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PubMed1999

Indirect modulation of dopamine D2 receptors as potential pharmacotherapy for schizophrenia: I. Adenosine agonists.

OBJECTIVE: To review preclinical and clinical information related to pharmacologic modulation of dopamine D2 receptors as potential novel antipsychotic therapy. Specifically, to summarize the data that suggest a modulatory action of adenosine A2A receptors on dopamine D2 receptors and, therefore, a possible rational role of adenosine A2A agonists as novel antipsychotic agents. DATA SOURCES: Primary and review articles were identified by MEDLINE search (from 1966 to May 1998) and through secondary sources. STUDY SELECTION AND DATA EXTRACTION: All of the articles identified from the data sources were evaluated and all information deemed relevant was included in this review. DATA SYNTHESIS: For all of the older and many of the newer antipsychotic agents, there is a strong correlation between clinical antipsychotic activity and affinity for dopamine D2 receptors. Unfortunately, dopamine D2 receptors are believed to also be involved in the adverse effect profile of these agents. The indirect modulation of dopamine D2 receptors, rather than direct block, might produce antipsychotic effects without the usual adverse reactions. Several lines of evidence from animal studies suggest that the use of selective A2A agonists might represent a novel approach to the treatment of psychoses. CONCLUSIONS: Dopamine receptor modulation might represent a novel antipsychotic approach or adjunct therapy. The data regarding adenosine agonists (particularly selective A2A receptor agonists) are inconclusive at the present time. Direct clinical demonstration of effectiveness is required.

Adenosine↗

PubMed2002

Continuous infusion of coagulation factor products.

OBJECTIVE: To review clinical information related to the use of continuous infusion factor products in patients with hemophilia. Specifically, case reports and open-label trials are summarized involving the use of factor VIII and recombinant factor VIIa for a variety of indications including surgical prophylaxis, acute bleeding, primary prevention, and management of inhibitors. In addition, issues surrounding the use of continuous infusion of factor products such as pharmacokinetic rationale, stability/sterility, and cost are reviewed. DATA SOURCES: Primary and review articles were identified through a MEDLINE search (1990-June 2001) and through secondary sources. STUDY SELECTION AND DATA EXTRACTION: All articles identified from the data sources were evaluated, and all information deemed relevant was included in this review. DATA SYNTHESIS: Data concerning the administration of factor products are primarily detailed in open-label trials and case reports. Comparisons between intermittent bolus injections and continuous infusion of factor products are limited and primarily compare continuous infusion regimens with historical controls. The rationale behind the continuous-infusion approach is linked to the pharmacokinetics of factor products administered via this route. Pharmacokinetic data reveal that, with continuous infusion of factor products, a reduction in clearance and a maintenance of factor serum concentrations are noted. CONCLUSIONS: Administration of factor products (factor VIII and recombinant factor VIIa) via continuous infusion has produced favorable hemostatic effects compared with intermittent bolus injections. The advantages of continuous infusion include maintenance of a constant factor concentration, thereby reducing risk of bleeding from excessively low trough concentrations, and a decrease in factor consumption related to a reduction in factor clearance with constant infusion. Manufacturers recommend using reconstituted factor products either immediately or within 1-3 hours after reconstitution; however, several studies have found the products to be stable and sterile for longer periods.

Blood Coagulation Factors↗

PubMedDate not supplied

Anakinra treatment of patients with rheumatoid arthritis.

