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Emergency Medicine

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Alternative to traditional CPR training is simple, quick, inexpensive, and more effective

A new study shows that medical students who recently used a 34-minute video self-instruction (VSI) training program for adult cardiopulmonary resuscitation (CPR) had better overall CPR performance than medical students trained using the traditional American Heart Association Heartsaver course. If validated by further research, VSI may provide a simple, quick, and inexpensive alternative to traditional CPR instruction for health care workers and, perhaps, the general population, concludes Allan Braslow, Ph.D., of the Agency for Health Care Policy and Research.

Dr. Braslow, first author Knox H. Todd, M.D., M.P.H., of Emory University, and their colleagues randomly assigned 91 incoming freshman medical students to the Heartsaver CPR course or the VSI course, which included a cardboard training dummy with functional obstructing airway, inflatable lungs, and compressible chest. In contrast to traditional CPR training, the VSI course focuses only on the critical elements of CPR: ventilation and chest-compression techniques, allowing the viewer to practice on the dummy as the tape runs. In traditional classroom courses, trainees often share a dummy and have minimal practice time. Two to 6 months after training, blinded observers (who did not know which training students had received) evaluated the students on their ability to perform CPR for simulated cardiac arrest.

VSI trainees displayed superior overall performance compared with traditional trainees. In fact, 43 percent of traditional trainees were judged not competent to perform CPR compared with only 18 percent of VSI trainees. Of the VSI trainees, 81 percent could open the airway after the first set of chest compressions, and 71 percent could open the airway between subsequent sets, compared with 43 percent and 34 percent, respectively, of traditional trainees. The median chest-compression rate and number of total and perfect compressions were similar for both groups over the 2-minute testing period.

Details are in "Randomized, controlled trial of video self-instruction versus traditional CPR training," by Drs. Todd and Braslow, Robert T. Brennan, Ed.D., and others, in the March 1998 Annals of Emergency Medicine 31(3), pp. 364-369.

Reprints (AHCPR Publication No. 98-R043) are available from the AHCPR Publications Clearinghouse.

Editor's Note: Select to access a summary of the final report from this project in the June 1998 issue of Research Activities.

Research agenda described for emergency care

Ninety-three million people visited hospital emergency departments (EDs) in 1994. Half of these visits were not urgent, and 42 percent were for injuries. These statistics show that there is a need for outcomes research to provide information to purchasers, plans, providers, and patients on the quality and efficiency of ED care.

How can we best measure the quality of ED care? How does it contribute to overall patient outcomes and at what price? These questions are the focus of an outcomes research agenda for ED care that should include studies on the organization and financing of ED care, as well as their impact on quality and patient outcomes, according to Lisa Simpson, M.B., B.Ch., Deputy Administrator of the Agency for Health Care Policy and Research.

In a recent commentary, first author Alexander K. Ommaya, Sc.D., M.A., Dr. Simpson, and Elinor Walker cite a particular need for development of quality measures of pediatric emergency management, since 25 percent of ED visits involve children younger than 15 years of age. Studies also should explore the type and level of care that is most efficiently delivered in the ED versus other parts of the care system, as well as the optimal makeup of clinical ED staff. For instance, when is physician supervision, advanced life support, or other ancillary medical staff involvement warranted?

Injury and illness severity scales are needed that work in both triage and research settings, and studies should be done to evaluate and improve ED patient satisfaction and adherence to prescribed treatment. Dr. Simpson and her colleagues stress the need to examine the role of EDs in providing preventive care and screening in low-income populations who have traditionally relied on the ED for both emergency and nonurgent care. Finally, they discuss the need for studies to identify the costs of care delivered in the ED.

Details are in "More on assessing outcomes of emergency care," by Drs. Ommaya and Simpson and Ms. Walker, in the March 1998 Annals of Emergency Medicine 31(3), pp. 301-303.

Reprints (AHCPR Publication No. 98-R042) are available from the AHCPR Publications Clearinghouse.

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Minority Health

Missed appointments are linked to shorter breast cancer survival among black women

Black women are more apt than white women to be diagnosed with later-stage breast cancer and to survive a shorter time after diagnosis. According to a recent study supported by the Agency for Health Care Policy and Research (HS06217), race is not nearly as important to breast cancer survival as compliance with appointments, and black women are simply much more likely to miss medical appointments than white women. Helping women comply with their appointments and alleviating barriers to compliance will aid breast cancer survival, suggests Roy Penchansky, D.B.A., of the University of Michigan, the study's principal investigator.

