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Performance Budget Submission for Congressional Justification

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How AHCPR's Research Helps People


During the past decade, the work of the Agency for Health Care Policy and Research (AHCPR) focused mainly on the development of knowledge, leaving translation, adoption, and measurable impact to other forces. However, it is clear that the work of research is only "half done" with the publication of findings in major research journals. AHCPR's fiscal year 2000 budget request represents a clear shift in its research focus towards promoting the adoption and use of research findings. The following are examples of how AHCPR-funded research has been translated into practice and the kind of research that will be increased and intensified at the fiscal year 2000 request level.


Contents

Stroke Prevention
Prostate Disease
AHCPR Research and Medicare Policy
Low Birthweight PORT
Heart Disease
Community-Acquired Pneumonia
Back Pain
Ear Infections
Put Prevention Into Practice (PPIP)
Reducing Medical Errors
Quality Assessment Tool and State Quality Initiatives
Informing Federal and State Policy on Market Consolidations
Consumer Assessment of Health Plans (CAHPS®)
Technology Assessments
Diabetes and Quality Improvement
MEPS Data

Stroke Prevention

Stroke is the leading cause of serious, long-term disability in the United States. Atrial fibrillation (AF), a condition that causes 80,000 strokes annually in Medicare patients, occurs in 1.9 million Americans over the age of 65. One-third of patients with AF who should be getting anticoagulation aren't receiving the drug therapy.

  • The Stroke Patient Outcome Research Team (PORT) helped establish anticoagulation ("blood-thinning") drug therapy as the treatment of choice for stroke prevention for patients with atrial fibrillation, and, if the therapy is used properly, is less dangerous to prescribe than many physicians previously believed.
  • However, anticoagulation is underutilized, and when used, monitoring may be inadequate according to a survey of 2,000 physicians across the country.
  • Subsequently, Peer Review Organizations (PROs) implemented projects in 42 States to increase anticoagulation rates in these patients. Data from 20 of these States showed that the frequency with which eligible patients were discharged on anticoagulation therapy increased to 71 percent from 58 percent before the projects began. Researchers estimate that this quality intervention may have prevented over 1,200 strokes.

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Prostate Disease

In 1995, there were 2.9 million ambulatory care visits due to enlargement of the prostate and 2.4 million visits due to prostate cancer. Prostate cancer caused 34,000 deaths in 1996. In 1994, 88,000 biopsies of the prostate and 284,000 prostatecomies were performed.

  • Many accomplishments of the AHCPR-funded prostate Patient Outcomes Research Teams (PORTs) involve clarification of the risks and benefits of treatment and involvement of patients in the treatment decision.
  • In collaboration with the American Urological Association (AUA), the PORT developed and validated the AUA symptom index to help quantify prostate symptoms. The symptom index is used to manage patients once a diagnosis of enlargement of the prostate is made. Its greatest use is in determining who will benefit most from surgery. It can also be used to evaluate patients over time. For example, it can be used at yearly visits to see if a patient's symptoms are getting worse or it can be used after surgery to see how symptoms have improved. It can also be used to compare outcomes for different urologists following a variety of interventions. This index was found to be a much better measure of symptom severity than a number of physiological and anatomic measures commonly used in practice.
  • The PORT's close collaboration with the AUA has been instrumental in implementing its findings and the use of the AUA symptom score. Now 99 percent of practicing urologists and 61 percent of primary care physicians are aware of the symptom score, and over 60 percent of practicing urologists now use the symptom score. Its use has changed the way urologists and primary care physicians practice, with greater attention to informed patient decisionmaking.
  • Men with noncancerous enlargement of the prostate will make different choices of whether to undergo surgical, non-surgical or no treatment when informed of the potential risks and benefits of each option. When an interactive video disc, the Shared Decisionmaking Program, was used in two managed care settings, 27 percent of men initially favoring surgery changed their mind and opted for watchful waiting. And, regardless of the treatment chosen, participation in decisionmaking, through the use of the video disc, increased patient satisfaction.
  • National rates of surgery for noncancerous enlargement of the prostate have decreased 50 percent in the last 10 years. Although, overall rates had decreased 20 percent before the PORT was funded, the investigators' key findings in part led to this result. The PORT showed that the risks of surgery are higher than previously appreciated; the benefits of surgery are less than physicians and patients knew with no increase in survival; and complications from watchful waiting are lower than previously thought. When presented with all the facts, many men choose not to have surgery.

