The cost of work-related physical assaults in Minnesota

OBJECTIVE

To describe the long-term productivity costs of occupational assaults.

DATA SOURCES/STUDY SETTING

All incidents of physical assaults that resulted in indemnity payments, identified from the Minnesota Department of Labor and Industry (DLI) Workers' Compensation system in 1992. Medical expenditures were obtained from insurers, and data on lost wages, legal fees, and permanency ratings were collected from DLI records. Insurance administrative expenses were estimated. Lost fringe benefits and household production losses were imputed.

STUDY DESIGN

The human capital approach was used to describe the long-term costs of occupational assaults. Economic software was used to apply a modified version of Rice, MacKenzie, and Associates' (1989) model for estimating the present value of past losses from 1992 through 1995 for all cases, and the future losses for cases open in 1996.

PRINCIPAL FINDINGS

The total costs for 344 nonfatal work-related assaults were estimated at $5,885,448 (1996 dollars). Calculation of injury incidence and average costs per case and per employee identified populations with an elevated risk of assault. An analysis by industry revealed an elevated risk for workers employed in justice and safety (incidence: 198/100,000; $19,251 per case; $38 per employee), social service (incidence: 127/100,000; $24,210 per case; $31 per employee), and health care (incidence: 76/100,000; $13,197 per case; $10 per employee).

CONCLUSIONS

Identified subgroups warrant attention for risk factor identification and prevention efforts. Cost estimates can serve as the basis for business calculations on the potential value of risk management interventions.

Comparison of DNA repair protein expression and activities between human fibroblast cell lines with different radiosensitivities

In order to investigate the molecular basis of variation in response to ionising radiation (IR) in radiotherapy patients, we have studied the expression of several genes involved in DNA double-strand break repair pathways in fibroblast cell lines. Ten lines were established from skin biopsies of cancer patients with different normal-tissue reactions to IR, and 3 from a control individual. For all 10 test cell lines, the cellular radiosensitivity was also known. Using Western blots we measured, in non-irradiated cells, the basal expression levels of ATM, Rad1 and Hus1, involved in the control of cellular DNA damage checkpoints, together with DNA-PKcs, Ku70, Ku80; XRCC4, ligaseIV and Rad51, involved in radiation- induced DSB repair. We also analysed the in vitro enzymatic activities, under non-irradiated conditions, of the DNA-PK and XRCC4/ligaseIV complexes. The levels of expression of the different proteins were similar in all the cell lines, but the activities of the DNA-PK and XRCC4/ligaseIV complexes showed some differences. These differences did not correlate with either the normal tissue response of the patient in vivo or with cellular radiation sensitivity in vitro. The activity differences of these enzyme complexes, therefore, do not account for the variation of responses seen between patients.

Comparison of DNA repair protein expression and activities between human fibroblast cell lines with different radiosensitivities

In order to investigate the molecular basis of variation in response to ionising radiation (IR) in radiotherapy patients, we have studied the expression of several genes involved in DNA double-strand break repair pathways in fibroblast cell lines. Ten lines were established from skin biopsies of cancer patients with different normal-tissue reactions to IR, and 3 from a control individual. For all 10 test cell lines, the cellular radiosensitivity was also known. Using Western blots we measured, in non-irradiated cells, the basal expression levels of ATM, Rad1 and Hus1, involved in the control of cellular DNA damage checkpoints, together with DNA-PKcs, Ku70, Ku80; XRCC4, ligaseIV and Rad51, involved in radiation- induced DSB repair. We also analysed the in vitro enzymatic activities, under non-irradiated conditions, of the DNA-PK and XRCC4/ligaseIV complexes. The levels of expression of the different proteins were similar in all the cell lines, but the activities of the DNA-PK and XRCC4/ligaseIV complexes showed some differences. These differences did not correlate with either the normal tissue response of the patient in vivo or with cellular radiation sensitivity in vitro. The activity differences of these enzyme complexes, therefore, do not account for the variation of responses seen between patients.

