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Grant final reports now available from NTIS

The following grant final reports are now available for purchase from the National Technical Information Service (NTIS). Each listing identifies the project's principal investigator (PI), his or her affiliation, grant number, and project period and provides a description of the project.

Assessing the Implementation and Impact of Clinical Quality Improvement Efforts. Stephen M. Shortell, Ph.D., Northwestern University, Evanston, IL. AHCPR grant no. HS08523, project period 9/30/95 to 9/29/98.

The objective of this study was to assess the impact of continuous quality improvement/total quality management (CQI/TQM) and organizational culture on a comprehensive set of outcomes of care for coronary artery bypass graft (CABG) surgery and total hip replacement (THR) surgery patients. Clinical, patient satisfaction, functional health status, and cost data were collected for 3,045 CABG patients and 1,369 THR patients enrolled from 16 hospitals. Measures of CQI/TQM maturity and culture for each hospital were also obtained. Detailed risk-adjusting generalized estimating equations were used to estimate the impact of a hospital's CQI/TQM maturity and culture on patient-level outcomes of care for CABG and THR. Except for a positive association with patient satisfaction, the analyses did not demonstrate any consistent support for CQI/TQM having a significant impact on the quality and cost of these two clinical procedures. (Abstract, executive summary, and final report, NTIS accession no. PB99-139198; 188 pp, $44.00 paper, $17.00 microfiche.)

Can Hospital Policies Be Developed to Serve as Standards of Practice when Conflicts Occur over Life-Sustaining Treatment? Lawrence Schneiderman, M.D., University of California, San Diego, CA. AHCPR grant HS09534, project period 7/1/97 to 12/31/98.

This State-wide conference took place on February 20, 1998, in San Diego, CA, and brought together California health care professionals, lay people, medical ethicists, lawyers, and members of the judiciary. They gathered to explore the possibility of developing institutional end-of-life medical treatment policies that would serve as a basis for standards of practice when conflicts occur. Based on the results of this conference, it appears likely that at this time a consensus standard of practice regarding futile end-of-life treatments in the presence of disputes will be drawn very narrowly at best.

However, it is not necessary that there be unanimous agreement on a single standard, since there is room in the law for what is called a "respectable minority." For example, most hospital personnel agreed that life-sustaining treatment of a permanently unconscious patient is unwarranted. The successful resolution of disputes over end-of life treatments may depend not on hospitals going to court to defend their futility policy but on the willingness of the "respectable minority" hospitals to accept the transfer of such patients. (Conference, abstract, executive summary, and final report, NTIS accession no. PB99-154411; 34 pp, $25.50 paper, $12.00 microfiche.)

Communication Skills Training for Primary Care Patients. Donald J. Cegala, Ph.D., Ohio State University, Columbus, OH. AHCPR grant HS09520, project period 6/1/97 to 8/31/98.

The purpose of this study was to assess the effectiveness of a training booklet designed to instruct patients in communication skills for enhancing information exchange during the primary care medical consultation. Twenty-five family medicine doctors and 150 patients participated in the study. Patient participants in three intervention conditions were compared: trained, informed, and untrained. Each of the 25 doctors saw 2 patients in each intervention condition. Major results indicate that trained patients engaged in significantly more information seeking and provision, had greater delayed recall, and were more compliant with treatment recommendations. (Abstract and executive summary, NTIS accession no. PB99-139511; 12 pp, $23.00 paper, $12.00 microfiche.)

Critical Pathways and Feedback to Improve Quality. Steven D. Pearson, M.D., Brigham and Women's Hospital, Boston, MA. AHCPR grant HS08311, project period 6/1/95 to 11/30/98.

