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Most outcomes of type-II diabetic and hypertensive patients
are unrelated to system of care or physician specialty
The tendency of health maintenance organizations (HMOs) to use
fewer medical resources and physician specialists compared with
traditional fee-for-service (FFS) medicine has caused concern
that this managed care approach could translate into worse health
outcomes for patients. However, this concern appears to be
unwarranted for patients with non-insulin-dependent diabetes
mellitus (NIDDM) or hypertension. These patients have similar
outcomes whether they are treated by generalist physicians or
specialists (cardiologists or endocrinologists) and whether they
are cared for in an FFS or prepaid managed care setting.
These findings are striking, given the tripled enrollment of
Americans in HMOs in the past 10 years and the historically
higher costs of FFS medicine and specialty practice, notes
Sheldon Greenfield, M.D., of Tufts University Medical School, who
led the study, which was supported by the Agency for Health Care
Policy and Research (HS06665). Dr. Greenfield and his colleagues
compared the outcomes of patients with hypertension or NIDDM at 2
years and 4 years and calculated their 7-year mortality rate.
Patients in Boston, Chicago, and Los Angeles were drawn from
three different systems of care (FFS patients; prepaid patients
in solo or small single-specialty groups or in large
multispecialty group practices; and patients in staff-model
The researchers found that no one system of care or physician
specialty achieved consistently better 2-year and 4-year outcomes
or lower death rates for these patients. The one notable
exception was the better foot-ulcer and infection outcomes for
NIDDM patients (who are prone to infections of the extremities)
treated by endocrinologists.
For more information, see "Outcomes of patients with hypertension
and non-insulin-dependent diabetes mellitus treated by different
systems and specialties," by Dr. Greenfield, William Rogers,
Ph.D., Maureen Mangotich, M.D., M.P.H., and others, in the
November 8, 1995, Journal of the American Medical Association 274(18), pp. 1436-1444.
Heart disease patients in America achieve better functioning
than their Canadian counterparts
American heart attack patients undergo coronary diagnostic and
revascularization procedures at twice the rate of Canadian
patients, but they have equal rates of death and recurrent heart
attacks. Yet Americans experience better functional status
following heart attack (for example, less activity-limiting
angina) than Canadians. This difference in functional status may
be due to different patterns of managing heart disease in the two
countries, according to a study supported in part by the Agency
for Health Care Policy and Research (HS06503 and the Cardiac
Arrhythmia Patient Outcomes Research Team [PORT-II], HS08362).
Led by Mark A. Hlatky, M.D., F.A.C.C., of the Stanford University
School of Medicine, the researchers measured quality of life in
patients enrolled in seven American and one Canadian site in the
Bypass Angioplasty Revascularization Investigation. This
multicenter, randomized clinical trial involved patients with
multivessel coronary disease.
Results showed that the 350 American and Canadian patients
without symptoms of heart disease prior to study enrollment had a
similar quality of life. However, of the 860 patients with
previous symptoms of heart disease, 27 percent of Americans vs.
16 percent of Canadians rated their health excellent. Americans
had higher overall health and functional status scores but
similar emotional and social health scores. These findings
suggest that the lower functional status of Canadian patients
with a previous history of heart disease or after heart attack is
more likely to be due to differences in medical care in the two
countries than to differences in nonmedical factors such as
climate or culture.
More details are in "Better functional status in American than
Canadian patients with heart disease: An effect of medical
care?" by Louise Pilote, M.D., M.P.H., Martial G. Bourassa, M.D.,
F.A.C.C., Constance Bacon, Ed.M., and others, in the Journal of
the American College of Cardiology 26(5), pp. 1115-1120, 1995.
Recent findings from the low birthweight PORT
The Patient Outcomes Research Team (PORT) on Low Birthweight in
Minority and High-Risk Women, supported by the Agency for Health
Care Policy and Research (contract 282-92-0055), examines ways to
prevent low birthweight (LBW) and improve the outcomes of LBW
infants. Led by Robert L. Goldenberg, M.D., of the University of
Alabama at Birmingham, PORT researchers recently published
findings on the importance of family planning in preventing low
birthweight and the impact of magnesium sulfate on labor duration
and cesarean-section (c-section) rates.
