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Patients' Role in the Use of Radiology Testing for Common Office Practice Complaints
Ira B. Wilson, MD, MSc;
Kim Dukes, MA;
Sheldon Greenfield, MD;
Sherrie Kaplan, MPH, PhD;
Bruce Hillman, MD
Arch Intern Med. 2001;161:256-263.
ABSTRACT
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Background Radiological studies are an important component of ambulatory medical
costs, and guidelines often focus on their appropriate use. However, little
is known about the correlates of the use of those services, particularly the
influence of patients' preferences on physicians' utilization decisions.
Objectives To study patients presenting for outpatient treatment of respiratory
problems and low back pain, and to examine the magnitude of the effect of
the patients' perceived need for radiological studies (radiology preference
score) on use of those services.
Design Cross-sectional survey.
Setting Office practices of generalist physicians in predominantly rural areas
of 8 states.
Participants A total of 52 generalist physicians agreed to enroll consecutive Medicare-eligible
patients making office visits for respiratory problems or low back pain. Of
1785 eligible patients invited to participate, 132 (7%) refused and 1137 (69%)
of 1653 returned questionnaires.
Measurements Radiology utilization rates (plain film, computed tomographic scan,
or magnetic resonance image scan) were determined by patient self-report.
To assess perceived need for radiological studies, we asked patients how necessary
they believed an x-ray film was in the evaluation of 4 common complaints (respiratory
problems, low back pain, knee pain, and knee swelling). A summary radiology
preference score was created from 3 of the 4 items, excluding the item referring
to the patients' index complaint.
Results Six hundred fifteen respiratory and 522 low back pain patients were
enrolled; mean ages were 69 and 64 years, respectively. Radiology utilization
rates were 37% for respiratory and 26% for low back pain patients. In multiple
logistic regression models, for respiratory patients radiology utilization
was related significantly to the radiology preference score (odds ratio [OR]
for fourth quartile compared with first quartile, 1.94; 95% confidence interval
[CI], 1.11-3.37; P = .02), to having a physician
who owned radiology equipment (OR, 1.81; 95% CI, 1.23-2.66; P = .002), and current smoking (OR, 1.58; 95% CI, 1.04-2.41; P = .03). For low back pain patients, radiology utilization
was significantly related to the radiology preference score (OR for fourth
compared with first quartile, 2.55; 95% CI, 1.29-5.06; P = .007), bothersomeness of the pain (OR for fourth compared with
first quartile, 3.74; 95% CI, 1.74-8.04; P<.001),
and a diagnosis of osteoporosis (OR, 1.67; 95% CI, 1.01-2.75; P = .04).
Conclusions Patients' perceived need for radiological studies was significantly
associated with use of those services for outpatients with respiratory problems
and low back pain. These findings suggest that patients communicate their
wishes to physicians, either directly or indirectly, regarding services they
think are necessary. Differences in physicians' adherence to guidelines regarding
radiology utilization may in part reflect variations in patients' perceived
need for those services. Efforts to educate patients about when radiological
studies are medically indicated may be an important complement to practice
guidelines or other utilization-related financial incentives.
INTRODUCTION
RESPIRATORY complaints and low back pain are among the most common symptoms
for which outpatients seek care. In 1995, nearly 70 million visits (7.9% of
all ambulatory visits) were made to providers for cough, throat symptoms,
upper respiratory tract symptoms, or shortness of breath; and approximately
23 million visits (2.7% of all ambulatory visits) were made for back symptoms
and low back pain.1 Although there are no good
estimates of the proportion of these respiratory visits that included radiological
testing, such testing is frequent for patients with low back pain.2, 3
Because the costs associated with utilization of ambulatory radiological
studies are substantial, utilization and quality management efforts often
attempt to reduce the use of unnecessary diagnostic radiological services.4, 5, 6, 7 A number
of recent interventions that have attempted to reduce radiology utilization
by guidelines and feedback,8 mandatory radiological
consultation,9 and financial penalties10 have failed. One reason for this failure may be that
not enough is known about the determinants of use of radiological testing.
In particular, little is known about how patients' beliefs about the preferences
for radiological testing affect physicians' test-ordering practices. Although
it is increasingly appreciated that patients are active and important participants
in health care decisions,11, 12
to our knowledge, the impact of patients' perceptions about the need for specific
services on utilization of those services has not been studied.
