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AHCPR announces availability of new software for use in assessing and improving health care quality

A new software tool, the Healthcare Cost and Utilization Project (HCUP) quality indicators (QIs), is now available free from the Agency for Health Care Policy and Research. The HCUP QIs aid routine self-assessments of inpatient care and/or evaluations of community access to primary care. Designed for use with already available administrative data, HCUP QIs save users the time and expense involved in collecting patient data. The tool is user-friendly and comes with easy-to-follow instructions that do away with the need for specially trained experts in clinical data and statistics. The HCUP QIs can be run on either microcomputers or mainframes, using SAS or SPSS programs.

The HCUP QIs contain 33 clinical performance measures that cover three dimensions of care:

  • Potentially avoidable adverse hospital outcomes; 16 mortality and complication rates can be calculated for common elective procedures—such as hip replacements—that typically are associated with a low risk of adverse outcomes.
  • Appropriateness of inpatient procedures; nine utilization rates can be calculated for which there are concerns about over- or underutilization, such as cesarean section deliveries.
  • Potentially avoidable hospital admissions; HCUP QI users can indirectly track access to primary care for eight conditions thought to be largely preventable with adequate access to primary care, such as influenza among the elderly.

This new tool will enable users to screen patient care data and highlight clinical areas appropriate for more in-depth, definitive study. HCUP QIs are not designed to identify hospitals as or "bad" performers. They are intended to help health care providers "good" and community partnerships that want to build a quality and access assessment program from the ground up at little cost.

The HCUP QIs have been field tested widely by individual hospitals, hospital associations, State health departments, statewide data associations, and other organizations. This tool was developed by AHCPR researchers in partnership with several State hospital associations and State agencies and with the help of leading data and quality experts. The developers used information from AHCPR's HCUP project, a unique multi-State inpatient care database, in creating the HCUP QIs.

The HCUP QI kit, Outcome, Utilization, and Access Measures for Quality Improvement, comes with two diskettes, a software user's guide, technical methods manual, fact sheet, and an article reprint, "Quality indicators using hospital discharge data: State and national applications," that was published in the February 1998 Joint Commission Journal on Quality Improvement. The kit (AHCPR Publication No. 98-0048) is available from the AHCPR Publications Clearinghouse.

For more detailed information, select to access the HCUP QI Fact Sheet. To download the QI software, select the HCUP QI. The article reprint is not available online, but you may request it from the AHCPR Publications Clearinghouse (AHCPR Publication No. 98-R041).

AHCPR publishes PORT final report on ischemic heart disease

The following grant final report is now available from the Agency for Health Care Policy and Research and the National Technical Information Service (NTIS).

Outcome Assessment Program for Ischemic Heart Disease: Final Report of the Patient Outcomes Research Team. Elizabeth DeLong, Ph.D., Clinical Research Institute, Durham, NC; and David B. Pryor, M.D., Allina Managed Care, Minneapolis, MN. AHCPR grant HS06503, project period July 1990 to December 1995.

Coronary artery disease (CAD) remains the primary cause of death and major morbidity in the United States. Significant clinical manifestations of CAD are seen in one of every three men and one of every ten women by age 60. The AHCPR-supported Ischemic Heart Disease Patient Outcomes Research Team (IHD PORT), led by Elizabeth R. DeLong, Ph.D., and David B. Pryor, M.D., identified sources of variation in diagnostic and treatment strategies for chronic ischemic heart disease, with the twin goals of improving patient outcomes and making optimal use of health care resources. Alternative procedures studied included cardiac catheterization and revascularization with either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG) surgery. Analysis of patient outcomes and preferences regarding potential outcomes helped to define appropriate indications for these procedures. The researchers also devised new approaches and methods for outcome assessment, including integration of detailed clinical and claims databases. Patient-specific feedback and educational programs for physicians were employed to demonstrate the feasibility of bringing about voluntary change in physicians' practice patterns.

A limited number of free copies of Ischemic Heart Disease: Patient Outcomes Research Team Final Report are available from the AHCPR Publications Clearinghouse (AHCPR Publication No. 98-N003).

When free copies are exhausted, the report may be purchased from the National Technical Information Service (NTIS accession no. PB98-156557; 74 pp, $29.50 paper, $12.00 microfiche).

