Aleda E. Lutz VA Medical Center

OVERVIEW: There are currently 22.5 million living U.S. military veterans, and this number is expected to increase dramatically as military personnel return from Iraq and Afghanistan. Although honorably discharged veterans may qualify for health care through the U.S. Department of Veterans Affairs (VA), only about 25% of all veterans take advantage of this benefit; a majority seek services in non-VA settings. It's imperative for nurses in all civilian care settings to understand the impact that military service has on veterans' health. This article provides an overview of veterans' unique health care issues, focusing particularly on traumatic brain injury, polytrauma, hazardous exposures, chronic pain, posttraumatic stress disorder, military sexual trauma, substance use disorders, suicide, and homelessness. Evidence-based assessment tools and treatment guidelines for these health issues are discussed. A resource table provides telephone numbers and Web sites offering tools, educational materials, and veteran services. A second table provides detailed veteran-centered health assessment and screening questions.

The literature surrounding health literacy and its importance in everyday practice are reviewed. Health literacy includes a patient’s reading, writing, and numeracy skills, as well as his or her cultural experiences, understanding of health concepts and pathophysiology, and basic communication skills. Over one third of the American population lack the skills necessary to understand health information, make health care decisions, or follow medication instructions. Independent risk factors for low health literacy include poor socioeconomic status, ethnicity, older age, and limited education. Mounting evidence suggests that low health literacy leads to poor health outcomes, increased mortality, increases in health care costs, and poorly self-managed chronic diseases. Communication with a pharmacist to gain clarification of medication instructions is often the last opportunity to ensure that patients understand how to use their medications appropriately. Low health literacy is not always easily recognized, as patients use well-practiced coping mechanisms or avoidant behaviors. Clear communication strategies help patients become more involved in their care plans and increase positive interactions. Tools to assess health literacy have been developed and can be used by pharmacists to guide education and counseling. Advanced methods of written and oral communication should be used to improve patient comprehension and understanding. Tools such as simple word-recognition tests or comprehensive tests of functional health literacy can be used in daily practice to assess patients’ health literacy. Being familiar with communication techniques such as the Indian Health Service, teach back, and Ask Me 3 can help facilitate individualized medication-related education and maximize patient comprehension.

•We describe a regional campaign to reduce hospital-acquired conditions.•Catheter-associated urinary tract infection (CAUTI) prevention was the first focus.•CAUTI rates significantly declined in nonintensive care units after the initiative.•Qualitative evaluation provided several themes for improving regional initiatives.•A regional collaborative appears to be a useful strategy for reducing patient harms. BackgroundEndemic health care-associated safety problems, including health care-associated infection, account for substantial morbidity and mortality. We outline a regional No Preventable Harms campaign to reduce these safety problems and describe the initial results from the first initiative focusing on catheter-associated urinary tract infection (CAUTI) prevention.MethodsWe formed a think tank composed of multidisciplinary experts from within a 7-hospital Midwestern Veterans Affairs network to identify hospital-acquired conditions that had strong evidence on how to prevent the harm and outcome data that could be easily collected to evaluate improvement efforts. The first initiative of this campaign focused on CAUTI prevention. Quantitative data on CAUTI rates and qualitative data from site visit interviews were used to evaluate the initiative.ResultsQuantitative data showed a significant reduction in CAUTI rates per 1,000 catheter days for nonintensive care units across the region (2.4 preinitiative and 0.8 postinitiative; P = .001), but no improvement in the intensive care unit rate (1.4 preinitiative and 2.1 postinitiative; P = .16). Themes that emerged from our qualitative data highlight the need for considering local context and the importance of communication when developing and implementing regional initiatives.ConclusionsA regional collaborative can be a valuable strategy for addressing important endemic patient safety problems. Endemic health care-associated safety problems, including health care-associated infection, account for substantial morbidity and mortality. We outline a regional No Preventable Harms campaign to reduce these safety problems and describe the initial results from the first initiative focusing on catheter-associated urinary tract infection (CAUTI) prevention. We formed a think tank composed of multidisciplinary experts from within a 7-hospital Midwestern Veterans Affairs network to identify hospital-acquired conditions that had strong evidence on how to prevent the harm and outcome data that could be easily collected to evaluate improvement efforts. The first initiative of this campaign focused on CAUTI prevention. Quantitative data on CAUTI rates and qualitative data from site visit interviews were used to evaluate the initiative. Quantitative data showed a significant reduction in CAUTI rates per 1,000 catheter days for nonintensive care units across the region (2.4 preinitiative and 0.8 postinitiative; P = .001), but no improvement in the intensive care unit rate (1.4 preinitiative and 2.1 postinitiative; P = .16). Themes that emerged from our qualitative data highlight the need for considering local context and the importance of communication when developing and implementing regional initiatives. A regional collaborative can be a valuable strategy for addressing important endemic patient safety problems.