Despite their use by the majority of American hospitals, few controlled research studies have assessed the effectiveness of "critical pathways." This study evaluated the critical pathways developed at a large teaching hospital for five common surgical procedures: coronary artery bypass graft (CABG) surgery, total knee replacement, colectomy, thoracic surgery, and hysterectomy. A total of 6,796 patients underwent one of the procedures during the study. For most procedures, postoperative length of stay was already falling significantly during the period before pathway implementation. Following implementation, lengths of stay fell significantly for all of the study procedures: 21 percent for total knee replacement; 9 percent for CABG surgery; 7 percent for thoracic surgery; 5 percent for hysterectomy; and 3 percent for colectomy. These reductions in length of stay were matched, however, by the neighboring hospitals that did not have critical pathways or specific efficiency initiatives. The researchers concluded that critical pathways were associated with a period of rapid reduction in postoperative length of stay for the five study procedures. Secular trends at nearby hospitals, however, produced comparable reductions, raising questions about the marginal effectiveness of critical pathways as a method to increase efficiency in a competitive environment. (Abstract, executive summary, and final report, NTIS accession no. PB99-154494; 16 pp, $23.00 paper, $12.00 microfiche.)

Continuous Detection and Treatment of Depression in a Large HMO. Gregory A. Nichols, M.B.A., Kaiser Foundation Research Institute, Oakland, CA. AHCPR grant HS07991, project period 8/1/93 to 7/31/95.

This study compared the skill of family practice, primary care, and internal medicine physicians in communicating the detection of depression to their patients, the subsequent treatment of depressive disorders, and the patients' use of health care resources. Depressed patients were identified from Kaiser Permanente Northwest (KPNW) members through a two-stage questionnaire process. Those with an identifiable primary care physician (n=1,161) were linked to their resource utilization via databases maintained by KPNW as part of its usual course of business. There were significant differences between family practice and internal medicine physicians in their rates of communicating depression detection. Also, family practice patients had more visits and were more likely to use antidepressant medications. (Abstract and dissertation, NTIS accession no. PB99-148819; 188 pp, $44.00 paper, $17.00 microfiche.)

Effect of Sleep Promotion in the Critical Care Unit. Carrie J. Wallace, R.N., Ph.D., LDS Hospital, Salt Lake City, UT. AHCPR grant HS09335, project period 9/1/96 to 8/31/98.

The primary objective of this research was to measure the impact of soft foam earplugs to reduce noise during the night time hours on the sleep of critically ill subjects. Patients older than l8 years of age who met the enrollment criteria were studied using a randomized, unblinded, crossover study design. Sleep was measured on two nights with one "washout" night in between; the order of earplugs was randomly assigned. Other potentially important sleep disrupters were also measured. Five males and eight females—12 of whom were on mechanical ventilation—were studied. Significantly more REM sleep occurred when earplugs were worn. All subjects' sleep architecture was severely disturbed, with or without earplugs. An increased opportunity for sleep on the night earplugs were worn was evident. Further research is needed to determine the clinical importance of increased REM sleep in critically ill patients and the use of earplugs to enhance sleep. (Abstract, executive summary, and dissertation, NTIS accession no. PB99-129991; 13 pp, $23.00 paper, $12.00 microfiche.)

Evaluating a Multi-Hospital Quality Improvement Strategy to Implement Clinical Guidelines for Radiographic Contrast Agents. John B. Hernandez, Ph.D., RAND Corp., Santa Monica, CA. AHCPR grant HS09686, project period 9/30/97 to 5/31/98.

This study involved a randomized, controlled trial and qualitative evaluation of a quality improvement strategy to implement clinical guidelines for radiographic contrast agents. Hospital representatives were trained in quality improvement methods to implement the guidelines in their own hospitals using a step-by-step guideline implementation protocol and other tailored resources. Overall, the strategy was unsuccessful in improving adherence to the guidelines in the intervention group. A comparative case study was conducted to examine the impact of key organizational factors on adherence and to identify successful strategies for overcoming barriers to adherence. Intraorganizational financial incentives were found to be particularly important in predicting the extent of guideline adherence. (Dissertation, NTIS accession no. PB99-117277; 182 pp, $44.00 paper, $17.00 microfiche.)

Experiences of Low-Income Women with Breast Cancer. Anne S. Kasper, Ph.D., University of Illinois, Chicago. AHCPR grant HS09558, project period 9/30/97 to 3/30/99.

