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Do Elderly Medicare Recipients Contact Physicians Appropriately?

^a University of Missouri–St. Louis
^b University of California at Los Angeles

Margo-Lea Hurwicz, Department of Anthropology, University of Missouri–St. Louis, 8001 Natural Bridge Road, St. Louis, MO 63121-4499 E-mail: hurwicz{at}umsl.edu.

Decision Editor: Fredric D. Wolinsky, PhD

	Abstract

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Objectives. This research identified characteristics of persons and their illness episodes that predict appropriate and inappropriate decisions to seek medical care.

Methods. This study analyzes 1,292 health care decisions of 885 elderly members of an HMO in Los Angeles. Illness episodes are divided into three categories based on the expertise of a panel of 22 geriatricians, using a formal mathematical analysis derived from anthropological consensus theory. These categories are physician visit not recommended, physician visit recommended, and physician visit mandatory. Physician contact is regressed on a list of variables derived from Andersen's behavioral model separately for each group of episodes.

Results. Although the variables indicating perceived seriousness and duration of the episode consistently predict the decision to contact a physician, regardless of whether that contact is considered appropriate by the geriatrician panel, the variables indicating other illness responses and predisposing personal attributes have less consistent patterns of significance.

Discussion. The category of episodes (visit recommended) for which predisposing personal attributes figure most strongly in the treatment decision is the one for which there are no clear cultural directives to action. Implications for health education and policy are drawn from the findings.

COMMUNITY-DWELLING older adults are responsible for a significant proportion of the discretionary physician visits made in the United States. Given an increasing concern over the equitable allocation of scarce medical resources, it is particularly important for health policy makers and planners to understand factors associated with decisions to seek medical care when dealing with acute symptoms or flare-ups of chronic conditions. This study presents a multidisciplinary approach to identifying predictors of appropriate and inappropriate decisions about medical care-seeking for specific illness episodes. It divides a sample of illness episodes experienced in 1986 and 1987 by Medicare recipients in an HMO into three groups based on the consensus of 22 physicians as to whether medical care is mandatory, recommended, or not recommended. It then evaluates predictors of physician contact selected from the health services use literature.

	Health Service Research on Older Adults

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Andersen's behavioral model of health services use (Aday and Awe 1997; Andersen 1968, Andersen 1995) is the theoretical framework most widely used for studying physician utilization among older adults (Aday and Awe 1997; Wolinsky 1994). Predictors of health services use are divided into predisposing, enabling, and need factors. Variables indicating an individual's predisposition to seek medical care include demographic traits such as age, sex, marital status, and past illness; social structural attributes such as education, occupation, race/ethnicity, and religion; and health beliefs. Individual-level enabling variables, including income, insurance coverage, type of, and access to a regular source of care, may limit an individual's ability to carry out an action to which s/he is predisposed. Need-for-care variables include perceived disability, symptoms, diagnoses, general state, and evaluated symptoms and diagnoses (Wolinsky 1994). Aday and Awe 1997, who along with Andersen 1995 remind us that this model has gone through several revisions and modifications, suggest that initially this dimension included other illness responses.

Other theoretical frameworks, such as the health belief model (Janz and Becker 1984), have been used to study the health behavior of older adults. Krause 1990 provides a detailed discussion of both the behavioral and health belief models, and suggests that as they share many variables, they can be integrated into a life stress perspective. Others have suggested, however, that these two models already have been integrated in practice (Aday and Awe 1997; Andersen 1995).

Although the outcome dimension of the behavioral model includes illness episodes as units of analysis, Wolinsky 1994 notes that most utilization studies rely on contact and volume measures of physician visits. As a result, they do not identify factors associated with care-seeking for particular symptoms or illness episodes, and they provide little insight into why people decide to go to the doctor for some symptoms, but not for others.

Pescosolido 1992 draws our attention to the history in medical sociology and anthropology of the "illness career" perspective, which takes individual illness episodes as its analytic focus and seeks to discover factors and strategies involved in decisions to seek help. She offers the Social Organization Strategy as a framework for the study of illness-related decision-making that is complementary to rational choice models. However, as applied, this approach uses the same independent variables as the behavioral model. Anthropologists have developed illness-related decision models that abstract an ordered set of rules from ethnographic data (Garro 1986; Mathews and Hill 1990; Young 1981). Recently, Weller, Ruebush, and Klein 1997 compared an ethnographic decision model to a health service approach and concluded that, although the approaches lead to similar substantive conclusions, the health services approach, exemplified by Andersen's behavioral model, made it easier to select predictor variables.

