ALPHA BLOCKERS AND HYPERTENSION Ð HOW MANY ARE AT RISK FOR SUBOPTIMAL THERAPY? C.L. Bryson 1 ; 1 Puget Sound VA, Seattle, Washington PURPOSE: This study defines the number of people at risk for suboptimal therapy with hypertension who are only on alpha blockers. Results of randomized controlled trials have provided substantial evidence that antihypertensives differ in their ability to mitigate outcomes of CHF, CVA, MI and renal failure in the hypertensive population despite nearly equivalent blood pressure control. This is of particular interest because of the early termination of one arm of the ALLHAT study in which the alpha-1 blocker doxazosin was associated with a doubling of the rate of incident heart failure. Doxazosin is less effective for preventing the outcome of CHF than chlorthalidone in hypertensive patients. This result was unexpected, since doxazosin has favorable effects on other surrogate markers including serum lipids. Alpha-1 blockers are an effective treatment for prostatism, and fifty percent of men have histologic evidence of BPH by 60 years of age. It is difficult to quantitate the exposure of alpha-1 blockers for hypertension in elderly men on pharmacy data alone because information about the patient' s comorbid illnesses is necessary to interpret the indication for the agent. This is true not only for alpha-1 blockers but also for other antihypertensives. METHODS: The National Ambulatory Medical Care Survey (NAMCS) is a national survey of physician visits that records not only physician diagnoses but also patient therapy. It was a sampling study that was carefully performed and allows extrapolation to the national visits during the study times. The NAMCS data was analyzed with STATA. The provided weights were utilized to expand the results to projected national averages. Summary measures were computed for variables of interest while maintaining acceptable relative standard errors. RESULTS: This presentation or poster will present the results of the analysis of the 1998 NAMCS for antihypertensive use, with an accent on alpha blocker usage as a single drug. Approximately 3.5 to 4% of the hypertensive population appears to be treated with only an alpha blocker, which is between 840,000 to 1 million patients. Interestingly, about half of these are women. Only 15% of hypertensives were on diuretics. Time trends and usage by indication may also be presented from prior NAMCS data. A correlation with VA data will be available as well by the time of presentation as a result of an ongoing project. CONCLUSION: An estimation of the use of different antihypertensive agents correlated with indication is important, particularly in light of recent clinical trials. An estimate of the use of alpha-1 blockers as single agents prior to changes in recommendations will help enumerate the size of the population at risk for suboptimal pharmacotherapy with regard to cardiovascular endpoints. It will also provide context for the importance of findings from clinical trials of antihypertensive agents. (3) clinical cues found empirically to be used by clinicians to differentiate sinusitis from viral URIs. Agreement between diagnostic approaches was determined using the Kappa statistic. RESULTS: Of 91 eligible patients, 61 (67%) agreed to participate in the study. Mean age was 42 years (range 12 ± 78), 43 (70%) were women, and mean duration of symptoms was 4.7 days (range 1 ± 23). Forty-four patients (72%), 6 patients (10%), and 11 patients (18%) were diagnosed with sinusitis by each diagnostic approach respectively. Agreement between diagnostic approaches ranged from kappa=0.08 (approach 1 compared to approach 2) to kappa=0.39 (approach 2 compared to approach 3). CONCLUSION: Three published approaches to diagnosing sinusitis modified for telephone use exhibited poor to marginal agreement. More research is needed to determine a valid tool for telephone diagnosis of sinusitis before the diagnosis and treatment of acute sinusitis solely through telephone contact can be recommended. Increasingly, hospices are developing affiliations with academic medical centers. However, little is known about hospice patients referred from academic medical centers, and how their needs may differ from those of the general population of hospice patients. Therefore, the purpose of this study was to identify differences between patients referred to an urban, non-profit hospice from academic vs. non-academic medical centers. METHODS: In this retrospective cohort study, 1,691 patients admitted to an inpatient and outpatient hospice program were identified between January of 1997 and January of 1999, and data were gathered until discharge or death. RESULTS: Patients referred from academic medical centers were younger, had higher incomes, and were less likely to have Medicare or Medicaid. Patients referred from academic medical centers were less likely to have a Do Not Resuscitate order or a living will, and had more medical and nursing needs. Survival analysis revealed no difference in length of stay between patients referred from academic and non-academic medical centers. CONCLUSION: Patients referred to hospice from academic medical centers have