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Grant final reports now available from NTIS

The following grant final reports are now available for purchase from the National Technical Information Service (NTIS). Each listing identifies the project's principal investigator, his or her affiliation, grant number, and project period and provides a description of the project.

California Multicultural Health Information Institute. Carmen R. Nevarez, M.D., Public Health Institute, Berkeley, CA. AHRQ grant HS10071, project period 5/24/99-9/30/99.

The Public Health Institute convened the first California Multicultural Health Information Institute (MCHII) Symposium held May 26-28, 1999 at Preservation Park, Oakland, CA. The Symposium helped launch the MCHII, developed the concept for a Multicultural Health Information Institute Resource Center and its technical assistance capacity, and contributed ideas to the design and implementation of an Institute Web site to improve multicultural health statistics, data, and information accessibility. The symposium and the Multicultural Health Information Institute was developed through a collaborative effort between government, community, research, and academia.

Abstract, executive summary, final report, and attachments, NTIS accession no. PB2001-101628; 44 pp. ($25.50 paper, $12.00 microfiche) are available from NTIS.

Competition and Voluntary Disclosure of Quality Information: Theory and Empirical Evidence from HMO Markets. Zhe Jin, University of California, Los Angeles. AHRQ grant HS10168, project period 7/1/99 to 6/30/00.

This researcher investigated how market mechanisms affect the flow of information between sellers and buyers about the quality of health care services. The researcher examined which factors motivate health maintenance organizations (HMOs) to voluntarily disclose private information about their own service quality through the National Committee of Quality Assurance (NCQA) and found that competition plays a prominent role in encouraging disclosures. In comparison, disclosure costs and local demand factors explain some cross-sectional variations in disclosure decisions but contribute little to explaining changes in disclosures over time. The researcher also investigated how Medicare beneficiaries respond to the NCQA information in their actual choices of health plans and found mixed evidence. After controlling for contract-county fixed effects, one set of the information, i.e. whether a plan participates in the NCQA HEDIS report, has a positive and significant impact on consumer choice of health plan. This is consistent with the theoretical predication that disclosing HMOs are likely to be high quality firms. But the effect of another set of information, i.e. whether a plan has sought accreditation via the NCQA, is sensitive to competitive environments and the extent to which an HMO provides services to Medicare patients.

Abstract and executive summary of dissertation (NTIS accession no. PB2001-101798; 12 pp, $23.00 paper, $12.00 microfiche) are available from NTIS.

Depression Care Using Computerized Decision Support. Bruce L. Rollman, M.D., M.P.H., University of Pittsburgh, Pittsburgh, PA. AHRQ grant HS09421, project period 9/30/96-3/31/00.

This report describes the first large-scale clinical trial to analyze the clinical outcomes resulting from providing primary care physicians with electronic feedback and ongoing treatment advice for patients with major depression or any other psychiatric condition. It describes the study goals, summarizes findings, and presents detailed information on the methodology employed during the study. The conceptual considerations and practical barriers to electronic guideline dissemination encountered by the researchers have implications for others considering EMR-based strategies to improve the quality of primary care for depression and other chronic conditions.

Abstract, executive summary, and final report (NTIS accession no. PB2001-101677; 130 pp, $36.00 paper, $17.00 microfiche) are available from NTIS.

Dissemination of a Quit Smoking Program: 1-Year Followup. Clara Manfredi, Ph.D., University of Illinois, Chicago. AHRQ grant HS09837, project period 9/30/98-9/29/00.

