Obesity appears to be more prevalent in adults with sensory, physical, and mental health conditions. Health care practitioners should address weight control and exercise among adults with disabilities.

To compare the accuracy of dermatologists and primary care physicians (PCPs) in identifying pigmented lesions suggestive of melanoma and making the appropriate management decision to perform a biopsy or to refer the patient to a specialist.Data Sources: Studies published between January 1966 and October 1999 in the MEDLINE, EMBASE, and Can-cerLit databases; reference lists of identified studies; abstracts from recent conference proceedings; and direct contact with investigators. Medical subject headings included melanoma, diagnosis, screening, primary care, family practitioner, general practitioner, internal medicine, dermatologist, and skin specialist. Articles were restricted to those involving human subjects.Study Selection: Studies that presented sufficient data to determine the sensitivity and specificity of dermatologists' or PCPs' ability to correctly diagnose lesions suggestive of melanoma and to perform biopsies on or refer patients with such lesions.Data Extraction: Two reviewers independently ab-stracted data regarding the sensitivity and specificity of the dermatologists and PCPs for diagnostic and biopsy or referral accuracy. Disagreements were resolved by discussion. The quality of the studies was also evaluated.Data Synthesis: Thirty-two studies met inclusion criteria; 10 were prospective studies. For diagnostic accuracy, sensitivity was 0.81 to 1.00 for dermatologists and 0.42 to 1.00 for PCPs. None of the studies reported specificity for dermatologists; one reported specificity for PCPs (0.98). For biopsy or referral accuracy, sensitivity ranged from 0.82 to 1.00 for dermatologists and 0.70 to 0.88 for PCPs; specificity, 0.70 to 0.89 for dermatologists and 0.70 to 0.87 for PCPs. Receiver operating characteristic curves for biopsy or referral ability were inconclusive. Conclusions:The published data are inadequate to demonstrate differences in dermatologists' and PCPs' diagnostic and biopsy or referral accuracy of lesions suggestive of melanoma. We offer study design suggestions for future studies.

Risk adjustment (RA) consists of a series of techniques that account for the health status of patients when predicting or explaining costs of health care for defined populations or for evaluating retrospectively the performance of providers who care for them. Although the federal government seems to have settled on an approach to RA for Medicare Advantage programs, adoption and implementation of RA techniques elsewhere have proceeded much more slowly than was anticipated. This article examines factors affecting the adoption and use of RA outside the Medicare program using case studies in six U.S. health care markets (Baltimore, Seattle, Denver, Cleveland, Phoenix, and Atlanta) as of 2001. We found that for purchasing decisions, RA was used exclusively by public agencies. In the private sector, use of risk adjustment was uncommon and scattered and assumed informal and unexpected forms. The most common private sector use of RA was by health plans, which occasionally employed RA in negotiations with purchasers or to allocate resources internally among providers. The article uses classic technology diffusion theory to explain the adoption and use of RA in these six markets and derives lessons for health policy generally and for the future of RA in particular. For health policy generally, the differing experiences of public and private actors with RA serve as markers of the divergent paths that public and private health care sectors are pursuing with respect to managed care and risk sharing. For the future of RA in particular, its history suggests the need for health service researchers to consider barriers to use adoption and new analytic technologies as they develop them.

Certification SIR,-I am pleased to see that the Ministry of Pensions and National Insurance will soon no longer require healthy patients to waste our surgery time by attending for the sole purpose of obtaining final certificates.Is it too much to hope that a similar common-sense attitude will prevail over forms F.W.8 and Mat.B. 1 (which certify on two different occasions to the same office that the same patient is in the same condition) and that they will now be combined ?-I am, etc., Warrington.

No abstract