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Care for HIV-infected patients with PCP varies substantially among hospitals
Hospitals disagree on how to care for HIV-infected patients who are hospitalized for Pneumocystis carinii pneumonia (PCP). For instance, a study supported in part by the Agency for Health Care Policy and Research (HS06494) found that two municipal hospitals with considerable experience treating these patients differed markedly in their strategy for diagnosing PCP and in their use of intensive care for patients with PCP. At Hospital A, 85 percent of patients had the diagnosis definitively confirmed by sputum analysis or bronchoscopy (before antibiotics were prescribed) versus only 26 percent of patients at Hospital B. Hospital B only confirmed PCP diagnosis with bronchoscopy for those patients who did not respond to initial antibiotic treatment.
Nevertheless, both hospitals initiated antibiotic treatment effective against PCP for nearly 90 percent of patients within the first 48 hours of hospital admission. In addition, adjunctive corticosteroid therapy was used in 21 percent of patients at Hospital A and 23 percent of patients at Hospital B. However, Hospital A used intensive care far more often than Hospital B (19 percent vs. 3 percent of patients).
For HIV-related PCP, appropriate prophylactic therapy, antibiotic treatment, and adjunctive corticosteroid therapy have been well defined. In contrast, some controversy remains about appropriate strategies for diagnosis and use of intensive care resources for patients with HIV-related PCP, explains lead author J. Randall Curtis, M.D., M.P.H., of the University of Washington, Seattle. These were the areas of difference shown between hospital A and hospital B
in this study and even among doctors practicing at two teaching hospitals of the same medical school in a 1996 study by coauthor Charles L. Bennett, M.D., Ph.D., of Northwestern University, Chicago, and his colleagues.
Despite differences in the process of care, survival rates were similar at the two institutions (75 percent vs. 76 percent), even after controlling for patient demographic factors and severity of illness. Care outcomes, such as mortality, are often used as a hospital's report card for quality of care. The researchers point out that a better way to improve quality of care is to identify and target specific elements in the process of care that can be changed to improve outcomes, as was done in this study. However, when process factors are heavily debated, as in this case, then
marked differences in rates may exist without any difference in outcomes.
Details are in "Variations in medical care for HIV-related Pneumocystis carinii pneumonia," by Dr. Curtis, Matthew Ullman, Ph.D., Ann C. Collier, M.D., and others in the August 1997 CHEST 112(2), pp. 398-405; and "Patterns of care for HIV-related Pneumocystis carinii pneumonia in a university medical program: A case study," by Dr. Bennett, Dr. Ullman, Gordon M. Dickinson, M.D., and others, in the November 1996 Clinical Performance and Quality Healthcare 4, pp. 186-189.
Early stage of infection rather than poor detection may be to blame for recent HIV-contaminated blood transfusions
Early stage of infection rather than insensitive detection tests is the most likely culprit in recent cases of blood transfusions contaminated with HIV, the virus that causes AIDS, concludes a study supported in part by the Agency for Health Care Policy and Research (NRSA training grant T32 HS00020). These contaminated transfusions have usually occurred in areas where AIDS epidemics are just getting underway.
Because of their increasing sensitivity, ELISA tests for HIV antibodies rarely miss HIV-infected blood. However, blood from newly-infected persons usually has very low levels of HIV antibodies that do not show up on ELISA tests during the first 6 months of infection. Thus, failure to detect HIV-contaminated blood in areas of new epidemics is most often due to the window of time between infection and seroconversion (when detectable amounts of antibodies develop in the blood) rather than to testing errors, explains Eugene Litvak, Ph.D., of the Harvard School of Public Health.
Dr. Litvak and his colleagues examined the impact of the seronegative window on the false-reassurance rate (FRR), that is, when the ELISA test shows no HIV infection even though the person is in fact infected. They used a model of HIV and AIDS incidence to derive an estimate of the probability of those who are infected remaining in the seronegative window (about 0.03). They then estimated the FRR as a function of the probability of remaining in the seronegative
window, the prevalence of HIV in a given area, and the inherent sensitivity of the ELISA test.