We therefore examined the relationship between patients' perceived need
for radiological studies and use of radiological testing in a population of
elderly outpatients. We focused on episodes of care for respiratory complaints
and low back pain in Medicare-eligible outpatients because these are common
problems among the elderly and because we believed elderly patients would
be sufficiently experienced with these clinical problems to have developed
preferences about the need for diagnostic radiological tests. Local practice
patterns can vary widely,13 so we studied patients
seeking care in 52 different outpatient physicians' offices from 8 different
states. We hypothesized that patients who perceived radiological studies as
"necessary" for quality care would express this perception of need, either
explicitly or implicitly, to physicians, and that physicians would respond
with greater use of radiological studies.
SUBJECTS AND METHODS
SUBJECTS
This study was part of a larger initiative to assess the impact of a
radiological reimbursement policy change instituted by the United Mine Workers
of America Health and Retirement Funds (hereafter Funds) on radiology utilization.10
PHYSICIANS
Eligible physicians were generalists (internal medicine, family practice,
and general practice) with 30 or more Funds patients in their panel. Most
practiced in rural (coal mining) areas. We used a quota sampling strategy
with a goal of enrolling 60 physicians. Using the Funds' claims-history and
provider databases, 449 generalist physicians were identified. All were sent
an invitation to participate by mail. Follow-up telephone calls were made
by a physician who personally invited them to participate. Because of the
possibility that radiology utilization would differ for physicians who owned
their own imaging equipment,14 efforts were
made during the telephone follow-up phase of physician enrollment to oversample
self-referring physicians who comprised only 20% of eligible physicians.
PATIENTS
Receptionists in participating physicians' offices were asked to enroll
30 or more consecutive eligible patients. Patients were eligible if they visited
the outpatient office of a participating physician for a respiratory problem
or low back pain during the study period and had either Funds or Medicare
insurance. Funds patients were Medicare eligible, and the Funds administered
both the Medicare and supplemental insurance components of physician reimbursements
for Funds beneficiaries. Eligible patients with respiratory problems could
have shortness of breath, cough, or allergy symptoms, such as runny nose or
chest congestion. Eligible patients with low back pain could have acute or
chronic low back pain.
Patient enrollment took place between September 1, 1994, and August
1, 1995. Nonrespondents were contacted by telephone and answered an abbreviated
series of sociodemographic and health questions.
DATA COLLECTION
Patients were surveyed by mail 1 month after the enrollment visit. The
patient questionnaire included specific items about receipt of radiological
studies, patients' perceptions of the necessity of radiological services,
condition-specific symptoms and functioning; health habits and personal characteristics;
the presence and severity of comorbid conditions; utilization of radiological
services; and general health status.
We asked participating physicians about practice characteristics, background
and training, and whether plain films, computed tomographic (CT) scanning,
and magnetic resonance image (MRI) scanning were done at their offices.
VARIABLES
Dependent Variable
Radiology utilization was determined by patients' self-report. Descriptions
of x-ray films, CT scans, and MRI scans were provided, and patients were asked
whether they had received such a test or tests in the 4 weeks since the enrollment
visit. A dichotomous utilization variable was created reflecting any radiology
utilization.
Independent Variables
Four items were developed to assess patients' perceptions of the necessity
of radiological studies in the evaluation of physical complaints that are
common in the elderly. We asked patients how necessary they thought it was
"in order to get the best medical care" to get an x-ray or a scan for each
of the following common problems: pain in the lower back, cough, knee pain,
and swelling of the knee. Each item was measured using a 5-point Likert scale
ranging from "very necessary" to "not at all necessary." One "radiology preference
score" was created for patients with respiratory complaints and another for
patients with low back pain. In each case, the scale was the sum of 3 preference
score items that did not pertain to the index condition. The item referring
to the index complaint was not included in the radiology preference scale
because of the possibility that the patients' actual recent experience (receiving
or not receiving an x-ray examination) might influence their perception of
the necessity of an x-ray for that particular complaint. Thus, for respiratory
patients, the scale was composed of items about low back pain, knee pain,
and knee swelling; and, for low back pain patients, the scale was composed
of items about cough, knee pain, and knee swelling. The scale was the sum
of the 3 items, transformed linearly to a 0 to 100 scale where a higher score
represents the perception that radiological studies are necessary to get the
best medical care. We performed principal components analyses to verify hypothesized
item groupings. Internal consistency reliability was assessed using Cronbach  .15 To assess validity, we tested whether imaging rates
were higher for patients in the fourth quartile of the radiology necessity
score than for patients in the first quartile.
