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Articles 
Elliott S. Fisher, David E. Wennberg, Thérèse A. Stukel, Daniel J. Gottlieb, F. L. Lucas, and Étoile L. Pinder The more inpatient-based and specialist-oriented pattern of practice observed in high-spending regions largely explains regional differences in Medicare spending. Neither quality of care nor access to care appear to be better for Medicare enrollees in higher-spending regions.
Elliott S. Fisher, David E. Wennberg, Thérèse A. Stukel, Daniel J. Gottlieb, F. L. Lucas, and É toile L. Pinder Medicare enrollees in higher-spending regions receive more care than those in lower-spending regions but do not have better health outcomes or satisfaction with care.
Yasushi Shiratori, Shuichiro Shiina, Takuma Teratani, Masatoshi Imamura, Shun'taro Obi, Shin'pei Sato, Yukihiro Koike, Haruhiko Yoshida, and Masao Omata After tumor ablation by ethanol injection, interferon therapy may enhance survival in selected patients with chronic hepatitis C and hepatocellular carcinoma.
Marco J.L. van Strijen, Wouter de Monyé, Jan Schiereck, Gerard J. Kieft, Martin H. Prins, Menno V. Huisman, Peter M.T. Pattynama for the Advances in New Technologies Evaluating the Localisation of Pulmonary Embolism (ANTELOPE) Study Group* In patients with suspected pulmonary embolism, helical computed tomography can be used safely as the primary diagnostic test to rule out pulmonary embolism. Serial compression ultrasonography has limited additional value.
Brief Communications
Erik K. Alexander, Shelley Hurwitz, Jenny P. Heering, Carol B. Benson, Mary C. Frates, Peter M. Doubilet, Edmund S. Cibas, P Reed Larsen, and Ellen Marqusee Thyroid nodules are common and most often benign, but the natural history of benign nodules is unclear. The authors found that most solid, benign thyroid nodules grow. Therefore, an increase in nodule volume alone is not a reliable predictor of malignancy.
Reviews
Tami de Araujo, Isabel Valencia, Daniel G. Federman, and Robert S. Kirsner This case-based review discusses potential causes of leg ulcers, clinical characteristics suggesting that leg ulcers are due to venous disease, diagnostic procedures, therapy (including compression therapy, growth factors and other medical treatments, and surgery), and specialist referral.
Perspectives
Ira Byock and Steven H. Miles Medicare denies hospice coverage to patients with terminal illnesses who enroll as participants in phase I studies, which assess the toxicity and dosing of potential treatments for incurable diseases. Such exclusions are not defensible on ethical or clinical grounds.
Clinical Guidelines
Robert J. Desnick, Roscoe Brady, John Barranger, Allan J. Collins, Dominique P. Germain, Martin Goldman, Gregory Grabowski, Seymour Packman, and William R. Wilcox Fabry disease is an X-linked recessive lysosomal storage disorder. Although the disease presents in childhood and culminates in cardiac, cerebrovascular, and end-stage renal disease, diagnosis is often delayed or missed. This paper reviews the key signs and symptoms of Fabry disease and provides expert recommendations for diagnosis, follow-up, medical management, and enzyme replacement therapy.
Editorials
Kenneth I. Shine In this issue, Fisher and colleagues convincingly show that excellent outcomes for patients can be achieved in regions that do less, but do it right. The challenge is to convince the public that a lean style of practice is not about rationing but about better care.
Charles E. Phelps The national scope, careful control of possibly confounding variables, and underlying design of Fisher and colleagues' study make this study possibly the most compelling yet showing that increased treatment intensity does not bring with it commensurate gains in health.
Gail R. Wilensky An increasing amount of attention has been given to the importance of improving quality and patient safety in Medicare. We need to find ways to encourage better practices, not discourage them by creating disincentives. We need more thought about how to reward physicians who practice high-quality conservative medicine.
Susan Dentzer The firestorm that greeted the release of the Women's Health Initiative findings on hormone therapy has two main lessons: 1) Although crucial in disseminating health information, the media should not be relied on as the primary means of communicating a complicated health story to the public, and 2) the National Institutes of Health should supply an "instant context" for any given study by pulling together the extensive knowledge that already exists across the institutes.
On Being a Doctor
Natalie A. Mariano A heart writes mysterious stories, and we record them on cardiograms. Sharp, black lines etched across fine gray graph paper trace the electrical current that surges through heart muscle. Each little blip and spike narrates a detail of a story.
Letters Screening for Colorectal Cancer
Acute Hepatocellular-Cholestatic Liver Injury after Olanzapine Therapy
Furosemide Challenge in Patients with Heart Failure and Adverse Reactions to Sulfa-Containing Diuretics
Antral Injections of Botulinum A Toxin for the Treatment of Obesity
Food and Drug Administration Approval of Buprenorphine–Naloxone for Office Treatment of Addiction
Correction: Postmenopausal Estrogen Replacement and Risk for Venous Thromboembolism
Ruth Kirschstein
John H. Hansen-Flaschen Pulmonary diseases, including chronic lung disease and pneumonia, are the third leading cause of death in the United States. This Update summarizes articles in six areas: chronic obstructive pulmonary disease, the acute respiratory distress syndrome, tuberculosis, thoracic imaging, sleep apnea, and end-of-life care. | ||||||||||||||||||||||||||||||||||||||||||||||||||
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