This study assessed the implementation of a smoking cessation program in 17 agencies providing case management visits to women in maternal and child health (MCH) programs over a 2-year period after the program was disseminated to case managers through a training workshop. The researchers interviewed 22 administrators and 63 case managers in the 17 agencies to assess agency-level implementation processes and degree of program implementation by case managers. They found that identification and recording of smoking status occurred for all case management clients. This component was institutionalized through the availability of a computerized instrument and specific protocols and contractual requirements for its use. Implementation of the other program components varied. Counseling of smokers was common and supported by agency and MCH policies but probably limited to minimal advice to quit. Status updates and repeated counseling at subsequent visits and referral of smokers to other services were less common. Booklets about quitting and client-provider "agreement" forms were not easily available and hardly ever used. These other components were not supported by agency-level implementation processes, such as having specific protocols and documentation requirements, or ensuring supplies of intervention materials. In contrast, program implementation by case managers was best predicted by agency-level factors, including perceived priority of counseling to the agency, documentation requirements, having protocols that required counseling, and a smaller client caseload. Perceived client interest, program effectiveness, and positive feedback from smokers also improved implementation.

Abstract, executive summary, and final report (NTIS accession no. PB2001-102565; 60 pp, $27.00 paper, $12.00 microfiche) are available from NTIS.

Evaluation of a Model of Managed Care for Sickle Cell Disease. Thomas R. Konrad, Ph.D., University of North Carolina, Chapel Hill. AHRQ grant HS09553, project period 9/30/97-9/29/99.

Relationships between hospital resource use by sickle cell patients, their clinical profiles, and hospital characteristics were examined for 6,362 patients with a primary diagnosis of sickle cell disease using International Classification of Clinical Services (ICCS) and American Hospital Association (AHA) survey data. Random effects least squares regression analyses explored relationships between patient and hospital characteristics and hospital charges and length of stay, including controls for disease severity. Results indicated that disease severity and age related significantly to total hospital charges, length of stay, and average daily charges. Payment source was unrelated to charges or resource use. Hospitals without trauma centers had daily charges 22 percent lower than hospitals with such centers. An algorithm developed to predict lengths of stay and charges can be used to estimate potential cost savings from intensive outpatient management of painful sickle cell episodes. Charges for hospitalization for painful episodes with no major or minor comorbidities are about $1,400 per day or $4,000 per hospitalization. If hospitalizations could be prevented, some accrued savings could be invested in improved clinical management through outpatient admissions or ambulatory care programs.

Abstract, executive summary, and final report (NTIS accession no. PB2001-101436; 22 pp, $23.00 paper, $12.00 microfiche) are available from NTIS.

First Rocky Mountain Workshop on How to Practice Evidence-Based Health Care. Phoebe L. Barton, Ph.D., University of Colorado, Denver. AHRQ grant HS10073, project period 7/1/99-6/30/00.

Over the past 25 years, clinicians, epidemiologists, biostatisticians, health economists, and others have been working together to combine basic scientific principles with common sense in order to arm clinicians and other decisionmakers with the skills necessary to practice evidence-based health care. Although local efforts to introduce and teach the concepts of evidence-based medicine have been developing in many programs and practices around the country, larger efforts aimed at state-of-the-art training by nationally and internationally recognized experts have been limited or nonexistent in the United States. The goal of this workshop was to introduce and teach the concepts of evidence-based medicine to clinicians and other decisionmakers. Using a problem-based, small-group format, participants at this August 1999 workshop developed questions, identified and synthesized relevant evidence, critically appraised the evidence, and learned to apply these skills in a clinical setting.

Abstract, executive summary, and final report (NTIS accession no. PB2001-101799; 24 pp, $23.00 paper, $12.00 microfiche) are available from NTIS.

Health Insurance and Use of Medical Care by the Disabled. Virginia Wilcox-Gok, Ph.D., Northern Illinois University, Dekalb. AHRQ grant HS07687, project period 7/1/96-7/31/97.