	Measuring the Appropriateness of Treatments

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Although the behavioral model includes "evaluated need" (Aday and Awe 1997; Andersen 1995; Wolinsky 1994), its applications do not often take into account professional opinion on whether particular symptoms actually require medical attention. The few papers that address this issue have problems involving units of analysis, small numbers of both symptoms and expert raters, and perhaps most importantly, inability to evaluate the expertise of the experts, that limit their generalizability.

Whereas the Symptoms-Response Ratio (Taylor, Aday, and Andersen 1975) assesses the extent to which populations or subgroups obtain services judged medically necessary by a panel of physicians, it does not evaluate the behavior of specific individuals. Haug 1981 classified individual utilization as appropriate or not based on an expert panel's evaluation of a set of 10 common ailments. She did not, however, report the ailments, the number of experts, or how agreement among the panel was assessed. Wilkinson, Darby, and Mant 1987 and Stoller, Pollnow, and Forster 1994 both used panels of three physicians to evaluate, respectively, actions taken for symptoms deemed not serious by respondents and actions recommended by respondents for 15 common symptoms.

	A Consensus Analysis Approach to Episode Classification

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Consensus analysis, a technique developed by cognitive anthropologists, provides a way to assess the expertise of informants and keep the less knowledgeable from influencing conclusions about cultural domains where there is no external standard for truth (Romney, Weller, and Batchelder 1986). Here, the domain of interest is the appropriate treatment of symptoms, and the experts are physicians chosen for their training and experience. The procedure applies factor analytic techniques to a question-by-informant matrix, assigns a coefficient to each informant indicating level of expertise in the domain, and evaluates the overall fit of the consensus model. Given adequate fit, it provides an answer key, using Bayesian techniques to estimate the correct answer for each question. (See Romney et al. 1986, for a more detailed description of consensus analysis.)

Hurwicz 1995 used Consensus Analysis software (Borgatti 1992) to analyze data from 22 physicians who were asked to rate 106 National Ambulatory Symptom Classification (NASC) codes using three categories: (a) physician visit not recommended—reasonable probability of no treatable underlying disease; (b) physician visit recommended—reasonable probability of treatable underlying disease; and (c) physician visit mandatory—reasonable probability of serious underlying disease. The consensus among physicians made it possible to assign 2,395 illness episodes reported during a multiwave longitudinal study to the correct category with confidence. What people actually did was compared to the physicians' a priori assessment of what they should have done.

	Study Objective and Hypotheses

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The analyses in the present study are based on methodology developed in the research discussed previously (Hurwicz 1995) and two earlier studies. Berkanovic and Hurwicz 1989 developed regression models for both physician visit volume and contact during illness episodes, using predictor variables derived from the utilization literature. Variables measured as attributes of the individual were blocked separately from variables measured as characteristics of specific illness episodes, to allow for isolation of their effects. Hurwicz and Berkanovic 1991 analyzed separately episodes of musculoskeletal illness, musculoskeletal injury, and respiratory illness, using a similar set of predictors, and found unique patterns in the correlates of care-seeking for each.

The contribution of this study is to analyze separately person-episodes classified by the physician panel as "visit not recommended," "visit recommended," and "visit mandatory." This analysis permits the isolation both of episodes involving physician contact that has been judged medically unnecessary and of episodes involving the failure to contact a physician when this has been judged medically necessary. It asks if there are attributes of either the illness or the person that help us to understand inappropriate physician contacts or failure to make appropriate contacts.

There are three hypotheses: (a) Need, measured as perceived seriousness and duration of the episode, is significantly related to physician contact for all episode types (Hurwicz and Berkanovic 1991); (b) Different combinations of other illness responses are significantly associated with physician contact within each of the three episode types (following Pescosolido 1992). Bed days and lay consultation are positively associated with physician contact, and nonprescription medication use is negatively associated (Berkanovic and Hurwicz 1989; Hurwicz and Berkanovic 1991); and (c) Different combinations of predisposing personal attributes are associated with physician contact within each of the three episode types. Variables were selected from previously reported analytic models tested on these data (Berkanovic and Hurwicz 1989; Hurwicz and Berkanovic 1991). They include sex, age, education, work status, dissatisfaction with past care, and past experience with a chronic condition. Two other predisposing variables, race/ethnicity and immigration status, were added. Because only Medicare recipients enrolled in an HMO were interviewed, both insurance status and the structural aspects of the providing system were considered constant.

