Objective: To examine the impact of an interdisciplinary, collaborative practice intervention involving a primary care physician, a nurse, and a social worker for community-dwelling seniors with chronic illnesses.Methods: A concurrent, controlled cohort study of 543 patients in 18 private office practices of primary care physicians was conducted. The intervention group received care from their primary care physician working with a registered nurse and a social worker, while the control group received care as usual from their primary care physician. The outcome measures included changes in number of hospital admissions, readmissions, office visits, emergency department visits, skilled nursing facility admissions, home care visits, and changes in patient selfrated physical, emotional, and social functioning.Results: From 1992 (baseline year) to 1993, the two groups did not differ in service use or in self-reported health status. From 1993 to 1994, the hospitalization rate of the control group increased from 0.34 to 0.52, while the rate in the intervention group stayed at baseline (P=.03). The proportion of intervention patients with readmissions decreased from 6% to 4%, while the rate in the control group increased from 4% to 9% (P = .03). In the intervention group, mean office visits to all physicians fell by 1.5 visits compared with a 0.5-visit increase for the control group (P = .003). The patients in the intervention group reported an increase in social activities compared with the control group's decrease (P=.04). With fewer hospital admissions, average per-patient savings for 1994 were estimated at $90, inclusive of the intervention's cost but exclusive of savings from fewer office visits. Conclusions:This model of primary care collaborative practice shows potential for reducing utilization and maintaining health status for seniors with chronic illnesses. Future work should explore the specific benefit accruing from physician involvement in the collaborative practice team.

We prospectively evaluated 91 patients with involuntary weight loss. Thirty-two (35%) had no identifiable physical cause of weight loss, whereas the remainder had various physical illnesses. During the year after the index visit, 23 (25%) of the patients died and another 14 (15%) deteriorated clinically. Physical causes of weight loss were clinically evident on the initial evaluation in 55 of 59 patients. The four patients in whom the diagnosis was initially missed had cancer, and in only one of these patients was the illness truly occult. Because diagnoses were usually made rapidly in patients with a physical cause of weight loss, we conclude that involuntary weight loss is rarely due to "occult" disease. We developed a decision rule that used six attributes to correctly identify 57 of 59 patients (97%) with a physical cause of weight loss and 23 of 32 patients without. Thus, our rule may help in the early triage of patients with involuntary weight loss.

The authors investigated whether identification of corpus callosal (CC) involvement might increase the specificity of magnetic resonance (MR) imaging in differentiating multiple sclerosis (MS) from other periventricular white matter diseases (PWDs). They prospectively evaluated 42 patients with MS and 127 control patients with other PWDs. Ninety-three percent of the MS patients demonstrated confluent and/or focal lesions involving the callosal-septal interface (CSI). These lesions characteristically involved the inferior aspect of the callosum and radiated from the ventricular surface into the overlying callosum. CSI lesions were optimally demonstrated on sagittal long repetition time (TR)/short echo time (TE) images and frequently (45% of cases) went undetected on axial images. Only 2.4% of the control patients had lesions of the CC. The authors conclude that midsagittal long TR/short TE images are highly sensitive and specific for MS and that callosal involvement in MS is more common than previously reported.

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The spinal tap, or lumbar puncture, has indisputable value; opinions differ, however, on the amount of that value. The procedure has variable utility depending on the clinical indications and the results of tests on the cerebrospinal fluid. Its greatest value is in the evaluation of infectious or malignant meningitis; for most other diseases, it provides additional, but not essential, information. Because of the potential risk of the spinal tap, decisions about when to do the procedure must be made carefully. A probability analysis is provided to elucidate the usefulness of data from cerebrospinal fluid tests.