OBJECTIVE: To summarize the safety data arising from clinical trials of anakinra, a human recombinant form of interleukin-1 receptor antagonist (IL-1Ra) developed for the treatment of rheumatoid arthritis (RA). DATA SOURCES: Primary articles and abstracts identified through the National Library of Medicine's PubMed database (1982-2001) and secondary sources. STUDY SELECTION AND DATA EXTRACTION: All the articles and abstracts identified from the data sources were evaluated and all information deemed relevant was included in this review. DATA SYNTHESIS: Overall, anakinra was shown in 4 trials to be efficacious as monotherapy or combination therapy, compared with placebo, for the treatment of active RA. The magnitude of clinical improvement tended to increase with increasing doses of anakinra. In monotherapy trials, the primary adverse event was injection-site reactions, which usually were mild and transient. In com bination therapy (anakinra plus methotrexate), the frequency and severity of adverse events were similar to those seen in the monotherapy trials. CONCLUSIONS: The use of anakinra in patients with RA inhibits disease activity with a favorable tolerability profile.

Antirheumatic Agents↗

PubMed2002

Current and emerging therapy for primary pulmonary hypertension.

OBJECTIVE: To review the epidemiology, pathophysiology, clinical symptoms, and diagnostic workup of primary pulmonary hypertension (PPH) and to discuss the available data on the current and emerging therapies being used to treat this disorder. DATA SOURCES: Primary and review articles were identified with a MEDLINE search (1966-December 2001) and through secondary sources. STUDY SELECTION AND DATA EXTRACTION: All articles identified from the data sources were evaluated and all information deemed relevant was included in this review. DATA SYNTHESIS: In the absence of a definable cause, PPH is a disorder classified by a progressive increase in pulmonary vascular resistance and mean pulmonary artery pressure. A relatively rare condition, PPH has an annual incidence of 1-2 cases per million people, slightly higher in women than men. The prognosis is poor, with a mean survival time of 2.8 years after diagnosis if untreated. Vasoconstriction, vascular remodeling, and thrombosis are hallmarks of the disease process. Anticoagulation and vasodilators are the most commonly employed treatment options, showing benefits in clinical outcomes, hemodynamic parameters, and mortality. Several new vasodilators are being evaluated for the treatment of PPH. Bosentan was recently approved as the first oral agent for the treatment of PPH. Iloprost, treprostinil, and beraprost are investigational agents in Phase III studies. CONCLUSIONS: Until additional studies and experience with these agents become available, calcium-channel blockers (CCBs) remain the first option for therapy. For patients not responding to CCBs, therapeutic options will now include epoprostenol and bosentan. Since there are no comparison trials between these 2 agents, therapeutic decisions should be based on patient-specific concerns. Clinical data and experience support the use of epoprostenol; however, in patients at risk or considered unsuitable candidates, bosentan may become a preferred option. Additional studies are warranted to address the potential therapeutic benefits of combination therapy and long-term benefits of agents to treat PPH.

Anti-Inflammatory Agents↗

PubMedDate not supplied

A brief primer on automated signal detection.

BACKGROUND: Statistical techniques have traditionally been underused in spontaneous reporting systems used for postmarketing surveillance of adverse drug events. Regulatory agencies, pharmaceutical companies, and drug monitoring centers have recently devoted considerable efforts to develop and implement computer-assisted automated signal detection methodologies that employ statistical theory to enhance screening efforts of expert clinical reviewers. OBJECTIVE: To provide a concise state-of-the-art review of the most commonly used automated signal detection procedures, including the underlying statistical concepts, performance characteristics, and outstanding limitations, and issues to be resolved. DATA SOURCES: Primary articles were identified by MEDLINE search (1965-December 2002) and through secondary sources. STUDY SELECTION AND DATA EXTRACTION: All of the articles identified from the data sources were evaluated and all information deemed relevant was included in this review. DATA SYNTHESIS: Commonly used methods of automated signal detection are self-contained and involve screening large databases of spontaneous adverse event reports in search of interestingly large disproportionalities or dependencies between significant variables, usually single drug-event pairs, based on an underlying model of statistical independence. The models vary according to the underlying model of statistical independence and whether additional mathematical modeling using Bayesian analysis is applied to the crude measures of disproportionality. There are many potential advantages and disadvantages of these methods, as well as significant unresolved issues related to the application of these techniques, including lack of comprehensive head-to-head comparisons in a single large transnational database, lack of prospective evaluations, and the lack of gold standard of signal detection. CONCLUSIONS: Current methods of automated signal detection are nonclinical and only highlight deviations from independence without explaining whether these deviations are due to a causal linkage or numerous potential confounders. They therefore cannot replace expert clinical reviewers, but can help them to focus attention when confronted with the difficult task of screening huge numbers of drug-event combinations for potential signals. Important questions remain to be answered about the performance characteristics of these methods. Pharmacovigilance professionals should take the time to learn the underlying mathematical concepts in order to critically evaluate accumulating experience pertaining to the relative performance characteristics of these methods that are incompletely defined.