greater needs for nursing and medical care than do patients referred from non-academic medical centers. These results have important implications for hospice planning and policy. If they are replicated in other hospice settings, they suggest that hospices that establish ties with academic medical centers may be caring for patients with more symptoms, and more needs for care. Such differences should be considered in drawing up plans for affiliations. They might also be considered on a more global scale in assessing reimbursements to hospices by Medicare and other payers. were younger than 65 years, and 8 had concomitant valvular disease leaving 145 patients for analysis. Data collection was complete. The mean age was 77 years, and women comprised 55% of the cohort. According to the AFI criteria, 38% of the population had an annual stroke risk of < 4.3% while 50% of the population had an annual stroke risk < 3.6% by SPAF (p < .05). There was agreement between the AFI and SPAF in estimating the patients with the highest stroke risk of 8% annually (43% and 50%, respectively). The OBRI estimated 91% of all patients to have a bleeding risk of 12% over two years while 9% of the cohort had the highest estimated bleeding risk of 53% over 48 months. In all but the highest stroke risk groups, the OBRI-estimated bleeding risk exceeded the expected benefits of anticoagulation. CONCLUSION: In this population of elderly patients with atrial fibrillation, the use of published risk stratification indices has limited clinical utility, mainly because of the difficulty in balancing the relative risks in the group with low and intemediate stroke risk. In particular, the validated OBRI does not seem applicable to the stable outpatient elderly population, and its use might actually deter the appropriate anticoagulation of patients. PURPOSE: Cold angina is explained with increased coronary``vascular resistance''. The temperature of the lower extremities in cold weather and the temperature of blood during hibernation is approximately 228C. It is suggested that when blood temperature decreases from 36.68C to 228C, blood viscosity increases 26.13%. The aim of this study is determination of the effect of the increased blood viscosity on circulatory system. METHODS: Changes in circulatory parameters due to increased viscosity can be calculated with Poiseuille' s hydrodynamics equation. In the equation, blood flow rate in m3/sec is Q=%a4/ 8 L(F1-F2) and peripheric resistance of a vessel is R=(F1-F2)/Q, where a is the radius, L is the length of vessel, is blood viscosity, F1 is the initial and F2 is the final pressure at the two ends of a vessel. RESULTS: According to these equations, flow rate decreases 20.72 % and peripheral resistance increases 20.72 % when viscosity increases 20.72 % due to cold environment. This state can be compensated by increased cardiac work as 20.72 % increase in blood pressure or 5.9 % increase in the vessel radius. CONCLUSION: The term``peripheral resistance'' is more correct for the explanation of cold angina than vascular resistance, because peripheral resistance can cover blood viscosity (resistance against blood flow) and vascular resistance (change in diameter, length and shape of vessel). These calculations show that decreased temperature and increased viscosity of the blood in the skin and lower extremities in cold weather results in increased peripheral resistance and circulatory work. Due to sclerotic vessel has no vasodilatation capacity, Y Â schemia risk is high for the coronary atherosclerotic patient. Unfortunately, similar circulatory changes caused by the cooling of the pulmonary blood in cold weather are unknown. The information above shows that the mechanism of cold angina gains an additional explanation with increased blood viscosity and peripheral resistance due to decreased blood temperature, for the first time. This method is important for further evaluation of the dynamics of the circulatory system. RESULTS: CC occurred in 13 patients (14.4%) including 8 patients who experienced 11 major complications. There was a trend toward more CC with age > 60, anesthesia duration > 3 hours, creatinine > 2.4, and vascular and emergency surgery. The ASA scale and revised cardiac index(Lee) performed better than the original Goldman and Detsky indices. The ACC and ACP algorithms were best at identifying low risk patients, but some of this effect was due to the results of non-invasive tests. (Table 1 ) Exercise capacity, Eagle criteria, and Larsen's index were not predictive of CC. CONCLUSION: Although our group of patients had relatively few major complications, we were able to validate the predictive ability of various indices to stratify perioperative risk; however, statistical significance of the differences could not be achieved due to the small numbers. The goals of risk indices are to identify low risk patients requiring no further workup and to select other patients potentially benefiting from additional testing or interventions. Other management strategies, including perioperative beta-blockers, will be needed to reduce complications in the intermediate and high risk groups, and in emergency surgery