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Anderson, J.P., Kaplan, R.M., Coons, S.J., and Schneiderman, L.J. (1998). "Comparison of the Quality of Well-being Scale and the SF-36 results among two samples of ill adults: AIDS and other illnesses." (AHCPR grants HS05617 and HS06912). Journal of Clinical Epidemiology 51(9), pp. 755-762.

This study compares the results of using two measures of health-related quality of life, the SF-36 and the Quality of Well-being Scale (QWB) with other scoring methods to characterize health outcomes over time in 201 adults with serious illnesses, including cancer and AIDS. The SF-36 includes nine dimensions of illness (morbidity). The QWB is a preference-based measure that combines morbidity and mortality into a single number. All patients received both measures at baseline and at 6-month intervals thereafter over a period of 2.5 years. The QWB captured outcomes that characterize the AIDS syndrome. The SF-36 differentiated between AIDS and other illnesses on some scales but without consistent direction. The QWB showed a decrease in quality of life over time for both patients with AIDS and other illnesses, while the SF-36 did not. This is because many patients died, and these deaths were counted as outcomes by the QWB and as missing data by the SF-36. The QWB appears to better capture outcomes of serious illness over time than does the SF-36, conclude the researchers.

Berkey, C.S., Hoaglin, D.C., Antczak-Bouckoms, A., and others (1998). "Meta-analysis of multiple outcomes by regression with random effects." (AHCPR grant HS05936). Statistics in Medicine 17, pp. 2537-2550.

Earlier studies have shown how to perform fixed-effects meta-analysis of studies, when each study provides results on more than one outcome per patient, and these multiple outcomes are correlated. The fixed-effects, generalized-least-squares approach analyzes the multiple outcomes jointly within a single model, and it can include covariates, such as duration of therapy. However, unexplained differences often remain, even after taking into account known or suspected covariates. To address this problem, these authors propose two random-effects approaches for the regression meta-analysis of multiple correlated outcomes in a meta-analysis of periodontal clinical trials.

Callahan, C.M., Wolinsky, F.D., Stump, T.E., and others (1998). "Mortality, symptoms, and functional impairment in late-life depression." (AHCPR grants HS07632 and HS07763). Journal of General Internal Medicine 13, pp. 746-752.

For this study, the researchers correlated physical decline and depressive symptoms among 300 patients aged 60 years and older who scored 16 or higher on the Centers for Epidemiologic Studies Depression Scale and 100 control patients who scored lower than this threshold during routine primary care office visits from 1990 to 1993. They followed the patients through 1996, documenting changes in depressive symptoms and functional impairment over time and calculating risk of death. Symptoms of depression were not associated with death. The strongest predictors of death in this group were smoking history, older age, male sex, and evidence of poor nutrition. Patients with depressive symptoms during the initial interview (baseline) reported nearly twice the functional impairment of those without depressive symptoms and were more likely to report depressive symptoms and functional impairment at subsequent interviews. Also, decline in physical functioning was independently correlated with a concurrent increase in depressive symptoms, even when accounting for patients' prior level of depressive symptoms.

Christakis, N.A., and Iwashyna, T.J. (1998). "Attitude and self-reported practice regarding prognostication in a national sample of internists." (NRSA training grant T32 HS00080). Archives of Internal Medicine 158, pp. 2389-2395.

A physician's assessment that a patient is "terminally ill" is critical to decisions such as withdrawal or withholding of life support and in qualifying patients for the Medicare hospice benefit. However, doctors vary in their definition of "terminal" illness and find such prognostication stressful, according to this study. The researchers analyzed the responses of 697 internists to a survey assessing their attitudes and practices with respect to predicting a patient's survival time. They also obtained comments from 162 physicians and interviewed 20 other physicians. Results showed that the physicians in this study disagreed on the meaning of "terminal." About 68 percent defined it as having less than 16 weeks to live, and 32 percent defined terminal as having 16 or more weeks to live. About 60 percent of these doctors said they find predicting a patient's survival time stressful and difficult, so much so that 44 percent wait to be asked by a patient before offering predictions. About 90 percent of the doctors said they avoid being too specific in their predictions, and 57 percent reported inadequate training on prognostication.

Christiansen, C.L., Gortmaker, S.L., Williams, J.M., and others (1998, November). "A method for estimating solid organ donor potential by organ procurement region." (AHCPR grant HS07118). American Journal of Public Health 88(11), pp. 1645-1650.

These authors sought to develop a method for estimating potential solid organ donors and measuring donation performance in a geographic region based on readily available data on the hospitals in that region. They reviewed the medical records of a random sample of 89 hospitals from three regions to attain a baseline of donor potential, as well as data on a range of hospital characteristics. They found that five hospital characteristics predicted donor potential: hospital deaths, hospital Medicare case-mix index, total hospital staffed beds, medical school affiliation, and trauma center certification. They aggregated hospital estimates to obtain regional estimates, which indicated that actual donations represented from 28 to 44 percent of the potential in the regions studied.

