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The Outcome of Outcomes Research at AHCPR: Appendix 3

Appendix 3. Health Status Measurement Instruments

Disease-Specific Health Status Measures from PORTs

PORT1stauthorTitle of paperDisease-specific health status measureNewly devel-
Classification of
of study
Back PainJensen, MPValidity of the Sickness Impact Profile Roland scale as a measure of dysfunction in chronic pain patientsSIP Roland scaleNoEvaluativeReliability, validity
Back PainPatrick, DLAssessing Health-Related Quality of Life in Patients with SciaticaSIP Roland scaleNoEvaluativeValidity
Total Knee ReplacementBombardier, CComparison of a generic and a disease-specific measure of pain and physical function after knee replacement surgeryWOMACNoPredictiveValidity
PneumoniaFine, MJComparison of a disease-specific and a generic severity of illness measure for patients with community-acquired pneumoniaPneumonia severity of illness index (PSI)YesDiscriminitiveValidity
CataractSteinberg, EPThe VF-14: An index of functional impairment in patients with cataractVF-14YesDiscriminitiveReliability, validity
CataractCassard, SDReproducibility and responsiveness of the VF-14VF-14NoEvaluativeReliability, validity
Prostate DiseaseBarry, MJThe American Urological Association Index for benign prostatic hyperplasiaAUA symptom indexYesPredictive, evaluativeReliability, validity
Prostate DiseaseBarry, MJCorrelation of the American Urological Association Symptom Index with self-administered versions of the Madsen-Iversen, Boyarsky, and Maine Medical Assessment program system indexesAUA symptom indexNoDiscriminitiveValidity
Prostate DiseaseFowler, FJQuality of life assessment for evaluating benign prostatic hyperplasia treatmentsCondition-specific impact score, Maine Medical Assessment Program (MMAP) prostate symptom indexYes, noDiscriminitive, discriminitiveReliability, validity
Prostate DiseaseBarry, MJMeasuring disease-specific health status in men with benign prostatic hyperplasiaSymptom problem index (SPI), BPH impact index (BII)Yes, yesDiscriminitive, discriminitiveReliability, validity
Prostate DiseaseBarry, MJUsing repeated measures of symptom score, uroflowmetry, and prostate specific antigen in the clinical management of prostate diseaseAUA symptom indexNoEvaluativeReliability
Prostate DiseaseBarry, MJThe American Urological Association Index: Does mode of administration affect its psychometric properties?AUA symptom indexNoDiscriminitiveReliability
Prostate DiseaseBarry, MJBenign prostatic hyperplasia specific health status measures in clinical research: how much change in the American Urological Association symptom index and the benign prostatic hyperplasia impact index is perceptible to patients?AUA symptom index, BIINoEvaluativeValidity


Disease II

O'Leary, MPA brief male sexual function inventory for urologyBrief sexual function indexYesDiscriminitiveReliability, validity


Disease II

Barry, MJMeasurement of overall and disease-specific health status: does the order of questionnaires make a difference?AUA symptom index, MMAP symptom index, BIINoDiscriminitiveValidity

(1) HSM is Health Status Measurement. Classification of HSMs (column 6) is based on Kirshner, Guyatt: J Chron Disease 38:27, 1985.

Notes: Papers were identified from collections of PORT publications if they discussed development or validation of HSMs. Papers that reviewed pre-existing disease-specific HSMs or utilized an HSM were not included.

Discriminitive—Distinguishes between individuals in absence of gold standard. Used for diagnosis or screening.
Predictive—Classifies individuals when there is a gold standard that may be too risky or expensive for routine use. Also used for diagnosis or screening.
Evaluative—Measures longitudinal change.

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Appendix 4. List of Research Projects Pertaining to Practice Variations (1989-96)

Total Number of Projects: 46; Estimated Total Funding Amount: $179 Million


Care, Costs, and Outcomes of Local Breast Cancer (PORT II)
Principal Investigator:Jack Hadley, Ph.D.; Georgetown University Medical Center; Washington, DC 20007
Purpose:To identify the determinants of and calculate cost-effectiveness ratios for three alternative treatments for local breast cancer in the elderly.

Evaluation of Practice Variations and Costs for Cancer
Principal Investigator:Sheldon M. Retchin, M.D., M.S.P.H.; Medical College of Virginia; Richmond, VA 23298
Purpose:To assist policymakers in their efforts to reduce practice variations, and ultimately improve the effectiveness of care for cancer patients.

