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Conference on smoking cessation focuses on implementing AHCPR-sponsored guideline in the medical community

One in every five deaths in America is due to tobacco use, and the number of young people who begin to smoke increases each year. To address this continuing problem, smoking cessation experts and advocates met in Washington, DC, on September 17 and 18 to mobilize the medical community to implement the smoking cessation guideline released in April 1996 by the Agency for Health Care Policy and Research. The guideline, which was developed by a multidisciplinary panel of experts, targets primary care clinicians, smoking cessation specialists and programs, health care administrators, insurers, and large purchasers of health insurance (e.g., employers).

The guideline underscores the critical role that primary care clinicians can play by encouraging patients to quit smoking, and it provides step-by-step directions on how to achieve this goal. According to the guideline, physicians, dentists, nurses, and other caregivers should ask patients at every visit whether they smoke, record this information in the patient's file, and offer to help smokers quit. The guideline panel found nicotine replacement therapy (nicotine patches or gum), skills training, and clinician counseling (even as brief as 3 minutes) to be most effective.

The September 1996 conference addressed such issues as barriers to changing a health systems approach to tobacco dependence and to reaching the medically underserved, examples of how to make smoking cessation work, and reactions of stakeholders such as health systems, purchasers and employers, and consumers. Also addressed were ways to change provider behavior, as well as financing and reimbursement issues.

The conference, "AHCPR Smoking Cessation Guideline—Goals and Impact," was sponsored by the Society for Research on Nicotine and Tobacco, with support from The Robert Wood Johnson Foundation, the Centers for Disease Control and Prevention's Office on Smoking and Health, and the National Cancer Institute. The guideline is available in several formats: as a detailed clinical practice guideline, a consumer pamphlet, a primary care clinician pamphlet, and a quick reference guide for smoking cessation specialists; select Smoking Cessation for more information.

Institute of Medicine calls for fundamental changes in primary health care

Fundamental changes are needed to improve and expand primary health care in the United States in order to address the many challenges facing the Nation's health care system, according to a new report by an Institute of Medicine (IOM) committee. Rapid and profound alterations in the organization and financing of health care in the United States are forcing a shift away from costly care by specialists and toward primary care physicians, who can diagnose and treat a wide range of problems, notes the IOM committee.

In its report, the IOM committee recommends steps to provide all Americans with primary care services and details a plan for creating a well-trained primary care work force that would increase access to high-quality health care. In explaining the need to reshape primary care, the IOM committee notes that the only Federal group charged with expanding the knowledge base for primary care practice is the Agency for Health Care Policy and Research's Center for Primary Care Research, which was formally established in July 1995.

Among several recommendations by the committee is creation of a nonprofit consortium of professional societies, private foundations, government agencies, health care organizations, and representatives from the public to coordinate efforts that will promote and enhance primary care.

The Institute of Medicine is a private, nonprofit organization that provides health policy advice under a congressional charter granted to the National Academy of Sciences. The committee's work was supported in part by AHCPR.

The IOM report, Primary Care: Americas Health in a New Era, is available in two volumes from the National Academy Press, 2101 Constitution Avenue, N.W., Washington, DC 20418; phone 800-624-6242. The cost is $42.95 (prepaid) plus shipping charges of $4.00 for the first copy; subsequent copies are available at a reduced price. Call the National Academy Press for more information.

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AHCPR releases first evidence report on colorectal cancer screening

The Agency for Health Care Policy and Research has released the first evidence report under its new Evidence-based Practice Initiative. According to the report, evidence has shown that screening is effective in detecting early-stage colorectal cancers and their precursors. Early detection and treatment are the primary means of preventing deaths from colorectal cancer.

Colorectal cancer is the third most commonly diagnosed cancer and the second leading cause of cancer death in the United States. In 1996, an estimated 133,500 new cases of colorectal cancer were diagnosed, and colorectal cancer accounted for 54,900 deaths.

