetic and DNA content analysis in these multiple myeloma patients are discussed along with the lack of correlations between DNA content and chromosome number. Refined chromosome banding analysis awaits technical improvements before we can understand which chromosome material (if any) makes up the "extra" amounts of DNA in these patients. None of the correlations tested can be used as diagnostic or prognostic aids for multiple myeloma. ^

The utility of rapid participatory appraisal for community assessment, diagnosis, and policy development

The selection of a model to guide the understanding and resolution of community problems is an important issue relating to the foundation of public health practice: assessment, policy development, and assurance. Many assessment models produce a diagnosis of community weaknesses, but fail to promote planning and interventions. Rapid Participatory Appraisal (RPA) is a participatory action research model which regards assessment as the first step in the problem solving process, and claims to achieve assessment and policy development within limited resources of time and money. Literature documenting the fulfillment of these claims, and thereby supporting the utility of the model, is relatively sparse and difficult to obtain. Very few articles discuss the changes resulting from RPA assessments in urban areas, and those that do describe studies conducted outside the U.S.A. ^ This study examines the utility of the RPA model and its underlying theories: systems theory, grounded theory, and principles of participatory change, as illustrated by the case study of a community assessment conducted for the Texas Diabetes Institute (TDI), San Antonio, Texas, and subsequent outcomes. Diabetes has a high prevalence and is a major issue in San Antonio. Faculty and students conducted the assessment by informal collaboration between two nursing and public health assessment courses, providing practical student experiences. The study area was large, and the flexibility of the model tested by its use in contiguous sub-regions, reanalyzing aggregated results for the study area. Official TDI reports, and a mail survey of agency employees, described policy development resulting from community diagnoses revealed by the assessment. ^ The RPA model met the criteria for utility from the perspectives of merit, worth, efficiency, and effectiveness. The RPA model best met the agencies' criteria (merit), met the data needs of TDI in this particular situation (worth), provided valid results within budget, time, and personnel constraints (efficiency), and stimulated policy development by TDI (effectiveness). ^ The RPA model appears to have utility for community assessment, diagnosis, and policy development in circumstances similar to the TDI diabetes study. ^

Long-term central venous catheter-related candidemia: A new approach towards diagnosis and management

A case-series analysis of approximately 811 cancer patients who developed Candidemia between 1989 and 1998 and seen at M. D. Anderson Cancer Center, was studied to assess the impact and timing of central venous catheter (CVC) removal on the outcome of fungal bloodstream infections in cancer patients with primary catheter-related Candidemia as well as secondary infections. ^ This study explored the diagnosis and the management of vascular catheter-associated fungemia in patients with cancer. The microbiologic and clinical factors were determined to predict catheter-related Candidemia. Those factors included, in addition to basic demographics, the underlying malignancy, chemotherapy, neutropenia, and other salient data. Statistical analyses included univariate and multivariate logistic regression to determine the outcome of Candidemia in relation to the timing of catheter removal, type of species, and to identify predictors of catheter-related infections. ^ The conclusions of the study aim at enhancing our mastery of issues involving CVC removal and potentially will have an impact on the management of nosocomial bloodstream infections related to timing of CVC removal and the optimal duration of treatment of catheter-related Candidemia. ^

Health care policy analysis of Medicaid's early and periodic screening, diagnosis, and treatment (EPSDT) benefit in Colorado

