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New functional index can predict stroke survivors' likelihood of achieving a modified level of functional recovery
A newly developed index, based on certain characteristics of stroke survivors when they enter a rehabilitation facility, can predict which patients are more likely to achieve a modified level of functional independence. In other words, the index can predict which stroke patients are more apt to leave the rehabilitation facility, be able to eat, groom, and dress the upper body by themselves, manage bowel and bladder functions without accidents, transfer between bed and chair without physical assistance, and either propel a wheelchair or walk (with or without help).
Based on the index, the likelihood of achieving this stage of functioning was dramatically lower for patients who were older; unemployed; had longer times since stroke onset; had lower scores on daily living activities, mobility, and cognitive subscales; or were admitted from the community rather than from an acute hospital service. About 95 percent of persons who achieved modified functional independence, as defined above, were discharged home from rehabilitation facilities, compared with only 67 percent of those who did not achieve it, according to a study supported in part by the Agency for Health Care Policy and Research (HS07595).
Knowing a patients prognosis at the beginning of rehabilitation can help family caregivers plan for the type of care that will be needed when the patient is sent home, explains Margaret G. Stineman, M.D., of the University of Pennsylvania. Dr. Stineman and her colleagues constructed the Stroke RAM Index based on the records of 3,760 patients, who were discharged from 96 rehabilitation facilities in 31 States during 1990. The stage of modified functional independence predicted by the index was achieved by only 26 percent of patients functioning below this stage when they entered rehabilitation. The researchers point out the need for more tailored programs of treatment and community support services to assist these patients.
Details are in "A prediction model for functional recovery in stroke," by Dr. Stineman, Greg Maislin, M.S., M.A., Roger C. Fiedler, Ph.D., and Carl V. Granger, M.D., in the March 1997 issue of Stroke 28(3), pp. 550-556.
Racial differences persist in self-perceived health among elders who live alone
About 30 percent of elderly blacks and whites live alone. It has been thought that elderly blacks may be at higher risk of poor health than white elderly persons because of social and economic disadvantages. However, a recent study shows that older blacks who live alone are not at any higher risk of poor health than older whites who live alone, even though they perceive their health as poorer than their white counterparts.
It may be that blacks ascribe a different meaning than whites to the same level of functional capacity. Or it may be that some black elders, as a result of past difficulties in acquiring the health services they need, may be more pessimistic about their abilities to cope with declining health. This is important, since research has repeatedly linked perception of poor health with a higher rate of health problems and death, explains Chuck W. Peek, Ph.D., of the University of Florida, the study's lead investigator. His study, supported in part by the Agency for Health Care Policy and Research (NRSA Fellowship HS00086), was based on a sample of 1,200 survey respondents, who were selected in 1990 from among community-dwelling residents 65 years of age and older living in one of four counties in north Florida.
Black and white elders living alone did not differ significantly in number of chronic conditions, overall health status, and ability to perform daily living tasks such as eating and dressing. However, black elders were significantly more apt to report difficulty carrying out instrumental activities of daily living, such as shopping for groceries or doing light housework, than white elders living alone. These differences were accounted for in some but not all cases by other factors known to affect health, such as being female, older, and poor.
See "Race differences in the health of elders who live alone," by Raymond T. Coward, M.S.W., Ph.D., Dr. Peek, John C. Henretta, Ph.D., and others, in the May 1997 Journal of Aging and Health 9(2), pp. 147-170.
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Community-based prevention programs can positively affect some risky behaviors among disadvantaged youths
A recent study, supported in part by the Agency for Health Care Policy and Research (HS07392) found that disadvantaged black youths who participated in a community-based risk-behavior-reduction program were more apt to postpone initiation of specific risky behaviors, such as sexual intercourse. They also were less likely, if they did experiment with certain risky behaviors—for example, alcohol or tobacco use—to permanently adopt them. The
possibility of preventing experimentation from leading to adoption is an encouraging finding, according to Bonita Stanton, M.D., of the AHCPR-funded Center for Minority Health Research at the University of Maryland, Baltimore.