This evidence report is expected to improve the early detection and treatment of colorectal cancer by giving clinicians and others state-of-the-art information on screening and diagnostic tests to help them reduce the morbidity and mortality associated with this deadly disease, according to AHCPR's Administrator, Clifton R. Gaus, Sc.D. AHCPR's Evidence-based Practice Initiative, established in October 1996, will provide medical societies, health care systems, purchasers, health plans, and others with a scientific foundation for developing and implementing their own clinical practice guidelines, performance measures, and other quality improvement tools. In December 1996, AHCPR issued a Request for Proposals to fund Evidence-based Practice Centers to produce future evidence reports and also published a notice in the Federal Register inviting nominations for report topics.

The Colorectal Cancer Screening Evidence Report is based on a systematic review of 3,500 citations from the scientific literature published between 1966 and 1994. The review found evidence that a reduction in deaths from colorectal cancer can be achieved through detection and treatment of early-stage colorectal cancers and the identification and removal of adenomatous polyps, the precursors of colorectal cancer. Other evidence showed that:

  • Colorectal cancer incidence rises with age, beginning around age 40, and is higher in men than in women (60.4 versus 40.9 per 100,000 per year).
  • Survival from colorectal cancer is closely related to the clinical and pathological stage of the disease at diagnosis. Up to 90 percent of patients with cancer limited to the bowel wall will be alive 5 years after diagnosis, compared with 35 to 60 percent of patients with lymph node involvement, and less than 10 percent of patients with metastatic disease.
  • Racial differences in colorectal cancer survival have been observed. The 1983 to 1989 5-year relative survival for colon cancer was 61 percent among white men, 50 percent among white women, 48 percent among black men, and 49 percent among black women. Black men and women with colorectal cancer have a 50 percent greater probability of dying of colon cancer than do white men and women.
  • Well-established risk factors for colorectal cancer include older age, male sex, history of inflammatory bowel disease, certain hereditary conditions, and a family history of colorectal cancer. However, about 75 percent of all colorectal cancer occurs in people with no known risk factors.
  • Most Americans are not screened for colorectal cancer. More than two-thirds of patients present with advanced disease. Information from the National Health Interview Survey (NHIS) indicates that in 1992, only 17.3 percent of people aged 50 and older had undergone fecal occult blood testing the previous year, and 9.4 percent had undergone sigmoidoscopy in the previous 3 years.
  • Screening with fecal occult blood testing has been shown to reduce colorectal cancer mortality. Screening with flexible sigmoidoscopy can reduce colorectal cancer mortality risk, but clinical trials have not been performed that directly assess mortality reduction.
  • Double contrast barium enema and colonoscopy are proven methods of identifying polyps and colorectal cancer, but they have not been studied as screening tests.
  • Further research is needed to demonstrate the effectiveness of colorectal cancer screening tests and determine proper intervals for such testing.

The information contained in AHCPR's evidence report is the basis for a clinical practice guideline by the American Gastroenterological Association (AGA) on colorectal cancer screening scheduled for publication in the February issue of Gastroenterology. AGA led a consortium that directed an AHCPR-sponsored clinical practice guideline panel on colorectal cancer screening. Work on the AHCPR-sponsored guideline was discontinued when the Agency ended its clinical practice guideline program and began developing evidence reports. AGA then decided to sponsor its own science-based guideline on colorectal cancer screening.

An Executive Summary (AHCPR Publication No. 97-0302) of the Colorectal Cancer Screening Evidence Report is available from the AHCPR Publications Clearinghouse. Select for the summary of the report online.

AHCPR plans conference for summer '97

Mark your calendars now—July 20-23, 1997, will be the dates for the AHCPR-sponsored conference, "Translating Evidence into Practice," to be held at the Renaissance Hotel, Washington, DC. The conference will focus on evidence-based practice, including implementation of guidelines, development and implementation of other quality improvement tools, and related legal and ethical issues.

