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Glazer, J., and McGuire, T.G. (2002). "Multiple payers, commonality and free-riding in health care: Medicare and private payers." (AHRQ grant HS10803). Journal of Health Economics 21, pp. 1049-1069.

The three largest groups of health plan purchasers in the United States are employers, Medicaid plans, and Medicare. In the case of hospitals, Medicare is the largest payer, but Medicare alone accounts for only 40 percent of the total payments. The authors of this paper study the interactions between a public payer for health care, modeled on Medicare, which sets a price and takes any willing provider; a private payer, which limits providers and pays a price on the basis of quality; and a provider/plan, in the presence of shared elements of quality. They conclude that the provider compromises in response to divergent incentives from payers. For instance, the private sector dilutes Medicare payment initiatives, and may, under some circumstances, repair Medicare payment policy mistakes. By committing to a price, Medicare can free-ride on the private payer and set its prices too low. Medicare may focus too much on its health plan payment formula with little effect on the quality of services offered by plans.

Hersh, W.R. (2002, October). "Medical informatics: Improving health care through information." (Cosponsored by AHRQ and the National Library of Medicine). Journal of the American Medical Association 288(16), pp. 1955-1958.

This article addresses factors that motivate work in medical informatics, emerging solutions, and the barriers that remain. The author discusses the core themes that underlie all applications of medical informatics and unify the scientific approaches across the field. The core application using patient-specific information is the electronic medical record (EMR), which is more legible, easier to access, and more secure than the paper-based medical record. The main challenge is to integrate the EMR into the busy clinical workflow. Decision support systems, which apply knowledge-based information (for example, online resources and research studies) to patient data, emerged from artificial intelligence and expert system research in the 1970s and 1980s that attempted to model the clinical diagnostician. Many challenges remain, but the need to improve documentation, reduce error, and empower patients will continue to motivate the use of information technology in health care.

Insinga, R.P., Laessig, R.H., and Hoffman, G.L. (2002). "Newborn screening with tandem mass spectrometry: Examining its cost-effectiveness in the Wisconsin newborn screening panel." (AHRQ National Research Service Award training grant T32 HS00083). Journal of Pediatrics 141, pp. 524-531.

Newborn screening for more than 20 fatty acid oxidation and organic acidemia disorders can be conducted with the use of tandem mass spectrometry (MS/MS). Some States have instituted State-wide screening programs for some or all of these disorders, while others provide screening services on an optional or pilot basis. This study found that in Wisconsin, MS/MS screening for medium-chain acyl-CoA dehydrogenase deficiency (MCAD) alone out of a neonatal screening panel for 14 disorders was cost-effective for a hypothetical group of 100,000 infants. Under conservative assumptions, screening for MCAD alone yielded an incremental cost-effectiveness ratio of $41,862 per quality-adjusted life year (QALY). With the use of more realistic assumptions, screening became more cost-effective ($6,008/QALY). Adding the incremental costs of detecting the 13 other disorders on the screening panel still yielded a result well within accepted norms of cost-effectiveness ($15,252/QALY).

Katchman, A.N., McGroary, K.A., Kilborn, M.J., and others (2002). "Influence of opioid agonists on cardiac human ether-a-go-go related gene K+ currents." Journal of Pharmacology and Experimental Therapeutics 303(2), pp. 688-694.

Torsades de pointes is a potentially fatal form of ventricular arrhythmia that typically occurs under conditions where cardiac repolarization is delayed (indicated by prolonged QT intervals on electrocardiographic recordings). These conditions can be precipitated by drugs that block the cardiac potassium channels responsible for mediating ventricular repolarization. A recently developed cell line that was stably transfected with the human ether-a-go-go related gene (HERG) has proven useful for evaluating drugs suspected of causing delays in cardiac repolarization. Two opioid agonists used to treat narcotic addiction, methadone and L-alpha-acetyl-methadol hydrochloride (LAAM), are suspected of contributing to this cardiac problem. These authors evaluated the ability of various opioid agonists, including methadone, codeine, and morphine, to block the cardiac human HERG K+ current (IHERG) in human cells stably transfected with the HERG potassium channel gene. Results demonstrated that LAAM and methadone can block IHERG in transfected cells at clinically relevant concentrations, thereby providing a plausible mechanism for the adverse cardiac effects observed in some narcotic addicts receiving these drugs.

Korthuis, P.T., Asch, S., Mancewicz, M., and others (2002). "Measuring medication: Do interviews agree with medical record and pharmacy data?" (AHRQ grant HS08578). Medical Care 40(12), pp. 1270-1282.