The researchers randomized 383 black youths 9 to 15 years of age to intervention and control groups. The intervention program focused on decisionmaking about behaviors that place youths at risk for AIDS, as well as behaviors that can protect against AIDS and other health problems. It consisted of eight weekly meetings conducted privately with groups of friends at the recreation centers and a 1-day session conducted at a rural campsite, monthly booster sessions over a 6-month period to review information and skills, and annual booster sessions at 15 and 27 months.
Intervention youths who were not engaging in unprotected sexual intercourse at the beginning of the study were more likely to continue to avoid this risky behavior than control youths. With the exception of unprotected sexual intercourse, the cumulative incidence of each risk behavior did not differ notably between intervention and control youths. However, the intervention did seem to avert the adoption (engage in a behavior for 1 year or more) of eight risky behaviors compared with experimentation (time-limited involvement). This difference was significant for drug use
(16 percent vs. 4 percent) and was of borderline significance for cigarette smoking (25 percent vs. 15 percent). However, intervention youths were not less likely than control youths to experiment with a risky behavior.
Details are in "Evolution of risk behaviors over 2 years among a cohort of urban African-American adolescents," by Dr. Stanton, Xiaoyi Fang, Ph.D., Xiaoming Li, Ph.D., and others, in the April 1997 Archives of Pediatric and Adolescent Medicine 151, pp. 398-406.
Most deaths among homeless persons occur in mid-life and are preventable
Homeless persons in the United States, who number between 500,000 and 3 million, often die in their 40s from preventable causes. A study of homeless adults in Boston found that the leading cause of death among homeless persons there depended on age. Homicide was the leading cause of death among men 18 to 44 years of age, followed by traumatic injury and poisoning (including alcohol- and drug-related deaths). AIDS was the leading cause of death in homeless men and women 25 to 44 years of age. Heart disease and cancer accounted for the most deaths in persons 45 to 64 years of age, with an incidence three times higher than that of the general population, according to the study which was supported by the Agency for Health Care Policy and Research (NRSA training grant HS00020).
Efforts to reduce the mortality rate among homeless persons should focus on these causes, concludes Stephen W. Hwang, M.D., M.P.H., formerly of the Harvard School of Public Health and now with St. Michael's Hospital in Toronto. Dr. Hwang and his colleagues determined the causes of death for 17,292 adults seen by the Boston Health Care for the Homeless Program from 1988 to 1993 by comparing the program's patient database with the Massachusetts death registry
during the same years.
The average age at death was 47 years. Surprisingly, conditions generally associated with homelessness—cold exposure and tuberculosis—were not common, but pneumonia and influenza were frequent causes of death, even in younger age groups. The AIDS epidemic had an enormous effect on homeless individuals, with AIDS or HIV affecting one-fourth of the homeless population.
Homeless persons may be at increased risk for pneumonia and influenza because of a high prevalence of alcoholism, smoking, HIV infection, and chronic disease. The high risk of death from homicide and accidental injury is a predictable result of poverty, substance abuse, and living on the streets. Finally, the increased number of deaths during the first week of each month coincides with the arrival of disability checks, which often leads to a flurry of substance abuse, injuries, and deaths.
The authors recommend consideration of a campaign to vaccinate all homeless persons against pneumonia and influenza, as well as improved alcohol and drug treatment programs for homeless persons.
Details are in "Causes of death in homeless adults in Boston," by Dr. Hwang, E. John Orav, Ph.D., James J. O'Connell, M.D., and others, in the April 15, 1997 Annals of Internal Medicine 126(8), pp. 625-628.
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Primary Care Research
Many new challenges confront primary care researchers
Clinical studies that ignore the context of daily medical practice are likely, at best, to be of questionable interest or use to medical directors and other policymakers within health care plans. At worst, the findings of such studies may be misleading. Most clinical studies in primary care will need to include consideration of the organization, planning, financing, and administration of health services, as well as their outcomes.