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AHCPR Research and Medicare Policy

AHCPR research has also been a rich source of information for Medicare program policymakers, as they made administrative decisions and assessed the effects of program policies.

  • AHCPR—sponsored research documenting the extent of errors in medication delivery was the basis for a recent proposal by the Health Care Financing Administration (HCFA) that hospitals participating in Medicare be required to have systems in place to evaluate adverse drug events and address medication errors.
  • AHCPR-supported researchers studied the outcomes of patients with pneumonia, a common cause of hospitalization in elderly people. They developed a clinical prediction rule for clinicians to determine which patients with pneumonia can be safely treated at home, an option that not only reduces Medicare costs but is preferred by many patients.
  • AHCPR, in partnership with other groups, is sponsoring a set of projects that will provide evidence-based research about how particular managed care policies affect the quality of care for patients living with chronic illness. By examining what managed care features affect the quality of care for people with diseases such as glaucoma, high blood pressure, and chronic lung disease and how they get their care, AHCPR research is laying the groundwork for the next decade's strategies—to know not only what is effective, but how to manage care so that Medicare patients get the best care possible.

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Low Birthweight PORT

Though infant mortality rates in the United States have declined, the incidence of low birthweight babies has increased over the last 15 years. Seventy percent of infant mortality traces to low birthweight newborns. Also, low birthweight babies often require extensive and costly treatments. An AHCPR-sponsored PORT studied the use of corticosteroid drugs as one treatment to reduce morbidity and mortality in these newborns. It is known that for these premature newborns, corticosteroids can prevent many of the complications associated with prematurity—respiratory distress syndrome, brain hemorrhage, and death.

  • Based on the PORT's work and other findings, health care organizations, continuing medical education directors at hospitals, deans of medical schools, and directors of State and county medical societies received recommendations to change their practices. The media and major medical journals also covered the release of the recommendations.
  • Prior to the release of the recommendation, only 30 percent of newborns delivered prematurely received corticosteroids. By 1996, this had risen to 70 percent.
  • PORT researchers also used a five-step intervention to increase doctors' use of corticosteroids. The quality improvement program included enlisting local medical opinion leaders to encourage doctors to administer corticosteroids, grand rounds (teaching method) on corticosteroids, reminders in medical charts to use them, regular discussions with doctors on the various preterm scenarios, and ongoing feedback on their performance. This intervention resulted in an additional 33 percent increase in the use of corticosteroids over and above the increase seen at institutions that did not receive the intervention.
  • The PORT review contributed to New York State and United HealthCare policies to improve rates of appropriate use.

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Heart Disease

Heart disease is the number one cause of death in the United States. According to death certificates, there were 734,000 heart disease deaths in 1996. There were over 4 million hospital admissions and 20 million hospital days due to heart disease in 1995. It is estimated that there are 13,900,000 victims of angina (chest pain), heart attack and other forms of coronary heart disease.

Acute Cardiac Ischemia Time-insensitive Predictive Instrument (ACI-TIPI)

There are an estimated 1.25 million heart attacks yearly in the United States. Of the patients who go to emergency rooms, approximately 5 percent are not admitted. AHCPR-supported research developed a computerized decision-support system added on to a standard electrocardiograph (ECG), called the Acute Cardiac Ischemia Time-insensitive Predictive Instrument (ACI-TIPI). When a patient with chest pain comes to the emergency department, the instrument aids rapid evaluation by combining patient risk factors with an ECG analysis to compute the likelihood of a heart attack.

