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AHCPR's new guide helps Americans choose quality health care

The Agency for Health Care Policy and Research has released a new interactive guide to help families make decisions about their health care. The new guide was unveiled at the kickoff event of the Department of Labor's new employee benefits education campaign, which aims to empower workers in job-based health plans to make informed health benefit decisions.

Your Guide to Choosing Quality Health Care takes users step-by-step through the process of making important health care decisions. It is based on research about the information people want and need when making decisions about health plans, doctors, treatments, hospitals, and long-term care.

The Guide is one component of the Department of Health and Human Service's efforts to address the findings of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, released in March 1998. The Commission recommended "strengthening the hand of consumers" by encouraging them to consider information on quality when making health care decisions.

AHCPR is working with public- and private-sector partners to disseminate Your Guide to Choosing Quality Health Care, and the Agency is assisting the Health Care Financing Administration (HCFA) in adapting the tool for its Medicare beneficiaries. Additionally, AHCPR and the Midwest Business Group on Health are cooperating on a joint dissemination and evaluation project, with the participation of several of the coalition's member companies, including Bank One Corporation, Bell & Howell Company, YMCA of the USA, and others.

This guide is part of AHCPR's growing tool box of instruments designed to help improve quality, including CAHPS® (Consumer Assessment of Health Plans), a survey and reporting tool that provides detailed information on the experiences people have had with their health care providers and insurance plans (in Research Activities, February 1998); the Healthcare Cost and Utilization Project (HCUP) quality indicators (QI) software for use in assessing inpatient care (in Research Activities, September 1998); CONQUEST, a clinical performance measures database (in Research Activities, June 1997); evidence reports/technology assessments (select for the article in this issue); and other quality improvement measures.

Select to access Your Guide to Choosing Quality Health Care online. In addition, a limited number of print copies are available from the AHCPR Publications Clearinghouse.

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Use of predictive instrument in the ER could save more than $700 million annually

A new add-on to a standard electrocardiograph, originally developed with funding from the Agency for Health Care Policy and Research, could help hospitals reduce inappropriate admissions to cardiac care units (CCUs) without lowering the quality of care for patients. According to the AHCPR-funded study (AHCPR grant HS07360), combining a computer with a traditional instrument—the electrocardiograph—used in emergency departments could prevent 200,000 unnecessary hospitalizations and more than 100,000 admissions to CCUs per year nationwide. This translates into a savings of roughly $728 million each year in hospital costs or approximately $100 saved for each of the 6 million to 7 million emergency room visits annually for chest pain.

Harry P. Selker, M.D., of the New England Medical Center and Tufts University School of Medicine, led the researchers and developers of this predictive instrument and the running of the clinical trial. When using this decision support system, doctors type in the patient's sex, age, and the presence of chest pains, and the instrument computes and prints on the EKG printout the probability of acute cardiac ischemia, which occurs when there is inadequate blood supply to the heart—a precursor of a heart attack. More informed, doctors in the ER can better decide on hospitalization or discharge and treatment options.

The trial, which included 10,700 patients, found a reduction in CCU admissions from 15 to 12 percent of patients without cardiac ischemia. For patients with stable angina, the CCU admission rate dropped from 26 to 13 percent, and there was a 45 to 56 percent increase in discharges to the home. Appropriately, for patients with acute myocardial infarction (heart attack) and unstable angina, the decision support system did not reduce hospital admissions and treatment.

For more information, see "Use of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) to assist with triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia," in the December 1, 1998, Annals of Internal Medicine 129(11), pp. 845-855.

Consultation between generalists and cardiologists enhances care for heart attack patients

Heart attack patients treated in the hospital by a generalist who consults with a cardiologist are as likely to receive life-saving drugs as those treated by a cardiologist. Thus, consultation between generalists and specialists may improve the quality of care for patients with acute myocardial infarction (AMI, heart attack), concludes a study supported in part by the Agency for Health Care Policy and Research (HS07357).

Recent debates sparked by cost-containment concerns and managed care have focused on the performance of more expensive specialists versus generalist physicians. But this debate has ignored the important issue of coordination of care between the two, points out Stephen B. Soumerai, Sc.D., of Harvard Medical School. Dr. Soumerai and his colleagues reviewed the charts of 1,716 AMI patients treated at 22 Minnesota hospitals during 1992 and 1993. They compared use of recommended medications: thrombolytics (clot busters), aspirin, beta blockers, and lidocaine therapy for eligible patients who were treated by a generalist alone, a generalist in consultation with a cardiologist, and a cardiologist alone.