	Methods

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Data Source
The study population.
Data are from a 1-year, seven-wave longitudinal study conducted in 1986–1987 with 1,034 Medicare recipients who were enrolled in a network model HMO in Los Angeles, CA. The baseline interview established the sociodemographic attributes of the population. Sixty percent were women; in 1986, the mean age was 72 (SD = 5.9). Eighty-nine percent were non-Hispanic White, 5% were Hispanic, and 4% were African American. Eighteen percent were born elsewhere and immigrated to the United States. Seventy-four percent were retired, and 26% were still working or keeping house at the time of the study. The mean education level was 12 years (SD = 3.4), but more than one third (38%) had been to college. More detailed descriptions of the study population and comparisons with other populations can be found elsewhere (Berkanovic and Hurwicz 1989, Berkanovic and Hurwicz 1992).

Survey procedures.
Seven waves of telephone interviews were conducted at 2-month intervals. At the beginning of each interview after the baseline, the participants were asked first to list all injuries or accidents, and then to list separately all episodes of illness or flare-ups of chronic conditions they had experienced since the previous interview. If more than one episode was reported during the 2-month interval, the respondents were asked to select the one they felt was the most severe. If the most severe episode was composed of more than one symptom, the major symptom/condition indicated by the respondent was used as its label. They were asked to provide detailed information regarding how they had treated this episode. All respondents had been provided "memory aids" (health diaries) in which they were asked to record these responses as they occurred.

Of 1,034 individuals age 65 and older who were interviewed at baseline, 1,009 (98%) completed an additional interview. Of these, 885 (88%) reported at least one episode of illness; 2,493 "most severe" episodes (2.8 per person) were recorded over the study year. All illness episodes reported in this study were classified according to the NASC codes (Berkanovic and Hurwicz 1989; National Center for Health Statistics 1974).

Although these data were collected over a decade ago, the HMO model they represent is still viable. Furthermore, this is the most complete data set available for the analysis of individual episodes of illness among older adults of which we know. Unlike the data sets used by Fleming, Giachello, and Andersen 1984 and Pescosolido 1992, it includes nonserious as well as serious episodes. We believe the advantages of this data set outweigh its limitations.

Data Preparation
Using the illness episode as the unit of analysis is attractive because theoretically it is possible for a given individual to behave appropriately at times and inappropriately at others. Of the 2,493 illness episodes collected, 2,395 (96%) could be given 1 of the 106 NASC codes rated by the physicians, and thereby classified into 1 of the 3 categories based on consensus analysis (Hurwicz 1995). To prepare the data for analysis, the database containing the 2,395 illness episodes was divided into three separate analysis files: (a) episodes coded "visit not recommended," (b) episodes coded "visit recommended," and (c) episodes coded "visit mandatory."

To ensure statistical independence, the first episode reported in each category by each respondent was selected for analysis. Thus, a given individual respondent could have an episode in each of the 3 analysis files, in 2 of the 3 analysis files, or in 1 of the 3 analysis files. This procedure yielded a total of 1,292 person-episodes that had all the data necessary for the planned multivariate analyses. Three hundred eighty-five respondents reported at least one episode in the "visit not recommended" category, 646 respondents reported at least one "visit recommended" episode, and 261 reported at least one "visit mandatory" episode.

Table 1 indicates (for person-episodes used in the multivariate analyses) the proportion seeking medical care for symptoms/conditions with more than five self-reports, by episode category. Symptoms/conditions with five or fewer mentions are aggregated and listed as "Other" within each category. Most of the episodes in the "visit not recommended" category are colds; only 18% of these episodes were brought to the attention of physicians. Fifty-five percent of the episodes in the "visit recommended" category were brought to the attention of physicians. These are predominantly musculoskeletal symptoms and the flu, as well as other respiratory, digestive, general body, and skin symptoms. Many of the "visit mandatory" episodes are serious respiratory and cardiovascular symptoms, along with face, neck, and abdominal pain; physicians were contacted for 72% of the episodes in this category. The distribution of the reduced sample of 1,292 episodes is very similar to the distribution of the 2,394 episodes. In the aggregate, the proportion brought to medical attention in each group is within 2% of being the same as the proportion of the full set of episodes analyzed previously (Hurwicz 1995).

