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Ballantyne, J.C., Carr, D.B., deFerranti, S., and others (1998). "The comparative effects of
postoperative analgesic therapies on pulmonary outcome: Cumulative meta-analyses of
randomized, controlled trials." Anesthesia and Analgesia 86, pp. 598-612, 1998.
When postoperative patients are relatively pain-free, their lung function is improved. They can
readily expand their chests, breathe deeply, cough well, and cooperate with physical therapy. They
also are less likely to develop pulmonary complications. According to this study, some pain
relievers more effectively reduce these complications than others. The study found that individuals
who receive epidural opioids or local anesthetics after surgery have fewer postoperative
pulmonary problems than those given systemic opioids. The researchers performed a
meta-analysis of data from randomized, controlled trials that assessed the effects of seven specific
pain treatments on respiratory function in postoperative patients: epidural opioid, epidural local
anesthetic, epidural opioid with local anesthetic, thoracic versus lumbar epidural opioid,
intercostal nerve block, wound infiltration with local anesthetic, and intrapleural local anesthetic.
Compared with systemic opioids, epidural opioids significantly decreased the incidence of
atelectasis (inadequate lung expansion or lung collapse) and slightly reduced pulmonary infections
and pulmonary complications overall. Epidural local anesthetics increased lung oxygen
concentration and decreased the incidence of pulmonary infections and overall pulmonary
complications compared with systemic opioids.
The researchers conclude that postoperative epidural analgesia can significantly decrease the incidence of pulmonary problems.
Cohen, S.B. (1998). "Sample design of the 1996 Medical Expenditure Panel Survey Medical
Provider Component." Journal of Economic and Social Measurement 24, pp. 25-53.
The Agency for Health Care Policy and Research's Medical Expenditure Panel Survey (MEPS) is
the only federally sponsored national survey that provides a foundation for estimating the impact
of changes in sources of payment and insurance coverage on different groups such as the poor,
the elderly, veterans, the uninsured, and racial and ethnic minorities. The Medical Provider
Component (MPC) in MEPS was primarily designed to reduce the bias associated with national
medical expenditure estimates based on data reported by household respondents. MEPS collects
provider-reported charge and payment data for medical care events reported by households to
improve the accuracy of national estimates of health care expenditures that are derived from the
This paper, by Steven B. Cohen of AHCPR's Center for Cost and Financing Studies, provides a
summary of the analytical objectives and survey design of the MPC. Reprints (AHCPR
Publication No. 98-R082) are available from the AHCPR Publications Clearinghouse.
Doeksen, G.A., Johnson, T., Biard-Holmes, D., and Schott, V. (1998, Winter). "A healthy health
sector is crucial for community economic development." (AHCPR grant HS08633). Journal of
Rural Health 14(1), pp. 66-72.
When a community's health care facilities and services deteriorate or become inadequate, it
hinders the community's growth and adversely affects its quality of life. This study presents a
detailed model for measuring the economic effects of the health sector on the local economy of
Perry, OK. The researchers present the total effects of the health sector on Perry's employment, income, retail sales, and sales tax collection by health
category (hospitals, doctors and dentists, nursing and residential facilities, other medical and
health services, and pharmacies). Application of the model in nine Oklahoma counties found that
people directly working in the health sector accounted for about 9 percent of the total
employment for each county. Using multipliers to estimate total effects, including secondary
employment, the health sector accounted for about 14 percent of all employment. The researchers
conclude that a healthy health sector greatly contributes to the economic health of a county.
Fiscella, K., Franks, P., and Clancy, C.M. (1998). "Skepticism toward medical care and health
care use." Medical Care 36(2).
Carolyn M. Clancy, M.D., Director of the Agency for Health Care
Policy and Research's Center for Outcomes and Effectiveness Research, and her colleagues from
the University of Rochester School of Medicine and Dentistry surveyed a nationally representative
sample of 18,240 people 25 years and older about their health status and behavior, use of health
care services, and attitudes toward health care. Analysis of survey results found that skepticism in
this sample was associated with younger age, white race, lower income, less education, and higher
health perceptions. After adjustments were made for these variables, skepticism was associated
with less healthy behavior, not having health insurance, not having one's own physician, not being
able to choose a physician, fewer physician and emergency department visits, less frequent
hospitalizations, lower annual health care expenditures, and less compliance with recommended
preventive screening (e.g., Pap smears and mammograms).