patients. The ACC and ACP each published guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Both were evidence-based, but the ACC also used expert consensus opinion in the absence of strong evidence. Because of this difference, the guidelines may present conflicting opinions. The purpose of this study was to compare their recommendations with respect to non-invasive testing (NIT) and evaluate risk stratified clinical outcomes. METHODS: We retrospectively reviewed records of 90 patients (pts) undergoing 104 major intra-abdominal or vascular procedures in a large, urban teaching hospital. Patients were classified into low, intermediate, or high (including emergency) risk groups based on the algorithms. We then compared the ACC and ACP recommendations for NIT and subsequent clinical outcomes for each group. Major complications were defined as cardiac death, MI, ischemia, CHF, and VT. RESULTS: Eleven major complications occurred in 8 pts, 3 of whom had MI' s (1 cardiac death). Of the 104 procedures, 30 were emergent (1 MI). Additionally, 9 and 5 pts respectively were classified in a high risk group by ACC and ACP criteria. The remaining pts were divided into test or no test subgroups ( Table 1 ). The ACC recommended NIT for 11 of these lowintermediate risk pts, 2 of whom had postop MI' s, and no test for the other 54 pts, none of whom had major complications. The ACP recommended NIT for 6 of 14 intermediate risk pts, 1 of whom had an MI, and no test for the 55 low risk pts, 1 of whom had an MI. ACP guidelines recommended no test in 7 of the 11 pts (1 had an MI) in whom the ACC suggested testing . The guidelines agreed otherwise. CONCLUSION: Both ACC and ACP algorithms separated low risk patients from intermediate-high risk ones. Because of differing concepts regarding exercise capacity and NIT in non-vascular surgery, the ACP classified more patients as low risk and recommended fewer NIT' s; however, the clinical outcomes appeared comparable (despite the small numbers). Physician judgement and personal preference for the guidelines will determine the approach regarding NIT for an individual patient undergoing elective surgery. Future studies will need to clarify the best approach for high risk/emergency patients. were independent risk factors for lower extremity amputation in patients with PAD. Although the burden of certain atherosclerotic risk factors is higher in minority patients, the impact of this burden does not account for the increased risk of the outcome of lower extremity amputation in these two populations. As we do not have information on the severity of disease, race/ethnicity may be a marker for the severity of PAD. Further research is needed to better understand the reason (s) why race/ethnicity is independently associated with poor outcomes in PAD. PURPOSE: Whether patients and their providers make comparable assessments of the severity of pain, the likelihood of improvement and optimal treatment strategies when patients present with an acute episode of low back pain is not known. We sought to evaluate the level of concordance on these dimensions between patients and providers at the time that individuals with acute low back pain (ALBP) enrolled in a randomized controlled trial (RCT) of usual care versus choice of complementary and alternative medical (CAM) therapy. METHODS: Baseline data obtained by face to face interview at RCT enrollment. Eligible subjects were adult members of a multi-specialty medical practice who reported experiencing uncomplicated ALBP for less than 3 weeks with no co-morbid explanation for symptoms. Enrollees were randomized to either usual care or to a choice of chiropractic, massage, acupuncture or usual care. Enrollees' medical providers completed a written survey at the time they referred a patient to the study. RESULTS: Of the 80 enrolled in the study to date, the mean age was 42, 51% were women, and 58% were white. Sixty-seven of the enrollees' providers (84%) responded to a questionnaire about the enrollee's ALBP. The mean patient-reported severity score for back pain on a scale of 0 ± 10, with 10 representing the worst pain ever, was 8.0 (s.d. 1.6, range 4 ± 10); providers reported a mean score of 6.3 (s.d. 2.1, range 1 ± 9). Providers substantially underestimated patients' pain (t=5.48, p < .001), with 24% of the enrollees describing their pain as 10/10 and none of the providers rating pain higher than 9/10. Providers and patients had similar expectations for recovery. On a 0 ± 10 scale, with 10 representing complete improvement in 6 weeks and 0 representing no improvement, patients reported a mean score of 8.4 (s.d. 1.8, range 4 ± 10) and providers a score of 8.1 (s.d. 2.5, range 1 ± 10), t=.84, p=.40. The majority of patients (55%) expressed a preference for massage, 31% for chiropractic, 12% for acupuncture, and 1% for usual care. Thirty-two percent of the providers accurately anticipated the type of therapy the patient said s/he would choose, 18% thought that the modality the patient preferred was the best choice for that patient. Only 7% believed the therapy preferred by the patient was the best treatment for ALBP in general. Patients presenting to a