Automation↗

PubMed2000

How cigarette additives are used to mask environmental tobacco smoke.

OBJECTIVE: To understand the tobacco industry's research on and use of cigarette additives that alter the perception of exposure to environmental tobacco smoke (ETS). DATA SOURCES: Internal documents from four websites maintained by the major US tobacco manufacturers and company patents pertaining to the use of ETS altering additives obtained from the US Patent and Trademark Office online database. STUDY SELECTION: Electronic searches of the four industry websites and the US patent database were conducted using keywords to identify relevant data. DATA EXTRACTION: Industry documents and patents obtained using an exploratory snowball sampling method were reviewed and grouped into four general categories according to whether the additive(s) described affected ETS visibility, odour, irritation, or emissions. Accuracy of isolated findings was validated through cross comparison of the data sources. DATA SYNTHESIS: Results of this preliminary study provide evidence that tobacco manufacturers have conducted extensive research on the use of chemical additives to reduce, mask, or otherwise alter the visibility, odour, irritation, or emission of ETS. CONCLUSIONS: Findings suggest that the tobacco industry uses additives to reduce the perception of ETS. To protect the public, appropriate regulation of tobacco additives should be mandated.

Humans↗

PubMed1997

Acute pain management: operative or medical procedures and trauma.

OBJECTIVE: To review the topics presented in the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline for Acute Pain Management and provide updated information on therapeutic issues as necessary. DATA SOURCES: AHCPR Clinical Practice Guideline for Acute Pain Management: Operative or Medical Procedures and Trauma. A MEDLINE search (1990 to June 1996) of English-language literature pertaining to pain assessment and management was performed. Reference lists from relevant articles also served as a literature source. STUDY SELECTION AND DATA EXTRACTION: All articles identified from the data sources were evaluated. Relevant information, as determined by the authors, was included in the review. DATA SYNTHESIS: Inadequate acute pain management continues to be recognized as a problem due to limited health professional education on the treatment of pain, inadequate patient empowerment, negative connotations associated with opioid analgesics (e.g., fear of "addiction"), federal regulations associated with prescribing opioid analgesics, and difficulty in assessing pain. The widespread inadequacy in pain management prompted the development of the AHCPR Clinical Practice Guideline for Acute Pain Management, which was published in 1992. In addition to reviewing the pain guideline, this article includes updated information on ketorolac tromethamine, tramadol, local anesthetics, sedation, regional anesthetic techniques, and the management of opioid adverse effects. CONCLUSIONS: The AHCPR Clinical Practice Guideline for Acute Pain Management is a comprehensive, yet functional, review for clinicians. Most issues relating to acute pain assessment and management are adequately discussed. Overall, this guideline is a worthwhile general resource to clinicians. It is important, however, for clinicians managing acute pain issues to supplement this guideline with more detailed and current information.

Analgesics↗

PubMed1998

Ambulatory management of chemotherapy-induced fever and neutropenia in adult cancer patients.

