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Alison, J.J., Kiefe, C.I., Wall, T., and others (2005). "Multicomponent Internet continuing medical education to promote chlamydia screening." (AHRQ grant HS11124). American Journal of Preventive Medicine 28(3), pp. 285-290.

A multicomponent Internet-based continuing medical education (mCME) intervention can favorably influence chlamydia screening for at-risk women seen in primary managed care offices, according to this study. The intervention, consisting of four case-based learning modules, was tailored in real time to each physician and included office-level feedback of chlamydia screening rates. Screening rates for comparison offices declined from 18.9 percent before the intervention to 12.4 percent after the intervention, while screening rates for intervention offices declined only slightly, from 16.2 percent to 15.5 percent.

Arcury, T.A., Gesler, W.M., Preisser, J.S., and others (2005, February). "The effects of geography and spatial behavior on health care utilization among the residents of a rural region." (AHRQ grant HS09624). Health Services Research 40(1), pp. 135-155.

Geographic and spatial behavior factors play an important role in rural health care use, concludes this study. The researchers surveyed 1,059 adults in 12 rural North Carolina counties about their health care visits in the preceding year across geographic, sociodemographic, cultural, and health variables. After accounting for several factors, having a driver's license and distance traveled for regular care were significantly related to health care use for regular check-ups and chronic care, as were age, sex, and ethnicity; household income; and medical need. Geographic measures were related to regular check-ups and chronic care but not to acute care visits.

Aujesky, D., Auble, T.E., and Yealy, D.M. (2005). "Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia." (AHRQ grant HS10049). American Journal of Social Medicine 118, pp. 384-392.

The Pneumonia Severity Index is better at predicting 30-day mortality among patients with community-acquired pneumonia (CAP) than two other prediction rules, concludes this study. The investigators compared three prediction rules in their ability to predict 30-day mortality among 3,181 patients with CAP in 2001: the Pneumonia Severity Index, CURB (confusion, urea nitrogen, respiratory rate, and blood pressure), and CURB-65 (for patients aged 65 or older). The Pneumonia Severity Index classified a greater proportion of patients as low risk (68 percent) than either a CURB score less than 1 or a CURB-65 score less than 2 (61 percent). Also, these patients had a slightly lower mortality rate than those identified as low risk by CURB scores (1.4 vs. 1.7 percent).

Barnato, A.E., Labor, R.E., Freeborne, N.E., and others (2005, January). "Qualitative analysis of Medicare claims in the last 3 years of life: A pilot study." AHRQ grant HS10561. Journal of the American Geriatrics Society 53, pp. 66-73.

The goal of this study was to examine whether qualitative interpretation of administrative claims could yield insights into patient care for older people nearing the end of life, including continuity, errors, and cause of death. Two independent clinicians analyzed Medicare claims for 100 fee-for-service enrollees without disability or end-stage renal disease who died during the period 1996-1999 and had at least 36 months of continuous Part A and Part B enrollment before death. They found that most patients were chronically ill and received many health care services during the 3 years before death. Three-quarters of the patients lacked continuity of care, and a medical error was identified in 13 percent of cases. The clinician abstracters disagreed about assignment of a single cause of death in 28 percent of cases. The researchers conclude that qualitative claims analysis can illuminate many problems in the care of chronically ill older people at the end of life and deserves further study.

Beach, M.C., Price, E.G., Gary, T.L., and others (2005, April). "Cultural competence: A systematic review of health care provider educational interventions." (AHRQ contract 290-02-0018). Medical Care 43(4), pp. 356-373.

Cultural competence training shows promise as a strategy for improving the knowledge, attitudes, and skills of health professionals. However, there is no evidence to show that it improves patient adherence to therapy, health outcomes, and/or equity of services across racial and ethnic groups, according to this review of relevant studies published from 1980 through June 2003. Overall, 17 of 19 studies showed such training improved the knowledge of health professionals, 21 of 25 studies showed that it improved their attitudes, and 14 of 14 studies showed a beneficial effect on skills. There also was good evidence that this training improved patient satisfaction, but evidence was poor on its ability to influence treatment adherence.

Bourgeois, J.A., Maddock, R.H., Rogers, L., and others (2005, March-April). "Neurosarcoidosis and delirium." AHRQ grant HS11540. Psychosomatics 46(2), pp. 148-150.