OBJECTIVES: Zonisamide (1,2-benzisoxazole-3-methanesulfonamide) is a novel anti-seizure medication approved for use in the United States as adjunct therapy in the treatment of partial seizures in adults with epilepsy. It has also been used to treat other conditions including intractable pain. The aim of this study was to determine the usefulness of zonisamide in patients whose seizures were not controlled after having been treated with at least three other currently available anticonvulsant medications or in patients whose pain control was suboptimal despite the use of commonly used drug regimens. METHODS: This was a retrospective study documenting the efficacy of zonisamide in 48 consecutive patients who presented at an outpatient neurology clinic at a Veterans Administration hospital. The patients were diagnosed with refractory partial seizures (n = 21) or a variety of intractable neuropathic pain syndromes (n = 27). RESULTS: Sixteen out of 21 seizure patients (76%) experienced a 50% or greater reduction in seizure frequency when zonisamide (100-200 mg daily) was added to their existing anticonvulsant medication regimen. Of 27 patients with neuropathic pain, 17 (59%) responded to zonisamide, reporting subjective reduction in pain by at least 50%. The most common adverse events were gastrointestinal upset, somnolence, and one case of skin rash. CONCLUSIONS: In this study, zonisamide appeared to be an effective adjunct therapy in the treatment of partial seizures in adults who continued to experience frequent episodes while taking other anticonvulsant medications, and in adults whose neuropathic pain was not well controlled with analgesics. These promising results must be tempered by the fact that this investigation included a small patient population in an uncontrolled study design. Further research into the efficacy and tolerability of zonisamide in these areas is warranted.

LOGIE, JAMES W. M.D.; BISHOP, HARRY M. M.D.; BULLINGTON, DONALD C. M.D.; CHEEK, GEORGE W. JR. M.D.; CRABTREE, HODGE M.D.; FISH, JAMES C. M.D.; LILLIE, RICHARD H. M.D.; MACRIS, JACK A. M.D.; MIDDLETON, EDWIN E. M.D.; MILLER, ELMER B. M.D.; NORTHWAY, ROBERT M.D.; OREBAUCH, JOHN M.D.; RANNICK, GILBERT M.D.; RIFE, CHARLES SHERRILL M.D.; RUSSELL, SHERWOOD M.D.; THIEME, E. THURSTON M.D. Author Information

The health care needs of veterans, especially those who have served in combat zones and their families are complicated, challenging, and interrelated. Physical limitations impact mental health, and mental health problems affect every aspect of adjustment to civilian life. Comfort theory offers a simple and holistic pattern for identifying needs, creating interventions to meet those needs, and evaluating the effects of those interventions. The aim of this article is to demonstrate how comfort theory has been applied throughout 1 Veterans Administration System to fulfill the goal of providing quality veteran-centric care. The application of comfort theory to daily patient and family care, discharge planning, and follow-up in various settings, as well as ways to enhance institutional integrity and branding are discussed.

Patient rehabilitation following anterior cruciate ligament reconstruction is a continuing challenge for physical therapists. This study compared the effectiveness of an established protocol to a new program which included Protonics exercise. Sixty patient (42 males and 18 females; mean age = 24.7 +/- 3.9 years; age range = 19-30 years) were randomly assigned into two groups: Group 1 received the established protocol and Group 2 received a Protonics exercise regimen. Both groups were measured for the time needed for return to unrestricted activity on the basis of objective, functional, and clinical exams; all tests were repeated at a 1-year follow-up exam. Group 2 completed treatment an average of 3.3 weeks sooner than Group 1 (mean = 19.8 vs. 23.1 weeks) at an average lower cost of $990.00 per subject. All subjects had good functional outcomes at the 1-year follow-up exam. It was concluded that the Protonics exercise program was more clinically and cost-effective than the other program, although both methods were successful for postsurgical anterior cruciate ligament rehabilitation.