Treatment Choices and Outcomes in Prostate Cancer
Principal Investigator:James A. Talcott, M.D., S.M.; Dana-Farber Cancer Institute; Boston, MA 02115
Purpose:To enhance the understanding of treatment for early prostate cancer.

Breast Cancer Screening Policy and Practice
Principal Investigator:Thomas R. Taylor, M.D., Ph.D.; University of Washington; Seattle, WA 98195
Purpose:To (1) describe primary care physician performance related to screening mammography in a randomly selected group of family medicine practices; (2) identify factors associated with differences in primary care physician decision policies and practice; and (3) test the efficacy of an educational intervention based on physician decision policies in improving physician breast cancer screening practice.

Cardiovascular Disease

Right Heart Catheterization: Appropriate/Effective Use
Principal Investigator:Alfred F. Connors, Jr., M.D.; University of Virginia; Charlottesville, VA 22908
Purpose:To determine the (1) effectiveness of right heart catheterization (RHC) in terms of survival, functional status, quality of life, and satisfaction with care; (2) variation in use of RHC in seriously ill patients; and (3) association in RHC and utilization of resources in critically ill. The results of the study will be of direct relevance to health policymakers, to purchasers of medical care, to physicians, and their patients who seek guidance in the cost-effective use of RHC, and to investigators who wish to refine the indications for use of this common and expensive technology.

Outcomes Assessment Program in Ischemic Heart Disease (PORT)
Principal Investigator:Elizabeth R. DeLong, Ph.D.; Clinical Research Institute; Durham, NC 27705
Purpose:To identify sources of variation in the medical care of patients with chronic ischemic heart disease in order to develop strategies to prevent adverse outcomes or inappropriate use of resources.

Diagnostic Uncertainty and Variation in Use of Services
Principal Investigator:Lee A. Green, M.D., M.P.H.; University of Michigan; Ann Arbor, MI 48109
Purpose:To demonstrate that differences in hospital admission rates for acute ischemic heart disease result directly from different physician decisionmaking patterns, and to show that the differences are concentrated among those patients presenting the greatest uncertainty in diagnosis.

The Consequences of Variation in Treatment for Acute Myocardial Infarction (PORT)
Principal Investigator:Barbara J. McNeil, M.D., Ph.D.; Harvard Medical School; Boston, MA 02115
Purpose:To study the treatment of acute myocardial infarction (AMI), specifically, the use of diagnostic and therapeutic interventions during and shortly after hospitalization for AMI and their value in improving patient survival, health status, functional capacity, and quality of life in the chronic post-AMI period. The results of these analyses were used to develop and disseminate recommendations that will help physicians effectively treat AMI patients.

Primary Care Lipid Practice and Policy
Principal Investigator:William E. Neighbor, M.D.; University of Washington; Seattle, WA 98195
Purpose:To determine the degree to which primary care physician clinical decision policies accurately reflect practice in screening and management of hypercholesterolemia in hypertensive patients. The study developed an intervention to modify physician decision policies and practice.

Predictions and Outcomes in Congestive Heart Failure
Principal Investigator:Roy M. Poses, M.D.; Memorial Hospital of Rhode Island; Pawtucket, RI 02860
Purpose: To examine whether the quality of physicians' predictions were influenced unfavorably by cognitive biases or inappropriate use of heuristics, and whether the variability in physicians' decisions resulted from variability in the way they weigh patient variables and institutional factors.

Race and Gender Differences in Clinical Decision Making
Principal Investigator:Kevin A. Schulman, M.D., M.B.A.; Georgetown University Medical Center; Washington, DC 20007
Purpose:To examine whether physician decisionmaking contributes to race and gender differences in patterns of medical care for coronary artery disease (CAD). The project should provide insight into the role of physician decision- making in limiting access to cardiac procedures among blacks and women.

Assessment of Coronary Care Unit Use in Different Hospitals
Principal Investigator:Harry Selker, M.D., M.S.P.H.; New England Medical Center; Boston, MA 02111
Purpose:To examine variations in the decision to admit patients to coronary care units in different hospitals, including both clinical factors and demographic characteristics such as patient age, sex, race, and insurance status.

Childbirth and Prenatal Care

Hospital and Regional Factors in C-Section Rate Variations
Principal Investigator:Laura B. Gardner, M.D., Ph.D., M.P.H.; Axiomedics Research, Inc.; Los Altos, CA 94022
Purpose:To assess the relationship between hospital and regional characteristics and variations in Caesarean section rates in California. It observed changes in regional, hospital, and patient-related variables over time.