Other independent variables included sociodemographic, clinical, and
nonclinical variables. Sociodemographic variables included age, sex, race,
income, and education. Patient-reported clinical variables included condition-specific
symptom severity, functioning related to those symptoms, comorbid conditions,
and general functioning and well-being. Health habits included current smoking
and current alcohol use. Condition-specific clinical factors for respiratory
patients included patients' reports of a prior diagnosis of black lung, emphysema,
chronic bronchitis, frequency of cutting down on usual activities because
of respiratory problems, and symptom severity. Upper- and lower-tract respiratory
symptom severity was assessed using scales modified from Monto and Cavallaro, 16 which included fever. For back pain patients, condition-specific
clinical factors included the presence of sciatica, frequency of cutting down
on usual activities due to pain, bothersomeness of pain, chronicity, and a
history of back surgery. We did not ask back pain patients about fever because
empirical studies show that fever is uncommon in general medical outpatients
being evaluated for back pain.17, 18
Low back pain was classified as chronic if patients reported that they had
the pain all the time. The presence and severity of comorbidities were assessed
using a 64-item modified form of the Total Illness Burden Index (TIBI)19, 20 designed to capture domains salient
to an elderly population. General functioning and well-being were assessed
using the Medical Outcomes Study SF-36.21
Nonclinical variables included insurance coverage and physician self-referral
vs radiologist-referral classification. For insurance, patients were classified
as having either Medicare or Funds coverage. Insurance type was provided by
physicians' offices. Funds beneficiaries receive full reimbursement, with
no copayments, for all outpatient diagnostic imaging examinations. However,
the supplemental insurances of the Medicare patients in the study could vary
widely and could potentially impact utilization of radiological services.
To measure this barrier, we asked patients how much out-of-pocket costs interfered
with their ability to "get the lab tests, x-rays, and scans that the doctor
recommends."
Physicians were classified as either self-referring or radiologist-referring
according to their responses to a survey item inquiring whether they routinely
obtained plain films in their own office (self-referring physicians). We used
data from the Funds' administrative database to validate this classification.
The Funds' database classified physicians as self-referring if they had charged
a professional fee, a technical fee, or both for performing and/or interpreting
a radiological study in the 6 months preceding January 1, 1994. For the 38
physicians who could be classified using both survey and database approaches,
there was agreement between the 2 methods in 82% of cases ( statistic,
0.63).
ANALYSES
Sampling Bias Analyses
We used data from the Funds' administrative database to compare characteristics
of participating (n = 52) and nonparticipating (n = 397) physicians, and demographic
and health data from the telephone survey to compare participating and nonparticipating
patients. We did not attempt to ask nonparticipants whether they had received
an x-ray film because follow-up interviews were done 3 to 6 months after the
index visit and we believed patients' recall would be unreliable.  2 Tests were used for dichotomous variables and t tests for continuous variables. In addition, we compared patients'
scores on the 8 dimensions of the SF-36 with published age-group norms.21
Unit of Analysis
Our sampling strategy produced a sample of patients nested within 52
physicians' practices. To model utilization, we used hierarchical modeling
techniques to examine the effects of physician-level variables on radiology
utilization. The hierarchical logistic regression analysis was performed using
SAS Proc Mixed (SAS Institute Inc, Cary, NC) with a macro designed to model
the logistic link function. There was no statistically significant effect
due to the individual physician. We therefore used the patient as the unit
of analysis in subsequent utilization modeling.
Utilization Modeling
Independent variables in utilization analyses included all clinical
and nonclinical variables. We examined bivariate relationships between the
dependent variable and each independent variable using t tests and 2 tests. Variables with bivariate relationships
to radiology utilization with a P value of less than
.10 were candidates for inclusion in multiple logistic regression models and
were checked for multicollinearity. Direct entry multiple logistic regression
models were also developed to investigate potential effect modifiers where
appropriate.
The radiology preference score was treated as a continuous variable
in all initial analyses. After its multivariable statistical significance
was established, it was divided into quartiles and modeled using dummy variables
to facilitate presentation in tables. Frequency of cutting down on usual activities
because of respiratory problems, lower respiratory tract symptoms, and bothersomeness
of low back pain were treated similarly.
