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Good communication is a key factor in avoiding malpractice
Primary care physicians who listen to their patients and use a more friendly manner during visits
may reduce the risk that they will be sued for malpractice, according to a recent study funded by
the Agency for Health Care Policy and Research (HS07289).
The research team was led by Wendy Levinson, M.D., formerly of Oregon Health Sciences
University and Legacy Good Samaritan Hospital and Medical Center, Portland, OR, and now
Chief of the Section of Internal Medicine at the University of Chicago. They audiotaped at least
10 routine patient visits each with 59 primary care physicians and 65 general and orthopedic
surgeons in Colorado and Oregon. Subjects were randomly selected and were divided into two
groups depending on their malpractice claims history. The 1,265 audiotapes were analyzed by
coders who did not know whether the physicians fit into the "claims" or "no-claims" group. The
study found significant differences in communication styles between primary care physicians who
had been filed against and those who had not. The differences for surgeons were not as clear.
Primary care physicians in the no-claims group spent more time with patients during routine office
visits than those in the claims group, an average of 18.3 minutes compared with 15 minutes. In
addition to the length of the visit, researchers found several other differences in the interaction
between physicians and patients. Primary care physicians in the no-claims group were more likely
than physicians with claims to orient patients to the process of the visit by telling them exactly
what was going to happen during the office visit. These physicians, who had no malpractice
claims filed against them, also asked patients for their opinions and elicited questions and were
more likely to use humor and to laugh during an office visit.
Length of visits with surgeons did not have the same association as it did for primary care
physicians. Furthermore, the study did not identify differences in communication styles that could
predict the malpractice risk for surgeons. Researchers attribute this to several possibilities. First,
routine communication may not be as important as how surgeons communicate when things go
wrong. Second, communication with their surgeon may not be as important to patients initiating a
malpractice claim as other factors, including true negligence, surgical complications, or financial
incentives. Third, patients may not look to surgeons for interpersonal communication, but rather
technical expertise presented in a more businesslike manner.
Researchers are conducting further quantitative analyses to gain more understanding of the
communication patterns of surgeons. In the meantime, they suggest that physicians who improve
their communication skills and incorporate these behaviors into routine practice can decrease their
For more information, see "Physician-Patient Communication: The relationship with malpractice
claims among primary care physicians and surgeons," in the February 19, 1997, issue of the
Journal of the American Medical Association 277(7), pp. 553-559.
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Patient Outcomes/Effectiveness Research
New medication reduces serious problems and repeat operations
A powerful new antiplatelet agent can substantially reduce major complications and the need for
repeat revascularization procedures following initial coronary angioplasty. And despite the cost of
additional bleeding problems caused by the medication, it nevertheless recoups most of the cost of
the therapy and has the potential to pay for itself, concludes a study supported in part by the
Agency for Health Care Policy and Research (HS05636 and HS06503). The agent, c7E3 Fab or
abciximab, prevents the clumping together of platelets that can lead to life-threatening blood clots.
A multicenter trial recently reported that use of c7E3 Fab in first-time angioplasty patients
resulted in a 35 percent reduction in deaths, heart attacks, and the need for repeat
revascularization within 30 days, as well as other clinical events related to abrupt closure of a
coronary artery following angioplasty. The medication also reduced by 23 percent subsequent
major ischemic (deficient blood flow to the heart) events, such as heart attack or death or the
need for revascularization (another angioplasty or bypass surgery) up to 6 months after initial
This economic substudy examined the economic tradeoff between reduced ischemic events and
increased major bleeding during initial hospitalization with use of c7E3 Fab. Results showed that a
potential cost savings of $622 per patient during the initial hospitalization from reduced acute
ischemic events with c7E3 Fab was offset by an equivalent rise of $521 due to increased bleeding
episodes. Baseline medical costs for c7E3 Fab therapy averaged $13,577 (exclusive of drug cost)
compared with $13,434 for placebo.
