whether cost is one of the considerations which physicians take into account when they order laboratory tests, we surveyed a random sample of 4th year students, interns, 3rd year residents, and attending staff (faculty) at McGill teaching hospitals. The survey included a series of questions involving a brief presentation of a clinical problem, and required the respondent to decide whether he or she would order a specific laboratory test. The following is an example. A 32-year-old, previously healthy male complains of a productive cough of 6 days, mild fever and malaise. He has rales in the left base, temp. 1010 F., HR 100 regular. He is otherwise well, and the Temainder of the physical exam is normal. Would you order a chest x-ray for this patient: a) if the chest x-ray cost $5. b) if the chest x-ray cost $15. c) if the chest x-ray cost $30. d) if the chest x-ray cost $60. e) if the chest x-ray cost more than $60. f) would not order a chest x-ray. The reader may wish to select an answer before proceeding. Respondents were categorized as "cost conscious" if responses a) through d) were selected, and "clinically absolute" if either e) or f) was selected. To this question more than half the respondents indicated that they would order a chest x-ray only if the cost were less than a specified dollar amount. The attending staff and more senior trainees tended to be less influenced by questions of cost. Perhaps the most striking finding was the extent of the disagreement between the clinically absolute physicians in their approach to these problems. Of the clinically absolute, 57% would have done

the chest x-ray at any cost, and 43 % would not have ordered the chest x-ray. The disagreement was evident even within specialities. This evidence suggests that physicians do not fully understand which diagnostic tests are likely to be helpful and reinforces the argument that more research is needed to solve some very elementary problems in medical care. Physicians in this survey were asked to estimate the actual costs of the laboratory tests used in the 11 clinical situations. Hospital administrators were asked to provide actual costs. Although the latter were very cooperative, these figures were not readily available, and discrepancies between and within hospitals were apparent. However, after considerable effort, actual cost figures were obtained. Mean estimates of cost for most tests were 30% to 300% higher than actual costs. The high cost estimates were seen, as well, in the subgroup of physicians at the hospitals that had initiated the educational programs. It is clear that physicians do not know the costs of laboratory tests they order, and that they believe the cost is much greater than it actually is. We concluded from this survey: * Physicians may take cost into account when ordering laboratory tests. * There is considerable disagreement, even within specialties at a single teaching institution, about the need for ancillary diagnostic information. * Physicians markedly overestimate the actual cost of laboratory tests. Moreover, those least certain about the actual costs of tests seemed to be the administrators of the hospitals surveyed and in some cases the laboratory directors. Who will render the physician cost-conscious?

Practical steps toward cost control

HALOG CREAM Halclnonide 0.1% Halog Cream (halcinonide, 0.1%) is intended for use as an anti-inflammatory a9ent for topical application. Halo9 Cream, 0.1%, provides 0.1% halcinonede, in a specially formulated waterwashable base consisting of .iyceryImonostearate, cetyl alcohol, myristyl stearate, isopropyl palmitate, polysorbate 60, and propylene glycol. ACTION: Haiog Cream, 0.1%, produces significant or complete therapeutic responses in patients with acute or chronic corticosteroid-responsive dermatoses. INDICATIONS: Habg Cream, 0.1%, is indicated for topical application for relief of the many acute or chronic corticosteroid-responsive dermatoses. CONTRAINDICATIONS: Turberculous, fungal and most viral lesions of the skin (including herpes simplex, vaccinia and varicella). Haiog Cream is not intended for use in the eye nor in the external auditory canal of patients with perforated eardrums. WARNINGS: Systemic side effects may occur and must be kept in mind particularly during use over large areas or for an extended period of time. Occasionally, symptoms of steroid withdrawal may deveiop when the medication is stopped after proionged use. Pregnancy: Safety has not been established. Potential benefit should be weighed against possible hazard. PRECAUTIONS: If local infection (other than those cited in CONTRAINDICATIONS) exists, suitable concomitant antimicrobial therapy should be administered. If a favourable response does not occur promptly, application of the corticosteroid should be discontinued until the infection is adequately controlled by approrriate measures. ocal irritation or sensitization deveiops, halcinonide cream should be discontinued.

