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We investigated variations in the oral anticoagulant treatment of atrial fibrillation by physicians in three specialties: family physicians (or general practitioners), general internists, and cardiologists. Results showed general agreement in the anticoagulation decision regarding patients with either mitral valve disease or a history of chronic alcohol abuse, but substantial disagreement in other categories of patients. Estimations of the risk of embolization and risk of hemorrhage differed widely among all physicians, cardiologists generally rating the embolization risks lower than the other physicians. A physician's treatment decision was strongly related to the relative risk of embolism vs hemorrhage derived for each case. A relationship between physician specialty and treatment decision was also demonstrated, with cardiologists least likely, and family practitioners most likely, to institute anticoagulation in nonrheumatic patients with atrial fibrillation. The reason for this variation appears to be differences in the estimated risk of systemic embolism.

Objectives. —To examine temporal trends and geographic variation in radical prostatectomy rates and short-term outcomes. Design. —Population-based study of radical prostatectomy for the years 1984 through 1990. Poisson regression was used to estimate temporal and regional effects. Setting. —The 50 states and the District of Columbia. Participants. —A 20% national sample of male Medicare beneficiaries aged 65 years or older. Main Outcome Measures. —Rate of radical prostatectomy; 30-day mortality; and major cardiopulmonary complications, vascular complications, or surgical repairs within 30 days of radical prostatectomy. Results. —A total of 10598 radical prostatectomies were identified. The adjusted rate of radical prostatectomy in 1990 was 5.75 times that in 1984. The relative increase was similar in all age groups. Substantial geographic variation existed in rates from 1988 through 1990: all states in the New England and Mid-Atlantic regions had rates equal to or below 60 per 100 000 male Medicare beneficiaries, while all states in the Pacific and Mountain regions had rates equal to or above 130 per 100 000. The mortality and morbidity after radical prostatectomy are not trivial for older men (aged 75 years and older)—almost 2% died and nearly 8% suffered major cardiopulmonary complications within 30 days of the operation. Conclusion. —The sharp increase and wide geographic variation in radical prostatectomy rates make the evaluation of this surgical procedure a pressing issue. The rising rate of radical prostatectomy among men aged 75 years and older merits special attention. ( JAMA . 1993;269:2633-2636)

Objective. —To model the impact of initial therapy on outcomes for men with localized (clinical stage A or B) prostatic carcinoma. Design. —A decision analysis modeling three strategies: radical prostatectomy, external-beam radiation therapy, and watchful waiting, with delayed hormonal therapy if metastatic disease develops. We modeled the main benefit of treatment as a reduction in the chance of death or disutility from metastatic disease. These benefits were offset in the model by the risks of treatment-related morbidity and mortality. The model was used to analyze expected outcomes by tumor grade (well, moderately, and poorly differentiated) for men 60 to 75 years of age. Data. —Probabilities and rates for important clinical events, obtained through review of the literature for prostatic carcinoma and analysis of Medicare claims data. Main Results. —Several patterns emerged within the range of uncertainty about the risks and benefits of treatment for prostatic carcinoma. In patients with well-differentiated tumor grades, based on clinical staging, treatment at best offers limited benefit in terms of quality-adjusted life expectancy and may result in harm to the patient. Among patients with moderately or poorly differentiated tumors, if we use the most optimistic assumptions about treatment efficacy, then patients aged 60 to 65 years would benefit from either radical prostatectomy or external-beam radiation therapy, compared with watchful waiting. However, in most other cases, treatment offers less than a 1-year improvement in quality-adjusted life expectancy or decreases the quality-adjusted life expectancy compared with watchful waiting. Invasive treatment generally appears to be harmful for patients older than 70 years. Conclusions. —Radical prostatectomy and radiation therapy may benefit selected groups of patients with localized prostate cancer, particularly younger patients with higher-grade tumors. However, our model shows that in most cases the potential benefits of therapy are small enough that the choice of therapy is sensitive to the patient's preferences for various outcomes and discounting. The choice of watchful waiting is a reasonable alternative to invasive treatment for many men with localized prostatic carcinoma. (JAMA. 1993;269:2650-2658)