Accelerated hyperfractionated radiotherapy combined with induction and concomitant chemotherapy for inoperable non-small-cell lung cancer--impact of total treatment time

Tumour cell proliferation during conventionally fractionated radiotherapy (RT) can negatively influence the treatment outcome in patients with unresectable non-small-cell lung cancer (NSCLC). Accelerated and hyperfractionated RT may therefore have an advantage over conventional RT. Moreover, earlier studies have suggested improved survival with addition of cisplatin-based chemotherapy (CT). We present here the results of combined treatment with induction and concomitant CT and accelerated hyperfractionated RT in a retrospective series of patients with advanced NSCLC. Between August 1990 and August 1995, 90 consecutive patients, aged 42-77 years (median 63 years), with locally advanced unresectable or medically inoperable NSCLC and good performance status were referred for treatment: stage: I 23%, IIIa 37%, IIIb 40%. Patient histologies included: squamous cell carcinoma 52%, adenocarcinoma 34% and large cell carcinoma 13%. The treatment consisted of two courses of CT (cisplatin 100 mg/m2 day 1 and etoposide 100 mg/m2 day 1-3 i.v.), the second course given concomitantly with RT. The total RT dose was 61.2-64.6 Gy, with two daily fractions of 1.7 Gy. A one-week interval was introduced after 40.8 Gy to reduce acute toxicity, making the total treatment time 4.5 weeks. Concerning toxicity, 33 patients had febrile neutropenia, 10 patients suffered from grade III oesophagitis and 7 patients had grade III pneumonitis. There were two possible treatment-related deaths, one due to myocardial infarction and the other due to a pneumocystis carinii infection. The 1-, 2- and 3-year overall survival rates were 72%, 46% and 34%, respectively; median survival was 21.3 months. Fifty-nine patients had progressive disease: 21 failed locoregionally, 29 had distant metastases and 9 patients had a combination of these. Pretreatment weight loss was the only prognostic factor found, except for stage. However, the results for stage IIIb were no different from those for stage IIIa. We conclude that the survival results compare favourably with those of most other studies with a manageable toxicity.

Describing patients' normal tissue reactions: concerning the possibility of individualising radiotherapy dose prescriptions based on potential predictive assays of normal tissue radiosensitivity. Steering Committee of the BioMed2 European Union Concerted Action Programme on the Development of Predictive Tests of Normal Tissue Response to Radiation Therapy

Clinical radiotherapeutic doses are limited by the tolerance of normal tissues. Patients given a standard treatment exhibit a range of normal tissue reactions, and a better understanding of this individual variation might allow for individualisation of radiotherapeutic prescriptions, with consequent improvement in the therapeutic ratio. At present, there is no simple way to describe normal tissue reactions, which hampers communication between clinic and laboratory and between groups from different centres. There is also no method for comparing the severity of reactions in different normal tissues. This arises largely because there is no definition of a "normal" reaction, an "extreme" reaction or the particular term "over-reactor" (OR). This report proposes definitions for these terms, as well as a simple terminology for describing normal tissue reactions in patients having radiotherapy. The "normal" range represents the individual variation in normal tissue reactions amongst large numbers of patients treated in the same way which is within clinically acceptable limits. The term "OR" is applied to an individual whose reaction is more severe than the normal range but also implies that this forced a major change in the radiotherapeutic prescription or that the reactions were very severe or fatal. A "severe OR" would develop serious problems with a typical radical dose, while an "extreme OR" would have such difficulties at a much lower dose. To describe the normal range, a numerical scale is suggested, from 1 to 5, resistant to sensitive. The term "highly radiosensitive" (HR) is suggested for category 5. An "informal" relative scale, as suggested here, is quick and simple. It should allow comparison between different hospitals, compensate for differences in radiotherapeutic dose and technique and allow comparison of reactions between different anatomical sites. It should be adequate for discriminating patients at the extremes of the normal range from those at the centre. It is hoped that the definitions and terminology proposed here will aid communication in the field of predictive testing of normal tissue radiosensitivity.

The apparent fracture toughness of acrylic bone cement: effect of three variables