After accounting for clinical differences among patients, there was no variation in use of these effective agents between patients cared for by a cardiologist and those treated by a generalist who consulted a cardiologist. Probability of consultative versus cardiologist use of thrombolytics was 0.73 for both, 0.86 and 0.85 for aspirin, and 0.59 and 0.57 for beta-blockers, respectively. Also, patients treated by a cardiologist or generalist who consulted a cardiologist consistently received more of these medications than patients treated only by a generalist.

See "Consultation between cardiologists and generalists in the management of acute myocardial infarction," by Donald J. Willison, Sc.D., Dr. Soumerai, Thomas J. McLaughlin, Sc.D., and others, in the September 14, 1998, Archives of Internal Medicine 158, pp. 1778-1783.

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Outcomes/Effectiveness Research

Amoxicillin works as well as newer, more costly, antibiotics for treating uncomplicated acute sinusitis

Acute sinusitis is a common problem typically treated with a wide variety of antibiotics as well as decongestants. Apparently, the newer, more expensive, broad-spectrum antibiotics are no more effective than the traditional, less costly drugs such as amoxicillin, concludes a study supported in part by the Agency for Health Care Policy and Research (HS07782). Small differences in efficacy may exist, but they are unlikely to be clinically important. Thus, the newer broad-spectrum antibiotics, which are effective against a wide range of bacteria, should be reserved for specific circumstances in order to avoid the potential of increasing antimicrobial resistance to antibiotics, explains Joseph Lau, M.D., of New England Medical Center.

The researchers performed a meta-analysis of 27 trials involving 2,717 patients with acute sinusitis or acute exacerbation of chronic sinusitis. In some cases, these trials compared antibiotics with placebo; in other cases, they compared amoxicillin or folate inhibitors, such as co-trimoxazole, to newer, more expensive antibiotics. Overall, in two-thirds of the cases of sinusitis, there was spontaneous improvement or cure without antibiotic treatment. But compared with placebo, antibiotics decreased the incidence of clinical failures (no change or worsening of signs and symptoms) by half.

More expensive antibiotics did not substantially decrease the risk of clinical failure among 1,553 patients compared with amoxicillin. The benefit of treatment with newer antibiotics compared with amoxicillin was less than one failure averted per 100 patients, a clinically negligible effect. The results were similar for folate inhibitors, but the data were more limited. The researchers conclude that current evidence does not justify the use of expensive, broad-spectrum antibiotics in outpatient treatment of uncomplicated acute sinusitis.

More details are in "Are amoxycillin and folate inhibitors as effective as other antibiotics for acute sinusitis? A meta-analysis," by Sarah D. de Ferranti, M.D., M.P.H., John P. Ioannidis, M.D., Dr. Lau, and others, in the September 1998 British Medical Journal 317, pp. 632-637.

Evaluation by a neurologist seems to be associated with better survival for many stroke patients

According to a recent study, most patients who were hospitalized for a first ischemic stroke and did not have atrial fibrillation (irregular heart beat) survived longer if they were admitted to a neurology service or evaluated by a neurologist.

The researchers analyzed medical records of all residents of Rochester, MN, who were determined to have had a cerebral infarction (stroke) when they were admitted to the hospital during the 5-year period from January 1, 1985 through December 31, 1989. The results indicted that the probability of survival 1 year after the event was 0.833 for patients admitted to hospital neurology services, 0.773 for those admitted to general services with neurology consultation, and 0.463 for those on general services. These results did not apply to patients with atrial fibrillation, whose survival rate was the same under neurologist consultation or generalist care and lower under neurological services.

The researchers examined the influence of various predictors of survival after cerebral infarction available from the extensive medical records system maintained by the Mayo Clinic. However, David Matchar, M.D., the principal investigator of the Stroke Prevention Patient Outcomes Research Team (PORT)—a project supported by the Agency for Health Care Policy and Research (contract 290-91-0028)—cautions that the conclusions of this study cannot be regarded as definitive, since this study involved a population-based cohort, and it was not a randomized trial. Nevertheless, the study does provide some of the strongest evidence to date that patients seen by neurologists tend to have better outcomes than other patients. Dr. Matchar notes that further research is needed to help determine the reasons for these differences.