The purpose of this thesis is to identify "best practice" recommendations for successful implementation of the EPSDT outreach program at Memorial Health System's Hospital for Children in Colorado Springs through a policy analysis of Medicaid EPSDT services in Colorado. A successful program at Memorial will increase education and awareness of EPSDT services, enrollment, and access to and utilization of health care services for eligible children. Methodology utilized in this study included questionnaires designed for the EPSDT contract administrator and outreach coordinators/workers; analysis of current federal and state policies; and studies conducted at the federal and state level, and by various advocacy groups. The need for this analysis of EPSDT came about in part through an awareness of increasingly high numbers of children in poverty and who are uninsured. Though the percentage of children living in poverty in Colorado is slightly below the national average (see Table 2), according to data analyzed by The Annie E. Casey Foundation, the percentage of children (0-18) living in poverty in Colorado increased from 10% in 2000 to 16% in 2006, a dramatic increase of 60% surpassed by only one other state in the nation (The Annie E. Casey Foundation, 2008). By comparison, the U.S. percentage of children in poverty during the same time frame rose from 17% to 18% (The Annie E. Casey Foundation, 2008). What kind of health care services are available to this vulnerable and growing group of Coloradans, and what are the barriers that affect their enrollment in, access to and utilization of these health care services? Barriers identified included difficulty with the application process; system and process issues; a lack of providers; and a lack of awareness and knowledge of EPSDT. Fiscal restraints and legislation at the federal and state level are also barriers to increasing enrollment and access to services. Outreach services are a critical component of providing EPSDT services, and there were several recommendations regarding outreach and case management that will benefit the program in the future. Through this analysis and identification of a broad range of barriers, a clearer picture emerged of current challenges within the EPSDT program as well as a broad range of strategies and recommendations to address these challenges. Through increased education and advocacy for EPSDT and the services it encompasses; stronger collaboration and cooperation between all groups involved, including providing a Medical Home for all eligible children; and new legislation putting more money and focus on comprehensive health care for low-income uninsured children; enrollment, access to and utilization of developmentally appropriate and quality health care services can be achieved. ^

Near infra-red-activatable nanocarriers for selective cancer diagnosis and treatment

Standard treatment strategies for cancer patients include surgery, radiation therapy, and chemotherapy. Although these strategies have been proven effective, they also have associated limitations. An attractive and innovative approach that can be used alone or in combination with the above modalities is based on the systemic or topical administration of a nanomaterial-based photoactive compound. Interaction with light in the near infrared (NIR) region results in either emission of fluorescence, which can be used for photodetection, or absorption of light which results in phototherapy. Nanomaterials have the advantage of providing multi-functional and unique properties in a single device that cannot be readily acquired with conventional small molecular weight compounds. ^ In this study, three different novel nanocarrier systems were designed and evaluated in mediating photodetection and phototherapy in the NIR. The first compound synthesized was a dual-labeled magnetic resonance/optical imaging agent for sentinel lymph node mapping and biopsy. This dual-labeled agent combines the high resolution of magnetic resonance imaging with the highly sensitive detection of optical imaging. The second imaging agent was an activatable optical imaging agent used to monitor cathepsin B activity in vivo and to probe the degradation of poly(L-glutamic acid). This polymeric nanocarrier offers highly sensitive technique for the detection of enzymatic activity, with is not yet possible with small molecular weight compounds. The third agent was a C225-conjugated hollow nanoshell that is targeted to epidermal growth factor receptors. This targeting agent has been demonstrated to mediate photothermal therapy both in vitro and in vivo. ^ These nanocarrier systems are an invaluable tool for the detection of cancer and many other diseases. With improved targeted delivery of these agents, the ability to diagnose diseases will become more sensitive and more specific. Finally, when designed properly, these agents would allow concurrent diagnosis and treatment of patients of various diseases. ^