university-based clinic were screened for MD using the PRIME-MD. Eligible patients also had a 17-item Hamilton Rating Scale for Depression (HRS-D) !12. Patient satisfaction with their PCP was assessed at baseline using a 5-point Likert scale and later dichotomized to``very satisfied'' or``not very satisfied'' for our analysis. The HRS-D was repeated at 6 months. Recovery was defined as a HRS-D 7. Information about depression treatment, such as pharmacotherapy, number of visits, and referral to a mental health specialist was abstracted from the EMR. RESULTS: Between 4/96 and 12/98, 211 depressed patients met all protocol eligibility criteria and completed a baseline interview. Of the 193(91%)patients who completed 6 month interviews, their baseline mean HRS-D was 20, 71% were women, 24% were African American and 119 (62%) reported being``very satisfied'' with their PCP. No differences in HRS-D or satisfaction were noted by gender, race or medical comorbidity. Although``very satisfied'' patients had significantly lower baseline HRS-D, the difference of only one point was not considered clinically significant. At 6 months 43(22%)of the patients recovered.``Very satisfied'' patients were more likely to recover at 6 months than those who were``not very satisfied'' (31% vs 8%, OR 5.1, 95%CI=2.0 ± 12.8). This association persisted after controlling for baseline HRS-D scores, medical co-morbidity and process measures for depression care (adjusted OR 5.3, 95%CI=2.0 ± 13.8). A baseline report of``very satisfied'' was not significantly associated with subsequent number of PCP visits, medications prescribed, or mental health referrals. CONCLUSION: Patients who are``very satisfied'' with their PCP are more likely to recover from a MD episode. Patient recovery has been found to be related to physicians engendering confidence in their patient's recovery. It is tempting to speculate that PCPs who stimulate greater optimism in their patients, improve satisfaction and subsequent recovery from depression. Assessment of patient satisfaction early in the therapeutic relationship may identify patients at risk for poor recovery from MD. Smoking is a significant issue among the homeless, but little is known about their willingness to quit or their interest in assistance with quitting. We therefore sought to determine what proportion of homeless persons smoked, whether they were ready to stop smoking, and whether they had preferences for smoking cessation treatments. METHODS: We anonymously surveyed homeless adults at nine sites in Pittsburgh, including emergency shelters, drop-in centers, transitional housing, a community health center, and residential substance abuse treatment programs. All persons at each site were approached during 2-hour blocks; 97% of those present completed the survey. Measures included demographic characteristics, living situation, smoking behavior, readiness to change smoking behavior (based on a stage-of-change model), self-efficacy to stop smoking (rated from 1 to 10), nicotine dependence (Fagerstrom scale), and preferred method of smoking cessation. RESULTS: 273 persons completed the survey, of whom 87% met criteria for homelessness. The sample was middle aged (mean age 42 years), male (81%), and minority (63%). Of the 68% who were current smokers, 87% had interest in quitting, and 39% indicated readiness to quit smoking within the next six months. Compared to those not ready to quit, persons were significantly (p < 0.05) more likely to be ready to quit if they had high self-efficacy (47% vs. 21%), knew persons who would support their smoking cessation efforts (47% vs. 13%), or smoked within 30 minutes of awakening (40% vs. 31%). Readiness to quit was not associated with gender, ethnicity, substance abuse, nicotine dependence, or type of shelter. Participants self-efficacy to quit smoking was significantly higher with assistance, compared to their selfefficacy without assistance (6.3 vs. 4.8, p = 0.000). Treatments preferred by persons ready to quit included nicotine replacement (33%), counseling (15%), bupropion (Zyban) (7.5%), and nicotine in combination with other treatments (12%); one-third (33%) indicated``nothing'' or`q uitting cold-turkey'' would help. CONCLUSION: The majority of homeless persons smoke, many are ready to stop smoking, and most believe they will be more successful with treatments such as nicotine replacement. There is an urgent need to develop and implement smoking cessation programs for the homeless. METHODS: We used data from a national telephone survey that examined attitudes and beliefs of Americans toward participation in clinical research. A distrust index, scores ranging from 0most trusting to 7-most distrusting, was created using the sum of the responses to a seven-item measure of trust. The dependent variable in these analyses, high levels of distrust, was categorized as 5 on the distrust index. Of 1000 survey respondents, there were 527 Black and 382 White respondents eligible for this analysis (n = 909). RESULTS: Black respondents were more likely than White respondents not to trust that``their doctor would fully explain research participation'' (41.7% vs. 23.4%, p < 0.01) and less