Deyo, R.A., Battie, M., Beurskens, A.J., and others (1998). "Outcome measures for low back pain research: A proposal for standardized use." (AHCPR grant HS08194). Spine 23(18), pp. 2003- 2013.

The measurement of patient outcomes in clinical studies of low back pain has been vexing for many investigators. Traditionally, they used physiologic measures such as range of motion and muscle strength. But in many cases, such measures are only weakly associated with outcomes that are more relevant to patients and society, such as symptom relief, daily functioning, and work status. In this study, an expert panel considered reliability, validity, responsiveness, and practicality in recommending a standard battery of six questions. The questions addressed pain symptoms, function, well-being, disability, disability in a social role, and satisfaction with care. The questionnaire is short enough to be used in routine care settings for quality improvement and research purposes. An expanded outcome set includes measures of severity and frequency of symptoms, a measure of general health status, and questions about satisfaction with symptoms, three types of "disability days," and an optional single item on overall satisfaction with medical care.

Hoffman, J.R., Wolfson, A.B., Todd, K., and others (1998). "Selective cervical spine radiography in blunt trauma: Methodology of the National Emergency X-Radiography Utilization Study (NEXUS)." (AHCPR grant HS07809). Annals of Emergency Medicine 32, pp. 461-469.

Because physicians don't want to miss cervical spine injury, which can produce catastrophic neurologic disability, they often make extremely liberal use of radiography in patients who have received blunt trauma. However, this practice exposes large numbers of patients to x-ray imaging at considerable expense while detecting injuries in a small minority. Clinical criteria that could identify patients at sufficiently low risk to decide that cervical spine radiography is unnecessary would help reduce costs and unnecessary radiation exposure. The National Emergency X-Radiography Utilization Study (NEXUS) is a very large, federally supported, multicenter study designed to define the sensitivity for detecting significant cervical spine injury of criteria previously shown to have high negative predictive value. NEXUS will be conducted at 23 different emergency departments across the United States and is projected to enroll more than 20 times as many patients with cervical spine injury as any previous study.

Horgas, A.L., Wilms, H.U., and Baltes, M.M. (1998). "Daily life in very old age: Everyday activities as expression of successful living." (NRSA fellowship F32 HS00077). The Gerontologist 38(5), pp. 556-568.

Adults 70 to 100 years of age spend about one-third of the waking day (16 hours) on chores such as shopping, paying bills, and doing housework. They spend about half of the day on leisure activities, mostly watching television and reading. Finally, they spend about 3 hours (19 percent of the day) resting. Most of the typical day is spent alone and at home, whether home is an apartment, house, or nursing home. Age and residence make a significant difference in how the day is spent, regardless of sex, education, or income. For instance, those older than age 90 and those in long-term care facilities perform fewer overall activities and spend more time resting. Elderly people spend about 3 hours of the day with their spouse or partner, 40 to 50 minutes a day with roommate(s) or groups of people and professional caregivers, and only 15 to 20 minutes a day with children, relatives, and friends. The researchers interviewed a representative sample of 516 people, 70 to 105 years of age and living in Berlin, Germany, about how they spent each day and then correlated activities with sociodemographic characteristics.

McDonald, C.J., Overhage, J.M., Dexter, P.R., and others (1998). "Canopy computing: Using the web in clinical practice." (AHCPR grants HS07719 and HS08759). Journal of the American Medical Association 280(15), pp. 1325-1329.

Physicians need tools that can easily join all the separate sources of clinical information under one umbrella, where they and other health care professionals can easily and quickly access patient information and other data. The World Wide Web offers most of the tools needed to create this ideal, according to the authors of this commentary. The Web tools they refer to range from e-mail addresses and browser displays to security measures that restrict access to confidential patient information. Armed with a Web browser, an authorized user could access all modes of clinical information, including text data, such as echocardiogram reports; graphic tracings, such as ECGs; images, such as x-rays; and sound recordings, such as physician dictation. Moreover, a user on a Web browser could access any Web-enabled clinical system to which he or she had access rights. A number of academic medical centers have wrapped their electronic medical record system in browser technology, enabling physicians to access a whole library of medical knowledge without leaving their workstation or losing their place in a patient's electronic chart.

Mendelson, D.N., Goodman, C.S., Ahn, R., and Rubin, R.J. (1998). "Outcomes and effectiveness research in the private sector." (AHCPR contract 290-96-0009). Health Affairs 17(5), pp. 75-90.

