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AHCPR requests topic nominations for evidence reports and technology assessments

The Agency for Health Care Policy and Research has issued a request for topic nominations for the second round of evidence reports and technology assessments that will be developed by AHCPR's 12 Evidence-based Practice Centers (EPCs). The topics selected will receive funding in fiscal year 1998, which began October 1. The EPCs will conduct literature reviews and assess and synthesize scientific evidence for each topic.

These EPC reports and assessments are designed to help public and private entities develop and implement quality improvement tools and programs tailored to their own settings and populations. These may include practice guidelines, clinical pathways, review criteria, performance measures, and other quality improvement initiatives. The evidence reports and assessments also may be used to inform health care decisions for coverage or reimbursement policies.

The formal solicitation, which appears in the November 28 issue of the Federal Register, outlines the selection criteria and AHCPR's selection process. Topic nominators may become resources to the EPCs as they develop the evidence reports and assessments. The nominators also may be asked to review draft versions of the reports or technology assessments.

Topic nominations should be submitted by January 30, 1998 to Douglas B. Kamerow, M.D., M.P.H., Director, Center for Practice and Technology Assessment, AHCPR, 6000 Executive Boulevard, Willco Building, Suite 310, Rockville, MD 20852.

AHCPR and HMO Research Network seek applicants for senior managed care scholar position

The application deadline has been extended to February 27, 1998 for a senior managed care scholar position to be located at the offices of the Agency for Health Care Policy and Research in Rockville, MD, a suburb of Washington, DC. AHCPR and the HMO Research Network are sponsoring this full-time, 12- to 18-month position; the target starting date is June 15, 1998. The scholar will be based in AHCPR's Center for Organization and Delivery Studies but will serve as an Agency-wide resource on managed care and on building research partnerships with managed care organizations and others.

The scholar will be expected to perform research and policy analyses, alone and in collaboration with colleagues inside and outside the Agency. The scholar will advise the Agency in its efforts to form research partnerships with industry and serve as an Agency-wide resource on managed care. To meet these expectations, the applicant should have a doctoral level degree in a clinical or social science field and an established record of research productivity. Further, applicants must be full-time employees of a governmental, educational, or not-for-profit organization that has as one of its principal functions the offering of professional advisory, research, educational, or developmental services concerned with public management.

Applicants should submit a curriculum vitae, descriptions of pertinent experience and interests, and a two-page letter of intent that fully describes the projects they would like to undertake. Applicants will be notified of the selection by March 31, 1998.

For more information, please contact Bernard Friedman, Ph.D., Center for Organization and Delivery Studies; Phone (301) 427-1404; E-mail:

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Research Briefs

Coffey, R.M., Ball, J.K., Johantgen, M., and others (1997, September). "The case for national health data standards." Health Affairs 16(5), pp. 58-72.

As the varied uses of health care data have grown, so has the need for standards. The Health Insurance Portability and Accountability Act of 1996 contains groundbreaking provisions to encourage the development of a national health information system through the establishment of standards. This paper, authored by former staff of the Agency for Health Care Policy and Research, compares statewide inpatient data systems to one standard—the Uniform Bill (UB)—to understand how standards have been used and how they can be improved. Comparisons revealed three areas for improvement. Modification to some UB data elements (e.g., universal adoption of numeric values for reporting patients' sex; consistent format for reporting zip codes) would better serve the information needs of health care policymakers and improve the uniformity of health data nationally. Compliance with UB standards by statewide data systems would make data more comparable and easier to share. Consensus on common, derived elements that are not part of the UB would enhance the ability to combine data across State systems.

Reprints (AHCPR Publication No. 98-R012) are available from the AHCPR Publications Clearinghouse.

Cohen, S.B. (1997, August). "An evaluation of alternative PC-based software packages developed for the analysis of complex survey data." The American Statistician 51(3), pp. 285-292.

National surveys conducted by government organizations, industry, political organizations, and market research firms often share the same survey design objective, that is, to minimize the variance in survey estimates. As a consequence, most large-scale national health care surveys are characterized by sample designs with varying degrees of complexity, with design features that include clustering, stratification, disproportionate sampling, and multiple stages of sample selection. Thus, data from complex survey designs require special consideration with regard to variance and data analysis as a consequence of significant departures from simple random sampling assumptions. Using data from the National Medical Expenditure Survey, which is characterized by a complex survey design, Steven B. Cohen, Ph.D., of AHCPR's Center for Cost and Financing Studies, compares three software programs developed for the analysis of complex survey data in a personal computing environment: Strata, SUDAAN, and WesVarPC. The comparisons concentrate on user facility, computational efficiency, and program capabilities.

Reprints (AHCPR Publication No. 98-R001) are available from the AHCPR Publications Clearinghouse.