The study findings also suggest that the ischemic stroke patients assigned to neurologists were more likely to have uncommon or unusual stroke mechanisms. Thus, they formed a subgroup for whom carotid ultrasound, MRI (magnetic resonance imaging), cerebral angiography, and carotid endarterectomy may be more cost effective, safer, and more appropriate. Neurologists are associated with a higher use of these more expensive and technologically advanced techniques.

More details are in "Ischemic stroke: Outcomes, patient mix, and practice variation for neurologists and generalists in a community," by George W. Petty, M.D., Robert D. Brown, M.D., Jack P. Whisnant, M.D., and others in Neurology 50, pp. 1669-1678, 1998.

Informal social support is linked to improved diabetes management among blacks

The prevalence of noninsulin-dependent (adult-onset) diabetes mellitus is 50 to 60 percent higher among blacks than whites in the United States. Blacks with diabetes are more likely than whites with this disease to rely on informal social networks to manage their disease. Receipt of social support appears to be associated with improved diabetes management among blacks, concludes a study supported by the Agency for Health Care Policy and Research (HS07386, MEDTEP Minority Research Center). Most studies examining the impact of social support on control of blood sugar levels (to prevent serious diabetes complications) have been based on predominantly white patients, notes Marvella E. Ford, Ph.D., of the Henry Ford Health System, Case Western Reserve University.

Dr. Ford and her colleagues reviewed the literature and found six studies that examined the relationship between social support and glycemic control among black adults with diabetes. Social support ranged from help with diet supervision and medication assistance to blood sugar monitoring and general support. In one study, social support was significantly associated with health behaviors such as diet, exercise, having regular blood pressure tests, taking medications as prescribed, and foot care. Another study involving people with insulin-dependent diabetes found that women complied better with insulin regimens when they were satisfied with the social support they received.

Although social support may be associated with better glycemic control, increased social support may not be accompanied by an actual increase in glycemic control, explain the researchers. They call for more studies, particularly randomized trials, that include blacks from all socioeconomic groups to increase understanding of the role of social support in diabetes management.

See "Social support among African-American adults with diabetes, Part 1: Theoretical framework," and "Part 2: A review," by Dr. Ford, Barbara C. Tilley, Ph.D., and Patricia E. McDonald, Ph.D., R.N., in the Journal of the National Medical Association 90(6), pp. 361-365, and 90(7), pp. 425-432, 1998.

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Subcutaneous injections of epoetin work as well and cost less than IV epoetin for treating anemia in most dialysis patients

Treatment of anemia in hemodialysis patients with the hormone, recombinant human erythropoietin (epoetin), has improved cardiovascular function and quality of life. Intravenous epoetin is very costly for patients requiring long-term hemodialysis. However, a new study shows that subcutaneous injections of epoetin can maintain the hematocrit (red blood cells) in a desired target range (30 to 33 percent of blood) at one-third the average weekly dose of intravenously administered epoetin at an average cost savings of more than $1,100 per patient year.

This result may occur because epoetin administered subcutaneously (given via an injection) has a longer half-life, that is, it stays in the body longer than intravenously administered epoetin, explains James S. Kaufman, M.D., of the Boston Veterans Affairs Medical Center. In a study supported by an interagency agreement between the Department of Veterans Affairs and the Agency for Health Care Policy and Research, Dr. Kaufman and his colleagues randomly assigned 208 patients at 24 hemodialysis centers who were receiving long-term hemodialysis and epoetin therapy to treatment with either subcutaneous or intravenous epoetin.

During the 26-week maintenance phase (hematocrit maintained at 30 to 33 percent of blood), the average weekly dose of epoetin was 32 percent less for patients receiving it via subcutaneous injection compared with patients receiving intravenous epoetin. Although it has been thought that subcutaneously administered epoetin might be associated with pain at the injection site, only one patient in the subcutaneous therapy group withdrew from the study because of such pain. Eighty-six percent of patients rated this pain as ranging from absent to mild.

See "Subcutaneous compared with intravenous epoetin in patients receiving hemodialysis," by Dr. Kaufman, Domenic J. Reda, M.S., Carol L. Fye, R.Ph., M.S., and others, in the August 27, 1998 New England Journal of Medicine 339, pp. 578-583.

