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Women with AIDS can cut their risk of death in half by seeking care from more experienced clinics

Women with AIDS reduce their risk of death by 50 percent when treated at clinics that are highly experienced in treating HIV-infected patients, according to a study supported by the Agency for Health Care Policy and Research (HS06465). This finding adds to the growing evidence linking hospital and physician HIV experience with improved outcomes for patients with HIV disease and AIDS. It is based on a retrospective study of 887 New York State Medicaid-enrolled women diagnosed with AIDS in 1989 to 1992 who were treated at 117 State clinics.

Women treated at high-experience clinics (treated 100 or more patients with HIV disease since 1986) from 1991-1992 reduced by half their relative risk of death compared with patients treated at low-experience clinics (treated less than 20 patients with HIV since 1986) during the same time period. After adjusting for patient demographics and clinical variables, 71 percent of patients in high-experience clinics were alive 21 months after AIDS diagnosis compared with 53 percent of women in low-experience clinics.

Clinics that care for many patients with HIV often offer ancillary services, support staff, and specially focused care protocols. For instance, in this study, standard HIV protocols, onsite clinical trials, and infectious disease specialists on staff were more common among high-experience clinics, notes Leona E. Markson, Sc.D., the study's principal investigator. Clinic HIV experience was not significantly associated with women's survival in the early years of the study (1989 to 1990). This was perhaps due to greater availability of interventions that modify the disease's course in the later study years, such as prophylaxis for Pneumocystis carinii pneumonia (PCP), a serious and common infection among HIV-infected patients. On the other hand, it also may be that it took until the later study years for many clinics to gain sufficient experience, suggests lead author Christine Laine, M.D., M.P.H., Assistant Professor of Medicine at Jefferson Medical College.

For more information, see "The relationship of clinic experience with advanced HIV and survival of women with AIDS," by Drs. Laine, and Markson, Linda J. McKee, M.H.S., and others, in AIDS 12(4), pp. 417-424, 1998.

Largest study to date profiles HIV seropositive compared with high-risk seronegative women

By 1995, complications from infection with the human immunodeficiency virus (HIV) had become the third leading cause of death among all U.S. women ages 25 to 44 years and the leading cause of death among black women in this age group. The Women's Interagency HIV Study (WIHS) is the largest study to date to profile HIV seropositive women compared with high-risk seronegative women. With participation by the Agency for Health Care Policy and Research, the National Institutes of Health, and the Centers for Disease Control and Prevention, the WIHS began in August 1993 to comprehensively examine the impact of HIV infection in U.S. women.

Conducted by the WIHS Collaborative Study Group, it profiled the HIV risk factors, demographics, and health and insurance status of 2,058 HIV-seropositive women compared with 567 high-risk seronegative women who ranged in age from 16 to 73. Women were enrolled in the study at 23 different sites from many regions of the country. They were interviewed and examined during an initial baseline visit and during followup visits every 6 months between October 1994 and November 1995.

The two cohorts were matched on demographic and key risk factors. More than half of the women in each group were living below the poverty level; about one-fourth were Hispanic, over half were black, and less than 20 percent were non-Hispanic white. Behaviors placing these women at risk for HIV exposure were similar for both the seropositive and seronegative groups. Injection drug use was reported by 34 percent of seropositive women vs. 28 percent of seronegative women; the women also reported heterosexual contact (42 percent vs. 26 percent), transfusion risk (4 percent vs. 3 percent), and no identified risk (20 percent vs. 43 percent).

More HIV-positive women than HIV-negative women had some form of health insurance coverage (82 percent vs. 59 percent) and a current primary health care provider (93 percent vs. 67 percent). About half of the women in each group reported barriers to receiving health care (52 percent vs. 47 percent), and many of the women were caring for dependent children (42 vs. 41 percent). Slightly less than one-third of the women in each group had experienced forced sexual contact as a child (31 percent vs. 27 percent).