These investigators examined public and private health insurance coverage and use of medical care by disabled Medicare enrollees using the National Medical Expenditure Survey (1987) data. Supplemental health insurance was analyzed jointly with three measures of medical care use: probability of a doctor visit, number of visits, and probability of a hospital stay. They found that Medicare enrollees are much more likely than disabled enrollees to have private health insurance. Disabled Medicare enrollees are more likely than aged enrollees to have Medicaid coverage or to have no coverage beyond Medicare. Among Medicare enrollees with private health insurance, the aged are twice as likely as the disabled to have individual insurance policies. Disabled Medicare enrollees are more likely than the aged to have Medicaid, while aged Medicare enrollees are more likely to have private health insurance. Private health insurance has a direct negative effect on having at least one visit to an emergency room and having at least one hospital admission.

Abstract, executive summary, and final report (NTIS accession no. PB2001-101762; 78 pp, $29.50 paper, $12.00 microfiche) are available from NTIS.

Managed Care, Physician Referral, and Medical Outcomes. David E. Grembowski, Ph.D., University of Washington, Seattle. AHRQ grant HS06833, project period 5/1/95-11/30/99.

The goal of this project was to determine whether managed care controls are associated with reduced access to specialists and worse outcomes of care among primary care patients with pain and depressive symptoms. In a prospective cohort design, 17,187 patients were screened in the waiting rooms of 261 primary physicians in the Seattle area to identify 2,850 English-speaking adult patients with pain and/or depressive symptoms. Patients were followed for 6 months to measure referrals, specialist care, and outcomes. The intensity of managed care was measured for health insurance plans, offices, and physicians. The researchers looked for associations between managed care variables, access to specialists, and outcomes. They found that referrals and use of specialty care were common and similar in less versus more managed plans and offices. However, for pain patients and low-income depression patients, a financial penalty for referral was associated with fewer referrals. Depression patients who were referred for speciality care had fewer referrals to psychiatrists. Health outcomes were similar in less versus more managed settings, but patient dissatisfaction with their primary physicians was greater in more managed plans and offices. Managed care generally was not associated with reduced access to specialists and adverse health outcomes, but reductions in patient satisfaction with primary physicians were detected.

Abstract, executive summary, and final report (NTIS accession no. PB2001-102024; 26 pp, $23.00 paper, $12.00 microfiche) are available from NTIS.

Managed Care, University Research, and Training Partnerships. Alfred A. Rimm, Ph.D., Case Western Reserve University, Cleveland, OH. AHRQ grant HS09797, project period 8/1/98-7/31/00.

The objective of this project was to strengthen linkages between health services researchers at Case Western Reserve University medical school and affiliated hospitals and Henry Ford Health System, which has a strong managed care component; develop health services research (HSR) curricula; and build HSR capacity. This was accomplished through a survey of health care professionals in the two institutions regarding their interests in and need for training in HSR methods and techniques. The survey results can be used to inform the design of HSR training programs for health care professionals working in academic medical centers and managed care organizations. The researchers also developed an annotated syllabus that summarizes key concepts and publications on conducting HSR in managed care settings. It can be used for self-study by researchers who are beginning research in managed care settings and in planning traditional HSR courses, short courses, and training modules.

Abstract, executive summary, and final report (NTIS accession no. PB2001-101629; 66 pp, $27.00 paper, $12.00 microfiche) are available from NTIS.

Multisited Ethnography of the Emergence of Hospitalist Medicine. Philippa Strelitz, M.P., University of California, San Francisco. AHRQ grant HS10169, project period 8/1/99-7/31/00.

Today, when patients need hospital care, primary care physicians often "hand off" their patients to hospitalists, who work full-time in inpatient settings and specialize in caring for acutely ill patients. The hospitalist model is rapidly becoming the pervasive model of inpatient health services delivery, but its impact on and consequences for patients and physicians have yet to be examined. This researcher tracked the emergence of hospitalist medicine and explored its impact and consequences for patients and physicians from a cultural perspective at the local level—in a community hospital and a teaching hospital in Northern California—and at the national level, by investigating the academic, professional, and political activities geared towards legitimizing hospitalists.