Sarcoidosis is a systemic inflammatory disease, which may involve multiple organ systems such as lungs, liver, bones, lymph nodes, skin, eyes, and muscles. Neurosarcoidosis, which means involvement of the nervous system, is seen in less than 10 percent of cases. This paper describes the case of a 39-year-old woman who came to a psychiatric hospital with incoherent speech, auditory hallucinations, and distractibility that had begun months earlier and worsened over 2 weeks. Her case was complicated by long-term cocaine and alcohol use. She was put on the antipsychotic, risperidone, and tested for numerous infectious diseases. Eventually, neurosarcoidosis was diagnosed through computed tomography and an open brain biopsy. Treatment of neurosarcoidosis includes higher doses of corticosteroids than are used for sarcoidosis. Cyclosporine, methotrexate, cranial irradiation, and neurosurgical intervention may also be indicated.

DeLong, E.R., Lytle, B.L., Cowper, P.A. and others (2005, March). "Research, managed care, and patient privacy: Challenges to successful collaboration." (AHRQ grant HS09940). Journal of Clinical Outcomes Management 12(3), pp. 151-156.

Managed care organizations (MCOs) can collaborate with an academic research organization (ARO) to examine the clinical and economic impact of new programs, such as chronic disease management, particularly over the long-term. However, the process of obtaining funding and executing a successful study would benefit from specific safeguards and sufficient incentives to offset the risks to MCOs, concludes this study. The investigators analyzed a government-funded collaborative research project on coronary artery disease involving an ARO and the electronic files of several MCOs. Fear of negative publicity for MCOs and increased patient privacy concerns created barriers to patient contact, which could dramatically affect study duration and response rates.

Fremont, A.M., Bierman, A., Wickstrom, S.L., and others (2005, March). "Use of geocoding in managed care settings to identify quality disparities." (AHRQ contract 290-00-0012). Health Affairs 24(2), pp. 516-526.

Tracking quality-of-care measures is essential to improve care, particularly for vulnerable populations. Although managed care plans routinely track quality measures, few examine whether their performance differs by enrollee race/ethnicity or socioeconomic status (SES), in part because plans do not collect that information. These investigators show that plans can begin examining and targeting potential disparities using indirect measures of enrollee race/ethnicity and SES based on geocoding. Using such measures, they demonstrate disparities within both Medicare+Choice and commercial plans on Health Plan Employer Data and Information Set (HEDIS) measures of diabetes and cardiovascular care.

Hahn, H.D., and Belt, T.L. (2004, December). "Disability identity and attitudes toward cure in a sample of disabled adults." Journal of Health and Social Behavior 45, pp. 453-464.

These researchers interviewed disabled activists who were members of the organization ADAPT, Americans Disabled for Assistance Programs Today. They surveyed a total of 156 demonstrators with disabilities during two ADAPT social action events in 1995 and 1998. Participants were asked to rate their response to the statement, "Even if I could take a magic pill, I would not want my disability to be cured," on a scale from one (strongly disagree) to seven (strongly agree). Forty-seven percent agreed with the statement (score of 5-7), 45 percent disagreed (score of 1-3), and 8 percent were ambivalent (score of 4). Only two factors predicted that a person would not want a cure for their disability: positive sense of personal identity with the disability and early age of onset of disability.

Leeper, N.J., Werner, L.S., Dhaliwal, G., and others (2005, April). "One surprise after another." AHRQ grant HS11540. New England Journal of Medicine 352(14), 1474-1479.

This paper chronicles the emergency department presentation, hospital care, and eventual diagnosis of a 22-year-old man with a history of cocaine use and current alcohol use who arrived at the hospital with abdominal pain and symptoms of lung infection. The eventual diagnosis was myocarditis, with a potential underlying cocaine-induced or alcohol-related cardiomyopathy with a superimposed viral infection. Following treatment, this patient's followup echocardiogram showed some early signs of improved heart wall motion, but a substantial minority of patients with this condition never regain normal cardiac function.

Marcus, M., Maida, C.A., Freed, J.R., and others (2005). "Oral white patches in a national sample of medical HIV patients in the era of HAART." (AHRQ grant HS08578). Community Dentistry and Oral Epidemiology 33, pp. 99-106.