Despite reported safety of the blood supply, many people prefer to store their own blood for transfusions

Despite the reported safety of the blood supply, many people continue to be fearful of getting transfusions of blood from other people (allogeneic transfusions). Only 12 to 18 people each year become infected with HIV through blood transfusions out of more than 10 million transfusions given to nearly 4 million U.S. patients each year. But even when individuals are educated about the relatively low risks of allogeneic blood transfusion, the perception of risk remains substantial enough for them to have their own blood drawn and stored prior to surgery in case they need a transfusion (autologous blood donor program, ABD). In fact, many individuals are willing to pay substantial amounts to store and receive their own blood, conclude two studies supported in part by the Agency for Health Care Policy and Research (National Research Service Award training grant T32 HS00020) and led by Stephanie J. Lee, M.D., M.P.H., of Brigham and Women's Hospital, Boston.

In an initial pilot survey of 235 patients seeking ABD at one site, Dr. Lee and her colleagues found that 53 percent of those seeking to donate their own blood were concerned about the risk of infection, and 37 percent were worried about receiving the "wrong" blood from allogeneic transfusions. In a second study, the researchers randomized 412 autologous blood donors from three study sites to receive risk information (202 patients) or not to receive it (210 patients). The first group was told that the risk of contracting HIV from an allogeneic transfusion was 1 in 500,000, hepatitis 1 in 3,300, and immediate death 1 in 500,000. Both groups were told about the probability of dying in a car crash (1 in 600,000) or plane crash (1 in 250,000), or being hit by lightning (1 in 3.4 million).

Responses to questionnaires by both groups showed that risk education did not substantially decrease individual's willingness to pay (WTP) for ABD. WTP, if not covered by insurance, was high ($1,100 in the informed group and $1,900 in the uninformed group) and correlated with a person's level of apprehension about allogeneic transfusion, perceived risk of requiring a transfusion, and income. WTP varied between $400 and $1,600 when the perceived risk of needing a transfusion varied between 1 percent and 99 percent. Also, individuals who most dreaded prospects of an allogeneic transfusion were willing to pay as much as $2,800 compared with $200 by those who dreaded it the least. Finally, when annual income varied between $5,000 and $100,000, the WTP varied between $200 and $2,100. The authors conclude that aversion to allogeneic transfusions is deep-seated and unlikely to be changed by educational approaches that rely on lowering risk perceptions.

Details of both studies are in "Perceptions and preferences of autologous blood donors," by Dr. Lee, Bengt Liljas, Ph.D., W. Hallowell Churchill, M.D., and others in the August 1998 issue of Transfusion 38, pp. 757-763; and "The impact of risk information on patients' willingness to pay for autologous blood donation," by Dr. Lee, Dr. Liljas, Peter J. Neumann, Sc.D., and others, in Medical Care 36(8), pp. 1162-1173, 1998.

Age affects recovery from traumatic brain injury

Older adults don't recover as quickly or completely after traumatic brain injury as younger adults. They require dramatically longer to emerge from coma and are more apt to require neurosurgery or suffer from complications such as cardiac arrest and sepsis, finds a study supported in part by the Agency for Health Care Policy and Research (HS06497).

In spite of equivalent levels of initial depth of coma as measured by the Glasgow Coma Scale, adults in this study who were 60 years of age and older on average required more than a week to emerge from coma compared with less than 24 hours for younger patients. They also were more likely to be disabled or dependent on others and to be unemployed 1 year after their injury than younger adults. Similar neurologic insults may be less well tolerated by the aging brain, or it may have reduced capacity to recover, suggests Sureyya S. Dikmen, Ph.D., of the University of Washington.

Dr. Dikmen and her colleagues prospectively studied 411 hospitalized patients aged 18 to 80 years, who were diagnosed with mild to severe traumatic brain injury. About 70 to 75 percent of those under age 50, 48 percent of those aged 50 to 59, and 20 percent of those 60 years and older achieved a good recovery 1 year after injury. At that point, more than twice as many individuals older than age 60 were in a severe disability/vegetative state or dead compared with those 50 to 59. This was five times the number of patients younger than 50 who were in such a state.

The rate of neurosurgery for subdural hematomas (pooling of the blood in the injured brain) was twice as high among individuals older than 60 years compared with those under 30 years of age (24 percent vs. 11 percent). The greater proportion of complications and subdural hematomas in older head-injured patients probably contributes to their increased length of coma and poorer outcomes. These results suggest that the Glasgow Coma Scale—an instrument commonly used to measure the severity of depth of coma—may underestimate the extent of brain injury in the elderly. Age effects need to be separately added or accounted for, conclude the authors.

For details, see "Aging effect on psychosocial outcome in traumatic brain injury," by Barbara Rothweiler, Ph.D., Nancy R. Temkin, Ph.D., and Dr. Dikmen, in the August 1998 Archives of Physical Medicine and Rehabilitation 79, pp. 881-887.