Enthusiasm for outcomes research—especially studies that identify the most effective methods for preventing, diagnosing, treating, and managing common health conditions—will continue. However, there is an even stronger interest in studies that will produce results which are directly applicable to real-world settings. The costs as well as the effectiveness of primary care practices will become increasingly important outcome measures, according to a recent commentary authored by David Lanier, M.D., of the Agency for Health Care Research's Center for Primary Care Research, and Carolyn Clancy, M.D., Acting Director of that Center and Director of AHCPR's Center for Outcomes and Effectiveness Research.
The national trend toward quality measurement in health care will add significantly to the research agenda in primary care. Studies are needed to inform strategies for assessing and improving the quality of primary care delivery in a fair and accurate manner. Future studies also should place increased emphasis on patient preferences and involvement in the decisionmaking process in order to meet market-driven concerns among managed care organizations (MCOs) about consumer satisfaction and the explosion of health-related information available to both providers and
patients through the media and over the Internet.
Health care in the United States is changing rapidly, making it more important than ever to link researchers and practitioners. To do this, primary care research will need to involve multiple practices or clinical sites, according to Drs. Lanier and Clancy. They suggest the establishment of various types of practice laboratories or centers of excellence that would operate in primary care settings across the country. Such labs might involve community practices, MCOs, and academic medical centers. The challenge will be to forge sustainable partnerships and identify sufficient
resources to guarantee their success. The researchers encourage MCOs to engage at least in the development of primary care research infrastructures, if not in the direct financial support of research projects.
Details are in "Primary care research: Current challenges, future needs," by Drs. Lanier and Clancy, in the May 1997 issue of the Journal of Family Practice 44(5), pp. 434-438.
Reprints (AHCPR Publication No. 97-R080) are available from the AHCPR Publications Clearinghouse.
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AHCPR News and Notes
Quality Commission's first priority is a "Consumers' Bill of Rights"
President Clinton issued an Executive Order in September 1996 establishing the National Advisory Commission on Consumer Protection and Quality in the Health Care Industry. As set forth in the Executive Order, the Commission's role is "to advise the President on changes occurring in the health care system and recommend measures as may be necessary to promote and assure health care quality and value, and protect consumers and workers in the health care system." The Commission is making progress toward its mission; a final report, including the Commission's recommendations, is due to the President by March 30, 1998.
As its first task, the Commission is developing a "Consumers' Bill of Rights" in health care, including recommendations for enforcing the rights at the Federal, State, and local levels. The Consumers' Bill of Rights is due to the President in the fall. To meet this fast-approaching deadline, the Commission's Subcommittee on Consumers' Rights, Protections, and Responsibilities met in Washington, DC, in mid-August to continue its work on the Bill of
The 32-member Commission is co-chaired by Secretary of Health and Human Services, Donna E. Shalala, and the Secretary of Labor, Alexis M. Herman. Commission members, appointed March 26, 1997, represent a broad spectrum of health care expertise drawn from the private sector, including consumer advocates, institutional providers, health care workers, State and local government officials, and health care purchasers. As Senior Advisor on Quality to Secretary
Shalala, John M. Eisenberg, M.D., Administrator of the Agency for Health Care Policy and Research, coordinates HHS's support for the Commission. AHCPR is staffing a liaison office to serve as a link between HHS and the Commission.
The Commission's four subcommittees are:
- Subcommittee on Consumers' Rights, Protections, and Responsibilities.
- Subcommittee on Performance Measurement and Quality Oversight.
- Subcommittee on Quality Improvement Environment.
- Subcommittee on Roles and Responsibilities of Public and Private Purchasers and Quality Oversight Organizations.
The Subcommittees meet on the first day of the Commission's 2-day meetings, which are held each month. During its first three meetings, the Commission heard testimony from numerous witnesses representing a wide array of disciplines within the health care industry, as well as witnesses from various government agencies. All meetings of the Commission and its Subcommittees are open to the public.