Klerman, L.V., Phelan, S.T., Poole, V.L., and Goldenberg, R.L.
(1995). "Family planning: An essential component of prenatal
care." Journal of the American Medical Women's Association 50(5),pp. 147-151.
Proper spacing of pregnancies and delay or prevention of
pregnancy among women at high risk for poor birth outcomes could
lower the rate of LBW infants, according to a recent review of
the literature by Low Birthweight PORT researchers. One report of
single births, in which the prior pregnancy ended with the birth
of a live infant, found a relative risk for LBW of 1.63 for
whites and 1.46 for blacks when the interval until the next
pregnancy was less than 6 months. The effect of interval on
birthweight remained after controlling for age, birth order,
race, marital status, and educational level. The link between
unintended conceptions and LBW is probably related to inadequate
prenatal care (counseling, family planning) during the previous
pregnancy, smoking, alcohol use, and inadequate weight gain, note
the researchers. In one study, the LBW rate for both well-timed
and mistimed (too early) pregnancies was 5 percent, and for
unwanted births it was 8.8 percent. About 24 percent of births to
smoking women were unwanted compared with 11 percent of births to
nonsmoking women. The relationship between unintended pregnancies
and behaviors associated with increased risk of LBW suggests that
family planning might prevent some cases of LBW by reducing the
rate of unintended pregnancies, conclude the researchers.
Atkinson, M.W., Guinn, D., Owen, J., and Hauth, J.C. (1995).
"Does magnesium sulfate affect the length of labor induction in
women with pregnancy-associated hypertension?" American Journal
of Obstetrics & Gynecology 173(4), pp. 1219-1222.
For women with pregnancy-associated hypertension, use of
magnesium sulfate (compared with phenytoin) to prevent
hypertension-related seizures does not prolong the induction of
labor, nor does it result in an increase in c-section deliveries,
according to members of the Low Birthweight PORT. This is
contrary to the common impression among clinicians. The
researchers studied women with a single pregnancy in vertex
presentation between 32 and 42 weeks gestation who required
labor induction for hypertension-related problems. Fifty-four
women with similar characteristics were randomized to receive
either magnesium sulfate or phenytoin (Dilantin) to prevent
seizures. The interval from labor induction to delivery and the
rate of c-sections were similar in both groups. Neonatal outcomes
also were similar in both groups, and no women had seizures.
Prostate PORT examines costs and effectiveness of prostate
cancer screening among elderly men
The Prostate Patient Outcomes Research Team (PORT-II) was funded
by the Agency for Health Care Policy and Research (HS08397) to
assess therapies for localized prostate cancer and benign
prostatic hyperplasia (BPH). The researchers, led by Michael J.
Barry, M.D., of Harvard Medical School, recently published a
series of four papers that discuss whether or not Medicare should
reimburse physicians for prostate-specific antigen (PSA) testing
for early detection of prostate cancer. The American Cancer
Society recommends that men 50 years of age and older have this
test annually. The first paper in the series was summarized in
the November/December 1995 issue of Research Activities. The
other three papers are discussed here.
Coley, C.M., Barry, M.J., Fleming, C., and others (1995).
"Should Medicare provide reimbursement for prostate-specific
antigen testing for early detection of prostate cancer? Part II:
Early detection strategies." Urology 46(2), pp. 125-141.
In this paper, the Prostate PORT-II researchers describe and
discuss the benefits and drawbacks of commonly used tests for
early detection of prostate cancer, including digital rectal
examination (DRE), PSA measurement, transrectal ultrasound
(TRUS), and transrectal needle biopsy of the prostate (TRNB).
The researchers point out that age has a complex effect on the
results of screening for prostate cancer. For example, the
specificity of PSA, and probably DRE as well, deteriorates as
more men in the population have greater amounts of BPH.
