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Despite greater risk factors, black men and women are only half as likely as whites to have heart attacks

Among patients presenting to the emergency department (ED), black men and women are half as likely as their white counterparts to develop acute myocardial infarction (AMI or heart attack) and 60 percent as likely to develop acute cardiac ischemia (ACI, insufficient blood supply to the heart muscle), even though they are more at risk for heart disease because of higher rates of smoking, hypertension, and diabetes. Whites, on the other hand, are more likely to have existing coronary artery disease, as indicated by their more frequent histories of angina, AMI, and use of cardiac medications, according to a study supported by the Agency for Health Care Policy and Research (HS07360).

As part of the ACI-TIPI Clinical Trial, investigators studied 10,673 patients (including 6,600 whites and 3,401 blacks) at 10 hospitals around the country, including all those patients 30 years of age or older who arrived at the ED with chest pain or other symptoms suggestive of ACI. Upon ED admission, more black women had chest pain as a primary symptom, and a higher proportion of black men and women had additional symptoms, including shortness of breath, abdominal pain, nausea, vomiting, and dizziness, as well as high blood pressure.

These multiple symptoms more often resulted in noncardiac diagnoses for blacks than whites, according to Harry P. Selker, M.D., M.S.P.H., of New England Medical Center, the study's principal investigator. Six percent of black men versus 12 percent of white men were diagnosed with AMI, while 8 percent of black men versus 20 percent of white men were diagnosed with angina pectoris (searing chest pain). Only 14 percent of black men had chest pain or other symptoms due to ACI, compared with 32 percent of white men. Noncardiac diagnoses were established for half of black men and women, one-third of white men, and 39 percent of white women. Only 4 percent of black women were diagnosed with AMI compared with 8 percent of white women, and 12 percent of black women versus 17 percent of white women were diagnosed with angina pectoris. Chest pain and other symptoms were attributed to ACI in 16 percent of black women and 25 percent of white women.

Details are in "Causes of chest pain and symptoms suggestive of acute cardiac ischemia in African-American patients presenting to the emergency department: A multicenter study," by Charles Maynard, Ph.D., Joni R. Beshansky, R.N., M.P.H., John L. Griffith, Ph.D., and Dr. Selker, in the Journal of the National Medical Association 89(10), pp. 665-671, 1997.

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Elderly/Long-term Care

Effective treatment of geriatric urinary incontinence depends on proper assessment

Urinary incontinence (UI) affects 15 to 30 percent of the population and half of those living in nursing homes. But this often embarrassing condition is underreported by patients and underdiagnosed by doctors. Proper diagnosis of geriatric UI includes distinguishing temporary and persistent UI and the factors causing them from permanent UI, according researchers at the University of North Carolina at Chapel Hill, who were supported by the Agency for Health Care Policy and Research (National Research Service Award training grant T32 HS00032).

For instance, delirium promotes incontinence by increasing disorientation and decreasing patient awareness of the need to void. Mobility impairment affects the ability to reach the toilet in time. These factors should be managed by environmental manipulations, scheduled toileting, toilet substitutes and pads, and attention to skin care. Also, UI due to anticholinergic, narcotic, and beta-adrenergic drugs can be improved by switching or discontinuing medication or modifying the dosage schedule when appropriate, explain Theodore M. Johnson II, M.D., and Jan Busby-Whitehead, M.D.

There are three broad types of treatment for management of UI: behavioral (kegel exercises, bladder training, dietary changes, and prompted voiding), medication (anticholinergic agents, alpha-adrenergic agents, and estrogen), and surgery (collagen injection, sling procedure, and bladder neck suspension). According to Drs. Johnson and Busby-Whitehead, distinguishing the type of UI the person has is critical in order to prescribe the appropriate treatment.

It is very difficult to correctly diagnose UI based solely on the patient's medical history, note the researchers. They recommend that physicians evaluate all patients for urinary tract infection, post-void residual volume, and simple cystometry measures of bladder capacity and stability. Physicians should not use urodynamic tests such as uroflowmetry and cystometry as screening tools because they do not differ significantly for continent and incontinent patients. Instead, urodynamic tests should be used selectively as confirmatory tests to help determine the therapeutic approach.