Reprints (AHCPR Publication No.
98-R031) are available from the AHCPR Publications Clearinghouse.
Fitzmaurice, J.M. (1998). "A new twist in U.S. health care data standards development: Adoption
of electronic health care transactions standards for administrative simplification." International
Journal of Medical Informatics 48, pp. 19-28.
U.S. health care expenditures fell from double digit levels in the 1970s and 1980s to 9.2 percent in
1991 down to 5.5 percent in 1995. Health plans, payers, and providers examined their business
processes and became convinced that conducting some common transactions electronically with
uniformly implemented standards for health care data would reduce their costs. In 1996, they
prevailed on Congress to pass a bill that addresses administrative simplification by calling for the
adoption of such standards and their uniform implementation. This paper by J. Michael
Fitzmaurice, Ph.D., of the Agency for Health Care Policy and Research, describes these
standards, the process of their mandated adoption by the U.S. Secretary of Health and Human
Services, and the implications for future health care informatics standards development and
Reprints (AHCPR Publication No. 98-R053) are available from the AHCPR Publications Clearinghouse.
Gray, D.T., and Weinstein, M.C. (1998, April). "Decision and cost-utility analyses of surgical
versus transcatheter closure of patent ductus arteriosus: Should you let a smile be your umbrella?"
(AHCPR grant HS06302). Medical Decision Making 18, pp. 187-201.
These researchers used decision and cost-utility analyses to consider the tradeoffs of treating
patent ductus arteriosus (PDA) using conventional surgery versus transcatheter implantation of
the umbrella-like Rashkind occluder. Physicians and informed lay parents assigned utility scores to
success and complications of these procedures seen in prognostically similar pediatric patients
with isolated PDA treated from 1982 to 1987. On a 1 to 100 scale (worst to best observed
outcome), the median expected utility for surgery was 99.96 versus 98.88 for the occluder.
Surgery was also favored in results of most sensitivity analyses and most cost-utility analyses,
with a mean overall simulated cost of $8,838 for surgery versus $12,466 for the occluder. The
researchers conclude that use of the inherently less invasive but less successful, more risky, and
more costly occluder conferred no apparent net advantage.
Hupcey, J.E. (1998, April). "Establishing the nurse-family relationship in the intensive care unit."
(NRSA fellowship F32 HS00094). Western Journal of Nursing Research 20(2), pp. 180-194.
This researcher conducted extensive unstructured interviews with 10 ICU family members and 10
ICU nurses at a large rural teaching medical center to examine nurse-family relationships in the
ICU. Strategies used by nurses to develop the ICU nurse-family relationship included showing
commitment to the patient—spending time with the patient or family, respecting family rituals, and
showing empathy; spending more time with difficult families or sharing some limited personal
information; and being an advocate for the family, bending or breaking the rules on occasion,
sharing information, and willingly explaining procedures and technology. Families used such
strategies as looking for signs of a nurse's competence and genuine interest in the patient; making
overtures such as being friendly and helpful, giving gifts or positive feedback, and staying out of
the way; and showing trust. Nurses' behaviors that weakened the relationship included
depersonalizing the patient and family, questioning their intentions, complaining about them, and
rigidly maintaining hospital policy. Families set up barriers to a positive relationship by not sharing
potentially important information, being overly emotional, or ignoring the plan of care.
Lipscomb, J., Ancukiewicz, M., Parmigiani, G., and others (1998). "Predicting the cost of illness:
A comparison of alternative models applied to stroke." (AHCPR contract 290-91-0028). Medical
Decision Making 18 suppl., S39-S36.
The growing availability of large administrative and clinical data sets offers new opportunities for
a more general approach to disease cost forecasting. This approach is the estimation of
multivariable cost functions that yield predictions at the individual level, conditional on intervention(s), patient characteristics, and other factors. This paper demonstrates how to
evaluate competing models on the basis of predictive validity using three alternative criteria: root
mean square error, for evaluating predicted mean cost; mean absolute error, for evaluating
predicted median cost; and a logarithmic scoring rule, an information-theoretic index for
evaluating the entire predictive distribution of cost. To illustrate these concepts, the authors
conducted a split-sample analysis of data from a national sample of Medicare-covered patients
hospitalized for ischemic stroke in 1991 and followed to the end of 1993. They investigated five
models for their ability to predict the cost of stroke illness.
