A major issue in acute care is the overuse of antibiotics, which has led to the development of strains of bacteria that are resistant to available antibiotics (Centers for Disease Control and Prevention, 1994a). Antibiotics are almost never an appropriate treatment for people with a common cold because almost all colds are caused by a virus, for which antibiotics are not effective. However, in a study of Medicaid beneficiaries diagnosed with a cold in Kentucky during a one-year period from 1993 to 1994, 60 percent filled a prescription for an antibiotic (Mainous et al., 1996). In a national study of patient visits in 1992, 51 percent of adult patients and 44 percent of patients younger than 18 years old diagnosed with a common cold were treated with antibiotics (Gonzales et al., 1997; Nyquist et al., 1998).

Other types of medications are also not always used in the most appropriate manner. Among hospitalized elderly patients with depression who were discharged on antidepressant medication, 33 percent were on a dose below the recommended level (Wells et al., 1994b). In a study of 634 patients with depression or depressive symptoms in Boston, Chicago, and Los Angeles, 19 percent were treated with minor tranquilizers and no antidepressants (Wells et al., 1994a), despite the lack of evidence that tranquilizers work for depression and the risk that they will cause side effects or addiction (Depression Guideline Panel, 1993).

Patients with chronic conditions, for which certain routine examinations and tests are crucial in order to prevent complications, do not all get the care they need. Diabetes mellitus causes several complications that are less likely to occur with good care. One of these complications is an eye condition called diabetic retinopathy, which is the leading cause of new blindness among persons aged 20 to 74 in the United States. It is recommended that patients with insulin-dependent diabetes mellitus have an annual dilated eye examination (the clinician uses drops to enlarge the pupil to see behind it more easily) starting five years after diagnosis and that patients with non-insulin-dependent diabetes mellitus have the exam annually starting at the time of diagnosis. In a national study in 1989, only 49 percent of adults with either type of diabetes had undergone a dilated eye examination in the past year (66 percent in the past two years), and 61 percent had undergone any type of eye exam in the past year (79 percent in the past two years). Twenty percent of diabetics had no eye exam in the past two years. Among diabetics who were at particularly high risk for vision loss because they already had retinopathy or because they had had diabetes for a long time, 61 percent and 57 percent, respectively, had a dilated examination in the past year (Brechner et al., 1993).

Sometimes surgery is performed on people who do not need it. A study of seven managed care organizations revealed that about 16 percent of hysterectomies performed during a one-year period from 1989 to 1990 were carried out for inappropriate reasons. An additional 25 percent were done for reasons of uncertain clinical benefit (Bernstein et al., 1993b). There are also examples of patients who need surgery but do not receive it. In a study of four hospitals, 43 percent of



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