See "Diagnostic assessment of geriatric urinary incontinence," by Drs. Johnson and Busby-Whitehead, in the October 1997 American Journal of Medical Science 314(4), pp. 250-256.

Characteristics of a nursing home's management team affect the likelihood it will adopt innovations

Nursing homes whose top managers (director of nursing [DON] or administrator) are well-educated, involved in professional societies, and who have been in the job a long time, are more likely to adopt innovations that cut costs and meet Government regulations than homes whose top managers lack these attributes, according to a study supported in part by the Agency for Health Care Policy and Research (National Research Service Award training grant T32 HS00011).

The Minimum Data Set (MDS) is a tool used for the preliminary assessment of physical and psychosocial functioning of nursing home residents that is still being introduced in nursing homes. It identifies areas for further evaluation and helps facilities track resident outcomes for quality assurance and improvement. To determine which nursing home management teams were early adopters of a computerized version of the MDS, Nicholas G. Castle, Ph.D., of AtlaniCare Health Systems, and Jane Banaszak-Holl, Ph.D., of the University of Michigan, examined tenure, education, and involvement in a professional society, as well as relative homogeneity within the top management team of 236 nursing homes in 10 States. Of these, 52 percent were chain-owned.

The researchers analyzed data from a telephone survey of nursing home administrators and directors of nursing after implementation in 1993 of a Federal law requiring nursing homes to identify and track residents' care preferences and their physical and psychosocial functioning. They also used data from the Medicare/Medicaid Automated Certification Survey and the Area Resource File. The researchers found that 50 percent of chain facilities and 44 percent of nonchain facilities had computerized the MDS. As combined educational levels of the administrator and DON increased, the likelihood of the nursing home adopting a computerized version of the MDS increased by about one-third. As the degree of professional involvement of the top management team increased (society membership, attendance at meetings), the likelihood of the home computerizing the MDS almost doubled. Nursing homes belonging to chains that had asked their members to use computers in the past were nine times more likely to have computerized the MDS. In general, chain facilities were not as affected by external factors that played a role in whether nonchain homes adopted the MDS, such as local income, size of the community's elderly population, and Medicaid reimbursement level.

More details are in "Top management team characteristics and innovation in nursing homes," by Drs. Castle and Banaszak-Holl, in The Gerontologist 37(5), pp. 572-580, 1997.

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Outcomes/Effectiveness Research

Clinical trial results may be markedly affected when small numbers of high-risk patients are included

The results of clinical trials generally apply to average patients. Some treatments may be effective for all patients and under all conditions. But in other cases, it would be a mistake to extrapolate results driven by the experiences of high-risk patients to patients at low risk, or vice versa. For some diseases, both the disease and the patient populations change over time.

Instead of aiming at average estimates, mega-trials should study very heterogeneous groups but stratify them into risk subgroups. This would give particularly low-risk or high-risk patients a better idea how they might benefit from the treatment, concludes a study supported in part by the Agency for Health Care Policy and Research (HS07782).

This conclusion is based on analysis of human immunodeficiency virus (HIV)-related trials and trials of magnesium in acute myocardial infarction conducted by John P. Ioannidis, M.D., and Joseph Lau, M.D., of Tufts University School of Medicine in Boston. They found that subtle differences in patient inclusion or exclusion criteria can result in important differences in representation of patients with distinct responses to treatment. For instance, if substantial treatment benefit is seen mostly in very sick patients but patients at lower risk experience excess harm due to toxicity, only high-risk patients would be expected to experience a net benefit from treatment. Patients who are not at high risk may be the majority of those treated, however, and they may experience an excess of harm from the therapy. Therefore, a clinical trial enrolling patients from a homogeneous low-risk population will probably find the therapy to be useless, but at the same time, the trial may miss detecting its efficacy for high-risk patients.

