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AHCPR funds new studies
Appropriate and effective use of right heart catheterization,
home care of infants with neonatal chronic lung disease, medical
and surgical superspecialization, and the effects of the market
structure on HMOs are among the topics to be studied in a series
of 12 new grants awarded by the Agency for Health Care Policy and
The following descriptions of the 12 new projects include the
principal investigator's name and affiliation, first-year
funding, and project period.
Adoption of Cancer Pain Guidelines in Managed Care.
Solomon, Ed.D., Education Development Center, Inc., Newton, MA;
$581,087, 6/01/96 to 5/31/00.
To conduct a randomized controlled study of cancer patients
and their providers in managed care clinics to determine the
effectiveness of a two-tiered (organizational and individual)
dissemination strategy of the AHCPR-sponsored cancer pain
AHCPR UI Guideline: Application in Nursing Homes. Nancy M.
Watson, M.S., Ph.D., University of Rochester, Rochester, NY;
$201,635, 6/1/96 to 5/31/99.
To evaluate the impact of the AHCPR-supported clinical
guideline on urinary incontinence in adults in the nursing home
Assessing Pediatric Quality of Life in a Clinical Trial.
D. Annett, Ph.D., University of New Mexico, Albuquerque; $36,329,
6/1/96 to 5/31/98.
To examine the relationship between a disease-specific pediatric
quality-of-life measure and (1) current asthma symptom severity
as measured in the Childhood Asthma Management Program (CAMP),
(2) sociodemographic variables as measured in the CAMP study, and
(3) the general multidimensional measures of quality of life
utilized in the CAMP study. Additionally, to determine the best
clinical and psychosocial predictors of disease-specific quality
Cardiac Procedure Use: A Prospective Cohort Study. Thomas
M.D., M.S.C., Brigham and Women's Hospital, Boston, MA; $654,677,
7/1/96 to 6/30/99.
To evaluate the reasons for the racial differences and
differences among male and female patients in the use of cardiac
tests and procedures. The study group will be identified at the
time of emergency room presentation with chest pain and
subsequently followed for all procedures, both invasive and
noninvasive, for 1 year.
Community-Based Pharmaceutical Care: A Controlled Trial.
Weinberger, M.D., Indiana University, Indianapolis; $590,656,
6/1/96 to 5/31/00.
To develop algorithms, materials, and an educational program to
facilitate pharmaceutical care and, subsequently, conduct a
randomized, controlled trial of the effects of providing
pharmacists with these materials and patient-specific
Effects of Health Care Market Structure on HMOs. Jack
M.D., Georgetown University, Washington, DC; $307,437, 7/01/96 to
To analyze the impact of the recent growth and concentration of
HMOs on employers, health insurance coverage decisions, health
care premiums, and employees' health insurance choices.
Facilitating Home Care of Neonatal Chronic Lung Disease.
Michael O'Shea, M.D., Bowman Gray School of Medicine,
Winston-Salem, NC; $266,967, 7/1/96 to 6/30/01.
To measure the outcomes and expenses associated with two
interventions that facilitate home care of infants with chronic
Impact of Prospective Drug Use Review on Health. Frank A.
Ph.D., Pennsylvania State University, University Park; $184,099,
8/1/96 to 7/31/98.
To (1) conduct a descriptive epidemiological analysis of
psychotropic drug use, prescribing patterns, and yield of
Prospective Drug Utilization Review (ProDUR) screen failures. The
study will examine two 24-month periods, before and after
interventions, and compute estimates of drug-related outcome
measures; and (2) evaluate the independent effects of two
different procedures on health outcomes including both outcomes
from changes in prescribing practices and differential mortality,
morbidity, and health services utilization.
Right Heart Catheterization: Appropriate/Effective Use.
Connors, Jr., M.D., Case Western Reserve University, Cleveland,
OH; $372,595, 7/1/96 to 6/30/98.