Dr. Penchansky and his colleagues Daniel L. Howard, Ph.D., of the University of North Carolina at Chapel Hill, and Morton B. Brown, Ph.D., of the University of Michigan reviewed the clinical records of 246 white and black women receiving care at three closed panel health maintenance organizations (HMOs) who were diagnosed with breast cancer, stage II or beyond. Almost all women, whether black or white, were employed or had employed spouses and were covered for well and sick care within the HMOs. The investigators analyzed the data to predict determinants of cancer stage and survival and found that missed appointments and stage of cancer were the key determinants of survival. The effect of race on survival was marginal after adjusting for these factors.

Nearly four times as many black women as white women (15 percent vs. 4 percent) missed two or more scheduled appointments before the identification of breast cancer symptoms, nearly tripling the black women's risk of being diagnosed at a later stage. Four times as many black women as white women also missed two or more appointments after the identification of these symptoms (8 percent vs. 2 percent). These missed appointments quadrupled their risk of death and resulted in black women having nearly 7 months longer than white women between identification of cancer symptoms and mastectomy. The researchers call for more studies to determine whether missing appointments is a patient behavior that is freely chosen or a marker for imperfections in the health care setting, including the doctor-patient relationship.

See "Disaggregating the effects of race on breast cancer survival," by Drs. Howard, Penchansky, and Brown, in Family Medicine 30(3), pp. 228-235.

Latinos could benefit from culturally appropriate smoking cessation programs

Latinos' smoking behavior and attitudes differ from those of non-Latino white smokers, and they need more effective smoking cessation programs, according to a study supported in part by the Agency for Health Care Policy and Research (HS07373). For instance, Latinos most often quit smoking because of criticism by family, concern about damaging their children's health, and a desire to set a good example for their children. Whites more often cited concerns about their own health and the desire to achieve a difficult goal (not smoking). Finally, Latinos were more likely than whites to believe that tobacco is not addictive, and whites were more inclined than Latinos to continue smoking to avoid weight gain.

Latinos smoked fewer cigarettes per day than whites (9.7 vs. 20.1), with 56 percent of Latinos and 12 percent of non-Latino whites reporting that they smoked one to nine cigarettes per day. However, differences in attitudes and beliefs about cigarette smoking were independent of the number of cigarettes smoked and level of education.

If the goal of public health media programs is to encourage Latinos to quit smoking cigarettes, they should emphasize quitting for the sake of the family's health and decrease emphasis on quitting to improve personal health, according to Eliseo J. Perez-Stable, M.D., co-director of the AHCPR-supported MEDTEP Research Center for Diverse Populations at the University of California, San Francisco. Also, physicians who want to boost Latino patients' motivation to quit smoking should focus on maintenance of the family's health and personal appearance, as opposed to maintenance of personal health or getting rid of an addiction.

These findings are based on a random survey of current smokers, 18 to 65 years of age, including 312 Latinos and 354 non-Latino whites, derived from the 1990 San Francisco census. However, these findings are not generalizable to other Latino populations, such as Puerto Ricans and Cubans, who are heavier smokers, cautions Dr. Perez-Stable.

More details are in "Ethnic comparison of attitudes and beliefs about cigarette smoking," by Dr. Perez-Stable, Gerardo Marin, Ph.D., and Samuel F. Posner, Ph.D., in the March 1998 Journal of General Internal Medicine 13, pp. 167-174.

Like others with type 2 diabetes, Mexican Americans make personal adjustments to their treatment regimen

Type 2 (adult-onset) diabetes is two to three times more prevalent among Mexican Americans than the general population. To prevent high blood sugar levels that can lead to serious problems, each day patients with type 2 diabetes must control their diet, exercise, check blood glucose levels, and take medication. It is not surprising that, like many other diabetics, Mexican Americans cut corners and make personal adjustments to their treatment, concludes a study by staff of the Mexican-American Medical Effectiveness Research Center at the University of Texas. The study was supported by the Agency for Health Care Policy and Research (HS07397).

The study found that unrealistic confidence in the power of their medicine, the desire to avoid certain symptoms and feel "normal" socially, and economic problems prompt Mexican Americans to adjust their treatment regimen. Even those who are motivated to adhere to their treatment regimen and have good blood sugar control make adjustments.

Physicians should not presume ignorance or lack of motivation is behind poor outcomes. Instead, they should discuss treatment with their patients and educate them about how they can tailor self-care behaviors in a way that minimizes social role conflict without compromising their health, explains Jacqueline Pugh, M.D., the study's principal investigator. Dr. Pugh and her colleagues interviewed a sample of 51 Mexican-American patients being seen for type 2 diabetes at two public clinics.

