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Grant final reports now available from NTIS

The following grant final reports are now available for purchase from the National Technical Information Service (NTIS). Each listing identifies the project's principal investigator (PI), his or her affiliation, grant number, and project period and provides a brief description of the project.

Analysis of X-inefficiency in U.S. hospitals. Michael D. Rosko, Ph.D., Widener University, Chester, PA. AHRQ grant HS09845, project period 4/1/99-3/31/00.

These researchers examined the correlates of X-inefficiency in 1,966 U.S. urban hospitals in 1997. Stochastic frontier analysis was used to estimate inefficiency scores for each hospital in the study. The estimated level of X-inefficiency ranged from 3 percent to 84.2 percent, with a mean of 12.6 percent. Preliminary results confirm many of the hypotheses developed from X-inefficiency theory. The results suggest that X-inefficiency is inversely associated with financial pressure (i.e., HMO penetration, dependence on Medicare and Medicaid, and uncompensated care), and competition. Further, not-for-profit hospitals were more X-inefficient than their for-profit counterparts. The estimated inefficiency scores were found to be robust over a variety of model specifications and had the anticipated correlations with a number of variables expected to be associated with inefficiency, including teaching status, size, cost per adjusted admission, for-profit status, full-time staff per patient day, and profitability.

Copies of the abstract, executive summary, and final report (NTIS accession no. PB2001-100369; 42 pp, $25.50 paper, $12.00 microfiche) are available from the National Technical Information Service (NTIS).

Compensation and the Quality of Hospital Care. June F. O'Leary, M.S., University of California, Los Angeles. AHRQ grant HS09681, project period 9/30/97-9/29/00.

The goal of this study was to examine the effects of market competition and managed care penetration on hospital quality by focusing on one condition (acute myocardial infarction or AMI), in one State (California) during the period 1992 through 1995 (n = 306 hospitals x 4 years = 1,224). Competition was measured using a Hirschman-Herfindahl Index (HHI) with managed care represented by county HMO (health maintenance organization) penetration. Quality was measured using the hospital risk-adjusted 30-day AMI mortality rate developed under the California Hospital Outcomes Project. Using process of care data from the Cooperative Cardiovascular Project, the researchers were able to validate this measure as an indicator of quality. When comparing the hospitals with the lowest mortality to those with the highest mortality, differences in the rates of aspirin use during hospitalization, ACE (angiotensin converting enzyme) inhibitors at discharge, aspirin at discharge, and volume were all found to be statistically significant. The researchers conclude that in this study increased competition was associated with greater mortality.

Copies of the abstract and executive summary of dissertation, NTIS accession no. PB2001-101441; 20 pp, $23.00 paper, $12.00 microfiche are available from the National Technical Information Service (NTIS).

Dissemination of Guidelines for Pneumonia Length of Stay. Michael J. Fine, M.D., M.Sc., University of Pittsburgh, Pittsburgh, PA. AHRQ grant HS08282, project period 9/30/96-3/31/00.

This randomized trial was designed to assess the effect of implementing a project-designed medical practice guideline intervention for reducing the duration of intravenous (IV) antibiotic therapy and length of stay (LOS) for patients hospitalized with community-acquired pneumonia (CAP). Physician groups in seven Western Pennsylvania hospitals were randomized to either the multifaceted guideline dissemination intervention or the control (no intervention). A total of 608 study patients were enrolled: 283 in the intervention arm and 325 in the control arm, with no significant differences in baseline patient characteristics between the two arms. The estimated hazard of stopping IV therapy was 1.19, and the estimated hazard of hospital discharge was 1.14 for LOS, adjusted for pneumonia risk class and site. Hazard ratios for LOS varied from 0.71 to 2.28 by site. There were no differences in mortality, morbid complications, rehospitalization, symptoms, functional status, return to usual activities, or satisfaction with care between intervention and control patients. There were no significant differences overall in medical costs between study arms, most likely due to large variability among patients. Guideline dissemination effectively reduced duration of IV antibiotic therapy and LOS without adversely affecting patient outcomes.

Copies of the abstract, executive summary, and final report, NTIS accession no. PB2001-100508; 142 pp, $36.00 paper, $17.00 microfiche are available from the National Technical Information Service (NTIS).