Measuring medication use is particularly important in chronic conditions such as HIV infection. For specific medications, agreement between alternative data sources is fair to substantial, but it is lower for key drug classes. Relying on one data source may lead to misclassification of drug exposure status, caution these investigators. They evaluated medication agreement among patient interviews, medical records, and pharmacy data on a probability sample of HIV-infected participants in the HIV Cost and Services Utilization Study (HCSUS). Kappa (agreement) varied from 0.38 for nucleoside reverse transcriptase inhibitors to 0.70 for protease inhibitors, when comparing drug classes in interview versus medical record, interview versus pharmacy data, and medical record versus pharmacy data. The percentage of medications reported in medical records was greater than that reported in interviews or pharmacy data.

Mitchell, J.M., Hadley, J., and Gaskin, D.J. (2002). "Spillover effects of Medicare fee reductions: Evidence from ophthalmology." (AHRQ grant HS08689). International Journal of Health Care Finance and Economics 2, pp. 171-188.

These researchers investigated whether ophthalmologists changed their provision of non-cataract services to Medicare patients over the time period 1992-1994, when the Medicare Fee Schedule (MFS) resulted in a 17.4 percent reduction in the average fee paid for a cataract extraction. Using a model of physician behavior, they estimated a supply function of non-cataract procedures that included three price variables (own price, a Medicare cross-price, and a private cross-price) and an income effect. The Medicare cross-price and income variables capture spillover effects. They found that the Medicare cross-price was significant and negative, implying that a 10 percent reduction in the Medicare fee for a cataract extraction will cause ophthalmologists to supply about 5 percent more non-cataract services. The income variable was highly significant, but its impact on the supply of non-cataract services was trivial. This suggests that physicians behave more like profit-maximizing firms than target-income seekers.

Mower, W.R., Hoffman, J.R., Herbert, M., and others (2002, November). "Developing a clinical decision instrument to rule out intracranial injuries in patients with minor head trauma: Methodology of the NEXUS II investigation." (AHRQ grant HS09699). Annals of Emergency Medicine 40(5), pp. 505-514.

The fear of failing to identify brain injury has led to the liberal and potentially excessive use of computed tomographic (CT) scanning of patients with blunt head trauma who have even a remote possibility of intracranial injury. This practice exposes large numbers of patients to the expense and radiation exposure associated with CT imaging while detecting injuries in a small number of patients. Previous studies suggest the possibility of developing a decision instrument to identify patients with blunt head injury who have essentially no risk of significant intracranial injury and for whom CT scanning would be unnecessary. The National Emergency X-Radiography Utilization Study II is a large, multicenter, prospective study designed to derive a decision rule for CT imaging of patients with blunt head injury. This study, described in this article, is being conducted in 21 different emergency departments across the United States and Canada. It will enroll more than 10 times as many patients with head trauma as any currently published study.

Silverman, M., Terry, M.A., Zimmerman, R.K., and others (2002, October). "The role of qualitative methods for investigating barriers to adult immunization." (AHRQ grant HS09874). Qualitative Health Research 12(8), pp. 1058-1075.

In 1999, the Agency for Healthcare Research and Quality funded a study of barriers to adult immunization. The research provided an opportunity to explore the issue using various methods, including a qualitative observational study that would assess organizational and cultural features of selected primary care practices and their impact on immunization rates. Understanding the relationship of cultural features to immunization rates would contribute significantly to the study's primary goals of determining barriers to adult immunizations and designing appropriate interventions for increasing immunization rates. In this article, the authors describe the short-term qualitative data collection system and the contributions made by the qualitative study to the parent project. They provide a system that can be replicated or modified for use in projects designed to assess complex attitudes and behaviors that affect health outcomes.

Sokol, P., and Cummins, D.S. (2002, October). "A needs assessment for patient safety education: Focusing on the nursing perspective." (AHRQ grant HS12043). Nursing Economics 20(5), pp. 245-248.

In January 2002, the National Patient Safety Foundation convened a focus group of professional nurses to capture their ideas on the sources of medical errors and ways to reduce them. This article summarizes the group's ideas, perceptions, and philosophies, all of which reflect the profession of nursing and its duty, role, and responsibility to assure patient safety. The nurses discussed the system and culture of tolerance for error (which conveys the message that it is okay to commit an error) and barriers to reporting and resolving errors. They also discussed ways to break down these barriers, which ranged from reporting near misses and practicing market leverage to use of error support groups and education. The nurses also suggested that medical education should focus on learning through the experience of others and rehearsing anticipated error scenarios. A Web-based patient safety education module for nurses is being created to raise nurse competence related to these and other issues.

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Current as of February 2003
AHRQ Publication No. 03-0017

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