Delays in diagnosis and referral and treatment for hematologic malignancies

The purpose of this thesis project was to identify factors that may contribute to a delay in the diagnosis, referral or treatment of the hematologic malignancies. This thesis is a secondary data analysis of both qualitative and quantitative data collected during a pilot study for a parent CDC study to determine factors related to time to diagnosis, referral, and treatment of chronic lymphocytic leukemia (CLL), chronic myelogenous leukemia (CML), multiple myeloma (MM), and myelodisplastic syndrome (MDS). To identify patterns for referral, as well as explore referral, treatment, and follow-up patterns, MDACC performed a pathways analysis, and conducted semi-structured interviews with hematologic cancer patients to help identify factors related to delays. Interviews were also conducted with primary care physicians and community hematologists/oncologists to help identify factors associated with optimal and sub-optimal patterns of diagnosis and referral. The results of these analyses suggest a set of factors that may be related to a fairly smooth and rapid trajectory to treatment, and factors that may be related to a slower, more disrupted trajectory. Factors that may be especially important to facilitating rapid treatment include the presence of cues to seek diagnosis in the patient's environment and the patient recognizing and acting upon these cues to seek immediate medical attention. Furthermore, providers who perform behaviors including recognizing cues as indicators of hematologic malignancies and conducting appropriate diagnostic testing effectively and efficiently indicate that these behaviors may also contribute to shorter times to diagnosis. In regards to referrals, direct and effective communication between providers and patients, as well between providers themselves helped facilitate speedier referrals. A patient's insurance status as well as the presence or absence of social support in his environment served as factors that may increase or decrease time to diagnosis, referral, and treatment for a hematologic malignancy. Further research is needed to define delay to diagnosis, referral and treatment in order to improve early diagnosis, referral, and treatment of hematologic malignancies.^

Influence of trust on HIV diagnosis and care practices

Many factors have been studied as potential correlates in delayed HIV diagnosis and delayed linkage to HIV healthcare. Few studies have analyzed the association of trust as a correlate in HIV diagnosis and HIV medical treatment delays. This study sought to assess the effect of patient trust in physicians and trust in the healthcare system, and whether diminished levels of trust affect delays in HIV diagnosis and/or linking to HIV healthcare, among a cohort of newly diagnosed HIV-infected persons, in Harris County, Texas.^ This study is a secondary data analysis from the Attitude and Beliefs and the Steps of HIV Care Study, also known as the Steps Study, a prospective observational cohort study. From January 2006 to October 2007 patients newly diagnosed with HIV infection and not yet in HIV primary care were recruited from publically funded HIV testing sites in Houston, Texas.^ Two outcomes were assessed in this study. The first outcome sought to determine the influence of trust and whether decreased levels of trust predicted delays in HIV diagnosis. Trust in physicians and trust in the healthcare system were measured via 2 validated trust scales. Trust scores of those with late diagnosis (CD4 counts <200 cells/mm3) were compared statistically with those with early diagnosis (CD4 counts ≥ 200 cells/mm3) in a cross sectional study design. Trust was not found to be predictive of delays in HIV diagnosis. ^ The second outcome utilized the same trust scales and a prospective cohort study design to assess whether there were differences in trust scores between those who successfully linked to HIV healthcare, compared to those who failed to link to HIV healthcare, within 6 months of diagnosis. Patients with higher trust in physicians and trust in the healthcare system were significantly more likely to be linked to HIV healthcare than those with lower trust.^ Overall, this study showed that among low-income persons with undiagnosed HIV infection, low trust is not a barrier to timely diagnosis of HIV infection. Trust may be a factor in promoting a prompt linkage to HIV healthcare among those who are newly diagnosed.^

Concordance between medical records and personal interview in ascertaining breast cancer and diabetes status: Analysis of the south Texas women's health project