Barry, M.J., Fleming, C., Coley, C.M., and others (1995).
"Should Medicare provide reimbursement for prostate-specific
antigen testing for early detection of prostate cancer? Part III:
Management strategies and outcomes." Urology 46(3), pp. 277-289.
In a review of management strategies, members of the Prostate
PORT-II discuss the controversy surrounding the optimal treatment
for clinically localized prostate cancer. In the United States,
the preference is for aggressive treatment, with urologists
generally preferring radical prostatectomy. In recent years there
has been considerable regional variation in the use of this
procedure, whose risks include perioperative death, medical
complications, long-term incontinence and impotence, and urethral
stricture disease. The researchers also discuss strategies to
determine the stage of prostate cancer, including surgery, and
the risks and benefits of expectant management (watchful
waiting), a commonly used strategy for clinically localized
cancer worldwide. Finally, they review issues surrounding the
followup treatment after curative therapy, such as radiation or
androgen deprivation therapy.
Barry, M.J., Fleming, C., Coley, C.M., and others (1995).
"Should Medicare provide reimbursement for prostate-specific
antigen testing for early detection of prostate cancer? Part
IV:Estimating the risks and benefits of an early detection
program." Urology 46(4), pp. 445-461.
In this paper, the Prostate PORT-II researchers estimate the
risks, benefits, and costs of an early prostate cancer detection
program among older men. They outline several assumptions they
use to model health outcomes of early detection of prostate
cancer for men ages 65 to 75 years. They detail the expected harm
and maximal benefit of DRE and PSA screening cohorts of 100,000
men at 65, 70, and 75 years of age for prostate cancer. Based on
their assumptions and data, 28-40 percent of Medicare-age men who
are screened would have suspicious results on DRE and PSA
testing. This proportion is very high compared with other common
screening tests, such as mammography for breast cancer screening
(up to 6 percent), fecal occult blood testing for colorectal
cancer screening (2 to 5 percent), or Papanicolaou smears for
cervical cancer screening (1 to 13 percent). The researchers
present estimated costs and discounted benefits, in terms of
life-years and days saved per person screened, given certain cost
assumptions favoring early detection and treatment. They conclude
that it is premature to offer a Medicare benefit for PSA testing
for early detection of prostate cancer when a legitimate question
can be raised about whether such screening does more harm than
Clinical characteristics combined with a patient's report of
visual functioning predict degree of improvement following
Physicians and their patients who have cataracts may be able to
predict which patients will have improved visual function
following cataract surgery, according to a study supported in
part by the Agency for Health Care Policy and Research (National
Research Service Award fellowship F32 HS00048). The study shows
that younger age, poorer preoperative visual function, posterior
subcapsular cataract, absence of age-related macular
degeneration, and/or diabetes can predict the probability of
substantial improvement following cataract surgery.
Carol M. Mangione, M.D., M.S.P.H., of Brigham and Womens
Hospital, and her colleagues developed a predictive model based
on these five characteristics. To develop the model, they studied
visual function preoperatively and at 3 and 12 months after
cataract surgery in 424 patients to find out which
characteristics influenced visual function outcomes. They
measured improvement in visual function using the Activities of
Daily Vision Scale (ADVS), which includes such activities as day
and night driving, reading, and sewing.
Using their model, they classified 145 patients into three groups
with probabilities of substantial improvement in visual function
of 85 percent, 34 percent, and 3 percent. They conclude that
preoperative clinical characteristics can be combined with a
standardized patient report of visual functioning to predict
which patients have the greatest probability of improving in
common visual activities after surgery.
For more information, see "Prediction of visual function after
cataract surgery," by Dr. Mangione, E. John Orav, Ph.D., Mary G.
Lawrence, M.D., and others, which appears in the October 1995
Archives of Ophthalmology 111, pp. 1305-1311.