Measures indicating numbers or presence of chronic conditions usually represent need in analyses based on Andersen 1968 model of health service utilization. In this analysis, however, the presence of a chronic condition at baseline is used as a proxy for probable past experience with illness and medical care, and resulting knowledge about disease. It does not indicate that the person-episode being analyzed is a first occurrence or flare-up of a chronic condition.

Two variables measure perceived need at the episode level. Perceived seriousness of the episode was determined by asking participants directly how serious they thought the episode was, offering them the alternatives of very serious, somewhat serious, not too serious, and not serious at all. Duration of the episode was the number of days the episode lasted reported by the participant. Although physician contact may occur before an illness episode is considered to be over, we include the entire duration of the episode as a proxy for severity.

Three dichotomous variables indicate the presence or absence of other illness response strategies used during the episode. They include: (a) whether the person spent at least 1 day in bed; (b) whether they talked to someone who was not a medical doctor about the illness (such as a friend or family member); and (c) whether they took nonprescription medications. Because these responses could occur at any time during the episode, we take these variables as indicators of co-occurring strategies rather than antecedents during an episode.

Dependent variable.
The dichotomous dependent variable is the answer, for each episode, to the question: "Did you contact a doctor for this problem?" We did not reverse code the responses for the "visit not recommended" category; therefore, a positive response indicates an inappropriate decision for "visit not recommended" episodes and an appropriate decision for "visit recommended" and "visit mandatory" episodes.

Statistical Analyses
Logistic regression, using the person-episode as the unit of analysis, makes it possible to assess the conditional odds of each variable being associated significantly with whether a physician was consulted for an episode. The independent variables were blocked in two groups, following the procedures established in our earlier studies (Berkanovic and Hurwicz 1989; Hurwicz and Berkanovic 1991). These are (a) predisposing-personal attributes, measured at the level of the individual, and (b) need-related episode characteristics, measured for each illness. Other illness responses are included in the second block. The -2 log likelihood, the receiver-operating characteristic, and the Hosmer-Lemeshow chi-square are used to test the goodness of fit for each step.

It was important to apply the same model to each of the three episode categories, so that the results could be compared substantively. Techniques suggested by Hosmer and Lemeshow 1989(82ff.) were used to develop a full logistic regression model. Variables that were statistically useful in any one of the categories were retained. An a priori decision to retain sex and age in the models because of their importance in the modeling of health behavior resulted in sex being the only retained variable that is not significant in any equation. Variables that were considered, but dropped from the model, include marital status, living arrangements, religious affiliation, a frailty (susceptibility) index, subjective self-rated health, number of symptoms reported for the episode, number of other unrelated illness episodes reported for the interval, and the restricted activity illness response.

Although age and education in years, dissatisfaction index scores, and duration of episode in days were modeled as continuous, their odds ratios were later modified statistically using the "units" function in SAS (1997) to facilitate interpretation. The resulting odds ratios indicate the increase in the "risk" of physician contact for every increase in the specified number of units of the variable (5 years of age, 6 years of education, 3 index points of dissatisfaction, and 7 days of duration; Hosmer and Lemeshow 1989).

To provide sensitivity assessments of whether the estimates are robust in reduced form, each model was rerun using only variables that were significant.

	Results

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Table 3 shows the results of the logistic regression analyses. All three equations have acceptable fit using the -2 log likelihood chi-square (p values .001), the receiver-operating characteristic (ranging from .78 to .85), and the Hosmer-Lemeshow goodness-of-fit statistics (p values ranging from .40 to .94). Reducing the models to include only the 5, 7, and 6 significant variables, respectively, produces substantively similar results (details available on request), suggesting the stability of the models.

Both perceived seriousness and reported duration of the episode are significant predictors of physician contact for "visit not recommended" episodes. For example, the odds of a person who perceives their illness to be "somewhat" serious contacting a physician are 3.5 times that of a person who feels it is "not too" serious. The odds of physician contact increase significantly with the number of days an episode lasts. When the effect of a 7-day change in duration is calculated, the odds ratio is 1.79 (95% CI = 1.45, 2.23). On the other hand, the odds of a person who uses over-the-counter remedies during the episode contacting a physician are .38 times that of a person who does not.