Accurate ascertainment of risk factors and disease status is vital in public health research for proper classification of research subjects. The two most common ways of obtaining this data is by self-report and review of medical records (MRs). South Texas Women’s Health Project was a case-control study looking at interrelationships between hormones, diet, and body size and breast cancer among Hispanic women 30-79 years of age. History of breast cancer, diabetes mellitus (DM) and use of DM medications was ascertained from a personal interview. At the time of interview, the subject identified her major health care providers and signed the medical records release form, which was sent to the designated providers. The MRs were reviewed to confirm information obtained from the interview.^ Aim of this study was to determine the sensitivity and specificity between MRs and personal interview in diagnosis of breast cancer, DM and DM treatment. We also wanted to assess how successful our low-cost approach was in obtaining pertinent MRs and what factors influenced the quality of MR or interview data. Study sample was 721 women with both self-report and MR data available by June 2007. Overall response rate for MR requests was 74.5%. MRs were 80.9% sensitive and 100% specific in confirming breast cancer status. Prevalence of DM was 22.7% from the interviews and 16% from MRs. MRs did not provide definite information about DM status of 53.6% subjects. Sensitivity and specificity of MRs for DM status was 88.9% and 90.4% respectively. Disagreement on DM status from the two sources was seen in 15.9% subjects. This discordance was more common among older subjects, those who were married and were predominantly Spanish speaking. Income and level of education did not have a statistically significantly association with this disagreement.^ Both self-report and MRs underestimate the prevalence of DM. Relying solely on MRs leads to greater misclassification than relying on self-report data. MRs have good to excellent specificity and thus serve as a good tool to confirm information obtained from self-report. Self-report and MRs should be used in a complementary manner for accurate assessment of DM and breast cancer status.^

Pediatric obesity: Managed care collaborating with providers to improve diagnosis and treatment

Child overweight and obesity reaches across ethnic, cultural, socioeconomic and regional barriers. It must be assessed, diagnosed and treated to help families make sustainable behavior changes. Treatment recommendations have been made to address pediatric overweight and obesity. They include screening for risk factors, monitoring BMI trends and educating patients and families to make small sustainable changes. Health insurance companies can play a meaningful role in supporting and facilitating provider education and behavior change to diagnose, treat and prevent pediatric overweight and obesity.^ The aims of this thesis were: (1) Describe a disease management program that uses evidence-based practices to create provider behavior change related to pediatric obesity screening, diagnosis and treatment. (2) Identify ways to improve the implementation of the program based on the perceptions of participating clinicians.^ A literature review was completed to evaluate current recommendations for screening and treating pediatric obesity using the Ovid data base. The evidenced-based recommendations were compared against the practices of the Healthy Lifestyles Program (HeLP). The literature confirmed that HeLP is following evidence-based recommendations for assessment, diagnosis and treatment of pediatric obesity.^ A Children’s Mercy Family Health Partners focus group was convened to create a provider survey. The goals of the survey were to assess providers’ perception of the Healthy Lifestyles Program (HeLP). The survey was sent out through email using Survey Monkey. All survey responses were anonymous. The survey was sent to a total of 80 providers who had completed HeLP. Twenty-five percent responded. The survey results were evaluated to make recommendations for HeLP.^ Results of the survey included motivating factors for participation in HeLP. Concern about the increasing prevalence of pediatric obesity was a frequent motivator for participation. Provider barriers to obesity diagnosis were evaluated. Lack of time during clinic visits a frequent barrier to obesity diagnosis. ^ In conclusion several recommendations for the HeLP were made based on survey results. It is recommended that the program evaluate methods and tools for facilitating effective weight management follow up visits. Promotional materials should highlight the increasing prevalence of pediatric obesity when advertising HeLP. These recommendations will be used to refine the current Healthy Lifestyles Program.^

Thrombolytic therapy for acute myocardial infarction: A cohort study to evaluate a selective approach to invasive diagnosis and therapy. The Corpus Christi Heart Project

