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Bader, J.D., Shugars, D.A., and Bonito, A.J. (2001, October). "Systematic reviews of selected dental caries diagnostic and management methods." (AHRQ contract 290-97-0011). Journal of Dental Education 65(10), pp. 960-968.

These authors systematically reviewed the research literature on several methods for diagnosis and management of dental caries. Based on the literature reviewed, they could not establish point estimates or reasonable range estimates for the diagnostic validity of methods used to diagnose carious lesions. There were too few reports of diagnostic performance involving primary teeth, anterior teeth, and root surfaces. Studies on managing individuals at high risk of carious lesions showed fair evidence for the efficacy of fluoride varnish to prevent dental caries; evidence for other methods was incomplete.

Bosco, L. (2001). "Databases for outcomes research: What has 10 years of experience taught us?" Pharmacoepidemiology and Drug Safety 10, pp. 445-456.

This author describes how various programs are related to the mission of the Agency for Healthcare Research and Quality. For example, the Evidence-based Practice Center program was developed to provide systematic reviews on common and expensive conditions and health technologies and to ensure that the information is used to improve health care outcomes and costs. The National Guideline Clearinghouse™ provides an Internet-based source of clinical practice guidelines that are produced by clinical specialty organizations to improve health care delivery and outcomes. AHRQ also has supported the development of databases to track hospital use on a State-by-State basis. The Healthcare Cost and Utilization Project (HCUP) allows comparisons between States and within regions of individual States. The Centers for Education and Research on Therapeutics program was developed to conduct real world evaluations to better understand the benefits and risks of single and combined therapy.

Reprints (AHRQ Publication No. 02-R031) are available from the AHRQ Publications Clearinghouse.

Cardon, J.H., and Showalter, M.H. (2001). "An examination of flexible spending accounts." (AHRQ grant HS10829). Journal of Health Economics 20, pp. 935-954.

Flexible spending accounts (FSAs) for health and child care expenses are exempt from Federal, State, and payroll taxes and thus are attractive to both employees and employers. A recent survey of 681 major U.S. firms suggests that 79 percent of these employers offered such accounts in 1995, and that a rapidly growing share of employees are taking advantage of these offerings. These authors developed a framework for analyzing FSA participation and usage and explored patterns of FSA usage using data from a benefits firm for 1996, including an examination of types of FSA expenditures and their timing. In this paper, they estimate some simple econometric models of participation decisions and also the decision of how much to put into an FSA. Some evidence suggests that much of an FSA election amount is based on foreknowledge of expenditures, and that participants tend to spend their election amount early, thus obtaining an interest-free loan.

Chapman, G.B., Brewer, N.T., Coups, E.J., and others. (2001). "Value for the future and preventive health behavior." (AHRQ grant HS09519). Journal of Experimental Psychology 7(3), pp. 235-250.

Recent research on decisionmaking has explored intertemporal choice, that is, making decisions that involve a trade-off between something now and something later. Although much research has assessed discounting of delayed outcomes by using hypothetical scenarios, little research has examined whether these discounting measures correspond to real-world behavior. These authors report the findings from three studies that examined the relationship between scenario measures of time preference and preventive health behaviors that require an up-front cost to achieve a long-term benefit. Responses to time preference scenarios showed weak or no relationship to influenza vaccination, adherence to a medication regimen to control high blood pressure, and adherence to cholesterol-lowering medication. The finding that scenario measures of time preference have a surprisingly weak relationship to actual behavior representing intertemporal trade-offs places limits on the application of time preference research to the promotion of preventive health behavior.

Glance, L.G., and Osler, T.M. (2001, November). "Comparing outcomes of coronary artery bypass surgery: Is the New York Cardiac Surgery Reporting System model sensitive to changes in case mix?" (AHRQ grant K08 HS11295). Critical Care Medicine 29(11), p. 2090-2096.