Objective.— This study compared the efficacy and safety of quinine sulfate, vitamin E, and placebo in the treatment of nocturnal leg cramps. Design.— A random-order, double-blind, placebocontrolled crossover trial was performed. Setting.— The study was conducted at the Veterans Affairs Medical Center, White River Junction, Vt. Participants.— Twenty-seven male veterans, aged 38 to 73 years, who experienced at least six leg cramps per month were recruited through the general medicine walk-in clinic or were referred from other clinics. Fifty-five subjects were contacted, 30 were enrolled consecutively, and 27 completed the study. Intervention.— Subjects received, in random order, quinine sulfate (200 mg at supper and 300 mg at bedtime), vitamin E (800 U at bedtime), or placebo for 4-week periods. These periods were separated by 4-week washout intervals. Outcome Measures.— Patients reported cramp frequency, severity, and sleep disturbance caused by cramps. Results.— Compared with treatment with placebo, quinine reduced the frequency of cramps and sleep disturbance, but not the average cramp severity. Thirteen of 27 patients had at least a 50% reduction in the number of cramps while receiving quinine; the response was usually seen within 3 days. There was evidence of a mild increase in side effects while subjects received quinine. Vitamin E was not effective in reducing leg cramp frequency, severity, or sleep disturbance. Conclusions.— Quinine sulfate, but not vitamin E, is superior to placebo in the treatment of nocturnal leg cramps. (Arch Intern Med. 1992;152:1877-1880)

Design. —Randomized trial. Setting. —A primary care clinic. Patients. —Four hundred ninety-seven men aged 54 years or older. Objective. —We examined the hypothesis that substituting clinician-initiated telephone calls (telephone care) for some clinic visits would reduce medical care utilization without adversely affecting patient health. Intervention. —Clinicians were asked to double their recommended interval for face-to-face follow-up and schedule three intervening telephone contacts; for control patients, the follow-up interval recommended by their clinician was unchanged. Main Outcome Measures. —Use of medical services and health status. Results. —During the 2-year follow-up period, 7% of patients withdrew or became unavailable. Telephone-care patients had fewer total clinic visits, scheduled and unscheduled, than usual-care patients (19%, P P =.006), fewer admissions, and shorter stays in the hospital (28% fewer total hospital days, P =.005), and 41% fewer intensive care unit days ( P =.03). Estimated total expenditures for telephone care were 28% less per patient for the 2 years ($1656, P =.004). For the subgroup of patients with fair or poor overall health at the beginning of the study (n= 180), savings were somewhat greater ($1976, P =.01). In this subgroup, improvement in physical function from baseline ( P =.02) and a possible reduction in mortality ( P =.06) were also observed. Conclusion. —We conclude that substituting telephone care for selected clinic visits significantly reduces utilization of medical services. For more severely ill patients, the increased contact made possible by telephone care may also improve health status and reduce mortality. ( JAMA . 1992;267:1788-1793)

• We investigated variations in the oral anticoagulant treatment of atrial fibrillation by physicians in three specialties: family physicians (or general practitioners), general internists, and cardiologists. Results showed general agreement in the anticoagulation decision regarding patients with either mitral valve disease or a history of chronic alcohol abuse, but substantial disagreement in other categories of patients. Estimations of the risk of embolization and risk of hemorrhage differed widely among all physicians, cardiologists generally rating the embolization risks lower than the other physicians. A physician's treatment decision was strongly related to the relative risk of embolism vs hemorrhage derived for each case. A relationship between physician specialty and treatment decision was also demonstrated, with cardiologists least likely, and family practitioners most likely, to institute anticoagulation in nonrheumatic patients with atrial fibrillation. The reason for this variation appears to be differences in the estimated risk of systemic embolism. ( Arch Intern Med . 1990;150:81-84)

