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2. Highlights of AHCPR-Sponsored Research on
Home care of very low birthweight infants with chronic lung disease.1 A randomized controlled trial is assessing and comparing the outcomes and costs of two
interventions to facilitate the home care of oxygen-dependent infants with chronic lung disease.
These two potential alternatives to prolonged hospitalization involve multi-disciplinary
center-based followup care versus community-based followup care by a nurse. Thomas O'Shea,
Principal Investigator (Grant No. HS-07928) (7/1/96-6/30/01).
Strategies for care of very low birthweight infants.1 This study will evaluate outcomes in school-aged children who were very low birthweight infants,
using three population-based data sets from the Netherlands, Canada, and the United States.
Recommendations will be made for the development of ethical, cost effective, and appropriate
strategies for clinical management and resource allocation. Nigel S. Paneth, Principal Investigator
(Grant No. HS-08385) (9/30/96-9/29/99).
Family Linkages supporting hyperbilirubin (neonatal jaundice) guidelines.1 This effort will develop and implement a computer-based decision-support system to help different types of providers identify and treat infants at risk for developing neonatal jaundice (hyperbilirubinemia) by providing better access to patient records and guidelines. More than half of all infants born in hospitals develop jaundice within 48 hours of discharge. Charles J. Homer, Principal Investigator (Grant No. HS-09390) (9/30/96-9/29/99).
Impact of prenatal Medicaid program on newborns' health.1 This effort will examine how the Medicaid program affects newborns' health. Specifically, it will
isolate the impact of individual Medicaid program components on birth outcomes. Christopher
Trenhom, Principal Investigator (Grant No. 9332) (9/1/96-8/31/97).
Estimated costs and benefits of the postpartum mandate.1 This study will evaluate the costs and health consequences of mandates requiring insurers to pay
for a minimum 48-hour hospital stay for mothers and newborns after a vaginal delivery or 96
hours following a cesarean section. Three related policy questions will be addressed: 1) How will the mandate affect health? 2) How much will the mandate cost? 3) Is the mandate cost effective?
Jesse Malkin, Principal Investigator (Grant No. HS-09342) (9/1/96-8/31/97).
Variations in management of childbirth and patient outcomes. An expert Patient Outcomes Research Team (PORT) is examining the use and outcomes of
cesarean section as compared to alternatives. Variations and correlates of specific diagnostic and
treatment procedures used during labor and delivery also are analyzed. For example, based on a
meta-analysis of nine studies, researchers found a significantly higher risk of fetal injury or death
in term breech infants whose mothers were allowed a trial of labor prior to undergoing cesarean
section. While in either case the risk for infant injury or death was small, the researchers
recommended that the respective risks of each mode of delivery be considered. Gifford DS,
Morton SC, Fiske M, Kahn K. A meta-analysis of infant outcomes after breech delivery.
Obstet Gynecol 85(6):1047-1054, 1995. (Contract No. 282-90-0039).
Low birthweight in babies of minority and high-risk women. This PORT examines ways to prevent low birthweight and improve the outcomes of low
birthweight infants. (Contract No. 282-92-0055). For example:
- In a controlled trial, researchers found that zinc supplements in pregnant women whose blood
zinc levels were low early in pregnancy resulted in heavier babies with larger head
circumferences. Goldenberg RL, Tamura T, Neggers Y, et al. The effect of zinc
supplementation on pregnancy outcome. JAMA 274(6):463-468, 1995.
- Based on an evaluation of the literature, researchers found that while bed rest is used
extensively to treat a wide variety of pregnancy conditions, there is little proof of effectiveness.
They suggest that the use of bed rest be curtailed until specific benefits are established through
a randomized clinical trial. Goldenberg RL, Cliver SP, Bronstein J, et al. Bed rest in
pregnancy. Obstet Gynecol 84(1):131-136, 1994.
