Health Care Utilization

Blacks hospitalized for congestive heart failure more often than whites

Black men younger than 60 years of age are twice as likely as similarly aged white men to be hospitalized for congestive heart failure (CHF). Black women in this age group are nearly three times as likely as similarly aged white women to be hospitalized for CHF. Older blacks are hospitalized 1.5 times more often than whites for this condition, according to a recent study supported by the Agency for Health Care Policy and Research (HS07373). The higher prevalence of hypertension and diabetes among blacks, conditions that can contribute to CHF, explains most of the racial differences in CHF hospitalization.

After adjusting for these conditions and risk factors, such as smoking and high cholesterol, race was no longer a factor in CHF hospitalizations of men and older women. However, after this adjustment, black women younger than 60 years still were 1.5 times more likely to be hospitalized for CHF than their white counterparts. Additional burdens, such as responsibility for child care or the effects of poverty, may impair the ability of younger black women to receive care and attend to their medical needs, suggests Eugene Washington, M.D., M.Sc., of the Medical Effectiveness Research Center for Diverse Populations based at the University of California School of Medicine, San Francisco.

The investigators studied the first hospitalization for CHF of 64,877 enrollees in a large health maintenance organization. These patients had been free of CHF at a health checkup at or after the age of 40 years. However, these results may not apply to uninsured or indigent populations, cautions Dr. Washington.

Details are in "Hospitalization for congestive heart failure: Explaining racial differences," by Mark Alexander, Ph.D., Kevin Grumbach, M.D., Joe Selby, M.D., M.P.H., and others, in the Journal of the American Medical Association 274(13), pp. 1037-1042, 1995.

FDA guidelines reduce unnecessary dental x-rays

Currently, the treatment plan of most patients seeking general dental care is developed after a clinical examination and a full-mouth set of radiographs. In 1988 the U.S. Food and Drug Administration (FDA) issued guidelines to assist dentists in selecting a limited set of x-rays for the examination. This change in practice was intended to reduce patient exposure to radiation without compromising patient care.

Even though the rationale for the guidelines was formally endorsed by dental professional groups, there is evidence that they are not being used and that use of full-mouth sets remains common. General dentists have been concerned about the risk of missed disease and resulting malpractice claims based upon a failure to diagnose disease.

A recently completed study, supported by the Agency for Health Care Policy and Research (HS06670), showed that dentists following the FDA guidelines reduced the number of periapical radiographs (showing tooth crown to root tip) by 43 percent. Kathryn A. Atchison, D.D.S., M.P.H., Stuart C. White, D.D.S., Ph.D., and colleagues at the University of California, Los Angeles, Schools of Dentistry and Public Health, evaluated use of the guidelines for assessment of 490 new adult dental patients.

The researchers confirmed that there was a small increased risk of not detecting an abnormal condition, compared with use of a full-mouth examination. However, the number of missed radiographic findings was very low (approximately 4 percent), considering the level of variability in diagnosis reported in the literature. Most missed findings would have had no effect on the patient's treatment.

The researchers noted that demonstration of missed conditions does not necessarily indicate flaws in the guidelines, since allowances must be made for the potential harm of radiation exposure, the costs associated with the additional radiographs, and possible unnecessary care resulting from false positive diagnoses made on the basis of too many radiographs. They concluded that the FDA guidelines are sufficiently reliable and offered suggestions for their implementation by dentists.

See "Assessing the FDA guidelines for ordering dental radiographs," by Drs. Atchison and White, Virginia F. Flack, Ph.D., and Edmond R. Hewlett, D.D.S., in the Journal of the American Dental Association 126 (10), pp. 1372-1383, 1995.

Editor's Note: For a more complete discussion of the FDA guidelines and radiographic assessment of the periodontium, see "Efficacy of the FDA selection criteria for radiographic assessment of the periodontium," by the same authors in the Journal of Dental Research 74(7), pp. 1424-1432, 1995.

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