The qualitative interviews revealed that during parties or social gatherings, many patients would either eat small portions of the "forbidden" food or eat properly and take their medicine (hypoglycemia pills or insulin), but they would drink alcohol in an effort to feel "normal." A majority of patients studied found treatment costs to be a problem.

To conserve resources, patients reported that they may take their medicine less often or only monitor their blood glucose when they are feeling ill or not complying with the medications or diet. More than half of the patients reported that they make decisions based on how they feel, which is not always an accurate indicator of their health status (proper blood glucose level), notes Dr. Pugh.

Details are in "How patients adapt diabetes self-care recommendations in everyday life," by Linda M. Hunt, Ph.D., Dr. Pugh, and Miguel Valenzuela, in the March 1998 Journal of Family Practice 46(3), pp. 207-215.

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HIV/AIDS Research

Survey shows that public health insurance programs cover more than half of all people diagnosed with AIDS

According to a recent survey, more than half (54 percent) of respondents with AIDS had public health insurance coverage in 1991 and 1992. In contrast, 36 percent of respondents who had symptoms of infection with the human immunodeficiency virus (HIV) but had not yet developed AIDS and 29 percent of asymptomatic respondents had public insurance.

The high proportion of public coverage among people with AIDS is undoubtedly due to the fact that in 1991 to 1992 an AIDS diagnosis presumptively qualified a person as disabled for purposes of establishing eligibility for Supplemental Security Income and Medicaid, according to John A. Fleishman, Ph.D., of the Agency for Health Care Policy and Research, the study's author. He used data from the AIDS Cost and Services Utilization Survey (ACSUS), which followed 1,949 HIV-infected adults over an 18-month period during 1991 and 1992. In the first interview, 33 percent of all respondents had private insurance, 40 percent had public coverage (Medicaid, Medicare, CHAMPUS), and 27 percent had no insurance. Among the group with AIDS, corresponding figures were 32 percent, 54 percent, and 14 percent.

During the 18-month study period, 23 percent of respondents reported a change in insurance status, and 27 percent reported a change in employment status. Only 15 percent lost private coverage during the study period. Transitions from no insurance to public coverage occurred most frequently, probably because of the process by which HIV disease progression and exhaustion of financial resources result in eligibility for Medicaid. An increasingly greater proportion of HIV-infected individuals are members of minority or disadvantaged groups who traditionally are more likely to lack private insurance. This trend implies that the role of Medicaid in financing HIV care will continue to grow, concludes Dr. Fleishman.

See "Transitions in insurance and employment among people with HIV infection," by Dr. Fleishman, in the Spring 1998 Inquiry 35, pp. 36-48.

Reprints (AHCPR Publication No. 98-R059) are available from the AHCPR Publication Clearinghouse.

HIV-infected patients would benefit from more aggressive screening and treatment of AIDS-related symptoms

As infection with the human immunodeficiency virus (HIV) moves toward full-blown AIDS, affected persons develop symptoms such as fever, weight loss, and diarrhea. An HIV-infected person battling five symptoms has half the physical and social functioning and emotional well-being of an infected person with no symptoms, concludes a study supported in part by the Agency for Health Care Policy and Research (HS06775).

Clinicians should aggressively screen and treat patients for these common symptoms to improve their quality of life, suggests William E. Cunningham, M.D., M.P.H., of the University of California at Los Angeles. For instance, salicylates could diminish night sweats and muscle pains (myalgias), and metoclopramide, megace, or tetrahydrocannabinol may improve appetite.

Dr. Cunningham and his colleagues administered to 205 HIV-infected patients at two hospitals 11 scales measuring various aspects of health-related quality of life (HRQL) and detailed questions about six symptoms: myalgias, exhaustion, anorexia/nausea/vomiting, night sweats, fever, and weight loss. Physical symptoms among this group were very common, with about half reporting myalgias (56 percent), nausea (44 percent), or night sweats (45 percent), and two-thirds reporting total exhaustion at least two or three times per week in the previous month.

Except for weight loss, physical symptoms were strongly related to all measures of quality of life. On 0 (worst) to 100 (best) point scales, mean scores ranged from 34 (for individuals having all five symptoms other than weight loss) to 78 (for those with no symptoms) for physical function; 43 to 79 for emotional well-being; and 36 to 73 for social function. After the researchers adjusted the scores for helper T-lymphocyte cell counts, duration of illness, and patient demographic characteristics, the symptom-HRQL relationship remained strong.

See "Constitutional symptoms and health-related quality of life in patients with symptomatic HIV disease," by Dr. Cunningham, Martin F. Shapiro, M.D., Ph.D., Ron D. Hays, Ph.D., and others, in the February 1998 American Journal of Medicine 104, pp. 129-136.

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