AHCPR funds studies to examine patient referral patterns and the use of computers in clinical decisionmaking

The Agency for Health Care Policy and Research recently funded 13 new primary care research projects: eight projects to determine how the referral of primary care patients to medical specialists and other specialized services affects the quality and cost of health care; and five projects to improve primary care services overall. Other studies recently funded by AHCPR will explore the benefits of using computerized decision-support systems in everyday clinical practice. These new studies are described below.

Primary Care Research

More than half of all Americans are now covered by managed care plans, which often require the use of a primary care physician or gatekeeper to manage the referral of patients from primary to specialty care. To strengthen the scientific base underpinning the referral policies of health plans, AHCPR issued a call in early 1996 for research applications on the referral of patients to specialists.

The following eight studies, with total estimated funding of $4.79 million, were chosen from among the applicants. Each study will run for 2 years.

  • Nephrologist Care and Outcomes in Renal Insufficiency (AHCPR grant HS09398). Jerome L. Avorn, M.D., Brigham and Womens Hospital, Boston, MA. Total estimated funding: $634,179. To investigate the appropriate timing of patient referrals to a nephrologist prior to the diagnosis of end-stage renal disease (ESRD); to examine how use of a nephrologist affects the clinical course and outcomes of ESRD; and to investigate other related issues.
  • Specialty Care in Closed Versus Open Access HMOs (AHCPR grant HS09414). Jose Escarce, M.D., University of Pennsylvania, Philadelphia, PA. Total estimated funding: $707,328. To examine the use of primary care and specialist services by patients in a closed-panel gatekeeper HMO plan versus those in a point-of-service (POS) plan. To investigate whether primary care physicians refer patients in the two plans at different rates and the factors influencing the choice of specialists.
  • Referrals in Primary Care (AHCPR grant HS09397). Peter Franks, M.B.B.S., M.S., Highland Hospital, Rochester, NY. Total estimated funding: $469,112. To examine variations in referral rates among primary care physicians in a large managed care organization, as well as the characteristics of the patients, physicians, and practices associated with the variations and the impact of referral rate variations on costs and patient outcomes.
  • Unmet Need and Use of Vision Care by Medicare Beneficiaries (AHCPR grant HS09424). Carol Mangione, M.D., University of California, Los Angeles, School of Medicine. Total estimated funding: $694,285. To investigate how the use of specialist referrals and services may be affected by payment organization and examine the use of vision care services for Medicare patients in fee-for-service versus capitated managed care settings.
  • Patterns of Referral and Care for Children on Medicaid (AHCPR grant HS09416). James Perrin, M.D., Massachusetts General Hospital, Boston. Total estimated funding: $245,892. To examine the consequences of referring children enrolled in Medicaid to pediatric specialists, compared with adult specialists, for common and uncommon chronic pediatric conditions.
  • Specialty Referrals Among California Physician Groups (AHCPR grant HS09372). Joseph Selby, M.D., Kaiser Foundation Research Institute, Oakland, CA. Total estimated funding: $725,925. To examine the determinants of referral among 6,300 adult California managed care patients with one of three common chronic conditions; the possible effect of plans financial arrangements and utilization management techniques on referral decisions; and the possible association between referral patterns and quality of care.
  • Managed Care and the Primary-Specialty Care Interface (AHCPR grant HS09377). Barbara Starfield, M.D., M.P.H., Ambulatory Sentinel Practice Network, Denver, CO. Total estimated funding: $909,794. To characterize referral patterns by primary care physicians and determine how those patterns and the coordination of referrals are influenced by financial incentives and organizational controls imposed by managed care organizations.
  • Analysis of Physician Referrals of Medicare Patients (AHCPR grant HS09439). Bruce C. Stuart, Ph.D., Pennsylvania State University, University Park. Total estimated funding: $403,397. To characterize patterns of physician referrals and consultations in the treatment of noninstitutionalized elderly and disabled Medicare beneficiaries and identify differences in costs and patient outcomes associated with specialist referrals for treatment of cardiovascular disease in Medicare patients.