This study was an investigation into the influences of rehabilitation procedures on the long-term success of postsurgical knee patients. In a blind retrospective paradigm, the cases of 5,381 patients (2,417 females, 2,964 males; mean age, 32.7 years; age range, 13 to 61 years) were reviewed to correlate rehabilitation methods with postsurgical success. Postsurgical success was defined as patient resumption of required activities without symptom recurrence, over a period of 5 years after surgery. The four rehabilitation methods studied were programs of no exercise, home exercise, isotonic exercise, and isokinetic exercise. Statistical analysis revealed significant differences at the P = 0.05 level for comparison of the isokinetic exercise to the other methods on the basis of rehabilitation interval (isokinetic, 8.9 +/- 3.7 weeks; isotonic, 12.3 +/- 6.1 weeks; home, 10.0 +/- 4.5 weeks) and correlation to success (isokinetic, r = 0.92, isotonic, r = 0.48, home, r = 0.09, no exercise, r = 0.00). It was concluded that rehabilitation methods that incorporate isokinetic exercise are more efficient and effective than nonisokinetic programs in the long-term successful management of postsurgical knee patients.

Infections occur among all clinical domains. The changing nature of microbes, viruses and infections poses a great threat to the overall well-being in medicine. Clinicians in the infectious disease (ID) domain deal with diagnostic as well as treatment uncertainty in their everyday practice. Our current health information technology (HIT) systems do not consider the level of clinician expertise into the system design process. Thus, information is presented to both novice and expert ID clinicians in identical ways. The purpose of this study was to identify the cognitive strategies novice ID clinicians use in managing complex cases to make better recommendations for system design. In the process, we interviewed 14 ID experts and asked them to give us a detailed description of how novice clinicians would have dealt with complex cases. From the interview transcripts, we identified four major themes that expert clinicians suggested about novices' cognitive strategies including: A) dealing with uncertainty, B) lack of higher macrocognition, C) oversimplification of problems through heuristics and D) dealing with peer pressure. Current and future innovative decision support tools embedded in the electronic health record that can match these cognitive strategies may hold the key to cognitively supporting novice clinicians. The results of this study may open up avenues for future research and suggest design directions for better healthcare systems.

Case Reports1 March 1960FATAL METHEMOGLOBINEMIA DUE TO WELL WATER NITRATESROBERT BUCKLIN, M.D., F.A.C.P., M. K. MYINT, M.D.ROBERT BUCKLIN, M.D., F.A.C.P.Search for more papers by this author, M. K. MYINT, M.D.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-52-3-703 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptAmong the many causes of acquired methemoglobinemia, that due to ingestion of well water containing high levels of nitrates is an entity one should consider in a cyanotic infant with a negative history and physical findings. Some other causes of methemoglobinemia are aniline, phenacetin, acetanilid, sulfonamides, nitrobenzene, various nitrites, nitroglycerin, bismuth subnitrate, ammonium nitrates, contact with dyed blankets, laundry marks on diapers, freshly dyed shoes, inhalation of nitrous gases in arc welding, and ingestion of crayons containing p-nitroaniline.5Methemoglobin is a derivative of hemoglobin, where ferrous porphyrin complex is converted to the ferric form, which does not combine with oxygen.3...Bibliography1. : Water supply: nitrate in potable waters and methemoglobinemia, A. P. H. A. Yearbook 40, 5: 110 (May) 1949-1950. Google Scholar2. CornblathHartman MAF: Methemoglobinemia in young infants, J. Pediat. 33: 421-425 (Oct.) 1948. CrossrefMedlineGoogle Scholar3. Finch CA: Methemoglobinemia and sulfhemoglobinemia, J. Clin. Investigation 28: 265, 1949. MedlineGoogle Scholar4. LembergLegge RJW: Hematin compounds and bile pigments, 1949, Interscience Publications, Inc., New York, quoted by Wintrobe.5 Google Scholar5. Wintrobe M: Clinical hematology, 4th Ed., 1956, Lea and Febiger, Philadelphia, pp. 174-176. Google Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: Saginaw, Michigan*Received for publication October 16, 1958.From the Department of Pathology, Saginaw General Hospital, Saginaw, Michigan.Requests for reprints should be addressed to Robert Bucklin, M.D., 1447 North Harrison Street, Saginaw, Michigan. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited ByAcute Methemoglobinemia Following Attempted Suicide by DapsonNoninvasive in vivo monitoring of methemoglobin formation and reduction with broadband diffuse optical spectroscopyMethemoglobinemiaUnexplained acute severe methaemoglobinaemia in a young adultExperimental Studies of Methemoglobinemia Due to Percutaneous Absorption of Sodium NitriteFatal Methemoglobinemia Caused by Liniment Solutions Containing Sodium NitriteMethemoglobinemia Caused by the Accidental Contamination of Drinking Water with Sodium NitriteSaltpeter ingestionAmyl nitrite-induced hemolytic anemiaAmmonium nitrate cold pack ingestionHematologic Aspects of ToxicologyDrug- and Chemical-Induced MethaemoglobinaemiaMethemoglobin levels in the patient population of an acute general hospitalMethemoglobinemiaFatal Methemoglobinemia Resulting from Ingestion of Isobutyl Nitrite, a “Room Odorizer” Widely Used for Recreational PurposesThe Metabolism of Methemoglobin in Human ErythrocytesNitrates, nitrites, and methemoglobinemiaMethemoglobinemia from Well Water Nitrates: A Complication of Home DialysisDAVID J. CARLSON, M.D., FRED L. SHAPIRO, M.D.Successful Treatment of Methemoglobinemia Secondary to Silver Nitrate TherapyReproduction in the guinea pig as affected by chronic administration of potassium nitrate and potassium nitrite 1 March 1960Volume 52, Issue 3Page: 703-705KeywordsHemoglobinInfantsIngestionMethemoglobinemiaNitratesOral administrationPancreasPorphyrinsRespirationSulfonamide Issue Published: 1 March 1960 PDF DownloadLoading ...