The researchers found that the FRRs for two blood donor groups—one with an HIV prevalence of 0.004 and a typical probability of remaining in the seronegative window (0.03), and the other with a higher prevalence of HIV (0.017) but fewer donors in the window (probability of 0.003)—are equal (140 FRRs per 1 million donors) if the blood is negative on a single ELISA test. After two negative tests or a single test that can detect antibodies more reliably, however, the FRR is much higher in the group with the higher probability of new infection (120 FRRs per million compared with 50 per million). This is because the greater numbers of donors in the window more than offsets the lower prevalence of HIV infection. These findings suggest that the traditional strategy of soliciting blood donors from populations with low HIV prevalence may not always be optimal, unless such populations are truly low risk (i.e., those with a low probability of having individuals in the seronegative window).
For more details, see "Whose blood is safer? The effect of the stage of the epidemic on screening for HIV," by Dr. Litvak, Joanna E. Siegel, Sc.D., Stephen G. Pauker, M.D., and others, in the October 1997 Medical Decision Making 17(4), pp. 455-463.
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AHCPR News and Notes
From the Administrator: Health services research has a vital role to play in America's changing health care marketplace
Editor's Note: The following is a summary of a recent journal article authored by AHCPR
Administrator, John M. Eisenberg, M.D.
Consumers, health care plans, health care providers, and policymakers have long relied on clinical research to test the effectiveness and side effects of a new drug or treatment. They can now turn to health services researchers to uncover which health care options work, when, and at what cost, notes John M. Eisenberg, M.D., Administrator of the Agency for Health Care Policy and Research, in a recent commentary. Health services research also can guide decisions about clinical services and the organization and financing of health care.
Dr. Eisenberg points out that as health care delivery becomes more consolidated and organized into integrated systems, decisions will be made less often at the local level and more often will be corporate decisions made at the level of practices, clinics, hospitals, networks, or entire plans.
To discriminate between innovations that work and those that do not, health services researchers apply strict methods of evaluation science to measure the impact of organizational and financing changes on the quality and cost of care, just as clinical researchers measure the effects and side effects of a new drug. New organizational and financing arrangements should be subjected to the same unbiased scrutiny to which we subject clinical innovations, notes Dr. Eisenberg. It is not enough to know that clinical services are safe, effective, and appropriate if the structure for
delivering that care is shaky.
The health services research field has the potential to provide the tools, methods, and information that can help to measure, explain, and ultimately improve the delivery of health care. In addition, health services research can clarify which managed care interventions work best and when. In market-oriented health care, the preferences and values of patients, combined with information about how they can achieve their preferences, will drive decisionmaking by patients and those acting on behalf of patients. Partnerships among providers, employers, researchers, and plans are
necessary to make sure we capture the information necessary to perform research that reflects current market conditions, concludes Dr. Eisenberg.
Details are in "Health services research in a market-oriented health care system," by Dr. Eisenberg, in the January/February 1998 issue of Health Affairs 17(1), pp. 98-108. Reprints (AHCPR Publication No. 98-R014) are available from the AHCPR Publications Clearinghouse.
American College of Physicians' District of Columbia Chapter honors AHCPR's Administrator
John M. Eisenberg, M.D., Administrator of the Agency for Health Care Policy and Research, has been awarded the prestigious John F. Maher Memorial Laureate Award by the District of Columbia Chapter of the American College of Physicians. The award was conferred on Dr. Eisenberg at the Chapter's annual scientific meeting held January 16 and 17 at the Uniformed Services University of the Health Sciences in Bethesda, MD.
In selecting Dr. Eisenberg for this award, the Chapter cited his lifelong contributions to the practice of internal medicine, to his community, and to the American College of Physicians. He served as a member of the American Board of Internal Medicines Board of Directors from 1987 to 1993 and its Executive Committee from 1992 to 1993. He was a member of the American College of Physicians' Board of Regents from 1996 to 1997, and was elected to mastership of the College in 1996.
Recipients of the John F. Maher Memorial Laureate Award are senior physicians who are Masters or Fellows of the American College of Physicians, with a long history of excellence and peer approval of their accomplishments in the practice of internal medicine and participation in College affairs. Congratulations to Dr. Eisenberg on this well-deserved award.
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New brochure provides women with treatment choices for noncancerous uterine conditions
The Agency for Health Care Policy and Research has published a new brochure to help women better understand and make decisions about the kinds of treatment they can choose for noncancerous uterine conditions, such as fibroids or endometriosis. These conditions are common and affect 1 in 10 U.S. women ages 18 to 50. The 32-page brochure, Common Uterine Conditions: Options for Treatment, is designed to supplement a woman's discussion with her clinician about various treatment options, including hysterectomy.