RESULTS
PHYSICIAN CHARACTERISTICS
Participating physicians were from 8 different states: Alabama, Indiana,
Kentucky, Pennsylvania, Tennessee, Utah, Virginia, and West Virginia. They
were mostly male (n = 48; 92%), had a mean age of 50 years, and had been practicing
at their current practice site for an average of 17 years (Table 1).
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Table 1. Characteristics of 52 Physicians
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To assess whether our quota sampling strategy for physicians had introduced
important biases, we examined differences between participating and nonparticipating
physicians. By design, participating physicians were more often self-referring
for radiological examinations than nonparticipating physicians (P<.05). Participating physicians were also more likely to practice
in a group practice as opposed to solo practice (P<.05)
settings. There were no differences between participating and nonparticipating
physicians in any other salient study characteristics.
PATIENT CHARACTERISTICS
During the enrollment period, 1785 eligible patients were invited to
participate. One hundred thirty-two (7%) refused, and 1137 (69%) of 1653 returned
questionnaires. For respiratory patients, the mean age was 69 years, 45% were
women, and 62% had Medicare insurance (Table 2). Educational levels were low, with a mean of 8.4 years
of education. For back pain patients, the mean age was 64 years, 54% were
women, and 68% had Medicare insurance. For back pain patients, the mean age
was younger than 65 years because of patients who qualified for Medicare due
to disability (Supplemental Security Income recipients). In both groups, 98%
of patients were white and 58% had a yearly income of less than $15 000
per year. Thirty-nine percent of respiratory and 37% of back pain patients
had a self-referring physician.
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Table 2. Patient Sociodemographic Characteristics
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To determine the nature of patients' response bias, 191 (37%) of the
516 nonrespondents were contacted by telephone and responded to a short survey.
Compared with survey respondents, nonrespondents contacted by telephone reported
worse role function and emotional function, were younger, were not as well
educated, and had lower incomes (all P<.05). There
were no differences in sex, race, or overall health ratings.
CLINICAL CHARACTERISTICS
Forty-three percent of respiratory patients reported that they were
current smokers, 46% had emphysema, 51% had chronic bronchitis, 46% reported
a diagnosis of "black lung," and 11% had a history of non–skin cancer
(Table 3). Thirty-two percent
reported having to cut down their usual activities "a lot" due to their respiratory
problems, and 39% reported that their health was "poor" (the most extreme
of 5 response categories). Thirty-seven percent of respiratory patients had
at least 1 chest radiological study during the study period.
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Table 3. Patient Clinical Characteristics, Radiology Utilization Rates,
and Radiology Preference Score*
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Fifty-three percent of the back pain patients were current smokers and
7.3% had a history of non–skin cancer (Table 3). The back pain was characterized as chronic by 56% of patients
and 18% reported having had back surgery. Forty-two percent were bothered
"a lot" or "extremely" by sciatica, and 59% reported cutting down on usual
activities "a lot" or "a whole lot" because of back pain. Thirty-five percent
described their health as "poor." Having a radiological procedure during the
study period was reported by 26% of back pain patients.
For both respiratory and low back pain patients, mean scores were below
the 25th percentile for patients 65 to 75 years on all 8 dimensions of the
SF-36 (data not shown).
PATIENTS' PERCEIVED NEED FOR RADIOLOGY STUDIES
A score of 100 indicated that a patient believed that a radiological
study was "very necessary" for all 3 complaints, and a score of 50 indicated
that a radiological study on average was "sometimes necessary." The mean radiology
preference scores for both respiratory and back pain patients were 49 and
43, respectively (Table 3). In
principal components analyses (not shown), the 3 items comprising the radiology
preference score formed a single factor for both respiratory patients and
low back patients. Internal consistency reliability as assessed by Cronbach
was high for both respiratory and low back pain patients at 0.82 and 0.75,
respectively.
UTILIZATION ANALYSES
Respiratory Problems
In bivariate analyses, shown in the left-hand column of Table 4, radiology preference score was significantly related to
radiology utilization, with patients in the fourth quartile of the preference
score more likely to have a radiological study compared with those in the
first quartile (44% vs 29%; P = .008). Patients of
self-referring physicians more often underwent radiological studies than patients
of radiologist-referring physicians (45% vs 31%, P<.001).