Low Birthweight in Minority and High-Risk Women (PORT)
Principal Investigator:Robert L. Goldenberg, M.D.; University of Alabama; Birmingham, AL 35233
Purpose:To (1) identify and understand practice variations prior to and during pregnancy that aim to prevent low birthweight and related negative sequelae; and (2) develop and disseminate clinical, client, and care system treatment choices to maximize improvements in the use of effective practices for minority and high-risk women.

The Impact of Specialty on Cesarean Section Rates
Principal Investigator:William J. Hueston, M.D.; Eau Claire Family Medicine Clinic; Eau Clinic, WI 54701
Purpose:To expand on the hypothesis that Caesarean section rates differ for family physicians and obstetricians by examining physician specialty along with other variables that are known to influence Caesarean section rates. Differences between the two specialties suggest alterations in physician training, which is useful in curtailing the rapid rise in C-section rates.

Variations in Management of Childbirth and Patient Outcomes (PORT)
Principal Investigator:Emmett Keeler, Ph.D.; RAND Corporation; Santa Monica, CA 09407
Purpose:To (1) examine the use and outcomes of Caesarean section versus its alternatives; (2) analyze variations and correlates of specific diagnostic and treatment procedures utilized in the course of labor and delivers; and (3) develop clinical recommendations and a series of interventions for disseminating information to distinct audiences of patients and physicians.

Practice Variations in Prenatal and Intrapartum Care
Principal Investigator:Roger A. Rosenblatt, M.D., M.P.H.; University of Washington; Seattle, WA 98195
Purpose:To study the variations in obstetrical care for women with low-risk pregnancies in Washington State. This study contributed information to reduce the cost of routine obstetrical care for women with low-risk pregnancies without impairing patient outcomes.

Dental Disease

A New Multicarrier Database for Dental Care Evaluation
Principal Investigator:William J. Hayden, Jr., D.D.S., M.P.H.; University of Missouri; Kansas City, MO 64108
Purpose:To develop a multipayer database to examine provider and practice variation of charges and to explore provider treatment behaviors.

Gastrointestinal Diseases

Evaluation of Clinical Outcomes in Small Areas of Michigan
Principal Investigator:Laurence F. McMahon, Jr., M.D., M.P.H.; University of Michigan; Ann Arbor, MI 48109
Purpose:To examine small-area variations in Michigan communities for cholecystectomies and procedures used in the diagnosis, treatment, and screening of colon cancer. A community-based educational intervention was designed, conducted, and assessed to improve care and patient outcomes.

Pediatric Gastroenteritis Patient Outcomes Research
Principal Investigator:Nancy Merrick, M.D.; MEDSTAT Group; Santa Barbara, CA 93111
Purpose: To (1) evaluate alternative therapies for pediatric gastroenteritis and describe which are most effective within different clinical populations; (2) identify the factors that inhibit use of the most effective and appropriate therapies, including physician practice patterns and patient access problems; and (3) recommend improvements in interventions for pediatric gastroenteritis.

Outcome Assessment of Patients with Biliary Tract Disease (PORT)
Principal Investigator:J. Sanford Schwartz, M.D.; University of Pennsylvania; Philadelphia, PA 19104
Purpose:To improve the evaluation, management, and health outcomes of patients with biliary tract disease.

Minority Health

Urban Health Institute at Harlem Hospital Center
Principal Investigator:Charles K. Francis, M.D.; Harlem Hospital Center; New York, NY 10037
Purpose:To establish the Harlem Hospital Center Urban Health Institute to help optimize the effectiveness of medical resources and services in urban African American populations by examining variability in current medical practice and the relation between clinical outcomes and practice variation.

Musculoskeletal Conditions

Chiropractic Versus Medical Care for Low Back Pain
Principal Investigator:Hal Morgenstern, Ph.D.; UCLA School of Public Health; Los Angeles, CA 90095
Purpose:To assess the effectiveness and cost-effectiveness of four popular management strategies used in the treatment of low back pain. The results of this project will have important implications to national health care policy and clarify the roles of medical doctors, chiropractors, and physical therapists in the treatment of low back pain.

Pediatric Conditions

Outcomes Associated with Therapy for Otitis Media
Principal Investigator:Stephen Berman, M.D.; University of Colorado; Denver, CO 80262
Purpose:To describe current practice patterns and expenditures for the management of otitis media in pediatric Medicaid recipients using the Colorado Medicaid Medical Events Database (M-Med) as a source of data.