Cataract PORT publishes recent findings
Cataracts are the second leading cause of blindness in the United
States. Nearly one out of five persons 65-74 years of age (18
percent) and almost half (46 percent) of those aged 75-84 years
have cataracts that impair their everyday activities and ability
to live independently. The Cataract Patient Outcomes Research
Team (PORT) was funded by the Agency for Health Care Policy and
Research (HS06280) to study variations in cataract management,
patient outcomes, and the economic aspects of cataract treatment.
PORT researchers, led by Earl P. Steinberg, M.D., M.P.P., of The
Johns Hopkins University, recently published the results of three
studies, discussed below. They examine physician use of
preoperative tests for healthy cataract patients, patient
expectations vs. outcomes of cataract surgery, and the impact of
second-eye vs. first-eye cataract surgery on visual acuity,
function, and patient satisfaction.
Bass, E.B., Steinberg, E.P., Luthra, R., and others (1995). "Do
ophthalmologists, anesthesiologists, and internists agree about
preoperative testing in healthy patients undergoing cataract
surgery?" Archives of Ophthalmology 113, pp. 1248-1256.
A 1991 national survey of ophthalmologists, anesthesiologists,
and internists shows that these physicians varied from each other
and within their own specialty in their reported use of
preoperative medical tests for healthy cataract patients and in
their reasons for using these tests. For example, 50 percent of
ophthalmologists, 40 percent of internists, and 33 percent of
anesthesiologists frequently or always obtained a chest x-ray
film, while 20 percent, 27 percent, and 37 percent, respectively,
never obtained a chest x-ray film for these patients. Similarly,
70 to 90 percent of ophthalmologists, 73 to 79 percent of
internists, and 41 to 79 percent of anesthesiologists frequently
or always obtained a complete blood cell count, electrolyte
panel, and electrocardiogram, while 4 to 11 percent, 13 to 17
percent, and 9 to 28 percent, respectively, never obtained these
tests. Moreover, many of the physicians believed that some tests
were unnecessary but performed them for reasons ranging from
medicolegal concerns to institutional requirements.
Tielsch, J.M., Steinberg, E.P., Cassard, S.D., and others.
(1995). "Preoperative functional expectations and postoperative
outcomes among patients undergoing first eye cataract surgery."
Archives of Ophthalmology 113, pp. 1312-1318.
For this study, Cataract PORT researchers recruited 772 patients
undergoing first-eye cataract surgery from 75 ophthalmology
practices in three urban areas. The patients in this study had
high expectations of improved visual functioning after cataract
surgery, and in most cases, their expectations were fulfilled.
About 61 percent of patients achieved or surpassed their expected
level of postoperative functioning. However, patients older than
75 years or with coexisting visual problems experienced a larger
gap between expected and actual postoperative function than
patients who were younger or had no coexisting visual problems.
The researchers suggest that, in selected cases, more
comprehensive counseling may reduce the discrepancy between
expected and actual outcomes of cataract surgery.
Javitt, J.C., Steinberg, E.P., Sharkey, P., and others (1995).
"Cataract surgery in one eye or both?" Ophthalmology 102(11), pp.
In a study of the same group of patients described above, the
Cataract PORT researchers showed that the 36 percent of patients
who underwent cataract extraction in the second affected eye
during the 1-year study period had 61 percent greater improvement
in their visual function, 27 percent less trouble with vision,
and 24 percent greater improvement in satisfaction with their
vision compared with those who underwent surgery in only one eye.
At 12 months after first-eye surgery, patients who had undergone
surgery in both eyes demonstrated a 1.6-fold greater improvement
in visual function, were 2.1 times as likely to report no trouble
with their vision, and were 2.7 times more likely to be satisfied
with their vision than patients who had only one cataract
removed. The improvement was greater in older patients and those
with worse vision in their second eye prior to surgery. These
findings support the AHCPR Cataract Guideline Panel's
recommendation that the main indication for cataract surgery in
the second eye should be the same as that for surgery in the
first eye—namely, impairment in the patient's ability to
function in everyday life due to his or her vision.
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