Available research demonstrates that low-income women are more likely to be diagnosed with breast cancer at a later stage and to have higher mortality. Many economically disadvantaged women are uninsured, often deterring access to treatment services. However, this exploratory study demonstrates that for 24 urban poor and low-income women, the lack of insurance is only one of several factors that impede access to and create difficulties with receiving appropriate breast cancer care. For these women, the multiple disadvantages of poverty that preceded and followed a diagnosis of breast cancer created significant delays and compromised the diagnosis, treatment, recovery, and perhaps survival of the women. However, where there were programs specifically designed for poor and low-income women with breast cancer, a number of the women received generally appropriate and timely care. (Abstract, executive summary, and final report, NTIS accession no. PB99-154437; 92 pp, $29.50 paper, $12.00 microfiche.)

Factors Affecting the Bargaining Power of Pharmacies and Insurers. John M. Brooks, Ph.D., University of Iowa, Iowa City. AHCPR grant HS09541, project period 9/01/97 to 8/31/98.

In the face of escalating health care costs, insurers have taken a more active role in bargaining with providers over the prices of medical care services. Unfortunately, there has been little research to help policymakers understand the effects of these changes on provider reimbursements. The goal of this study was to fill this information gap by modeling the bargaining power of pharmacies in their price negotiations with insurers and investigating the extent that bargaining power varies with characteristics of the pharmacy insurer and pharmacy market. Empirical estimates were obtained using pharmacy/insurer transactions from Medstat's 1994 Marketscan Database. The researchers found statistically significant variation in pharmacy bargaining power across markets, insurers, and pharmacy types. With respect to market structure, pharmacy bargaining power was negatively related to pharmacies per capita and pharmacies per employer and positively related to pharmacy concentration at higher concentration levels. In addition, pharmacy bargaining power declined as the percentage of independent pharmacies in an area increased. With respect to socioeconomic conditions, pharmacy bargaining power was higher in areas with lower per capita income and higher rates of public assistance. (Abstract, executive summary, and final report, NTIS accession no. PB99-134892; 22 pp, $23.00 paper, $12.00 microfiche.)

Flexible Spending Accounts and Health Insurance Decisionmaking. Matthew L. Maciejewski, Ph.D., University of Minnesota, Minneapolis. AHCPR grant HS09341, project period 9/30/96 to 6/30/98.

Flexible spending accounts (FSAs) are an important, yet unexplored, health benefit that allows employees to shelter out-of-pocket medical expenses from taxation. Employee out-of-pocket premiums also may be exempt from taxation via pre-tax premium contributions. The purpose of this study was to measure the effect of these tax exemptions on the characteristics of health plans offered by a national sample of large city and county governments. A model of employer provision of the tax exclusion for employee-paid premiums and FSAs is estimated to explain their respective influences on cost-sharing, premiums and enrollment. The study addressed four research questions: (1) What factors influence employer provision of flexible spending accounts? (2) Does offering an FSA have an impact on health plan cost-sharing? (3) What is the overall effect of an FSA on health plan premiums? (4) How does offering an FSA affect health plan choice? Health plan cost-sharing and total premiums were estimated as a two-part model with sample selection and a least squares model with sample selection, respectively. This study provides the first empirical evidence of the effect of FSAs on health plan cost-sharing, total premiums, and health plan market share. (Abstract, executive summary, and dissertation, NTIS accession no. PB99-129868; 308 pp, $58.00 paper, $23.00 microfiche.)

Healthy People 2000: Taking Action with Children and Families. Mary A. Baroni, Ph.D., R.N., Marquette University, Milwaukee, WI. AHCPR grant HS09362, project period 2/1/97 to 1/31/99.

This grant supported an interdisciplinary research conference convened by Marquette University College of Nursing. Specific objectives were to (1) define issues relevant to the delivery of health care services for children, (2) disseminate research information to policymakers, agency administrators, and practitioners, and (3) apply research findings and lessons learned from model programs to the development of collaborative ventures that can bridge research, practice, and policy in the evolving context of managed care and welfare reform. (Conference report, NTIS accession no. PB99-154460; 30 pp, $23.00 paper, $12.00 microfiche.)

In Whose Care and Custody? Orphans of the HIV Epidemic in Historical and Global Perspective. Carol Levine, the Orphan Project of New York City. AHCPR grant HS07872, project period 9/1/93 to 8/31/95.

