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Older women are less likely to receive chemotherapy and radiation treatment after breast cancer surgery

Invasive breast cancer is the second leading cause of cancer death in elderly women, and the older the women become, the less likely they are to receive chemotherapy or radiation treatment in addition to breast surgery (adjuvant therapy) to prevent cancer recurrence. These women also are less apt to have axillary lymph nodes assessed to determine how far their cancer has spread, concludes a study supported in part by the Agency for Health Care Policy and Research (HS06589).

Researchers from the Massey Cancer Center, Virginia Commonwealth University, examined the patterns of initial breast cancer surgery (forms of mastectomy and breast-conserving surgery or BCS), cancer stage, and adjuvant therapy for 3,361 women with local and regional breast cancer listed in the Virginia cancer registry from 1985 to 1989. They linked these data to Medicare claims and census data for the same years.

Optimal breast cancer management should include measuring tumor size, estrogen receptor levels (a woman's natural estrogen speeds the growth of cancer that is estrogen-receptor positive), axillary lymph node dissection in stage 1 and 2 disease to determine whether the cancer has spread to the lymph nodes, use of anti-estrogen (tamoxifen) therapy for estrogen-positive node cancer, and radiation therapy for women following BCS. This study showed that although tamoxifen therapy was used in about 32 percent of women with node-positive cancer regardless of their age, use of chemotherapy declined by two-thirds per decade of age, and radiation therapy use declined from two-thirds of women aged 65 to 69 to only 7 percent of women aged 85 and older. The probability that a woman would not receive an axillary lymph node assessment increased 2.5 fold for every decade of age, although it must be noted that the benefits of this procedure remain controversial for certain elderly women.

In all women over age 65 with breast cancer, after adjusting for nodal involvement, older age was a modest predictor against any adjuvant therapy. Coexisting illnesses, which tend to be more prevalent among older elderly women, may dissuade doctors from performing certain procedures. However, this study showed no significant effect of coexisting illnesses on receipt of adjuvant therapy after adjustment for other variables affecting its use. Older age remained the key determinant of which women received adjuvant cancer therapy.

See "Variation in staging and treatment of local and regional breast cancer in the elderly," by Bruce E. Hillner, M.D., Lynne Penberthy, M.D., M.P.H., Christopher E. Desch, M.D., and others, in Breast Cancer Research and Treatment 40, pp. 75-86, 1996.

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Women's and Family Health

Equalizing payments for cesarean and vaginal deliveries has little effect on cesarean rates

One reason cited for the high rate of cesarean deliveries in the United States is the profit motive. Some suspect that the higher fees that physicians receive for cesareans may be one reason they favor this procedure over vaginal delivery. Not so, says a recent study by the Management and Outcomes of Childbirth Patient Outcomes Research Team (PORT), which is supported by the Agency for Health Care Policy and Research (contract 290-90-0039).

When physicians were paid the same for both types of delivery, they did not decrease their rate of cesareans. The opportunity costs of waiting out a difficult labor, the fear of malpractice suits, and the impact of a bad outcome on self-respect, reputation, and long-term profits may be more important to cesarean decisions than the current fees. Despite the limited impact on cesarean rates, equalizing fees may be beneficial because physicians' costs are similar for both procedures, explain Emmett B. Keeler, Ph.D., of RAND and Thomas Fok, M.S., of Blue Cross of California, who authored the study.

The researchers examined the impact of a change in fees paid to physicians under a payment reform initiated by the California Blue Cross in May 1993. One of its preferred provider organizations equalized fees for the two procedures by increasing the fee for vaginal delivery by 3 percent and reducing the fee for cesarean delivery by an average of 18 percent. Drs. Keeler and Fok collected data on the method of delivery for the 5,252 cases in the affected plans for 12 months before and the 6,515 cases for 12 months after the fee change, including the mothers age, whether she had a prior cesarean, and whether the baby was in a breech position. After adjusting for case-mix, the overall cesarean rate dropped by a nonsignificant 0.7 percent.