Coronary perfusion with thrombolytic therapy and selective reperfusion by percutaneous transluminal coronary angioplasty (PTCA) were examined in the Corpus Christi Heart Project, a population-based surveillance program for hospitalized acute myocardial infarction (MI) patients in a biethnic community of Mexican-Americans (MAs) and non-Hispanic whites (NHWs). Results were based on 250 (12.4%) patients who received thromobolytic therapy in a cohort of 2011 acute MI cases. Out of these 107 (42.8%) underwent PTCA with a mean follow-up of 25 months. There were 186 (74.4%) men and 64 (25.6%) women; 148 (59.2%) were NHWs, 86 (34.4%) were MAs. Thrombolysis and PTCA were performed less frequently in women than in men, and less frequently in MAs than in NHWs.^ According to the coronary reperfusion interventions used, patients were divided in two groups, those that received no-PTCA (57.2%) and the other that underwent PTCA (42.8%) after thrombolysis. The case-fatality rate was higher in no-PTCA patients than in the PTCA (7.7% versus 5.6%), as was mortality at one year (16.2% versus 10.5%). Reperfusion was successful in 48.0% in the entire cohort and (51.4% versus 45.6%) in the PTCA and no-PTCA groups. Mortality in the successful reperfusion patients was 5.0% compared to 22.3% in the unsuccessful reperfusion group (p = 0.00016, 95% CI: 1.98-11.6).^ Cardiac catheterization was performed in 86.4% thrombolytic patients. Severe stenosis ($>$75%) obstruction was present most commonly in the left descending artery (52.8%) and in the right coronary artery (52.8%). The occurrence of adverse in-hospital clinical events was higher in the no-PTCA as compared to the PTCA and catheterized patients with the exception of reperfusion arrythmias (p = 0.140; Fisher's exact test p = 0.129).^ Cox regression analysis was used to study the relationship between selected variables and mortality. Apart from successful reperfusion, age group (p = 0.028, 95% CI: 2.1-12.42), site of acute MI index (p = 0.050) and ejection-fraction (p = 0.052) were predictors of long-term survival. The ejection-fraction in the PTCA group was higher than (median 78% versus 53%) in the no-PTCA group. Assessed by logistic regression analysis history of high cholesterol ($>$200mg/dl) and diabetes mellites did have significant prognostic value (p = 0.0233; p = 0.0318) in long-term survival irrespective of treatment status.^ In conclusion, the results of this study support the idea that the use of PTCA as a selective intervention following thrombolysis improves survival of patients with acute MI. The use of PTCA in this setting appears to be safe. However, we can not exclude the possibility that some of these results may have occurred due to the exclusion from PTCA of high risk patients (selection bias). ^

Estimates of hospital and physician costs of epilepsy in the United States for 1995 comparing the provider -based survey method and a patient -based medical charts and billing method

This investigation compares two different methodologies for calculating the national cost of epilepsy: provider-based survey method (PBSM) and the patient-based medical charts and billing method (PBMC&BM). The PBSM uses the National Hospital Discharge Survey (NHDS), the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Ambulatory Medical Care Survey (NAMCS) as the sources of utilization. The PBMC&BM uses patient data, charts and billings, to determine utilization rates for specific components of hospital, physician and drug prescriptions. ^ The 1995 hospital and physician cost of epilepsy is estimated to be $722 million using the PBSM and $1,058 million using the PBMC&BM. The difference of $336 million results from $136 million difference in utilization and $200 million difference in unit cost. ^ Utilization. The utilization difference of $136 million is composed of an inpatient variation of $129 million, $100 million hospital and $29 million physician, and an ambulatory variation of $7 million. The $100 million hospital variance is attributed to inclusion of febrile seizures in the PBSM, $−79 million, and the exclusion of admissions attributed to epilepsy, $179 million. The former suggests that the diagnostic codes used in the NHDS may not properly match the current definition of epilepsy as used in the PBMC&BM. The latter suggests NHDS errors in the attribution of an admission to the principal diagnosis. ^ The $29 million variance in inpatient physician utilization is the result of different per-day-of-care physician visit rates, 1.3 for the PBMC&BM versus 1.0 for the PBSM. The absence of visit frequency measures in the NHDS affects the internal validity of the PBSM estimate and requires the investigator to make conservative assumptions. ^ The remaining ambulatory resource utilization variance is $7 million. Of this amount, $22 million is the result of an underestimate of ancillaries in the NHAMCS and NAMCS extrapolations using the patient visit weight. ^ Unit cost. The resource cost variation is $200 million, inpatient is $22 million and ambulatory is $178 million. The inpatient variation of $22 million is composed of $19 million in hospital per day rates, due to a higher cost per day in the PBMC&BM, and $3 million in physician visit rates, due to a higher cost per visit in the PBMC&BM. ^ The ambulatory cost variance is $178 million, composed of higher per-physician-visit costs of $97 million and higher per-ancillary costs of $81 million. Both are attributed to the PBMC&BM's precise identification of resource utilization that permits accurate valuation. ^ Conclusion. Both methods have specific limitations. The PBSM strengths are its sample designs that lead to nationally representative estimates and permit statistical point and confidence interval estimation for the nation for certain variables under investigation. However, the findings of this investigation suggest the internal validity of the estimates derived is questionable and important additional information required to precisely estimate the cost of an illness is absent. ^ The PBMC&BM is a superior method in identifying resources utilized in the physician encounter with the patient permitting more accurate valuation. However, the PBMC&BM does not have the statistical reliability of the PBSM; it relies on synthesized national prevalence estimates to extrapolate a national cost estimate. While precision is important, the ability to generalize to the nation may be limited due to the small number of patients that are followed. ^

