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Highlights From Recent AHCPR Research Findings

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Media Advisory Date: July 26, 1999

The U.S. Department of Health and Human Service's 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 June 1999 issue of AHCPR's Research Activities.

Use of Hormone Replacement Therapy May Be More Strongly Linked to Sociodemographic Factors than Clinical Factors

Postmenopausal women at risk for heart disease are reported to gain the most health benefits from hormone replacement therapy (HRT). Yet these women were no more likely than other postmenopausal women to use HRT in 1995, according to an AHCPR-supported study. Nancy L. Keating, M.D., M.P.H., of Harvard Medical School, and colleagues, analyzed a national sample of postmenopausal women during 1995. They found that about 38 percent of postmenopausal women were using HRT during that year. Rates of HRT use did not differ by smoking status, family history of heart attack, or other cardiovascular risk factors. On the other hand, college graduates were nearly four times more likely to use HRT than women who had not graduated from high school, and women in the South and West were nearly three times more apt to use HRT than those in the Northeast. Older women were less likely to use HRT than younger postmenopausal women.

["Use of hormone replacement therapy by postmenopausal women in the United States," by Dr. Keating, Paul D. Cleary, Ph.D., Alice S. Rossi, Ph.D., and others, in the April 6, 1999 Annals of Internal Medicine 130, pp. 545-553.]

Managed Care Has Spread from the United States to Latin America With an Uncertain Effect on Health Care Quality and Access

With an increasing saturation of the managed care market in the United States, many managed care organizations (MCOs) are exporting their managed care product to Latin America for substantial profits. Overall revenues from managed care in Brazil during 1995 were nearly $3 billion. Access to large pension funds that support health insurance systems, fewer restrictions as compared with the United States, and a surplus of Latin American doctors who are willing to work for relatively low wages are just a few of the incentives, according to researchers. But the effects of managed care on access to health care and the quality of care for Latin Americans are unknown, concludes an AHCPR-supported study. Karen Stocker, M.A., of the University of New Mexico, Albuquerque, and her colleagues based their findings on a review of studies on exportation of managed care from 1980 through 1998, as well as interviews with top executives, and a review of Web sites and annual reports of key companies. Researchers found, for example, that in Chile every year about 24 percent of patients covered by MCOs receive services in public clinics and hospitals because they cannot afford copayments. Also, lengthy means testing to qualify for free care at self-managed public hospitals in Argentina and Brazil has resulted in an average 30 to 40 percent rejection rate at some hospitals.

["The exportation of managed care to Latin America," Ms. Stocker, Howard Waitzkin, M.D., Ph.D., and Celia Iriart, Ph.D., in the April 8, 1999, New England Journal of Medicine 340(14), pp. 1131-1136.]

State-Required Hospital Forms Don't Accurately Document Eligible Organ Donors or Donation Consent

Many states require hospitals to complete an organ donation form for each patient who dies while in the hospital. The hospital reports the patient's organ and tissue donation eligibility status, whether an organ request was made to the family, and the family's response. However, these forms often are inaccurate and tend to overestimate the organ donor pool, concludes an AHCPR-supported study. It found that Ohio Department of Health (ODH)-mandated organ donation forms reported almost four times more eligible organ donors than actually existed (151 vs. 39 patients identified by medical chart review). Also, the forms identified 21 families as consenting to organ donation compared with only 14 families identified through chart review. Laura A. Siminoff, Ph.D., of Case Western Reserve University, and Kristine A. Nelson, R.N., M.N., of Lifebanc, compared the State-required forms with detailed chart reviews on 2,270 patients who died in 1997 at four trauma hospitals in Ohio and with interviews with staff at organ procurement organizations and clinicians at the hospitals.

["The accuracy of hospital reports of organ donation eligibility, requests, and consent: A cross-validation study," by Dr. Siminoff, and Ms. Nelson, in the March 1999 Joint Commission Journal on Quality Improvement 25(3), pp. 129-135.]

Doctors Who Feel Pressured by Insurers to Reduce Services Are More Apt to be Dissatisfied with Medical Practice

Some managed care plans use financial incentives to influence physicians to use fewer health resources. According to a recent AHCPR-supported study, doctors who perceive incentives by managed care plans to reduce health care services tend to be more dissatisfied with the practice of medicine than doctors who don't perceive such incentives. Jack Hadley, Ph.D., of Georgetown University Medical Center and his colleagues conducted a 1997 telephone survey of 1,549 physicians located in 75 large metropolitan areas. About 15 percent of doctors surveyed perceived moderate or strong incentives to reduce care, 70 percent reported no incentives, and 15 percent reported an incentive to increase services. Researcher found that doctors who perceive moderate or strong incentives to reduce care were 1.5 to 3.5 times more likely to report dissatisfaction with their practices. They were also more likely to feel that they had less freedom to care for patients the way they would prefer and that they had less professional autonomy to practice good medicine. Although financial incentives to reduce services are not widespread, there is a legitimate reason to be concerned about possible adverse effects on the quality of care, notes Dr. Hadley.

["Perceived financial incentives, HMO market penetration, and physicians' practice styles and satisfaction," Dr. Hadley, Jean M. Mitchell, Ph.D., Daniel P. Sulmasy, M.D., Ph.D., and M. Gregg Bloche, M.D., J.D., in the April 1999 Health Services Research 34(1), pp. 307-321.]

Other articles in Research Activities include findings on:

  • Impact of access to HIV treatments on care for poor and uninsured patients.
  • Adolescent reports of preventive health care received.
  • Variation in primary care physician referral rates.
  • Impact of hospital choice on HIV care.
  • Greater risk of death among medical skeptics.
  • Effect of do-not-resuscitate orders on hospital costs.
  • Poorer prognosis of hospitalized patients with pneumonia.
  • Prediction of health care use from a single question.
  • Hospital views of hospital quality of care report cards.
  • Research needs of community and migrant health centers.
  • Role of hospital networks in rural hospital survival.
  • Nursing home factors that reduce the risk of hospitalization.
  • Costs of treating sinusitis and conjunctivitis.
  • Impact of managed care on hospital-physician relationships.
  • Cryosurgery as a second-line therapy for prostate cancer.
  • Survey to help consumers choose the best health plan.
  • Reliability of physician report cards.

For additional information, contact the AHCPR Press Office, (301) 427-1364: Salina Prasad, (301) 427-1864 (

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