Why did equalizing fees have so little effect? One possibility is that a 21 percent shift in relative payments for these procedures is not enough to change physician behavior, according to the researchers. They nevertheless argue that equalization of fees may improve patient trust, since such payments better reflect physicians costs and make it clear that choices are made primarily to benefit the patient.

See "Equalizing physician fees had little effect on cesarean rates," by Dr. Keeler and Mr. Fok, in the December 1996 issue of Medical Care Research and Review 53(4), pp. 465-471.

Time of day and hospital factors affect rate of cesarean deliveries for fetal distress

After increasing for many years, the rate of cesarean deliveries has finally reached a plateau in the United States. However, it appears that nonclinical factors continue to play a significant role in physicians' use of cesarean section (c-section). For example a recent study, supported in part by the Agency for Health Care Policy and Research (HS07012), found that c-sections are more likely to occur at night—between 9 p.m. and 3 a.m.—and in hospitals that treat many high-risk pregnancies. Fetal heart rate patterns that might be tolerable during the day, when services are readily available, result in earlier interventions when physicians or patients are fatigued or when fewer support staff are available, explains William J. Hueston, M.D., of the University of Wisconsin-Madison School of Medicine.

Dr. Hueston and Richard R. McClaflin, M.D., of the University of South Dakota, Sioux Falls, retrospectively reviewed the charts of a random sample of 6,440 women who gave birth at five hospitals during 1991 and 1992. They stratified women based on risk status and compared the time of delivery, maternal socioeconomic factors, and obstetric variables for women who had a c-section for fetal distress compared with women who gave birth vaginally.

The diagnosis of fetal distress was responsible for about 16 percent of all c-sections performed at the participating hospitals. As the percentage of high-risk women increased, the c-section rate for fetal distress also increased in a nearly linear fashion. But even in low-risk women, c-section for fetal distress occurred more often when the institution cared for a higher percentage of high-risk women.

The rates of c-section for fetal distress were relatively constant between 3 a.m. and 9 p.m. but increased from 9 p.m. to 3 a.m. Even after adjusting for other factors affecting cesarean delivery, time of day continued to be associated with c-section for fetal distress. However, this time factor was weaker than other factors, such as protracted labor and a prior cesarean delivery. C-sections linked to longer labors may reflect increased anxiety on the part of the physicians caring for the women. Alternatively, the longer first stage of labor could represent an increased risk to the fetus from prolonged labor, notes Dr. Hueston.

See "Variations in cesarean delivery for fetal distress," by Drs. Hueston and McClaflin, in the November 1996 issue of The Journal of Family Practice 43(5), pp. 461-467.

Both overtreatment and undertreatment pose problems for children with acute gastroenteritis

Acute gastroenteritis, manifested by vomiting and diarrhea, is a common illness among young children, with roughly two episodes annually for each child less than 5 years of age in the United States. Many children with this condition may be getting too much medical care, while others may not be getting enough, according to a recent study supported by the Agency for Health Care Policy and Research (contract 282-90-0043).

Steven Fox, M.D., S.M., M.P.H., of AHCPR's Center for Outcomes and Effectiveness Research, and his colleagues Nancy Merrick, M.D., M.S.P.H., and Bruce Davidson, Ph.D., M.P.H., reviewed the literature concerning the incidence, health care resource utilization, and current patterns of treatment for acute gastroenteritis in children. They found that physician and parent practices continue to differ from practice parameters recommended by the American Academy of Pediatrics (AAP).

One main point of difference involves the use of oral rehydration therapy (ORT). Experts recognize ORT as a simple and effective way to avert the dangerous dehydration that can accompany gastroenteritis. Properly and promptly used ORT can usually eliminate the need for intravenous rehydration and should prevent nearly all mortality from acute gastroenteritis. Yet each year in the United States, more than 200,000 children under age 5 are hospitalized for gastroenteritis, while approximately 300 children—mainly infants—still die from the preventable dehydration that untreated gastroenteritis can cause.