On the other hand, when clinical trials do not strictly enroll a very homogeneous population, high-risk patients may inadvertently predominate in the control or the treatment group and distort results. In other words, this small group of high-risk patients may be responsible for most of the treatment complications or the greatest improvement due to treatment. In small trials enrolling fewer persons, this effect often results in "surprising" or "unexpected" results, according to Drs. Ioannidis and Lau.

For more information, see "The impact of high-risk patients on the results of clinical trials," by Drs. Ioannidis and Lau, in the Journal of Clinical Epidemiology 50(10), pp. 1089-1098, 1997.

Southeast stroke belt has two to three times the rate of elevated blood pressure of other U.S. regions

The proportion of persons with elevated blood pressure (EBP), a precursor of hypertension, which is a well-established risk factor for stroke, varies regionally across the United States, with the so-called "stroke belt" in the Southeast having the highest prevalence of EBP. For instance, 25 percent of black men in Birmingham, AL, have EBP, as compared with 9 percent in Chicago, where rates were lowest. High salt diets or family history of hypertension, although linked to hypertension, do not fully explain the Southeast's higher rates of EBP. Accounting for known dietary, behavioral, and familial correlates of hypertension did not change regional differences in EBP in a study supported in part by the Agency for Health Care Policy and Research (HS09446).

Catarina I. Kiefe, Ph.D., M.D., of the University of Alabama at Birmingham, and her colleagues followed a group of 5,115 black and white men and women, aged 18 to 30 in 1985 or 1986, for 7 years at four centers: Birmingham, AL; Chicago, IL; Minneapolis, MN; and Oakland, CA. Regional disparities did not show up initially but became more apparent as the population aged. Compared with Birmingham, Chicago and Minneapolis had one-third the prevalence of EBP and Oakland one-half. EBP for black and white men ranged from a low in Chicago (9 percent for black men and 5 percent for white men) to a high in Birmingham (25 percent for black men and 14 percent for white men). Although not significantly different, the incidence of EBP for black and white women was highest in Birmingham. Birmingham also had the highest 7-year incidence (11 percent) and overall prevalence at year 7 (14 percent). These differences were consistent regardless of race or sex. Birmingham showed the highest sodium intake and lowest potassium and magnesium intakes, as well as the highest proportion of persons with a family history of hypertension (67 percent). After further analysis, known dietary, behavioral, and familial correlates of hypertension did not fully explain disparities between Birmingham and other regions. In fact, adjusting for many factors that correlate with hypertension—such as body mass index and weight gain, physical activity, dietary intake, alcohol and tobacco use, education, oral contraceptive use, and family history of hypertension—had only limited impact on geographic differences in EBP rates.

The authors call for further studies to investigate whether these differences become more marked as the study population ages. They believe continued followup will lead to a better understanding of the known geographic variability in stroke morbidity and mortality.

More details are in "Regional disparities in the incidence of elevated blood pressure among young adults: The CARDIA study," by Dr. Kiefe, O. Dale Williams, Ph.D., Diane E. Bild, M.D., M.P.H., and others, in Circulation 96(4), pp. 1082-1088, 1997.

Health status questionnaire accurately assesses changes over time in quality of life after elective surgery

One multidimensional measure of health status can capture changes in health-related quality of life (HRQL) after elective surgery and help assess a person's need for in-home services after hospital discharge, according to a study supported by the Agency for Health Care Policy and Research (HS06573). The Short Form Health Survey (SF-36) questionnaire, for example, found that patients undergoing hip arthroplasty, thoracic surgery, or abdominal aortic aneurysm repair had worse physical function and more role limitations due to health problems 1 month after surgery than they had prior to surgery. However, by 6 months after surgery, the majority of patients experienced significant gains in most health dimensions, and these were sustained 1 year after surgery.

The SF-36 assesses health status in eight areas: health perception, bodily pain, physical function, physical role, social function, emotional role, mental health, and vitality. How much each of these areas changes depends on the type of surgery and timing of followup after surgery. For instance, for total hip arthroplasty patients, responsiveness was greatest for the SF-36 scales that measure physical constructs. However, for patients undergoing the other two procedures, all eight areas changed significantly at various points of recovery.