In addition, AHCPR has funded five other studies, with total estimated funding of $3.54 million, to improve primary care. Project periods vary from 2 to 4 years. They are:

  • Prevention and Competing Demands in Primary Care Practice (AHCPR grant HS08776), 1996-1999. Principal investigator: Benjamin F. Crabtree, Ph.D., University of Nebraska Medical Center, Omaha. Total estimated funding: $879,978. To investigate why primary care physicians do or do not provide preventive health services as part of their practice, and to study the competing demands on physicians for the delivery of medical and clinical preventive services.
  • Effective Organization of Adolescent Health Services (AHCPR grant HS08192), 1996-1998. Principal investigator: Jonathan B. Klein, M.D., University of Rochester School of Medicine, Rochester, NY. Total estimated funding: $311,642. To analyze how the organization of adolescent health services affects teenagers' access to care.
  • State Service-Contingent Programs for Health Providers (AHCPR grant HS09165), 1996-1999. Principal investigator: Donald E. Pathman, M.D., M.P.H., University of North Carolina, Chapel Hill. Total estimated funding: $546,766. To evaluate the effectiveness of State service-contingent programs and the various methods they use to reduce shortages and inappropriate distribution of primary care providers.
  • Health Education in an HMO: Effectiveness and Efficiency (AHCPR grant HS08641), 1996-2000. Principal investigator: Ronald W. Toseland, Ph.D., State University of New York, Albany. Total estimated funding: $1.22 million. To compare the short- and long-term effects of a managed care program to teach health education, coping, and other skills to individuals who care for their frail elderly spouses and to examine the impact of the training on caregivers' and care recipients' health care utilization and costs.
  • Couples' Preference for Prostate Cancer Screening. (AHCPR grant HS08992), 1996-1998. Principal investigator: Robert J. Volk, Ph.D., University of Texas Medical Branch, Galveston. Total estimated funding: $586,610. To determine the appropriateness of prostate cancer screening from the perspectives of men who have the disease and their spouses. To examine differences in prostate-cancer-screening preferences among Mexican-American, black, and non-Hispanic white husbands and wives.

Computerized Support for Clinical Decisionmaking

AHCPR will spend a total of $4.55 million over the next 3 years to support a series of studies that will explore the benefits of using computerized decision-support systems in everyday clinical practice. AHCPR expects that these projects will move medical decisionmaking computer software programs beyond the laboratory and into primary care networks. The studies are intended to determine whether everyday use of these systems can improve health care quality, efficiency, and effectiveness at a reduced cost. Each project will focus on a clinical area where the diagnosis and management of illnesses are suboptimal.

This research is a component of AHCPR's participation, as one of 12 member agencies, in the High Performance Computing and Communications Program of the United States (HPCC) and in the National Information Infrastructure (NII), an initiative of President Clinton and Vice President Gore. HPCC and NII promote increased speed and capacity of computers and electronic networks, as well as make the transmission and storage of data more secure.

AHCPR aims to link HPCC technology to community health needs, specifically in the areas of computer-based patient records, computerized decision-support systems, and telemedicine. With its research in these areas, AHCPR is evaluating promising technologies for measuring outcomes, access, and costs of health care and for delivering improved quality of care.

These newly funded, 3-year studies will use networks such as the Internet as vehicles for extending the use of computer systems beyond academic medical centers and into the offices of primary care physicians. The following five studies were funded:

  • Computerized Decision Support for Posttransplant Care (AHCPR grant HS09407). Principal investigator: Keith M. Sullivan, M.D., Fred Hutchinson Cancer Research Center, Seattle, WA. Total estimated funding: $1.51 million. To look at improving primary care physicians abilities to manage postdischarge bone marrow transplantation patients by developing, implementing, and evaluating a World Wide Web-based computerized decision-support system. Such a system would facilitate information exchange and guide interactions among physicians in different locations and centrally located experts in bone marrow transplantation.
  • Family Linkages Supporting Hyperbilirubinemia Guidelines (AHCPR grant HS09390). Principal investigator: Charles J. Homer, M.D., Childrens Hospital, Boston, MA. Total estimated funding: $726,589. To develop and implement a computer-based decision-support system that will improve access to patient records and practice guidelines to help providers identify and treat infants at risk for developing significant medical problems associated with hyperbilirubinemia.
  • Depression Care Using Computerized Decision Support (AHCPR grant HS09421). Principal investigator: Bruce L. Rollman, M.D., University of Pittsburgh, Pittsburgh, PA. Total estimated funding: $644,409. To develop and implement a computerized decision-support system that prompts primary care physicians to implement treatment recommendations based upon the AHCPR-sponsored practice guideline on depression in primary care and, subsequently, to conduct a randomized clinical trial of the clinical outcomes and costs of providing care this way. To evaluate the effects of disseminating the depression guideline by computer on physicians' knowledge, attitudes, and practices.
  • Evaluating Computer Decision Support for Preventive Care (AHCPR grant HS09507). Principal investigator: Stephen M. Downs, M.D., University of North Carolina, Chapel Hill. Total estimated funding: $878,855. To expand and modify for everyday use in pediatric office practices an existing guideline-based computerized decision system for childhood preventive services and evaluate the effects of the system on processes of care and outcomes of patients in private pediatric practices.
  • Interactive, Guideline-Based Decision Support on the Web (AHCPR grant HS09436). Principal investigator: David F. Lobach, M.D., Ph.D., Duke University Medical Center, Durham, NC. Total estimated funding: $785,343. To create a clinical decision-support system that uses a World Wide Web-based guideline server which is directly accessible from electronic medical records systems and protects patient confidentiality. To study the increased use of guideline recommendations by clinicians who have access to the decision-support system.

In addition, AHCPR has funded one other study on computerized decision support through an interagency agreement with the National Library of Medicine. The study, "Computerized Decision-Support Deployment in Diverse Clinical Settings," will be led by Michael G. Kahn, M.D., Ph.D., Barnes Jewish Hospital, St. Louis, MO. In this study, researchers will implement and evaluate two computerized drug monitoring systems—DoseChecker and ADE Monitor—and design and implement a drug alert notification subsystem in different clinical settings within the Washington University and Barnes Jewish Hospital health system. The alert notification subsystem will be evaluated for differences in expert system performance, physician acceptance, and clinical impact.

Registration deadline nears for AAHP managed care conference

The "Building Bridges III: Translating Research into Action" research conference, sponsored by the American Association of Health Plans and the Agency for Health Care Policy and Research, will be held April 3-4, 1997, at the Doubletree Hotel in New Orleans, LA. You must register by Friday, March 21, 1997, in order to take advantage of a reduced registration fee.

This is the third conference in a series that is intended to build bridges between the research community and those who use the results of managed care research. Some of the topics to be covered in plenary and breakout sessions include an overview of current research activities; how research is being used by health plans, purchasers, and the research community; how financing and organization affect health care outcomes; research on special populations; mental health and managed care; innovations in performance measurement; consumer survey research; collaborative research; risk assessment and quality of care; guidelines; and future challenges in managed care research.

The registration fee is $400 until March 21, 1997, and $450 thereafter, including on-site registration. For more information, contact the AAHP Registrar, 1129 20th Street, N.W., Suite 600, Washington, DC 20036; phone (202) 778-3269, fax (202) 778-8506.

New publications available from AHCPR and NTIS

The following publications and final reports are now available from the Agency for Health Care Policy and Research and the National Technical Information Service (NTIS).

Health Technology Assessment. AHCPR's Center for Health Care Technology recently published a Health Technology Assessment and a Health Technology Review. These reports, which are now available from AHCPR, are usually prepared to assist federally financed health care programs, such as Medicare and CHAMPUS (Civilian Health and Medical Program of the Uniformed Services), with coverage decisions. Health Technology Assessments present detailed analyses of the risks, clinical effectiveness, and uses of medical technologies. Health Technology Reviews are usually composed when the available medical evidence is limited and the published medical or scientific literature is insufficient in quality or quantity for a detailed assessment.

Hotta, S.S. (1996). Living Related Liver Transplantation: Health Technology Review No. 13 (AHCPR Publication No. 96-0059).