Hysterectomy, the surgical removal of the uterus, has been a traditional treatment for these conditions, but many women may not be aware that more options are available to them. In 1995, more than 583,000 hysterectomies were performed in the United States. It is second to cesarean section as the operation most frequently performed on women. By age 65, more than 37 percent of all women in the United States will have had a hysterectomy.
Hysterectomy is not the only option for treating noncancerous uterine conditions and, for some women, it may not be the best option. Alternatives to hysterectomy include medicine, hormone treatment, a more conservative type of surgery, changes in diet or exercise, and watchful waiting.
For some women, a hysterectomy can significantly improve their quality of life, but for others, less invasive procedures may be successful and preferred, particularly for women who would like to become pregnant.
The brochure describes many of the noncancerous uterine conditions that can lead to hysterectomy or another type of treatment. The most common conditions are uterine fibroids—which are solid masses of noncancerous tissue that can cause pain and excessive bleeding—and endometriosis, a condition in which uterine tissue grows outside the uterus and may cause extreme pain. Other conditions discussed in the brochure include uterine prolapse (tilting or
slipping of the uterus), ovarian cysts, excessive bleeding, painful periods, endometrial hyperplasia (abnormal thickening of the uterine lining), chronic pelvic pain, and pelvic inflammatory disease (a serious infection that, if not treated, may result in severe pain and life-threatening illness).
The pros and cons of available treatments are listed for each condition, and there is a discussion of the various types of hysterectomy. The brochure includes a list of frequently asked questions and their answers, a glossary to help women become familiar with technical terms, and questions a woman may want to ask her doctor. The brochure also encourages women to get a second opinion and make sure they understand what to expect from any type of surgery or alternative treatment.
Print copies of Common Uterine Conditions: Options for Treatment (AHCPR Publication No. 98-0003) are available free from the AHCPR Publications Clearinghouse. Select for the online version.
Helping smokers quit
The Agency for Health Care Policy and Research (AHCPR) has launched a new smoking cessation "Two-Three Initiative" that encourages all clinicians to take part in helping their patients who smoke to quit. The initiative highlights the AHCPR-sponsored Smoking Cessation Clinical Practice Guideline, released last year, and follows on the heels of an AHCPR-funded report (AHCPR Publication No. 97-R049) released in late 1997 that found smoking cessation efforts to be cost effective.
The new initiative recommends that "Two Questions"—"Do You Smoke?" and "Do You Want To Quit?"—be part of every medical assessment by clinicians. The questions should be followed by an intervention as brief as "Three Minutes" in which the clinician recommends smoking cessation treatments proven to work. Research has shown that smokers have the best chance of quitting when their health care providers get involved.
Because of clinicians' unique access to the smoking population, doctors, nurses, dentists, pharmacists, and other health care providers are an important part of any solution that includes strategies to help the millions of Americans who want to quit smoking. To assist clinicians in the intervention, AHCPR has developed a Smoking Cessation Consumer Tool Kit, complete with four easy-to-read, black and white, reproducible, one-pagers that address particular concerns of smokers: First-Time Quitters, Multiple Quit Attempts, Pregnancy and Smoking, and Smokers Facing Surgery. Clinicians also are encouraged to refer patients to local smoking cessation programs and chapters of the American Cancer Society, the American Lung Association, and the American Heart Association for additional help.
Print copies of the Smoking Cessation Consumer Tool Kit, Two Questions, Three Minutes, A Lifetime of Difference for Your Patients (AHCPR Publication No. 97-0062), are available from the AHCPR Publications Clearinghouse.
The AHCPR Smoking Cessation Guideline materials are available as follows (select titles for online versions):
AFMR Outstanding Investigator Award goes to Harry Selker
For the first time, the American Federation for Medical Research (AFMR) has selected a health services researcher to receive its prestigious Outstanding Investigator Award. Harry P. Selker, M.D., M.S.P.H., will receive the award on May 3, 1998, during the AFMR Plenary Session at the Biomedicine '98 meeting in Washington, D.C. Dr. Selker currently is Chief of the Division of Clinical Care Research and Director of the Center for Cardiovascular Health Services Research at the New England Medical Center, and Associate Professor of Medicine at Tufts University School of Medicine in Boston.