The SF-36 moderately correlated with other indicators of physical function and health perception measured by other instruments used in the study. The patterns of change and consistency of results with other instruments suggest that differences detected with the SF-36 are valid, conclude Thomas Lee, M.D., of Harvard Medical School, Lee Goldman, M.D., M.P.H., of the University California, San Francisco School of Medicine, and their colleagues. They analyzed responses given by 528 adult patients admitted for the three elective surgeries to the SF-36, the Specific Activity Scale, five validated health transition questions, and a 0-to-100 scale measure of global health at 1, 6, and 12 months after surgery.

See "Health-related quality of life after elective surgery," by Carol M. Mangione, M.D., M.S.P.H., Dr. Goldman, E. John Orav, Ph.D., and others, in the November 1997 Journal of General Internal Medicine 12, pp. 686-697.

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Health Care Delivery

Patients' treatment preferences reflect the value they place on different health outcomes

Patients' choices for life-sustaining treatments are generally consistent with their preferences for different health conditions, and this relationship remains consistent over time. When these preferences are inconsistent, it is for understandable reasons, according to a study supported in part by the Agency for Health Care Policy and Research (HS06343).

Researchers from the Veterans Affairs Puget Sound Health Care System and the University of Washington, led by Robert A. Pearlman, M.D., M.P.H., interviewed seven groups of people at baseline and 6, 18, and 30 months later. Participants were asked whether they would want six treatments in five different health states, which they were asked to rate in varying degrees as better or worse than death. The researchers measured the increase in odds of refusing life-sustaining treatment for each one-point change in health state ratings. They considered preferences to be concordant (consistent) if treatments were refused in health states rated as worse than death and accepted in health states rated as better than death.

Treatment refusal differed by health state. Coma had the highest rate of treatment refusal. Fifty-two percent of study participants rated permanent coma as worse than death, 31 percent rated it as better than death, and the majority of treatments were refused. The current health state had the lowest rate of treatment refusal; dementia, severe stroke, and severe pain had similar rates of refusal in the middle range for every treatment.

As would be expected, the percentage of treatment refusals for all treatments increased as the health state rating went from much better than death to much worse than death. For example, a change in health state rating from a little worse than death to somewhat worse than death was associated with a 70 to 94 percent increase in the odds of treatment refusal. Preferences were generally consistent over time, particularly when the health state ratings were stronger, that is, much worse than death or much better than death.

The 115 participants who rated their current health state as better than death but did not want treatment had good reasons. Either they believed that receiving treatment would lead to a worse state of health—such as machine dependency or increased dysfunction (71 percent)—or that the treatments themselves were unacceptable (46 percent). Being a burden to others was another stated reason for not wanting treatment in both current and hypothetical health states (22 and 23 percent, respectively).

See "Validation of preferences for life-sustaining treatment: Implications for advance care planning," by Donald L. Patrick, Ph.D., M.S.P.H., Dr. Pearlman, Helene E. Starks, M.P.H., and others in the October 1, 1997 Annals of Internal Medicine 127, pp. 509-517.

Doctors' counseling about reducing risky behaviors falls short of national goals

About 40 percent of U.S. deaths due to nongenetic causes in 1990 were attributable to unhealthy behaviors such as excessive eating, alcoholism, smoking, unsafe sex, and not wearing seat belts. Unfortunately, doctors still are not doing enough to meet national goals for counseling patients about reducing these risky behaviors, concludes a study supported by the Agency for Health Care Policy and Research (HS08841).

Physicians who counsel patients about unhealthful behaviors can make a difference. In this study, 49 percent of patients who were counseled by their doctors about smoking tried to cut down or quit smoking based on the doctors' advice. Nearly half of those who tried to stop smoking were successful. A 50 percent increase in smoking discussion by doctors (from 53 percent to 80 percent) would result in a 6 percent decrease in smoking, a potential 24,000 annual deaths delayed, and $3 billion in annual cost savings to society, note Deborah A. Taira, Sc.D., and Dana Gelb Safran, Sc.D., of New England Medical Center.

