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Other Clinical Areas

Resident Physicians' Practice Style and Patient Outcomes
Grant/Contract Number: HS06167
Project Period: 03/90-08/94
Principal Investigator: Klea D. Bertakis, M.D., M.P.H.
Institution: University of California
Sacramento, CA 95817
Purpose: To evaluate the differences in practice styles between internists and family practitioners and to compare the results of care provided by these specialties for a randomized panel of patients over a 1 year period. Changes in health status, patient satisfaction, and costs were also measured. The study utilized randomization, specific outcome criteria, direct observation, and retrospective chart reviews.

Ethnicity and Attitudes Toward Advance Care Directives
Grant/Contract Number: HS07001
Project Period: 03/93-02/95
Principal Investigator: Leslie J. Blackhall, M.D.
Institution: University of Southern California
Los Angeles, CA 90033-4526
Purpose: To obtain information that would help in designing and implementing better methods of obtaining advance care directives in ethnically diverse populations. The study tested the hypotheses that (1) ethnicity may affect attitudes toward advance care directives and (2) the effect of ethnicity on attitudes is mediated by demographic factors, cultural norms, and beliefs about the health care system. The study provided a better understanding of the social and cultural differences necessary to increase participation in decisions on serious illness in multiethnic populations. Attitudes were measured by using a questionnaire and conducting interviews.

Surgical Blood Transfusion: Variation and Outcome
Grant/Contract Number: HS07322
Project Period: 04/93-05/96
Principal Investigator: Jeffrey L. Carson, M.D.
Institution: UMDNJ-Robert Wood Johnson Medical School
New Brunswick, NJ 08903-0019
Purpose: To perform a multicenter retrospective study to (1) describe the independent risk factors for perioperative transfusions in patients with hip fracture, using analysis to determine whether the decision to transfuse is driven primarily by patient- and procedure-related variables or is significantly influenced by institutional practice styles independent of patient and procedure characteristics; and (2) describe the effect of transfusions on the operative death rate in patients with hip fracture by comparison with similar patients not receiving transfusions.

Computer Assisted Guidelines for Admission Testing
Grant/Contract Number: HS06418
Project Period: 04/91-03/93
Principal Investigator: Randall D. Cebul, M.D.
Institution: MetroHealth Medical Center
Cleveland, OH 44109-1998
Purpose: To compare the direct medical costs associated with three approaches to admission testing (battery testing, testing requested by the admitting physician, and computer based testing that reflects expert opinion); and to compare the effects of these three approaches on diagnostic yield, diagnostic procedure related complications, and readmission rates. Because the results of the randomized controlled trial proved favorable to the computer based expert system, the project provided important evidence and a technology to improve admission testing practices.

Testing the Effectiveness of Advance Medical Directives
Grant/Contract Number: HS08180
Project Period: 03/95-02/00
Principal Investigator: Peter H. Ditto, Ph.D., M.A.
Institution: Kent State University
Kent, OH 44242-0001
Purpose: To (1) use a randomized controlled trial to compare the ability of three different methods of collecting advance directive information to improve the agreement between decisions made by elderly outpatients and their surrogates about the use of life-sustaining treatments, (2) follow patients longitudinally for 2 years to measure the stability of elderly outpatients' decisions about life sustaining treatments over time and across changes in health state, and (3) interview hospitalized study patients and their surrogates to compare treatment preferences and predictions made prior to hospitalization to those made during actual illness episodes.

Medical Care Use and Costs for Adults with Sleep Apnea
Grant/Contract Number: HS08281
Project Period: 07/94-12/96
Principal Investigator: Dennis G. Fryback, Ph.D.
Institution: University of Wisconsin
Madison, WI 53706
Purpose: To compare the patterns of health care utilization and imputed costs among persons with sleep apnea to those of persons without the disorder. The Wisconsin Sleep Cohort Study is analyzing the relationship of medical care utilization and cost to the degree of apnea. Other analyses are investigating observed gender differences in referral for sleep apnea workup.

Effectiveness and Outcomes of Non-Cardiac Surgery
Grant/Contract Number: HS06573
Project Period: 01/91-09/94
Principal Investigator: Lee Goldman, M.D., M.P.H.
Institution: University of California
San Francisco, CA 94143
Purpose: To (1) determine the rate of adverse short term cardiac and non cardiac surgical outcomes among major non-cardiac patients, (2) identify factors that predict these outcomes, (3) identify factors influencing the length of postoperative stay, and (4) assess the long term effectiveness of high volume procedures. Detailed prospective clinical and health status data were gathered during preoperative and postoperative evaluations and during followup interviews.