Gallagher, T.C., Anderson, R.M., Koegel, P., and Gelberg, L. "Determinants of regular source of care among homeless adults in Los Angeles." (AHCPR grant HS06696). Medical Care 35(8), pp. 814- 830, 1997.

Many homeless adults in Los Angeles are burdened by physical illness, substance dependence, and chronic mental illness. Most (80 percent) of them are men, and many are alcoholics and veterans. Nearly half lack a regular source of health care or, in the case of veterans, do not make use of Veterans Administration services. Besides the usual barriers to having a regular source of care that affect the poor, the homeless face additional barriers which are associated with their difficult lifestyle, namely entrenched homelessness, social isolation, and frequent difficulty just obtaining food, shelter, and clothing.

These researchers explored the determinants of having a regular source of care in a community-based sample of homeless adults in Los Angeles using a health services use model. Analysis showed that 57 percent of the sample had a regular source of care. For those with a regular source of care, 30 percent sought treatment from a hospital outpatient department, 23 percent used a hospital emergency room, 25 percent visited a community or homeless clinic, 14 percent received care at a government clinic, and 9 percent were treated in a private physician's office. Homeless adults who more frequently had difficulty meeting their subsistence needs were less likely to have a regular source of care. The researchers suggest that locating health care facilities at sites of other services for the homeless, such as shelters and soup lines, and provision of or assistance with subsistence needs by health facilities might be an incentive for the homeless to maintain contact with the health care system. They believe that social isolation may be a more important barrier to access to care than chronic psychiatric problems or substance use among the homeless.

Lenert, L.A., Morss, S., Goldstein, M.K., and others (1997). "Measurement of the validity of utility elicitations performed by computerized interview." (AHCPR grant HS08349). Medical Care 35(9), pp. 915-920.

Few data have been collected on whether utility assessments validly measure patient preferences for certain treatments. These authors used a computerized survey to describe and measure preferences for three common side effects of antipsychotic drugs: tardive dyskinesia (TK), akathesia (AKA), and pseudo-parkinsonism. They then compared the validity of elicitations in 41 healthy volunteers and 22 schizophrenic patients. To assess the validity of each groups' responses, the authors compared the consistency of subjects' rank-order of the desirability of states across methods of preference assessment (utilities): visual analog scale (VAS), pair-wise comparison (PWC), and standard gamble (SG), the so-called CAMPA (consistency across methods of preference assessment) test. They found that 97 percent of healthy volunteers and 70 percent of patients thought they understood the task required of them. However, only 78 percent of healthy subjects and 44 percent of patients had a consistent rank ordering of preferences among VAS and PWC ratings; only 80 percent and 61 percent, respectively, had a consistent rank ordering preference among SG and PWC ratings. The authors conclude that the CAMPA test can identify potentially invalid preference ratings that may bias the population utilities for health states. They call for further research on this topic.

Mandelblatt, J.S., Fryback, D.G., Weinstein, M.C. (1997, September). "Assessing the effectiveness of health interventions for cost-effectiveness analysis." (AHCPR grant HS08395). Journal of General Internal Medicine 12, pp. 551-558.

This paper offers an overview of modeling to estimate net effectiveness in a cost-effectiveness analysis (the difference in effectiveness between an intervention and the alternative to which it is being compared). Many of the principles described for estimating effectiveness apply equally to determining costs in a cost-effectiveness analysis. The main difference is that health events are weighted by costs in the numerator of the cost-effectiveness ratio, while they are often weighted by preference values in the denominator. Preference values, or utilities, reflect the fact that individuals or populations with similar ability (or disability) to function may regard that level of functioning differently. The authors point out that calculating net effectiveness in a cost-effectiveness analysis involves accounting for the many complex events that follow from the decision to intervene with patients or populations; rarely will it be based on results from a single study.

McCormick, K.A., Cummings, M.A., and Kovner, C. (1997). "The role of the Agency for Health Care Policy and Research in improving outcomes of care." Nursing Clinics of North America 32(3), pp. 521-542.

In this article, AHCPR staff members Kathleen A. McCormick, Ph.D., R.N., Mary A. Cummings, Dr.P.H., R.N., and Chris Kovner, Ph.D., R.N., describe some of AHCPR's major accomplishments and current priorities in improving patient outcomes and health care quality. AHCPR is charged with helping consumers, health care providers, purchasers, health plan managers, and policymakers improve the quality and cost-effectiveness of health care services. Reprints (AHCPR Publication No. 98-R002) are available from the AHCPR Publications Clearinghouse.