AHCPR announces new U.S. Preventive Services Task Force

Agency for Health Care Policy and Research Administrator John M. Eisenberg, M.D., has announced the appointment of Alfred O. Berg, M.D., M.P.H., as chair of the reconvened U.S. Preventive Services Task Force (USPSTF). Fourteen other Task Force members also have been appointed, representing the fields of behavioral medicine, family medicine, geriatrics, internal medicine, nursing, obstetrics and gynecology, pediatrics, and preventive medicine.

The USPSTF, an independent panel of preventive health experts, was first convened in 1984 by the U.S. Public Health Service. Its charge is to evaluate the scientific evidence for the effectiveness of a range of clinical preventive services (screening, immunizations, and counseling for health behavior change) and to produce age-specific and risk factor-specific recommendations for these services.

Recommendations of the Task Force were first issued in 1989 in the Guide to Clinical Preventive Services. Revised recommendations developed by a reconvened panel were published in 1996 in a second edition of the Guide. The Task Force has increased awareness among health care providers and patients that prevention is an integral part of primary health care. According to Dr. Eisenberg, the reconvened Task Force will play a critical role in ensuring that clinicians have up-to-date information—based on new research and technological advances—on preventive services proven to work in primary care settings.

To speed implementation of new and updated USPSTF recommendations, individual reports and recommendations will be released as they are completed. It is anticipated that the third full edition of the Guide will be ready for release in late 2002.

Dr. Berg is Professor and Acting Chair, Department of Family Medicine, at the University of Washington, Seattle. He is an experienced family physician and methodologist and a national leader within the American Academy of Family Physicians and Society of Teachers of Family Medicine.

Dr. Berg's many professional achievements include membership in the Institute of Medicine of the National Academy of Sciences, service on the USPSTF from 1990 to 1995, co-chairmanship of the AHCPR-sponsored Otitis Media Guideline Panel from 1991 to 1995, and participation as chair and moderator for the 1993 Sexually Transmitted Diseases Treatment Guideline Panel, Centers for Disease Control and Prevention.

The panel members, listed by specialty, are:

Family Medicine

  • Paul Frame, M.D., Tri-County Family Medicine, Cohocton, NY, and Clinical Associate Professor of Family Medicine, University of Rochester, Rochester, NY.
  • Steven H. Woolf, M.D., M.P.H., Professor of Family Medicine, Department of Family Practice, Medical College of Virginia- Virginia Commonwealth University, Fairfax, VA.

Internal Medicine

  • Cynthia D. Mulrow, M.D., M.Sc., Professor of Medicine, University of Texas Health Science Center and Audie Murphy VA Hospital, San Antonio, TX.
  • Harold C. Sox, Jr., M.D., Professor and Chair, Department of Medicine, Dartmouth Medical School, Lebanon, NH.

Nursing

  • Janet D. Allan, Ph.D., R.N., C.S., F.A.A.N., Dean, School of Nursing, University of Texas Health Science Center, San Antonio, TX.
  • Nola J. Pender, Ph.D., R.N., F.A.A.N., Associate Dean for Academic Affairs and Research, School of Nursing, University of Michigan, Ann Arbor, MI.

Obstetrics and Gynecology

  • Jeffrey F. Peipert, M.D., M.P.H., Associate Professor of Obstetrics and Gynecology, and Community Health, and Director of Clinical Research, Brown University School of Medicine, Providence, RI.
  • Carolyn Westhoff, M.D., M.Sc., Associate Professor, Obstetrics and Gynecology, and Public Health, Columbia University, New York, NY.

Pediatrics

  • Charles J. Homer, M.D., M.P.H., Assistant Professor of Pediatrics, Harvard Medical School, Boston, MA.
  • Tracy A. Lieu, M.D., M.P.H., Physician Investigator, Division of Research, The Permanente Medical Group, Oakland, CA.
  • Modena E. Wilson , M.D., M.P.H., Professor of Pediatrics and Director, Division of General Pediatrics, Johns Hopkins University, Baltimore, MD.

Geriatrics

  • Risa Lavizzo-Mourey, M.D., M.B.A., Sylvan Eisman Professor of Medicine and Health Care Systems, and Director, Institute on Aging, University of Pennsylvania, Philadelphia, PA.