During the 6-month followup, c7E3 Fab decreased repeat hospitalization rates by 23 percent and
repeat revascularization by 22 percent, producing a mean savings of $1,270 per patient (exclusive
of drug cost). With a cost of $1,407 for the c7E3 Fab regimen (a bolus and12-hour infusion), the
cumulative net 6-month cost to switch from standard care to routine c7E3 Fab averaged $293 per
These findings are from one part of a prospective study of the multicenter EPIC (Evaluation of
c7E3 for the Prevention of Ischemic Complications) trial, which was conducted between 1991
and 1992 and involved 2,038 patients at 56 U.S. hospitals who were at high risk for ischemic
complications following angioplasty. The researchers conclude that c7E3 Fab is the first
medication demonstrated to improve the clinical outcomes of angioplasty patients, while
recouping most of the cost of therapy required to produce these benefits.
For more information, see "Economic assessment of platelet glycoprotein IIb/IIIa inhibition for
prevention of ischemic complications of high-risk coronary angioplasty," by Daniel B. Mark,
M.D., M.P.H., J. David Talley, M.D., Eric J. Topol, M.D., and others, in Circulation 94(4), pp. 629-635, 1996.
Studies examine recent angioplasty experience by
geographical region and patients' sex
Two recent studies, conducted by David J. Malenka, M.D., and other members of the Northern
New England Cardiovascular Disease Study Group, compare angioplasty experiences in Northern
New England with other regions of the country and look at differences in outcomes between men
and women undergoing angioplasty. The two studies, described below, were supported in part by
the Agency for Health Care Policy and Research through the Ischemic Heart Disease Patient
Outcomes Research Team (PORT, HS06503) project, which is led by Elizabeth R. DeLong,
Ph.D., of Duke University.
Malenka, D.J., and the Northern New England Cardiovascular Disease Study Group.
(1996). "Indications, practice, and procedural outcomes of percutaneous transluminal
coronary angioplasty in Northern New England in the early 1990s." American Journal of
Cardiology 78, pp. 260-265.
Ninety percent of patients undergoing coronary angioplasty in Northern New England will have
success, that is, the procedure will open up the blocked vessel that is restricting blood flow to the
heart. For many patients with coronary artery disease, the procedure is a preferred alternative to
medical management or coronary artery bypass graft (CABG) surgery. Less than 1 percent of
patients die, and less than 5 percent will need CABG for a failed angioplasty. These results are
similar to those of patients in New York and California and add practical clinical data to that of
controlled studies, according to the Northern New England Cardiovascular Disease Study
The researchers conducted a prospective study from 1989 through 1993 of the current
indications, practices, and procedural outcomes of percutaneous transluminal coronary
angioplasty (PTCA) in Northern New England. This procedure involves threading a catheter into
the blocked heart vessel to inflate a balloon and flatten plaque against the vessel wall to open up
the artery. Thirty-five cardiologists contributed data on 12,232 PTCA patients at hospitals in New
Hampshire and Maine, plus one hospital in Massachusetts. Unstable angina (46 percent), stable
angina (23 percent), and postinfarction angina (21 percent) were common indications for the
Overall, 87 percent of patients had one-vessel PTCA, including 66 percent of those with
multivessel disease. Ninety percent of the procedures were successful; 88 percent of patients had
one or more lesions successfully dilated with no adverse results. The risk of death, nonfatal heart
attack, or coronary artery bypass grafting was 6 percent. These results were similar to reports
from registries in other regions but different from the National Heart, Lung, and Blood Institute
PTCA Registry, which included patients with prior PTCA and more patients with multiple vessel
Malenka, D.J., O'Connor, G.T., Quinton, H., and others (1996). "Differences in outcomes
between women and men associated with percutaneous transluminal coronary
angioplasty." Circulation 94(Suppl. II), pp. 99-104.
Heart disease is the leading cause of death among women in the United States. Two invasive
revascularization procedures, CABG surgery and coronary angioplasty, are often used to open up
blocked coronary arteries. It is well known that women are more likely than men to die in the
hospital after CABG; a recent study shows that women also are more likely to die following
Even though angioplasty was nearly 90 percent successful in opening up blocked arteries for both
men and women, women had 1.6 times greater risk of death following the procedure than men.
Also, more women (5.3 percent) than men (4.5 percent) had to undergo bypass surgery or
suffered a heart attack following angioplasty.
Women undergoing angioplasty tend to be older and are more likely to be hypertensive and
diabetic. These factors account for their excess risk for nonfatal problems after angioplasty,
according to the study. But women's elevated risk of death compared with men's risk following
angioplasty remained, even after adjusting for these factors.