Abstract, executive summary, and final report (NTIS accession no. PB2001-101437; 16 pp, $23.00 paper, $12.00 microfiche) are available from NTIS.

Predictors of Health Insurance Coverage After Welfare Exit. Julie A. Hudman, Ph.D., Johns Hopkins University, Baltimore, MD. AHRQ grant HS10162, project period 7/1/99-6/30/00.

This author examined how welfare reform affects health insurance for low-income families. Primary data were collected in three cities from 30 in-depth interviews with caseworkers and local welfare office administrators. Also, data from the National Survey of America's Families (NSAF), supplemented with State-level policy variables, were analyzed. The study found that welfare reform has had unintended and negative effects on health coverage for families. Generosity of a State's Medicaid does not, by itself, explain health coverage provided to former welfare recipients. Welfare policies, especially diversion policies such as mandatory job search, and time-limit policies play a significant and negative role in the ability of families who have left welfare to maintain Medicaid coverage. Furthermore, administration of Medicaid and welfare were found to make a difference in health coverage; welfare messages spill over to Medicaid. Finally, the author found that the front-line personnel implementing welfare reform play a very important role in families' health coverage. Welfare reform has given Medicaid the opportunity to operate as a stand-alone health insurance program for low-income working families and to reduce its image as a welfare program. However, it will only work if States take full advantage of this opportunity.

Abstract and executive summary (NTIS accession no. PB2001-101796; 16 pp, $23.00 paper, $12.00 microfiche) are available from NTIS.

Public Mental Health Outcomes Risk-Adjustment. Michael S. Hendryx, Ph.D., Washington Institute for Mental Illness Research and Training, Spokane. AHRQ grant HS09851, project period 7/1/99-6/30/00.

"Mental Health Outcomes Risk Adjustment: A National Research Development Conference" took place in Spokane, WA, August 16-18, 1999. The conference included research presentations on issues and methods of mental health outcomes risk-adjustment and workgroup discussions to identify specific next steps that participants could undertake to advance the field.

Abstract and final conference report (NTIS accession no. PB2001-101797; 14 pp, $23.00 paper, $12.00 microfiche) are available from NTIS.

Race, Socioeconomic Status, and Family Structure: Determinants of Long-term Care Arrangements. Kathleen Cagney, Ph.D., Johns Hopkins University, Baltimore, MD. AHRQ grant HS09334, project period 9/30/96-9/29/97.

This author explored whether the use of skilled nursing facility (SNF) care and Medicare home health (HH) differs by race and investigated the extent to which family structure and socioeconomic status (SES) explain any differences observed. Linking the 1989 National Long-term Care Survey to Medicare claims data, the author used a Cox proportional hazards modeling approach to examine SNF care and HH, both individually and as competing risks, over a 5-year period. Age at first use is the outcome measure, consistent with the analysis of long-term care as a life-course transition. Results indicate that blacks postpone both HH and SNF care until a later age than whites, and that both children and grandchildren play a part in deferring this use until they are even older. When formal assistance is needed, blacks are more apt than whites to use HH over SNF care. The racial difference in SNF use is even greater than that previously reported for all types of nursing home use combined. SES has little influence on the risk differential. Results suggest that there are differences in need, preference, or access that are yet to be identified. Closer examination of factors determined at earlier stages of the life course may provide additional insights.

Abstract, executive summary, and final report (NTIS accession no. PB2001-101778; 256 pp, $54.00 paper, $23.00 microfiche) are available from NTIS.

Racial Differences in Medical Care Satisfaction. Jennifer Malat, Ph.D., University of Michigan, Ann Arbor. AHRQ grant HS09894, project period 8/1/98-4/30/00.