Drs. Taira and Safran and their colleagues mailed a survey to a random sample of Massachusetts State employees in 12 health plans. With the resulting responses (n=6,549), they examined the relationship between patient income, health risk behaviors, prevalence of physician discussion of these behaviors, and receptiveness of patients to their doctors' advice.

Low-income patients were more likely to be obese and to smoke and less likely to wear seat belts and exercise than those with higher household incomes. Stress and alcohol consumption increased with income, but the proportion of heavy drinkers (more than 20 drinks per week) did not vary significantly. According to reports from patients at risk in each area, 73 percent of physicians discussed exercise, 70 percent discussed diet, 61 percent discussed stress, 53 percent discussed smoking, 39 percent discussed alcohol consumption, 19 percent discussed safe sex, and 16 percent discussed seat belt use. Overall, 19 percent of patients surveyed believed that their doctor gave them too little advice on health risk behaviors.

Doctors were more apt to discuss diet and exercise with high-income patients in need of counseling in these areas than with low-income patients. On the other hand, they were more apt to discuss smoking with low-income than high-income patients who smoked. Low-income patients in general were much more likely than high-income patients to try to change their behavior based on their doctors' advice.

Details are in "The relationship between patient income and physician discussion of health risk behaviors," by Drs. Taira and Safran, Todd B. Seto, M.D., and others, in the November 5, 1997 Journal of the American Medical Association 278(17), pp. 1412-1417.

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Use of Data/Medical Informatics

Medical informatics conference explores cutting-edge technologies

Medical data mining to uncover factors contributing to preterm birth, Internet-based patient interviews, and Web-based clinical information systems that enable referring physicians at remote sites to access a hospital's clinical database are just a few of the many topics addressed at the 1997 Annual Fall Symposium of the American Medical Informatics Association held in Nashville, TN. The conference theme, "Emergence of Internetable Health Care: Systems That Really Work," was addressed in 273 scientific manuscripts, 29 panels, and 131 posters that the Society published in the 1997 Annual Fall Supplement to the Journal of the American Medical Informatics Association and in the CD-ROM Extended Proceedings.

Seventeen of the studies presented at the conference were supported in whole or in part by the Agency for Health Care Policy and Research. They are:

  • Bichindaritz, I., Bradshaw, J.M., Sullivan, K.M., and others. "Distributed reuse of knowledge in a computerized decision support system for bone-marrow post-transplant care over the World-Wide Web," p. 844, AHCPR grant HS09407.
  • Bourie, P.Q., Dresch, J. and Chapman, R.H. "Usability evaluation of an on-line nursing assessment," p. 914, AHCPR grant HS08749.
  • Das, A.K., and Musen, M.A., "A foundational model of time for heterogeneous clinical databases," p. 106, AHCPR grant HS06330.
  • de Estrada, W.D., Murphy, S., and Barnett, G.O. "Puya: A method of attracting attention to relevant physical findings," p. 509, AHCPR grant HS06575.
  • Einbinder, J.S., Klein, D.A., and Safran, C.S. "Making effective referrals: A knowledge-management approach," p. 330, AHCPR grant HS08749.
  • Flowers, C.R., Garber, A.M., Bergen, M.R., and Lenert, L.A. "Willingness-to-pay utility assessment: Feasibility of use in normative patient decision support systems," p. 223, AHCPR grant HS07818.
  • Hulse, M., Zielstorff, R.D., and Estey, G. "User-interface design of a Web-based clinical decision support system," p. 951, AHCPR grant HS06575.
  • Jones, P.C., van Wingerde, F.J., and Safran, C., "An Internet-based patient interview," p. 954, AHCPR grant HS08749.
  • Kittredge, R., Usman, R., Melanson, F., and others. "Experiences in deployment of a Web-based CIS for referring physicians," p. 320, AHCPR grant HS06575.
  • Lobach, D.F., Gadd, C.S., and Hales, J.W., "Structuring clinical practice guidelines in a relational database model for decision support on the Internet," p. 158, AHCPR grant HS09436.
  • Lush, M.T., and Henry, S.B. "Nurses' use of health status data to plan for patient care: Implications for the development of a computer-based outcomes infrastructure," p. 136, AHCPR NRSA training grant T32 HS00026.
  • McDonald, C.J., Overhage, J.M., Tierney, W.M., and others. "The Regenstrief medical record system 1997: A system for clinical pervasive and city-wide computing," p. 1027, AHCPR grant HS07719.
  • Murphy, S.N., Rabbani, U.H., and Barnett, G.O. "Using software agents to maintain autonomous patient registries for clinical research," p. 71, AHCPR grant HS06575.
  • Prather, J.C., Lobach, D.F., Goodwin, L.K., and others. "Medical data mining: Knowledge discovery in a clinical data warehouse," p. 101, AHCPR grant HS09436.
  • Prather, J.C., Lobach, D.F., Hales, J.W., and others, "Exploratory data analysis to detect preterm risk factors," p. 984, AHCPR grant HS09331.
  • Sands, D.Z., Chapman, R.H., Goodman, S., and others. "Drug allergies and reactions program: A new paradigm to record complete information," p. 998, AHCPR grant HS08749.
  • Zielstorff, R.D., Estey, G., Vickery, A., and others. "Evaluation of a decision support system for pressure ulcer prevention and management: Preliminary findings," p. 248, AHCPR grant HS06575.