To determine: (1) variation in the use of right heart
catheterization (RHC) in seriously ill patients; (2) the
effectiveness of RHC in terms of survival, quality of life, and
satisfaction with care; (3) the cost of RHC; and (4) the
appropriateness of RHC use.
Selective Cervical Spine Radiography in Blunt Trauma.
Mower, M.D., M.E., M.S., University of California, Los Angeles;
$621,570, 8/1/96 to 7/31/98.
To determine whether clinical criteria can reliably exclude
cervical spine injury in "no risk" blunt trauma victims without
misidentifying any injured patient; if so, the use of
radiographic cervical spine imaging could be reduced.
Superspecialization of Medical and Surgical
Escarce, M.D., University of Pennsylvania, Philadelphia;
$271,721, 6/1/96 to 5/31/98.
To examine the patterns and determinants of superspecialization,
the phenomenon in which physicians narrow their scope of practice
to a small set of services chosen from the larger set of services
for which they are trained.
Understanding Health Values of HIV-Infected Patients. Joel
Tsevat, M.D., M.P.H., University of Cincinnati Medical Center,
Cincinnati, OH; $160,160, 9/1/96 to 8/31/97.
To use focus groups and interviews to gain an understanding of
the health values of 100 HIV-infected patients and to develop and
test a conceptual model of their health values.
AHCPR publishes two HCUP-3 Research Notes
The following two Research Notes are part of an ongoing series of
publications derived from research conducted by the Agency for
Health Care Policy and Research using data from the Healthcare
Cost and Utilization Project. This series provides the results of
analyses on health policy issues important to the Nation's health
care providers and patients.
Elixhauser, A. (1996). Clinical Classifications for Health
Research Version 2: Software and User's Guide (AHCPR
No. 96-0046). Healthcare Cost and Utilization Project (HCUP-3)
Research Note 2.
Clinical Classifications for Health Policy Research (CCHPR)
Version 2 provides a way to classify diagnoses and procedures
into a limited number of categories. CCHPR aggregates individual
hospital stays into larger diagnosis and procedure groups for
statistical analysis and reporting. This product provides
information required to use CCHPR:
- A description of the CCHPR categorization scheme.
- Electronic files containing the translation of ICD-9-CM
diagnosis and procedure codes into CCHPR categories.
CCHPR Version 2 is based on ICD-9-CM codes that are valid for
January 1980 through October 1995. There is one classification
scheme for diagnoses (260 categories) and one classification
scheme for procedures (231 categories).
Duffy, S.Q., Elixhauser, A., and Sommers, J.P. (1996).
and Procedure Combinations in Hospital Inpatient Data (AHCPR
Publication No. 96-0047). Healthcare Cost and Utilization Project
(HCUP-3) Research Note 3.
This Research Note contains information on the most
combinations of diagnoses and procedures for hospital inpatients.
It helps to answer the questions "What is this procedure used
for?" and "How is this diagnosis managed?" The analysis is based
on data from the 1992 Nationwide Inpatient Sample, a component of
AHCPR's Healthcare Cost and Utilization Project. For each of the
100 most frequently performed principal procedures, the authors
list the five principal diagnoses most commonly recorded on
discharge abstracts of patients who had that procedure during the
hospitalization. For each of the 100 most frequent diagnoses,
they also list the five principal procedures most commonly
performed. Median charges and length of stay for each
diagnosis-procedure combination also are provided, along with
estimates of standard errors.
Examples of findings cited in this Research Note include:
- More than one-quarter of all cesarean sections are
for a principal diagnosis of previous C-section.
- Charges for amputation of lower extremity vary from $14,930
for diabetes mellitus with complication to $28,499 for
aortic and peripheral arterial embolism or thrombosis.
- Median charges are $20,237 for hospitalized heart attack
patients who undergo angioplasty as their principal
procedure, compared with $47,244 for patients who undergo
- About one-half of all patients with cancer of the prostate
received open prostatectomy, and 29 percent received
transurethral resection of the prostate.
