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Medical Liability

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Malpractice claims for physician omission are both less common and more likely to be paid than other malpractice suits

Defensive medicine is said to add at least $15 billion a year to health care expenditures in the United States. Yet if physicians ordered more diagnostic tests and monitoring procedures than they do now in order to avoid lawsuits for missed diagnoses or problems, they would actually avert very few malpractice suits, says a study supported by the Agency for Health Care Policy and Research (HS07236). These omission-related claims are uncommon. The average physician practicing in 1 of 15 specialties studied would be sued for omitting a necessary diagnostic test once every 59 years, according to the study.

Researchers at RAND in Santa Monica, CA, examined medical claims brought against physicians practicing in selected specialties over a 12-year period (1977 to 1989). The claims were included in a database of an anonymous, physician-owned, medical society-sponsored physician malpractice insurer in one State. Claims resulting from physician omission were considered important in less than 9 percent of claims and of central importance in 4 percent. However, compared with other types of medical malpractice suits, omission-related claims were more likely to be paid, had a higher median payment, and were more often associated with significant patient injury or death. The finding of more frequent payment remained even after controlling for physician specialty, geographic region, and degree of patient injury.

During the study period, insured physicians incurred claims at a rate of 24 per 100 physician-years. Compared with medical specialists, surgical specialists had about three times the rate of all-cause claims and about twice the rate of omission-related claims. Within the medical specialties, the likelihood of payment for omission-related claims was more than twice that of other claim types, and the median payment was $34,000 greater. All else being equal, the estimated odds of any payment for omission-related claims were nearly five times higher than for other claims. Among the omission-related claims resulting in payment, most were for relatively inexpensive routine tests, not cutting-edge technologies.

Details are in "Omission-related malpractice claims and the limits of defensive medicine," by Richard L. Kravitz, M.D., John E. Rolph, Ph.D., and Laura Petersen, M.P.H., December 1997 Medical Care Research and Review 54(4), pp. 456-471.

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Elderly/Long-term Care

Use of physical restraints in nursing homes has declined, but the same types of residents are being restrained

One in four nursing home residents was physically restrained in 1993, but there was wide variation in the use of wrist or ankle restraints, restrictive vests, and geri-chairs by homes. This figure represents a 30-percent reduction in the number of nursing home residents who typically were restrained prior to passage of the 1987 Nursing Home Reform Act (NHRA).

The NHRA gave nursing home residents the right to be free from any physical or chemical restraint imposed purely for purposes of discipline or convenience. On the other hand, the type of residents restrained since passage of the NHRA has not changed. Residents with physical or cognitive impairment who take antipsychotic medications, have a history of falls, or have problems with mobility are significantly more likely to be restrained than other residents, according to a study supported in part by the Agency for Health Care Policy and Research (National Research Service Award training grant T32 HS00011).

It may be that the threshold level for restraint use has risen, but the underlying rationale for use may not have changed, says Nicholas G. Castle, Ph.D., of AtlantiCare Health Systems in Egg Harbor Township, NJ. Dr. Castle and his colleagues Barry Fogel, M.D., and Vincent Mor, Ph.D., of Brown University examined 24 resident and facility factors relevant to use of restraints. They merged 1990 and 1993 Health Care Financing Administration (HCFA) evaluation data with corresponding Medicare and Medicaid survey data on a total of 268 facilities in 10 States and found that 36 percent of residents in 1990 and 26 percent of residents in 1993 were restrained, but the types of residents restrained were similar.

In 1990, 56 percent of residents limited in their ability to carry out three or more daily living activities and 54 percent of residents with low cognitive performance scores were restrained, as well as 48 percent of residents taking antipsychotic medications and 38 percent of those with a history of falls. For the 1993 groups, the percentages were generally lower, although they followed a similar pattern. At the facility level, three factors were significant: ratio of full-time-equivalent nurse aides per resident, average occupancy rates, and level of competition with other homes.

See "Risk factors for physical restraint use in nursing homes: Pre- and post-implementation of the Nursing Home Reform Act," by Drs. Castle, Fogel, and Mor, in The Gerontologist 37(6), pp. 737-747, 1997.

Physiological measures alone are insufficient to assess treatment impact for chronic diseases like Alzheimer's

People with Alzheimer's disease and their families find little significance in treatment-related spinal fluid chemistry changes or even changes in digit-span memory. For them, the person's ability to function and lessened family strain are paramount. That's the difference in orientation between traditional clinical research with its emphasis on hard physiological changes and outcomes and effectiveness research, which selects relevant measures of patient outcome depending on the disease or condition being studied.

Outcomes research goes beyond physiologic measures to include measures of change in functional status or quality of life, as well as patient burden. These are very important in chronic diseases such as Alzheimer's, explain Carolyn M. Clancy, M.D., and James K. Cooper, M.D., of the Agency for Health Care Policy and Research.