We examined the incidence of health problems in elite-level amateur boxing athletes who sparred, trained, or competed at the United States Olympic Training Center in Colorado Springs, Colorado from January 1, 1977 through June 30, 1992. We think this is the first study to examine both injuries and illnesses in a population of elite-level athletes. We collected data on 1,776 reported problems (1219 injuries, 557 illnesses) from standard medical report forms completed by the permanent and volunteer sports medicine staff. We classified the information based on type, body region, location, description, and occurrence. There were significant differences between the frequency of injuries and illnesses and between the classifications and regions for each type of problem. Collectively, serious injuries represented only a relatively small percentage (6.1%) of all problems. We concluded that illnesses comprised a small but important portion of problems, that most illnesses involved respiratory tract infections (71%), that there is only a small risk for serious injury, and that injuries occur in a hierarchy of upper extremity (441, 25%), head/face (344, 19%), lower extremity (267, 15%), and spinal column (167, 9%) for amateur boxers.

BACKGROUND: Outcomes data on the use of cerebral embolic protection devices (CPDs) with transcatheter aortic valve replacement (TAVR) remain limited. Previous randomized trials were underpowered for primary outcomes of stroke prevention and mortality. METHODS: The National Inpatient Sample and Nationwide Readmissions Database were queried from 2017 to 2018 to study utilization and inpatient mortality, neurological complications (ischemic stroke, hemorrhagic stroke, and transient ischemic attack), procedural complications, resource utilization, and 30-day readmissions with and without use of CPD. A 1:3 ratio propensity score matched model was created. RESULTS: Among 108,315 weighted encounters, CPD was used in 4380 patients (4.0%). Adjusted mortality was lower in patients undergoing TAVR with CPD (1.3% vs. 0.5%, p < 0.01). Neurological complications (2.5% vs. 1.7%, p < 0.01), hemorrhagic stroke (0.2% vs. 0%, p < 0.01) and ischemic stroke (2.2% vs. 1.4%, p < 0.01) were also lower in TAVR with CPD. Multiple logistic regression showed CPD use was associated with lower adjusted mortality (odds ratio (OR], 0.34 [95% confidence interval [CI], 0.22-0.52), p < 0.01) and lower adjusted neurological complications (OR, 0.68 (95% CI, 0.54-0.85], p < 0.01). On adjusted analysis, 30-day all-cause readmissions (Hazard ratio, HR 0.839, [95% CI, 0.773-0.911], p < 0.01) and stroke (HR, 0.727 [95% CI, 0.554-0.955), p = 0.02) were less likely in TAVR with CPD. CONCLUSION: We report real-world data on utilization and in-hospital outcomes of CPD use in TAVR. CPD use is associated with lower inpatient mortality, neurological, and clinical complications as compared to TAVR without CPD.