Preventive Medicine

  • Steven M. Teutsch, M.D., M.P.H., Senior Research Scientist, Merck & Co., Inc., West Point, PA.

Behavioral Medicine

  • Carole Tracy Orleans, Ph.D., Research and Evaluation Division, Robert Wood Johnson Foundation, Princeton, NJ.

For more information on the U.S. Preventive Services Task Force, contact Barbara Gordon, assistant to David Atkins, M.D., M.P.H., Coordinator for Clinical Preventive Services, Center for Practice and Technology Assessment, at (301) 427-1636. Select to access the full report of the Guide to Clinical Preventive Services, 2nd Edition. Printed copies of the Guide may be purchased for $20 from the AHCPR Publications Clearinghouse.

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New projects funded

The following small project grants and National Research Service Award (NRSA) training grant were awarded recently by the Agency for Health Care Policy and Research. Readers are reminded that the results of studies usually are not available until a project is completed or nearing completion.

Research Grants

Assessing the variability in time to treatment in surgery
Project director: Mark R. Chassin, M.D.
Organization: Mount Sinai School of Medicine
New York, NY
Project number:AHCPR grant HS09698
Period: 9/30/98 to 9/29/02
First year funding: $423,950

Outcomes of instability on discharge in urban hospitals
Project director: Ethan A. Halm, M.D.
Organization: Mount Sinai School of Medicine
New York, NY
Project number: AHCPR grant HS09973
Period: 9/30/98 to 9/29/01
First year funding: $250,952

Rapid MR vs. x-ray: Randomized outcome trial for back pain
Project director: Jeffrey G. Jarvik, M.D.
Organization: University of Washington
Seattle, WA
Project number: AHCPR grant HS09499
Period: 9/30/98 to 12/31/01
First year funding: $459,867

Small Project Grants

Medical innovation and changes in practice patterns
Project director: Michael Chernew, Ph.D.
Organization: University of Michigan
Ann Arbor, MI
Project number: AHCPR grant HS09838
Period: 8/1/98 to 7/31/99
Funding: $76,178

Racial differences in medical care satisfaction
Project director: Jennifer Malat, M.A.
Organization: University of Michigan
Ann Arbor, MI
Project number: AHCPR grant HS09894
Period: 8/1/98 to 12/31/99
Funding: $29,482

Taking account of diabetes-related productivity
Project director: Jill Lavigne, M.S.
Organization: University of Rochester
Rochester, NY
Project number: AHCPR grant HS09891
Period: 8/1/98 to 5/31/99
Funding: $31,495

Value of independence in assisted living facilities
Project director: Paula C. Carder, B.S.
Organization: Portland State University
Portland, OR
Project number: AHCPR grant HS09886
Period: 9/1/98 to 4/30/99
Funding: $32,398

Conference Grant

Improving health outcomes in diverse populations
Project director: Barbara Tilley, Ph.D.
Organization: Henry Ford Health System
Detroit, MI
Project number: AHCPR grant HS09824
Period: 9/1/98 to 2/28/99
Funding: $38,500

National Research Service Award

Health services research training program
Project director: Harold S. Luft, Ph.D.
Organization: University of California
San Francisco, CA
Project number: NRSA training grant T32 HS00086
Period: 7/1/98 to 6/30/03
First year funding: $255,581

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Research Briefs

Arnett, R. (1998). "Health services data sources in the U.S." In Armitage, P., and Colton, T. (Editors), Encyclopedia of Biostatistics, Volume 3; New York: John Wiley & Sons, pp. 1869-1877.

This book chapter, authored by Ross Arnett, Director of AHCPR's Center for Cost and Financing Studies, briefly describes health services data systems in the United States. These include federally sponsored health care surveys and other related data systems, such as inventories of health care providers. These data systems have served as the primary data sources to assess the Nation's overall level of health and health care needs and to help identify deficiencies in the health care delivery system. Reprints (AHCPR Publication No. 98-R072) are available from the AHCPR Publications Clearinghouse.

Cohen, S.B. (1998). "Small area estimation." In Armitage, P., and Colton, T. (Editors), Encyclopedia of Biostatistics, Volume 5; New York: John Wiley & Sons, pp. 4128-4131.

