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Quality Improvement Goal of AHRQ-Supported Research in the June 13 Issue of the Journal of the American Medical Association

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Press Release Date: June 12, 2001

Thousands of Medicare patients with diabetes mellitus or atrial fibrillation—a rapid, erratic heart beat—could benefit from two new quality improvement tools developed with the support of the Agency for Healthcare Research and Quality (AHRQ). The test results for these tools are published in two articles in the June 13 issue of the Journal of the American Medical Association (JAMA). Findings from a third AHRQ-funded study in the same issue could improve care at the end of life by encouraging more end-of-life discussions between HIV patients and their doctors.

Improving the Quality of Diabetes Followup Care

In the diabetes study, University of Alabama at Birmingham researchers found that physicians who received periodic feedback reports based on chart reviews of their care of Medicare fee-for-service patients with diabetes mellitus, plus performance goals called "achievable benchmarks of care," significantly outperformed similar doctors who received only the chart reviews and standard performance feedback. Patients of doctors who were provided the benchmarks had 33 percent to 57 percent higher odds of receiving long-term glucose control measurement, serum cholesterol testing, foot exams and influenza vaccinations than patients of the other physicians. Achievable benchmarks of care are standards of excellence attained by top performers among peer physicians, which provide a reference for doctors to assess their own performance.

According to the study's leader, Catarina I. Kiefe, Ph.D., M.D., if achievable benchmarks of care were used widely for improving the quality of medical care for diabetics, the estimated increase in influenza vaccinations would reduce the incidence of the disease, which can lead to pneumonia, and could prevent as many as 584 deaths a year from the diseases among Medicare patients. For details, see "Improving Quality Improvement Using Achievable Benchmarks for Physician Feedback: A Randomized Controlled Trial" by Dr. Kiefe, Jeroan Allison, M.D., O. Dale Williams, Ph.D., and others.

Improving the Appropriateness of Care for Patients with Atrial Fibrillation

In the atrial fibrillation (AF) study, researchers led by Brian F. Gage, M.D., of Washington University School of Medicine, found that their new CHADS2 method for predicting risk of stroke in patients with this condition is more accurate than existing methods. CHADS2 is an acronym for the risk factors for stroke in patients with AF—congestive heart failure, hypertension, advanced age, diabetes and a prior stroke.

While physicians agree that warfarin therapy is favored when the risk of stroke is high, and aspirin when it is low, there has been little agreement on how to predict the risk of stroke. By more accurately estimating the risk of stroke in a patient with AF, doctors and their patients can make better decisions about which anti-thrombotic therapy to use. CHADS2 may be especially helpful for identifying low-risk patients who, by taking aspirin, can avoid the office visits, expense and risks of taking warfarin, which has to be closely monitored because of its higher risk of causing bleeding.

For more information, see "Stroke Risk in Atrial Fibrillation; Validation of Clinical Prediction Rules for Stroke: Results from the National Registry of Atrial Fibrillation," by Dr. Gage, Amy D. Waterman, Ph.D., and William Shannon, M.D.

Improving Care at the End of Life for HIV Patients

The third AHRQ-funded study in the June 13 issue of JAMA found that half of all HIV-infected persons in the United States—and especially-African Americans, Hispanics, intravenous drug users, and less well educated individuals—never talk about end-of-life care with their doctors. Such discussions could result in better understanding by physicians of what types of care patients desire when they are very ill and close to death. In addition, discussions may lead to a patient designating a surrogate to make decisions if he or she is unable to do so.

End of life discussions occurred more often in a continuous, trusting patient-physician relationship. Advance directives—documents that can specify a surrogate decision maker or describe wishes for care at the end of life—were completed much more often when doctors and patients discussed these issues.

Lead author Neil S. Wenger, M.D., of the University of California at Los Angeles, suggests that given the low rate of end-of-life discussions, clinicians and other providers initiate these. The analysis is a part of the HIV Cost and Services Utilization Study conducted by a consortium led by RAND Health under the direction of Martin F. Shapiro, M.D.

For more information see "End-of-Life Discussions and Preferences Among Persons with HIV," by Dr. Wenger, David E. Kanouse, Ph.D., Rebecca L. Collins, Ph.D., and others.

Note to Editors: For interviews of Dr. Kiefe, contact Tracy Bischoff at (204) 934-8935 ( To interview Dr. Gage, contact Anne Enright Shepherd at (314) 286-0119. Dr. Wenger, the lead author of the third study, is currently in Israel, but can be reached by telephone at 011-972-8-646-6008, by cell phone at 011-972-51-450286, or E-mail:

For more information, please contact Robert Isquith, (301) 427-1539 (


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