Owens, D.K. (1998, March). "Use of medical informatics to implement and develop clinical
practice guidelines." (AHCPR grant HS08362). Western Journal of Medicine 168, pp.
This article explores how medical informatics can help clinicians find, use, and create practice
guidelines. The author asserts that physicians can make the most of clinical practice guidelines by
integrating them within information systems and electronic medical records, but that lack of
computing infrastructure in many clinical settings is a barrier to such integration. He suggests that
to successfully implement guidelines in information systems, developers create more specific
recommendations than those that have been required of traditional guidelines. He also suggests
using reusable software components to create guidelines in order to make the development of
protocols faster and less expensive. Finally, he recommends use of decision models to produce
Paltiel, A.D., Scharfstein, J.A., Seage III, G.R., and others (1998, April). "A Monte Carlo
simulation of advanced HIV disease: Application to prevention of CMV infection." (AHCPR
grant HS07317). Medical Decision Making 18 suppl., pp. S93-S105.
These researchers introduce a mathematical model they have developed to simulate the natural
history of HIV illness in patients with CD4 counts below 300/mm3 and to project the costs and
consequences of alternative strategies for preventing AIDS-related complications. They
demonstrate how to use the model to assess the cost-effectiveness of oral ganciclovir to prevent
cytomegalovirus (CMV) infection. They find that compared with alternative interventions, CMV
prophylaxis does not appear to be a cost-effective use of scarce HIV clinical care funds. However,
targeted prevention in patients at higher-risk for CMV-related disease may warrant
Poses, R.M., De Saintonge, D.M.C., McClish, D.K., and others (1998, April). "An international
comparison of physicians' judgments of outcome rates of cardiac procedures and attitudes toward
risk, uncertainty, justifiability, and regret." (AHCPR grant HS06274). Medical Decision Making 18, pp. 131-140.
Rates of invasive cardiac procedures are substantially lower
in the United Kingdom than in the United States. One factor attributed to clinical practice
variations is how physicians handle uncertainty. This study used measures of risk, uncertainty,
justifiability, and regret relevant to use of four invasive cardiac treatments among 51 U.K.
physicians and 171 U.S. physicians. The U.K. physicians had significantly more discomfort with
uncertainty than did the U.S. physicians, as reflected by higher scores on the stress scale (median
of 48 vs. 42) and the reluctance-to-disclose-uncertainty scale (40 vs. 37). There was no clear
international difference in perceived need to justify decisions or in regret. The authors conclude
that physician uncertainty may not affect practice variations, and that the causes and implications
of practice variations remain unclear.
Reschovsky, J.D. (1998, April). "The demand for post-acute and chronic care in nursing homes."
Medical Care 36(4), pp. 475-490.
Patients admitted to nursing homes for post-acute care following a hospital stay are a growing but
still small proportion of all nursing home patients. The growth in these nursing home admissions
are the result of financial incentives to physicians and hospitals from public and private insurers to
reduce hospital lengths of stay (LOS). Post-acute care patients are more apt to have private
instead of public insurance coverage and shorter stays than people seeking nursing home
admission for chronic care. Also, nursing homes treat these two types of patients differently. They
seem to be more sensitive to market conditions when deciding to admit people seeking chronic
care, who are often Medicaid patients. As a result, these patients usually find it more difficult to
gain admission than post-acute care patients, according to this study by James D. Reschovsky,
Ph.D., formerly of AHCPR and now with the Center for Studying Health Systems Change. He
used data on a sample of elderly individuals from the National Long-Term Care Channeling
Demonstration to develop the model, using Medicare payments to estimate nursing home demand.
