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Media Advisory Date: January 20, 2000
The Agency for Healthcare Research and Quality (AHRQ) works to improve the quality of health care, reduce costs, and broaden access to essential services. Here are some of the findings described in the latest issue of AHRQ's Research Activities.
Study Findings Call into Question Quality of Hospital Care Provided to Seriously Ill Elderly Blacks
Elderly black patients hospitalized for heart failure or pneumonia in three large states received poorer overall quality of care than other Medicare patients treated for the same illnesses, according to an AHRQ-funded research project. And, for one of every 200 patients treated, such disparities may have resulted in death. Using separate nurse and physician panel reviews of 2,200 medical records, researchers at Harvard's School of Public Health studied the outcomes of Medicare patients aged 65 and older. Quality disparities between races showed up in even basic hospital services such as physical exams, simple diagnostic tests, standard drug therapies and patient history-taking. And for community hospitals treating black heart failure patients, quality differences—when compared with teaching facilities—were even more pronounced. The project, led by Arnold M. Epstein, M.D. of the Harvard School of Public Health, is part of AHRQ's overall effort to speed the pace of translating research into practice and help reduce or eliminate differences in the quality of care. The findings in this particular study were based on medical records from over 500 hospitals in Illinois, New York and Pennsylvania for years 1991-1992.
["Quality of care by race and gender for congestive heart failure and pneumonia," by Dr. Epstein, John Z. Ayanian, M.D., Joel S. Weissman, Ph.D., and Scott Chasen-Taber, Ph.D., in the December 1999 issue of Medical Care 37(12), pp. 1260-1269.]
Financial Incentives Influence Doctors' Decisions About Mental Health Treatments
The mental health services a person receives depends not only on the benefits covered by his or her health plan, but also on the financial incentives offered to doctors to provide or withhold such services. For instance, a new AHRQ-supported study found that patient mental health visits went down 25 percent when doctors were no longer paid on a fee-for-service (FFS) basis but instead were given a fixed payment per patient (case rate) for all covered mental health treatment. FFS revenue raised visits by 34 percent relative to the case rate effect with no FFS revenue. Also, doctors paid by case rate appeared to refer patients to services less costly to themselves as substitutes for their own services, such as medications, self-help programs, and community health centers, notes study author Meredith B. Rosenthal, Ph.D., of the Harvard School of Public Health. She surveyed 26 group practices and independent practice associations about financial incentives, organizational factors influencing mental health treatment choice, and internal reimbursement schemes.
["Risk sharing in managed behavioral health care," by Dr. Rosenthal, in the September 1999 Health Affairs 18(5), pp. 204-213.]
Certain Factors Indicate Which Patients Are at Risk of Cardiac Problems After Major Noncardiac Surgery
Cardiovascular complications can occur in patients undergoing noncardiac surgery, according to an AHRQ-supported
study. Among those at increased risk for such complications are patients undergoing high-risk surgery (e.g., intraperitoneal, intrathoracic, or suprainguinal vascular surgery) and patients with a history of ischemic heart disease, congestive heart failure, or cerebrovascular disease. Also at greater risk are patients who are treated preoperatively with insulin and those whose preoperative serum creatinine is over 2.0 mg/dL. Based on
these and other findings, researchers at Brigham and Women's Hospital and Harvard Medical School developed an index to predict postoperative cardiac problems in noncardiac patients. The index could be used, for example, to confine routine noninvasive testing to patients at moderate risk for complications. The study was based on 4,315 patients aged 50 or older undergoing elective major noncardiac surgery procedures at a tertiary-care teaching hospital.
["Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery," by Thomas H. Lee, M.D., S.M., Edward R. Marcantonio, M.D., S.M., Carol M. Mangione, M.D., S.M., and others in the September 7 Circulation 100, pp. 1043-1049.]
Cholesterol Reduction Guidelines for Primary Prevention Should Complement More Effective Secondary Prevention Efforts
Reducing cholesterol levels among those who already have coronary artery disease (CAD) is more effective than
preventing elevated levels in people without CAD. Therefore, clinical guidelines for primary prevention issued by the National Cholesterol Education Program (NCEP) should be complementary to secondary prevention efforts, according to an AHRQ supported-study. The comparatively greater benefits of secondary prevention are due to the higher risks of those who already have CAD and to the more aggressive goal of LDL reduction set for this group. Researchers found that prevention efforts in those without CAD would yield only about half the benefits of prevention efforts for those with CAD, despite requiring nearly twice as many person-years of treatment. The study, led by Milton C. Weinstein, Ph.D., of the Harvard School of Public Health, estimated the potential for the NCEP guidelines under varying assumptions to reduce CAD morbidity and mortality. Weinstein and colleagues also studied NCEP potential for reducing mortality between years 2000 and 2020. The study used a simulated model of the U.S. population, aged 35-84 years.
["The relative influence of secondary versus primary prevention using the National Cholesterol Education Program adult treatment panel II guidelines," by Dr. Weinstein, Lee Goldman, M.D., M.P.H., Pamela Coxson, Ph.D., Maria G.M.
Hunink, M.D., Ph. D., and others, in the September 1999 Journal of the American College of Cardiology 34(3), pp. 768-776.]
Other articles in Research Activities include findings on:
- Alternative to medication for common type of tachycardia.
- Shared decisionmaking in prostrate screening decisions.
- Surgeons' attitudes and area variations in knee surgery.
- Preference by HMO-enrolled women for OB/GYNs in routine gynecological exams.
- Impact of monthly Medicaid recertification on quality of children's health care.
- Comparison of expenditures for Medicare beneficiaries in two HMO types.
- New therapies for schizophrenia patients.
- Improving depression care by primary care doctors in local managed care settings.
- Benefits of Virginia rural cancer outreach program.
- Cost-effectiveness of azithromycin in preventing a common AIDS infection.
For additional information, contact AHRQ Public Affairs, (301) 427-1364: Salina Prasad, (301) 427-1864 (SPrasad@ahrq.gov).