Whether women's poorer outcomes following angioplasty are partly due to their shorter stature
or smaller arterial diameter remains to be determined. Even if women have a higher procedural
risk of an adverse outcome, the excess risk is small, and it may be that the long-term success of
the procedure is good. Thus, the risk of the procedure may be acceptable, concludes the Northern
New England Cardiovascular Disease Study Group. The group prospectively analyzed data on
12,232 patients who underwent angioplasty between 1989 and 1993.
Angiography patients fare better when treated in high-volume
Coronary angiography permits radiographic visualization of the coronary arteries with the use of
contrast material that is injected into the heart via a catheter. Its use to diagnose heart problems in
patients with acute myocardial infarction (AMI or heart attack) varies widely among hospitals.
But patients treated in hospitals with high angiography use rates, especially patients judged by
published criteria to need angiography, fare better than patients treated at hospitals with low
angiography rates, according to a study supported in part by the Agency for Health Care Policy
and Research (HS08362). These findings suggest potential underuse of this effective procedure,
according to the researchers.
They assessed the risk of death from heart disease and of any heart disease event such as another
heart attack or rehospitalization within 1 to 4 years in 6,851 patients hospitalized with AMI at 16
Kaiser Permanente hospitals from 1990 through 1992. The investigators found that 89 percent of
patients who met the criteria for use of angiography underwent the procedure at hospitals with
higher angiography use rates versus 66 percent of patients at hospitals with lower rates. Hospital
variation in angiography use was related to on-site angiography capability, not patient
demographic or clinical differences, according to the researchers.
After adjustment for patient demographic and clinical characteristics, being hospitalized at a
hospital with a higher rate of angiography was associated with a 25 percent lower risk of death
from heart disease and a 15 percent lower risk of any heart disease event. For patients who did
not meet the criteria indicating a need for angiography, the apparent benefits of being treated at
hospitals with higher angiography rates were smaller than for those who met the criteria (15
percent vs. 33 percent lower risk of death and 10 percent vs. 29 percent lower risk of any heart
See "Variation among hospitals in coronary angiography practices and outcomes after myocardial
infarction in a large health maintenance organization," by Joe V. Selby, M.D., M.P.H., Bruce H.
Fireman, M.A., Robert J. Lundstrom, M.D., and others, in the December 19, 1996, issue of theNew England Journal of Medicine 335, pp. 1888-1896.
Study questions advisability of shifting care of elderly heart
attack patients from cardiologists to primary care doctors
Shifting the care of elderly heart attack patients from cardiologists to primary care physicians may
be a mistake, caution researchers supported by the Agency for Health Care Policy and Research
(HS06503 and HS08805). They found that elderly heart attack patients who were admitted to a
hospital by a cardiologist were 12 percent less likely to die within 1 year than those admitted by a
primary care physician. This survival advantage was partly due to cardiologists use of more
cardiac procedures and medications that are associated with improved survival.
Patients admitted by cardiologists underwent more diagnostic and therapeutic procedures, had
longer hospital stays (8 or 9 days instead of 1 week), and received more medications to treat
ischemic heart disease than patients treated by physicians in internal medicine, family medicine, or
general practice. Compared with patients admitted by primary care physicians, those admitted by
cardiologists underwent more coronary angiography (49 percent vs. 18 to 36 percent),
revascularization procedures (22 percent vs. 7 to 14 percent), stress testing (14 percent vs. 9 to
11 percent), nuclear imaging (19 percent vs. 7 to 15 percent), and echocardiography (55 percent
vs. 40 to 52 percent). Also, 6 percent more of the patients admitted by cardiologists were
considered eligible for thrombolytic (clot-busting) therapy.
Health care strategies that shift the care of elderly heart attack patients from cardiologists to
primary care physicians may lower resource use and potentially lower costs, but they also may
lead to decreased survival, conclude the researchers. The AHCPR-supported Ischemic Heart
Disease Patient Outcomes Research Team (PORT), based at Duke University Medical Center,
studied detailed clinical data from the Cooperative Cardiovascular Project (CCP) on 8,241
Medicare patients hospitalized for heart attacks from June through December 1992.
For more information, see "Outcome of acute myocardial infarction according to the specialty of
the admitting physician," by James G. Jollis, M.D., Elizabeth R. DeLong, Ph.D., Eric D. Peterson,
M.D., M.P.H., and others, in the December 19, 1996, issue of the New England Journal of
Medicine 335, pp. 1880-1887.