This project supported a symposium that yielded a more complete understanding of the history of the world's response to crises involving children without parents or care. Specifically, participants concluded that American society's response to such children consisted of a series of radically different care models, with each model recognizing the previous model's weaknesses. The current model, foster care, has demonstrated some weaknesses. Participants believed that in trying to determine what will work best for today's problem of caring for orphans of the HIV epidemic, several prior models must be considered, and the successful aspects of each should be used in developing solutions. (Abstract, executive summary, and final report, NTIS accession no. PB99-133621; 14 pp, $23.00 paper, $12.00 microfiche.)

Managed Care Strategies and the Performance of Rural Hospitals. Astrid Knott, Ph.D., University of Iowa, Iowa City. AHCPR grant HS09899, project period 8/1/98 to 9/30/98.

This study analyzed the relationship between the adoption of a managed care contracting strategy and physician-hospital integration activities and the performance of rural hospitals in Iowa and Nebraska. The effect of contracts with a variety of health maintenance organizations (HMOs) on two performance measures were studied. Data were provided by the AHA Annual Survey and a survey of rural hospital CEOs. Analysis of the cross-sectional data included factor analysis for variable reduction and OLS regression. The results did not support the hypothesized positive relationship between having managed care contracts and rural hospital performance. However, the number of HMO contracts was positively related to expenses. The hypothesis of a positive relationship between participation in physician-hospital organizations (PHOs) and occupancy rates also was not supported. Participation in closed PHOs was negatively related to occupancy. (Abstract and executive summary of dissertation, NTIS accession no. PB99-154452; 18 pp, $23.00 paper, $12.00 microfiche.)

Measuring Primary Care Quality in Managed Care Systems. Donald A. Barr, M.D., Stanford University, Stanford, CA. AHCPR grant HS09350, project period 9/30/96 to 9/29/98.

The purpose of this study was to test a new methodology to assess patient satisfaction with a primary care office visit. Researchers greeted patients at the entrance to a primary care facility and accompanied them throughout their visit (except during actual examination and treatment), simultaneously gathering observational and patient survey data. The methodology was well accepted by patients, with 79 percent of eligible patients agreeing to participate. This method presents a feasible alternative to telephone or written satisfaction surveys and has the advantage of gathering both patient data and data pertaining to structural characteristics of the visit. It was possible to demonstrate that structural characteristics significantly affect a patient's satisfaction with care, as measured by a standard nine-item satisfaction score. In addition to the well known beneficial effect of continuity of care, the study demonstrated that one of the most powerful determinants of patients' satisfaction is the courtesy, sensitivity, and respect with which they are treated by the nonphysician staff they encounter. In addition, the study identified a possible effect of ethnicity on patients' perception of primary care visit quality, with minority patients reporting lower satisfaction with this aspect of care than white patients. (Abstract, executive summary, and final report, NTIS accession no. PB99-119653; 72 pp, $27.00 paper, $12.00 microfiche.)

Outcomes and Costs of Inpatient Antidepressant Drugs. Deborah L. Ackerman, Ph.D., University of California, Los Angeles. AHCPR grant HS09551, project period 9/30/97 to 7/31/98.

Cost-benefit studies in outpatient settings have indicated that the higher initial cost of the selective seratonin-reuptake inhibitors (SSRIs) for treating depression may be offset by higher expenses of tricyclic antidepressants (TCADs) associated with monitoring and managing side effects. This inpatient study was conducted to evaluate the relative costs and benefits of different treatment regimens and to provide descriptive information about antidepressant drug use. A retrospective review was conducted of computerized administrative data covering all admissions between July 1, 1994, and July 1, 1997, to the UCLA Neuropsychiatric Hospital. The SSRIs were the most commonly prescribed antidepressants. The atypicals (trazondone, bupropion, and nefazodone) and SSRIs were also associated with highest charges: $2,000 to $3,000 higher than the TCADs. The atypicals were also associated with $3,000 higher charges than venlafaxine. After controlling for diagnosis, severity, age, length of stay, and comorbidity, the atypicals were associated with $500 to $1,000 higher charges for services and procedures. The source of the higher charges for atypicals was electroconvulsive therapy (ECT), billed more often and for more procedures per patient. Readmission rates were similar across drug classes. (Abstract, executive summary, and final report, NTIS accession no. PB99-114134; 130 pp, $36.00 paper, $17.00 microfiche.)