See "The Women's Interagency HIV Study," by Susan E. Barkan, Ph.D., Sandra L. Melnick, Dr.P.H., Susan Preston-Martin, and others in the March 1998 Epidemiology 9(2), pp. 117-125.

Community-based programs for HIV-infected people need flexibility to respond to changes in functional status

Recent advances in the treatment of human immunodeficiency virus (HIV) infection are enabling affected people to remain in the community longer than in the past. Many of these people, especially those who have developed AIDS, have limitations in physical functioning, particularly in energy-demanding activities. Community-based programs targeted at people with HIV infection need to be sensitive to potential changes in functional status over time, says a new study by the Agency for Health Care Policy and Research.

Using data from the AIDS Costs and Service Utilization Survey, study authors John A. Fleishman, Ph.D., of AHCPR, and Stephen Crystal, Ph.D., of Rutgers University, examined the prevalence of limitations in physical functioning measured three times over the course of a year in a sample of 1,784 adults with HIV infection. They found that the most prevalent physical limitation involved engaging in vigorous activities (55 percent of the sample) and the least prevalent limitation was for general activities of daily living (12 percent of the sample). For each of six activities, the prevalence of limitations rose with increasing disease severity. However, the study found that at each stage of illness, including full-blown AIDS, people varied widely in their functional status. For example, nearly one-fourth of people with AIDS reported no functional limitations at all, whereas 20 percent reported severe impairment associated with limitations in activities of daily living.

During the year, 42 percent of individuals did not change their functional status, 42 percent became worse, and 15 percent had improved functioning. Given the episodic nature of many opportunistic infections associated with HIV disease, the short-term declines in functioning caused by these infections may be followed by improved functioning or even complete recovery. Case management and service authorization procedures must be flexible to meet these changing needs, conclude the authors.

For details, see "Functional status transitions and survival in HIV disease: Evidence from the AIDS Costs and Service Utilization Survey," by Drs. Fleishman and Crystal, in Medical Care 36(4), pp. 533-543, 1998.

Reprints (AHCPR Publication No. 98-R052) are available from the AHCPR Publications Clearinghouse.

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AHCPR funds new studies

The research projects, cooperative agreements, small grants, conference grant, and fellowship listed here were funded recently by the Agency for Health Care Policy and Research. Readers are reminded that the results of studies usually are not available until after the project is completed or nearing completion.

Research Projects and Cooperative Agreements

Community-based health services research curriculum
Project director: Charles J. Homer, M.D.
Organization: Children's Hospital
Boston, MA
Project number: AHCPR grant HS09792
Period: 7/1/98 to 6/30/01
First year funding: $71,953

Financial incentives and care of chronic cardiac patients
Project director: Barbara J. McNeil, M.D., Ph.D.
Organization: Harvard Medical School
Boston, MA
Project number: AHCPR grant HS09929
Period: 7/1/98 to 6/30/00
First year funding: $253,040

Health services research across disciplines
Project director: Harold S. Luft, Ph.D.
Organization: University of California
San Francisco, CA
Project number: AHCPR grant HS09787
Period: 7/1/98 to 6/30/01
First year funding: $53,807

Health services research training program for clinicians
Project director: Alvin I. Mushlin, M.D.
Organization: University of Rochester
Rochester, NY
Project number: AHCPR grant HS09799
Period: 7/1/98 to 6/30/01
First year funding: $85,566

Innovations incentive initiative in HSR training program
Project director: Mark V. Pauly, Ph.D.
Organization: University of Pennsylvania
Philadelphia, PA
Project number: AHCPR grant HS09790
Period: 9/1/98 to 8/31/01
First year funding: $54,076

Primary care intervention for obesity
Project director: Everett Logue, Ph.D.
Organization: Summa Health System
Akron, OH
Project number: AHCPR grant HS08803
Period: 5/1/98 to 4/30/02
First year funding: $323,122

