Physicians 65 and older were more likely to feel that quality of health care is asignificant problem (p < 0.01), but there were no differences in physician responsesby gender, specialty, practice type, or by whether they had ever had a malpracticesuit filed against them. Of the public respondents, females, those over 65, and thosewith lower incomes were more likely to believe quality of health care is a problem(p < 0.01). Public responses did not differ by race or level of education. CONCLUSION: There is a marked disparity in public vs. physicians' perceptions of the quality and safety of health care in the U.S., as well as in the need for a national agenda directed towards reporting and reduction of medical errors. Physicians should recognize that a majority of the public believes that the quality of health care is a significant problem and that mandatory reporting of medical errors is widely supported. PURPOSE: Studies have found that African ± Americans (AA) tend to receive poorer quality care and experience poorer clinical outcomes than Caucasians (C) across a variety of medical conditions. However, little is known about racial differences in care and recovery from major depression (MD) in primary care settings. METHODS: We examined data collected as part of a clinical trial testing the effectiveness of disseminating a depression treatment guideline via an electronic medical record system (EMR). Patients presenting for routine care by a board-certified primary care physician (PCP) at a university-based clinic were screened for MD using the PRIME-MD and their PCPs were subsequently informed of this finding. Study patients had a Hamilton Rating Scale for Depression (HRS-D) score !12 and were not in treatment with a mental health specialist (MHS). The HRS-D was repeated at 6 months to ascertain recovery (HRS-D 7) . Data about depression treatment such as number of visits and discussions of depression, counseling, pharmacotherapy, and referral to a MHS, was abstracted from the EMR. Non AA/C patients were excluded from our analyses (3%) given the focus of this report on comparing differences between AAs and Cs. RESULTS: Between 4/96 and 12/98, 204 depressed patients (25% AA) met all protocol eligibility criteria and completed a baseline interview. They were cared for by 15 PCPs (100% C; 53% male; median age 39 years). At 6 months, 187 (92%) had follow-up information available including 47 (24%) AAs and 140 (73%) Cs. AA and C patients were similar at baseline on level of depressive severity (mean: HRS-D AA = 21 vs. C = 20), age (mean: 44 vs. 43), gender (female: 64% vs. 73%), employment (fulltime: 45% vs. 58%), medical comorbidity (2+ conditions: 57% vs. 59%), and history of depression (43% vs. 49%). AAs had a mean of 3.1 contacts with their PCP including 1.4 contacts discussing depression while Cs had 2.9 and 1.3 contacts, respectively over a 6-month period following study entry. PCPs documented counseling their AA patients for MD for 15%, recommending pharmacotherapy for 57%, and recommending a MHS referral for 28%. These rates were comparable for C patients (15%, 54%, and 35%, respectively). Overall, a similar proportion of AA and C patients recovered from their MD episode at 6-months (21% vs. 24%). CONCLUSION: Although inadequate caregiving and poor treatment outcomes are commonly found among patients with MD who are cared for by PCPs, we were unable to identify any disparities in care or recovery rates for MD among the AA and C patients enrolled in our clinical trial. Future studies should confirm our results and examine methods for improving the delivery of guideline-based treatments for patients of all races experiencing MD. PURPOSE: Hepatitis C viral infection represents a substantial clinical and public health burden. In New York City (NYC) with its diverse ethnic population and large proportion of immigrants, characterizing the subgroup-specific burden of HCV is important to target HCV diagnosis, treatment and prevention efforts. Our objective was to describe the clinical and epidemiologic features of HCV infection in NYC, and to assess the sub-population specific burden of HCV mortality. METHODS: We used data collected by the New York City Department of Health (NYCDOH) Vital Statistics office to identify all persons who died with a diagnosis of HCV coded as a primary or contributing cause of death between 1992 and 1997. Demographic data collected by this office was analyzed. To obtain information regarding cause of death, clinical characteristics, and risk factors for HCV infection, we performed medical record reviews on the subset who died during 1996 ± 1997. RESULTS: Between1992 and 1997, 1002 persons met the case definition for HCVassociated death. Eight hundred and ninety were identified as NYC residents. Median age at death was 55 (3 ± 97); 56% were male; 39% white non-Hispanic, 32% Hispanic, 22% black non-Hispanic, 4% Asian-Pacific Islander, 3% other and unknown. Forty eight percent were foreign born. Three hundred and nine (81%) of the 1996 ± 1997 medical records requested were received. Of these, 26 could not be reviewed because of insufficient information. Of the 283 medical records reviewed 156 (55%) had a risk factor for HCV infection reported. Of these, injection drug use accounted for 73%and