A Perspective Study of an Out-of-Hospital Birth Center. William Swartz, M.D., Primary Care Perinatal Services, San Diego, CA. AHCPR grant HS07161, project period 9/30/93 to 9/29/98.

This study evaluated the safety (maternal and neonatal health outcomes), costs, and patient satisfaction of a collaborative model of nurse-midwives and obstetricians with freestanding birth center option for delivery of low-risk women, as compared with a traditional U.S. model of perinatal services (obstetrician and hospital delivery). A prospective cohort study was conducted (1,815 birth center and 1,150 traditional care subjects) from 1994 to 1997. Baseline comparability was established using a validated methodology to determine perinatal risk and birth center eligibility. Data were collected via medical record abstraction and patient questionnaires. Patient satisfaction was measured at 6 weeks postpartum using a validated questionnaire. Costs per birth were compared using a resource utilization/activity-based cost methodology. Results suggest similar maternal and neonatal morbidity in the two groups, with lower rates of cesarean section (11 vs. 19 percent) and assisted delivery (8 vs. 18 percent) in the birth center group. Patient satisfaction scores were similar. The costs per birth in the collaborative management model were 16 percent less for the payor perspective ($4,541 vs. $5,427); 15 percent more for the provider/medical group perspective ($894 vs. $778); and 22 percent less for the facility perspective ($1,451 vs. $1,858). Study results support the safety, cost-effectiveness, and patient acceptability of a collaborative management/ freestanding birth center model. (Abstract, executive summary, and final report; NTIS accession no. PB99-148827; 86 pp, $29.50 paper, $12.00 microfiche.)

Promoting Health in the African-American Community: The Role of the Church. Lorna Harris, University of North Carolina School of Nursing, Chapel Hill. AHCPR grant HS08619, project period 3/1/95 to 2/28/97.

The project's purpose was to plan and coordinate a State-wide conference to educate leaders of North Carolina's black churches about the role churches can play in helping to meet the objectives of Healthy People 2000. Using a Braithwaite and Taylor (1992) coalition partnership approach, a community-based health education project was developed with members of the North Carolina Interdenominational Ushers' Association (NCIUA). The conference results were establishment of 10 health advocacy committees in local churches, compilation of proceedings and a resource directory, and creation of a health steering committee of NCIUA members to plan and develop future health promotion projects. (Abstract and executive summary, NTIS accession no. PB99-137564; 24 pp, $23.00 paper, $12.00 microfiche.)

Randomized Trial of a Systematic Implementation of an Advance Directive Program in Six Nursing Homes. David Molloy, M.D., McMaster University, Hamilton, Ontario, Canada. AHCPR grant HS07878, project period 6/1/94 to 8/31/98.

The researchers examined the effects of systematic implementation of the Let Me Decide (LMD) advance directive on patient and family satisfaction with involvement in decisionmaking and on health care resource expenditures in six Ontario nursing homes. One home in each pair was randomized to receive the LMD program where competent residents or families of incompetent residents completed LMD. Patients and families completed satisfaction questionnaires, and data on health care costs were collected. Forty-nine percent of competent residents and 78 percent of families of incompetent residents in the intervention homes completed directives. Satisfaction with health care did not differ between intervention and control homes. Residents of intervention homes experienced fewer hospitalizations than those in control homes and consumed fewer resources than control home residents. There was no difference in mortality between the two groups. Administration of the LMD advance directive in nursing homes reduced hospitalizations and costs without affecting mortality or residents' and relatives' satisfaction. (Abstract, executive summary, and final report, NTIS accession no. PB99-148835; 67 pp, $29.50 paper, $12.00 fiche)

Resource Use in Seriously Ill Medicare Beneficiaries. Joan J. Teno, M.D., Brown University, Providence, RI. AHCPR grant HS09129, project period 7/1/97 to 6/30/98.