OBJECTIVE: To review the literature on the management of low-risk adults with chemotherapy-induced fever and neutropenia (CIFN). Included in the review are methods to identify these patients, management options, and economic impact associated with nontraditional treatment options. DATA SOURCES: A MEDLINE and bibliographic search (January 1966-December 1997) for all English-language studies evaluating the identification and treatment of adult, low-risk CIFN patients was completed. Reference lists from identified articles also served as literature sources. STUDY SELECTION AND DATA EXTRACTION: All human studies identified from the data sources were evaluated. Pertinent information, excluding pediatric studies, was selected and critically evaluated for discussion. DATA SYNTHESIS: Alterations in prominent bacterial isolates in CIFN, newer antibiotic choices, enhanced focus on patient comfort, and cost-containment directives have promoted recent research identifying adult cancer patients with low-risk CIFN. Using this information to select low-risk CIFN patients, several investigators have completed trials using antibiotic therapy applicable to the ambulatory setting. Additionally, some investigators have included the use of an oral outpatient antibiotic regimen. Limited data indicate that this approach is a reasonable treatment option for selected patients. CONCLUSIONS: A subset of adult patients with CIFN are at low risk for serious morbidity and mortality when treated with broad-spectrum antibiotics in the ambulatory setting. Managing these patients with this approach requires close patient selection, intense follow-up, data collection, and ongoing evaluation to determine efficacy and patient safety. Currently, ambulatory treatment with oral antibiotics for CIFN is not considered standard of care. Further studies of larger size designed to confirm low-risk patient characteristics and optimal antibiotic selection are required.

Adult↗

PubMedDate not supplied

Using ICPC in a computer-based primary care information system.

INTRODUCTION: Although the framework of the episode of care offers much promise in examining the process of primary health care, the development of episode-oriented, automated data sources has proceeded slowly. Experience with the International Classification of Primary Care (ICPC) in the European Community has confirmed its usefulness in creating and analyzing episodes of care, but it has seen little use in the United States. We describe the development of a Primary Care Information System (PCIS), which employs ICPC to create episodes of care from routinely collected clinical data. METHODS: The PCIS is a partially computerized medical information system running on a standard Macintosh microcomputer. The PCIS integrates ICPC, ICD-9-CM, and CPT-4 coding structures to provide episode-oriented data for clinical, administrative, research, and reimbursement needs. The performance of the PCIS was assessed based on five major issues: clinician cooperation, data-entry accuracy, validity of episode data, cost, and perceived value to users. RESULTS: The data collection and entry process required minimal additional effort from clinicians and data-entry personnel, and data-entry accuracy exceeded published estimates for other primary care data sources. Data management costs of about $1 per encounter compare favorably to published estimates for other office-based clinical information systems. The major problem seen during pilot testing was inaccurate tracking of episode boundaries through changes in providers and consequent changes in labels for problems and diagnoses. This problem has been addressed in development of the second-generation PCIS. CONCLUSION: The combination of an episode-oriented framework such as ICPC and a flexible medical information system provides a promising platform for the study of the content and process of primary health care.

Family Practice↗

PubMed2003

European Union diabetes indicators: fact or fiction?

Diabetes mellitus is one of the major causes of morbidity and mortality in EU/EFTA countries. Monitoring risk factors for diabetes and its complications will offer the possibility to evaluate the development in time as well as the influence of possible interventions. In this investigation a list with core and secondary indicators is proposed. Availability of these indicators and their data sources is discussed. An important variability of data sources is used in EU/EFTA countries, interfering with the comparability of the outcome. Further harmonisation as well as continuous evaluation of data sources will be necessary to provide reliable tools to monitor diabetes mellitus and its outcome on a routine basis.

Comorbidity↗

PubMedDate not supplied

A critical appraisal of the quality of quality-of-life measurements.