Safety and effectiveness of homemade cereal-based oral rehydration therapy for infants
(PORT-II). Diarrhea with dehydration among children younger than age 5 accounts for more than 10 percent
of hospitalizations for that age group, and for about 500 deaths each year. The condition is
preventable and treatable with oral rehydration therapy—the administration of a balanced
of electrolytes and glucose or starch. This controlled experimental study will evaluate the safety
and effectiveness of low-cost, homemade, cereal-based oral rehydration solutions. Alan Meyers,
Principal Investigator (Grant No. HS-08335) (8/1/94-9/30/96).
Impact of variations in diagnosis and treatment on outcomes and costs for infants with
high fever. This study is examining variations in diagnosis and treatment of febrile infants with an emphasis
on infants younger than 2 months. Differences affecting outcomes and costs will be assessed.
Robert Pantell, Principal Investigator (Grant No. HS-06485) (5/1/93-1/31/98).
Illness severity and practice variations in newborn intensive care units. This project is identifying variability in outcomes from neonatal intensive care units that are not
attributable to illness severity, and also is identifying variations in practice that may increase costs
without improving outcome. Douglas Richardson, Principal Investigator (Grant No. HS-07015)
Lower mortality rates of high-risk infants born in hospitals with advanced neonatal
intensive care units. Researchers from the low birthweight PORT published research showing that
high-risk infants born in hospitals with advanced neonatal intensive care units (level III NICUs)
have a 38 percent lower death rate than similar infants born in hospitals without NICUs. Infants
born in hospitals with intermediate-level NICUs had a risk of dying comparable to that of infants
born in hospitals without NICUs. The researchers recommend that urban areas concentrate
high-risk deliveries in a small number of hospitals with level III NICUs. Phibbs CS, Bronstein
JM, Buxton E, Phibbs RH. The effects of patient volume and level of care at the hospital of birth
on neonatal mortality. JAMA 276(13):1054-1059, 1996.
Health Care Services Organization, Access, Use, Quality, and Costs
Patterns of referral and care for children on Medicaid.1 This study focuses on the consequences of the referral of children enrolled in Medicaid to
pediatric specialists, compared with specialists for adults, for common and uncommon pediatric
chronic conditions. James Perrin, Principal Investigator (Grant No. HS-09416)
Effective organization of adolescent health services.1 This study will analyze how the organization of adolescent health services affects teenagers'
access to care. Jonathan B. Klein, Principal Investigator (Grant No. HS-08192)
Primary care services for low-income children in health maintenance organizations
(HMOs).1 This effort will assess the performance of different types of managed care organizations in the
organization and delivery of primary care services to children. It will take into account plan
features that affect provider and consumer behavior; examine possible variations in the attainment
of primary care among enrollees with different racial, ethnic, economic, and family characteristics;
and contribute to the development of better tools to measure primary care from the consumer
perspective. Margarita Patricia Hurtado, Principal Investigator (Grant No. HS-09339)
Research agenda conference on quality of pediatric care.1 The purpose of the conference is to develop and disseminate a national research agenda on quality
of care measures for children, and to set priorities for issues that demand immediate and
long-term attention from the research community and from policymakers. The conference will be
convened in May 1997 by the Association for Health Services Research (AHSR), with
cosponsorship from AHCPR, the Centers for Disease Control and Prevention, the National
Institutes of Health, the Health Resources and Services Administration, the Health Care Financing
Administration, the David and Lucille Packard Foundation, and Pfizer, Inc. Background papers
for the conference will be published as a supplement to AHSR's official journal, and a resulting
research agenda will be widely disseminated. Alice Hersh, Principal Investigator (Grant No.
Adjusting capitation rates may not prevent discrimination against chronically ill children. If a plan or provider is paid the same rate for a patient with chronic health problems as for a
generally healthy patient, there is a financial incentive to discriminate against patients with more
serious illnesses. Capitation adjustment methods, which adjust capitated rates to compensate
plans for increased costs associated with chronic medical problems, is one approach to eliminating
the incentive to discriminate against children with chronic conditions. This study tested several
capitation methods and found that none would eliminate the disincentive to enroll children with
costly conditions, and special health care needs would not be eliminated by any of the capitation
methods tested. Fowler EJ, HealthSystem Minnesota, and Anderson GF. Capitation adjustment
for pediatric populations. Pediatrics 98(1), pp. 10-17, July 1996.