This study successfully merged the clinically rich data base from the Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatments (SUPPORT) with Medicare claims data. The impact of the SUPPORT intervention and the Patient Self-Determination Act on long-term resource use was examined. Each of these largely educational interventions did not impact on long-term resource use. Descriptive analyses highlighted important opportunities to improve end-of-life resource use. For high-cost patients, the majority of physicians had not communicated with the patient or their family members by the 14th day of an ICU stay. Objective estimates of prognoses from a multivariate model would not have resolved the medical decisions, given that the majority of patient prognoses were not at a futility threshold. A second important finding is that only 41 percent of patients who preferred a palliative approach reported that care was consistent with that preference. Resource use was higher in the cases where patient preferences were not being followed. (Abstract, executive summary, and final report, NTIS accession no. PB99-139206; 40 pp, $25.50 paper, $12.00 microfiche.)

Risk Sharing in Managed Care. Meredith B. Rosenthal, Ph.D., Harvard Medical School, Boston, MA. AHCPR grant HS09660, project period 9/30/97 to 9/29/98.

Managed care continues to evolve. In its early form, the industry relied on "command and control" mechanisms to influence physician practice style and reduce the cost of care. In response to the backlash from physicians and patients against the encroachment of managed care into the doctor-patient relationship, health plans are seeking alternative ways of containing costs. This research explored one of these alternatives that is increasingly prevalent and controversial: risk sharing with providers. There is concern that putting physicians at risk for the cost of treating patients compromises ethical principles and may lead to reductions in the quality of care. The research involved issues related to the design of risk-sharing contracts as well as their impact in an outpatient mental health setting. The findings indicate that behavioral health providers do reduce the duration of mental health therapy, given financial incentives to do so. As compared with managed fee-for-service, a fixed per case payment system resulted in 15 to 17 percent fewer visits. It also appears that providers substitute "free" services, such as referrals to self-help groups and community care, when additional therapy becomes costly. No impact on mental health status was found. (Dissertation, NTIS accession no. PB99-114118; 186 pp, $44.00 paper, $17.00 microfiche.)

Rural Low Birthweight Children and Their Families: Visions for the Future. Barbara Sachs, Ph.D., University of Kentucky Research Foundation, Lexington, KY. AHCPR grant HS07950, project period 9/30/94 to 9/29/96.

This project supported a conference that aimed to (1) improve communication, networking, and collaboration between tertiary care and community-based providers of health care to rural low birthweight (LBW) children and their families; (2) develop recommendations for changes in health care practice and health care policy and programs, as well as suggest new research directions for LBW children and their families in rural settings; and (3) disseminate recommendations based on conference proceedings to health care providers, policymakers, and researchers. Program content was based on responses to two preconference Delphi surveys about barriers to care for these families. Barriers to care involved family, provider, and systems issues. Conference participants included parents, health care professionals, and policymakers who participated in both large and small group sessions. Strategies suggested to overcome barriers were related to transportation, finances, improved provider-family communication, and better care coordination. (Abstract, executive summary, final report, and appendixes, NTIS accession no. PB99-133738; 82 pp, $29.50 paper, $12.00 microfiche.)

Toward a Women's Health Outcomes Research Agenda. Margaret A. Anderson, M.A., Society for the Advancement of Women's Health Research, Washington, DC. AHCPR grant HS09548, project period 9/30/97 to 9/29/98.

This project supported a conference focused on the role of outcomes research in women's health. The meeting provided an opportunity to assess current knowledge of women's health based on data derived from outcomes studies, evaluate the inclusion of women and the use of analysis by sex in outcomes research focused on women's health, and begin to identify a research agenda for the future. In addition, participants discussed private and public responsibilities for producing outcomes measures related to women's health and identified areas for collaboration. Medical and health specialty groups provided written statements about advances and challenges related to outcomes research in their arena. Finally, the meeting provided an opportunity for participants to consider how to translate research results into action or policy, for example, defining and shaping disease management, promoting evidence-based medicine, and developing practice guidelines that affect women. (Abstract and conference report, NTIS accession no. PB99-143448; 48 pp, $25.50 paper, $12.00 microfiche.)

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