Morris F. Collen

Pain Tolerance: Differences According to Age, Sex and Race

The nature and extent of group differences in pain tolerance according to age, sex and race were examined. The method of pain tolerance determination was mechanical pressure on the Achilles tendon, performed on 41 , 119 subjects as part of the Kaiser-Permanente Automated Multiphasic Screening examination. The results showed that, on the average, a) pain tolerance decreases with age; b) men tolerate more pain than women; and c) Whites tolerate more pain than Orientals, while Blacks occupy an intermediate position. When the results of this study are compared with earlier work, it appears that, with increasing age, tolerance to cutaneous pain increases and tolerance to deep pain decreases.

Smoking Habits and the Leukocyte Count

In 86,488 multiphasic examinations, mean leukocyte counts were highest in cigarette smokers, intermediate in ex-cigarette and cigar or pipe smokers, and lowest in nonsmokers. Among the races, whites had the highest, yellows next, and blacks the lowest leukocyte counts. The leukocyte count was related to quantity smoked, inhalation, and smoking duration. Most groups who changed smoking habits showed corresponding changes in leukocyte counts. Higher leukocyte counts in smokers appeared largely to be a direct effect of smoking, although a small part of the increase seemed attributable to chronic bronchitis. A contribution of genetic or constitutional differences between smokers and nonsmokers was not ruled out. “Normal” leukocyte count values should take into account age, sex, race, and smoking status.

Evaluating periodic multiphasic health checkups: a controlled trial.

Abstract In 1964 a controlled trial was initiated to evaluate the effectiveness of a program of urging subjects to take periodic multiphasic health checkups (MHCs) in preventing or postponing morbidity, disability, and mortality. A group of over 5000 Kaiser Foundation Health Plan members aged 35–54 at entry to the study has been urged to take MHCs annually. Along with a comparable group of members not so urged, these subjects have been followed for 11 years. Use of outpatient clinic services, other than those services forming part of the MHC was similar in the urged (study) group and in non-urged (control) group. Overall, hospital use was also similar in the two groups. There was no difference between the overall groups in self-reported disability. However, selfreported disability was significantly less common in the older study group men (aged 45–54 at entry), largely due to less disability from hypertension complications, ischemic heart disease, and back conditions. This provides a hypothesis as to a beneficial effect in a specific age-sex group that should be tested further. Mortality from a set of conditions hypothesized in advance to be most postponable or preventable through periodic MHCs was significantly lower in the study group as a whole, primarily due to fewer deaths from hypertension complications and colorectal cancer. On the other hand, suicides and lympho-hematopoietic cancer deaths were significantly more common in the study group, though reanalysis of the data revealed little relationship between these latter death rates and actual MHC exposure. Total mortality, from all causes combined, was slightly lower in the study group, but this difference was not statistically significant. Though the prevalence of a number of disability and mortality risk factors was somewhat higher in the control group at entry, adjustment for these differences did not eliminate the statistically significant control group excesses in disability (older men only) and potentially postponable cause mortality. With regard to processes by which increased study group MHC exposure may have caused the observed health outcome differences, there was more identification and treatment of hypertension, hyperlipidemia, cigarette smoking, obesity, and diabetes in the study group, though the differences were not large. There also was a trend toward earlier diagnoses of colorectal cancer in the study group, due mostly to MHC-related sigmoidoscopy. When the economic impact of all major health-related events was estimated for the older men in the 1965–1975 period, there was a net difference of over

Evaluation of an ambulatory medical-care delivery system.

2100 per man, favoring the study group. The health outcome rates for the women and the younger men indicated that there would be no savings for these other study group subjects, were similar cost analyses to be made.