Factors Influencing Hospital Contracting with Managed Care. Jack Zwanziger, Ph.D., University of Rochester, Rochester, NY. AHRQ grant HS09529, project period 6/1/97-5/30/00.

The objective was to study the factors that influenced the contracting decision between managed care plans and general acute hospitals during 1994-1998 and any changes that occurred between 1993 and 1996-1997. The researchers identified managed care organizations that contracted in 46 metropolitan statistical areas for inclusion in the study. A response rate greater than 80 percent resulted in 400 plans participating in the study. Each plan provided a list of hospitals included in their network. Multivariate analyses were used to determine which plan and hospital characteristics significantly influenced the contracting patterns of managed care organizations. Between 1993 and 1996-1997, the size of the hospital networks tended to increase over time, but the contracting patterns did not change significantly. That is, those hospitals considered to be desirable in 1993 were still desirable in 1996.

Copies of the abstract, executive summary, and final report, NTIS accession no. PB2001-100462; 38 pp, $25.50 paper, $12.00 microfiche are available from the National Technical Information Service (NTIS).

Immunization Barriers: A Study of Generalist Physicians. Richard K. Zimmerman, M.D., M.P.H., University of Pittsburgh, Pittsburgh, PA. AHRQ grant HS08068, project period 7/1/94-6/30/99.

The researchers used computer-assisted telephone interviews in 1995 to survey 1,236 primary care physicians across the country about childhood immunizations. Half (47 percent) of the respondents said they were less likely to vaccinate children seen during acute-care visits compared with those seen during well-child visits, while 52 percent treated the situations the same. Some physicians were overly cautious when interpreting contraindications. More than half (58 percent) reported that they would be likely to refer an uninsured child to a public health vaccine clinic but were unlikely to refer an insured child. Almost all (90 percent) of the physicians who did not receive free vaccine supplies were likely to refer an uninsured poor child, compared with 44 percent of physicians who received free vaccine. The researchers compared provider responses with immunization data from children they vaccinated and found that a greater percentage of children were vaccinated on time when providers received free vaccine (77 percent vs. 48 percent for MMR and 82 percent vs. 66 percent for DTP#4).

Copies of the abstract, executive summary, and final report, NTIS accession no. PB2001-100177; 86 pp, $29.50 paper, $12.00 microfiche are available from the National Technical Information Service (NTIS).

Improving Health Outcomes in Diverse Populations. Barbara Tilley, Ph.D., Case Western Reserve University, Detroit, MI. AHRQ grant HS09824, project period 9/1/98-2/28/99.

AHRQ funded 11 Medical Treatment Effectiveness Program (MEDTEP) Research Centers on Minority Populations in 1991. These MEDTEP centers carried out many research projects across multiple disease areas, with a special emphasis on understanding racial/ethnic differences in health status and barriers to care in vulnerable populations. This 1-day conference gave the centers a forum in which to discuss their research findings and progress, specifically the "lessons learned" from this activity. The conference also included a discussion of future research priorities involving minority health issues. In addition, the researchers discussed their experiences in developing minority investigators and methodological developments, including advancements in measuring health status and outcomes.

Copies of the abstract and executive summary of conference proceedings, NTIS accession no. PB2001-101442; 16 pp, $23.00 paper, $12.00 microfiche are available from the National Technical Information Service (NTIS)

Incentives in a Specialty Care Carve-Out. Moira Inkelas, Ph.D., Santa Monica, CA. AHRQ grant HS10008, project period 9/30/98-4/30/00.

This study focused on the impact of a managed care carve-out policy on expenditures and "case-finding" for children with chronic disabling conditions in California. The study population included about 200,000 children with Title V-eligible medical diagnoses. Monthly Medicaid claims covering pre- and post-carve-out periods (1994-1997) were analyzed as a panel with control group comparisons. Control groups included children in mandatory managed care, voluntary or excluded managed care, and fee-for service. There was a significant increase in Title V program participation and substantial provider response to the carve-out policy's financial incentives. Carving-out medical care services from a Medicaid managed care expansion can affect provider behavior, program costs, and case-finding of children with special health needs.