Liver transplantation is a successful and accepted procedure for the treatment of selected patients who have end-stage liver disease. Since the first successful living related liver transplantation (LRLT) was accomplished in 1989, other LRLTs, in which a segment or lobe of the liver from a living donor is transplanted into a recipient, have been performed in medical centers around the world. Results of the limited number of LRLTs performed indicate that the patient and graft survival rates are comparable to the outcomes of liver transplants performed using cadaveric livers. Almost all of the recipients have been infants or young children. Parents or other family members served as donors and recovered from the surgical procedures without notable complications. The report is available from the AHCPR Publications Clearinghouse.

Holohan, T.V. and Handelsman, H. (1996). Lung-Volume Reduction Surgery for End-Stage Chronic Obstructive Pulmonary Disease: Health Technology Assessment No. 10 (AHCPR Publication No. 96-0062).

Lung-volume reduction surgery (LVRS) has been proposed as a palliative treatment for selected patients with diffuse emphysema and end-stage chronic obstructive pulmonary disease who have failed conventional therapy. A number of surgical techniques have been used that are designed to reduce lung volume by surgical resection or laser plication (tucking and folding to reduce size). These techniques are designed to restore previous compromised lung elastic recoil so that expiratory airflow obstruction is reduced, respiratory mechanics are improved, and disabling dyspnea (labored breathing) is relieved. Preliminary data derived from both published and unpublished sources indicate some favorable short-term benefits of LVRS. However, objective postoperative data are available for only a small proportion of patients, and long-term followup data are not available. In addition, these surgeries are associated with significant morbidity (and an estimated surgical mortality rate of 6 percent) and prolonged hospital stays in a substantial percentage of patients. Patient selection criteria are not uniform, and they are changing. In addition, controversy continues concerning the most appropriate surgical techniques for various categories of patients. The current data do not permit a logical and scientifically defensible conclusion regarding the risks and benefits of LVRS, according to the authors. The report is available from the National Technical Information Service.

Information to Guide Physician Practice.

With the ever-increasing scope and complexity of clinical information, clinicians often find it hard to stay abreast of current medical knowledge. To better understand the dynamic environment in which medical information is organized and disseminated, the Agency for Health Care Policy and Research, in collaboration with the Department of Health and Human Services' Office of the Assistant Secretary for Planning and Evaluation, sponsored a study to analyze sources of information available to physicians. Researchers from The Lewin Group, of Fairfax, VA, reviewed 233 articles from the literature relating to the information environment faced by clinicians, synthesized major themes, and created an interactive database to allow easy access to this literature. In addition, they reviewed online electronic information sources. The researchers analyzed the mechanisms that physicians use to determine which information is most valuable and the effects of information use on physician behavior and clinical practice patterns. Project findings were tested in three focus groups: both attending and resident physicians in an academic medical center, and health care providers in a small rural practice. Select for a summary of the study.

A full report of the study and a four-disk database are available as a set from the National Technical Information Service (NTIS accession no. PB97-500250; 102 pp, $50.00 set)

Oregon Consumer Scorecard Project: Final Report.

The final report of the Oregon Consumer Scorecard Project describes the development and testing of prototype consumer-oriented health plan scorecard materials that can be used by other States in developing materials for their residents. It includes copies of the consumer guide developed by the consortium and the Oregon Health Plan consumer satisfaction survey used in this project. The primary purpose of scorecards is to aid consumers in choosing a health plan that best meets their individual needs and preferences for how health services are delivered. Scorecards are intended to aid consumer decisionmaking in two ways: one, by providing comparative health plan information that is based on the expressed information preferences of consumers, and two, by serving as an educational tool in those areas of health plan performance where consumers lack understanding on how various plans "manage" health care. A secondary goal is that the scorecard be suitable for use as a comparative performance measurement tool that provides feedback to health plans, purchasers, and State policymakers about how well health plans are performing and meeting the expectations and needs of consumers. The materials were developed, with AHCPR support (contract 282-93-0036), by the Oregon Consumer Scorecard Consortium. This public/private consortium represents a partnership between more than 50 active members, including analysts from the health services research community and experts in consumer information and quality performance measurement, representatives from most of the plans that participate in the Oregon Health Plan Medicaid Program, and members of the community at large.

