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Deyo, R.A. (1998). "Using outcomes to improve quality of research and quality of care." (AHCPR grant HS08194). Journal of the American Board of Family Practice 11(6), pp. 465-473.
This article by the leader of the Back Pain Patient Outcomes Research Team points out that outcomes research focuses on the end results of patient care in terms of symptoms, disability, and survival rather than physiology, laboratory results, or imaging. Effectiveness in routine care is a function of efficacy but also of diagnostic accuracy, physician skill in applying a treatment, patient compliance, and perhaps other factors that are artificially optimized in the clinical trial setting. Dr. Deyo uses the case of treating low back pain to discuss how a physician might evaluate whether following guidelines on a particular condition actually improved patient outcomes such as quality of life and mortality. He points out that in the case of back pain symptoms, function and quality of life can be quantified in a meaningful way, and that a great variety of well-validated instruments are available for use. However, their adoption and widespread use in routine care settings for outcomes management will require far better data systems and more resources than are currently available.
Paradise, J.L. (1998). "Otitis media and child development: Should we worry?" (Joint NICHD-AHCPR grant HD26026). Pediatric Infectious Disease Journal 17(11), pp. 1076-1083.
Whether chronic early childhood middle ear infections (otitis media) cause impaired speech, language, cognition, and psychosocial development later in life remains unresolved. At issue in particular is the common practice of subjecting infants and young children with persistent otitis media with effusion (OME) to tympanostomy tube placement specifically to reduce the risk of developmental impairment. Currently, children younger than age 3 years undergo an estimated 313,000 such placement operations per year. This article describes a prospective study designed to address questions about the adverse effects of OME, whether they are permanent or transient, and whether they are preventable by timely tube placement. The study will enroll a large sample of normal infants before 2 months of age and identify those in whom OME persists during the first 3 years of life. The researchers will randomly assign those children with persistent OME to either prompt tube placement or to delayed tube placement and administer a battery of standardized developmental tests to those children and to a sample of others at ages 3, 4, and 6 years.
Porell, F., and Caro, F.G. (1998). "Facility-level outcome performance measures for nursing homes." (AHCPR grant HS07587). The Gerontologist 38(6), pp. 665-683.
Nursing home facility performance measures are not highly associated with various structural facility attributes, concludes this study. The researchers measured facility performance by comparing actual resident outcomes with expected outcomes (for instance, survival rate, functional status, pressure ulcers, and restraint use) derived from quarterly predictions or resident-level econometric models over a 3-year period (1991-1994). The intercorrelations among the nine outcome performance measures were relatively low and not uniformly positive. Performance measures were not highly associated with various structural facility attributes. Relatively few facilities exhibited consistent superior or inferior performance over time. Overall, the correlations suggest that there are few nursing homes with uniformly much better or much worse than expected performance on the patient outcomes measured.
Randolph, A.G., Guyatt, G.H., and Calvin, J.E. (1998). "Understanding articles describing clinical prediction tools." (NRSA fellowship F32 HS00106). Critical Care Medicine 26(9), pp. 1603-1612.
The authors of this paper want to teach clinicians how to evaluate the validity, results, and applicability of articles describing clinical prediction tools. They use as an example an article describing a rule to predict the need for intensive care unit admission in patients arriving at the emergency room with chest pain. To properly evaluate results of the article, clinicians need to know what the prediction tool is, how well it categorizes patients into different levels of risk, and what the confidence intervals are around the risk estimates. Also, valid prediction tools are not applicable in every patient population. Before using the tool in patient care, clinicians should ensure that the tool maintains its prediction power in a new sample of patients, that the patients are similar to patients used to test the tool, and that the tool has been shown to improve clinical decisionmaking.
Raube, K., Handler, A., and Rosenberg, D. (1998). "Measuring satisfaction among low-income women: A prenatal questionnaire." (AHCPR grant HS08115). Maternal and Child Health Journal 2(1), pp. 25-33.