Blacks are less likely than whites to be satisfied with their health care. The author tested three potential sources of the gap in satisfaction: one, racial differences in health status, two, differences at the structural level in access to and source of care, and three, differences at the individual level in how health care providers treat patients. The author analyzed original focus group data and secondary quantitative data from the 1995 Detroit Area Study and found that blacks' worse average health status does not account for lower satisfaction with health care providers. Also, the quantitative data did not indicate that access to or source of care can explain much of the racial gap in satisfaction with care. However, in nearly every focus group participants explained that patients with Blue Cross/Blue Shield receive better care than those covered by health maintenance organizations or public insurance. Finally, whites' reduced social distance from their health care provider—i.e., their greater likelihood of having a same-race health care provider and of having a higher income like their health care provider—explains much of the racial variation in satisfaction. Focus group data support the importance of having a health care provider with whom there is a personal connection.

Abstract and executive summary (NTIS accession no. PB2001-102023; 22 pp, $23.00 paper, $12.00 microfiche) are available from NTIS.

Required Request: Determinants of Family Consent. Laura A. Siminoff, Ph.D., Case Western Reserve University, Cleveland, OH. AHRQ grant HS08209, project period 9/1/96-12/31/99.

The goal of this project was to examine the factors affecting decisions about the donation of organs, tissues, and corneas. The authors recruited 420 organ-eligible families from nine acute care general hospitals in two metropolitan areas. This 4-year study involved collection of analogous data from donor-eligible patients' families and the HCPs (health care providers) and relevant OPO (organ procurement organization) staff directly involved in requesting donation. The family interview was an in-depth, taped interview designed to document potential donor families' experiences and the factors affecting their decisions about donation. The HCP interview was a briefer, structured interview designed to elicit information about discussions with the family. Cases were identified through prospective review of all deaths at study hospitals. Almost 80 percent of all eligible families were asked to donate organs, but only 46.2 percent actually agreed to donate. Major factors associated with lack of consent were older age of patients, ethnicity (black race), spending less time discussing donor-related issues, spending less time with OPO staff person, and the family holding less positive beliefs about organ donation and transplantation prior to entering the hospital setting. The authors identified areas that are potentially amenable to public education and in-hospital interventions.

Abstract, executive summary, and final report (NTIS accession no. PB2000-105180; 40 pp, $25.50 paper, $12.00 microfiche) are available from NTIS.

Risk Adjustment Methods for Hysterectomy Complications. Evan R. Myers, M.D., M.P.H., Duke University Medical Center, Durham, NC. AHRQ grant HS09760, project period 5/1/98-4/30/00.

Risk adjustment methods based on administrative data may not accurately predict adverse outcomes for conditions or procedures that are performed in younger, healthier populations. The researchers used hospital discharge data from North Carolina from 1988-1994 to assess the ability of logistic regression models to predict surgical and medical complications after hysterectomy, a commonly performed procedure in younger women. Models for medical complications had better discrimination then models for surgical complications. To determine if uncoded factors explained some of the surgical complication risk, the researchers examined records of all women undergoing hysterectomy for uterine fibroids, the most frequent single indication for hysterectomy and one with substantial racial differences in incidence and outcome, at a single institution from 1992-1998. Although black women had a significantly higher crude risk for complications, the majority of this risk was attributable to differences in baseline characteristics—specifically obesity, anemia, increasing uterine size, and adhesions. Oophorectomy (removal of an ovary) and other concurrent procedures also were significant independent predictors of complications. Given the high incidence of fibroids, a risk-adjustment model based on these factors could have substantial public health impact by allowing comparison of outcomes between providers if validated in prospective studies in different settings.

Abstract, executive summary, and final report (NTIS accession no. PB2001-101763; 86 pp, $29.50 paper, $12.00 microfiche) are available from NTIS.

Trial of Two Decision Aids for Colon Cancer Screening. James G. Dolan, M.D., Unity Health System, Rochester, NY. AHRQ grant HS10728, project period 9/30/99-9/29/00.