New York State has published mortality rates for coronary artery bypass graft (CABG) surgery since 1991. This information has served as a report card for the State's hospitals and cardiac surgeons. These mortality rates have been risk-adjusted, that is, adjusted for the severity of illness of patients. For this study, the researchers used a database that included information on all patients undergoing CABG surgery in 32 New York hospitals in 1996. They used the New York State Cardiac Surgery Reporting System (CSRS) model to assess the impact of case-mix variation on the standardized mortality ratio (SMR), which is defined as the ratio of a hospital's observed mortality rate to the expected mortality rate, given the severity of illness of a hospital's patients. The SMR is used to quantify health care outcomes. They found that changes in patient case mix were associated with significant changes in the SMR. However, there was no difference in the identity of quality outliers (hospitals that performed significantly better or worse than the benchmark) when using either the SMR or the SMR adjusted for the effects of case mix. The researchers conclude that risk-adjusted measures of outcomes in CABG patients using the CSRS mortality model may not completely adjust for differences in case mix.

Hunt, L.M., and Arar, N.H. (2001). "An analytical framework for contrasting patient and provider views of the process of chronic disease management." (AHRQ grant HS07397). Medical Anthropology Quarterly 15(3), pp. 347-367.

An important role of medical anthropologists is to help explain the health behaviors of patients to clinicians—for example, patients' noncompliance with treatment recommendations. In this paper, medical anthropologists present an analytical framework for contrasting patient and physician goals, strategies, and evaluation criteria in chronic disease management, using examples from research on management of care for patients with type 2 diabetes. Their approach examines the contrasting views of patients and providers within the dynamic process of long-term care. They present several case studies to illustrate patient and physician differences in this regard.

Miller, M.R., Elixhauser, A., Zhan, C., and Meyer, G.S. (2001, December). "Patient safety indicators: Using administrative data to identify potential patient safety concerns." Health Services Research.

Based on 2.4 million discharge records in the 1997 New York State Inpatient Database, these authors developed patient safety indicators (PSIs) to identify potential in-hospital patient safety problems for the purpose of improving hospital quality of care. They examined the prevalence of PSI events and associations between PSI events and patient-level and hospital-level characteristics, length of stay, in-hospital mortality, and hospital charges. As a result, the researchers developed PSIs for 12 distinct clinical situations and an overall summary measure. The 1997 event rates per 10,000 discharges varied from 1.1 for foreign bodies left during a procedure to 84.7 for birth traumas. Discharge records with PSI events involved longer hospitals stays, higher rates of in-hospital mortality, and higher total charges than records without PSI events. The researchers conclude that until better error reporting systems are developed, the PSIs can serve to shed light on the problem of medical errors.

Reprints (AHRQ Publication No. 02-R039) are available from the AHRQ Publications Clearinghouse.

Parkerson, G.R., Harrell, F.E., Hammond, W.E. and Wang, X-Q. (2001). "Characteristics of adult primary care patients as predictors of future health services charges." (AHRQ grant HS09821). Medical Care 39(11), pp. 1170-1181.

Estimating the differential use of health services based on patient characteristics (that is, case mix), so-called utilization risk assessment, is a potentially useful approach for resource allocation or risk adjustment in managing health care. However, precise measurement is difficult. These authors observed adult primary care patients to test whether health-related quality of life (HRQOL), severity of illness, and diagnosis at a single primary care visit were comparable case-mix predictors of future 1-year charges in all clinical settings within a large health system. Of 1,202 patients, 84 percent had followup in the primary care clinic, 63 percent in subspecialty clinics, 15 percent in the emergency room, and 10 percent in the hospital. The researchers found that HRQOL, severity of illness, and diagnosis were all comparable predictors of 1-year health services charges in all clinical sites. However, they were most predictive for primary care charges and were more accurate in combination than alone.

Rosko, M.D., (2001, December). "Impact of HMO penetration and other environmental factors on hospital X-inefficiency." (AHRQ grant HS09845). Medical Care Research and Review 58(4), pp. 430- 454.

