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Barnett, S., and Franks, P. (1999, November). "Telephone ownership and deaf people: Implications for telephone surveys." (AHRQ grant HS09539). American Journal of Public Health 89(11), pp. 1754-1756.

Of the 23 million Americans with hearing loss, 4.8 million people cannot hear or understand normal speech. Little is known about the health status and use of health services by deaf people. Often researchers who need to gather public health data use less costly telephone surveys instead of in-home interviews. However, telephone surveys risk marginalizing prelingually deafened adults (adults who became deaf before 3 years of age), concludes this study. This is because of low telephone ownership by this group and language barriers between the deaf and the hearing communities. The researchers used 1990 and 1991 data from the National Health Interview Survey to examine the relationship between telephone ownership and age at onset of deafness. They found that prelingually deafened adults were less apt than members of the general population to own a telephone, whereas those who lost their hearing after age 3 (postlingually deafened adults) were as likely as members of the general population to own a telephone.

Dionne, C.E, Von Korff, M., Koepsell, T.D., and others. (1999). "A comparison of pain, functional limitations, and work status indices as outcome measures in back pain research." (AHRQ grant HS06168). Spine 24(22), pp. 2339-2345.

The outcomes of patients with back pain are measured by pain, functional limitations, and work status. These outcomes are often considered interchangeable in back pain research. However, this study shows that these indexes of back pain outcome are related but not equivalent and should not be regarded as interchangeable. These results argue for a clearer distinction of outcome measures in back pain research, conclude the researchers. They studied the outcomes of 720 patients who sought care for back pain in primary care settings of a large health maintenance organization in 1989 and 1990. They interviewed the patients 1 month and 2 years later and found moderate agreement between pain and functional limitation measures and work status. Pain and functional limitation change scores agreed moderately with improvement in work status but were poorly associated with decline in work status.

Donaldson, G.W., Moinpour, C.M., Bush, N.E., and others. (1999, December). "Physician participation surveys: A randomized study of inducements to return mailed research questionnaires." (AHRQ grant HS09407). Evaluation and the Health Professions 22(4), pp. 427-441.

A modest financial reward can significantly improve physician response rates to research surveys, but telephone followup may be inefficient and even ineffective, according to a recent study. The authors randomly selected 400 doctors providing followup care to patients who received bone marrow or blood stem cell transplants at a cancer research center to determine interest in receiving Internet-based transplant information. The doctors were assigned to receive mailed surveys with either no compensation or a $5 check and either no followup call or a followup call 3 weeks after the mailing. Overall, 52 percent of doctors returned the surveys. Including the $5 check in the mailer significantly increased the probability of returning the surveys (58 percent vs. 46 percent). In contrast, the telephone followup had no overall effect.

Harris, L.E., Swindle, R.W., Mungai, S.M., and others. (1999). "Measuring patient satisfaction for quality improvement." (AHRQ grant HS08823). Medical Care 37(12), pp. 1207-1213.

Surveys used for health plan quality reporting are usually administered annually to health plan enrollees to assess satisfaction with both the health plan and health care services. However, these researchers developed and tested a visit-specific questionnaire/patient-satisfaction instrument that may be used for quality improvement. The instrument was reliable and valid for identifying differences in satisfaction between primary care practice sites. The survey, conducted in five adult and pediatric primary care sites, focused on patient satisfaction with the provider, office, and access to care. It included the Medical Outcomes Study Visit-specific Questionnaire, the American Board of Internal Medicine Patient Satisfaction Questionnaire, and locally developed items. Satisfaction with the provider and with the office were independently correlated with overall satisfaction in both adult and pediatric samples. Satisfaction with access was significantly correlated with overall satisfaction only for adults. Adult patients who disenrolled from the health plan were less satisfied with the office compared with patients who remained with the plan.

Iezzoni, L.I., Davis, R.B., Palmer, R.H., and others. (1999). "Does the complications screening program flag cases with process of care problems?" (AHRQ grant HS09099). International Journal for Quality in Health Care 11(2), pp. 107-118, 1999.

The Complications Screening Program (CSP) aims to identify 28 potentially preventable complications of hospital care using computerized discharge abstracts, including demographic information, and diagnosis and procedure codes. The researchers applied the CSP to computerized hospital discharge abstracts from Medicare beneficiaries admitted in 1994 to hospitals in California and Connecticut for major surgery or medical treatment. Of 28 CSP complications, 17 occurred sufficiently frequently to study. The final sample included 740 surgical and 416 medical discharges. Rates of process of care problems were high, ranging from 24.4 percent to 82.5 percent across CSP screens for surgical cases. Problems were lower for medical cases, ranging from 2 percent to 69.1 percent across CSP screens. However, the CSP did not flag discharges with significantly higher rates of explicit process problems than unflagged discharges, indicating that such an approach to identifying complications of care should be evaluated cautiously.

Kravitz, R.L., Bell, R.A., and Franz, C.E. (1999, November). "A taxonomy of requests by patients (TORP): A new system for understanding clinical negotiation in office practice." (AHRQ grant HS09812). Journal of Family Practice 48(11), pp. 872-878.

Requests are the primary means of patient-initiated action in office practice. But these requests can be problematic because they consume time and resources. In particular, patients' requests for diagnostic tests, medications, and referrals can be costly to capitated practices and may cause physician-patient discord if not handled appropriately. These researchers developed a new system—the Taxonomy of Requests by Patients (TORP)—for capturing and categorizing patients' requests in adult primary care. They used input from researchers, clinicians, and patient focus groups and assessed its reliability and validity in audiotaped encounters between 139 patients and 6 northern California internists. The 139 patients made 772 requests. Patients with better health status made fewer requests. Having more chronic diseases was associated with more requests for physician action. More patient requests were also associated with physician reports of longer visit times and increased visit demands. Patients with more unfulfilled requests had lower visit satisfaction.