Copies of the abstract, executive summary, and dissertation, NTIS accession no. PB2001-100337; 396 pp, $65.00 paper, $25.50 microfiche are available from the National Technical Information Service (NTIS).

Measurement of Homeless Patients' Satisfaction with Care. Carol L. Macnee, Ph.D., East Tennessee State University, Johnson City, TN. AHRQ grant HS09834, project period 9/30/98-12/31/99.

The goal was to develop and validate a reliable measure of satisfaction with care among homeless clients. The study was conducted in two phases: face-to-face interviews with 17 homeless individuals to explore their experiences of satisfaction with health care and the evaluation of several tools used to measure satisfaction with care. Five themes that represent satisfaction with health care were defined and were the basis for development of the 30-item Homeless Satisfaction with Care Scale (HSCS). A descriptive cross-sectional comparison was used to evaluate the HSCS and two established satisfaction measures in a sample of 168 homeless clients using a rural nurse-managed clinic or an urban Health Department clinic. The HSCS had good internal consistency, reliability, and correlated significantly with scores on the other two measures. Black homeless clients had significantly lower satisfaction scores than white homeless clients, suggesting the need to evaluate the relevance of items on satisfaction scales for black clients, as well as the appropriateness of primary care services for homeless clients who are black.

Copies of the abstract, executive summary, and final report, NTIS accession no. PB2000-108079; 32 pp, $25.50 paper, $12.00 microfiche are available from the National Technical Information Service (NTIS).

Mental Health Delivery in Primary and Specialty Care Settings. Annie G. Steinberg, M.D., Children's Seashore House, Philadelphia, PA. AHRQ grant HS09813, project period 4/1/98-6/30/99.

Over the last 10 years, children's mental health benefits have deceased significantly, primary care visits have become shorter, and interventions for children and adolescents have focused more on psychopharmacologic options. The evidence base for pediatric psychopharmacologic interventions is limited, with a widening gap between research in outcomes assessment and clinical practice. This, along with diminished access to services and rapid changes in the roles of the primary care provider and specialist, have dramatically altering "the playing field" of children's mental health. In response to these changes, the Children's Mental Health Alliance Project (CMHAP) was developed. CMHAP was a 1-year project that produced recommendations about the integration of evidence-based practice into primary and speciality care, made policy recommendations that optimize mental health services for children and adolescents, and provided direction for future research in the field.

Copies of the abstract, executive summary, and final conference report, NTIS accession no. PB2001-101443; 20 pp, $23.00 paper, $12.00 microfiche are available from the National Technical Information Service (NTIS).

Nursing Home Consumer Information System. Charlene A. Harrington, Ph.D., University of California, San Francisco. AHRQ grant HS07574, project period 4/1/95-3/31/99.

The goal of this study was to develop a nursing home consumer information system using data from the On-Line Survey Certification and Reporting (OSCAR) system data. The researchers created a uniform data base for calendar years 1991 through 1998 and prepared annual reports for each State for the Health Care Financing Administration's (HCFA) Web site. Using information from a survey of stakeholder opinions, an expert panel, and a factor analysis of Federal deficiencies, eight major quality factors were identified: quality of care; environment; treatment of residents; diet and nutrition; resident rights and assessment; drugs; and administration. A model consumer information system was developed and tested for usefulness with consumers. The final information system presented data on facility characteristics, resident characteristics, staffing, and deficiencies. The researchers worked with HCFA to implement the consumer information system on HCFA's Web site for all 16,500 nursing facilities in the United States. This was developed into the Medicare Nursing Home Compare Web site located at in the fall of 1999.

Abstract, executive summary, and final report, NTIS accession no. PB2001-100360; 16 pp, $23.00 paper, $12.00 microfiche are available from the National Technical Information Service (NTIS).

Pilot Feasibility Study for Heart Failure Surveillance. Robert J. Goldberg, Ph.D., University of Massachusetts Medical School, Worcester, MA. AHRQ grant HS09830, project period 9/30/98-3/31/00.