Some doctors continue to encourage parents to use inappropriate oral rehydration solutions (for example, juice, soda, or Gatorade). They recommend ORT for children with little evidence of dehydration and sometimes fail to provide it to those with moderate dehydration but prescribe intravenous hydration instead.

Meta-analysis of numerous small trials and larger series conducted in the United States and other developed countries suggests that the failure of ORT is infrequent (3 to 6 percent), even among children with moderate to severe dehydration. Some physicians and parents unnecessarily withhold ORT from children with vomiting. Others inappropriately restrict feeding, which should be restored immediately after rehydration. Often, pharmacologic agents are used that have little justification in acute diarrhea.

Factors that might explain the deviation of actual practice from expert recommendations have not been well studied. Earlier literature ascribed poor acceptance of ORT to insufficient knowledge of its efficacy and how to administer it. More recent evidence suggests that financial considerations (for parents as well as physicians) and support staff limitations may be even greater impediments. Factors contributing to lack of care in the fatal cases seem to include parents ignorance of the signs and importance of dehydration and limited access to care in socioeconomically disadvantaged areas.

The authors call for further research to determine why physicians and parents deviate from expert recommendations, whether this deviation really affects outcomes, and whether parents could be counted on to initiate and follow through with home ORT.

For more information, see "Treatment of acute gastroenteritis: Too much and too little care," by Drs. Merrick, Davidson, and Fox, in Clinical Pediatrics, pp. 429-435, 1996. Reprints (AHCPR Publication No. 97-R038) are available from the AHCPR Publication Clearinghouse.

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Patient Care/Clinical Decisionmaking

Benefits of blood pressure medication may not outweigh risks for some patients

Up to 50 million people in the United States have high blood pressure (hypertension) or are taking antihypertensive medications to lower their blood pressure. These medicines can cause fatigue, weakness, headache, joint and stomach aches, nausea, impotence, urinary tract problems, and a host of other problems.

In some cases, the potential benefits of antihypertensives may not outweigh their negative effects on quality of life. For instance, the health of a person treated with antihypertensive medications is comparable to that of an otherwise similar person 5 to 15 years older, according to a recent study supported in part by the Agency for Health Care Policy and Research (HS06491). On the other hand, antihypertensive medications can extend life by reducing the risk of stroke and coronary heart disease. Trade-offs between the side effects and benefits of antihypertensives should be presented to patients so they can make informed decisions about treatment, according to researchers from the University of Wisconsin, Madison.

The investigators interviewed 1,430 randomly selected adults aged 45 to 89 years, who participated in a study of health outcomes in Wisconsin. They obtained medical histories and health status measures ranging from energy and physical function to mental health, and they asked participants to rate their health. A total of 519 participants reported being affected by hypertension, most for 3 years or more and therefore likely to have accommodated to their diagnosis and treatment.

Results showed that persons with hypertension had significantly lower age-adjusted health status scores compared with those not affected by hypertension. Among those with hypertension, increasing numbers of antihypertensive medications were associated with lower reported general health status. The specific class of medication did not affect health status. In a subgroup analysis, combination medications taken in one pill had the same effects on health status as taking one medication. This suggests a potential for a quality-of-life benefit for combination medication that deserves future prospective research, conclude the researchers.

For more information, see "Health status and hypertension: A population-based study," by William F. Lawrence, M.D., M.S., Dennis G. Fryback, Ph.D., Patricia A. Martin, M.A., and others, in the November 1996 Journal of Clinical Epidemiology 49(11), pp. 1239-1245.