In Reply.— We share the curiosity expressed by Drs Flynn and Kiel about how provider continuity accounts for significant differences in duration of hospitalization in our study. However, we do not share their concern that the finding was an artifact caused by some unrecognized difference in the two large groups of prospectively randomized patients that made up our study population. Table 2, which demonstrated comparability of patients prior to the analysisperiod of the study, was shortened prior to publication. An appended Table 2 is published in this letter. In a separate manuscript, currently in preparation, we demonstrate that broad descriptions that profile patient health status forecast subsequent use of service better than disease diagnoses. Table 2 demonstrated that health status measures, as well as diagnoses, were comparable in both groups prior to the analysis period of the study.

• We studied the role of the upper gastrointestinal tract roentgenogram series (UGI) in the care of 483 ambulatory patients with varied abdominal complaints. The test was significantly abnormal about 20% of the time, rarely led to changes in therapy, and was ordered inappropriately 30% of the time (according to criteria devised by experts). Regardless of their test results, most patients' symptoms improved in the several months after the test. We created a simple rule, based on the patient's history, that would have led to a decrease in the number of inappropriately ordered tests without significantly compromising care. This decision rule may help to improve the utilization of the UGI by identifying patients who are unlikely to benefit from the test. ( Arch Intern Med 140:191-195, 1980)

A cross-sectional study was conducted on functional status of adults visiting primary care practices. Limitations in physical and mental function were assessed independently in 28 practices by patients (N = 1,227) and physicians (N = 47) using a simple global index of disability. Results indicated 12% of patients rated their physical limitations as major and 8% rated major emotional limitations during the past month. Comparable assessments by physicians were 5% and 4%, respectively. Differences between patients and physicians were statistically significant and are demonstrated to be clinically relevant. Patients' functional limitations were associated with increased utilization of ambulatory care, older age, lower level of education, unemployment, and a primary diagnosis of a chronic condition. We conclude that functional status can be routinely recorded in medical practice to help describe severity, predict utilization, and improve the physician-patient relationship.

We describe a patient with ulcerative colitis and extracolonic manifestations in whom diffuse interstitial pulmonary disease developed that was responsive to glucocorticoid therapy one year after total proctocolectomy. The patient presented in December 1983 with a subacute course marked by cough and progressive exertional dyspnea, abnormal chest examination results, and a chest roentgenogram that revealed diffuse interstitial and alveolar infiltrates. A transbronchial biopsy specimen revealed a polymorphic interstitial infiltrate, mild interstitial fibrosis without apparent intraluminal fibrosis, and no vasculitis, granulomas, or significant eosinophilic infiltration. Within one week of the initiation of daily high-dose steroid therapy, the patient's symptoms dramatically improved; chest roentgenogram and forced vital capacity (60%) improved at a slower rate. All three measures deteriorated when alternate-day prednisone therapy was started but once again improved until the patient was totally asymptomatic, chest roentgenograms were normal, and forced vital capacity was 80% of the predicted value 2 1/2 years later. (JAMA1988;260:62-64)

P6 an outpatient repeatedly sees the same practitioner, is his care influenced? This double-blind randomized trial examines the effects of outpatient health care provider continuity on the process and outcome of the medical care for 776 men aged 55 years and older. Participants were randomized to two different groups of provider care: provider discontinuity and provider continuity. The outcome of the continuity group was significantly different from that of the discontinuity group. During an 18-month period, patients who had been randomized to the continuity group had fewer emergent admissions (20% v 39%) and a shorter average length of stay (15.5 v 25.5 days). These patients also perceived that the providers were more knowledgeable, thorough, and interested in patient education. We conclude that continuity of outpatient provider care for men aged 55 years and older results in more patient satisfaction, shorter hospitalizations, and fewer emergent hospital admissions.