AHCPR seeks applicants for two senior-level positions
The Agency for Health Care Policy and Research is currently recruiting for the senior-level positions of Director, Center for Primary Care Research (CPCR), and Director, Center for Quality Measurement and Improvement (CQMI). The Director, CPCR, is a Senior Executive Service position, and the Director, CQMI, is a Senior Biomedical Research Service position. Both positions offer exciting and challenging opportunities for the right individual.
The Director, CPCR, directs and supports a program of extramural and intramural health services research on primary care, including evaluations of the quality, costs, and effectiveness of health care; rural health care services and systems; and special populations. Applicants must have an M.D., or equivalent degree with board certification or eligibility in a primary care speciality such as general internal medicine, family practice, or pediatrics. AHCPR is seeking applicants with a comprehensive understanding of the current issues in primary care research and major public
policy initiatives affecting primary care. The salary range for this position is from $103,897 to $123,100 per year. Applicants should make reference to vacancy announcement AHCPR-97-31.
The Director, CQMI, directs a national program of extramural and intramural health services research to evaluate the quality of health care, assess consumer perceptions of health care services and systems, and develop and test measures, methods, and tools for evaluating and improving the quality of care. The Director, CQMI, serves as the principal advisor to AHCPR's Administrator and other senior officials on critical issues related to quality measurement and improvement and coordinates the Agency's efforts in support of HHS's initiative to improve health care quality.
Candidates must have a doctoral-level degree in biomedicine or a related field and have experience in directing, conducting, or evaluating scientific research programs that deal with the measurement and improvement of the quality of health care procedures and clinical practices. The salary range for this position is from $79,935 to $133,600 per year. Applicants should refer to vacancy announcement AHCPR-97-32.
Copies of the full text vacancy announcements and further information on qualification requirements and application procedures are available online. AHCPR is an equal opportunity employer.
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Harris, R.A., and Nease, Jr., R.F. (1997). "The importance of patient preferences for
comorbidities in cost-effectiveness analysis." (AHCPR grants HS08362 and HS07373). Journal of Health Economics 16, pp. 113-119.
When evaluating the cost-effectiveness of various treatments for a given (index) medical condition, many analyses ignore the patient's other coexisting conditions. For instance, one cost-effectiveness analysis may only assess health with the index condition on a scale from health in the absence of the condition to death. A second analysis may only assess health with the index condition on a scale from ideal health to death. The latter studies assume that alleviating a health condition, such as angina, will bring an individual to ideal health, even though the individual
may be beset with other conditions that diminish quality of life, such as depression and congestive heart failure. Also, the sicker the patients are who are being studied, the greater the bias introduced by the omission of coexisting conditions in the cost-effectiveness analysis. With either scenario, failure to account for coexisting conditions leads to an overestimate of the efficiency (and underestimate of the cost-effectiveness ratio) of the treatments being considered.
McClellan, M., and Newhouse, J.P. (1997). "The marginal cost-effectiveness of medical
technology: A panel instrumental-variables approach." (AHCPR grants HS06341 and HS07638). Journal of Econometrics 77, pp. 39-64.
Cardiac catheterization (a diagnostic procedure that images blood flow to the heart muscle) and possible subsequent revascularization (angioplasty or bypass surgery) to restore and improve blood flow to the heart have been associated with essentially all of the growth over the past decade in hospital costs for treating elderly heart attack patients. The goal of this study was to develop evidence on the marginal cost and marginal outcome effects of intensive cardiac
procedures. The researchers used data on the treatment of heart attacks in the U.S. elderly population from 1987 to 1990 to estimate models of the incremental effects of intensive technologies. They used "difference-in-differences" estimation techniques with a very large number of observations and group effects to account for unobserved patient heterogeneity (patients who actually received different treatments probably differed substantially in unobserved
dimensions). Their analysis suggested that differential trends in patient composition across hospital types were unlikely to lead to substantial bias in their estimates, that using different kinds of hospitals as controls in the estimation procedure did not substantially affect results, and that hospital adoption decisions tended to be correlated with adverse shocks in ways that led to a downward bias in cost-effectiveness estimates. The most conservative cost-effectiveness estimate for the diffusion of invasive cardiac technologies is at least $40,000 per patient surviving to 1 year in 1987 dollars.
