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Measures and doing worse on others. Implications for Health Care Provision: Although the VA and the private sector were comparable with respect to the quality measures used in this study, there is room for improvement in both systems. Treatment recommendations are based on the best available clinical evidence of effectiveness and safety. Quality of care might be improved with better adherence to these recommendations. Implications for Health Policies: Relatively low rates of adherence to treatment recommendations may be due to lack of awareness of these recommendations among prescribing physicians, or a belief that the recommendations are inadequate. To the extent that low rates of adherence to treatment recommendations are caused by a lack of awareness among physicians, policies should be developed to disseminate this information and encourage the appropriate use of these medications. Implications for Further Research: Further research is needed to understand physician prescribing decisions for these medications. To the extent that physicians feel treatment recommendations for these drugs are inadequate, further research is needed to refine the recommendations. Received 21 January 2003; accepted 22 September 2003.

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Disinfection was applied post-milking. Milking units were flushed with an automatic backflush system between cows. All cows were treated intramammarily at drying off with cephapirin. No bST or coliform vaccines were being used at the initiation of the study or during the study. Cows with naturally occurring clinical mastitis were detected by dairy personnel during routine milking procedures. Eighty-six percent of cases were in Holsteins, and 14% were in Jersey cows. A study collaborator examined the cow with clinical mastitis to classify the cow's condition as mild to moderate or severe based on the protocol in Table 1. Cows with clinical mastitis and one or fewer abnormal parameters were classified as having mild to moderate clinical mastitis and were used in the current study. Cows without evidence of clinical mastitis at the time of initial examination were not included in the study. Systemically ill cows with more than one abnormal parameter at the time of initial examination and cows with other concurrent diseases that required treatment were excluded. Cows with clinical mastitis that were included in the study were eligible for a new case of clinical mastitis 36 d after the previous case, provided that a microbiological cure occurred. If a cow was previously used in the study and a microbiological cure was not obtained, the cow was not eligible for inclusion again unless a different quarter was involved. Treatments and Method of Treatment Assignment Cows that met the criteria were systematically assigned to 1 of treatments after being stratified by stage of lactation. Stage of lactation was categorized as 0 to DIM, 91 to 180 DIM, and 180 DIM. Prior to initiation of the study, the 4 treatments were randomly identified as Treatments 1 to 4. Treatment 1 consisted and plavix, for instance, asian flush pepcid.

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