Four personal attributes have a significant effect on physician contact during "visit recommended" episodes. Older participants compared with younger participants are more likely to seek care. The odds ratio is 1.29 (95% CI = 1.09, 1.51) for the effect of a 5-year increase in age. African Americans, compared with a reference group of all others, are 3.79 times more likely to seek care (the wide confidence interval somewhat reduces confidence in this result). Immigrants compared with U.S.-born participants are 1.69 times more likely to seek care. However, the odds of a person who reported a chronic condition at baseline contacting a physician are only .65 times that of a person who did not. When this block of variables is entered alone, the goodness-of-fit statistics are significant.

Episode characteristics are also significant predictors of physician contact for "visit recommended" episodes. A change of one unit of perceived seriousness doubles the likelihood of physician contact. The longer the episode lasts, the greater the likelihood of physician contact. The odds ratio is 1.23 (95% CI = 1.14, 1.32) for the effect of a 7-day change in duration. The odds of a person who uses over-the-counter medications contacting a physician are .62 times that of a person who does not use them.

For "visit mandatory" episodes, only one personal attribute is significantly associated with care-seeking. People who report that they are still working full or part time, or that they are still "keeping house" are .46 times as likely to seek care as those who are retired. The block of variables indicating predisposing personal attributes when entered alone produces significant goodness-of-fit statistics.

Greater perceived seriousness and longer duration are significantly associated with seeking medical care for "visit mandatory" episodes. The odds ratio for perceived seriousness is 1.7. For the effect of a 7-day change in duration, the odds ratio is 1.21 (95% CI = 1.06, 1.38). If a person uses over-the-counter medications at some point during the episode, the odds of their seeking medical care are .11 times that of a person who does not. However, the two other illness responses are positively associated with physician contact. Bed rest more than doubles the likelihood of "mandatory" medical care-seeking. Consultation with a neighbor, friend, or family member also more than doubles the likelihood of physician contact.

Because lay consultation is likely to co-occur with appropriate physician use for this type of episode, the role-relationship of the person consulted, and what they recommended, was explored further. Forty-five percent of lay consultation was with spouses, 22% with adult children, 11% with other relatives, and 22% with friends and neighbors. Sixty-four percent suggested medical care: visiting a doctor (52%), calling a doctor (10%), or going to an emergency room (2%). Six percent suggested taking "medications," and 2% suggested over-the-counter medications specifically. Four percent suggested resting, and 17% suggested doing nothing.

	Discussion

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As hypothesized, physician contact is significantly associated with a different set of variables within each category of episodes. Although need factors are important in all categories, the pattern of significant other illness responses varies by episode type, as does the pattern of predisposing factors. Because it was necessary to delete each person's repeat episodes within categories to ensure statistical independence, the sample sizes are relatively small, and in the case of "visit not recommended," the marginals on the outcome variable are less than optimal. As a result, differences in the significance of certain variables observed between groups reflect both power and likelihood, with power playing a larger than desirable role. Without additional research using larger samples of episodes, interpretations of the differences must therefore remain tentative. Nonetheless, the results are provocative, and we believe that they have implications for both health education and policy.

Perceived seriousness and duration both contribute to the models' explanatory power. However, the fact that this is true for illnesses where care is "not recommended" by the expert panel raises a policy question. Should an older adult be discouraged from seeking medical care for a cold s/he perceives to be serious? It has been argued that acting on the basis of perceived need always leads to appropriate choices (Andersen 1995). On the other hand, perceptions of the seriousness of specific symptoms may be mutable and therefore subject to the influence of health education.

The consistent negative association between nonprescription medication use and physician contact suggests that over-the-counter medications often substitute for medical care, as both Fleming and colleagues 1984 and Pescosolido 1992 found. Although participants may successfully treat cold, flu, and arthritis symptoms with over-the-counter remedies, self-medicating in the case of "visit mandatory" episodes, such as neck pain or abdominal pain, may mask serious symptoms. Therefore, health education identifying symptoms that should not be treated with nonprescription medications is supported by these results.