Occlusive Dressing Technique: The use of occlusive

dressings increases the percutaneous absorption of corticosteroids and the possibility of systemic effects. For patlents with extensive lesions it may be preferable to use a sequential approach. The patient should be kept under close observation during proionged occlusive therapy. Thermal homeostasis may be impaired if large areas of the body are occluded. Occasionally, a patlent may deveiop a sensitivity reaction to a particular occlusive dressing material or adhesive. If infection deveiops, discontinue the use of the occlusive dressings and institute appropriate antimicrobial therapy. ADVERSE REACTIONS: Significant local irritation is uncommon; a transient burnin9 sensation may occur in some patients. The use of corticosteroids under occlusive dressings is known to produce miliaria, folliculitis, pyoderma, or localized cutaneous atrophy; striae occasionally deveiop. Erythema, dryness, itching and change in skin pigmentation have been reported with topical steroids.

SYMPTOMS AND TREATMENT OF OVERDOSAGE:

Mild, reversible suppression of adrenal function, ecchymoses of the skin, peptic ulceration, hypertension, aggravation of infection, hirsutism, acne, edema and muscle weakness due to protein depletion are all toxic symptoms of corticosteroids. Animal studies suggest that overdosage may result in swollen breasts or lactation. Treatment is symptomatic; corticosteroid administration should be discontinued.

DOSAGE AND ADMINISTRATION: Usual adult dosage range: 2 to 3 applications dally.

STANLEY SINCLAIR, MD

There seems to be no disincentive to ordering lab tests in Canadian hospitals; especially so in teaching hospitals. The lines about serum rhubarb are tiresome but overuse continues. Certainly the places that have more sophisticated and expensive tests available without impediment are considered to be more desirable training centres. Among the tests available at a hospital, almost unlimited discretion is given to the medical staff, and rarely is one chided for irrelevant investigation. On the other hand, woe to the house officer who doesn't know the results of Dr. Sinclair is a family physician at Herzl family practice centre, Jewish General Hospital, Montreal.

Occlusive Dressing Technique: Gently rub a small

tests, seemingly chosen at random, when the chief does his rounds. In fact, anyone accountable to some chieflike figure in the wardsmanship game had best be sure that all bets are covered. Remember, this new admission had a headache and maybe he'll have an LP, and maybe there'll be pus and a negative culture, and that can mean bacterial endocarditis - so beside the 6-hourly blood cultures I'm going to order, I'd better also order a rheumatoid factor because sometimes it's positive in SBE. This scenario is improbable, 'but should it happen the test orderer would never be found out and set right, because the institution he

1060 CMA JOURNAL/MAY 7, 1977/VOL. 116

amount of the Halog Cream, 0.1%, into the lesion until the cream disappears. Then re-apply the cream, leaving a thin coating on the lesion and cover with a pliable non-porous film. Gcod results have been obtalned by applying Haiog Cream, 0.1%, under occlusion in the evening and reapplying Halog Cream, 0.1%, without occlusion in the moming (i.e. - 12-hour occlusion). Reapplication of the preparation is essential at each dressing change. DOSAGE FORMS: Haiog Cream is supplied as cream formulation contalning 0.1% halcinonide, in tubes of 15, 30 and 60 g. STORAGE: Store at room temperature. Avoid freezing. Avoid prolonged storage at temperatures exceeding 30'C. Product monograph available to physicians and pharmacists on request. References: 1. Data on file, Squibb Institute of Medical Research. 2. Sudilovsky A, Clewe TH: J Clin Pharmacol 15:779-784, 1975.3. Clark RF, Clement ER:Arch Derrnatol 111:731-733,1975. E R. SQUIBB & SONS LTD. ED 2365 COTE DE LIESSE, MONTREAL, QUE. H4N 2M7