  • This tool successfully reduced hospital admissions for patients who had chest pain but no heart attack, without reducing admissions for those who actually suffered a heart attack.
  • A major manufacturer of medical equipment has now incorporated this as a standard feature in all of its new ECG machines.
  • Nationwide, this could represent a savings of $728 million a year or $100 for each emergency department visit for chest pain, without compromising care.
  • In addition to improved efficiency, this intervention also allows physicians to identify patients who are actually having a heart attack more quickly so that administration of cardiac drugs, shown to reduce complications and death when given early, can be expedited.

Hospitalization and Heart Attacks

One group of AHCPR-funded investigators has tested the effectiveness of a chest pain observation unit, located in a hospital emergency department, for patients experiencing a possible heart attack. These chest pain units are areas with dedicated staff, resources and validated management protocols. Over 400 units are now established in urban emergency rooms across the country, and the number is increasing by 6 percent annually. The units have some very positive effects:

  • Fewer heart attacks go undiagnosed compared to hospitals without the observation units because fewer patients are mistakenly sent home without being observed. Simultaneously, fewer patients are admitted needlessly to the hospital.
  • Missed heart attacks decreased from 4.5 percent to 0.4 percent, while admission rates decreased from 57 percent to 48 percent.
  • Savings in total hospital costs are calculated at $567 per patient.
  • Patients who receive treatment in the chest pain units are more satisfied with their care, compared to those actually admitted to inpatient cardiac units for observation.
  • Since the dissemination of the results of this research, implementation of chest pain units are now widespread (38 percent of metropolitan Emergency Rooms).

Treatment for Coronary Artery Disease

Each year approximately 1 million Americans undergo cardiac revascularization procedures for coronary artery disease. In 1995, 434,000 has one type of procedure called a balloon angioplasty and 573,000 had another type called a coronary artery bypass graft (CABG).

The frequency of CABG surgery has been increasing steadily over the last 25 years. In 1989, the New York State Department of Health developed the Cardiac Surgery Reporting System (CSRS), to collect information on risk factors, mortality, and complications from CABG procedures. This information was then made available to the public.

  • AHCPR-funded researchers assessed 4 years of these data to determine whether the disseminated information had an effect on surgeon and hospital performance. They showed that the number of deaths statewide from CABG surgery dropped a substantial 41 percent over the study period, even though the number of surgeries actually increased during that time. However, both cardiac surgeons who performed more CABGs and hospitals where more CABGs were performed were found to be associated with lower mortality rates.
  • As a result of this study, the American College of Cardiology and the American Heart Association have developed recommendations for the minimum number of CABG procedures that can be performed by both hospitals and physicians.
  • Initially it was feared that both surgeons and hospitals were avoiding high-risk cases to improve their performance reports. However, further AHCPR research showed that the dramatic drop in mortality was not simply a result of shifting the sickest cases to the better performers. The decrease was found to be partly due to the exodus of surgeons who performed fewer procedures; an influx of new, high-performing surgeons moving into the State; and improved hospital policies for CABG surgery.
  • In short, the decrease was believed to be a direct result of the quality improvement activities undertaken by hospitals and physicians in New York to improve CABG outcomes in response to the AHCPR-funded research findings.

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Community-Acquired Pneumonia

Each year, 4 million adults develop community-acquired pneumonia (CAP), resulting in nearly 1 million hospitalizations, 452,000 of which are for Medicare patients. The annual cost is nearly $4 billion.

  • A multicenter study of Medicare patients determined that antibiotic administration within 8 hours of hospital arrival and blood culture collection within 24 hours of arrival were associated with lower 30-day mortality rates. The fact that States varied widely in the performance of these measures suggests that opportunities exist to improve hospital care of elderly patients with pneumonia.
  • In addition, analyses of outcomes in patients with CAP suggest that more expensive antibiotic therapy and longer length of stay do not confer improved outcomes. In a study of 564 patients 60 years old or younger, use of low cost antibiotics ($5.43 vs $18.51) were not associated with any significant difference in outcomes.
  • Finally, 30 Peer Review Organization (PRO) projects, involving 332 acute care hospitals, demonstrated an increase in the percentage of patients obtaining antibiotics within 4 hours from 51.7 percent to 60.1 percent. HCFA estimates that this improvement resulted in prevention of 700 deaths from pneumonia.