blood product transfusion accounted for 26%. We calculated a median years of potential life lost (YPLL) of 12 for the entire study population. During 1997 the proportion of deaths attributable to HCV in comparison to other causes of death was 0.9% among Hispanics, 0.5% among Asian among black and 0.2% among white. CONCLUSION: Although HCV causes death among all segments of the NYC population, it has disproportionately burdened Hispanics and young adults. While additional research on incidence, prevalence, and distribution of risk factors is necessary, these data suggest that primary and secondary prevention efforts against HCV infection be directed at the most vulnerable populations. Figure 1 shows proportions of physicians'``optimal choice'' according to different specialties. Family medicine favored flex-sig + FOBT strategy, gastroenterologists-colonoscopy and internists any of these two. Only about 13% of all physician favoured FOBT strategy. Most physicians indicated patient preference (78%), clinical status (48%) and cost to the patient (41%) as determinants of using strategy other than their preferred. Factors that would, in the opinion of physicians, keep patients from undergoing colonoscopy were: apprehension of pain (77%) and embarrassment (39%) as well as patient financial cost (55%). We analyzed data from a national random-digit-dial telephone survey conducted in 1994. We measured respondents' satisfaction with their regular physicians, health care services, health insurance, and life in general, using 4-point Likert scales (4 indicating highest rating). We hypothesized that if low patient satisfaction ratings among Asians were attributable to response tendencies, we should observe a similar pattern of responses among Asians across domains related and unrelated to health care. We also asked if respondents had ever changed physicians due to dissatisfaction. RESULTS: Respondents included 627 Asian, 1005 black, 1000 Hispanic, and 1114 white adults. Asian respondents were mainly Chinese (33%), Vietnamese (32%), and Korean (32%). Asians reported lower satisfaction with their physicians and health care services than other ethnic groups, even after adjusting for demographic and health-related variables. Asians also reported lower satisfaction with their health insurance and with life in general (Table; p < .001 for all comparisons of Asians vs. non-Asians). Asians' responses to all satisfaction measures were similar and were more normally distributed than non-Asians' responses, which were more skewed toward the highest ratings. Asians were less likely than non-Asians to report having changed physicians due to dissatisfaction (24% vs. 31%, p = .001). CONCLUSION: Asians recorded lower satisfaction ratings not only for physicians and health care services but also for life in general and, despite lower reported satisfaction, were less likely than non-Asians to have changed physicians due to dissatisfaction. These findings suggest that lower satisfaction ratings among Asians are due to different response tendencies rather than worse experiences or higher expectations of health care. Further research is needed to explain this phenomenon and assess its potential impact on performance measurement for physicians and health care organizations providing care for large numbers of Asian Americans. PURPOSE: Vascular catheter-related blood stream infections are costly and associated with substantial morbidity and mortality. Central venous catheters coated with antibacterial agents have been shown to be superior to non-coated catheters. Trial results suggest, however, that central venous catheters impregnated with minocycline/rifampin, although more expensive, are clinically superior to catheters impregnated with chlorhexidine/silver sulfadiazine. It remains unclear if minocycline/rifampin catheters are cost-effective for all high-risk patients or only those requiring longer-term catheterization. METHODS: We developed a series of decision analytic models using patient-level clinical trial data to determine if minocycline/rifampin catheters are cost-effective for patients requiring various durations of catheterization. We calculated incremental cost-effectiveness ratios for patients catheterized for durations ranging from 1 to 25 days. We simulated the use of 10,000 catheters and calculated the proportion of times that the catheters were cost-effective or costsaving at each duration of catheterization. The perspective was that of the healthcare payer; the time horizon was the period of hospitalization. RESULTS: The data were too sparse to estimate cost-effectiveness for patients catheterized less than 8 days. The probability that minocycline/rifampin catheters were cost-effective or costsaving compared to chlorhexidine/silver sulfadiazine catheters in patients expected to be catheterized at least 8 days was 91%. The probability minocycline/rifampin catheters were costeffective or cost saving in patients expected to be catheterized 13 days or longer was over 95%. These findings remained relatively consistent during one-way and multi-way sensitivity analyses. CONCLUSION: The probability that minocycline/rifampin catheters are cost-effective or cost-saving increases relative to the expected duration of use. There is insufficient