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Patients undergoing major surgery in hospitals with limited nursing staffs suffer more complications

Patients who have surgery done in hospitals that have fewer registered nurses per patient than other hospitals run a higher risk of developing avoidable complications following their operations, according to a new study by researchers at the Agency for Health Care Policy and Research. The study found hospitals that provided 1 more hour of nursing care per patient day than the average nursing care hours per patient day had almost 10 percent fewer patients with urinary tract infections and 8 percent fewer patients with pneumonia. An additional 1 hour per day of nursing care is about a 17 percent increase in nurse staffing levels.

After analyzing data from 506 hospitals in 10 States, Christine Kovner, Ph.D., R.N., an Associate Professor at New York University, and AHCPR researcher Peter Gergen, M.D., M.P.H., found that the fewer full-time equivalent registered nurses per inpatient day a hospital has, the greater the incidence of urinary tract infection, pneumonia, thrombosis (formation of blood clots), pulmonary congestion, and other lung-related problems following major surgery. These are complications that nurses often can prevent by getting patients out of bed and walking after surgery, by monitoring them closely, and by other hands-on nursing practices.

According to Dr. Kovner, who at the time of the study served as a Senior Nurse Scholar with AHCPR, the finding of a strong inverse relationship between registered nurse staffing and adverse patient events should be considered when developing strategies to reduce costs. About 1.2 million registered nurses work in hospitals, where they make up nearly a quarter of hospital staff and constitute hospitals' single largest labor cost.

Among the study's other findings are that large hospitals have significantly lower urinary tract infection rates than smaller ones; large and medium-sized hospitals have higher rates of lung-related disorders than smaller facilities; and both public and not-for-profit hospitals have significantly lower urinary tract infection rates than do for-profit hospitals.

The researchers based their findings on 1993 discharge data from AHCPR's Nationwide Inpatient Sample (NIS)—a component of the Agency's Healthcare Cost and Utilization Project (HCUP). They linked the NIS data to data on hospital characteristics from the American Hospital Association's 1993 Annual Survey of Hospitals. The investigators also used AHCPR's HCUP Quality Indicators (software that provides information about outcomes of patient care, use of inpatient services, and access to care in a community) to identify the procedures they wanted to examine.

Details are in "The relationship between nurse staffing level and adverse events following surgery in acute care hospitals," by Drs. Kovner and Gergen in the fourth quarter 1998 issue of Image: Journal of Nursing Scholarship 30, pp. 315-321. Reprints (AHCPR Publication No. 99-R032) are available from the AHCPR Publications Clearinghouse.

For more information on Dr. Kovner's tenure as a Senior Nurse Scholar at AHCPR, see the interview of Dr. Kovner conducted by Peter I. Buerhaus, R.N., Ph.D., of Harvard University, in the same issue of Image, pp. 311-314.

Abnormal heart rhythm means longer hospital stays for many patients undergoing non-cardiac surgery

Supraventricular arrhythmia (SVA), a type of abnormal heart rhythm, is a common problem among patients undergoing non-cardiac surgery. SVA is strongly associated with increased complications and longer hospital stays, notes Lee Goldman, M.D., M.P.H., of the University of California, San Francisco. In a study supported by the Agency for Health Care Policy and Research (HS06573), Dr. Goldman, Thomas H. Lee, M.D., M.Sc., and their colleagues examined the incidence of SVA among 4,181 patients 50 years of age or older who had major, nonemergency, noncardiac surgery and had a normal heart rhythm when evaluated prior to the operation.

SVA occurred in 2 percent of patients during surgery, 6 percent shortly after surgery, and in 8 percent of patients during their hospital stay for the surgery. Men and patients 70 years of age and older; patients with significant heart valve disease, a history of SVA or asthma, congestive heart failure, or premature atrial complexes on preoperative electrocardiograms; and patients who received certain types of anesthesia were 1.3 to nearly 5 times more likely than others to suffer SVA during their hospital stay. Also, SVA was more likely to occur among those undergoing certain procedures: abdominal aortic aneurysm (odds ratio, OR, 3.9; 1 is equal odds) and abdominal (OR, 2.5), vascular (OR, 1.6), and intrathoracic (OR, 9.2) procedures.