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AHCPR News and Notes

AHCPR and Kaiser join forces to study mental health in managed care

The Agency for Health Care Policy and Research and the Kaiser Permanente Medical Care Program in Northern California have begun a research project that could help all managed care organizations target and provide appropriate health services for enrollees and family members suffering from depression or other mental health problems. As a result, health plan enrollees could benefit from improved access to high quality preventive services, more productive mental health treatment, and added resources invested in continued service enhancements.

The research effort, led by Kaiser Permanente's Enid M. Hunkeler, M.A., and AHCPR's William D. Spector, Ph.D., will focus on mild depression—one of the most prevalent mental health problems among managed care patients—and on its interactions with chronic diseases, such as heart disease, and risky behaviors, such as alcohol, drug, and cigarette use, on nonpsychiatric health services utilization and costs. The researchers also will explore whether family members of enrollees who have mental health symptoms differ from family members of enrollees who do not have these symptoms in their use of other kinds of health services.

Findings from the project are expected to contribute to a more complete understanding of the actual health care costs of depression and other mental health symptoms, such as panic disorder, anxiety, and violent impulses in people who have other illnesses and those who do not. The research will also look at persons who may exhibit these symptoms but do not use health services.

Current research suggests that better targeting and appropriate use of mental health services are likely to have the most significant impact on persons with less severe mental problems and the elderly. Studies also suggest that many visits for physical problems actually stem from mental health problems. Around 10 percent of the population suffers from some form of depressive illness. About 4 percent of the population meets the criteria for major depression. These rates are twice as high among people seeking health care.

The California Division of Kaiser Permanente serves more than 5.3 million members throughout the State and has more than 7,000 physicians and over 55,000 employees. The research will be based on Kaiser Permanente data from a recent, large-scale telephone survey of a random sample of enrollees regarding their mental health symptoms, chronic disease, and alcohol, cigarette, and drug use, as well as data regarding their use and expenditures for care in Kaiser Permanente hospitals, emergency rooms, outpatient facilities, and other medical services in Northern California. The first findings from this research are expected in 1999.

For more information, select the press release.

AHCPR recognizes contributions of peer reviewers

Each year, hundreds of reviewers contribute their expertise to assist in the peer review of research grant applications. The Agency for Health Care Policy and Research would like to acknowledge and thank those who served as reviewers in 1997.

If you are interested in serving as a peer reviewer, please forward a current curriculum vitae to the Agency for Health Care Policy and Research, Office of Scientific Affairs, Attention Bonnie Campbell, 540 Gaither Road, Suite 2000, Rockville, MD 20850; or, you may fax a copy of your CV to Ms. Campbell at (301) 427-1561.

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