One measure of quality of care is how satisfied patients are with the care they receive. These researchers evaluated the reliability and construct validity of a prenatal care satisfaction scale. They tested the 22-item questionnaire, which included 6 dimensions of care, during telephone interviews with 101 Medicaid-insured, black and Hispanic first-time mothers 18 years of age and older. The dimensions of care satisfaction included the art of care, technical quality, access, physical environment, availability, and efficacy. The scale showed high reliability, as well as good construct validity.
Ren, X.S., and Amick III, B.C. (1998). "Cross-cultural use of measurements." (AHCPR grant HS09352). In Handbook of Immigrant Health, Loue, S., editor. New York: Plenum Publishing, pp. 81-99.
Most health status measures have been developed in English. Few studies have gathered systematic information on functioning and well-being among immigrant populations in the United States. In this book chapter, the authors address conceptual and methodological issues related to cross-cultural development and validation of health status instruments—that is, how best to design socially and culturally appropriate health status measurement instruments for different groups. To illustrate these issues, they discuss the development of a Chinese version of the Medical Outcome Study, 36-item Short-Form Health Survey.
Safran, D.G., Taira, D.A., Rogers, W.H., and others (1998). "Linking primary care performance to outcomes of care." (AHCPR grant HS08841). Journal of Family Practice 47(3), pp. 213-220.
The authors of this study examined the relationship between seven elements of primary care (accessibility, continuity, comprehensiveness, integration, clinical interaction, interpersonal treatment, and trust) and three outcomes (adherence to physician's advice, patient satisfaction, and improved health status). They used data derived from an observational study of 7,204 Massachusetts State employees who completed a questionnaire on doctor-patient relationships and care satisfaction. With other factors equal, patients who greatly trusted their primary care doctors and whose doctors knew them well were nearly three times more apt to follow their doctor's advice than those with very low levels of knowledge and trust (44 percent vs. 17 percent adherence). The likelihood of complete care satisfaction was five times greater among patients with high versus median levels of trust in their doctors (88 percent vs. 18 percent). The leading correlates of self-reported health improvements were integration of care, thoroughness of physical examination, communication, the doctor's knowledge of the patient, and trust.
Sterling, T.R., Moore, R.D., Graham, N.M., and others (1998). "Mycobacterium tuberculosis infection and disease are not associated with protection against subsequent disseminated M. avium complex disease." (AHCPR grant HS07809). AIDS 12, pp. 1451- 1457.
A history of tuberculosis (TB) infection or disease is not associated with protection against subsequent disseminated M. avium complex (MAC) disease in HIV-infected people. However, individuals with extrapulmonary TB are at increased risk for disseminated MAC, particularly at low CD4 cell levels, concludes this study. The researchers followed HIV-infected adults with CD4 lymphocyte counts below 100 between 1989 and 1996. They determined the relative risk of disseminated MAC based on history of prior opportunistic infection, MAC prophylaxis, and other factors. Among the 30 patients with active TB, 8 developed disseminated MAC, compared with 208 cases of disseminated MAC among 1,148 patients without prior TB infection or disease. Among the 10 patients with extrapulmonary TB, 5 developed disseminated MAC.
Wells, K.B. (1999, January). "The design of partners in care: Evaluating the cost-effectiveness of improving care for depression in primary care." (AHCPR grant HS08349). Social Psychiatry and Psychiatric Epidemiology 34(1), pp. 20-29.
This paper describes the design and implementation of Partners in Care, a study designed to examine cost-effectiveness of treatments for a range of depressive disorders in primary care settings for Mexican Americans and non-Hispanic whites. The researchers selected seven diverse managed care organizations and randomized their clinics to one of three interventions: basic quality improvement plus enhanced medication management (QI-MEDS), QI plus enhanced psychotherapy (QI-THERAPY), and usual care (UC). The goal was to increase the percentage of depressed patients who begin and adhere to appropriate treatment within a feasible practice budget. QI teams received 2 days of training in assessing and treating depression, educating primary care clinicians, and conducting quality assurance meetings. They enrolled 1,356 patients and then educated patients and physicians.
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AHCPR Publication No. 99-0026
Current as of March 1999