This chapter, by AHCPR senior researcher Steven B. Cohen, Ph.D., provides a review of alternative small area estimation techniques currently being implemented. Small area estimation can be defined as the application of model-based or indirect estimators that use data from surveys primarily designed to produce estimates of criterion measures at the national or regional level and to derive comparable estimates at more geographically disaggregated levels such as counties or other small areas. These techniques are typically characterized by prediction models or indirect estimators that make use of available survey data at the national or regional level, data on population characteristics at the State or local level, and available predictor data at the local level that are related to the criterion measure of interest. Reprints (AHCPR Publication No. 98-R073) are available from the AHCPR Publications Clearinghouse.

Cook, D.J., Levy, M.M., and Heyland, D.K. (1998). "How to use a review article: Prophylactic endoscopic sclerotherapy for esophageal varices." (NRSA fellowship F32 HS00106). Critical Care Medicine 26(4), pp. 692-700.

This paper explains the value of review articles and how to use them, using a case of a clinician trying to determine the effect of prophylactic sclerotherapy on mortality in patients with esophageal varices. The authors point out that rigorous reviews of particular medical areas are needed because of the rapid rate at which medical research findings are generated; the reality that single studies rarely provide definitive answers to clinical questions; and the fact that clinicians have very limited time to search, retrieve, and synthesize primary studies. They suggest a specific approach to using review articles. The authors note that inferences will be stronger if meta-analyses summarize a large number of similarly designed, methodologically rigorous trials with current concomitant treatment; if there are a substantial number of clinically important outcomes; and if the results are statistically homogeneous.

Feinglass, J., Yarnold, P.R., McCarthy, W.J., and Martin, G.J. (1998). "A classification tree analysis of selection for discretionary treatment." (AHCPR grant HS07184). Medical Care 36(5), pp. 740-747.

To study treatment bias in observational outcomes research, these authors used a classification tree analysis (CTA) model of clinical and psychosocial factors influencing selection of treatment (lower extremity bypass surgery or angioplasty) for patients with intermittent claudication. The study sample included 532 patients with mild to moderate lower extremity vascular disease without prior peripheral revascularization procedures or symptoms of disease progression. Results showed that 13 percent of the patients underwent interventional procedures within 6 months. Ten patient attributes were used in the CTA model, which had an overall treatment selection accuracy of 89.5 percent, achieving 58 percent of the theoretical possible improvement in selection accuracy beyond chance. The CTA model confirmed that lower extremity blood flow, leg symptom severity, impaired walking ability, poor physical and social functioning, and employment are important determinants of selection for lower extremity bypass or angioplasty.

Joffe, M.M., Hoover, D.R., Jacobson, D.R., and others (1998). "Estimating the effect of zidovudine on Kaposi's sarcoma from observational data using a rank preserving structural failure-time model." (Cooperative AHCPR and NCI grant). Statistics in Medicine 17, pp. 1073-1102.

Observational studies are sometimes useful in evaluating the effects of treatment on an intended outcome, conclude these researchers. They used observational data from the Multicenter AIDS Cohort Study of gay and bisexual men in the United States to determine whether zidovudine prevents the development of Kaposi's sarcoma among gay men infected with the human immunodeficiency virus. Such use of observational data is controversial. One reason is that physicians and patients often use intermediate predictors of the outcome to make treatment decisions, creating strong confounding factors that may be difficult to control. In fact, these researchers did encounter problems typical of observational studies—for example, missed information on important confounders for some study subjects at some points during their followup. Also, for many subjects, it was unclear whether treatment preceded disease or vice versa. Nevertheless, the authors show that with some modifications, structural nested failure-time models and G-estimation provide an appropriate and practical framework for dealing with these issues.

Levey, A.S., Schmid, C.H., and Lau, J. (1998, May). "Antilymphocyte antibodies, renal transplantation, and meta-analysis." (AHCPR Grants HS07782, HS08532) Annals of Internal Medicine 128(10), pp. 863-865.