Analysis suggested that people considering nursing home care for chronic conditions were more
likely to consider the economic aspects of this decision than those in need of post-acute care. The
supply of hospital beds, which served as a proxy for the role of physicians and discharge planners
in influencing demand decisions, was a more important factor in the demand for post-acute
nursing home stays. About half of short stays and one-fourth of long stays initially were paid for
by Medicare. Post-acute nursing home stays, as indicated by Medicare payment, should be mostly
short, whereas stays for chronic care (those without Medicare payment) will tend to be long. In
fact, more accurate predictions of the demand for nursing home care would be possible if the
payer was used as a proxy for expected LOS; indeed, this would be a better way of classifying
post-acute and chronic care nursing home stays than using the actual LOS, according to the
Reprints (AHCPR Publication No. 98-R057) are available from the AHCPR Publications Clearinghouse.
Rhoades, J. (1998, June). "Nursing homes—Structure and selected characteristics, 1987 and
1996." Statistical Bulletin, pp. 1-9.
This paper by AHCPR researcher Jeffrey Rhoades, Ph.D., briefly describes changes in the nursing home market over a 9-year period, from 1987 to 1996. Estimates
are based on the Institutional Population Component of the 1987 National Medical Expenditure
Survey (NMES) and the Nursing Home Component of the 1996 Medical Expenditure Panel
Survey (MEPS). As of January 1, 1996, about 1.56 million residents were receiving care in
16,840 nursing homes with 1.76 million beds. This compares with 1.36 million residents in 14,050
nursing homes with 1.48 million beds in 1987. There was also a significant drop in the supply of
nursing home beds relative to the elderly population. In 1987, only 28 percent of nursing homes
were certified by both Medicare and Medicaid, while this proportion increased to 73 percent in
1996. Nursing homes with only nursing home beds (not hospital-based; no personal care or
independent living beds) represented 87 percent of the market in 1987, but just 77 percent in
Reprints (AHCPR Publication No. 98-R058) are available from the AHCPR Publications Clearinghouse.
Sachs, B., and Hall, L.A. (1998, Winter). "Developing community partnerships to enhance care
for rural families with low birth weight children," (AHCPR grant HS 07950). Journal of Rural
Health 14(1), pp. 51-58.
Low birthweight (LBW) babies (5.5 pounds or less) comprise 7 percent of all births in the United
States each year, and they may be discharged from the hospital with needs that severely tax
parental resources. Parents in rural areas, in particular, often find inadequate community resources
to support care for their LBW infants. In recognition of this problem, researchers at the University
of Kentucky convened a conference involving health care providers, families with LBW children,
and policymakers in eastern Kentucky to identify the major health needs and concerns of families
with LBW infants. Conference participants identified a total of 51 barriers to providing health care
to these families, including transportation problems, lack of financial resources (family and
system), and lack of parenting knowledge and skills about health promotion and disease
prevention. Providers created barriers to care by lack of family-centered care, lack of knowledge
of resources to aid LBW children, not communicating with families in ways they could
understand, and not taking enough time with families, according to conference participants. Some
of the 23 system barriers were service issues, such as fragmented care; lack of health care
professionals prepared to provide care in rural settings; differing eligibility requirements for
various LBW programs; financial and funding issues; lack of coordinated services; and poor
communication among providers. As a result of the conference, a support program for families
with LBW children is being implemented and evaluated in one rural Kentucky county.
Tu, J.V., Weinstein, M.C., McNeil, B.J., and others (1998, April). "Predicting mortality after
coronary artery bypass surgery: What do artificial neural networks (AHCPR grants
HS08071 and HS08464). Medical Decision Making 18, pp. 229-235.
Neural networks are pattern-recognition algorithms that are modeled after the biological structure
of the human brain. It has been suggested that they may offer some advantages over classic
statistical approaches as predictive models for certain clinical problems. These researchers
compared the abilities of artificial neural network and logistic regression models to predict the risk
of in-hospital mortality after coronary artery bypass graft (CABG) surgery. They developed both
models using a training set of 4,782 patients undergoing CABG surgery in Ontario, Canada, in
1991 and validated them in two test sets of CABG patients in 1992 and 1993. They further
developed and validated these models and found that the predictions from the two models were
very highly correlated. The authors conclude that artificial neural networks and logistic regression
models learn similar relationships between patient characteristics and mortality after CABG
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AHCPR Publication No. 98-0050
Current as of August 1998