Canadian experience bolsters evidence for regionalization of
cardiac procedures in the United States
Mortality rates for patients in the United States who undergo coronary artery bypass graft
(CABG) surgery vary widely, depending on the surgeon performing the procedure and the
hospital and region where it is done. This is less true in Ontario, Canada, where the government
restricts cardiac surgery to several high-volume hospitals. This difference is probably due to
Canada's regionalization of CABG surgery so that experienced hospitals and cardiac
surgeons—who perform a large number of annual CABG surgeries—are the only ones
surgery, concludes a study supported in part by the Agency for Health Care Policy and Research
Jack V. Tu, M.D., Ph.D., F.R.C.P.C., of the Institute for Clinical Evaluative Sciences in Ontario,
and his colleagues on the Steering Committee of the Provincial Adult Cardiac Care Network of
Ontario, examined clinical risk factors and surgical outcomes of 15,608 patients undergoing
CABG surgery between 1991 and 1993 at the nine hospitals performing adult cardiac surgery in
Ontario. The overall in-hospital mortality rate after CABG surgery was low at 3 percent. The
amount of interhospital variation in risk-adjusted mortality rates was no greater than that expected
by chance alone. All Ontario hospitals performed more than 300 CABG procedures in 1992 and
1993 and only 2 of 42 cardiac surgeons performed less than 50 CABG procedures in 1993.
An American College of Cardiology/American Heart Association task force recommends that all
cardiac surgery hospitals perform a yearly minimum of 200 to 300 open heart operations and that
all cardiac surgeons perform a yearly minimum of 100 to 150 open heart operations—the
of which should be CABG operations—because frequency of operations performed has been
correlated with patient outcomes. This study provides further evidence that regionalization of
CABG surgery and a very low prevalence of low-volume cardiac surgeons have a positive impact
on surgical outcomes. The researchers conclude that this approach may avoid the problem of
low-volume hospitals and surgeons with higher-than-expected mortality rates found in U.S.
regions that have a mixture of low- and high-volume hospitals.
For more details, see "Coronary artery bypass mortality rates in Ontario: A Canadian approach to
quality assurance in cardiac surgery," by Dr. Tu, C. David Naylor, M.D., D.Phil., F.R.C.P.C., and
others, in the November 15, 1996 issue of Circulation 94(10), pp. 2429-2433.
Low Birthweight PORT publishes recent findings
Nearly 70 percent of all infant deaths and about one-third of all handicapping conditions are
associated with low birthweight. Determining the causes of low birthweight and treatments that
can prevent it are two goals of the Patient Outcomes Research Team (PORT) on Low
Birthweight in Minority and High-Risk Women, which is supported by the Agency for Health
Care Policy and Research (PORT contract 290-92-0055) and led by Robert L. Goldenberg, M.D.,
of the University of Alabama at Birmingham.
Five recent articles by members of the Low Birthweight PORT are summarized here. The first
two present findings on pregnancy loss following amniocentesis and factors influencing low
Three other articles discuss the following key findings: outcomes of newborns weighing less than
3 pounds improve when the mothers are given a combination of antenatal corticosteroids and
tocolytics; elective cesarean delivery of very large babies (over 9 pounds) is medically and
economically unsound for nondiabetic women; and mounting a randomized clinical trial to test the
effectiveness of maternally administered magnesium sulfate to prevent cerebral palsy in preterm
infants would require a huge, multicenter effort.
Wenstrom, K.D., Andrews, W.W., Tamura, T., and others (1996). "Elevated amniotic fluid
interleukin-6 levels at genetic amniocentesis predict subsequent pregnancy loss," American
Journal of Obstetrics and Gynecology 154(4), pp. 830-833.
The current rate of pregnancy loss following amniocentesis is 0.5 percent. However, women who
have high levels of interleukin-6 (IL-6) in the amniotic fluid during the second trimester are likely
to be at high risk for postprocedure pregnancy loss that is actually related to preexisting
intrauterine inflammation rather than the procedure itself, according to this study. IL-6 is a type of
protein secreted in response to infection or inflammation. The researchers measured IL-6 levels in
stored second-trimester amniotic fluid and maternal serum samples obtained from women
undergoing genetic amniocentesis at the University of Alabama at Birmingham from 1988 to
1995, who experienced spontaneous postprocedure loss within 30 days of amniocentesis, and
from normal control women who delivered at term. They found that four times as many women
who suffered postprocedure pregnancy loss had high amniotic fluid IL-6 levels (2.5 ng/ml or
more) than women who delivered at term (12 percent vs. 3 percent). The researchers conclude
that up to 12 percent of pregnancy losses following amniocentesis may result from preexisting
subclinical intrauterine inflammation. This inflammation is most likely localized and may not be
identified by maternal preprocedure blood levels of IL-6.