Multiple factors influence pediatric hospitalization rates. Researchers found that access to primary care per se did not appear to explain variations in rates
of pediatric hospitalization in three cities. Eighty-five percent of the children in cities with wide
variations in hospitalizations had a usual primary care source. Variations were found to be
associated with area-specific admission practices, and patterns of primary care involvement.
Perrin J. Variations in pediatric hospitalization rates: Why do they occur? Pediatr Ann 23(12):676-683, 1994; Homer CJ, Perrin JM, Kemper K, et al. Effect of socioeconomic status on
variation in pediatric hospitalization. Ambulatory Child Health 1:33-43, 1995; Perrin JM,
Greenspan P, Bloom SR, et al. Primary care involvement among hospitalized children. Arch
Pediatr Adolesc Med 150:479-486, 1996; Homer CJ, Szilagyi P, Rodewald L, et al. Does
of care affect rates of hospitalization for childhood asthma? Pediatrics 98(1), pp. 18-23,
(Grant No. HS-06060) (9/1/90-8/31/94).
Gatekeeping fails to prevent unnecessary emergency room use by pediatric Medicaid
patients. Researchers found that Medicaid managed care patients who were denied the use of emergency
rooms (ERs) via gatekeeping functions did not necessarily change their health care-seeking
behavior. Children denied an ER visit continued to use the ER at a significantly higher rate than
other children. Gadomski A. Diverting managed care Medicaid patients from pediatric emergency
department use. Pediatrics 95(2):170-178, 1995.
Generous Medicaid physician fees result in lower expenses for outpatient pediatric care.
Researchers found that low Medicaid reimbursement rates discourage physician participation in
the program and cause children to be seen in more expensive hospital emergency rooms and
outpatient departments. Analysis of 1987 national expenditure data indicates that average
outpatient health care expenditures for children on Medicaid were highest in the States with the
lowest payment rates. Cohen JW, Cunningham PJ. Medicaid physician fee levels and children's
access to care. Health Aff (Millwood) 14(1):255-262, 1995. (AHCPR Pub. No. 95-R003).
Physicians encouraged to learn about community resources in order to address
nonfinancial barriers to care. In assessing barriers to health care, researchers found economic factors to be only one barrier.
Other roadblocks included lack of knowledge about health care, language problems, inability to
obtain child care, transportation, long waiting times, and limited clinic hours. It was
recommended that physicians learn more about integrating community resources with health care
resources to address barriers. Margolis P. The rest of the access-to-care puzzle: addressing
structural and personal barriers to health care for socially disadvantaged children. Arch
Adolesc Med 149:541-545, 1995. (Grant No. HS-07106) (8/1/92-1/31/95).
Racial and ethnic differences found in the use of prescription medications. Descriptive statistics indicated that, even when controlling for other factors, such as
socioeconomic conditions, black and Hispanic children received fewer medications than did white
children. The researchers concluded that the relationship between racial and ethnic status and the
use of prescription medication mirrors other types of services, such as physician visits, and affirms
that minorities receive fewer health services than do whites. Hahn B. Children's health: racial and
ethnic differences in the use of prescription medications. Pediatrics 956:727-732, 1995.
(AHCPR Pub. No. 95-R006).
Measures of Children's Health Status
Developmentally sensitive instruments for valid assessment of child health status to be
developed.1 A new project will produce child health status instruments that reliably measure the health and
illness profile of children ages 5 to 11. After development of the parent version and a pictorial
version to obtain childrens perspectives of their own health, the instrument sets will be tested
systematically in geographically distinct populations with different racial and ethnic backgrounds.
Barbara Starfield, Principal Investigator (Grant No. HS-08829) (8/1/96-7/31/00).
Development of an adolescent health status measure. This project developed and validated an instrument to comprehensively assess adolescent health
status. The instrument is being used to assess the health status of populations and subpopulations
of adolescents in government-funded research projects and managed care organizations. Starfield
B, Riley AW, Green BF, et al. The adolescent child health and illness profile. A population-based
measure of health. Med Care 33(5):553-66, 1995.