As the prevalence of chronic obstructive pulmonary disease (COPD) continues to grow, management of the disease still faces considerable challenges. Despite the existence of effective pharmacological treatments, patient adherence is often poor. Side effects of medications and patients' concerns about potential side effects may contribute to poor adherence. Situated as they are at the frontline of patient care in the clinic, nurse practitioners play an important role in the management of COPD. This review discusses the current literature on medications available for management of COPD, focusing primarily on their safety and tolerability. This information can be particularly important for nurse practitioners, who can be invaluable in identifying side effects, and providing education to patients with COPD on the available treatments and the associated side effects. By helping patients to understand the balance of benefits and risks of treatment, nurse practitioners may be able to help improve adherence and thereby improve patient outcomes.

Athletes with shoulder problems are commonly referred to orthopaedic and sports physical therapists for rehabilitation. Many of these problems include some form of shoulder instability. The purpose of this study was to generate an isokinetic torque curve that is representative of the shoulder impingement syndrome that may affect high school baseball pitchers. A sample of 241 subjects, each diagnosed with an impingement syndrome in the right shoulder, was tested using a Cybex II+ dynamometer configured to duplicate the orthopaedic loose-packed and plane of the scapula positions of the shoulder complex. The subjects were tested concentrically across five maximal repetitions of internal and external rotation at the speeds of 60, 120, 180, 240, and 300 degree/sec; graphic records were collected at 60 degrees/sec. Descriptively, testing revealed a distinct isokinetic torque curve for the impingement syndrome compared with the noninvolved shoulder. This information might serve as a useful complement to traditional clinical procedures for the diagnosis of the shoulder impingement syndrome.

BACKGROUND AND OBJECTIVE: To analyze patients with chronic acalculous cholecystitis over ten years, during which laparotomy was replaced by laparoscopy as the dominant operation for cholecystectomy in regard to patient demographics, diagnostic evaluations, follow-up symptoms, and additional operations. METHODS: Of 7181 cholecystectomies from June 1985 to June 1995, 301 patients had chronic acalculous cholecystitis. All subsequent hospital admissions and emergency room visits were reviewed through May 1997. Office records were available for review in 158 cases. Two eras were defined, the open era from June 1985 through May 1990, and the laparoscopic era from June 1990 through June 1995. RESULTS: Twice as many patients with chronic acalculous disease underwent cholecystectomy after the advent of laparoscopy. Patients with chronic acalculous disease were significantly younger than patients with cholelithiasis in both open and laparoscopic cases. The percentage of white women increased from 64.7% in the open to 75.7% in the laparoscopic era (p<0.05). The numbers of preoperative diagnostic tests performed decreased from 4.7+/-2.4 in the open to 3.2+/-1.8 in the laparoscopic era (p<0.05). Twenty-two percent of patients had continued symptoms postoperatively, and 8 patients (2.7%) required other abdominal operations within one year of cholecystectomy. CONCLUSION: Chronic acalculous cholecystitis is a disease of white females, doubling in frequency over the decade of review. Of these, 78% of patients had resolution of their symptoms on long-term follow-up.

Precise reporting of surgical staging and operative data in multi-institutional protocol studies could provide a number of benefits: 1) fewer cases would be discarded because of inadequate data, 2) staff review time would be reduced, 3) there would be assurance that participating surgeons were performing similar operations on similar tumors, 4) the resulting precision in stratification should improve the likelihood of achieving accurate comparison of the treatment options under study, and 5) by comparing the surgical parameters with local-regional control of disease, the specific factors that have a statistically significant correlation with outcome could be identified. This paper presents a computer-based, anatomically oriented reporting instrument that should improve the reliability of surgical data available to multi-institutional protocols.