Outcomes and effectiveness research evaluates the impact of health care (for example, drugs, medical devices, and procedures) on health outcomes of patients and populations. The purpose of this study was to assess private-sector efforts in outcomes research and examine whether these efforts duplicate or overlap Federal outcomes research. The researchers reviewed published and unpublished literature on the topic; interviewed more than 30 experts involved in private-sector outcomes and effectiveness research; and convened an expert panel on the topic. They concluded that the main priority for this research in the private sector is its potential financial impact for the sponsoring organization. The authors suggest that AHCPR and private-sector entities can work together to identify and promote complementary actions to address unmet national research priorities, such as lung reduction surgery for emphysema. Also, AHCPR may be able to increase visibility for private-sector outcomes studies of public concern that otherwise might not receive adequate exposure due to loss of sponsor interest.

Murray, M.D., Loos, B., Tu, W., and others (1998). "Effects of computer-based prescribing on pharmacist work patterns." (AHCPR grant HS07763). Journal of the American Medical Informatics Association 5, pp. 546-553.

Computer-based prescribing results in major changes in the type of work done by hospital-based outpatient pharmacists, concludes this study. The researchers examined the impact of computer-based prescribing on the outpatient pharmacy of a health center. Total staff hours and prescriptions handled were similar before and after computer-based prescribing. But after implementation of computer-based prescribing, pharmacists spent about 13 percent more time correcting prescription problems, had 4 percent less idle time, and spent about 2 percent less time in discussions with others. Pharmacists also spent 34 percent less time filling prescriptions, 46 percent more time in problem-solving activities involving prescriptions, and 3 percent less time providing advice.

O'Dell, M.W., Hubert, H.B., Lubeck, D.P., and O'Driscoll, P. (1998). "Pre-AIDS physical disability: Data from the AIDS time-oriented health outcome study." (AHCPR grant HS06211). Archives of Physical Medicine and Rehabilitation 79, pp. 1200-1205.

This study shows that people who are infected with the human immunodeficiency virus (HIV) that causes AIDS demonstrate relatively low levels of physical dysfunction before they develop an AIDS-defining illness. The researchers studied a community-based sample of 531 asymptomatic and 345 symptomatic people with HIV infection, most of whom were white, well-educated, homosexual and bisexual men. The subjects were given an HIV health assessment questionnaire, which measured perceived disability in eight areas of mobility and activities of daily living. There were few differences between the asymptomatic and symptomatic groups. With few exceptions, less than 10 percent of the group perceived any physical limitations, and no more than 2 percent reported being "unable to perform" any given function. However, both groups demonstrated somewhat higher levels of physical dysfunction than an age-, race-, and education-matched comparison group of 2,567 adults without HIV infection.

Ozminkowski, R.J., White, A.J., Hassol A., and Murphy, M. (1998). "What if socioeconomics made no difference? Access to a cadaver kidney transplant as an example." (AHCPR grant HS07538). Medical Care 36(9), pp. 1398-1406.

To determine the influence of socioeconomic factors on organ allocation, the researchers used a telephone survey of 456 end-stage renal disease (ESRD) patients, the United Network for Organ Sharing's kidney transplant waiting list files, and Medicare data files. They examined both waiting list entry and receipt of a cadaver kidney transplant before and after adjusting for patients' attitudes about transplantation and their general health and functional status, factors that should influence transplant eligibility. Even after these adjustments, patients age 65 or younger were more likely than older patients to appear on a kidney transplant waiting list and to receive a transplant. Black patients were less than half as likely as white patients to receive a cadaver kidney transplant. Low-income patients were only about half as likely as middle-income patients to obtain a kidney transplant. High-income patients were about 1.5 times as likely as middle-income patients to be on a waiting list and nearly 3 times as likely to receive a transplant. According to the researchers, if socioeconomic factors did not affect organ allocation, 30 to 65 waiting list spots or transplants per 1,000 ESRD patients would shift from economically advantaged to disadvantaged people.

Payne, S.M., Thomas, C.P., Fitzpatrick, T., and others (1998). "Determinants of home health visit length." (AHCPR grant HS06843). Medical Care 36(10), pp. 1500-1514.

Home health care expenditures grew more than 400 percent between 1985 and 1995, more than three times faster than total national health care expenditures. Visit length affects home health agency costs. The researchers studied factors influencing visit length in 4,426 home health visits provided by skilled nurses from 12 Massachusetts home health agencies during 1992 and 1993. They compared visit length across four categories of skilled nursing home health visits which reflect recent changes in home health case mix—AIDS-related, hospice/terminal (HT), intravenous therapy (IV), and maternal and child health (MCH)—with general adult medical/ surgical (MS) visits. Skilled nurses classified visits into visit categories and correlated them with visit length. MS visits were the shortest (median of 30 minutes); HT visits were the longest (median of 59 minutes for HT only to 80 minutes for HT/AIDS). The remaining categories were intermediate in length (37 to 50 minutes). The three factors with greatest impact on visit length were visit type (hospital admission vs. other), terminal/caregiver factor, and clinical instability. Case coordination outside the visit was associated with longer visits. The researchers suggest that payers of home care consider adjusting per-visit reimbursement rates to reflect differences in visit length by category or consider incorporating functional limitations, clinical instability, and case coordination as classification variables.