evidence to suggest that minocycline/rifampin catheters are clinically or economically preferable to chlorhexidine/silver sulfadiazine catheters in patients catheterized less than 8 days. However, minocycline/rifampin catheters are likely to be cost-effective for patients expected to be catheterized for periods longer than 1 week, and are clinically and economically preferable for patients expected to be catheterized for 2 or more weeks. year, with an associated mortality of 10 to 20%per episode. Though many recent studies of nosocomial bacteremia have been reported, there are limited data focusing on communityacquired bacteremia. Given the morbidity, mortality, and economic consequences of community-acquired bacteremia, we decided to: (1) describe the epidemiology and microbiology of community-acquired bacteremia; (2) determine the crude mortality associated with such infections; and (3) identify independent predictors of mortality. METHODS: This prospective study was conducted at the Seattle Division of the Veterans Affairs Puget Sound Healthcare System from January 1, 1994 to December 31, 1997. All patients with clinically significant community-acquired bacteremia or fungemia were evaluated. Data were collected on demographics, co-morbid conditions, clinical parameters, microorganisms, source of infection, and patient outcome. RESULTS: During the study period, 387 bacteremic episodes occurred in 334 patients. Staphylococcus aureus (18%), Escherichia coli (15%), and coagulase-negative staphylococci (12%) were the most commonly isolated organisms. The most frequent sources were the urinary tract, intravascular catheters, and pneumonia. Overall, almost one-third of bacteremia cases were directly related to indwelling catheters: either intravascular (20%) or urinary (10%). Approximately 14% of patients died. Patient characteristics independently associated with increased mortality included shock (OR 3.7, p = 0.02), renal failure (OR 4.0, p = 0.003), and a`D o Not Attempt Resuscitation ''order (OR 21.7, p < 0.001). The risk of death was also higher in those whose source was pneumonia (OR 6.3, p = 0.03) or an intra-abdominal site (OR 10.7, p = 0.02), or if multiple sources were identified (OR 13.4, p = 0.003). The presence of fever (temperature > 38.08C) was associated with a decreased risk of death (OR 0.4; p = 0.005). CONCLUSION: Vascular and urinary catheters were implicated in a substantial proportion of infections, emphasizing the need for appropriate and judicious use of such devices. We will likely observe an increase in the incidence of such device-related infections as healthcare expands into the outpatient setting. Fortunately, many of these infections are potentially avoidable via established infection control practices used to prevent hospital-acquired infections. Thus, strategies that have been useful in preventing nosocomial device-related bacteremia could prove successful if adapted into the outpatient setting. If this is borne out, community-acquired bacteremia may increasingly become viewed as a preventable disease. PURPOSE: Despite known interactions, the occurrence of inappropriate medication and alcohol use has not been well described. We sought to assess 1) the prevalence of potential alcohol and medication interactions in hazardous and harmful drinkers in a primary care setting, 2) the association between this medication use and alcohol consumption, and 3) whether users of medications known to interact with alcohol are counseled by physicians regarding drinking. METHODS: We interviewed current hazardous drinkers (at least one drink in the past month, and at least one positive response to the CAGE alcoholism screening questionnaire or > 14 drinks per week/ > 4 drinks per occasion for men, 7 and 3 respectively for women) just prior to a visit with a primary care physician to determine the self-reported current (30 day) prevalence of use of medications that can interact with alcohol. Alcohol consumption was assessed by trained interviewers using a validated calendar method. Immediately after the physician visit, patients reported whether there had been a discussion about alcohol with the physician during the visit that day. RESULTS: The 312 subjects were 63% male, mean age was 44, and 63%had a high school education. Subjects saw one of 41 physicians. Most (78%) reported current use of medication that can interact with alcohol: 59% used non-steroidal anti-inflammatory drugs, 44%acetaminophen, 16%antihistamines, 10% each narcotics, antidepressants, and medication for sleep, 6% anxiolytics, and 3% blood thinners (i.e. warfarin). Users of these medications drank more drinks per drinking day (median 4.0 vs. 3.5, mean 5.8 vs 4.6, p = 0.04) and binge drank more often (median 2 vs. 1 binges in the past month, mean 6 vs. 5, p = 0.03) than nonusers. There was no discussion about alcohol use with the physician for 37%of users and 40% of non-users of medications that can interact with alcohol (p = 0.68). CONCLUSION: Most hazardous and harmful drinkers in a primary care setting were using prescription and nonprescription medications that can interact with alcohol. Users of these medications drank more than non-users. Many had no discussion about alcohol with their 3.20 +/À .68 3.20 +/À .66 3.11 +/À .77 3.27 +/À .69