This information can be used as a starting point by medical
professionals to compare their own practices with a nationwide
sample and by third-party payers and managed care organizations
to examine the impact of payment policies on practice patterns.
Health services researchers can use this information to generate
hypotheses for future research on the treatment of specific
New publications available from NTIS
The following publications and final reports are now available
from the National Technical Information Service (NTIS).
Cardiac Rehabilitation: Secondary Prevention. Guideline
Report, Number 17. Wenger, N.K., Froelicher, E.S., Smith,
Cardiac rehabilitation programs are long-term programs that
include medical evaluation, prescribed exercise, cardiac risk
factor modification, education, counseling, and behavioral
interventions. They are tailored to meet the needs of each
patient and are intended to limit the physiologic and
psychological effects of cardiac illness, reduce the risk for
future problems, control symptoms, stabilize or reverse the
atherosclerotic process, and enhance selected patients'
psychosocial and vocational status. In October 1995, the Agency
for Health Care Policy and Research released a clinical practice
guideline on cardiac rehabilitation. This report presents the
background materials and supporting documentation used by the
expert panel in developing the guideline. (NTIS accession no.
PB96-168307, 726 pp; $92.00 paper, $25.00 microfiche)
Consequences of Variation in Treatment for Acute MI. Final
of the Patient Outcomes Research Team. AHCPR grant HS06341,
9/30/89 to 2/28/95. Barbara J. McNeil, M.D., Ph.D., Harvard
Medical School, Boston, MA.
The Acute Myocardial Infarction Patient Outcomes Research Team
(AMI PORT) focused its research on the effectiveness of invasive
procedures (specifically angiography, bypass surgery, and
angioplasty) and medical therapies (including the use of
thrombolytic agents and other cardiac drugs). The PORT found
that, although survival of AMI patients has improved concurrent
with a dramatic increase in the use of invasive procedures, the
aspects of treatment most affecting long-term survival are
related to care received within the first day of admission. The
higher usage rates of invasive procedures do not appear to confer
any advantage, on average, with respect to health-related quality
of life. With respect to medical therapies, the PORT found that:
(1) use of thrombolysis and other beneficial drugs in AMI was
proven to be effective years before widespread acceptance of
their use by "experts"; (2) thrombolytic agents and beta blockers
are underutilized; (3) thrombolysis with streptokinase is
beneficial and cost effective for elderly patients in many
clinical settings; and (4) cardiologists appear more
knowledgeable than generalist physicians about the benefits of
drug therapies. This last finding is particularly important,
given the attention currently being focused on the role of
primary care providers as gatekeepers in the managed care
A Dynamic Stochastic Model of Medical Care Use and Work
AHCPR grant HS07964, 8/1/93 to 8/31/95. Donna L. Boswell, M.A.,
University of Minnesota, Minneapolis, MN.
The author uses data from the 1987 National Medical Expenditure
Survey (NMES) to focus on one aspect of health care demand: the
medical care consumption and absenteeism behavior of employed
individuals with acute illnesses. The theoretical framework
models the decision to visit a doctor and/or to miss work during
an episode of acute illness. The author uses structural
estimation to examine the parameters of the individual's
decisionmaking process. This estimation technique allows for the
introduction and evaluation of the impact of new public policy
initiatives relating to health care. The estimates also allow for
predictions of the change in use of physician services and
illness-related absenteeism that would arise with improvements in
access to health care through more complete health insurance and
sick leave coverage and with changes in consumer cost sharing.
Enhanced Accuracy of MRI for Staging Prostate Cancer.
HS07027, 9/1/92 to 12/31/95. Barbara J. McNeil, M.D., Ph.D.,
Brigham & Women's Hospital, Boston, MA.
Reading and decision aids were refined and applied to staging of
prostate cancer (limited vs. extensive disease) by magnetic
resonance imaging (MRI). The reading aid was a checklist of
relevant perceptual features of an image, each with a scale to
elicit a quantitative rating. The decision aid was a statistical
prediction rule, which merged the ratings with optimal weights
into a diagnostic probability. The aids provided substantial
increases in the diagnostic accuracy of MRI considered by itself.