Primary care performance and outcomes in Medicare
Project director: Dana G. Safran, Sc.D.
Organization: New England Medical Center
Boston, MA
Project number: AHCPR grant HS09622
Period: 7/1/98 to 6/30/02
First year funding: $499,749

Program in clinical effectiveness/evaluation sciences
Project director: Mark S. Roberts, M.D.
Organization: University of Pittsburgh
Pittsburgh, PA
Project number: AHCPR grant HS09784
Period: 5/1/98 to 4/30/01
First year funding: $67,317

Quality of care for children with special needs in managed care
Project director: Elizabeth A. Shenkman, Ph.D.
Organization: University of Florida
Gainesville, FL
Project number: AHCPR grant HS09949
Period: 7/1/98 to 6/30/01
First year funding: $261,438

Quality of care under varying features of managed care
Project director: Katherine L. Kahn, M.D.
Organization: University of California
Los Angeles, CA
Project number: AHCPR grant HS09951
Period: 7/1/98 to 6/30/01
First year funding: $518,140

Statistical study on measures of continuity of care
Project director: W. Wendy Lou, Ph.D.
Organization: Mount Sinai School of Medicine
New York, NY
Project number: AHCPR grant HS09474
Period: 9/1/98 to 8/31/01
First year funding: $163,843

Training evidence-based practitioners
Project director: Joseph Lau, M.D.
Organization: New England Medical Center
Boston, MA
Project number: AHCPR grant HS09796
Period: 7/1/98 to 6/30/01
First year funding: $68,590

Youth partners in care: Depression and quality improvement
Project director: Joan R. Asarnow, Ph.D.
Organization: University of California
Los Angeles, CA
Project number: AHCPR grant HS09908
Period: 8/1/98 to 7/31/03
First year funding: $622,646

Small Grants

Analyses of public policies: Coverage of HIV drugs
Project director: Robert J. Buchanan, Ph.D.
Organization: Medical University of South Carolina
Charleston, SC
Project number: AHCPR grant HS09819
Period: 9/1/98 to 2/28/00
First year funding: $40,019

Comparison of quality of life measures in heart failure
Project director: Susan J. Bennett, D.S.N.
Organization: Indiana University
Indianapolis, IN
Project number: AHCPR grant HS09822
Period: 7/1/98 to 6/30/00
First year funding: $40,384

Comparison of survey-based and claims-based risk assessment
Project director: George R. Parkerson, M.D.
Organization: Duke University Medical Center
Durham, NC
Project number: AHCPR grant HS09821
Period: 7/1/98 to 6/30/00
First year funding: $51,576

Factors shaping rural hospital managed care strategies
Project director: Astrid Knott, M.A.
Organization: University of Iowa
Iowa City, IA
Project number: AHCPR grant HS09899
Period: 8/1/98 to 7/31/99
Funding: $32,011

Health, health insurance, and welfare dynamics
Project director: Krista M. Perreira, B.A.
Organization: University of California
Berkeley, CA
Project number: AHCPR grant HS09821
Period: 8/1/98 to 7/31/99
Funding: $30,956

Physician-hospital organization and managed care contracts
Project director: Timothy S. Snail, B.S.
Organization: University of California
Berkeley, CA
Project number: AHCPR grant HS09881
Period: 8/1/98 to 5/31/99
Funding: $29,585

Practice variations in pain control at the end of life
Project director: Charles S. Cleeland, Ph.D.
Organization: University of Texas
Houston, TX
Project number: AHCPR grant HS09820
Period: 8/1/98 to 7/31/99
Funding: $75,437

Conference Grant

Data needs for studies of competition in market areas
Project director: Amy B. Bernstein, B.A.
Organization: The Alpha Center
Washington, DC
Project number: AHCPR grant HS09861
Period: 7/1/98 to 6/30/99
Funding: $89,699

National Research Service Award

A trial to improve residents' primary care in an HMO
Fellow: Steven R. Simon, M.D.
Organization: Harvard Pilgrim Health Care
Brookline, MA
Project number: NRSA fellowship F32 HS00128
Period: 1-year fellowship; Steven B.
Soumerai, Sc.D., sponsor
Funding: $35,476

New publications available from AHCPR

The following new publications are now available from the Agency for Health Care Policy and Research.