This editorial discusses two meta-analyses of randomized trials of the efficacy of induction therapy in patients undergoing kidney transplantation. Induction therapy is defined as the use of antilymphocyte antibodies immediately after transplantation to prevent acute rejection of a transplanted kidney. One meta-analysis used aggregate, summary data from published reports of the clinical trials, and the other meta-analysis used the primary data from individual patients. Meta-analysis of individual patient data offers several advantages over meta-analysis of aggregate data, including additional followup, especially of hard endpoints that may not have been reported earlier; estimates of survival curves rather than estimates at a single time point, allowing a check on the constancy of treatment effects over time; and regression analysis to check for differences in treatment effects across subgroups of individuals. Unfortunately, because it is so costly compared with meta-analysis of aggregate data, individual patient data analyses are infrequent. An alternative being investigated by the authors (with AHCPR support) is the use of meta-regression in which an aggregate measure of treatment effect (such as an odds ratio) in each study is related to an aggregate measure of risk in the study. The meta-analysis of aggregate data at 2 years of followup found a significant benefit of induction therapy, but it could not assess whether the benefit extended beyond 2 years or differed across subgroups of patients. The meta-analysis of the individual patient data (supplemented by updated followup information obtained during the meta-analysis) was able to discover that the initial benefit in the first 2 years was lost between years 2 and 5 of followup, and that greater benefit was found in presensitized patients (those who had antilymphocyte antibodies to more than 20 percent of a panel of blood donors).

Ren, X.S., and Chang, K. (1998). "Evaluating health status of elderly Chinese in Boston." (AHCPR grant HS09352). Journal of Clinical Epidemiology 51(5), pp. 429-435.

Demand is growing for measurement tools to assess health- related quality of life among the Chinese elderly population in the United States. Based on conventional mortality statistics, the public mistakenly views Chinese Americans as a "model" minority population with a low occurrence of health problems. This general perception has masked the serious health problems among elderly Chinese Americans, ranging from a higher incidence of liver and nasopharyngeal cancers to an elevated risk for heart disease, hypertension, and mental illness. Health services questionnaires, developed largely in English, often underrepresent Chinese Americans. These researchers used the newly developed Chinese version of the SF-36 health status questionnaire to explore how elderly Chinese perceive their own health. Based on 219 elderly Chinese recruited in Boston, the study found mixed results with regard to this perception. Although those interviewed perceived similar or better physical health compared with the norm for other U.S. populations, they reported worse mental health. Yet elderly Chinese are less likely to use mental health services due to the stigmatization of mental problems and their fear of disgracing the family.

Safran, D.G., Kosinski, M., Tarlov, A.R., and others (1998). "The primary care assessment survey: Tests of data quality and measurement performance." (AHCPR grant HS08841). Medical Care 36(5), pp. 728-739.

These authors examine the data quality and measurement performance of the Primary Care Assessment Survey (PCAS), a patient-completed questionnaire that uses formal definitions of primary care, which was administered to Massachusetts State employees. The PCAS measures seven domains of care through 11 summary scales: accessibility (organizational and financial), continuity (longitudinal, visit-based), comprehensiveness (contextual knowledge of patient, preventive counseling), integration, clinical interaction (clinician-patient communication, thoroughness of physical examinations), interpersonal treatment, and trust. Results showed that these scales demonstrated consistently strong measurement characteristics across all subgroups of this adult population. The authors conclude that widespread application of an assessment methodology, such as the PCAS, will afford an empiric basis through which to measure, monitor, and continuously improve primary care.

Wolinsky, F.D., Wyrich, K.W., Nienaber, N.A., and Tierney, W.M. (1998, June). "Generic versus disease-specific health status measures." (AHCPR grant HS07632). Evaluation & the Health Professions 21(2), pp. 216-243.

A major concern with generic health status measures is their inability to discriminate within disease groups and their lack of sensitivity to change over time. Although disease-specific measures are more relevant to patients and provide better discrimination and higher content validity, they limit the ability to compare across disease groups and are generally less comprehensive in covering multiple dimensions of health status. This study evaluated and compared the generic health status measure, the Medical Outcomes Study SF-36, and a disease-specific health status measure, a modified version of the Chronic Heart Failure Questionnaire (CHQ), among 670 outpatients known to have coronary artery disease (CAD) and/or congestive heart failure (CHF). The SF-36 was more comprehensive in its coverage of different health status domains. However, the CHQ had fewer problems with floor and ceiling effects, was more internally consistent, had better dimensional reproducibility, and exhibited less factorial complexity. The authors conclude that although both instruments are appropriate for patients with CAD and/or CHF, the CHQ has significantly better psychometric properties.

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