Aided MRI provided an increase in accuracy beyond prostate
specific antigen and biopsy Gleason grade for radiologists
specializing in MRI of the prostate but not for general body
Is Coronary Angiography Underused by Poor and Uninsured
AHCPR grant HS06916, 7/1/91 to 9/30/93. Marianne Laouri, Ph.D.,
RAND Corporation, Santa Monica, CA.
Prior studies have documented significant geographic variations
in the use of health services, as well as substantial levels of
inappropriate use. Other studies have shown differences in the
use of medical care, and cardiac procedures in particular, among
ethnic and socioeconomic groups and men and women. This study is
an investigation of the underuse of coronary angiography among
poor and uninsured patients who receive medical care at Los
Angeles County medical centers. Explicit criteria, based on a set
of indications for the clinical necessity of coronary
angiography, were used to measure underuse. Patients who
underwent exercise stress testing and had a positive stress test
at three Los Angeles County hospitals or at the private
university hospital between January 1, 1990 and June 3, 1991 were
eligible for inclusion in the study. Data were collected using
medical record abstraction and followup phone interviews. Of the
352 patients who met necessary indications, 56 percent underwent
coronary angiography within 12 months following the exercise
stress test. A higher proportion of patients from the private
hospital than from the county hospitals underwent necessary
coronary angiography 3 months after the stress test. The same was
true at 12 months. Women were significantly less likely than men
to have undergone necessary coronary angiography at 3 and 12
months after the stress test. No differences were observed
between African Americans or Latinos and non-Latino whites. These
findings demonstrate that a medical procedure for which overuse
has been demonstrated is also underused in both public and
private hospitals and in women. The author points out that
efforts to enhance the effectiveness of the Nation's health care
system should consider not only the elimination of inappropriate
care but also the underuse of needed medical services.
Methods for Survival Analysis in Outcomes Research.
AHCPR grant HS07137, 9/30/92 to 9/29/95. William A. Knaus,
M.D., George Washington University, Washington, DC.
This project investigated and extended understanding and use of
survival analysis in outcomes research by addressing seven
objectives or targets: the handling of missing values,
interaction among major predictive variables, the role of
variations in patient selection, updating of survival estimates,
confidence intervals and minimum data sets, the integration of
objective and subjective estimates, and estimation and validation
procedures. These seven targets represent methodologic challenges
that must be addressed if survival analysis is to have a major
impact on research design, clinical investigation, clinical
practice, and national health policy. By using clinically
accurate databases containing detailed disease, physiological,
and other patient characteristics, as well as short- and
long-term survival outcomes data, progress was made in all seven
Variations in Cataract Management: Patient and Economic
Final Report of the Cataract Patient Outcomes Research
Cataract surgery is the most common surgical procedure performed
on Medicare beneficiaries. The Patient Outcomes Research Team
(PORT) performed a literature review; analyzed Medicare claims
data; surveyed ophthalmologists, optometrists, anesthesiologists,
and internists; performed a prospective observational study of
over 750 patients undergoing first-eye cataract surgery; analyzed
patient preferences on potential outcomes of cataract surgery and
watchful waiting; and developed a decision analysis and
epidemiologic policy model. Substantial variation was documented
in the management of patients undergoing cataract surgery, and
several associated factors were identified. A reliable and valid
measure of a cataract's impact on a patient's functional status
was developed. This, combined with Snellen visual acuity, was
found to be a better measure of patients' need for and outcomes
of cataract surgery than Snellen visual acuity alone. Cataract
surgery's impact on patient functioning and satisfaction was
characterized. Associations were defined between patient outcome
and each of four factors: an ophthalmologist's annual volume of
surgery, intra-operative technique, patient characteristics, and
use of YAG-laser capsulotomy. The national impacts of alternative
strategies for managing cataract were projected.
Return to Contents
AHCPR Publication No. 96-0061
Current as of June 1996