3. Outpatient clinic utilization, hospitalization, and mortality experience after seven years☆

We designed a medical-care-delivery system specifically to relieve the impaired access to care that has invariably assompanied the elimination of personal fees by prepaid plans, Medicare and other third-party payment plans. The solution involved the entry of patients through a paramedically staffed health-evaluation servece that effectively separated patients into three basic health-status groups-the well and worried well (68.4 per cent); the asymptomatic sick (3.9 per cent); and the sick (27.7 per cent)--a process that permitted matching the needs of each group with appropriate services. The system achieved increased physician accessibility to new patients by 20 times, reduced the waiting time for new appointments from six to eight weeks to a day or two, saved physician time and costs for entry work to a day or two, saved physician time and costs for entry work-up by 70 to 80 per cent reduced total resources used throughout the year by +32,550 per 1000 entrants, and proved very satisfactory to patients and generally so to staff.

Sigmoidoscopy and mortality from colorectal cancer: The kaiser permanente multiphasic evaluation study☆

The Multiphasic Checkup Evaluation Study is a controlled clinical trial aimed at testing the efficacy of periodic Multiphasic Health Checkups in preventing or postponing illness, disability, and death. This paper reports on outpatient clinic utilization, hospitalization, and mortality experience of the study group subjects, who have been urged to undertake annual checkups, and of the control group subjects, who were not so urged, after the first seven years of the project effort. While there has been little difference in utilization of outpatient physician and laboratory services other than those directly connected with the Multiphasic Health Checkups, the study group subjects have had more diagnoses made. Among the men ages 45–54 at entry, hospital usage has been slightly lower in the study group, while the opposite has been the case among the women ages 45–54 at entry. The overall mortality rate has been slightly lower in the study group, while, for a group of causes of death defined as being potentially postponable or preventable, the study group mortality rate has been significantly lower (p < 0.05). There is no strong indication that chance fluctuation, underreporting, differentially selective loss to followup, or an initial study-control group health status disparity accounted for this last difference.

Dollar Cost per Positive Test for Automated Multiphasic Screening

The Kaiser Permanente Multiphasic Evaluation Study is often cited as evidence from a randomized trial that screening sigmoidoscopy reduces mortality from colorectal cancer. To examine the role of sigmoidoscopy in this reduction, we reviewed the 110 incident cases of colorectal cancer occurring among the 10,713 subjects from randomization in 1964 through 1982. Tumor stage at diagnosis, location, mode of discovery, and current mortality status were determined for each. We also reanalyzed chart review data for the years 1965 through 1974 to assess the difference in exposure to sigmoidoscopy between groups. Study group subjects, who were urged to have annual multiphasic health checkups (MHC), had both a lower cumulative incidence (4.3 vs 6.7 cases per 1000 persons) and a better stage distribution (86 vs 54% Stage B or better) than nonurged control subjects for colorectal cancers arising within reach of the sigmoidoscope. The lowered incidence accounted for two-thirds of the total difference in mortality. No appreciable difference in removal of colorectal polyps was seen between groups. Only a slight excess in exposure to sigmoidoscopy was seen in the study group (30 vs 25% of subjects examined at least once between 1965 and 1974), which was unlikely to account for more than a small fraction of the study groups decrease in mortality. Although the Multiphasic Evaluation Study did find a significantly lower mortality from colorectal cancer in the study group, it did not achieve a substantial difference in exposure to sigmoidoscopy. Its results are therefore inconclusive with respect to sigmoidoscopy and should not be used as evidence either for or against sigmoidoscopic screening.

General requirements for a Medical Information System (MIS).

Abstract The costs to identify a clinically important test by an automated multiphasic screening program provide useful information in planning for a specified target population. When 44,663 multip...

Towards automated medical decisions

Abstract The general requirements for planning and implementing a medical information system are extensive. Extraordinary requirements exist for capital, personnel and organization. The stringent requirements for high reliability and user utility for a real time system greatly increase hardware and software needs. The magnitude of the system necessitates careful time scheduling and modular implementation.

1. Methods and population

Abstract A computer algorithm is presented which will automatically develop a branched testing sequence to aid in medical decision making. The sequence is developed using the symptoms and test results of previously diagnosed patients. Data from one year of Kaiser-Permanente multiphasic screening program were used to demonstrate the technique for identifying patients with previously unrecognized diabetes mellitus. The branched testing sequence and two possible decision rules are presented.