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Back Pain

Back pain is a leading reason for physician visits, hospitalization, and work disability. An estimated two-thirds of adults have low back pain at some time in their lives. Back symptoms are the second leading symptomatic cause of all physician visits and are the leading cause for all visits to orthopaedic surgeons. It is estimated that low back pain is responsible for $24 billion in direct costs annually and, if one counts disability and lost work, $50 billion total annually.

  • As a result of an AHCPR-funded PORT on back pain, the standards of practice of back pain management have changed substantially. Ten years ago there was no evidence about the effectiveness of any of the many treatments for back pain. Now, the Low Back Pain Clinical Practice Guideline is used as a teaching tool in medical schools.
  • Outcome measures for Low Back Pain (LBP) developed by the PORT team are in use by the American Academy of Orthopaedic Surgeons and the North American Spine Society and have been disseminated nationwide.
  • In the face of escalating medical costs for injured workers, the Washington State Department of Labor and Industries worked with the back pain PORT to develop guidelines for elective lumbar fusion. Spinal fusion rates fell 33 percent after the guidelines went into effect, without any changes in outcomes.
  • A study published in the New England Journal of Medicine, comparing outcomes of patients with low back pain treated by chiropractors, physical therapists, or an inexpensive self-education booklet found that there were no differences in outcomes across the three groups.

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Ear Infections

Ear infections (otitis media), represent the sixth most common diagnosis for ambulatory care visits (22.7 million in 1996) and the third most common diagnosis for emergency department visits (3 million in 1995). About one-third of a pediatrician's time is spent diagnosing and managing ear infections. Approximately $5 billion is spent annually on direct costs of ear infections and a greater amount is estimated to be spent indirectly due to lost work, travel, long-term handicap and delayed language development. Ear infection is the most common cause for children to receive an antibiotic. Choosing the most effective and least expensive antibiotic is important because of the potentially avoidable expense as well as the potential to decrease the development of antibiotic resistance.

  • AHCPR-supported research showed that there was wide variation in the selection of antibiotics to treat ear infections and that less expensive antibiotics were associated with as good, or better, outcomes.
  • AHCPR research contributed to the development of a HEDIS quality measure that includes the use of Amoxicillin or other less-expensive first-line antibiotics as initial therapy for ear infections.
  • AHCPR research contributed to the American Academy of Pediatrics guidelines recommending the use of less-expensive first-line antibiotics as initial therapy for ear infections.

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Put Prevention Into Practice (PPIP)

Put Prevention Into Practice (PPIP) is a national, research-based public-private program to increase the appropriate use of clinical preventive services (screening, immunizations, and counseling). The Office of Disease Prevention and Health Promotion (ODPHP) launched PPIP in August 1994 as a way to improve implementation of the recommendations of the U.S. Preventive Services Task Force (USPSTF) and to overcome many of the barriers to the effective delivery of clinical preventive services. In 1998, management of the project was transferred to the AHCPR. (Select for About PPIP.)

PPIP materials are designed for three groups: health care systems and clinicians, the office/clinic staff, and consumers. All materials are research-based and promote a team approach to the delivery of preventive services. Materials include: the Clinician's Handbook of Preventive Services (2nd Edition), Personal Health Guide (for adults), and Child Health Guide, as well as a variety of posters, postcards, and sheets to track preventive care. Select to access PPIP materials online.

Since PPIP materials were first made available in 1994, private-sector companies; medical societies; academia; and Federal, State, and local government agencies have answered the call to action and have incorporated them into national, regional and local prevention-oriented clinical and educational activities. For example:

  • The Texas Department of Health made the improvement of the delivery of preventive services a priority in 1994 and established support systems throughout the State to encourage the implementation of PPIP. Specially trained registered nurses are stationed around the State in an effort to provide one-on-one instruction in the use of materials and PPIP implementation. The Department also provided start-up funds to primary care sites statewide, including several family practice residency programs, which have been successful change agents in implementing PPIP.
  • Using AHCPR's PPIP materials as a departure point, the Texas Department of Health developed companion pieces including a comprehensive health risk assessment, a targeted risk assessment, and a self-administered risk assessment, which are currently being pilot-tested in a rural health department. The Department also has plans to customize the Personal Health Guide to focus on the specific health needs of citizens in Texas.