This randomized controlled trial compared the effects of a patient decision aid based on multi-criteria decisionmaking theory with those of a simple education intervention on the process and outcome of decisions about colorectal cancer screening for 96 average-risk patients seen in a primary care office in Rochester, NY. Patients who used the decision aid had lower conflict regarding colorectal cancer screening decisions. This improvement in patients' decisionmaking process was due to increased knowledge, better clarity of values, and higher patient ratings of the quality of the decisions they made. There was no difference between the groups in decision outcomes: 52 percent of patients in the control group and 49 percent of patients in the experimental group completed planned screening tests. The decision aid had no effect on follow-through with screening decisions.

Abstract, executive summary, and final report (NTIS accession no. PB2001-102564; 68 pp, $27.00 paper, $12.00 microfiche) are available from NTIS.

Validation of Quality Measures for Hip Replacement. Jeffrey N. Katz, M.D., Brigham and Women's Hospital, Boston, MA. AHRQ grant HS09775, project period 7/1/98-6/30/00.

A panel of clinical and quality improvement experts recommended potential indicators of the quality of replacement (THR). The researchers validated these indicators empirically in a population-based sample of 5,211 Medicare beneficiaries who had primary THR in 171 randomly selected hospitals in three States. Urban, private, and teaching hospitals and hospitals with laminar airflow in the operating room and dedicated orthopedic units had lower rates of dislocation or infection within 90 days of surgery. These preliminary findings suggest that hospital characteristics are associated with outcomes and have a cumulative effect, but they do not fully explain the strong influence on outcome of hospital and surgeon case volume.

Abstract, executive summary, and final report (NTIS accession no. PB2001-101438; 40 pp, $25.50 paper, $12.00 microfiche) are available from NTIS.

Value of Medical Testing Prior to Cataract Surgery. Oliver D. Schein, M.D., M.P.H., Johns Hopkins University, Baltimore, MD. AHRQ grant HS08331, project period 9/1/94-8/31/00.

For this study, 18,189 patients undergoing 19,557 cataract surgeries at nine centers were randomized on a per operation basis to receive or not receive a standard battery of preoperative medical tests (electrocardiogram and complete blood count, and measurement of serum electrolytes, urea nitrogen, creatinine, and glucose) in addition to history and physical examination. Medical adverse events and interventions that occurred on the day of surgery through 7 days postoperatively were recorded. The medical outcomes of 9,408 patients undergoing 9,626 cataract surgeries in the no-routine-testing group and 9,441 patients undergoing 9,624 surgeries in the routine-testing group were assessed. The most frequent medical events during the study period were treatment for hypertension and arrhythmia (principally bradycardia). The overall rate of intra- and postoperative medical events was the same (31.3 events per 1,000 surgeries) in both groups. Further analysis revealed no benefit of routine testing by age, sex, race, American Society of Anesthesiologists (ASA) risk score, or medical history. The researchers conclude that routine medical testing before cataract surgery provides no measurable value in increasing the safety of cataract surgery.

Abstract, executive summary, and final report (NTIS accession no. PB2001-102025; 56 pp, $27.00 paper, $12.00 microfiche) are available from NTIS.

West Virginia Rural Managed Care Demonstration Center. Hilda R. Heady, M.S.W., West Virginia University, Morgantown. AHRQ grant HS08627, project period 9/30/94-9/29/00.

The West Virginia Rural Managed Care Demonstration Center supported activities that promote the delivery of cost-effective, quality care in rural areas. The primary objectives were to develop regional management information systems, develop leadership skills in rural primary care physicians, promote continuing education of rural providers in concepts of managed care, and educate policymakers and State health administrators regarding rural network formation and the development of locally owned, rural managed care products. The researchers assisted in network infrastructure development, helped the networks purchase software and hardware for their management information systems, and sponsored educational and leadership seminars for West Virginia providers.

Abstract, executive summary, and final report (NTIS accession no. PB2001-102562; 30 pp, $23.00 paper, $12.00 microfiche) are available from NTIS.

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