Assessment of the Variation and Outcomes of Pneumonia (PORT)
Grant/Contract Number: HS06468
Project Period: 09/90-03/96
Principal Investigator: Wishwa N. Kapoor, M.D., M.P.H.
Institution: University of Pittsburgh
Pittsburgh, PA 15213
Purpose: To examine the variation in medical care and outcomes in adults with community acquired pneumonia (CAP). The basic hypotheses are the following: (1) a significant proportion of the variation in hospitalization rates, the use of diagnostic tests, and therapeutic interventions is related to physician practice patterns and not to the clinical condition of the patients; (2) hospitalizations, intensive care unit admissions, diagnostic tests, and therapeutic interventions can be substantially reduced without increasing morbidity or mortality; and (3) such reduction will decrease medical care costs. Components of the research include a comprehensive review and assessment of the literature, an evaluation of the geographic variation in hospitalization rates and medical care, an assessment of patient outcomes using a cohort study, and an analysis of treatment costs.

Clinical Decision Making on Medical Adverse Events
Grant/Contract Number: HS07067
Project Period: 05/91-04/93
Principal Investigator: A. Russell Localio, J.D., M.P.H., M.S.
Institution: Pennsylvania State University
Hershey, PA 17033
Purpose: To examine the extent and nature of physician disagreement regarding medical care that resulted in adverse events. This study addressed the implications of empirical findings for current proposals regarding no fault patient compensation systems. Data were drawn from the Medical Practice Study that examined approximately 31,000 hospitalizations defined as disabling injuries caused at least in part by medical management in New York State in 1984.

The Impact of Litigation Risk on Caesarean Section Rates
Grant/Contract Number: HS07070
Project Period: 09/90-06/91
Principal Investigator: A. Russell Localio, J.D., M.P.H., M.S.
Institution: Pennsylvania State University
Hershey, PA 17033
Purpose: To test the hypothesis that a higher rate of litigation faced by providers of obstetrical care is associated with higher Caesarean section rates, using data collected by the Medical Practice Study Group. The Group collected hospital discharge data for one quarter of the hospitalizations in New York State in 1984, and virtually all malpractice claims data on actions against hospitals and physicians. In addition, it reviewed a sample of 31,000 records from 51 hospitals to obtain information on the incidence of adverse events discovered in hospitals across the State in 1984.

Volume, Outcome, Market Share, and Admission Rates
Grant/Contract Number: HS06216
Project Period: 04/90-03/93
Principal Investigator: Harold S. Luft, Ph.D.
Institution: University of California
San Francisco, CA 94109
Purpose: To examine the relationship between hospital and physician volumes and patient outcomes as well as to assess the influence of hospital outcomes on population based admission rates. The study described the changes in physician service specialization in New York State between 1981 and 1987, and analyzed the impact of these changes on accessibility of services, utilization of services, and patient mortality and readmission rates.

Outcomes of LRI in Nursing Home Residents
Grant/Contract Number: HS08551
Project Period: 09/96-09/99
Principal Investigator: David R. Mehr, M.D.
Institution: University of Missouri
Columbia, MO 65212
Purpose: To develop recommendations for the management of lower respiratory infections (LRI) in nursing home residents. The proposed prospective cohort study seeks to (1) develop and validate an LRI risk index using multivariable logistic regression or Cox Proportional Hazards modeling that distinguishes residents at low- and high-risk for mortality or functional decline; (2) examine the relationship between facility quality-of-life indicators, physician characteristics, and risk for mortality or functional decline; and (3) assess the relative cost of initial management in an acute care hospital versus initial nursing home care, particularly for low-risk residents

Quality Outcomes in Subacute Home Care Programs
Grant/Contract Number: HS09455
Project Period: 09/96-09/99
Principal Investigator: John N. Morris, Ph.D.
Institution: Hebrew Rehabilitation Center for Aged
Boston, MA 02131
Purpose: To create, validate, and set longitudinal benchmark change values for a series of outcome measures for use with rehabilitative-restorative care patients in two critical transitional settings following acute hospitalization nursing-home subacute and home care programs. The specific aims are to operationalize the outcome measures and to test the feasibility and validity of the outcome measures and benchmark standards in a prospective study in selected subacute and home-care based rehabilitation programs.

A Study of the Causes of Variations in Medical Care
Grant/Contract Number: HS06366
Project Period: 03/90-02/94
Principal Investigator: Charles E. Phelps, Ph.D.
Institution: University of Rochester
Rochester, NY 14627
Purpose: To explain variations in medical practice as a function of physician characteristics. The study determined the importance of various sources of information to individual physicians that they might use in recommending or making treatment choices for their patients. To do this, the study first calculated a doctor's propensities to use medical care, such as the propensity to hospitalize and the propensity to refer to specialists; second, the study correlated these propensities with identifiable features of the doctor, such as type and extent of training, location of training, age, and duration in the community.