likely to believe that they could ask their doctor questions (15.2 vs. 7.6%, p < 0.01). Black respondents were also more likely to disagree that``their doctor would not ask them to participate in research if the doctor felt there was harm" (37.2% vs. 19.7%, p < 0.01) and more likely to state that they felt their doctors sometimes exposed them to unnecessary risks (45.5% vs. 34.8%, p < 0.01). Blacks were more likely to believe that``someone like them'' would be used as a guinea pig without their consent (79.2 vs. 51.9, p < 0.01) and that their physician had given them treatment as part of an experiment without their permission (24.5% vs. 8.3%, p < .01). Black respondents has a significantly higher mean index score (3.1) than Whites (1.8) (p < 0.01). Nearly 30% of blacks compared to 9% of whites had scores 5 (p < 0.01) In unadjusted analyses, Blacks had more than 4 times the odds of whites of having a distrust index score 5. After controlling for other sociodemographic variables in the logistic regression model, race remained strongly associated with a higher distrust score (OR=3.6; 95% CI=2. 4,5.4) . CONCLUSION: We found important differences by race in distrust. Even after controlling for markers of social class, African Americans were less trusting. Investigators trying to engage African Americans in research must focus on developing interpersonal trust with community members by actively engaging the members in all aspects of research design development and dissemination of findings. We included clinical trials conducted in patients in the following areas: cardiovascular disease, diabetes mellitus, HIV/AIDS, and cancer. For each RCT we collected data on the number and percent of white and minorities (i.e., African Americans, Hispanic, Asian/Pacific Islander, and Native Americans) reported in the study samples. In addition to simple descriptive statistics, we used ANOVA to assess reporting of race before during and after 1993 ± 1995. RESULTS: A total of 253 RCTs met our inclusion criteria (29 diabetes, 84 cardiovascular and 50 cancer and 90 HIV/AIDS). Forty percent of RCTs did not report the race/ethnicity of the study sample. Of the RCTs that reported race (n=150), 29% of the study samples were minorities. There was no statistical difference in the percent of minorities in RCTs published before 1993 RCTs published before , between 1993 RCTs published before and 1995 RCTs published before , and after 1995 . In addition there was no difference in the percent minorities when stratified by disease. CONCLUSION: In diseases where there are significant disparities by race in health outcomes, a large number of RCTs did not report the race/ethnicity of the study sample. In addition, there has been no increase in the proportion of minorities in study samples before, during or after enactment of federal initiatives to increase the proportion of minorities in RCTs. For clinicians to have the highest level of evidence to effectively care for minority patients and reduce disparities in health outcomes, RCTs must consistently report race/ethnicity and the proportion of minorities included in study samples needs to increase. METHODS: 309 psychiatric outpatients underwent a personal interview assessing medical conditions and health status with the Medical Outcomes Study Short Form-36 (SF-36) survey. We assessed psychiatric severity with the Brief Psychiatric Rating Scale (BPRS) which rates psychiatric severity from 0 (none) to 6 (extremely severe) in 18 symptom constructs. Podiatric health was assessed using 9 items from the National Health Interview Survey (NHIS) and an additional item addressing foot pain. RESULTS: 57% of our sample were diagnosed with schizophrenia and the mean BPRS score was 22 reflecting moderate severity of psychiatric illness at the time of the interview. 70% of participants reported at least one of 8 medical problems. 82% of patients surveyed reported at least one podiatric problem and 40% reported at least 3 problems. The most common problems were foot pain (48%), nail disorders (35%), and corns/calluses (28%). The prevalence rates of podiatric disorders in our cohort were 4 ± 10 times higher than those reported by the general population in the 1990 NHIS. For example, 5.2% of the general population reported nail disorders, 5.0% reported foot infections, and 5.7% reported corns/calluses. In bivariate analysis, the total number of podiatric problems reported by the participants was inversely related to their scores in all eight domains and both summary scores of the SF-36 (all p < 0.001). After controlling for sociodemographic factors, psychiatric illness, and medical conditions, the total number of podiatric limitations remained significantly associated with lower patients ratings in 4 of the 8 SF-36 domains: bodily pain (p < 0.001), role limits-emotional (p = 0.002 ), social functioning (p = 0.03), and general health (p = 0.003) and both summary domains, physical component (p = 0.04) and mental component (p = 0.03). CONCLUSION: Persons with severe and persistent mental illness have markedly elevated rates of podiatric problems when compared to the general population. These problems are associated with worsened