Dr. Selker is being recognized for his fundamental contributions to both the field of quantitative clinical predictive modeling and the clinical management of patients with suspected acute myocardial ischemia. The hallmark of his research has been the successful integration of rigorous methodology with practical applications to important clinical problems, simultaneously advancing both science and clinical care. Dr. Selker's work demonstrates the substantial benefits that accrue when the fields of health services research and clinical research are brought together.
Dr. Selker has developed several instruments that can be used to triage and guide care for patients who present to the emergency department with chest pain or other symptoms suggestive of cardiac disease. The time-insensitive predictive instrument for acute cardiac ischemia, or ACI-TIPI, improves physicians decisionmaking in assessing whether a patient who has symptoms of acute ischemia should be hospitalized or sent home. The thrombolytic predictive instrument is used to identify patients with acute myocardial infarction (AMI, or heart attack) who are candidates for thrombolysis. These instruments allow clinicians to use baseline clinical features to estimate the probability of acute cardiac ischemia, mortality from AMI, key outcomes of ischemia, and indications of the risks and benefits of thrombolytic therapy for individual patients.
These instruments are already reducing costs in many emergency rooms, while maintaining and even improving health status and quality of care for patients who have acute ischemic events. Both the TIPI and the thrombolytic predictive instrument were developed by Dr. Selker and his colleagues with grant support from the Agency for Health Care Policy and Research.
Currently, Dr. Selker is principal investigator on three Federal research grants (two of which are funded by AHCPR), and he also is the principal investigator for an AHCPR-sponsored National Research Service Award training grant for postdoctoral fellowships in health services research.
Each year, AFMR bestows two awards on outstanding investigators in recognition of their research accomplishments. One award is given for basic science research by investigators who are working with and without human tissue or cells; the other award is based on clinical science research involving human subjects. We at AHCPR congratulate Dr. Selker on his many accomplishments and this well-deserved award.
AHCPR announces second conference on evidence-based practice
The Agency for Health Care Policy and Research will host "Translating Evidence into Practice '98," July 27-29, 1998, at the Renaissance Washington Hotel, Washington, DC. This second annual conference on evidence-based practice is being sponsored by AHCPR's Center for Practice and Technology Assessment. Conference participants will explore how health care research informs practitioner and consumer decisionmaking, as well as health policy development. Sessions will cover methodologies for synthesizing knowledge into products, strategies to enhance the usefulness of research evidence, and implementation strategies to achieve quality outcomes.
If you are interested in making a presentation at the conference, please contact Margaret Coopey in AHCPR's Center for Practice and Technology Assessment at (301) 427-1618, or by fax at (301) 427-1639.
New research report and grant final reports now available from NTIS
The following research report and grant final reports are now available from the National Technical Information Service (NTIS). For final reports, each listing identifies the projects principal investigator (PI), his or her affiliation, the grant number and project period, and provides a description the project.
Chiropractic in the United States: Training, Practice, and Research. Daniel Cherkin, Ph.D. (PI), Reed B. Phillips, D.C., Ph.D., Robert D. Mootz, D.C., and others, Group Health Cooperative of Puget Sound, Seattle, WA. AHCPR grant HS07915.
This research report was developed by the Center for Health Studies, Group Health Cooperative of Puget Sound, Seattle. In view of the growing popularity of chiropractic care, it is important that health care providers, insurers, policymakers, and individuals with back pain have a better understanding of the current capabilities and limitations of chiropractic care. This report, which reflects a collaboration among scholars, researchers, and practitioners from both the medical and chiropractic communities, provides an unbiased overview of what is and is not known about the
profession and practice of chiropractic. It contains information on the history and development of chiropractic, chiropractic training and licensure of practitioners, insurance coverage for chiropractic services, chiropractic in the health care system, and benefits and risks of spinal manipulation. It also discusses future chiropractic research priorities and policy issues.
Research report is available from the National Technical Information Service (NTIS accession no. PB98-111693; 140 pp, $31.00 paper, $14.00 microfiche)
Evaluation of Guidelines in Large Group Practices. Harold I. Goldberg, M.D., University of Washington, Seattle. AHCPR grant HS07652, project period 12/1/92 to 11/30/96.