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Reducing Medical Errors

AHCPR-supported research found that many adverse drug events are preventable if appropriate systems, such as computerized monitoring programs, are in place in hospitals to assure accuracy. As a result of this research:

  • Hospitals, ranging from the 700-bed Massachusetts General Hospital in Boston, where the study was conducted, to 60-bed rural community hospitals, are redesigning their information systems to prevent errors from occurring.
  • AHCPR supported "Enhancing Patient Safety and Reducing Errors in Health Care," a national-level conference that served as the springboard for the National Patient Safety Foundation (NPSF). The NPSF was launched in 1997 by the American Medical Association and a broad consortium of partners to investigate and reduce medical errors and promote drug safety.
  • The Joint Commission on Accreditation of Health Care Organizations (JCAHO) revised its policy on reporting medical errors largely as a result of AHCPR's research. Now, instead of placing an accredited hospital that reports a serious mistake on accreditation watch (thereby alerting the public to a possible downgrade of its standing), the hospital is now given time to investigate the root causes of the mistake and take corrective action.

Select for more information on reducing errors in health care.

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Quality Assessment Tool and State Quality Initiatives

Any improvement effort begins with information, and information empowers. Hospitals, hospital systems, and community and State health partnerships are using HCUP Quality Indicators (QIs) to glean information useful in identifying and targeting clinical areas appropriate for quality improvement initiatives.

  • The Healthcare Association of New York State applied HCUP QIs to discharge data from over 200 of its member hospitals throughout the State, and it provided each hospital with a customized report on the quality of care in the facility, including an analysis of how each compares with other hospitals. The customized hospital analyses resulted in a number of quality initiatives. For example, one hospital's analysis prompted a large health system to create a regional center of excellence for the care of its diabetic patients. Another QI analysis led the association and its partners to work to improve adult immunization rates. Overall, the feedback from hospitals was overwhelming:

    —This is a wonderful tool!

    —The reports are great. They raise interesting issues for us, and our physicians want their own copies.

    —We just completed our JCAHO survey. The surveyors were very impressed with [our QI] report. It helped to ensure a very successful survey.

  • The Utah Department of Health applies the QIs to discharge data from Utah hospitals to monitor hospital performance statewide. This project, which began in 1992, also provides each hospital with information on other Utah hospitals and hospitals nationally, which they can use to see how they compare.

  • The Hawaii Health Information Corporation, a private, nonprofit State data organization, uses the QIs to analyze data to support 22 acute care hospitals in their quality improvement efforts. The hospitals recently received approval from JCAHO to incorporate HCUP QIs in their performance management initiative.

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Informing Federal and State Policy on Market Consolidations

For the last decade our health care system has been in a state of transition, characterized by consolidations and rapidly changing markets. One need look no further than Aetna's 1998 acquisitions of NYLCare and Prudential Health Care, resulting in a 39 percent market share in Philadelphia and similarly potent positions in numerous other markets to get a glimpse of the scope of changes underway (New York Times, January 13, 1999). Some consolidations, spurred by interest in achieving efficiencies and containing health care cost, ultimately yield a positive benefit to consumers. Others, however, are driven by a desire to exert market power and maximize revenue, which ultimately translates into higher costs borne by consumers.

Federal and State decisionmakers look to AHCPR for evidence as they sort through the myriad of market activities and develop antitrust policies:

  • In 1998, AHCPR staff briefed staff from the Federal Trade Commission (FTC) and Department of Justice on how research can be used in Federal oversight of hospital mergers and how competition (concentration ratios) affects hospital prices.
  • Also in 1998, a team of AHCPR staff briefed the FTC on the role of quality in competition in health care markets.
  • AHCPR grantees directly have shared policy relevant findings with decisionmakers. A recent grantee has shared his work on hospital mergers with the FTC and the Medicare Payment Advisory Commission (formerly the Prospective Payment Assessment Commission).