Kuntz, K.M., Tsevat, J., Weinstein, M.C., and Goldman, L. (1999, December). "Expert panel vs. decision-analysis recommendations for postdischarge coronary angiography after myocardial infarction." (AHRQ grant HS07081). Journal of the American Medical Association 282(23), pp. 2246-2251.

Expert panels and decision-analytic techniques are increasingly used to determine the appropriateness of medical interventions, but these two approaches use different methods to process evidence. In fact, formal syntheses of both these approaches is warranted in future efforts at guideline development, concludes this study. The researchers compared the degree of importance of the clinical variables considered in expert panel ratings of appropriateness for postdischarge coronary angiography after myocardial infarction with a previously published decision-analytic model. They identified 36 clinical scenarios from the expert panel that could be simulated by the decision-analytic model. They found moderate to good agreement between the appropriateness score and both the health gain and the incremental cost-effectiveness ratio of coronary angiography compared with no angiography in the convalescent phase of acute myocardial infarction. However, several scenarios judged as inappropriate by the expert panel had cost-effectiveness ratios comparable with many generally recommended medical interventions.

Lin, A., Lenert, L.A., Hlatky, M.A., and others. (1999, December). "Clustering and the design of preference-assessment surveys in healthcare." (AHRQ grant HS08362). Health Services Research 34(5), pp. 1033-1045.

Many decisions regarding medical care depend on the relative importance that patients attach to different outcomes of care. Employing a clustering algorithm to analyze health status survey data enables researchers to gain a data-driven, concise summary of the experiences of patients, concludes this study. The authors surveyed 224 patients with ventricular arrhythmias treated at one site. They used the clustering algorithm to identify prototypical health states in which patients in the same cluster shared similar responses to items in surveys on physical and mental functioning and vitality. Cluster 1 (21 percent of patients) was characterized by high scores on physical functioning, vitality, and mental health. Cluster 2 (33 percent) had low physical function but high scores on vitality and mental health. Cluster 3 (29 percent) had low physical function and low vitality but preserved mental health. Cluster 4 (17 percent) had low scores on all scales. These clusters served as the basis of written descriptions of health states.

Mayer, M.L. (1999, December). "Using Medicaid claims to construct dental service market areas." (AHRQ grants HS06993 and HS09330). Health Services Research 34(5), pp. 1047-1062.

Few sources of data on private dental insurance claims exist. However, the Federal Government does mandate that State Medicaid programs cover dental services. Thus, for the under-21 population, Medicaid dental claims provide a rich source of data on dental care use and may be useful in delineating dental service market areas at the State level. These authors used North Carolina Medicaid data to construct market areas for dental services using a patient origin approach. They found that Medicaid claims data, when combined with provider licensure files, can be used to construct county-based market areas. Compared with market areas constructed using patient origin data, county-based market areas were an adequate proxy for dental markets. Using the county as the market area also avoided the time and computational costs associated with using a patient origin-based approach and facilitated the use of widely available data.

Selden, T.M. (1999). "Premium subsidies for health insurance: Excessive coverage vs. adverse selection." Journal of Health Economics 18, pp. 709-725.

In the United States, employment-related health insurance coverage is subsidized through the tax system. This tax subsidy can lead to excessive coverage and excessive spending on medical care. Yet the potential also exists for adverse selection to result in the opposite problem—insufficient coverage and underuse of medical care. Thomas M. Selden, Ph.D., an economist in AHRQ's Center for Cost and Financing Studies uses the well-known R-S model of adverse selection to show that a simple linear premium subsidy can correct market failure due to adverse selection. The optimal linear subsidy balances welfare losses from excessive coverage against welfare gains from reduced adverse selection. Indeed, a capped premium subsidy may mitigate adverse selection without creating incentives for excessive coverage, concludes Dr. Selden.

Reprints (AHRQ Publication No. 00-R012) are available from the AHRQ Publications Clearinghouse.

Shapiro, M.F., Berk, M.L., Berry, S.H., and others. (1999, December). "National probability samples in studies of low-prevalence diseases. Part 1: Perspectives and lessons from the HIV Cost and Services Utilization Study;" and Frankel, M.R., Shapiro, M.F., Duan, N., and others, "Part II: Designing and implementing the HIV Cost and Services Utilization Study Sample." (AHRQ grant HS08578). Health Services Research 34(5), pp. 951-968 and 969-992.

This two-part study examines the trade-offs inherent in selecting a sample design for a national study of HIV/AIDS and the adaptations, opportunities, and costs associated with the choice of national probability sampling. To produce a valid nationally representative probability sample of people with HIV/AIDS for the HIV Cost and Services Utilization Study (HCSUS), the researchers combined a provider-based multistage design with the M.D.-colleague recruitment model often used in non-probability site-specific studies. They collected data across the country on reported AIDS cases for metropolitan areas and rural counties. In selected areas, they analyzed the caseload of known providers for HIV patients and a random sample of other providers. For selected providers, they used anonymous patient visit records. The researchers concluded that it was possible to obtain all data necessary to implement a multistage design for sampling individual HIV-infected people under medical care with known probabilities. They succeeded in obtaining in-person or proxy interviews from individuals representing over 70 percent of the eligible target population.

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