Picken, H.A., Greenfield, S., Teres, D., and others (1998). "Effect of local standards on the implementation of national guidelines for asthma." (NRSA training grant T32 HS00060). Journal of General Internal Medicine 13, pp. 659-663.

Primary care physicians (PCPs) tend to disagree with certain aspects of national asthma care guidelines, and thus only comply with some care recommendations, according to this study. For example, a group of 42 New England PCPs surveyed for this study typically relied on clinical signs, such as wheezing, to diagnose asthma rather than pulmonary function testing as recommended by National Asthma Education Program (NAEP) Guidelines for the Diagnosis and Management of Asthma. Also, 83 percent of PCPs recommended training only patients with difficult-to-assess symptoms for in-home peak flow meter use to monitor lung capacity. Yet NAEP guidelines call for routine peak flow monitoring of all asthma patients. Monitoring of a patient's peak flow rate tracks fluctuations in his or her condition that can signal the need to begin, increase, or decrease asthma medication. On the other hand, the PCPs agreed with NAEP recommendations for the use of inhaled corticosteriods. The authors conclude that modifying or customizing guidelines through field testing with local PCPs will improve acceptance of national guidelines and lead to improvements in care.

Sugar, C.A., Sturm, R., Lee, T., and others (1998, October). "Empirically defined health states for depression from the SF-12." (AHCPR grants HS08349 and NRSA training grant T32 HS00028). Health Services Research 33(4), pp. 911-928.

When a medical intervention primarily improves quality of life, as in the case of depression, it is often difficult to assess its medical importance and cost-effectiveness. The authors of this study sought to define objectively and describe a set of clinically relevant health states that encompass the typical effects of depression on quality of life in an actual patient population. They used cluster analysis to group the patients according to appropriate dimensions of health derived from a health status questionnaire. The researchers found, on the basis of a combination of statistical and clinical criteria, that six states were optimal for summarizing the range of health experienced by depressed patients. In all the models, the relationship between health state category and clinical diagnosis was highly significant. The models also were sensitive to changes in patients' clinical status over time.

Winston, F.K., Shaw, K.N., Kreshak, A.A., and others (1998). "Hidden spears: Handlebars as injury hazards to children." (AHCPR grant HS09058). Pediatrics 102(3), pp. 596-601.

In apparently minor bicycle falls, handlebars can act as spears that cause serious abdominal injuries. This can happen even though the handlebars don't actually penetrate the skin. Handlebar impact has been associated with traumatic abdominal wall hernia, as well as kidney, intestinal, liver, splenic, and pancreatic injuries. The researchers studied the records of children 18 years and younger, who had been treated for serious bicycle-related injuries at an urban pediatric trauma center from 1995 to 1997. They also used on-site crash investigation to define the mechanism of serious bicycle handlebar-related injuries. Overall, 84 percent of serious injuries involved bicycle-motor vehicle collisions, and 16 percent resulted from landing on handlebars in apparently minor falls. About 77 percent of the handlebar-related injuries occurred as a result of five minor crash types: a loss of balance after hitting a different riding surface; sudden braking; the chain disengaging from the wheel; performance of a stunt; or a sudden turn of the front wheel. This type of injury could be avoided through bicycle redesign to both limit rotation of the front wheel and modify the ends of handlebars to make them softer or point them away from the rider. Also, knowing that seemingly minor bicycle falls can result in serious internal injuries may prompt doctors to make an earlier diagnosis.

Wolinsky, F.D., Wan, G.J., and Tierney, W.M. (1998). "Changes in the SF-36 in 12 months in a clinical sample of disadvantaged older adults." (AHCPR grant HS07632). Medical Care 36(11), pp. 1589-1598.

The SF-36 health status questionnaire is sufficiently sensitive for measuring changes in health outcomes during a 1-year period in older patients with debilitating disease, concludes this study. The researchers used the SF-36 at baseline and then 1 year later to evaluate 786 disadvantaged adults aged 50 to 99 who had participated in a clinical trial at a medical center. They analyzed changes in SF-36 scale scores over the study period. Mean baseline scores on the SF-36 scales were substantially below age-specific national norms. Internal consistency was unacceptable for the general health perception scale, adequate for the social function scale, and good for all the other SF-36 scales.

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AHCPR Publication No. 99-0019
Current as of February 1999

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