Current smokers had more chest radiological studies conducted than nonsmokers,
though the bivariate trend did not reach statistical significance (43% vs
34%; P = .07). More functional impairment due to
respiratory symptoms also was associated with greater utilization, with patients
in the fourth quartile more likely to have had a radiological study than those
in the first quartile (43% vs 28%; P = .02). There
was a trend toward more respiratory symptoms being associated with greater
radiology utilization when the fourth and first quartiles were compared (41%
vs 31%, P = .08). Insurance type (Funds vs Medicare),
difficulty with out-of-pocket costs for radiological procedures, age, sex,
case mix, a diagnosis of black lung, and a history of non–skin cancer
were not significantly related (P>.05) to radiology
utilization.
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Table 4. Significant Bivariate and Multivariable Correlates of Radiology
Utilization in Respiratory Patients*
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The multivariable model for respiratory patients (Table 4, right-hand column) included the following variables: radiology
preference score, the self-referral, smoking, frequency of reducing usual
activities because of respiratory problems, and lower respiratory tract symptom
score. The radiology preference score was significantly related to radiology
utilization for respiratory patients (OR, 1.94; 95% CI, 1.11-3.37; P = .02). Two other variables were also significantly related to utilization
in the multivariable model, having a self-referring physician (OR, 1.81; 95%
CI, 1.23-2.66; P = .002), and current smoking (OR,
1.58; 95% CI, 1.04-2.41; P = .03). Functional impairment
("cutting down") and respiratory symptoms were not significant in the multivariable
model.
Back Pain
As shown in the left-hand column of Table 5, in bivariate analyses, the radiology preference score was
significantly related to radiology utilization, with patients in the fourth
quartile of the preference score much more likely to have a radiological study
compared with those in the first quartile (34% vs 15%; P<.001). Pain severity ("bothersomeness") was also significantly
associated with utilization, with patients in the first quartile having more
radiological studies than those in the first quartile (39% vs 11%; P<.001). Patients who reported osteoporosis more often had radiological
studies than whose without osteoporosis (32% vs 20%; P
= .002). The difference between the utilization rates for self-referring and
radiologist-referring physicians was not statistically significant (29% vs
24%; P = .21). Difficulty with out-of-pocket costs,
insurance type, income, age, sex, case mix, current smoking status, history
of non–skin cancer, the presence of sciatica, and back pain chronicity
were not significant correlates (P<.05) of radiology
utilization.
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Table 5. Significant Bivariate and Multivariable Correlates of Radiology
Utilization in Patients With Back Pain*
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The multivariable model for back pain patients (Table 5, right-hand column) included the following variables: radiology
preference score, bothersomeness of pain, and osteoporosis. The radiology
preference score was independently associated with radiology utilization for
back pain patients with an OR comparing the fourth with the first quartile
of 2.55 (95% CI, 1.29-5.06; P = .007). Bothersomeness
of pain was significantly associated with radiology utilization with an OR
comparing the fourth with the first quartile of 3.74 (95% CI, 1.74-8.04; P<.001), as was a diagnosis of osteoporosis (OR, 1.67;
95% CI, 1.01-2.75; P = .04).
COMMENT
To determine factors associated with use of outpatient radiological
services, we studied a population of elderly, mostly rural-dwelling patients
from 8 different states who made office visits for respiratory problems and
low back pain. For both groups of patients, the perception that diagnostic
radiology was needed for the best quality care was significantly related to
radiology utilization.
This is the first study of which we are aware that attempts to correlate
patients' general perceptions about the need for specific medical services
to utilization of those services. Our findings support what clinical anecdotes
suggest—that patients communicate their wishes to physicians, either
directly or indirectly, regarding services they think are necessary, and that
this communication influences physicians' actions. While a number of studies
have measured patients' expectations about specific elements of the clinical
encounter,22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37
including expectations about diagnostic testing,22, 26, 29, 32, 33, 34
these studies largely have focused on the relationship between expectations
and patients' satisfaction,23, 26, 27, 28, 29, 31, 32, 34, 36, 37, 38
and not on actual utilization of services. This study also differs from others
in that we studied patients of multiple practitioners over a wide geographic
area, supporting the generalizability of the results.