The researchers investigated the feasibility of population-based surveillance for heart failure (HF) by reviewing the hospital and outpatient medical records of metropolitan Worcester, MA residents with possible HF. The medical records of patients hospitalized in 1997 for possible HF and related diagnostic categories in three Worcester hospitals were reviewed. The outpatient records of greater Worcester residents with possible HF seen in 1999 at the Fallon HMO, the largest managed care plan in Central Massachusetts, were also reviewed to determine the usefulness of outpatient records for identifying cases of confirmed HF. Separate standardized data abstraction forms were developed for the review of hospital and outpatient medical records. A computerized database was developed and is being used for the entry of all study data. After reviewing eight possible ICD-9 discharge diagnosis codes for possible HF, the diagnostic category of 428 (HF) yielded a high proportion of cases of confirmed HF. Data analyses are presently ongoing to explore in greater depth the utility of using hospital and outpatient medical records to establish population-based surveillance for HF.

Copies of the abstract and executive summary, NTIS accession no. PB2000-108078; 18 pp, $23.00 paper, $12.00 microfiche are available from the National Technical Information Service (NTIS).

Practice Variations in Pain Control at the End of Life. Charles S. Cleeland, Ph.D., The University of Texas, Houston. AHRQ grant HS09820, project period 8/1/98-7/31/00.

Very little is known about pain among noninstitutionalized elderly people in the United States. Using data from the Asset and Health Dynamics Among the Oldest Old (AHEAD), these researchers examined the prevalence and impact of pain on perceived health status among the general population aged 70 or older. AHEAD is a longitudinal population-based survey begun in 1993 that examines the dynamic interactions between health, family, and economic variables in the postretirement period. In this study, the researchers used 1993 public release data on 8,215 respondents to examine predictors of perceived health status. They found that elderly people who often have pain are more than twice as likely to characterize their health status as "poor." Other factors include functional impairment, chronic disease, minority race, lower level of education, physician visits, illness severity, and depression. This study provides empirical evidence on the widespread prevalence of pain and its significant impact on perceived health status in a previously understudied population.

Copies of the abstract, executive summary, and final report, NTIS accession no. PB2001-101139; 26 pp, $23.00 paper, $12.00 microfiche are available from the National Technical Information Service (NTIS).

Pressure Ulcer Rates in Describing Nursing Home Quality. Dan R. Berlowitz, M.D., M.P.H., Boston Medical Center, Boston, MA. AHRQ grant HS09768, project period 4/1/98-3/31/00.

Assessing and improving the quality of nursing home care remains a priority. Central to this task is the development of risk-adjusted outcome measures for use in profiling care. Pressure ulcer development is a particularly important measure of nursing home quality in that pressure ulcers are a common condition, associated with significant morbidity, that usually can be prevented by following best practices. The researchers used the Minimum Data Set (MDS), a national, comprehensive, resident assessment instrument to derive and validate a risk-adjustment model for development of pressure ulcers in nursing homes. They compared the model with other risk-adjustment models and demonstrated how Bayesian hierarchical modeling can be used to improve reports of nursing home performance. They found that the risk-adjusted rates of pressure ulcer development declined by more than 25 percent between 1991 and 1995 in a sample of over 100 nursing homes.

Abstract, executive summary, final report, and appendix, NTIS accession no. PB2001-100181; 66 pp, $27.00 paper, $12.00 microfiche are available from the National Technical Information Service (NTIS).

Prohibition on Health Insurance Underwriting: A Means of Making Health Insurance Available or a Cause of Market Failure? Mark J. Browne, Ph.D., University of Wisconsin, Madison. AHRQ grant HS08941, project period 6/1/98-5/31/00.

Underwriting restrictions are passed to discourage insurers from discriminating contrary to social policy. In addition to prohibiting socially unacceptable discrimination, underwriting restrictions also have the effect of changing the consumption of insurance. Health insurance underwriting restrictions that prohibit insurers from using disability status, sex, and age to classify risks will in theory result in greater insurance consumption by certain groups, including disabled individuals, women, and the elderly. Conversely, the prohibitions are expected to result in less health insurance consumption by others, including able-bodied individuals, males, and younger adults. The researchers analyzed data from the Current Population Survey to test their hypotheses in both the small group and individual markets for health insurance and found evidence consistent with the theory.

Copies of the abstract, executive summary, and final report, NTIS accession no. PB2001-100461; 20 pp, $23.00 paper, $12.00 microfiche are available from the National Technical Information Service (NTIS).