Among patients who had intrathoracic surgery, those receiving digoxin were at lower risk (OR, 0.2) for SVA than those not receiving digoxin. Length of stay was twice as long in patients who had SVA compared with those who did not. About one-third of this increase may have been due to measures used to treat the arrhythmias, which perhaps could be deferred to the outpatient setting, note the researchers. They also suggest that identifying and providing preventive measures to patients at increased risk for SVA might improve their care.

For more details, see "Supraventricular arrhythmia in patients having noncardiac surgery: Clinical correlates and effect on length of stay," by Carisi A. Polanczyk, M.D. M.Sc., Dr. Goldman, Edward R. Marcantonio, M.D., S.M., and others, in the August 15, 1998 Annals of Internal Medicine 129(4), pp. 279- 285.

Educational outreach programs can improve intensive care processes in rural hospitals

The low volume of patients and limited resources of many rural intensive care units (ICUs) makes it difficult to recruit and keep intensive care specialists. This leads to a lack of specialized staff, less staff experience in ICU care, and potentially less than ideal intensive care practices. An educational quality improvement outreach program can enhance care in rural ICUs by improving care processes and coordination. However, these improvements may not always translate into better patient outcomes, concludes a new study conducted by researchers at Washington State University and the University of Iowa and supported in part by the Agency for Health Care Policy and Research (HS07132).

The researchers randomly selected 12 rural Iowa hospital ICUs to receive the program and 8 similar ICUs that did not. A team of specialists experienced in ICU care visited the 12 selected rural ICUs. They reviewed patient records and provided feedback to local staff and doctors on concrete ways to improve care of individual patients based on compliance with recommended guidelines. This feedback proved to be a powerful incentive for changing physician and staff behavior. Patients in ICUs receiving this program decreased their average number of days on the ventilator by 2 compared with 0.1 in ICUs that did not receive the program.

Compliance with ventilatory management recommendations improved from 51 percent in the preintervention to 67 percent in the postintervention period but did not change significantly in the control group (52 percent vs. 49 percent, respectively). The program also enhanced other patient care processes, such as lab work, nursing, and dietary management. Yet, the program did not significantly reduce patient deaths or incidence of nosocomial (hospital-acquired) problems such as infections.

See "Outreach education to improve quality of rural ICU care," by Michael S. Hendryx, Ph.D., John F. Fieselmann, M.D., M. Jeanne Bock, R.N., C.I.C., and others, in the American Journal of Respiratory and Critical Care Medicine 158, pp. 418-423, 1998.

Advance directives appear to have a limited role in guiding end-of-life care for seriously ill patients

Written advance directives (ADs), often called living wills, provide instructions on end-of-life care for seriously ill people who are no longer able to make such decisions. In practice, however, it may be difficult for loved ones to know when a patient crosses the invisible threshold from very sick to actively dying. Therefore, they may not see ADs as applicable. The AD is more likely to be used to carry out the patient's wishes about end-of-life care when a family member or other patient surrogate is available to effectively advocate for the patient and communicate with the physician about the goals of care.

These conversations allow the physician and advocate to periodically reconsider the patient's prognosis and often allow a transition in the goals of care from cure to palliative end-of-life care, concludes Joan M. Teno, M.D.,M.S., of Brown University. In a study supported in part by the Agency for Health Care Policy and Research (HS07075), Dr. Teno and her colleagues from Dartmouth Medical School and George Washington University studied the effect of ADs in 14 seriously ill hospitalized adults who participated in the Phase II study to understand prognoses and preferences for outcomes, risks, and treatments (support). The intervention consisted of information on their prognoses and the services of a specially trained nurse to facilitate medical decisionmaking. The researchers analyzed patient medical records, narratives written by nurse facilitators, and when possible, patient, surrogate, and physician interviews to understand the complex social interactions involved in using ADs.

Each patient at some point had diminished capacity in which the AD should have been invoked. Yet ADs played an important role in decisionmaking in only 5 of the 14 cases. Several factors contributed to the limited role of ADs: patients were not considered hopelessly ill; family members or the surrogate were not available, were ineffectual, or were too overwhelmed to advocate for the patient; or the content of the AD was vague or not applicable to the clinical situation. The researchers recommend that ADs be recast from a formal, legal process of signing a document to a more dynamic process of communication and negotiation about the goals of care, so-called advance care planning.

See "Role of written advance directives in decision making: Insights from qualitative and quantitative data," by Dr. Teno, Marguerite Stevens, Ph.D., Stephanie Spernak, J.D., and Joanne Lynn, M.D., M.S., in the July 1998 Journal of General Internal Medicine 13, pp. 439-446.

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