In cemented arthroplasties, pores are almost invariably present at one or more of the so-called 'weak-link' zones (namely, the bone-cement interface, the cement mantle and the cement-implant interface). In the clinical milieu, arthroplasties are frequently subjected to cyclical loading. These conditions underscore the significance of the apparent fracture toughness (KISR) of the cement. The present work is an investigation of the effect of three variables on KISR of three commercial formulations of bone cement (namely, CMW3, PalacosR and Osteopal) measured using straight-sided chevron notched short rod specimens. For CMW3, the effect of mixing method was studied, with all cement constituents having been stored at ambient laboratory environment prior to being mixed. The highest KISR was obtained from material that was obtained from exposing the cement constituents to a passive vacuum for 20 s and then mixing them in a machine that subjected them to simultaneous mechanical mixing and centrifugation. For Palacos R, the effects of two variables [storage temperature of the cement constituents prior to being mixed (4 degrees C versus 21 degrees C) and mixing method (hand mixing versus vacuum mixing)] (taken individually) were studied. It was found that only mixing method exerts a significant effect on KISR. When room-temperature stored constituents were vacuum mixed, the KISR values for a low-viscosity cement (Osteopal) and a medium-viscosity cement of very similar composition (Palacos R) are not significantly different, indicating that the fracture resistance of bone cement is influenced more by its composition than its viscosity.

Anti-Ro (SSA) antibodies in rheumatoid arthritis patients with gold-induced side effects

The purpose of our study was to investigate the significance of the presence of anti-Ro antibodies found by us in an earlier study of rheumatoid arthritis (RA) patients with gold-induced side effects. Sera of 29 anti-Ro (SSA) positive RA patients who had gold-induced side effects were studied. All sera were examined by Western blot using recombinant antigens, encoding the Ro 60 kD and the La proteins. HLA typing was done in all patients. Thirteen patients reacted only with the Ro 52 kD antigen and all had severe skin eruptions caused by gold therapy. Another ten patients who reacted only with the Ro 60 kD antigen had other side effects to gold (six had proteinuria and four leucopenia). Six patients who reacted to all three antigens (Ro 52 kD, Ro 60 kD and La) had secondary Sjögren's syndrome. No significant statistical differences were noted in the incidence of HLA-DR3 between the subgroups of patients. Our data indicated that antibodies to the Ro 52 kD antigen are associated with skin eruptions in RA patients treated with gold.

Effects of irradiation on the biomechanics of osseointegration. An experimental in vivo study in rats

The present study reports on the late effects of increasing doses of radiation on the biomechanics of commercially pure titanium implants (fixtures) installed in the proximal tibia in 26 rats. Twelve weeks after various doses (10, 20, 30, and 35 Gy) of irradiation, the fixtures were inserted into rat tibiae, and after another eight weeks these were tested mechanically in vivo. Acute dose dependent skin reactions developed after all doses except 10 Gy, but most subsided within two to three weeks. There was a statistically significant reduction in torsion but the pull-out load was not significantly reduced for single doses up to 30 Gy. Histological analysis showed that bone remodelling was impaired. Shear stresses and shear moduli were estimated for the bone-implant interface and in the surrounding bone tissue. These estimated stresses and moduli were not found to be correlated to the dose of radiation.

Prognostic factors for acute and late skin reactions in radiotherapy patients

PURPOSE

Patients treated with identical radiotherapy schedules show a substantial variation in the degree of acute and late normal tissue reactions. To identify any possible contributing factors to this phenomenon, we have analyzed the treatments of 402 breast cancer patients.

METHODS AND MATERIALS

The patients received adjuvant postoperative radiotherapy between 1972 and 1985 and have been followed up since then. Multivariate analyses were performed with peak reflectance erythema and peak acute reaction score as endpoints for the acute reactions, and with progression rate of telangiectasia as well as telangiectasia score as endpoints for the late reactions. Twenty patient- and treatment-related factors were tested such as age, menopausal status, hemoglobin level, serum calcium, smoking habits, hypothyroidism, diabetes, hypertension, blood pressure, cardiovascular and autoimmune disease, the influence of hormone therapy and chemotherapy, pretreatment reflectance value, acute skin reactions, radiation quality, individual dose, bilateral fields, and the total effect (TE) for the dose schedule applied.

RESULTS

The TE was a strong prognostic factor for all endpoints. In addition to TE, blood pressure was prognostic for the peak erythema measured by reflectance spectrophotometry, and the pretreatment reflectance value was prognostic for the acute score. The only independent prognostic factors found for the progression of skin telangiectasia and telangiectasia score except for TE were the individual dose and the acute skin reactions.

CONCLUSIONS

These factors explained at most about 30% of the variance describing the total patient-to-patient variability for each endpoint. The remaining variability is still unexplained but may be related to individual differences in cellular radiosensitivity, partly determined by genetic variations and partly by unknown epigenetic factors.