Quality Improvement Organizations and Business Coalitions: A Guidebook to Collaborating for Quality Improvement. Virginia M. Paganelli, M.Ed., M.S.N., Center for Clinical Quality, Washington, DC. AHRQ grant HS10076, 8/1/99-7/31/00.

In 1999, several private-sector organizations convened a followup invitational workshop on community-based quality improvement in health care. The initial workshop, held in January 1997, included representatives from selected quality improvement organizations (QIOs), peer review organizations (PROs), and business coalitions from nine States who discussed opportunities for collaboration on quality improvement efforts. They reported on their collaborative activities at the followup meeting in 1999. They provided profiles and examples that can serve as a guide to promote collaboration between QIOs and business coalitions on community-based health care quality improvement projects. The conference report includes these profiles and examples, makes the "business case" for collaboration, and provides constructive guidance on the major steps involved in getting started. It also includes contact information for experts in community-based quality improvement.

Copies of the abstract, executive summary, and final report of a conference, NTIS accession no. PB2001-100179; 12 pp, $23.00 paper, $12.00 microfiche are available from the National Technical Information Service (NTIS).

Quality of Home Health Care: A Rural-Urban Comparison. Peter W. Shaughnessy, Ph.D., University of Colorado, Denver. AHRQ grant HS08031, project period 9/30/93-9/29/99.

The researchers measured quality by using patient outcomes—primarily discharge status and end-result outcomes (for example, improvement in ambulation between admission and discharge). They used primary and secondary national data from 1995-1996 on more than 7,200 rural and urban elderly men and women. The data covered home health care from admission to discharge or 120 days. The findings suggest less favorable outcomes for rural patients. Although end-result outcomes were similar for rural and urban nonhospitalized patients, rural patients had lower rates of discharge with goals met and higher rates of hospitalization. Also, total visits and resource use were lower for rural patients.

Copies of the abstract, executive summary, and final report, NTIS accession no. PB2001-101765; 168 pp, $41.00 paper, $17.00 microfiche are available from the National Technical Information Service (NTIS).

Specialty Societies and Health Care Purchasers Discuss a New Approach to Quality Improvement. Mark W. Legnini, Dr.P.H., M.P.H., Economic and Social Research Institute, Washington, DC. AHRQ grant HS10090, project period 1/18/00-7/18/00.

There is a huge gap between the quality of average medical care in this country and the quality of the best care that we know is possible and indeed available from certain providers. These researchers describe an approach that directly affects quality through the creation of externally accountable quality improvement programs involving collaboration between purchasers and providers. The ultimate objective of such programs would be ongoing assessment by physicians of the relationship between process and outcomes in an environment that encourages changes in practice to improve outcomes.

Copies of the abstract, executive summary, and final report of a conference, NTIS accession no. PB2001-100178; 22 pp, $23.00 paper, $12.00 microfiche are available from the National Technical Information Service (NTIS).

Statistical Method for Monitoring Nonacceptable Diagnosis Related Groups (DRGs). Marjorie Rosenberg, Ph.D., University of Wisconsin, Madison. AHRQ grant HS09826, project period 9/30/98-9/29/00.

The Medicare program, private insurers, and managed care organizations reimburse hospitals for inpatient admissions using the Diagnosis Related Group (DRG). The DRG is determined from a complicated algorithm based on patient medical records. Previous studies have generated concerns about "DRG upcoding," whereby incorrect DRG codes may be selected to obtain a higher reimbursement. Insurers rely on expensive manual audits of claims to verify the appropriateness of the underlying DRG coding. As part of a larger statistical system, these researchers developed a hierarchical Bayesian logistic regression for detecting claims with incorrect DRG coding using insurer claims data together with results from a manual audit. Estimates were developed from an insurer's 1993-1995 audited claims data and applied to 5,278 additional audited claims from the same timeframe (1,671 claims were coded incorrectly). For these 5,278 claims, the proposed system achieved 98 percent of the recovery of a complete audit at 88 percent of the cost of investigating the claim.

Abstract, executive summary, and final report (NTIS accession no. PB2001-101420; 18 pp, $23.00 paper, $12.00 microfiche) are available from the National Technical Information Service (NTIS).

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