OBJECTIVE: To evaluate how well quality of life is being measured in the medical literature and to offer a new approach to the measurement. DATA SOURCES: Original English-language articles having the term "quality of life" in their titles were identified from a recent Quality-of-Life Bibliography and from two MEDLINE searches. Articles were eligible for review only if they described or used one or more "quality-of-life" instruments. STUDY SELECTION: Twenty-five articles were randomly selected from each of the three data sources. DATA EXTRACTION: Each article was reviewed for its compliance with two sets of criteria having several components, which are cited under "Data Synthesis." DATA SYNTHESIS: (1) Investigators conceptually defined quality of life in only 11 (15%) of the 75 articles; identified the targeted domains in only 35 (47%); gave reasons for selecting the chosen quality-of-life instruments in only 27 (36%); and aggregated their results into a composite quality-of-life score in only 27 (38%) of 71 eligible articles. (2) No article distinguished "overall" quality of life from health-related quality of life; patients were invited to give their own separate rating for quality of life in only 13 articles (17%); and among 71 eligible articles, patients were asked to supplement the stipulated items with personal responses in only nine (13%) and to rate the importance of individual items in only six (8.5%). CONCLUSIONS: Because quality of life is a uniquely personal perception, denoting the way that individual patients feel about their health status and/or nonmedical aspects of their lives, most measurements of quality of life in the medical literature seem to aim at the wrong target. Quality of life can be suitably measured only by determining the opinions of patients and by supplementing (or replacing) the instruments developed by "experts."

Health Services Research↗

PubMed2002

Pathophysiology and first-line treatment of osteoarthritis.

OBJECTIVE: To review the pathophysiology of osteoarthritis (OA) and the various treatment modalities, focusing specifically on acetaminophen (APAP), nonsteroidal antiinflammatory drugs (NSAIDs), and cyclooxygenase-2 (COX-2) inhibitors as the primary treatment options. DATA SOURCES: Primary literature and tertiary references were identified by a MEDLINE search (1966-March 2001) and through other secondary sources. STUDY SELECTION AND DATA EXTRACTION: After evaluating the articles and references identified from the data sources, all the information that was judged relevant by the reviewers was included in the review article. DATA SYNTHESIS: OA is the most common joint disorder worldwide. Current research suggests that factors such as inflammation and changes in subchondral bone may play a larger role in the pathophysiology than previously thought. With this research and the development of COX-2 inhibitors, selecting the medication of choice for OA has become difficult. CONCLUSIONS: More research needs to be done before the pathophysiology of OA can be clearly determined. In the meantime, treatment should be based on clinical data and patient response. Studies have shown that APAP and NSAIDs have comparable efficacy, as do traditional NSAIDs and COX-2 inhibitors. APAP is associated with fewer toxicities than are the traditional NSAIDs. Due to their mechanism of action, the new COX-2 inhibitors should result in fewer adverse effects compared with traditional NSAIDs, but evidence from clinical trials has not been conclusive. Therefore, APAP should still be considered the drug of choice for OA.

Anti-Inflammatory Agents, Non-Steroidal↗

PubMed2001

A comparison of clinical outcome studies among cholesterol-lowering agents.

OBJECTIVE: To review and compare clinical trials of cholesterol-lowering agents that evaluated clinical end points as the primary outcome measure; specifically, to determine whether all agents that decrease cholesterol impact clinical outcomes similarly. DATA SOURCES: Primary articles were identified through a MEDLINE search (1966-February 2001) and through secondary sources. STUDY SELECTION AND DATA EXTRACTION: All of the articles identified from the data sources were evaluated. Articles that included clinical end points as the primary outcome measure were included in this review. DATA SYNTHESIS: Clinical trials were assessed according to study population (primary vs. secondary prevention of coronary artery disease), baseline and follow-up lipid profiles, and clinical outcome data. Both cardiac and noncardiac morbidity and mortality were evaluated. The differences in study populations, study methods, and changes in lipid values were compared and contrasted between trials to evaluate their effect on outcomes. CONCLUSIONS: Niacin and bile acid sequestrants should be considered as add-on therapy when therapeutic goals cannot be attained with a hydroxymethyl glutaryl-coenzyme A reductase inhibitor (stain). Estrogen therapy cannot be recommended solely for cardioprotection. Fibrates are most effective in patients with high baseline triglycerides, low baseline high-density lipoprotein cholesterol, and low to average low-density lipoprotein cholesterol (LDL). Statins are considered first line for the treatment of elevated LDL in both the primary and secondary prevention of coronary heart disease. They are well tolerated, have the strongest data to support their use, and have been shown to decrease total mortality.