A randomised placebo controlled study with ondansetron in patients undergoing fractionated radiotherapy

BACKGROUND

There are few randomised studies comparing anti-emetic drugs for the prevention of nausea and vomiting in patients treated with fractionated radiotherapy. The aim of the study was to compare the anti-emetic efficacy of 8 mg dose ondansetron twice a day with placebo.

MATERIALS AND METHODS

One hundred eleven patients who were to commence a course of 10 or more daily fractionated radiotherapy including the abdomen were included in the study. The patients recorded daily emesis, nausea and bowel habit and graded weekly symptoms of nausea, vomiting, diarrhoea and lack of appetite. The EORTC C30 questionnaire was completed.

RESULTS

67% of patients given ondansetron had complete control of emesis compared with 45% of patients with placebo (P < 0.05). The number of emetic episodes recorded on the worst day was 1.4 for the ondansetron group and 3.1 for the placebo group (P < 0.01). Patients given ondansetron had fewer days with emesis and nausea compared with placebo (P < 0.05). The mean sum score of patients weekly grading of symptoms showed that the ondansetron group had less inconvenience than the placebo group (P < 0.05). This difference persisted during the first three weeks, but not thereafter. Similarly, some quality of life measures showed significant differences in favour of the ondansetron group. More patients (n = 13) withdrew due to lack of efficacy in the placebo group compared with patients (n = 8) in the ondansetron group.

CONCLUSIONS

The present study illustrates that prophylactic anti-emetic administration of ondansetron is effective in preventing nausea and vomiting in patients undergoing fractionated radiotherapy of the abdomen.

Normal tissue radiosensitivity--how important is it?

The success of radiotherapy in eradicating tumours depends on the total radiation dose, but what limits this dose is the tolerance of the normal tissues within the treatment volume. Selection of the appropriate dose for all patients is based on a balance between minimising the incidence of severe normal tissue complications and maximizing the probability of local control. In patients treated to the same radical dose, a wide range of reactions is seen; in many clinical situations, radical doses are limited by the minority of patients whose normal tissues are particularly sensitive. Clinical studies of radiotherapy reactions have demonstrated that a large part of the spectrum of normal tissue reactions, perhaps as much as 80%, is due to differences in individual normal tissue sensitivity. This suggests that it might be possible to measure this sensitivity and to change treatment accordingly. The main objective of normal tissue sensitivity testing is to permit dose escalation without increased normal tissue complication rates in patients with more resistant normal tissues. Calculations suggest that the most "resistant' 40% of patients could be dose escalated by 17%-18%, which is likely to be associated with significant gains in local control, perhaps by as much as 34%-36%; this should translate into an increase in overall survival. It should also be possible to identify those relatively few patients who suffer serious normal tissue morbidity with conventional doses. Thus, if successful, predictive testing of normal tissue response should improve the therapeutic ratio of radiotherapy.

Fibroblast radiosensitivity versus acute and late normal skin responses in patients treated for breast cancer

PURPOSE/OBJECTIVE

To determine if the radiosensitivity of normal human skin fibroblasts, measured in early passage cultures, is significantly correlated with the degree of acute or late normal skin damage in patients treated for breast cancer with radiotherapy.

METHODS AND MATERIALS

In the 1970s, a series of breast cancer patients was treated at the Department of Oncology in Gothenburg, Sweden with postoperative irradiation to the parasternal region. Patients were treated bilaterally using different fractionation schedules and doses to the right and left fields. Peak acute reactions were scored on a six-point scale, and skin erythema was measured by reflectance spectrophotometry. Telangiectasia was graded over time on a six-point scale. In April 1992, two small skin biopsies were obtained from 22 patients in two treatment groups (i.e., four dose-fractionation schedules) and, using either delayed or immediate plating, fibroblast radiosensitivity was measured in early passage cultures by clonogenic survival, after high and low dose-rate irradiations. Survival at 2.0 Gy (SF2) was calculated from complete survival curves.

RESULTS

To test assay reproducibility, SF2 values derived from paired biopsies of the same patient (12 cases) were compared. A reasonably good correlation (p = 0.075) was obtained for SF2s determined by high dose-rate irradiations with immediate plating, but not for delayed plating or low dose-rate treatments. The median coefficient of variation in the replicate SF2s after high dose-rate treatment and immediate plating was 13%, suggesting that the poor correlation in paired SF2 values is due to the magnitude of the uncertainty in SF2 relative to the overall spread in SF2 values between patients (CV = 28%). Individual SF2 values and averaged values from patients with data from two biopsies were compared with the acute and late clinical reactions. A significant negative correlation was found between SF2 and relative clinical response, but only when averaged high dose-rate SF2 values and telangiectasia scores were compared. There was no significant correlation between average SF2 values and acute responses or between individual SF2 measurements and either the acute or late clinical response.