Goldenberg, R.L., Cliver, S.P., Mulvihill, F.X., and others (1996). "Medical, psychosocial,
and behavioral risk factors do not explain the increased risk for low birth weight among
black women." American Journal of Obstetrics and Gynecology 175(5), pp.
Black infants are more likely to be born smaller and preterm than white infants. However, a recent
study shows that low-income white women have more risk factors for low birthweight and
premature birth than low-income black women; these risk factors include smoking, low
prepregnancy weight, and low educational level. Nevertheless, black infants weighed about 200
gm less and were born an average of 4 days earlier than white infants; 17 percent of black infants
were born preterm compared with 11 percent of white infants. These findings were based on a
sample of 1,491 pregnant black and white women who were enrolled for prenatal care between
1985 and 1988. PORT researchers compared various demographic, medical, environmental, and
psychosocial risk factors with birth outcomes. By many criteria the black women in this study had
fewer risk factors than white women—they were better educated, smoked half as much,
less frequent use of illicit drugs, generally reported better housing, scored better on psychological
testing, and were heavier than the white women. These factors, as well as the increased
hypertension among black women, only explained about one-third of the black-white differences
in birthweight. Perhaps powerful but yet unknown risk factors more prevalent among black than
white women, or some predisposition to both preterm and low birthweight infants among black
women, account for their poorer birth outcomes, conclude the researchers.
Piper, J.M., Atkinson, M.W., Mitchel, Jr., E.F., and others (1996). "Improved outcomes
for very low birth weight infants associated with the use of combined maternal
corticosteroids and tocolytics," in The Journal of Reproductive Medicine 41(9), pp.
In this study, Low Birthweight PORT researchers found that infants weighing 500 to 1,500 g
(about 1 to 3 pounds) at delivery, whose mothers received combined treatment with tocolytic
drugs to inhibit preterm labor contractions and corticosteroids to hasten fetal growth, had better
outcomes than infants born to women who received no treatment. These infants had one-third the
odds of neonatal and infant death and about half the risk of neonatal seizures (an important source
of morbidity) as infants whose mothers received no treatment (the most common approach in
Tennessee during 1989 and 1990). While steroids alone were associated with improved maternal
outcomes, the use of combined therapy was associated with better neonatal outcomes than use of
corticosteroids alone or tocolytics alone. For infants whose mothers received both treatments, the
brief additional time in utero gained by tocolysis apparently provided a window of opportunity for
the corticosteroids to act. These findings were based on a retrospective study conducted on all
infants born in Tennessee in 1989 and 1990 who weighed less than 1,500 g at birth and had no
Rouse, D.J., Owen, J., Goldenberg, R.L., and Cliver, S.P. (1996, November). "The
effectiveness and costs of elective cesarean delivery for fetal macrosomia diagnosed by
ultrasound." Journal of the American Medical Association 276(18), pp.
About 97 percent of pregnant women are not diabetic. For these women, elective cesarean
delivery of large babies weighing about 9 pounds or more (4,000 g or larger) based on ultrasound
estimates is medically and economically unsound, conclude the Low Birthweight PORT
researchers. Elective cesarean delivery of very large infants has been recommended to avoid
problems extracting the shoulders (shoulder dystocia) during vaginal delivery, which can result in
fractures and neurologic injuries. The researchers compared three policies: management without
ultrasound, ultrasound and elective cesarean delivery for estimated fetal weight of 4,000 g or
more, and ultrasound and elective cesarean delivery for estimated fetal weight of 4,500 g (about
10 pounds) or more. They found that for each permanent injury to the brachial plexus (a network
of nerves that innervate the muscles and skin of the chest, shoulders, and arms) prevented by the
4,500-g policy, 3,695 cesarean deliveries were performed at an additional cost of $8.7 million
compared with 2,345 cesarean deliveries and an additional $4.9 million with the 4,000-g policy.