Many analysts have suggested that increased health maintenance organization (HMO) market penetration has led to hospital cost savings and increased efficiency. Findings from this study support that contention. The researchers examined the impact of HMO market penetration and other internal and external environmental factors on hospital X-inefficiency (the difference between optimal performance and actual performance) in a national sample of urban U.S. hospitals in 1997. They estimated average X-inefficiency in study hospitals at about 13 percent, meaning that they produced 13 percent less than they were capable of producing. Increases in managed care penetration, dependence on Medicare and Medicaid, membership in a multihospital system, and location in areas where competitive pressures and the pool of uncompensated care were greater were associated with less X-inefficiency. Not-for profit ownership was associated with increased X-inefficiency.

Selden, T.M., Levit, K.R., Cohen, J.W., and others. (2001, Fall). "Reconciling medical expenditure estimates from the MEPS and the NHA, 1996." Health Care Financing Review 23(1), pp. 161-178.

These authors compared 1996 estimates of national medical care expenditures from the Medical Expenditure Panel Survey (MEPS) and the National Health Accounts (NHA). The MEPS estimate for total expenditures in 1996 was $548 billion, and the NHA estimate for personal health care in 1996 was $912 billion. Apparently, much of this difference arose from differences in the scope of MEPS and NHA, rather than from differences in estimates for comparably defined expenditures, note the researchers. Once they adjusted the NHA for differences in included populations and types of services covered, they found a much smaller difference between MEPS and a comparably-defined NHA. However, given the magnitude of adjustments needed to align the NHA and MEPS, they conclude that any NHA-MEPS comparisons—especially comparisons pertaining to specific services or payment sources—should be viewed more as approximations than as precise estimates.

Reprints (AHRQ Publication No. 02-R027) are available from the AHRQ Publications Clearinghouse.

Sherbourne, C.D., Unutzer, J., Schoenbaum, M. and others. "Can utility-weighted health-related quality-of-life estimates capture health effects of quality improvement for depression?" (AHRQ grant HS08349). Medical Care 39(11), pp. 1246-1259.

Because different services compete for health care dollars, it is desirable to present cost-effectiveness (CE) results that compare alternative treatments or interventions. Utility methods that are responsive to changes in desirable patient outcomes are needed for CE analyses and to help in decisions about resource allocation. These investigators evaluated the responsiveness of different methods that assign utility weights to subsets of items on the Short-Form Health Survey (SF-36), a health status questionnaire, to average improvement in health resulting from quality improvement (QI) interventions for depression in 46 primary care clinics in six managed care organizations. Several utility-weighted measures showed increased utility values for patients in one of the QI interventions, relative to usual care, that paralleled the improved health effects for depression and emotional well being on the SF-36. However, QALY gains were small. Directly elicited utility values paradoxically showed a lower utility for patients who received the QI intervention than controls during the first year of the study. This raises concerns about the use of direct single-item utility measures or utility measures derived from generic health status measures in effectiveness studies for depression. Choice of measure may lead to different conclusions about the benefits and CE of treatment.

Zaslavsky, A.M. (2001). "Statistical issues in reporting quality data: Small samples and casemix variation." (AHRQ grants HS09473 and HS09205). International Journal for Quality in Health Care 13(6), pp. 481-488.

With broader understanding of case-mix adjustment and methods for analyzing small samples, quality data for individual clinical units can be analyzed and reported more accurately, concludes this author. He notes that case-mix variation is relevant to quality reporting when the clinical units being measured have differing distributions of patient characteristics that also affect the quality outcome. When this is the case, adjustment using stratification or regression may be appropriate. Such adjustments may be controversial when the patient characteristic does not have an obvious relationship to the outcome. Stratified reporting poses problems for sample size and reporting format, but it may be useful when case mix effects vary across units. Although there are no absolute standards of reliability, high reliabilities are desirable for distinguishing above- and below-average units. When small or unequal sample sizes complicate reporting, precision may be improved using indirect estimation techniques that incorporate auxiliary information. "Shrinkage" estimation can help to summarize the strength of evidence for clinical units with small samples.

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Current as of February 2002
AHRQ Publication No. 02-0015

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