Anticholesteremic Agents↗

PubMed2005

Linked analysis for definition of nurse advice line syndrome groups, and comparison to encounters.

INTRODUCTION: Nurse advice call centers are a potentially important source of data for syndromic surveillance purposes. For this reason, researchers at Johns Hopkins University Applied Physics Laboratory and Kaiser Permanente of the Mid-Atlantic States (KPMAS) have been collaborating to develop methods to use this data within the ESSENCE II Syndromic Surveillance System in the National Capital Region. OBJECTIVE: The objective of this report is to present a general method for finding syndrome groups in data sources that can be linked to physician encounters and to determine effective advice call syndrome groups for use with KPMAS advice data. METHODS: Advice calls are linked to physician encounters and stratified by patient age. They are placed in groups according to a maximum positive predictive value criterion. The groups are evaluated by correlating the resulting syndrome time series against physician encounter data. RESULTS: Potentially useful advice syndrome groups are found for respiratory, lower gastrointestinal (GI), and total GI syndromes for each age stratum. CONCLUSION: The time series of the advice data for respiratory, lower GI, and upper GI syndromes accurately predict the physician encounter time series for the corresponding syndromes for each age stratum.

Diagnosis-Related Groups↗

PubMed2004

Toward meaningful evaluation of clinical competence: the role of direct observation in clerkship ratings.

PROBLEM STATEMENT AND PURPOSE: The lack of direct observation by faculty may affect meaningful judgments of clinical competence. The purpose of this study was to explore the influence of direct observation on reliability and validity evidence for family medicine clerkship ratings of clinical performance. METHOD: Preceptors rating family medicine clerks (n = 172) on a 16-item evaluation instrument noted the data-source for each rating: note review, case discussion, and/or direct observation. Mean data-source scores were computed and categorized as low, medium or high, with the high-score group including the most direct observation. Analyses examined the influence of data-source on interrater agreement and associations between clerkship clinical scores (CCS) and scores from the National Board of Medical Examiners (NBME(R)) subject examination as well as a fourth-year standardized patient-based clinical competence examination (M4CCE). RESULTS: Interrater reliability increased as a function of data-source; for the low, medium, and high groups, intraclass correlation coefficients were.29,.50, and.74, respectively. For the high-score group, there were significant positive correlations between CCS and NBME score (r =.311, p =.054); and between CCS and M4CCE (r =.423, p =.009). CONCLUSION: Reliability and validity evidence for clinical competence is enhanced when more direct observation is included as a basis for clerkship ratings.

Certification↗

PubMed1998

Analysis, assessment, and presentation of risk-adjusted statewide obstetrical care data: the StORQS II study in Washington State. Statewide Obstetrics Review and Quality System.