Physician Opinions on the Diagnosis and Referral of Children with Cerebral Palsy to Physical Therapy
Principal Investigator: Suzanne K. Campbell, Ph.D., P.T.; University of Illinois; Chicago, IL 60612
Purpose:To explore the nature of physicians' beliefs in the efficacy of physical therapy in the management of children with cerebral palsy and to identify differences in referral decisions based on physician and child characteristics.

Assessment of Febrile Infants Less Than 2 Months of Age
Principal Investigator: Robert H. Pantell, M.D.; University of California; San Francisco, CA 94143
Purpose:To assess the relationship between diagnostic and treatment strategies and variations in clinical outcomes for febrile infants.

Regional Variation in Pediatric Hospitalization
Principal Investigator:James M. Perrin, M.D.; Massachusetts General Hospital; Boston, MA 02114
Purpose:To provide insight into pediatric admission decisions for five common childhood illnesses and determine appropriate criteria for childhood hospital utilization.

Illness Severity and Practice Variation Among Newborn ICUs
Principal Investigator:Douglas K. Richardson, M.D., M.B.A.; Beth Israel Deaconess Medical Center; Boston, MA 02215
Purpose:To (1) examine different outcomes [such as mortality, complications, resource use] from the neonatal intensive care unit (NICU) that are not attributable to patient severity; and (2) identify variations in practice that may increase cost without improving outcome.

Pharmaceutical Outcomes

Impact of Prospective Drug Use Review on Health Outcomes
Principal Investigator:Frank M. Ahern, Ph.D.; Pennsylvania State University; University Park, PA 16802
Purpose:To (1) conduct a descriptive epidemiological analysis of psychotropic drug use, prescribing patterns, and yield of prospective drug utilization review (ProDUR) interventions, and compute estimates of drug-related outcome measures; and (2) evaluate the independent effects of two different ProDUR procedures on health outcomes.

Geriatric Drug-Related Hospitalization
Principal Investigator:Helene L. Lipton, Ph.D.; University of California; San Francisco, CA 94109
Purpose: To examine whether inappropriate physician prescribing practices and poor patient compliance with drug regimen are associated with drug-related problems leading to hospital admission. This study helped to identify the critical first steps for developing effective interventions to reduce drug-related problems that lead to hospitalizations among geriatric populations.

Patient Outcomes with Antibiotic Therapy of Lyme Disease
Principal Investigator:G. Thomas Strickland, M.D., Ph.D.; University of Maryland; Baltimore, MD 21201
Purpose:To improve the quality of care in patients suspected of having Lyme disease by (1) investigating differences in patient outcomes resulting from variations in antibiotic therapy; and (2) performing a cost-effective analysis of the management of Lyme disease.

Prostate Disease

PORT-II for Prostatic Diseases
Principal Investigator:Michael J. Barry, M.D.; Massachusetts General Hospital; Boston, MA 02114
Purpose:To (1) define the current pattern of screening, diagnosis, and treatment of prostate disease among primary care physicians and urologists; (2) better define the effectiveness and cost of screening for carcinoma of the prostate with the tumor marker prostate-specific antigen (PSA); and (3) define and optimize outcomes for men with prostatic diseases seen in primary care settings.

Psychiatric Conditions

Schizophrenia Patient Outcomes Research Team (PORT)
Principal Investigator:Anthony F. Lehman, M.D.; University of Maryland; Baltimore, MD 21201
Purpose:To assess practice variations in the treatment and management of schizophrenia and analyze them for relative patient outcomes, resource use, and remaining scientific uncertainties. Recommendations for treatment and management will be developed and disseminated to practitioners and the public.

Variations in the Process and Outcomes of Care for Depression
Principal Investigator:Kenneth B. Wells, M.D., M.P.H.; RAND Corporation; Santa Monica, CA 90407
Purpose:To (1) examine variations in quality and outcomes of care for depression among different groups of depressed patients and for different types of treatment locations; and (2) determine how variations in outcomes correspond with variations in process of care for depressed patients.

Women's Health

Effectiveness and Outcomes of Hysterectomy
Principal Investigator:Kristen H. Kjerulff, Ph.D.; University of Maryland; Baltimore, MD 21201
Purpose:To (1) examine the decisionmaking process and outcomes of hysterectomy by focusing on mortality, morbidity, health status, functional capacity, and quality of life; (2) examine the extent to which surgical procedures and ovary removal affect outcomes; and (3) examine the extent to which patient race and other socioeconomic factors affect the decisionmaking process and outcomes of hysterectomy.