The researchers conducted a randomized controlled trial to determine the effectiveness of academic detailing (AD) techniques and continuous quality improvement (CQI) teams in increasing compliance with a national guideline for the primary care of hypertension and depression. Fifteen small group practices at four Seattle primary care clinics were assigned to one of three study arms—AD alone, AD plus CQI teams, or usual care. The investigators monitored the activity of 95 providers and 4,995 patients during year-long baseline and study periods to examine change in hypertension prescribing, blood-pressure control, depression recognition, use of older tricyclics, and scores on the Hopkins Symptom Checklist depression scale. Clinics varied considerably in their implementation of both the AD and the CQI team interventions. Across all sites, AD was associated with change in a single process measure: a five-point decline in the percentage of depressives prescribed first-generation tricyclics. No intervention effects were
demonstrated for CQI teams across sites for either disease condition. Within the clinics judged most successful at implementing change strategies, CQI teams and AD in combination did increase the percentage of hypertensive patients adequately controlled by 17 points. In conclusion, the AD techniques and the CQI teams evaluated were generally ineffective in improving guideline compliance.
Abstract and executive summary, are available from the National Technical Information Service (NTIS accession no. PB98-105059; 18 pp, $19.50 paper, $10.00 microfiche)
Home-Based Exercise in Patients with Heart Failure. Roberta Oka, D.N.S.C., R.N., University of California, San Francisco. AHCPR grant HS08772, project period 7/1/96 to 6/30/97.
The purpose of this randomized controlled study was to examine the effects of a 3-month supervised home-based aerobic and strength training program on functional status, physical fitness, and quality of life in 40 patients (31 men, 9 women) with New York Heart Association Class II-III heart failure due to left ventricular dysfunction (ejection fraction 23 percent). The mean age of patients in this sample was 56 years. Program adherence was excellent (95 percent). The researchers found that while there were no statistically significant effects on physical fitness as measured by peak oxygen uptake and functional status as measured by the human activity profile, there were trends suggesting that, given a larger sample size, significant effects could be demonstrated with this program. Although there were no statistically significant effects on physical fitness and self-rated functional status, arm strength and quality of life were improved. This program of exercise significantly reduced symptoms of dyspnea and fatigue and improved emotional function and mastery. This study demonstrates that quality of life may be enhanced independent of changes in functional status and physical fitness, although a larger sample size is needed to definitively answer this question.
Abstract, executive summary, and final report, are available from the National Technical Information Service (NTIS accession no. PB98-105007; 12 pp, $19.50 paper, $10.00 microfiche)
Labor Market Implications of Employer-Provided Health Insurance. Kanika Kapur, Ph.D., Northwestern University, Evanston, IL. AHCPR grant HS09333, project period 9/1/96 to 8/31/97.
This dissertation grant examined labor market problems arising from the link between employment and health insurance. It covered three main issues. First, the nonportability of employer-provided health insurance implies that if wages do not offset differences in the valuation of health insurance across jobs, individuals may not move to jobs with higher match-specific productivity. This phenomenon, called "job lock," was estimated using 1987 data from the National Medical Expenditures Survey (NMES). According to the study, individuals with medical conditions that lead to preexisting condition exclusions in small firms are less likely to move to insured small firms. Second, small firms that offer health insurance may attempt to avoid expensive premium variability by maintaining a work force with low expected health costs. Small firms that offer health insurance are less likely to hire and more likely to lay off workers with families that have medical conditions that lead to higher health insurance premiums. These results suggest that the link between small firm health insurance and employment leads to employment distortions. Third, States have implemented small group health insurance reforms such as portability reforms and premium rating reforms that limit or ban the use of health status in setting premiums. Using Current Population Survey data from 1991 to 1996, this study found that rating reforms increase job mobility and small firm employment opportunities for the sick. However, by redistributing health insurance costs from the sick to the old, rating reforms reduce job mobility and small firm
employment opportunities for the old. Furthermore, portability reforms that are unaccompanied by rating reforms reduce overall job mobility for sick individuals and increase the separation rate of sick individuals from insured small firm jobs.
This dissertation is available from the National Technical Information Service, NTIS accession no. PB98-109598; 238 pp, $44.00 paper, $19.50 microfiche)
Primary Care for High-Risk Indigent Infants. Sue R. Broyles, University of Texas Southwestern Medical Center, Dallas. AHCPR grant HS06837, project period 1/1/92 to 6/30/97.