The co-occurrence of lay consultation and bed rest with "mandatory" physician contact supports a linking hypothesis. These strategies may encourage or result from medical care-seeking (Fleming et al. 1984). Hurwicz and Berkanovic 1991 found that lay consultation and restricted activity most often precede physician contact during episodes of musculoskeletal and respiratory illness. Pescosolido 1992 found for the serious episodes they studied that 66% included both physician contact and consultation with family, friends, and/or coworkers. Wolinsky and Johnson 1991 noted that useful advice may be given in the context of routine social interactions. These findings suggest that health education identifying symptoms that require physician visits should be targeted to the friends and family of older adults.

Predisposing variables representing individuals' location in the social structure, and by implication their lifestyles, are significant in all analyses. The association of formal education with making the appropriate choice during "visit not recommended" episodes suggests that health education about the recognition and treatment of colds should target less formally educated individuals. However, it should be noted that the relationship between education and service use has not been consistent in the literature (Calsyn and Winter 2000).

Working is associated with failure to seek medical attention for "visit mandatory" episodes. Clearly, older adults who continue their productive economic roles of earlier life should be encouraged not to ignore symptoms of potentially serious illnesses. Furthermore, they should be encouraged to seek advice from significant others, because lay consultation is correlated with care-seeking for this type of episode. Therefore, interventions should target working older adults and their social networks; one obvious site for this would be the workplace.

Four predisposing variables are associated with a greater likelihood of care-seeking for illnesses that fall into the "visit recommended" category, in which the cultural command to seek care is less definite or urgent. Being African American, or having immigrated to the United States, serve as proxies for sociocultural attributes, including but not limited to lifestyle. Age and experience with a chronic condition are indicators of life cycle position. Without an in-depth ethnographic investigation, discussion of the reasons for these results must remain speculative.

Berkanovic and Telesky 1985 found in a general population sample that African Americans were more likely to seek care if they had a regular provider. To the extent that they lacked continuity of care before qualifying for Medicare, the finding for African Americans and immigrants might be a function of their newly acquired membership in an HMO. Because many countries of origin are represented in this group, it is unlikely that the immigrants are expressing a specific cultural bias. Perhaps something about their self-selection (Morgan 1973) or the immigration experience itself (Pescosolido 1986) is at work. On the other hand, the implied reference group—U.S.-born, non-African Americans—may share a "matter of fact" orientation to health and health care (Zborowski 1969; Zola 1973).

The tendency of the older old to seek care for these illness episodes may reflect their chronological age or social cohort membership. They may share an age-appropriate concern about their susceptibility to, and the probable consequences of, illnesses. Differences in their life course experiences may account for different expectations, definitions, or explanatory models.

The negative association between experience with a chronic condition and "recommended" care-seeking suggests several hypotheses. People may have learned from their physicians how to care for their flare-ups at home with prescription drugs and behavioral regimens. They may have learned that their physicians cannot provide alleviation and/or a cure. Or, they may have developed over time a strategy that combines physician advice with self-treatment.

When the characteristics of the illness episode itself drive care-seeking, as is the case with serious "visit mandatory" episodes, the influences of the sociocultural environment may not be strongly felt. However, when the symptoms are less serious, and biomedicine has not provided a clear directive regarding medical care, considerations related to past experiences, life-cycle position, and/or cultural values may be more important.

In summary, techniques from cognitive anthropology have enhanced the application of a health services approach to understanding older adults' decisions about medical care. Using physicians' shared norms to categorize actual illness episodes for multivariate analyses allowed the identification of predictors for both medically unnecessary and necessary physician contacts. These predictors can be used to identify specific target groups and health education strategies for each that may result in more effective health education interventions than are found in the one-size-fits-all advice too often given the entire population.

	Acknowledgments

 
The National Institute on Aging/National Institutes of Health supported both the original project, "Psychological Distress and the Aged's Use of Services" (R01 AG05181, Emil Berkanovic, P.I.) and the secondary analyses "Decisions About HMO Use for Symptoms of Late Life Illness" (R29 AG10887, Margo-Lea Hurwicz, P.I.). A preliminary version of this paper was presented in March 1992 at the annual meeting of the Society for Applied Anthropology in Memphis, TN.

The authors would like to thank the editor and five anonymous reviewers for their helpful advice, and Ms. Valerie W. Duffy for her technical assistance.

Received for publication February 23, 1999. Accepted for publication August 3, 2001.

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