Study explores relationship between leg blood flow and physical functioning in patients who have difficulty walking

Revascularization of the lower limbs to improve leg blood flow used to be reserved for patients with skin ulcers or gangrene or whose impaired lower circulation caused leg pain even at rest. But surgical bypass and endovascular procedures on the leg are being increasingly used to enhance the walking ability and quality of life of patients with intermittent claudication. These patients usually have no leg pain at rest, but leg pain, tension, and weakness increase as they walk short distances; the pain then subsides upon rest. Patients with poor limb blood pressure and the most difficulty walking short distances may be the best candidates for lower extremity surgery or angioplasty, according to a study supported by the Agency for Health Care Policy and Research (HS07184).

Joe Feinglass, Ph.D., Walter J. McCarthy, M.D., and their colleagues at Northwestern University studied the outcomes of 555 patients who visited vascular surgery offices or clinics from 1993 to 1995 with an abnormal leg blood flow as measured by the resting ankle-brachial index (ABI). The ABI is the ratio of ankle to upper arm blood pressure, which is normally 0.95 or more. Most of the patients had trouble walking one to three blocks and reported an average of about 5 years of claudication symptoms.

Some patients with low ABIs (0.4 to 0.6 range) were still able to function well, while others had relatively high ABIs (0.8 to 0.9 range) and rather poor functioning. At enrollment, an increment of 0.3 in ABI level was associated with a 6 percent higher physical functioning score (as measured by the 36-item Medical Outcomes Study SF36 Health Survey), and a 10 percent higher walking distance score as reported by the patient. Patients who have lower ABIs, lower initial functioning, and fewer disabling coexisting conditions, such as neurologic disease and arthritis, have a much greater association between blood flow and functioning, conclude the researchers.

According to Dr. McCarthy, the findings presented here suggest that major comorbid conditions such as cerebrovascular, lung, and neurologic disease and knee and back arthritis influence claudication patients' functioning and walking ability independently of limb blood pressure as measured by the ABI. Thus, knowledge of limiting comorbid symptoms is critical in planning these patients' management.

See "Effect of lower extremity blood pressure on physical functioning in patients who have intermittent claudication," by Drs. Feinglass and McCarthy, Rael Slavensky, R.N., M.A., and others, in the October 1996Journal of Vascular Surgery 24 (4), pp. 503-512.

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Patient Outcomes/Effectiveness Research

Patients' race, education, and preoperative functioning predict outcomes of hip replacement surgery

Total hip replacement (THR) results in less pain and better physical functioning for most patients who undergo the surgery. A recent study supported by the Agency for Health Care Policy and Research (HS07386) found that 84 percent of patients reported improvement in pain, and 76 percent reported improvement in physical functioning by 6 months after surgery. However, the study also found that blacks, persons with little education, and those with poorer preoperative health are less likely to benefit from this surgery. The study was conducted by researchers at the Medical Treatment Effectiveness Research Center (MEDTEP Center) on Minority Populations at Henry Ford Hospital Systems in Detroit, MI.

Black race was associated with 9.5 points less improvement in pain and 10.9 points less improvement in physical functioning, and low education was associated with 6.2 points less improvement in pain and 7.7 points less improvement in physical functioning 6 months after surgery. Also, for each additional medical condition the patient had—such as congestive heart failure, diabetes, or asthma—there were corresponding decreases of 4.6 points in pain improvement and 4.7 points in physical function improvement.

Patients with lower preoperative functioning were more apt to have lower postoperative function, but substantially more of these patients benefited from their surgery. The opposite was true for patients with high preoperative function. For each 10-point increase in preoperative score, patients could expect at least a 6-point decrease in postoperative improvement.

The researchers suggest that physicians use this information to advise patients about their probability of success from hip replacement surgery and to decide whether or not to offer the procedure to the patient. Findings were based on data analyzed in the American Medical Group Association Total Hip Replacement consortium database of patients undergoing THR at several centers. Patients undergoing THR completed self-administered questionnaires preoperatively and at 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively.