VELOSEF 250 CAPSULES VELOSEF 500 CAPSULES Cephradlne Capsules VELOSEF 125 FOR ORAL SUSPENSION VELOSEF 250 FOR ORAL SUSPENSION Cephradlne for Oral S.aspenslon VELOSEF FOR INJECTION, 500 mgand 1.0 g Cephradlne for Injection ACTION: Cephradine is a semi-synthetic, cephalosporin antibiotic eshibiting bactericidal activity through inhibition ot cell-wall synthesis. INDICATIONS: Infections in the respiratory and genitourinary tracts, and in the skin and soft tissues, due to susceptible organisms. Sensitivitytests should be pertorined: therapy may be instituted betore receiving the results. CONTRAINDICATIONS: Hypersensitivity to the cephalosporin group ot antibiotics. WARNINGS: There is evidence 01 partial cross-allergenicity between the penicillins and the cephalosporins. Therefore, cephradine should be used with caution in patients with known hypersensitivity to penicillins. Anftbiotics, including cephradine. should be used citubouslyandonly when absolutely necessary in patients with a history ot allergies, particularly to drugs. Usage during pregnancy and lactahon: Safety for use of this product during pregnancy has not been established. Cephradine is secreted in breast milk. PRECAUTIONS: Patients should be observed carefully dunng therapy. Allergic reactions require discontinuation of VELOSEF and appropriate treatment. Prolonged use of VELOSEF may result in overgrowth of nonsusceptible organisms: appropriate measures should be instituted. During long-term therapy, hematology, renal and hepatic functions should be monitored periodically. Patients with known or suspected renal impairment should be observed carefully since cephradine may accumulate at the serum and tissues unless dssage is suitably reduced. See DOSAGE AND ADMINISTRATION sechon. Indicatedaurgical proceduresshouldbe perforrnedinconjunctionwith antibiotic therapy; e.g.. the incision and drainage of abscesses. After treatment with cephalosporins, a fatse-positive reaction for glucose in the urine may occur, but not With enzyme-based tests. A false-positive Coombs' test has also been reported. VELOSEF for Injection is physically compatible with most commonly used intravenous fluids and electrolyte solutions (e.g. Destrose Injechon, SodiumChloride Injectionor M/6 Sodium Lactate). However, it is not compatible with Lactated Ringer's Solution or other calcium-containing infusion fluids. ADVERSE REACTIONS: Usually limited to gastrointestinal disturbances and sccasional hypersensitivity. but mayinclude hematological and hapatobiliary disturbances, as well as elevated BUN, LDH and serum creatinine. superinfection. vaginitis and joint pains. Thrombophlebitis following IV. injection and sterile abscesses after IM. injection have occurred. Only occasonally have adverse reactions been severe enough to warrant cessation of therapy.

DOSAGE AND ADENISTRATION: The presence of food in the

gastrointestinal tract delays absorption and reduces the peak serum level but does not affect the total amount of caphradine absorbed. VELOSEF Capsules and VELOSEF for Oral Suspension. Adufta: Respiratory tract infections: 250 mg, q6h or 500 mg q12h. Pneumococcal lobar poesmonia: 500 mg. q6f. or g ql2h: Genfourinary tract infections: 500 mg. q6h or 1 g q12h. Prolonged therapy is advisable for the treatment of prostatitis and epididymitis. Skin or soft Sasue infections: 250 mg q6h or 500 mg ql2h. Children: 25 to SO mg/kg/day, in two or four equally divided and spaced doses. e.g.: VELOSEF for Oral Suspension Child's Weight 125 mg/S ml 250 mg/5 ml lOkg(221bs) 4toltsp.qtih or lto2tap.ql2h 2Okg(441bs) lto2tsp.q6h (4toltsp.q6h or 2to4tap.ql2h or lto2tsp.ql2h itOkg(881bs) lto2tap.qtih or 2toittsp.ql2h Smaller doses then those indicated above should not be used. Forstitis media due tont. intluenzae. doses from 75to 100mg/kg/day are recommended. Masimum deify dose should not esceed 4 g. VELOSEF for Injection: For use in moderate, severe or life threatening infechons or where oral therapy is not possible. Aduft daily dose range is 2-4g. depending on the infection. In children, a dailydose of 50-100mg/kg is recommended. Allpahents; aft toimulahons: Largerdoses(upto gq6h inaduftsorupto25mg/kgqfthinchildren) may be given for severe or chronic infections: masimum daily dose should not esceed 4g. Therapy should becontinued fur amimimum of 48 to 72 hours after the patient becomes asymptomatic or evidence of bacterial eradication has been obtained. In infections caused by hemolytic streptococci, a minimum 10-day-treatment period is recommended. Stubbom infections may require treatment for several weeks with frequent bacteriological and clinical appraisal. A modihed dosage schedulein patientswithdecreased renal function is necessary. Each patient should be considered individually: the following schedule is recommended as a guideline. siSal loading dose: 750 mg. Maintenance dose: 500 rag at the time intervals listed below: Creatinine Clearance (mI/mis/i .73ma) >20m1/min 15-19 mI/mis 10-14 mI/mis 5-9 mI/mis