Cost effectiveness of practice guidelines to reduce asthma morbidity among children.1 This large, 5-year randomized clinical trial will test the cost-effectiveness of recently developed
practice guidelines designed to reduce asthma morbidity among children. In addition, researchers
will test new educational and organizational approaches to deliver pediatric asthma care in
managed care settings. The National Heart, Lung, and Blood Institute, which developed the
guideline to be used in the study, is contributing to this study. Kevin B. Weiss, Principal
Investigator (Grant No. HS-08368) (9/30/96-9/30/01).
Measuring quality of life in children with asthma.1 This study will examine the relationship between a general multi-dimensional approach and a
disease-specific approach to measuring quality of life in children with asthma. The two different
approaches will be assessed by administering the Pediatric Quality-of-Life Questionnaire to 600
asthmatic children and their parents who are participating in an asthma management program.
Robert D. Annett, Principal Investigator (Grant No. HS-09123) (6/1/96-5/31/98).
Medicaid managed care for asthma: Does plan type matter?1 This study explores potential differences in the patterns of clinical care provided to Massachusetts
Medicaid asthma patients enrolled in two different delivery systems. One is a modified
fee-for-service plan which uses a physician gatekeeper model and is managed by the State
Medicaid program. The other is a staff model HMO with the largest Medicaid enrollment among
participating HMOs in the State. Alexandra Shields, Principal Investigator (Grant No. HS-09327)
Patient outcomes and cost effectiveness of pharmaceutical care for pediatric asthma
patients. This 4-year randomized controlled trial will compare the impact of pharmacy-based interventions
with that of usual services on pediatric patients with asthma. Patients will be tracked and
monitored in terms of lung function and health status, school attendance, and asthma-related costs
to determine the cost-effectiveness of pharmaceutical care. Andreas Stergachis, Principal
Investigator (Grant No. HS-07834) (3/1/93-10/31/97).
Preventive treatment for asthma in minority children. Currently available treatments can prevent most hospitalizations for asthma episodes. However,
this study found that black and Hispanic preschoolers hospitalized for acute asthma episodes are
less likely than are white preschoolers to receive the most effective preventive therapy, either
before hospital admission or after discharge. Finkelstein J. Quality of care for preschool children
with asthma: the role of social factors and practice setting. Pediatrics 95(3): 389-394,
(National Research Service Award Training Grant No. HS-00020).
Consumer information on use of AZT to reduce perinatal HIV transmission. In 1994, an NIH-sponsored clinical trial found that the use of AZT by asymptomatic HIV-positive
women during pregnancy, labor, and childbirth, and by the newborn for 6 weeks following birth,
reduces the risk of perinatal HIV transmission from an average of 25 percent to 8 percent. In
collaboration with other U.S. Department of Health and Human Services agencies and outside
organizations, AHCPR developed consumer education materials in multiple languages and
formats (brochures, audiotapes, and videotapes) for educating HIV-infected pregnant women
about the benefits of treatment with AZT. HHS Pub. No. 96-0007, December 1995.
Emergency Medical Services for Children
Emergency medicine initiative with HRSA. In 1995, AHCPR and HRSA jointly awarded grants totaling $2.5 million for research leading to
improvements in emergency medical services for children. Projects include:
- Investigation of the relationship between cost containment and the quality of care in
intensive care units.
- Assessment of emergency medical services and patient outcomes in children.
- Development of improved methods for assessing injuries to assist selection of
- Comparison of the effectiveness of alternative emergency respiratory care technologies.
Clinical practice guideline: Acute Pain Management. This AHCPR-supported guideline recommends that health care providers be careful to assess the
extent of pain in children because children may not be able to communicate their pain, or may hide
pain to avoid injections or other unpleasant procedures. Since children vary greatly in their
cognitive and emotional development, the guideline encourages a flexible approach to pain
management. AHCPR Pub. No. 92-0032, February 1992.
