We reviewed the abstracts of 610 of these articles and then narrowed our selection down to 173 full-text articles. We also reviewed 159 guidelines. There were 13 (76%) guidelines in need of an update, 3 (18%) guidelines that were still valid, and 1 (6%) guideline for which we could not make a determination due to insufficient information. The guidelines had an estimated``shelf-life'' of 3 years (90% of the guidelines were still valid) to 5.9 years (upper bounds of the 95% CI). CONCLUSION: Our study provides the first empirical evidence of the rate at which guidelines go out-of-date. More than 75% of the AHCPR guidelines are in need of updating. We recommend re-evaluation at a minimum every three years with modifications in this timeline based on whether advances in the field are rapidly or slowly evolving. Future guidelines could facilitate the updating process by including an estimate of the type of evidence necessary to prompt revisions. PURPOSE: Critics state that some of the cost reductions demonstrated by hospitalist services may be explained by``cost shifting'' to the outpatient setting. Timely and appropriate patient follow up is also of concern. The purpose of our study was 2 fold: 1)determine if a significant portion of the cost savings realized by our hospitalist service could be attributed to``cost shifting'' and 2)determine if follow up issues were addressed as an outpatient. METHODS: During the 1998 ± 99 academic year, WVU implemented a hospitalist service (H) which was compared with the two other medicine services, one staffed by General Internists (GIM) and the other by subspecialists (SS). Inpatient cost (COST) and length of stay (LOS) were the main outcomes. 956 charts (321 for H, 257 for GIM, 378 for SS) were retrospectively analyzed in a blinded fashion to determine the following for each group: 1) percentage of patients discharged with workups needing to be performed (% W/TJ) 2) percentage of patients with tests or procedures scheduled as outpatient (% TEST) 3) average costs of test/procedures specified at discharge (F/U COST)(elective surgeries excluded). Of patients who had follow up within our system, 25 charts in each group were reviewed to determine follow up rates (% F/U). RESULTS: See table. Among the 3 groups, there were no significant differences in the percentages of patients discharged with test procedures or workups pending (p > 0.6).Patients who had longer LOS or who were followed in our system tended to have more outpatient test and workups scheduled (p < 0.0 1). In terms of cost specified at discharge, there were no significant differences (p = 0.09). There were no significant differences in percentage of issues followed up, however the numbers were small (p = 0.2). CONCLUSION:``Cost shifting'' does not appear to explain the cost benefits realized within our hospitalist system. Most of the issues specified at discharge tend to be followed up in the outpatient setting. While alerts about life-threatening drug-drug interactions are integrated into many medical information systems, few data are available regarding whether these warnings affect prescribing behavior or prevent patient injury. METHODS: We examined all consecutive cases of alerts warning of life-threatening drug-drug interactions during a six month period at a 700-bed academic tertiary care hospital. The alerts examined were the 7 with the most severe consequences from a database of known drug-drug interactions. Data were automatically collected each time a physician entered an order that triggered an interaction alert. The hospital information system logged the drug pair involved in the interaction, whether the alert was overridden, and any subsequent orders to discontinue one of the drugs in the pair. Adverse events attributable to the drug interaction were ascertained by chart review. RESULTS: Over 6 months, there were 168 life-threatening drug-drug interaction alerts (see table) . After 65(43%) of the alerts, physicians immediately discontinued one of the medications. For the 85(57%) alerts where both medications were given despite the alert, there were 2 adverse drug events, both involving the drug cisapride, and neither resulted in subsequent disability. CONCLUSION: Physicians overrode alerts about life-threatening drug-drug interactions more than half the time. When they did so, few adverse drug events occurred. These data suggest that the severity level of some drug-drug interactions may be set too high. For the small number of drug pairs that should never be given jointly, stronger safety measures should be put in place. people. Some plans claim that providing higher quality care raises costs and lowers profits, and that plans withdraw because they cannot sustain high quality care under current payment levels.