The Hysterectomy Decision: Assessment of Outcomes
Principal Investigator:Buell A. Miller, M.D.; Costal Women's Health Care; South Portland, ME 04106
Purpose:To examine the effectiveness and appropriateness of hysterectomies with the overall goal of improving decision- making regarding hysterectomy versus alternative treatment for individual patients. The project developed decision analytic models to define key probabilities and patient utilities driving the hysterectomy decision.

Other Clinical Areas

Resident Physicians' Practice Style and Patient Outcomes
Principal Investigator:Klea D. Bertakis, M.D., M.P.H.; University of California; Sacramento, CA 95817
Purpose:To evaluate the differences in practice styles between internists and family practitioners and to compare the results of care provided by these specialties for a randomized panel of patients over a 1-year period.

Surgical Blood Transfusion: Variation and Outcome
Principal Investigator:Jeffrey L. Carson, M.D.; UMDNJ-Robert Wood Johnson Medical School; New Brunswick, NJ 08903
Purpose:To describe the independent risk factors for perioperative transfusions in patients with hip fracture, using analysis to determine whether the decision to transfuse is driven primarily by patient-and procedure-related variables or is significantly influenced by institutional practice styles.

Assessment of the Variation and Outcomes of Pneumonia (PORT)
Principal Investigator:Wishawa N. Kapoor, M.D., M.P.H.; Montefiore University Hospital, UPMC; Pittsburgh, PA 15213
Purpose:To examine the variation in medical care and outcomes in adults with community-acquired pneumonia (CAP). Components of the research include an evaluation of the geographic variation in hospitalization rates and medical care, an assessment of patient outcomes, and an analysis of treatment costs.

A Study of the Causes of Variations in Medical Care
Principal Investigator:Charles E. Phelps, Ph.D.; University of Rochester; Rochester, NY 14627
Purpose:To explain variations in medical practice as a function of physician characteristics. The study determined the importance of various information sources which could be used by physicians to make treatment choices for their patients.

Inappropriateness and Variations in Hospital Use
Principal Investigator:Joseph D. Restuccia, Dr.P.H.; Boston University; Boston, MA 02215
Purpose:To study the relationship between small-area variations in Medicare hospitalization rates and rates of inappropriate hospitalization.

Practice Variation and Outcomes in Ambulatory Care
Principal Investigator:Barbara Starfield, M.D., M.P.H.; The Johns Hopkins University; Baltimore, MD 21205
Purpose: To (1) examine small-area variations in ambulatory care service use in Maryland; (2) determine the relationships between these variations, patient characteristics, provider characteristics, and the costs for quality of care; and (3) further develop methods for the study of primary care and ambulatory care services.

Variations in Physicians' Practice Style and Outcomes of Care
Principal Investigator:John E. Ware, Jr., Ph.D.; New England Medical Center; Boston, MA 02111
Purpose:To determine whether patients' health outcomes vary in relation to the system (health maintenance organization, a multispecialty group, or a solo fee-for-service) under which they receive their care.

AHCPR UI Guidelines: Application in Nursing Homes
Principal Investigator:Nancy M. Watson, Ph.D., M.S.; University of Rochester; Rochester, NY 14642
Purpose: To evaluate the dissemination and implementation of the 1992 AHCPR Guideline for Urinary Incontinence (UI) in nursing home settings. This study evaluates the UI practices of physicians, nurse practitioners, clinical nurse specialists, physician assistants, nursing staff, and nursing aides in 52 nursing homes in Upstate New York.

Guideline Implementation and Evaluation

A Physician Insurer's Impact on Early Cancer Detection
Principal Investigator:Stuart J. Cohen, Ed.D., M.A.; Bowman Gray School of Medicine; Winston-Salem, NC 21757
Purpose:To evaluate processes for increasing physicians' conformity with selected National Cancer Institute (NCI)-endorsed guidelines for the prevention and early detection of breast, cervical, skin, and prostate cancer, thereby leading to improved outcomes in cancer patients.

Impact of OB Practice Guidelines on Physician Behavior
Principal Investigator:Ronald D. Deprez, Ph.D.; Public Health Research Institute; Portland, ME 04101
Purpose:To evaluate the impact of five obstetrical care practice guidelines implemented by the Maine Medical Liability Demonstration Project (MLDP) on physician practice patterns. The study measured changes in C-section rates, diagnoses, physician behavior, and birth outcomes addressed by the guideline parameters.

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Page last reviewed October 1999
Internet Citation: The Outcome of Outcomes Research at AHCPR: Appendix 3. October 1999. Agency for Healthcare Research and Quality, Rockville, MD.