As they point out in a recent commentary, dementia researchers have long recognized that treatment-related physiological changes, while perhaps statistically significant, have no meaning to patients and their caregivers. Dementia researchers developed generic function measures such as the Alzheimer's Disease Assessment Scale that include both cognitive behavior and noncognitive behavior and attempt to capture the broad range of outcomes affected by dementia. Yet these generic functional measures, which are widely used in dementia research, do not take into account outcomes such as financial burden, service use, and unmet needs of caretakers. Rarely do dementia treatment studies include as outcomes the strain of the patient's belligerence on the household or the stress of inappropriate sexual behavior.

Alzheimer's disease offers distinctive challenges for outcomes researchers because of the multiple domains affected by the disease: clinical, functional, psychological, cognitive, and societal, as well as the effects on caregivers and families. Efforts to evaluate new treatments need to incorporate many perspectives so that the next generation of treatments will be used as effectively as possible, conclude the researchers.

Details are in "Outcomes and effectiveness research in Alzheimer's disease," by Drs. Clancy and Cooper, in Alzheimer's Disease and Associated Disorders 11(6), pp. 7-11, 1997. Reprints (AHCPR Publication No. 98-R026) are available from the AHCPR Publications Clearinghouse.

Studies focus on measuring quality in long-term care

Measurement of quality of care has focused on three domains: structure, process, and outcomes of care. The structure of care refers to the physical setting in which care is delivered, for example the number of nurses per patient, the presence of specific equipment, or the types of units involved. The process of care represents the steps taken to provide treatment to the patient. This may include when, which treatment, and how much treatment is given for a particular condition (e.g., back pain). Outcomes of care are the result of the patient's interaction with the health care system. Outcome measures may include mortality rates, readmission rates, complications, functional measures, and others.

William D. Spector, Ph.D., a senior researcher in the Agency for Health Care Policy and Research's Center for Organization and Delivery Studies, and his colleagues recently published the results of three studies that focus on quality measures for use in long-term care research. The articles are summarized here, and reprints are available from theAHCPR Publications Clearinghouse.

Spector, W.D., and Fleishman, J.A. (1998, January). "Combining activities of daily living with instrumental activities of daily living to measure functional disability." Journal of Gerontology: Social Sciences 53B(1), pp. S46-S57.

Measures of functional disability play a key role in studies of the aging process, clinical decisionmaking, studies that evaluate the outcomes of treatment, determinations of eligibility for certain services, and estimates of the need for long-term care services. Typically, functional disability is measured using two types of scales: activities of daily living (ADLs) and independent activities of daily living (IADLs). ADLs include activities related to hygiene and personal care, and IADLs include activities necessary to reside in the community such as shopping, managing personal finances, and meal preparation.

Assessments of functional disability that include both ADLs and IADLs allow a greater range of disability to be measured. In this article, Dr. Spector and John A. Fleishman, Ph.D., of AHCPR's Center for Cost and Financing Studies, propose a methodology for combining the data in these two scales that would provide a simplified measure to assess a person's level of functional disability.

Data from a nationally representative sample of nearly 3,000 elderly individuals who were disabled in IADLs or ADLs were used to determine the accuracy and usefulness of this approach. The analysis confirmed that a combined scale is the most efficient way to describe the data. Correlation was high between the combined scale and total hours of human help needed by an individual.

Many States use functional disability scales to determine eligibility for long-term care coverage. Use of the combined scale may allow for more sensitivity in measurements of functional disability and improved measurement of patient outcomes and quality, conclude the authors. Reprints (AHCPR Publication No. 98-R028) are available from theAHCPR Publications Clearinghouse.

Spector W.D. (1997). "Measuring functioning in daily activities for persons with dementia." Alzheimer Disease and Associated Disorders 11(Suppl. 6), pp. 81-90.

The mental and physical conditions of people with Alzheimer's disease and other dementias deteriorate from the onset of the disease until death. The increasing impairment of mental capacities eventually leads to loss of the ability to function independently. Measurement of functional disability is important for treating and studying dementia. It allows clinicians to track the connection between cognitive difficulties and performance of everyday activities. Additionally, it can be used as an outcome measure for researchers to evaluate the effectiveness of clinical treatments.

In this article, Dr. Spector reviews scales used in assessing an individual's ability to perform basic daily activities that are essential to maintain independence in the community. He reviews both generic scales and scales specifically designed for use with demented individuals, including both informant and performance measures. Scale assessment focuses mainly on the scaling properties and validity of the scales and whether there is measurement bias when applied to the demented population. In this study, Dr. Spector also attempts to clarify whether dementia-specific scales are measuring ability to function or cognitive abilities.