A limited number of copies of the Oregon Consumer Scorecard Project: Final Report (AHCPR Publication No. 97-N008) are available from the AHCPR Publications Clearinghouse. Additional copies of the report are available from the National Technical Information Service (NTIS accession no. PB97-117758; 142 pp, $31.00 paper, $14.00 microfiche).

Former Surgeon General Koop to be honored

The Royal Society of Medicine Foundation will honor former Surgeon General of the United States C. Everett Koop, M.D., at the Richard T. Hewitt Award Dinner to be held April 6, 1997, at the Cosmos Club in Washington, DC. The awards dinner honoring Dr. Koop will be held in conjunction with "Charting the Future of the Doctor-Patient Relationship," an international conference for physicians in academia, industry, government, and clinical practice interested in the doctor-patient relationship. The conference is being sponsored by the Royal Society and will be held April 6-8, 1997, also at the Cosmos Club.

For more information or to register, contact Mrs. Wilda Gallagher at the Royal Society of Medicine Foundation, 16 East 69th Street, New York, NY 10021; phone (212) 396-1103, fax (212) 396-1104.

AHCPR announces the availability of a workbook and audiotapes from the User Liaison Program

The Agency for Health Care Policy and Research's User Liaison Program has prepared two new products on managed care: a 275-page, spiral-bound workbook developed especially for local health officials, and a set of 10 audiotapes of a recent AHCPR-sponsored workshop intended for both State and local health officials.

The workbook, Assessing Roles, Responsibilities, and Activities in a Managed Care Environment: A Workbook for Local Health Officials, highlights the issues and questions that can help local officials assess and implement alternative roles, responsibilities, and activities for their local health departments (LHDs) in a managed care environment. In addition, it identifies key policy initiatives that may be important for local officials to consider as they carry out policy development efforts for their LHDs. Each chapter identifies a series of important questions that local health officials will need to answer in the process of developing a strategic plan for their LHDs. Most chapters conclude with a broader set of questions/issues that should help users synthesize the information they collect and identify key action steps to be taken or decisions to be made.

This workbook is the result of a collaborative effort between User Liaison Program and a public health work group comprising representatives from the National Association of County and City Health Officials, the Association of State and Territorial Health Officials, and the Association of Maternal and Child Health Programs.

Copies of the workbook (AHCPR Publication No. 96-0057) are available from the AHCPR Publications Clearinghouse.

A set of 10 audiotapes captures the presentations and discussions from the recent AHCPR-sponsored workshop for State and local health officials, "Local Health Departments in a Managed Care Environment: Challenges and Opportunities," which was held December 2-4, 1996, in St. Louis, MO. Topics covered by presenters include an overview of selected States policy directions, strengthening collaborations between public health and personal health care systems, LHD involvement in the direct delivery of personal health care services, assessing the impact of managed care on a community's health, and other high priority issues facing State and local health officials. These tapes are available as a set (AHCPR Audiovisual No. 97-AV01) from the AHCPR Publications Clearinghouse.

Attention Researchers: Proceedings Available

Copies of the proceedings from the Sixth Conference on Health Survey Research Methods, held in Breckenridge, CO, June 24-26, 1995, are available free from the University of Illinois. This 238-page volume contains 29 presentations organized into five sessions, as well as two discussion papers and a summary paper for each session. The sessions follow:

  • Measuring medical care and health status.
  • Research on survey questions.
  • Sampling and cooperation.
  • Special populations and sensitive issues.
  • Integrating surveys and other data.

Copies may be ordered from Bernita Rusk, Survey Research Laboratory, University of Illinois, 909 West Oregon Street, Suite 300, Urbana, IL 61801l; fax: (217) 244-4408; E-mail:

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