OBJECTIVE: To develop an effective, concise presentation of hospital-specific birth event and delivery-related complication rates, including significant deviations from expected rates calculated using risk-adjusted peer hospital data, for distribution to all Washington State hospitals with delivery services. DATA SOURCES: Complete data for calendar year 1993, including inpatient discharge records for mothers and newborns, birth certificates, and infant death records, for 74 hospitals from Washington state source files. STUDY DESIGN: Institutions were classified into four peer groups based on presence of neonatal intensive care units, number of births, and rural/urban location. Twenty-three clinical indicators of procedure (e.g., cesarean section) and complication rates were analyzed and presented. METHODS: For each indicator, observed and expected rates (adjusted within peer group for categorized baseline risk factors) were calculated and presented by institution. Effective graphic and numeric techniques for presenting significant deviations from expected rates were developed. Results were calculated in terms of numbers of events as well as rates. Approaches applicable to institutions with small numbers of deliveries were selected. PRINCIPAL FINDINGS: Exact confidence intervals (C.I.s) for event rates were superior to binomial or Poisson approximations for small hospitals. For calculating expected rates, indirect adjustment was used due to small numbers within risk factor categories. For all indicators, observed and expected rates along with 95 percent C.I.s for the true rate were presented graphically by institution for each peer group. Transforming C.I.s into "statistically acceptable ranges" allowed hospital personnel to assess their performance in terms of actual numbers of events as well as rates. CONCLUSIONS: Readily available statistical methods and straightforward descriptive approaches allow accurate presentation of outcomes for both large and small institutions.

Adult↗

PubMed2000

The validity of information on "race" and "Hispanic ethnicity" in California birth certificate data.

OBJECTIVE: To evaluate the validity of racial/ethnic information in California birth certificate data. DATA SOURCES: Computerized birth certificate data and postpartum interviews with California mothers. STUDY DESIGN AND DATA COLLECTION: Birth certificates were matched with face-to-face structured postpartum interviews with 7,428 mothers to compare racial/ethnic information between the two data sources. Interviews were conducted in Spanish or English during delivery stays at 16 California hospitals, 1994-1995. PRINCIPAL FINDINGS: The sensitivity of racial/ethnic classification in birth certificate data was very high (94 percent to 99 percent) for African Americans, Asians/Pacific Islanders, Europeans/Middle Easterners, and Latinas (Hispanics). For Native Americans, however, the sensitivity was only 54 percent. The positive predictive value of birth certificate classification of race/ethnicity was high for all racial/ethnic groups (96 percent to 97 percent). CONCLUSIONS: Despite limited training of birth clerks, the maternal racial/ethnic information in California birth certificate data appears to be a valid measure of self-identified race and Hispanic ethnicity for groups other than Native Americans.

Adolescent↗

PubMed1994

National diabetes programs. Application of capture-recapture to count diabetes?

OBJECTIVE: To evaluate the utility of capture-recapture methods using multiple, routinely collected, computerized data sources to estimate the numbers and prevalence of diabetes. Methods employed for regional and national monitoring of diabetes have been too inaccurate or too expensive. RESEARCH DESIGN AND METHODS: A survey was undertaken that used four sources of ascertainment to identify prevalent cases of known diabetes in community of Northern Italy: diabetic clinic and family physicians, hospital discharges, prescriptions, and reagent strips and insulin syringes. Capture-recapture methods were employed to estimate the number of missing cases and to adjust for undercount to accurately estimate the number of people who had diabetes. RESULTS: We identified 2,069 unique prevalent cases of known diabetes with the intensive case-finding procedure. The diabetic clinic and family physicians data source identified the largest number of cases. The evaluation of the two sample capture-recapture estimates showed that they were all biased downward because of dependencies between sources. Log-linear modeling was employed to take into account the dependence among all data sources and the heterogeneity of diabetic patients. This method estimated that 2,586 cases existed, resulting in an ascertainment-adjusted prevalence of 2.77% (95% confidence interval, 2.44-3.10). Thus, despite the active case identification, approximately 20% could not be identified. However, the number of cases and rates could easily be adjusted using capture-recapture. CONCLUSIONS: The study shows that a two-sample capture-recapture estimate could be very biased if the investigator is not assured that the sources are independent. However, if at least three data sources are employed, log-linear models allow estimation of the number and prevalence rate adjusted for the degree of undercount (in spite of both the dependence of data sources and the heterogeneity of the diabetic population). The critical factor, however, is that the application of multiple sources with capture-recapture methods could be applied across broad geographical areas and across time to have cost-effective monitoring of diabetes at local and national level.

Adolescent↗