Rates of cesarean delivery, shoulder dystocia, brachial plexus injury, and total costs were higher
for diabetic women with all three policies than for nondiabetic women. However, diabetic women
had more favorable ratios for both cesarean deliveries and cost per permanent injury avoided: 443
deliveries and $930,000 with the 4,500-g policy, and 489 deliveries and $880,000 with the
4,000-g policy. The researchers conclude that in pregnancies complicated by diabetes, elective
cesarean delivery of very large babies appears to be more tenable, although its merits remain
Rouse, D.J., Hauth, J.C., Nelson, K.G., and Goldenberg, R.L. (1996). "The feasibility of a
randomized clinical perinatal trial: Maternal magnesium sulfate for the prevention of
cerebral palsy." American Journal of Obstetrics and Gynecology 175(3), pp.
Premature babies have a higher risk than other newborns of developing cerebral palsy, a
neurologic disorder affecting motor function that occurs in about 2 per 1,000 live births. Because
survival of extremely premature infants has increased dramatically in recent years, the prevalence
of cerebral palsy has also risen. A few studies have indicated that intrapartum administration of
magnesium sulfate to the mother to delay preterm labor and delivery may reduce subsequent risk
of cerebral palsy in surviving preterm offspring. Although these findings are promising, a
randomized clinical trial would be most conclusive from the standpoint of establishing a causal
relationship between maternal intrapartum magnesium sulfate therapy and a decreased risk of
cerebral palsy in surviving preterm neonates. This study found, however, that such a randomized
trial would be a formidable undertaking, requiring a concerted multicenter effort. The research
team based its conclusion on a literature review used to calculate the cumulative rates of delivery,
neonatal survival, and cerebral palsy for progressively longer gestational age intervals beginning at
24 weeks gestation. The researchers calculated that in the 4-week interval from 24 to 28 weeks
of gestational age, the minimum number of neonates required to conduct a randomized trial would
be 1,189. But with loss to followup of neonates, maternal ineligibility, and failure of enrollment,
about 1 million pregnancies would be necessary to generate the necessary number of eligible
pregnant women to conduct the study.
Prostate cancer screening debate is analogous to early lung
cancer screening debate
Evidence from randomized controlled trials addressing whether screening for prostate cancer
actually reduces prostate cancer deaths may not be available for 10 to 15 years. In the meantime,
clinicians debate whether to screen now and stop later if prostate cancer screening proves
ineffective or does more harm than good, or to not screen now and start later if trials prove that
screening does more good than harm. This problem is similar to the early debate surrounding lung
cancer screening, note Mary McNaughton Collins, M.D., and Michael J. Barry, M.D., of
Massachusetts General Hospital. They reviewed published articles on lung and prostate cancer
screening and found many parallels.
Advocates of early detection of prostate cancer with digital rectal examination and
prostate-specific antigen (PSA) tests have compared prostate cancer screening with the effective
strategy of breast cancer screening, implying that prostate cancer screening should similarly
reduce cancer mortality. They also have cited the high burden of prostate cancer, the acceptable
accuracy of digital rectal examination and PSA tests, a stage shift to more localized and
potentially curable cases among men screened, and the theoretical curability of early-stage disease
as sufficient reasons to proceed with screening.
These arguments are reminiscent of early arguments in favor of lung cancer screening with chest
x-ray examination and sputum cytology, a practice ultimately proven ineffective in clinical trials.
Lung cancer screening advocates pointed enthusiastically to preliminary reports documenting a
shift toward localized, potentially curable lung cancer in screened patients relative to controls
(about 50 percent vs. 20 percent). But despite the stage shift, subsequent clinical trials did not
show a reduction in lung cancer deaths but did report problems and deaths following lung
resection for some of those screened. For this reason, the authors caution against widespread
dissemination of prostate screening without evidence from randomized controlled trials showing
that the screening does more good than harm. This work was supported in part by the Agency for
Health Care Policy and Research (Prostate Patient Outcomes Research Team-II, HS08397).
Details are in "Controversies in prostate cancer screening: Analogies to the early lung cancer
screening debate," by Drs. Collins and Barry, in the December 25, 1996, Journal of the
Medical Association 276(24), pp. 1976-1979.
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