CONCLUSION

The results of this study suggest that the degree of late telangiectasia is at least partially dependent upon the intrinsic cellular radiosensitivity of normal fibroblasts, but the relationship is not clear cut. Multiple replicate assays are necessary to obtain reliable estimates of fibroblast SF2 values using current techniques.

Does the interval between fractions matter in the range of 4-8 h in radiotherapy? A study of acute and late human skin reactions

Accelerated radiotherapy has the potential to increase local control of rapidly growing tumours. To determine the necessary time interval for complete repair of sublethal damage in normal tissue in a clinical situation, we have compared the acute and late skin reactions with 8 and 24 h between fractions, using the same dose per fraction and total dose. Forty-nine breast cancer patients participated in this study, and received bilateral parasternal irradiation to 50 Gy with 2 Gy per fraction as part of their adjuvant postoperative radiotherapy. The time interval between daily fractions was always 8 h on the left field and 24 h on the right, and the total treatment time was 2.5 and 5 weeks, respectively. The acute endpoint was erythema, measured by reflectance spectrophotometry and an acute reaction score for erythema and desquamation. The late endpoint was telangiectasia, scored on an arbitrary scale. The results have also been compared with those in a previously treated group of patients with 4 and 24 h between fractions. The degree of acute reactions was decreased with an 8-h interval compared with 24 h between fractions with the peak acute score as endpoint; no difference was seen with the peak reflectance measurements. The maximal expression occurs approximately 1 week earlier with the accelerated schedule, possibly as a consequence of the reduction of the treatment time. The pattern of the acute reaction for 8 h between fractions is similar to that for 4 h.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship between cellular radiation sensitivity and tissue response may provide the basis for individualising radiotherapy schedules

There is a wide variation in normal tissue reactions to radiotherapy and in many situations the severity of these reactions limits radiotherapy dose. Clinical fractionation studies carried out in Gothenburg have demonstrated that a large part of the spectrum of normal tissue reactions is due to differences in individual normal tissue sensitivity. If this variation in normal tissue reactions is due to differences in intrinsic cellular radiosensitivity, it should be possible to predict tissue response based on measurement of cellular sensitivity. Here we report the initial results of a study aimed at establishing whether a direct relationship exists between cellular radiosensitivity and tissue response. Ten fibroblasts strains, including four duplicates, were established from a group of patients in the Gothenburg fractionation trials who had received radiotherapy following mastectomy. Skin doses were measured and both acute and late skin changes were observed following radiotherapy. Right and left parasternal areas were treated with different dose fractionation schedules. Clonogenic assays were used to assess intrinsic cellular radiosensitivity, and all experiments were carried out without prior knowledge of the clinical response, or which strains were duplicates. Irradiation was carried out using 60Co gamma-rays at high dose-rate (HDR) of 1-2 Gy/min and low dose-rate (LDR) of 1 cGy/min. A spectrum of sensitivity was seen, with SF2 values of 0.17-0.28 at HDR and 0.25-0.34 at LDR, and values of D0.01 of 5.07-6.38 Gy at HDR and 6.43-8.12 Gy at LDR. Comparison of the in vitro results with the clinical normal tissue effects shows a correlation between cellular sensitivity and late tissue reactions, which is highly significant with p = 0.02. A correlation between cellular sensitivity and acute effects was noted in the left-sided parasternal fields, but not the right. This is thought to be coincidental, and without biological significance. Our results suggest that cellular sensitivity might form the basis for the development of an assay system capable of predicting late normal tissue effects to curative radiotherapy, which might allow dose escalation in some patients. Increased local control and cure, with unchanged or improved normal tissue complications, could result from such individualised radiotherapy prescriptions.