A randomized trial was conducted among inner-city, very-low-birthweight (VLBW) infants at high medical and social risk to determine whether comprehensive primary care reduced their incidence of life-threatening illness. VLBW infants requiring neonatal intensive care were randomized to receive either conventional care (CC)—which included well-baby care, care for chronic conditions, and developmental assessment—or primary care (PC), which included
care for acute illnesses 5 days a week and phone access to the PC provider 24 hours a day. Of 783 nursery survivors who were at comparable high risk, 394 received PC and 389 received CC. PC infants had more contacts with staff (20 vs. 7) and fewer ER visits (595 vs. 732), hospital says (2,352 vs. 2,877), and loss to followup (11 percent vs. 31 percent) by 1 year adjusted age. PC infants had 57 percent fewer ICU admissions (23 vs. 53) and 42 percent fewer ICU days (254 vs. 440). Total life-threatening illnesses were reduced among PC infants by 47 percent (33 vs. 62), despite similar
mortality (11 vs. 12). These findings indicate that PC improves health care delivery and reduces life-threatening illness among high-risk infants whose needs are not well met by the current health care system.
Abstract, executive summary, and final report are available from the National Technical Information Service (NTIS accession no. PB98-105042; 10 pp, $19.50 paper, $10.00 microfiche)
Randomized Trial Comparing Masked/Unmasked Meta-Analysis. Jesse A. Berlin, Sc.D., University of Pennsylvania, Philadelphia. AHCPR grant HS07728, project period 7/1/93 to 12/31/95.
Masking (blinding) of readers to identifying information about the original papers in meta-analyses has been recommended, but the effects of blinding on the results of actual meta-analyses have not been assessed. These researchers conducted a randomized trial in which five previously published meta-analyses were performed under blinded and unblinded conditions. The summary odds ratio was the main outcome measure calculated for each meta-analysis. The summary odds ratios were nearly identical for the blinded and unblinded meta-analyses. Blinding was extremely time
consuming. Therefore, the investigators recommend that blinding not be used when meta-analyses are performed.
Abstract, executive summary, and final report are available from the National Technical Information Service (PB98-109382; 102 pp, $28.00 paper, $14.00 microfiche)
Second Annual NRSA Training Meeting, 1996. Kevin A. Schulman, M.B.A., M.D., Georgetown University, Washington, DC. AHCPR grant HS09289, project period 5/1/96 to 4/30/97.
This project supported the Second Annual NRSA (National Research Service Award) Research Trainees Conference for trainees sponsored by the Agency for Health Care Policy and Research and the Bureau of Health Professions of the Health Resources and Services Administration through their NRSA programs. The conference was held June 7-8, 1996, in Atlanta, GA, in conjunction with the annual meeting of the Association for Health Services Research. The trainees meeting is an academic event dedicated to furthering the scholarship of trainees at different NRSA program sites. More than 150 trainees and program faculty members attended the conference.
A competitive abstract solicitation process resulted in 62 abstract submissions; 14 abstracts were selected for podium presentation, and 30 were chosen for poster presentations. Outstanding research by trainees was recognized with three awards given at the conclusion of the meeting.
Abstract, executive summary, and conference proceedings are available from the National Technical Information Service (NTIS accession no. PB98-109374; 126 pp, $31.00 paper, $14.00 microfiche)
Deadline extended for online subscriptions to Research Activities
In the November 1997 issue of Research Activities, we invited readers to indicate their interest in becoming online subscribers. Based on the very limited response we received to our invitation, we are not at this time planning to implement an online subscription option.
Before we make a final decision, however, we want to make sure we have an accurate assessment of readers' interest. Once again, we invite you to let us know, electronically, if you are interested in becoming an online subscriber to Research Activities. Send your request to firstname.lastname@example.org by March 31, 1998.
If you responded last time, we still have your information. Please do not respond again.
As noted previously, converting to an online subscription means that:
- You will be notified by E-mail as soon as an issue goes to the printer. This means you will have access to the latest issue 7 to 10 days before printed copies arrive in subscribers' mailboxes.
- Your E-mail notice will let you know that the issue is available on the AHCPR Web site for
viewing and/or downloading. An embedded link will be provided for those subscribers who are able to "point and click."
- You will no longer receive a printed copy of Research Activities.
- Your mailing information will be moved to an "electronic mailing list," and you will be able to communicate with us electronically about your subscription.
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