Dialysis Care: Choices, Outcomes, Costs, and Tradeoffs (PORT II)
Grant/Contract Number: HS08365
Project Period: 07/94-06/99
Principal Investigator: Neil R. Powe, M.D., M.P.H., M.B.A.
Institution: Johns Hopkins University
Baltimore, MD 21205-2223
Purpose: To (1) investigate factors that influence the choice of a particular dialysis prescription; (2) assess patient outcomes and costs of alternative dialysis prescriptions in the United States; and (3) formulate optimal dialysis strategies that take into account the perspectives of patients, providers, and payers. The project includes a study of mortality, morbidity, symptoms, quality of life, patient satisfaction, and costs associated with alternative dialysis prescriptions; a study of patient preferences for alternative prescriptions; and a survey of nephrologists and dialysis facility administrators to ascertain factors affecting the choice of therapy. It also involves a study of the impact of resource utilization in outpatient dialysis on mortality, morbidity, and overall costs for all facilities.

Adequacy of Home Care Plans for Chronically Ill Patients
Grant/Contract Number: HS06406
Project Period: 04/90-06/95
Principal Investigator: Enola K. Proctor, Ph.D.
Institution: Washington University
St. Louis, MO 63130
Purpose: To (1) test the adequacy of community care plans for Medicare beneficiaries discharged from acute to home care; (2) test the impact on care plan adequacy of withdrawal of Medicare reimbursement for home health services; (3) test the relationship between care plan adequacy and patient function during the period of posthospital recovery; (4) test the relationship between care plan adequacy and traditional dispositional criteria, such as readmission; and (5) identify factors associated with adequate care plans. A sample of 200 patients, hospitalized for congestive heart failure, was observed at discharge and during 14 weeks of home care. Data were obtained from professionals, medical records, and patients.

Inappropriateness and Variations in Hospital Use
Grant/Contract Number: HS06048
Project Period: 09/91-03/95
Principal Investigator: Joseph D. Restuccia, Dr.P.H.
Institution: Boston University
Boston, MA 02215
Purpose: To study the relationship between small area variations in Medicare hospitalization rates and rates of inappropriate hospitalization. A sample of Medicare hospital admissions from each area was identified for medical record review based on the proportion of the area's admissions that go to a particular hospital. A modified version of the Appropriateness Evaluation Protocol was then used to screen sample cases for inappropriateness. Multiple regression models were used to analyze how area hospitalization rates are related to inappropriateness both before and after differences in population and supply characteristics are taken into account.

Patient Centered Outcomes Method for Neurologic Disease
Grant/Contract Number: HS08582
Project Period: 09/95-09/98
Principal Investigator: Carolyn E. Schwartz, Sc.D.
Institution: Frontier Science and Technology Research Foundation
Brookline, MA 02146
Purpose: To develop a new patient centered outcomes methodology for chronic neurologic diseases that will eventually be used to develop practice guidelines for cost effective and efficacious preventive treatment. This project will use multiple sclerosis as a model and will apply a utility based approach that integrates patient preferences, neurologic function, and societal cost in its evaluation of treatment trade offs. Several health State models of societal cost will be used to evaluate the cost effectiveness and efficacy of interventions.

Effect of Specialty on Primary Care Practice in an HMO
Grant/Contract Number: HS08269
Project Period: 09/94-12/96
Principal Investigator: Joseph V. Selby, M.D., M.P.H.
Institution: Kaiser FDN Research Institute
Oakland, CA 94612-3433
Purpose: To examine differences in resource utilization and total costs during a 1-year period for patients of three groups of primary care physicians (family practitioners, general internists, and subspecialty internists). The study is being conducted in six health maintenance organization facilities where patients are routinely assigned to two of the three specialties without respect to their illnesses or complaints. The results will inform national policy on primary care.

Birth Outcomes, Satisfaction with Care and Malpractice
Grant/Contract Number: HS06499
Project Period: 09/90-03/94
Principal Investigator: Frank A. Sloan, Ph.D.
Institution: Duke University
Durham, NC 27708
Purpose: To examine the relationship between a physician's (obstetrician's) practice style and his or her malpractice claims experience. The study focused on birth and birth related outcomes in order to explain why some physicians' claims records vary, and used data obtained from interviews, closed claims files, Florida vital statistics, and hospital records. It used models of search behavior and deterrence to analyze precautionary actions of physicians who were at varying risks of being sued. The study provided information on birth outcomes, patient satisfaction, treatment styles, and patients of physicians with adverse claims experience versus other physicians.