self-perceived health status. Addressing podiatric health may be a successful way to improve the overall health of this population. PURPOSE: HIV continues to be a destructive problem in the urban poor. The SRO hotel population, a unique subset of the urban poor, is inadequately described in the literature. Our purpose is to describe the level of comprehensive health care, perceptions of health care, and utilization of health care services in the SRO hotel population served by both the Department of Acquired Immunodeficiency Syndrome (AIDS) Services Income Support (DASIS), a division of New York City's Department of Welfare, and CitiWide Harm Reduction, a community-based organization in the South Bronx. METHODS: Following a pilot survey, we conducted an extensive community-based survey of SRO hotel residents in the South Bronx from 8/99 to 4/00. We went door-to-door in all 10 DASIS-and CitiWide-served SRO hotels administering anonymous surveys to residents. The 34-item questionnaire included demographic information, health care utilization patterns, status of HIV disease and treatment, perceptions of quality of and access to health care, and drug use. RESULTS: Of the 190 hotel residents approached, 97% completed the survey. Of these residents, 91% reported being HIV-positive, 63% male, 59% Black, 34% Latino, and 62% active drug users. The average age is 41 years (range 20 ± 74 years), and 56% are high school graduates. The median length of stay in a single hotel is 4 months (range 1 day ± 32 years), and 96% have Medicaid. Of the 167 HIV-positive residents, 67% report having primary care providers. Of these individuals, 71% report receiving care in an infectious disease (ID) or HIVspecialty clinic. However, only 22% of 18 eligible residents report taking Mycobacterium avium complex (MAC) prophylaxis, 65% of 57 eligible residents report taking Pneumocystis carinii pneumonia (PCP) prophylaxis, and 44% of 88 eligible residents report taking antiretroviral medications. In the previous 6 months HIV-positive residents report a mean of 1.5 Emergency Department visits, and in the previous year they report a mean of 1.7 hospitalizations. Quality of care and access to care are perceived to be less than``good'' by 44% and 36% of HIV-positive residents, respectively. CONCLUSION: Among South Bronx HIV-positive SRO hotel residents, a largely substanceusing population with Medicaid, two thirds report having primary care providers. Yet a significant proportion of these individuals are not receiving medically recommended HIV therapy. Approximately half are dissatisfied with their quality of care, and one third with their access to care. In light of these findings, steps are currently being undertaken to address this deficiency in health care among HIV-positive individuals living in SRO hotels. PURPOSE: Although use of electronic medical record (EMR) systems is increasing, the effects on actual communication between patients and physicians have not been studied extensively. We sought to assess physician-patient communication patterns associated with use of an EMR system in an outpatient setting and provide an empirical foundation for larger studies. METHODS: We conducted a cross-sectional, case-control study involving analysis of videotaped physician-patient encounters, surveys of physicians and patients, and medical record reviews. The setting was an academic general internal medicine practice. We studied three physicians who used an EMR system (EMR physicians) and three who used solely a paper record (control physicians). A total of 204 patient visits were included in the analysis (mean = 34 for each physician). Makoul's SEGUE instrument was utilized for content analysis of whether physicians accomplished communication tasks during encounters. A separate, qualitative analysis by the authors sought evidence of general patterns of EMR and paper chart use. RESULTS: Compared to the control group, EMR physicians adopted a more active role in clarifying information and providing patient education. Overall, there were no statistically significant differences between the physician groups in mean duration of encounters, number of treatment options offered, or number of lab tests ordered. The qualitative analysis showed that physicians in both groups tended to direct their attention to the patient record during the initial portion of the encounter. The physical orientation of the computer keyboard/monitor and physicians' facility in typing were important determinants of attentiveness to the patient throughout the EMR encounters. CONCLUSION: EMR physicians' communication behaviors may reflect styles established before they began using an EMR system. Coupling education on patient-centered communication when physicians are trained on the use of EMR systems could enhance the effectiveness of providers using this tool. that might deter women from recommended screening. Another possible explanation for avoidance of BCS might be that some women are not sufficiently concerned about the consequences of metastatic breast cancer to submit to screening. We, therefore, measured womens' perceptions of metastatic breast cancer and compared them to