Clinical practice guideline: Management of Cancer Pain. The AHCPR guideline on cancer pain indicates that an aggressive approach to pain management
in children is necessary, but that clinicians should tailor assessment and management strategies to
each child's developmental level, personality style, and emotional and physical resources.
Clinicians should seek to form a therapeutic alliance with parent(s) and child. AHCPR Pub. No.
94-0592, March 1994.
Immunization/Disease Prevention for Children
Office systems to improve preventive care for children.1 This study will determine whether pediatric practices that use office systems for prevention have
higher rates of immunizations and screening for anemia, tuberculosis, and lead, and if rates vary in
relation to the number of system components used. Peter Margolis, Principal Investigator (Grant
No. HS-08509) (9/30/96-9/29/00).
Evaluating computer decision support for preventive care.1 This study will expand and modify for everyday use in pediatric office practices an existing
guideline-based computerized decision service for childhood preventive services. The study will
evaluate the effects of the system on process of care and outcomes of patients. Stephen M.
Downs, Principal Investigator (Grant No. HS-09507) (9/30/96-9/29/99).
Barriers to the immunization of children in the United States. Using a nationwide sample of 3,600 physicians in general and family practice and pediatrics, this
study will identify and quantify the knowledge, attitudes, and practices of the surveyed physicians
regarding immunization. Physicians responses will be validated through an audit of the actual
practices of selected study participants. Richard Zimmerman, Principal Investigator (Grant No.
Similarly, two AHCPR-supported rural health research centers are studying barriers to childhood
immunizations in rural America: the Colorado Center for Health Policy Research (Denver, CO)
(Contact No. 290-93-0039 and the Sheps Center for Health Services Research (Chapel Hill, NC)
(Contact No. 290-93-0038). Both centers are analyzing secondary data to assess gaps in rural
health provider practices in the immunization of children.
Adoption of children's vaccine guidelines. This study is designed to improve physicians' use of pediatric vaccine guidelines. The degree to
which pediatricians and family physicians are aware of immunization guidelines for selected
pediatric diseases, as well as whether they agree with and adhere to recommended schedules, will
be assessed. Researchers will identify factors that influence the visibility of guidelines, barriers to
dissemination and implementation, and recommend strategies for improvement. One report from this project found that, in 1994, less than two-thirds of family physicians were
following recommendations to routinely vaccinate infants against hepatitis B. Physicians'
reluctance stemmed from doubts about the efficacy of the vaccine.
Freed GL, Freeman VA, Clark
SJ, et al. Pediatrician and family physician agreement with and adoption of universal hepatitis B
immunization. J Fam Pract 42(6), pp. 587-592, 1996; and Stevens C, Freeman V, Konrad
al. Calculating a clinic's childhood immunization rate: costs and returns [letter]. Arch Fam
Med 5, p. 323, 1996. (Grant No. HS-07286) (7/1/92-6/30/96).
Pediatric preventive care incentives in a Medicaid HMO. This randomized controlled trial will assess the impact of a system of periodic feedback and
financial incentives on the compliance of a multi-site, mandatory Medicaid HMO with pediatric
preventive care clinical guidelines. Alan Hillman, Principal Investigator (Grant No. HS-07634)
Clinical practice guideline: Sickle Cell Disease. An AHCPR-supported guideline recommends screening of all newborns for sickle cell disease,
administering protective doses of penicillin to ward off infection in infants whose initial test
reveals presence of the disease, and improving genetic counseling for couples with the sickle cell
trait. AHCPR Pub. No. 93-0562, April 1993.
Child development in relation to early otitis media. This 5-year study examines whether persistent otitis media with effusion (fluid in the middle ear
without infection) during the first 3 years of life results in lasting impairments of speech, language,
and cognitive or psychosocial development and, if so, whether prompt insertion of tympanotomy
tubes will prevent or lessen impairment. The study also will determine whether longer waiting
periods can reduce the number of operations without adverse effects. Jack L. Paradise, Principal
Investigator (Grant 92-112-F).