Details are in "Patient-related risk factors that predict poor outcome after total hip

replacement," by Cynthia H. MacWilliam, M.B.A., Marianne Ulcickas Yood, M.P.H., James J. Verner, M.D., and others, in the December 1996 HSR: Health Services Research 31(5), pp. 623-638.

PSA testing for early detection of prostate cancer provides little useful information in men with BPH

Higher-than-normal blood levels of prostate-specific antigen (PSA) are often used as an indicator of possible prostate cancer. However, it is more difficult to interpret test results in men with benign prostatic hyperplasia (BPH, enlarged prostate), according to a study supported by the Agency for Health Care Policy and Research (HS08397).

Men with lower urinary tract symptoms characteristic of BPH—such as frequent or urgent need to urinate or incomplete bladder emptying—are those most apt to undergo PSA testing, even though the ability of the PSA test to discriminate potentially curable prostate cancer from BPH is dramatically lower in men with such symptoms than in randomly selected men.

From 30 to 60 percent of men with BPH but no pathologic evidence of prostate cancer will have a PSA level greater than 4.0 ng/mL, which is considered the upper limit of normal, explains Michael J. Barry, M.D., of Harvard Medical School. He and the Prostate Patient Outcomes Research Team (PORT) used PSA data from four groups of men aged 50 to 79 years. Group 1 was composed of men with prostate cancer for whom PSA levels were drawn preoperatively. PSA levels for men in this group were compared with PSA levels for men selected without regard for lower urinary tract symptoms (Group 2, unselected) and for men with BPH (Groups 3 and 4).

Among men with localized prostate cancer, 61 percent had PSA levels greater than 4.0 ng/mL, while 7 percent of unselected men and 32 percent of men with BPH had PSA values above this threshold. In unselected men, PSA concentrations between 4.1 and 6.0 ng/mL raised the likelihood of cancer over three-fold. But in men selected on the basis of symptoms, PSA concentrations greater than 10 ng/mL were needed to achieve a similar three-fold increase in the likelihood of cancer. Men with no or mild urinary tract symptoms and a PSA value above 4 ng/mL had about twice the odds of having organ-confined prostate cancer as men with moderate to severe symptoms and a PSA value above 4 ng/mL.

The researchers conclude that the usefulness of a single PSA test result in patients with BPH is questionable. The results can be enhanced by the use of likelihood ratios to stratify individual men along a continuum of risk for prostate cancer, rather than assigning the same risk to all men above a single threshold. Clinicians can use PSA in conjunction with likelihood ratios to modify the probability that their patient has a clinically localized, potentially curable malignancy.

See "Interpreting results of prostate-specific antigen testing for early detection of prostate cancer," by James B. Meigs, M.D., M.P.H., Dr. Barry, Joseph E. Oesterling, M.D., and Steven J. Jacobsen, M.D., Ph.D., in the Journal of General Internal Medicine 11, pp. 505-512, 1996.

Routine coronary angiography after heart attack is cost-effective for certain patients

Victims of heart attack (acute myocardial infarction, AMI), who survive the first 3 days of hospitalization, remain at risk for another nonfatal heart attack, angina, congestive heart failure, and sudden death. The routine use of angiography (image of the heart aided by dye infused into the heart through a catheter) in patients recovering from uncomplicated AMI is as cost effective as other treatment strategies for coronary heart disease, conclude members of the Acute Myocardial Infarction Patient Outcomes Research Team (AMI PORT).

The AMI PORT researchers (supported by the Agency for Health Care Policy and Research, HS06341) developed a decision model for AMI based on survey data from 1,051 patients who had suffered a recent heart attack. The model estimated quality-adjusted life expectancy and direct lifetime costs for two strategies: coronary angiography and treatment guided by its results versus initial medical therapy without angiography.