The study identifies six different strategies being used to construct functional scales for the demented and concludes that scales generally are not well validated. In some cases, questions remain as to which construct is being measured with these scales: cognition or disability. In addition, many scales may be unnecessarily complex and detailed. The findings of this study underscore the importance of more comprehensive analyses of the scaling properties embodied in the measures, as well as the development of a framework to separate out the impacts of the physical, cognitive, and environmental factors that affect an individual's ability to perform independent living tasks.

Article reprints (AHCPR Publication No. 98-R025) are available from the AHCPR Publications Clearinghouse.

Spector, W.D. and Fortinsky, R.H. (1998, February). "Pressure ulcer prevalence in Ohio nursing homes." Journal of Aging and Health 10(1), pp. 62-80.

Many nursing homes, States, and insurers, including Medicare and Medicaid, are collecting data on the occurrence of pressure ulcers and are now beginning to use this information to monitor quality. In this article, Dr. Spector and Richard H. Fortinsky, Ph.D., of Case Western Reserve University, examine pressure ulcer correlates in a representative sample of more than 15,000 Ohio nursing home residents.

The Clinical Practice Guideline, Pressure Ulcers in Adults: Prediction and Prevention, issued by AHCPR in 1992, indicates that in most cases, pressure ulcers are entirely preventable. Using a sample of more than 15,000 residents from 843 Ohio nursing homes in 1994, the authors found that 12 percent of residents had pressure ulcers, and 8 percent had ulcers that were stage 2 or greater. Important risk factors related to the presence of pressure ulcers included: history of pressure ulcers, new residents or readmissions, difficulty with activities of daily living, weight loss and dehydration, diabetes, edema, and incontinence.

Additionally, the authors found that rural nursing home residents were less likely to have pressure ulcers. They suggest that this may result from higher quality ulcer care being provided in rural nursing homes compared with those in urban areas. The authors conclude, however, that additional research is necessary to determine the precise reasons for this result. Reprints (AHCPR Publication No. 98-R027) are available from the AHCPR Publications Clearinghouse.

The findings from these three studies point to exciting developments in the use of quality measures, as well as the need for new and improved measures. If we are to improve health care quality, we first must be able to measure it accurately. A formidable barrier to the advancement of quality improvement is the development of measures that are generalizable, comparable, and easy to administer. The potential benefits to be gained from the use of such measures include better outcomes, improved patient care, reduced development of comorbidities, increased patient satisfaction, and lower costs.

Editor's note: Pressure ulcer guideline materials are available from the AHCPR Publications Clearinghouse, as follows:

Order from the U.S. Government Printing Office:

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Minority Health

Spanish-speaking Latinos report better health outcomes when their doctors also speak Spanish

For Spanish-speaking Latinos, having a doctor who speaks their language is good for their health, concludes a study supported in part by the Agency for Health Care Policy and Research (HS07373). While this may seem obvious, studies have not examined the impact of same-language communication on a patient's health.

Discussions about complex medical issues require an advanced level of language ability that most non-native Spanish speakers have not achieved, according to Eliseo J. Perez-Stable, M.D., the study's lead author. The researchers suggest that increasing the number of Latino health-care professionals in training and incorporating Spanish language classes where appropriate in the medical school curriculum could boost physician patient communication and health among Latinos. The study was carried out by a team of researchers from the MEDTEP Minority Research Center based at the University of California, San Francisco.

The investigators administered a health status questionnaire to a random sample of Latino and non-Latino men and women from a university-based clinic who had been diagnosed with hypertension or diabetes. They also reviewed patients' medical records for adherence to medications, use of health services, clinical health measures, and patient-physician language concordance. Among the 73 patients who responded to the questionnaire in Spanish, 60 percent were followed by clinicians who spoke Spanish, and 40 percent were followed by non-Spanish-speaking clinicians. Physician-patient language concordance was significantly associated with better functioning on three overall health status scales and six subscales.

Compared with non-Latino whites, Latinos reported a healthier view of their future on the health outlook subscale, felt less distressed about their health, and recounted fewer days where pain interfered with daily activities. Non-Latino whites tended to use more clinical services than Latinos, but only the number of visits to specialty clinics reached statistical significance. There were no significant differences by ethnicity in the number of primary care office visits, emergency room visits, hospitalizations, days hospitalized, diagnostic tests ordered, or unkept scheduled appointments in the preceding year. A similar proportion of Latinos and non-Latino whites did not take prescribed medications as directed (35 percent vs. 36 percent).

See "The effects of ethnicity and language on medical outcomes of patients with hypertension or diabetes," by Dr. Perez-Stable, Anna Napoles-Springer, M.P.H., and Jose M. Miramontes, M.D., in Medical Care 35(12), pp. 1212-1219, 1997.