Outcomes associated with therapy for otitis media. This study will describe the practice patterns and expenditures for management of pediatric otitis
media in Medicaid patients. Also, it will assess the effectiveness of pharmaceutical therapies and
other interventions in the prevention and management of persistent middle ear effusions and/or
recurrent otitis media in children. Stephen Berman, Principal Investigator (Grant No. HS-07816)
A comparative study of provider practices and outcomes in otitis media in three Nations. This study is comparing provider practices and outcomes for childhood otitis media in England,
the Netherlands, and the United States, where use of antibiotics differs substantially. Jack Froom,
Principal Investigator (Grant No. HS-07035) (9/1/93-8/31/97).
Clinical practice guideline: Otitis Media With Effusion in Young Children. This AHCPR-supported guideline recommends "watchful waiting" for most young children with
otitis media with effusion because the condition usually disappears without treatment within 3 to 6
months. The guideline notes that there are treatment options, but that when resulting
improvements are weighed against side effects and costs, antibiotic therapy may not be preferable
to waiting. The guideline also recommends lancing of the ear drum or insertion of tubes if the
condition has lasted more than 4 months and there is hearing loss in both ears. AHCPR Pub. No.
94-0622, July 1994.
Mental Health and Substance Abuse1
Development of a child mental health and substance abuse agenda. AHCPR has begun to develop and carry out a health services research agenda for improving
mental health and substance abuse services for children and youth focusing on services provided
in the general health sector.
Factors affecting children's access to mental health services. Children who had public insurance were found to be more likely than children who were either
uninsured or privately insured to have had at least one ambulatory visit to any medical provider
for a mental health problem. The greatest predictor of whether children with a problem had a
mental health visit was their mothers' use of mental health services. Cunningham PJ, Freiman
MP. Determinants of ambulatory mental health services use for school-age children and
adolescents. Health Serv Res, 31(4):409-427, 1996.
The Efficacy of Prenatal Care for Women and Children's Health. This conference, scheduled for June 26-27, 1997, will examine prenatal care interventions and
their effectiveness in enhancing both immediate and long-term health and development of women
and children. Conference participants will summarize and synthesize the current research on
prenatal care, develop recommendations for a research agenda that addresses gaps in the
literature, and disseminate findings to health care providers, managers, and policymakers.
Marie McCormick, Principal Investigator (Grant No. HS-09528) (1/1/97-12/31/97).
Taking Action With Children and Families. This conference, held March 13-14, 1997, examined health services and outcomes research for
children and adolescents, especially as applied to Medicaid settings. Research and demonstration
projects and community-based model programs were discussed in three symposia: 1) service
systems for at-risk infants and very young children; 2) community interventions to reduce asthma
morbidity in elementary school children; and 3) health promotion interventions to reduce
risk-taking behaviors among adolescents. Small working groups were also convened to
summarize findings and recommend future initiatives in each of the three topical areas. Ardene
Brown, Principal Investigator (Grant No. HS-09362) (2/1/97-1/31/98).
AHCPR's newest endeavor as a "science partner" with both public- and private-sector
organizations is the Evidence-based Practice Center (EPC) program. AHCPR will fund 8-10
Evidence-based Practice Centers (EPCs). These centers will work closely with professional
societies, health plans, and others to develop evidence reports and technology assessments. These
reports will form the scientific foundation for use by AHCPR science partners in developing their
own quality improvement tools. Applicants were asked to include evidence of their expertise in
child health. AHCPR is already working on two pilot evidence reports that concern children.
One report is on attention deficit hyperactivity disorder (ADHD), in coordination with
American Academy of Pediatrics, and the other is on valvular heart disease with the
College of Cardiology and the American Heart Association.
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1. Indicates projects newly funded in Fiscal Year 1996.
3. Additional Information
For more information on the above projects, contact:
Denise Dougherty, Ph.D.
Senior Advisor, Child Health
Agency for Healthcare Research and Quality
540 Gaither Road, Suite 2000
Rockville, MD 20850
Phone: (301) 427-1868
Fax: (301) 427-1561
U.S. Department of Health and Human Services
Public Health Service
Agency for Health Care Policy and Research
2101 E. Jefferson Street
Executive Office Center, Suite 501
Rockville, MD 20852
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Current as of November 1998