The physician's perception of medical error and its application to the development of an educational training tool.

It is becoming clear that if we are to impact the rate of medical errors it will have to be done at the practicing physician level. The purpose of this project was to survey the attitude of physicians in Alabama concerning their perception of medical error, and to obtain their thoughts and desires for medical education in the area of medical errors. The information will be used in the development of a physician education program.

Disparities in medical expenditure and utilization among hypertensive men and women in the U.S.: Cross-section and lifetime analysis

Objectives. To investigate procedural gender equity by assessing predisposing, enabling and need predictors of gender differences in annual medical expenditures and utilization among hypertensive individuals in the U.S. Also, to estimate and compare lifetime medical expenditures among hypertensive men and women in the U.S. ^ Data source. 2001-2004 the Medical Expenditure Panel Survey (MEPS);1986-2000 National Health Interview Survey (NHIS) and National Health Interview Survey linked to mortality in the National Death Index through 2002 (2002 NHIS-NDI). ^ Study design. We estimated total medical expenditure using four equations regression model, specific medical expenditures using two equations regression model and utilization using negative binomial regression model. Procedural equity was assessed by applying the Aday et al. theoretical framework. Expenditures were estimated in 2004 dollars. We estimated hypertension-attributable medical expenditure and utilization among men and women. ^ To estimate lifetime expenditures from ages 20 to 85+, we estimated medical expenditures with cross-sectional data and survival with prospective data. The four equations regression model were used to estimate average annual medical expenditures defined as sum of inpatient stay, emergency room visits, outpatient visits, office based visits, and prescription drugs expenditures. Life tables were used to estimate the distribution of life time medical expenditures for hypertensive men and women at different age and factors such as disease incidence, medical technology and health care cost were assumed to be fixed. Both total and hypertension attributable expenditures among men and women were estimated. ^ Data collection. We used the 2001-2004 MEPS household component and medical condition files; the NHIS person and condition files from 1986-1996 and 1997-2000 sample adult files were used; and the 1986-2000 NHIS that were linked to mortality in the 2002 NHIS-NDI. ^ Principal findings. Hypertensive men had significantly less utilization for most measures after controlling predisposing, enabling and need factors than hypertensive women. Similarly, hypertensive men had less prescription drug (-9.3%), office based (-7.2%) and total medical (-4.5%) expenditures than hypertensive women. However, men had more hypertension-attributable medical expenditures and utilization than women. ^ Expected total lifetime expenditure for average life table individuals at age 20, was $188,300 for hypertensive men and $254,910 for hypertensive women. But the lifetime expenditure that could be attributed to hypertension was $88,033 for men and $40,960 for women. ^ Conclusion. Hypertensive women had more utilization and expenditure for most measures than hypertensive men, possibly indicating procedural inequity. However, relatively higher hypertension-attributable health care of men shows more utilization of resources to treat hypertension related diseases among men than women. Similar results were reported in lifetime analyses.^ Key words: gender, medical expenditures, utilization, hypertension-attributable, lifetime expenditure ^