STEWART, WAYNE H. M.D.; BARTLETT, ROBERT M. M.D.; BISHOP, HARRY M. M.D.; CAMPBELL, DARRELL A. M.D.; GOLDSMITH, NEAL A. M.D.; MACLEAN, KENNETH M.D.; MIDDLETON, EDWIN A. M.D.; MUSSELMAN, MERLE M.D.; RANNICK, GILBERT M.D.; TAPPAN, WILLIAM M.D. Author Information

BACKGROUND: A mismatch between organizational priorities and system-level policies can negatively impact implementation and sustainment of classroom-based physical activity (PA) interventions. The purpose of this study was twofold: (1) present methods to systematically identify organization- and system-level implementation barriers, and (2) align organizational priorities and system policies by designing multi-level implementation strategies. This alignment will support implementation scale-up of a tailored PA intervention in one low-resource intermediate school district (ISD; 16 districts, 32 schools) in central Michigan. METHODS: Multi-level assessments of organizational readiness were conducted using the Hexagon Discussion and Analysis Tool to assess intervention-context fit, the Wellness School Assessment Tool 3.0 to evaluate district PA policy strength and comprehensiveness, and semi-structured interviews were conducted to assess administrative support and priorities related to PA programming. RESULTS: Our assessments revealed three implementation barriers: limited structural capacity to sustain teacher training, limited resources across districts and school buildings to support teachers, and misalignment of ISD and district PA policies and priorities. CONCLUSIONS: Greater attention to organizational capacity and existing infrastructure should be considered a priori to support effective implementation and sustainment of PA interventions in low-resource schools.

BACKGROUND: The Veterans Health Administration (VHA) does not routinely collect and document sexual orientation and gender identity (SOGI) data despite research on health disparities among sexual and gender minority (SGM) veterans. Due to the legacy of previous Department of Defense policies that prohibited disclosure of sexual or gender minority identities among active-duty personnel, minority veterans may be reluctant to respond to SOGI questions on confidential VHA surveys and in discussions with their VHA providers. Veterans may generally find SOGI questions uncomfortable and may not appreciate their relevance to health care. OBJECTIVE: The purpose of this research was to examine veterans' comfort in reporting identity characteristics on confidential VHA surveys and in discussion with their VHA providers and whether comfort differed by sociodemographic characteristics. RESEARCH DESIGN: The project involves the secondary analysis of quantitative data from a quality improvement survey project. SUBJECTS: A total of 806 veterans were surveyed. RESULTS: Overall, 7.15% endorsed sexual or gender minority identity which is a higher rate than the 4.5% noted in the general US population. Cisgender and heterosexual veterans were more comfortable reporting identity characteristics both on VHA confidential surveys and in discussion with VHA providers compared with SGM veterans. CONCLUSIONS: These data suggest that the majority of veterans feel comfortable reporting their identities both on surveys and in the context of health care. Understanding these perceptions can assist VHA programs in implementing SOGI data collection and disclosure in clinical care, creating a welcoming environment of care for SGM veterans that does not make veterans from other backgrounds feel uncomfortable.

OBJECTIVE: To examine drug expenses and overall health care resource utilization associated with a calcium channel blocker therapeutic interchange and conversion program. DESIGN: A pre/post analysis involving a retrospective cohort study design and primarily using administrative databases was done. The study was conducted from an institutional perspective using hospital-specific drug acquisition costs in 1997 dollars. SETTING: Veterans Administration Hospital, Saginaw, Michigan. PATIENTS: One hundred and one patients receiving extended-release nifedipine (Procardia XL) were converted to either amlodipine (Norvasc) or felodipine (Plendil) through the institution's conversion program. MAIN OUTCOME MEASURES: Change in total drug cost, secondary health resource utilization, study drug costs, cardiovascular drug costs, noncardiovascular drug costs, and change in severity of hypertension. RESULTS: Unexpectedly, the total cost of drug therapy was significantly higher during the nine-month postconversion period relative to the nine-month preconversion period (pless than0.001). Neither the total number of clinic visits nor the number of hospitalizations (cardiovascular or noncardiovascular) differed significantly between the preconversion and postconversion periods. No significant differences in the grade of hypertension was observed from the preconversion period to the postconversion period, although there were statistically significant drops in both systolic (mean reduction of 7.5 mm Hg; pless than0.001) and diastolic blood pressures (mean reduction of 5.6 mm Hg; pless than0.001). CONCLUSIONS: The increased drug expenses and significant change in blood pressure appear to have been due to an increased number of prescriptions filled in the postconversion period relative to the preconversion period. Further study is warranted to determine whether this unexpected finding was due to a pharmacological factor such as improved tolerability of the medications or to an effect of the process of conversion itself.