self-reported compliance with BCS. METHODS: A trained research assistant interviewed 106 women aged 50 to 75 years using a structured questionnaire that assessed patients' attitudes toward mammography and their compliance with BCS. Interviews were conducted in North Carolina and Florida. Patients preferences for the health state``life with metastatic breast cancer'' were measured using a standard gamble approach. Standard gamble results were converted to health utility scores(HUS) for which 1.0 = normal health and 0 = death. Descriptive statistics were compiled. Bivariate analysis was performed to identify possible associations with recent noncompliance with BCS. Demographic data, attitudes toward screening, and HUS were used as independent variables in this analysis. Due to the exploratory nature of this study and small sample size, a p-value of < 0.1 was used as the cutoff for statistical significance. RESULTS: Of the 106 women interviewed, 83% were high school graduates or above, 35% were African-American, and 89% had some form of health insurance. The mean age was 60 yrs. Two thirds of participants reported themselves to be at least in good health. The mean HUS for life with metastatic breast cancer was 0.39 with a median score of 0.25. Thirty-two of the one hundred-six women interviewed had not received BCS during the 2 years preceding this survey. Over 90% agreed that mammograms could save their life and that the actual x-ray would not lead to breast cancer or needless breast surgery. Bivariate associations with BCS non-compliance included worse self-reported health, education less that high school, African-American race, and high HUS (0.7 or above) for life with metastatic breast cancer. CONCLUSION: Poverty, African-American race, and lack of education have long been sited as sentinel characteristics for lower BCS rates. The above data suggest that optimistic perceptions of metastatic cancer might also contribute to these lower rates. If indeed, higher individual HUS, can be confirmed as an independent predictor of BCS non-compliance, then a standard gamble approach could be used to identify a group of patients that could benefit from a targeted educational intervention that aggressively portrays consequences of metastatic breast disease. PURPOSE: A recent analysis of secondary data revealed marked differences in lung surgery rates between African-Americans and whites who suffered from early stage, non-small cell, lung cancer. The disparity in treatment according to race led to an 8% reduction in 5 year survival for African-American patients. The authors were unable to sort out whether patient or physician factors explained the difference in surgical decision making. Because of this uncertainty, we decided to measure patient perceptions of progressive lung cancer and evaluate whether more optimistic perceptions of this disease could reasonably explain differences in surgical management. METHODS: We recruited a stratified, random sample of 160 individuals from church groups, health fairs, and medical clinics in urban areas of North Carolina and Florida. A trained research assistant administered an oral questionnaire to obtain demographic information and assess patient preferences using a standard gamble approach. Standard gamble results were converted to health utility scores (HUS) for which 1.0 = normal health and 0 = death. HUS for progressive lung cancer were analyzed according to race. We then constructed a decision model that evaluated lung cancer surgery vs. no surgery for stages I and II non-small cell cancer. The model accounted for racial differences in HUS for progressive disease. The model was intentionally biased against surgery by overestimating surgical risk and survival with progressive lung cancer. Sensitivity analysis was performed. RESULTS: The average age of the 160 patients interviewed was 59 yrs. Sixty-three percent were women, 42% were educated beyond highschool, 41% had incomes < $20,000, 15% had no health insurance, and 41% were African-American. The mean HUS for progressive lung cancer among African-Americans surveyed was 0.32 compared to 0.21 among whites. The decision model when applied to a 60 yr.old African-American male demonstrated a quality adjusted survival of 3.38 life years (QALY's) for the surgical therapy group compared to 0.48 QALY's for the``no surgery'' group. In the sensitivity analysis, if patient age was adjusted to 80 yrs., surgery still maintained a large advantage (1.58 QALY's for surgical treatment vs. 0.48 QALY's for``no surgery''). Even if surgical cure rate was reduced to 10% in the model, the advantage in QALY's remained for surgical patients(1.2 surgery vs. 0.48``no surgery''). CONCLUSION: Although African-Americans hold a much more optimistic view of progressive lung cancer than whites, the difference does not explain discrepancies in lung surgery decisions even when decision models are significantly biased against surgical intervention. Other issues, such as physicians' misinterpretation of patients' surgical risk and patients' mistrust or misunderstanding of physicians, need to be assessed in order to resolve discrepancies in lung cancer treatment and survival.