McDonald, C.J. (1997, May/June). "The barriers to electronic medical record systems and
how to overcome them." (AHCPR grants HS07719 and HS08750). Journal of the American Medical Informatics Association 4(3), pp. 213-221.
Institutions all want electronic medical record (EMR) systems. They want them to solve their record movement problems; to improve the quality and coherence of the care process; and to automate guidelines and care pathways to assist clinical research, outcomes management, and process improvement. EMRs are very difficult to construct because the existing electronic data sources—for example, laboratory systems, pharmacy systems, and physician dictation
systems—reside on many isolated islands with differing structures, differing levels of granularity, and different code systems. In this editorial, the author points out that to accelerate EMR deployment requires a focus on the interfaces instead of the EMR system. He also notes that interface solutions already exist in the form of standards (IP, HL7/ASTM, DICOM, LOINC, SNOMED, and others) developed by the medical informatics community. The existing solutions just need to be accepted. Additional research is needed to solve one remaining problem, which is the efficient capture of physician information in coded form.
Smith, A.R., Gerber, R.L., Hughes, D.B., and others (1997, April). "Assessment of physics quality assurance in United States radiotherapy facilities and comparison with American College of Radiology standard for radiation oncology physics for external beam therapy." Seminars in Radiation Oncology 7(2), pp. 157-162.
An abundance of complex technology has recently been introduced into radiation therapy, ranging from computer control of accelerators and electronic portal imaging to conformal radiation therapy and computed tomography-simulation. These researchers assessed the quality assurance (QA) programs of radiation therapy physics at 73 sites randomly selected from the 1,321 U.S. radiation therapy facilities. They compared the results with the Patterns of Care Study (PCS) Consensus Guidelines for Treatment Planning and the American College of Radiology Standard for Radiation Oncology Physics for External Beam Therapy. They estimated national averages for facilities having QA programs as follows: for treatment planning systems (44 percent), simulators (79 percent), accelerators (94 percent), film processors (62 percent), and blocking systems (55 percent). Only 63 percent of facilities obtained an independent check of their accelerator calibrations from a source outside the facility; 26 percent of facilities surveyed did not
have in vivo dosimetry capability. Based on deficiencies identified by this study and implementation of new technologies in radiation therapy, the researchers recommend a comprehensive national physics QA study.
Zucker, D.R., Schmid, C.H., McIntosh, M.W., and others (1997). "Combining single
patient (N-of-1) trials to estimate population treatment effects and to evaluate individual patient responses to treatment." (AHCPR grants T32 HS00060, HS08532, and HS07782). Journal of Clinical Epidemiology 50(4), pp. 401-410.
When treating individual patients, physicians may face difficulties using evidence from center-based randomized controlled trials due to limitations in the generalizability of these studies. To get around this, physicians often perform their own "informal" tests of treatment effectiveness. Single patient (N-of-1) trials provide a structure design for more rigorous assessment of medical treatments of chronic diseases but are applied only to the index patient. In this study, the authors present a hierarchical Bayesian random effects model to combine N-of-1 studies to obtain an estimate of treatment effectiveness for the population and to use this population information to aid
in the evaluation of an individual patients trial results. The model's treatment effect estimates are adjustments between the population estimate and the individual's observed results. This adjustment is based upon within-patient and between-patient heterogeneity. The researchers demonstrate this patient-focused method using published data from 23 N-of-1 trial results comparing amitriptyline and placebo for the treatment of fibromyalgia.
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AHCPR Publication No. 97-0070
Current as of August 1997