Health Technology Assessments. AHCPR's Center for Practice and Technology Assessment recently published two Health Technology Assessments. These reports, which are now available from AHCPR, are usually prepared to assist federally financed health care programs, such as Medicare and CHAMPUS (Civilian Health and Medical Program of the Uniformed Services), with coverage decisions. Health Technology Assessments present detailed analyses of the risks, clinical effectiveness, and uses of medical technologies.

  • Signal Averaged Electrocardiography. Health Technology Assessment No. 11. (AHCPR Publication No. 98-0020). This assessment examined the safety, effectiveness, and clinical utility of signal-averaged electrocardiography (SAECG). SAECG is a technique involving computerized analysis of segments of a standard surface electrocardiogram. Proponents of SAECG claim that it can eliminate the need for invasive techniques commonly used to identify high-risk patients for interventions that treat or prevent ventricular tachyarrhythmia and sudden death. Current data on SAECG show relatively consistent high negative predictive values, poor positive predictive values, and variable sensitivity and specificity when the technique is used on patients with cardiomyopathy or following myocardial infarction. The available evidence indicates that combining SAECG with other tests of cardiac function is superior to using any single test for risk assessment; however, the utility of SAECG alone as an indicator of risk remains unproven. SAECG combined with other standard tests of risk has been shown to have clinical utility in patients following an acute myocardial infarction. Other patient populations have not been shown conclusively to benefit from its use. Copies are available from the AHCPR Publications Clearinghouse.
  • 18F-Labeled 2-Deoxy-2-Fluoro-D-Glucose Positron-Emission Tomography Scans for the Localization of the Epileptogenic Foci. Health Technology Assessment No. 12. (AHCPR Publication No. 98-0044). The localization of epileptogenic foci that may respond to curative epilepsy surgery may be done by noninvasive surface electroencephalogram (EEG) recordings, clinical observations, computed tomography (CT), magnetic resonance imaging (MRI), and neuropsychologic tests. Other tests, such as invasive EEG, 18F-fluoro-deoxyglucose positron-emission tomography (FDG-PET or PET) scans, and single-photon-emission computed tomography (SPECT) scans have also been used to help identify candidates for this surgery. This assessment found that although substitution of the noninvasive PET scan for the invasive EEG recordings would be desirable, the available data were insufficient to determine whether PET scans might serve as a reliable substitute for EEG. A positive PET scan might contribute independent information for identifying epileptogenic site but could be noncontributory or confusing when hypometabolism is not seen or is seen in presumably normal brain areas. Available data do not indicate to what extent confirmatory PET scan findings might contribute to the management of patients with complex partial seizures. Copies are available from the AHCPR Publications Clearinghouse.

Medical Expenditure Panel Survey (MEPS). MEPS is the third in a series of nationally representative surveys of medical care use and expenditures sponsored by AHCPR. MEPS is cosponsored by the National Center for Health Statistics (NCHS). The first of these surveys, the National Medical Care Expenditure Survey (NMCES), was conducted in 1977, and the second, the National Medical Expenditure Survey (NMES), in 1987.

MEPS collects detailed information on health care use and expenses, sources of payment, and insurance coverage of individuals and families in the United States. Select for information about MEPS.

Thefollowing two MEPS Highlights on health insurance coverage and job-related health insurance are now available.