Model estimates of cost-effectiveness ratios for routine coronary angiography ranged from $17,000 to over $1 million per quality-adjusted year of life gained. Patients who had severe angina following the initial heart attack and experienced problems during the exercise tolerance test (a positive ETT) and those who had a prior heart attack (even with a negative ETT) typically had cost-effectiveness ratios of less than $50,000 per quality-adjusted year of life gained. Ratios for these high-risk patients compared reasonably well with those of other medical interventions, such as beta-adrenergic antagonist therapy after AMI.

Initial evaluation with the use of ETT followed by coronary angiography when the ETT is positive (symptom-driven angiography) is often advocated as the appropriate strategy for the evaluation of patients after AMI. However, certain patients who are at high risk before undergoing an ETT may remain at sufficiently high risk to warrant coronary angiography even with a negative ETT result. Also, previous studies have shown a trend toward improved 1-year survival in patients who received routine angiography following a heart attack over patients who received angiography only if they showed cardiac symptoms. Even in cases where the probability that three vessels are blocked (three-vessel disease) is small, the benefits that revascularization provides more than offset the small risk associated with angiography in the majority of patients, conclude the researchers.

More details are in "Cost-effectiveness of routine coronary angiography after acute myocardial infarction," by Karen M. Kuntz, Sc.D., Joel Tsevat, M.D., M.P.H., Lee Goldman, M.D., M.P.H., and Milton C. Weinstein, Ph.D., in Circulation 94(5), pp. 957-965, 1996.

Use of stroke prevention medication may vary with physician specialty

Medical therapy for patients with extracranial carotid stenosis (narrowing of the carotid artery) may vary with physician specialty, according to a recent study by the Stroke Patient Outcomes Research Team (Stroke PORT). The study is based at Duke University and supported by the Agency for Health Care Policy and Research (contract 290-91-0028).

PORT researchers David B. Matchar, M.D., Larry Goldstein, M.D., and their colleagues analyzed the responses of 1,006 physicians who participated in a national survey of stroke prevention practices. The survey included questions that asked physicians what medications they used in patients who had various degrees of narrowing of the carotid arteries with and without other symptoms of this condition.

The analysis showed that while 85 percent of all responding physicians always or often prescribe aspirin or other platelet antiaggregants, not all physicians prescribe them at the same rate. As measured by the odds ratio, neurologists or internists are about two-thirds more likely than surgeons to prescribe these medications.

Reported variation in use was even greater when physicians were asked about their use of anticoagulants. In comparison with surgeons, the odds of noninternist primary care physicians prescribing anticoagulants were about 5 times higher, the odds of internists prescribing anticoagulants were about 3.5 times higher, and the odds of neurologists prescribing anticoagulants were about 2 times higher. For all specialties, the use of anticoagulants also varied with the patients degree of carotid artery stenosis, symptom status, and the presence of surgical contraindications.

The researchers point out that some of the reported variations in practice may be attributed to physician uncertainty. Physicians in practice frequently must make recommendations without the benefit of unambiguous data from well-designed and well-conducted clinical trials. However, clinical trial data are rapidly becoming available to help guide the treatment of specific types of patients at elevated risk of stroke.

Details are in "U.S. national survey of physician practices for the secondary and tertiary prevention of ischemic stroke," by Dr. Goldstein, Arthur J. Bonito, Ph.D., Dr. Matchar, and others, in Stroke 27(9), pp. 1473-1478, 1996.

Type of health insurance and physician specialty influence treatment for depression

If you are depressed and see a psychiatrist or psychologist, you will probably receive psychotherapy and/or antidepressant medication. If you see a general medical provider (e.g., family physician, internist, or master's-level therapist in a group practice), you will be more apt to receive less intensive and more advice-oriented depression counseling. If you are in a prepaid insurance plan and see a general physician for depression, you will be less likely to receive counseling than under fee-for-service care. These are the findings of a study supported in part by the Agency for Health Care Policy and Research (HS06802) and led by Kenneth B. Wells, M.D., M.P.H., of RAND and the University of California, Los Angeles.