Overhage, J.M., Tierney, W.M., Zhou, A., and McDonald, C.J. (1997, September). "A randomized trial of "corollary orders" to prevent errors of omission." (AHCPR grants HS05626 and HS07719). Journal of the American Medical Informatics Association 4(5), pp. 364-375.

Errors of omission commonly occur in everyday medical practice. Physicians sometimes fail to order tests or treatments needed to monitor/ameliorate the effects of other tests or treatments. However, this study found that physician workstations, linked to a comprehensive electronic medical record, can efficiently decrease errors of omission and improve adherence to practice guidelines. The researchers randomized faculty and house staff from the Indiana University School of Medicine to an intervention or control group. When intervention physicians wrote orders for 1 of 87 selected tests or treatments, the computer suggested corollary orders needed to detect or ameliorate adverse reactions to the trigger orders. The physicians could accept or reject these suggestions. During the 6-month study, reminders about corollary orders were presented to 48 intervention physicians and withheld from 41 control physicians. Intervention physicians ordered the suggested corollary orders in 46 percent of instances when they received a reminder, compared with 22 percent compliance by control physicians. Physicians readily accepted some suggested orders and rejected others. Pharmacists had to initiate one-third fewer interventions with physicians in the intervention than in the control group.

Stineman, M.G., Goin, J.E., Tassoni, C.J., and others (1997). "Classifying rehabilitation inpatients by expected functional gain." (AHCPR grant HS07595). Medical Care 35(9), pp. 963-973.

In 1983, Medicare instituted a prospective payment system for acute care hospital services but excluded medical rehabilitation inpatients who could not be classified reliably using the diagnosis-related-group patient classification system. To create a more suitable payment system for medical rehabilitation, the authors developed a companion classification system to the original functional independence measure-function-related groups (FIM-FRGs), which classify patients having similar lengths of stay in a rehabilitation hospital or inpatient unit. The companion system presented in this article groups patients according to their gains in functional status during the rehabilitation stay and is based on data from 84,492 patients discharged from 252 rehabilitation facilities in 1992. The gain-FRGs system used four predictor variables: diagnosis leading to disability, admission scores on the motor subscales and cognitive subscales of the FIM, and patient age. The gain-FRGs system contained 74 patient groups and explained 21 percent of the variation in functional gain for patients. It should be considered for prospective payment systems because it gives the provider an incentive to improve patient outcomes, which is missing in a payment system based on FIM-FRGs alone, conclude the authors.

Styrt, B.A., Chaisson, R.E., and Moore, R.D. (1997). "Prior antimicrobials and staphylococcal bacteremia in HIV-infected patients." (AHCPR grant HS07809). AIDS 11(10), pp. 1243-1248.

Many drugs used to prevent opportunistic infections in persons with AIDS also have activity against common bacteria that cause pneumococcal, staphylococcal, Pseudomonas, and Haemophilus infections in these patients. This study was done to compare prior exposure to selected antimicrobial drugs in 48 HIV-infected patients who had S. aureus bacteremia and in 188 HIV-infected controls who did not at a hospital HIV clinic. Both groups had CD4 cell counts less than 200. Rifabutin use was associated with one-third decreased risk of S. aureus bacteremia. Bacteremia was not significantly associated with use of trimethoprim-sulfamethoxazole, quinolones, newer macrolides (azithromycin and clarithromycin), clindamycin, or dapsone. The researchers conclude that rifabutin may be associated with diminished risk of S. aureus bacteremia. However, they do not support deliberate use of rifabutin for this purpose until more information can be obtained that would permit balancing its benefits against potential risks such as adverse drug reactions and emergence of microbial resistance.

West, S.L., Savitz, D.A., Koch, G., and others (1997). "Demographics, health behaviors, and past drug use as predictors of recall accuracy for previous prescription medication use." (AHCPR grant HS06906). Journal of Clinical Epidemiology 50(8), pp. 975-980.

This study investigates factors that influence a person's recall of repetitive or short-term use of nonsteroidal antiinflammatory drugs (NSAIDs) and postmenopausal estrogen. The researchers compared information about use of these medications via telephone interviews with that obtained from the Group Health Cooperative of Puget Sound pharmacy database. They correlated recall accuracy with various sociodemographic characteristics, health habits, and cumulative drug history and the number of different NSAIDs or estrogens dispensed. For estrogen and short-term NSAID use, only higher educational attainment improved recall accuracy. The odds of recall were four and two times greater for those with some college and those with only a high school degree, respectively. For repetitively used NSAIDs, recall accuracy was associated with the number of NSAID prescriptions, the total number of drugs dispensed, and the number of different NSAIDs dispensed. The researchers conclude that recall accuracy of previous medication use differs by the type of drug and the repetitiveness of its use.

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AHCPR Publication No. 98-0011
Current as of December 1997

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