Basal cell density in human skin for various fractionation schedules in radiotherapy

Changes in the epidermal basal cell density (BCD) in human skin were determined during and immediately after fractionate radiotherapy. The basal cells are one of the target cell types responsible for acute skin reactions and measuring the BCD is a histological method for studying the time course and degree of reaction. Thirty-two patients with breast cancer participated in this study. They received postmastectomy radiotherapy to the thoracic wall. A 3-mm punch biopsy was taken from the irradiation field once a week for 6-10 weeks and the linear basal cell density was determined. Standard fractionation at two different dose levels (40 and 50 Gy) as well as hypofractionation and accelerated treatment have been investigated. For the first 3 weeks we found a constant decline in the BCD (about 0.8%/day), independent of dose and fractionation schedule. Using the nadir value as endpoint we found a dose-response relationship between 40 and 50 Gy, and for total effect (TE)-values in the range 430-1015. Compared to standard fractionation, hypofractionation showed somewhat less effect and accelerated fractionation showed significantly less effect. The reduced effect of accelerated fractionation is interpreted as a result of lack of cell cycle redistribution of cells between the two daily fractions in this type of tissue. The removal rate of dead or doomed cells could also affect the results for schedules with different overall time. The results of BCD were also compared to erythema.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic factors for local control and survival of cancer of the oral tongue. A retrospective analysis of 230 cases in western Sweden

During the 19-year period from 1970 to 1988, 289 cases of squamous cell carcinoma of the oral tongue were diagnosed in Western Sweden. In 230 of these, treatment regimens and results were analysed in an attempt to define prognostic factors for local control and survival. Tumour stages were: T1 26%, T2 32%, T3 30% and T4 13%. Nodal disease was seen in 32% of the patients. Sixty per cent of the patients had surgery, 74% external with or without combination with interstitial irradiation; and 32% received chemotherapy. The local control rate at five years was 59% (T1 66%, T2 67%, T3 44% and T4 0%). Survival at five years was 37% (T1 61%, T2 51%, T3 19% and T4 0%). By a multivariate procedure we demonstrate that the tumour related variables T-category, N-category and extension to the tonsillar region had a significant association with survival. Extension to the tonsillar region, extension to the floor of the mouth and level of neck nodes were significantly associated with local-regional control.

Prediction of normal-tissue tolerance to radiotherapy from in-vitro cellular radiation sensitivity

The success of radiotherapy depends on the total radiation dose, which is limited by the tolerance of surrounding normal tissues. Since there is substantial variation among patients in normal-tissue radiosensitivity, we have tested the hypothesis that in-vitro cellular radiosensitivity is correlated with in-vitro normal-tissue responses. We exposed skin fibroblast cell lines from six radiation-treated patients to various doses of radiation and measured the proportions surviving. There was a strong relation between fibroblast sensitivity in vitro and normal-tissue reactions, especially acute effects. Assessment of radiosensitivity could lead to improved tumour cure rates by enabling radiation doses to be tailored to the individual.

Changes in the basal cell density in pig skin after single radiation doses with different dose rates

Radiation-induced changes in the basal cell density (BCD) and the labelling index (LI) in the epidermis of pig skin were used to compare the effect of high and low dose rate irradiation. Single doses of 6, 12 and 24 Gy were applied at 1.5 and 0.02 Gy/min with two equal 137Cs sources. Punch biopsies were taken daily for 40 days. The linear BCD was calculated from histological sections. The LI was determined by an in vitro H3-thymidine labelling technique. We found a degenerative phase in the basal cell layer with a linear cell loss of 2% per day, independent of the dose and dose rate. The time and level of the minimum BCD were dose and dose rate dependent. The LI data indicated an increased proliferation rate after a 25% reduction in BCD, i.e. before the nadir was reached. From the BCD data an iso-effective dose factor of 1.8 was estimated for the two dose rates used, which was consistent with that determined from macroscopic scoring. The BCD can be used as an endpoint for comparison of different radiotherapy modalities and gives, together with the LI, further information on the time-course of the proliferation changes in the tissue.

Multifactor prediction of hospital service workload

Prediction of workload for hospital departments is a forecasting problem. Most forecasting techniques use time series methods. However, the unpredictability of hospital utilization which occurs because of environmental turbulence requires that predictions be based on strategic plans. Regression models developed from cross-sectional data can provide a methodology for linking predictions of service workload to strategic plans. The methodology is illustrated and evaluated in a pilot study, which produced models predicting measures of workload such as laboratory tests (R2 = .85), doses of medication given to inpatients (R2 = .43), outpatient prescriptions (R2 = .79), and x-rays (R2 = .86).