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Consumer Assessment of Health Plans (CAHPS®)

The Consumer Assessment of Health Plans (CAHPS®) provides an enrollee's-eye view of the quality of care and services provided by the plans based on a general assessment of the experiences of consumers with their plans (select to access CAHPS® Fact Sheet). CAHPS® information is provided to at least 90 million Americans consumers to make informed decisions about their health plan coverage by employers so they can select the plans they offer their employees and by the plans for quality monitoring and improvement. For example:

  • CAHPS® already has been used by more than 20 States, 10 employer groups, a wide range of health plans, and corporations including the Ford Motor Company.
  • In 1998, CAHPS® was adopted by the Office of Personnel Management for use by the Federal Employees Health Benefits Program to survey Federal employees and report the findings of the survey to them to help in the selection of health plans during the Federal open season. CAHPS® also was merged with the HEDIS Member Satisfaction Survey and will be used by the National Committee for Quality Assurance to evaluate and accredit commercial managed care plans. HCFA also has used a specially developed version of CAHPS® to survey Medicare enrollees in managed care plans to assess their experiences.
  • In the third quarter of 1997, the Ford Motor Company surveyed hourly and salaried employees in 13 Southeast Michigan plans and hourly employees in three Kansas City plans. A consumer report following CAHPS® recommendations was created and distributed to enrollees. In addition, an executive summary was issued to senior management.
  • Keystone Mercy Health Plan (Philadelphia, PA) surveyed its Medicaid members by telephone from September to October 1997 and presented the results using the CAHPS® print report format. Keystone Mercy plans to conduct CAHPS® on an annual basis.
  • The Texas Department of Health (Austin, TX) sponsored a survey of Medicaid managed care patients. The surveys were administered by mail and by phone during the spring and summer of 1998. Results of the survey were included in an annual report to the Texas Department of Health in September 1998, with tentative plans to survey additional plans in 1999.

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Technology Assessments

AHCPR's Technology Assessment on colon cancer screening contributed to Congress's decision to cover colorectal cancer screening as a Medicare program benefit and to HCFA's decisions regarding how to pay for this technology.

AHCPR's Technology Assessment on intermittent positive pressure breathing therapy (IPPB) contributed to HCFA's decision to restrict payment for some (ineffective) uses, while continuing to pay for specific uses. IPPB is a therapy that uses a ventilator to push additional air into the lungs of people who can breathe adequately on their own.

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Diabetes and Quality Improvement

A project sponsored by AHCPR that studied care in diabetic patients developed a new way of measuring disease severity based on a combination of patient-reported symptoms and other factors. This work has now become part of the Diabetes Quality Improvement Program, a common set of diabetes quality measures being developed jointly by HCFA and other groups to improve care and prevent later problems, such as kidney disease and skin ulcers, that are currently all too common in diabetic patients.

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MEPS Data

Using information generated from the Medical Expenditure Panel Survey (MEPS), information about near elderly workers and their insurance status was provided to policymakers throughout the country. This information was also summarized in the Economic Report of the President.

Between 1987 and 1996, the share of 55- to 64-year-old wage and salary workers who were covered by health insurance from a current employer—their own or a family member's—remained constant at 73 percent despite increased availability of health insurance from employers. While more employers of workers in this age group were offering coverage, the takeup rate—that is, the fraction of offers that were accepted by the worker—was falling. More of these older workers were getting their health coverage through a spouse's employer, as the share covered by health insurance from their main job fell by 2 percent, to 62 percent. The share of employees ages 55 to 64 who had access to health insurance coverage through either their own job or a family member's employment rose from 78 to 80 percent, but the percent of those with access who were covered dropped from 93 percent to 90 percent, possibly due to increased cost to the worker. Many of the rest had other private or public health insurance, but the fraction of 55- to 64-year-old non-self-employed workers who were uninsured increased by almost 3 percentage points, to 12 percent in 1996.

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