Highlights from Recent AHCPR Research Findings

Media Advisory Date: August 25, 1997

The Agency for Health Care Policy and Research (AHCPR) works to improve the quality of health care, reduce costs, and broaden access to essential services. Here are some of the findings described in the July issue of AHCPR's Research Activities.

Better Management of Patients Already Diagnosed with Heart Disease Is More Cost Effective than Primary Prevention

Reducing risk factors for coronary heart disease (CHD), such as smoking, obesity, and high blood pressure, in the general population is presumed to be a key factor in reducing CHD-related deaths. However, an AHCPR-supported study has found that improved management of patients who already have CHD may be more cost effective than primary prevention. Milton C. Weinstein, Ph.D., of the Harvard School of Public Health, and his colleagues developed a computer-simulation model of the U.S. population between the ages of 35 and 84 years, which simulates changes in risk factors, case-fatality rates, and coronary event rates, to forecast coronary mortality.

They found that 71 percent of the substantial decline in CHD deaths from 1980 to 1990 was explained by improvements in CHD management of persons with CHD, either through lipid-lowering medications or changes in diet or other risk factors. Only one-fourth of the decline was due to risk factor reductions in persons without CHD (primary prevention). The study indicates that improvements in the treatment of heart attacks has the potential to reduce mortality even further.

["The recent decline in mortality from coronary heart disease, 1980-1990," by Maria G.M. Hunick, M.D., Ph.D., Lee Goldman, M.D., M.P.H., Anna N.A. Tosteson, Sc.D., and others, in the February 19, 1997, Journal of the American Medical Association 277(7), pp. 535-542.]

Better Doctor-Patient Communication Could Enhance Treatment Compliance For HIV-Infected Patients

Approximately 12 to 42 percent of patients who have been prescribed zidovudine (ZDV), a drug which slows the progression of the human immunodeficiency virus (HIV) into full-blown AIDS, don't comply with their prescription. According to a study supported by AHCPR, patients who stop taking ZDV believe it is harmful, are skeptical of its ability to prevent illness, and feel that physicians' directives about its use in general can be disregarded. Researchers interviewed 141 AIDS patients at three sites in New York City between 1992 and 1993. Respondents were asked to rank several factors relating to medicine in general and ZDV in particular.

Patients who expressed the greatest concern about ZDV's side effects, which range from nausea and vomiting to anemia, were those who typically had taken the drug an average of eight months and decided to discontinue the drug themselves rather than on the advice of their physician. The findings indicate the importance of educating patients about the pros and cons of ZDV and establishing regular patient-clinician dialogue concerning patient's experiences with the drug.

["Zidovudine adherence in persons with AIDS: The relation of patient beliefs about medication to self-termination of therapy," by Meredith Y. Smith, Ph.D., M.P.A., Bruce D. Rankin, Ph.D., Anne Morrison, M.D., and Sandra Kammerman, M.D., in the April 1997 Journal of General Internal Medicine 12, pp. 216-223]

Childhood Diabetes Exacts a Heavy Economic Toll on Families, Even Those with Health Insurance

Families who have a child with insulin-dependent diabetes mellitus (IDDM) may face much larger out-of-pocket health expenditures than other families who have similar health care coverage because health plans often do not fully cover the syringes, insulin, and blood testing strips needed to manage the disease, according to a study funded by AHCPR. Thomas J. Songer, Ph.D., and his colleagues sent a questionnaire during 1989 to 1990 to 197 case families with a child with IDDM identified from the Allegheny County, PA, IDDM Registry and 142 control families with no diabetic children. The families were similar in race, household income, education, size, and health insurance coverage. They found that out-of-pocket expenses were 56 percent higher in the IDDM-affected families than in non-affected families with similar health insurance coverage.

["Health insurance and the financial impact of IDDM in families with a child with IDDM," by Dr. Songer, Ronald E. LaPorte, Ph.D., Judith R. Lave, Ph.D., and others, in the April 1997 issue of Diabetes Care 20 (4), pp. 577-584.

Advance Directives Don't Have Much Impact on End-Of-Life Patient Care

Advance directives have limited impact on end-of-life patient care because the few patients who have them seldom tell their doctors about them, according to a new study funded by AHCPR. Also, most written directives—living wills, health care proxies, and durable powers of attorney—are too vague to make a difference in the patient's care. Joanne Lynn, M.D., M.A., of the George Washington University's Center to Improve Care for the Dying, and her colleagues reviewed the charts of 4,804 dying patients and found only 688 written advance directives. Among these, only 3 percent were specific enough to guide physicians' decisions about particular life-extending treatment in an actual situation. The processes of writing and implementing directives must be improved to assure the intended impact, suggests Dr. Lynn. These findings are based on a 10-year study, called the Study to Understand the Prognoses and Preferences for Outcomes and Risks of Treatment, or SUPPORT, of the impact of advance directives on 10,000 seriously ill patients at five U.S. hospitals from 1989 to 1994.

[See the April 1997 Journal of the American Geriatrics Society 45, "Do advance directives provide instructions that direct care?" by Joan Teno, M.D., Sandra Licks, Dr. Lynn, and others (pp. 500-507), "Advance directives for seriously ill hospitalized patients: Effectiveness with the Patient Self-Determination Act and the SUPPORT Intervention, by Dr. Teno, Dr. Lynn, Neil Wenger, M.D., and others (pp. 508-512), and "The illusion of end-of-life resource savings with advance directives," by Dr. Teno, Dr. Lynn, Alfred E. Connors, Jr., M.D., and others (pp. 513-518).]

Other articles in Research Activities include findings on:

• Benefits of hormone replacement therapy outweigh risks of heart disease.
• Which patients benefit from angiography and angioplasty.
• Impact of length of hospital stay on bypass surgery outcomes.
• Differences in management of benign prostatic hyperplasia.
• Barriers to medical care among homeless adults.
• Providing prenatal care for poor women.
• Attitudes about life-support interventions in the pediatrics ICU.
• International variation in management of cataracts.
• Differences in management of patients at high risk of stroke.
• Consumers' understanding of quality-of-care report cards.
• Strengthening the evidence base for clinical practice.
• Changes over time in do-not-resuscitate orders.

For additional information, contact AHCPR Public Affairs: Karen J. Migdail, (301) 427-1855 (KMigdail@ahrq.gov) or Salina Prasad, (301) 427-1864 (SPrasad@ahrq.gov).