  • Health Insurance Coverage in America—1996. MEPS Highlights No. 4. (AHCPR Publication No. 98-0031). This Highlights presents selected information from Health Insurance Status of the Civilian Noninstitutionalized Population: 1996, MEPS Research Findings No. 1 (AHCPR Publication No. 97-0030). Major highlights include the following. During the first half of 1996, 83 percent of Americans, 218.8 million people, had some type of private or public health insurance coverage. About 68 percent had private health insurance; 15 percent were covered only by Medicare, Medicaid, or other public sources; and the remaining 17 percent were uninsured. Nearly 61 percent of the population had job-related coverage. Job-based coverage represented more than 89 percent of all private insurance. Nearly 69 percent of people under 65 years of age were covered by private insurance, 12 percent were covered by public insurance, and 19 percent were uninsured. Groups at high risk of being uninsured included racial/ethnic minorities (particularly Hispanic males), young adults ages 19 to 24, and people under 65 who were in good or fair health. Copies are available from the AHCPR Publications Clearinghouse.
  • Job-Based Health Insurance—1987 and 1996. MEPS Highlights No. 5. (AHCPR Publication No. 98-0032). This Highlights shows selected information from "More offers, fewer takers for job-based health insurance," an article by AHCPR researchers Philip F. Cooper, Ph.D., and Barbara S. Schone, Ph.D., published in the November/December 1997 issue of the journal Health Affairs. Reprints are available from AHCPR Publications Clearinghouse (AHCPR Publication No. 98-R008).
    MEPS Highlights No. 5 notes that the rate at which workers were offered health insurance through their job increased slightly from 1987 to 1996, but a growing proportion of workers turned down the coverage. The proportion of workers with access to any job-based health insurance (through their own or a family member's job) did not change. Some workers—notably Hispanics, workers under age 25, and low-wage workers—faced declines in access to job-based coverage. These groups also were more likely to turn it down if it was available and to be uninsured. From 1987 to 1996, the number of workers who turned down job-based health insurance jumped from 2.6 million to 6.3 million, an increase of 140 percent. Of the 6.3 million workers who declined job-based health insurance in 1996, 4.6 million were uninsured. Copies are available from the AHCPR Publications Clearinghouse.

AHSR awards honor current and former AHCPR grantees

Each year at its annual meeting, the Association for Health Services Research (AHSR) presents achievement awards to individuals who have made significant contributions to the field of health services research. This year, two awards—the 1998 Young Investigator Award and the 1998 Article-of-the-Year Award—were presented to researchers who are or have been associated with the Agency for Health Care Policy and Research. The awards were conferred at the 15th annual meeting of AHSR, held June 21-23, 1998, in Washington, DC.

The Young Investigator Award has been awarded each year since 1986. This year, it has been renamed the Alice S. Hersh Young Investigator Award in memory of AHSR's founding executive director and longtime CEO, who died unexpectedly in September 1997. One of two 1998 Young Investigator Awards was presented to John Z. Ayanian, M.D., M.P.P. Dr. Ayanian is Assistant Professor of Medicine and Health Care Policy at Harvard Medical School and Associate Physician in the Division of General Medicine at Brigham and Women's Hospital.

Dr. Ayanian is a former (1989 to 1991) National Research Service Award (NRSA) postdoctoral trainee from Harvard University's School of Public Health. His research interests include the relationship between sociodemographic factors-sex, race, and socioeconomic status-to the processes and outcomes of health care and the effects of physician and organizational characteristics on health care quality.

Thomas H. Rice, Ph.D., Professor and Chair of the Department of Health Services at the University of California, Los Angeles, received the Article-of-the-Year Award for 1998. Dr. Rice is Co-Director of the AHCPR-funded NRSA institutional training grant at UCLA. Dr. Rice was honored for his review article "Can markets give us the health system we want?" which appeared in the April 1997 issue of the Journal of Health Politics, Policy and Law 22, pp. 283-426.

Dr. Rice's research interests include the impact of physician payment policies, cost containment, competition and regulation, health insurance for the elderly, and managed care. Dr. Rice currently is editor of the journal Medical Care Research and Review.

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