Poor black and white patients use different reference points in evaluating their health status

Simply asking low-income black and white people to rate their health as excellent, very good, good, fair, or poor may not provide a very accurate picture of how they view their health. In fact, a new study suggests that blacks and whites use a different frame of reference when rating their health. For whites, general health and physical functioning determine how they assess their health. For blacks, bodily pain plays an important role in addition to general health. Assessment of how patients view their health will be more accurate and informative if they take into account patient demographics, as well as definitions of health and health expectations, according to a recent study that was supported in part by the Agency for Health Care Policy and Research.

The researchers conducted face-to-face interviews with 276 hospitalized patients (170 black and 106 white) within 24 hours of discharge and telephone interviews with 546 randomly selected nonhospitalized blacks and whites enrolled in a State-managed health care plan in the same urban area. Patients responded to a questionnaire with 36 items (SF-36) on health status and function, as well as two additional questions on health perceptions.

The goal was to assess patients' perceptions of their health at their current stage of recovery (newly discharged patients), whether it was better or worse than expected, how it compared with their health a year ago, and perceptions of their overall health.

Black patients tended to see their health more positively than did white patients, which is contrary to previous studies of black and white health perceptions. Blacks also tended to see their health as better than the previous year. However, after adjustment for insurance status, age, and education, the differences between blacks and whites were insignificant. For both samples, hospitalized and nonhospitalized, the most important predictors of white patients' ratings of overall health were general health functioning and physical functioning; for black patients, general health functioning and bodily pain were most important. Blacks may use health problems as a reference point and whites may use level of physical functioning as a reference point, note the researchers.

Details are in "Black-white differences in health perceptions among the indigent," by Celia O. Larson, Ph.D., Michael Colangelo, M.B.A., and Kimberly Goods, M.S.P.H., in the January 1998 Journal of Ambulatory Care Management 21(2), pp. 35-43.

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Dental Research

Researchers focus attention on children's dental health

The quality of scientific evidence underpinning routinely performed clinical dental services and self-care advice for children is considered to be only fair and perhaps insufficient by prevailing standards. Yet childhood dental problems can have significant long-term effects on adult oral health status.

In a recent commentary, James J. Crall D.D.S., Sc.D., encourages dental health services researchers and dental schools to become involved in developing a child health research agenda to give oral health the priority it deserves. A second article, also summarized here, describes an Agency for Health Care Policy and Research-funded study that demonstrated dentists' low use of molar sealants in Medicaid-insured children.

Crall, J.J. (1997, October)."Oral health component of child health services research." Journal of Dental Education 61(10), pp. 776-780.

The failure to more fully integrate dental education and dental care with other elements of health care has contributed to less than optimal integration and coordination of services for some patients and, in many cases, has narrowed the focus of professional dental education. Developing a child health research agenda is essential to advancing dental care and professional education and is relevant to educators as well as researchers and policymakers, according to James J. Crall, D.D.S., Sc.D., AHCPR's Dental Scholar-in-Residence.

As Dr. Crall notes, oral health considerations are not likely to have high visibility or priority within that agenda unless dental health services researchers and dental schools become involved. Some may think that it does not make sense to direct a portion of the already scarce resources available for dental health services research to children's issues. However, with an appropriate strategy, a small number of organized individuals and institutions can make a significant difference, concludes Dr. Crall.

Reprints (AHCPR Publication No. 98-R017) are available from the AHCPR Publications Clearinghouse.

Robison, V.A., Rozier, R.G., Weintraub, J.A., and Koch, G.G. (1997, December). "The relationship between clinical tooth status and receipt of sealants among child Medicaid recipients." (AHCPR grants HS06993 and HS00032). Journal of Dental Research 76(12), pp. 1862-1868.

Only a small number of dentists routinely provide Medicaid-insured children with sealants to help prevent cavities in premolars and molars. This decision appears to be based on age and need for sealants, finds this study. It also shows that the few Medicaid-insured children who did receive sealants tended to be white, younger, and have more frequent dental visits and fewer previous cavities. Children who did not receive sealants had twice the odds of having indicators for risk of future caries than children who did receive sealants. Also, children with past caries experience were not likely to get sealant care.

Children 6 to 11 years of age who needed sealants tended not to receive them, while children aged 12 to 15 who did not need sealants tended to receive them. This may indicate that older children who had no sealant need at the time of the survey and who had "survived" without caries until ages 12 to 15 were at lower caries risk, and thus they were viewed by dentists to be good sealant candidates, suggest the researchers. They analyzed the association between caries status and sealant need documented in a 1986-1987 State-wide school oral health survey in North Carolina with subsequent sealant use confirmed by Medicaid dental claims submitted during 1987 to 1992.

The authors suggest that certain features of the State Medicaid program could have influenced dentists' below average sealant use among this group of low-income children. The State required prior approval for sealant application. Also, sealants were and still are available to Medicaid-eligible children as a once-in-a-lifetime-benefit. But lack of maintenance and sealer reapplication will diminish their long-term effectiveness.

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