The study was based on observational data from the RAND Medical Outcomes Study of care for adult patients in health maintenance organizations, large multispecialty groups, and solo practices in Los Angeles, Boston, and Chicago. Information was obtained on depressed patient characteristics, counseling encounters, and counseling style.

The researchers found that although almost all depressed patients who were being treated by mental health specialists received brief counseling of at least 3 minutes, less than half of depressed patients treated by general physicians received such counseling, even patients with a current depressive disorder. Psychiatrists relied more on psychodynamic approaches, and psychologists relied more on behavioral therapies; both specialty groups provided longer sessions and used more formal psychotherapeutic techniques than general medical clinicians.

Counseling rates were lower under prepaid than fee-for-service care in general medical practices. Clinicians who treated more prepaid patients were less inclined to do face-to-face counseling, and they spent less time when they were counseling patients compared with clinicians who treated more patients enrolled in fee-for-service plans. However, these payment-based counseling differences were small relative to the very large and consistent differences in counseling style associated with medical specialty, according to the study's lead author, Lisa S. Meredith, Ph.D.

For more information, see "Counseling typically provided for depression," by Drs. Meredith and Wells, Sherrie H. Kaplan, Ph.D., M.P.H., and Rebecca M. Mazel, M.A., in the Archives of General Psychiatry 53, pp. 905-912, 1996.

Some eye doctors do not perform recommended tests following cataract surgery

Although serious complications of cataract surgery are rare, they can have a devastating effect on a patient's vision when they do occur. Therefore, ophthalmologists and optometrists involved in the postoperative care of cataract surgery patients need to identify serious complications as soon as possible. That is one reason why both the American Academy of Ophthalmology (AAO) and the Agency for Health Care Policy and Research-supported clinical practice guideline on cataract management recommend that patients be seen by the operating surgeon within 24 hours of surgery. But the rationale for specific recommendations regarding the number and timing of subsequent visits is less clear, and with increasingly smaller cataract surgery incisions, some of the recommendations on followup visits may no longer apply.

A recent AHCPR-supported study (HS06280) suggests that this may be the case. It shows that as early as 1992, a small percentage of ophthalmologists and optometrists had postoperative practice patterns that differed from those recommended by the AAO and the AHCPR-supported guideline. For instance, 3 percent of ophthalmologists did not routinely perform the first postoperative visit for the patients on whom they operated. Twelve percent of ophthalmologists said they or other eye professionals routinely saw patients without operative complications fewer than four times within the first 4 months following cataract surgery. These physicians were more apt to perform a high volume of cataract surgery or to use phacoemulsification, a type of small-incision surgery that is associated with faster postoperative rehabilitation. The increased use of this surgery may be one reason for the fewer visits, explain researchers from The Johns Hopkins University and Georgetown University.

They conducted a 1992 survey of randomly selected members of the AAO and the American Optometric Association. Results showed that 88 percent of responding ophthalmologists had patients with the recommended four or more visits within 4 months after surgery; 78 percent of responding optometrists saw patients three or more times after surgery. The content of postoperative visits did not always include tests recommended by the AAO and the AHCPR-sponsored guideline. For instance, the proportion of ophthalmologists and optometrists who usually performed at least one dilated fundus exam were 83 percent and 75 percent respectively, four or more slit-lamp exams (87 percent and 47 percent), four or more tonometry tests (74 percent and 42 percent), and two or more refractions (83 percent for both). The researchers conclude that more research is needed to determine whether these practices result in any differences in the risk of adverse patient outcomes compared with recommended practices.

See "Postoperative management of cataract surgery patients by ophthalmologists and optometrists," by Eric B. Bass, M.D., M.P.H., Phoebe D. Sharkey, Ph.D., Rajiv Luthra, M.D., M.P.H., and others, in the September 1996 Archives of Ophthalmology 114, pp. 1121-1127.

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