Practice Variation and Outcomes in Ambulatory Care
Grant/Contract Number: HS06170
Project Period: 03/89-08/92
Principal Investigator: Barbara Starfield, M.D., M.P.H.
Institution: Johns Hopkins University
Baltimore, MD 21205
Purpose: To (1) examine small area variations in ambulatory care in the State of Maryland; (2) determine the relationships between these variations, patient characteristics, provider characteristics, and the costs for quality of care; and (3) further develop methods for the study of primary care and ambulatory care services. Using Medicaid claims data and medical record reviews, the study tested the hypotheses that differences in access to care are related to urban, suburban, and rural location of residence; ambulatory use is inversely related to inpatient use of services; types of car sources are related to level of ambulatory use; and low use providers have a lower proportion of unnecessary hospital days.

Domestic Violence Identification: Outcomes/Effectiveness
Grant/Contract Number: HS07568
Project Period: 03/95-02/98
Principal Investigator: Robert S. Thompson, M.D.
Institution: Group Health Cooperative of Puget Sound
Seattle, WA 98101-1448
Purpose: To compare the effectiveness of an intensive multifaceted campaign versus a standard educational intervention strategy to improve practitioners' identification and management for adult victims of domestic violence seen in medical care.

Quality of Life and Seizures After Epilepsy Surgery
Grant/Contract Number: HS06856
Project Period: 07/91-03/93
Principal Investigator: Barbara G. Vickrey, M.D., M.P.H.
Institution: UCLA
Los Angeles, CA 90095-1769
Purpose: To (1) develop a standardized seizure classification system that corresponds most highly with patients' quality of life by evaluating relationships between quality of life measures and seizure outcomes cross sectionally, (2) evaluate changes in postsurgical seizure occurrence over time and effects on quality of life, (3) evaluate the relationships between a set of proposed variables such as age and duration of epilepsy before surgery and quality of life and seizure outcome measures, and (4) estimate the impact of surgical intervention by comparing quality of life and seizure outcomes in surgical patients with outcomes in a nonrandomized comparison group of patients who did not undergo surgery. The data collection activities included abstracting detailed clinical information from medical records.

Medical Care and Risks of Dysfunctional Chronic Pain (II)
Grant/Contract Number: HS07759
Project Period: 09/93-08/95
Principal Investigator: Michael R. Von Korff, Sc.D.
Institution: Group Health Cooperative of Puget Sound
Seattle, WA 98101-1448
Purpose: To investigate how a more rational and cost effective balance between medical intervention and self-care can be achieved for chronic pain, using two interrelated studies: Study 1, assessment of long term patterns of disability, medicine use, health care use, and health care costs among primary care back pain and headache patients; and Study 2, assessment of the doctor patient interaction in the primary care visit to identify facets of care that may impede or facilitate integration of cognitive-behavioral interventions into primary care for chronic pain. Patient interviews were conducted in Study 1, and physician-patient interactions were audiotaped.

Medical Care and Risks of Dysfunctional Chronic Pain (I)
Grant/Contract Number: HS06168
Project Period: 04/89-03/93
Principal Investigator: Michael R. Von Korff, Sc.D.
Institution: Group Health Cooperative of Puget Sound
Seattle, WA 98101-1448
Purpose: To determine if pain management methods employed by primary care physicians are associated with different risks of dysfunctional chronic pain (DCP) among patients with back pain, headache, and temporomandibular joint pain. This study assessed the extent of systematic physician variation in use of pain management methods hypothesized to increase DCP risk; investigated whether patients with DCP cluster within certain primary care practices; tested whether patients exposed to high risk pain management methods have increased risks of DCP; and tested whether physicians who use high risk methods have higher DCP risks among their patients than primary care physicians who use low risk methods, after adjusting for case mix.

Variations in Physicians' Practice Style and Outcomes of Care
Grant/Contract Number: HS06073
Project Period: 1/88-12/91
Principal Investigator: John E. Ware, Jr., Ph.D.
Institution: New England Medical Center
Boston, MA 02111
Purpose: To determine whether patients' health outcomes vary in relation to the system under which they receive their care. This study was a supplement to the Medical Outcomes Study, a 6 year study of patients with prevalent and treatable chronic conditions (hypertension, diabetes, heart disease, and depression) receiving their treatment from either a health maintenance organization, a multispecialty group, or a solo fee for service. The study involved independent examination of patients and medical record abstraction, monthly diaries, provider visit reports, self administered surveys, and telephone surveys.

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