Findings from this study have potentially important implications for
the design of utilization and quality management programs in which guidelines,
preauthorization, utilization profiling, and other related approaches are
used. Our data suggest that efforts to reduce utilization of radiological
studies that focus only on physicians and that do not take account of patients
perceptions of the need for such imaging, may be less effective than anticipated.
The same concerns may hold for other types of office-based testing, such as
laboratory testing. Recent physician-focused interventions that have attempted
to reduce radiology utilization by guidelines and feedback,8
mandatory radiological consultation,9 and financial
penalties,10 have failed. Stiell and colleagues39 successfully implemented a guideline focused on the
diagnostic evaluation of acute knee injuries, but the generalizability of
such acute-care guidelines to office practice where complaints are more chronic
may be limited. One small randomized trial that we are aware of supports the
premise that patients' expectations about receiving radiological studies for
low back pain can be modified.40
Compared with radiologist-referring physicians, self-referring physicians
in this study ordered more radiological studies for their patients with respiratory
complaints but not for their patients with low back pain. Previous studies,
which used the episode of care as the unit of analysis, found that self-referral
was consistently associated with higher radiology utilization.14, 41
Our data, which assess 2 types of radiology utilization in the same group
of physicians, suggest that the self-referral at the level of the individual
physician is not best understood as a simple, uniform economic inducement.
It is possible, for example, that the generalist physicians we studied were
more comfortable interpreting chest films than lumbar spine films, and that
this lack of comfort reduced the impact of whatever economic inducement existed
for self-referring physicians to order more lumbar spine films.
There are some relevant study limitations. First, patients' perceptions
about the necessity of radiological studies were not assessed prior to the
office visit. To eliminate the possibility that having or not having an x-ray
study for a respiratory complaint or low back pain influenced the radiology
preference score, we excluded the item that referred to the index condition
from the radiology score. Furthermore, the high internal consistency reliabilities
of the scales suggest that they capture a generalized perception on the part
of the patient about the role of x-ray films in the evaluation of acute complaints,
as opposed to a perception that varies according to the specific complaint.
Second, patients' self-report of radiology utilization may be inaccurate.
We did not review patients' charts to verify whether radiological studies
were done because the majority of the physicians in the study had to send
patients to radiologists to get radiological studies, and we thought it unlikely
that office records would capture this out-of-office utilization in an unbiased
way. Third, these data do not permit us to assess the appropriateness of the
radiological studies done for these patients. Fourth, we do know how many
of these patients were visiting their physician for the first time; such patients
would likely receive imaging more frequently. Because participants were elderly,
rural-dwelling patients with chronic medical conditions, we believe few were
likely to be visiting their physician for the first time. Fifth, these findings
may not be generalizable to younger patients or patients with higher levels
of education. Finally, because this study was cross-sectional in design, it
cannot prove causal relationships between the variables assessed.
Our findings have several important implications. Efforts to control
costs by "profiling" and comparing physicians or groups of physicians regarding
radiology utilization, and perhaps other types of utilization as well, may
be confounded by variations in patients' perceived need for different types
of services. More important, attempts to educate patients about when specific
types of utilization are medically necessary may be a useful complement to
interventions aimed at physicians such as practice guidelines and utilization-related
financial incentives.
AUTHOR INFORMATION
Accepted for publication May 17, 2000.
This work was supported by grant 022799 from the Robert Wood Johnson
Foundation, Princeton, NJ, and by the United Mine Workers of America Health
and Retirement Funds, Washington, DC. Dr Wilson was supported in part by a
Picker-Commonwealth Scholar's Award.
Presented in part at the Society of General Internal Medicine Annual
Meeting, Washington, DC, May 2, 1996.
We would like to acknowledge the valuable assistance provided by Catarina
Gilbert in collecting these data, and Amina Khan, MA, and Tara Tripp, MA,
in conducting analyses.
From the the Division of Clinical Care Research (Dr Wilson), the Primary
Care Outcomes Research Institute (Drs Greenfield and Kaplan), Department of
Medicine, New England Medical Center and Tufts University School of Medicine,
Boston, Mass; the Department of Radiology, University of Virginia, Charlottesville
(Dr Hillman); and DM-Stat, Inc, Medford, Mass (Ms Dukes).
Reprints and corresponding author: Ira B. Wilson, MD, MSc, New England
Medical Center, Box 345, 750 Washington St, Boston, MA 02111 (e-mail: IWilson{at}Lifespan.org).
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