The development of oral soft tissue lesions (oral white patches [OWP]) in patients with HIV is often a sign of declining local and systemic immune function. Based on interviews with 2,109 participants in the HIV Cost and Services Utilization Study (HCSUS), these researchers estimated that 35 percent of individuals with HIV disease reported at least one incident of OWP. Compared with those on highly active antiretroviral therapy (HAART), patients on other regimens or taking no antiviral medications were 23-46 percent more likely to report an incident of OWP. Compared with whites, blacks were 32 percent less likely to report OWP, while current smokers were 62 percent more likely to do so than nonsmokers. AIDS diagnosis and CD4 counts less than 500 significantly increased the likelihood of reporting OWP.

Needham, D.M., Bronskill, S.E., Calinawan, J.R., and others (2005). "Projected incidence of mechanical ventilation in Ontario to 2026: Preparing for the aging baby boomers." (AHRQ grant HS11902). Critical Care Medicine 33(3), pp. 574-579.

Due to aging baby boomers (individuals born between 1946 and 1966), use of mechanical ventilation will steadily increase to the year 2026, outpacing population growth that occurred in the 1990s, concludes this study. The authors project that 34,478 patients will be ventilated in 2026, representing an 80 percent increase from 2000. Given already limited intensive care unit resources and heavy use of acute care resources by ventilated patients, planning for this continued growth is necessary, advise the researchers. They standardized population-based, sex-specific, and age-specific mechanical ventilation incidences for adults for the year 2000 to population projections to estimate the incidence of mechanical ventilation in 5-year intervals from 2006 to 2026.

Phillips, L.S., and Langer, R.D. (2005, March). "Postmenopausal hormone therapy: Critical reappraisal and a unified hypothesis." (AHRQ grant HS07922). Fertility and Sterility 83(3), p. 558-566.

These authors hypothesize that hormone therapy initiated at the time of menopause should produce a decrease in coronary heart disease (CHD) over time. In contrast, hormone therapy begun years after menopause should produce an increase in CHD events shortly after therapy is begun, followed later by benefit. In women who require progestogens for endometrial protection, there should be greater CHD benefit from use of progestogens with less systemic activity. This unified hypothesis is consistent both with plausible biologic mechanisms and with evidence from animal studies, human observational studies, and human clinical trials such as the Women's Health Initiative, note the authors. They reviewed the literature to reconcile apparently conflicting evidence on the CHD benefit of postmenopausal hormone therapy.

Sinaiko, A.S. (2004, October). "Employers' responses to a play-or-pay mandate: An analysis of California's Health Insurance Act of 2003." (AHRQ grant HS10803). Health Affairs, online at

California, with 20 percent of its population uninsured and an unemployment rate of 6.2 percent, enacted the Health Insurance Act (known as SB2) in May 2004. The legislation, scheduled to be phased in starting in 2006, mandates that employers either provide employee health benefits that meet a minimum standard or pay a fee to the State to cover workers under a State-sponsored program. This author applies findings from the literature and an economic analysis to California data to estimate the potential reduction in wages, quantify the dispersion of risk across employers, and discuss other employment effects. The study found that although SB2 will bring eligibility for health coverage to a portion of the uninsured in California, it will be lower than the estimated 1.07 to 1.56 million individuals that researchers have projected.

Sulkowski, M.S., Mehta, S.H., Torbenson, M., and others (2005, March). "Hepatic steatosis and antiretroviral drug use among adults coinfected with HIV and hepatitis C virus." AHRQ grant HS07809. AIDS 19, pp. 585-592.

The goal of this study was to determine the prevalence and severity of hepatic steatosis (fatty liver) among patients coinfected with HIV and hepatitis C virus (HCV) who had been taking antiretroviral therapy (ART). Steatosis was assessed among a randomly selected subset of HIV-HCV coinfected patients who had received at least 2 years of ART. Liver histology was assessed in 112 patients, 74 percent of whom were taking ART at the time of biopsy. Steatosis was observed in 40 percent of HIV-HCV coinfected patients with extensive ART exposure and was associated with more severe HCV-related liver disease. Metabolic abnormalities (excess weight and hyperglycemia) and stavudine use were modifiable risk factors for steatosis in this population.

Watts, D.H., Fazarri, M., Minkoff, H., and others (2005, April). "Effects of bacterial vaginosis and other genital infections on the natural history of human papillomavirus infection in HIV-1-infected and high-risk HIV-1-uninfected women."(cosponsored by AHRQ, NIH, and CDC). Journal of Infectious Diseases 191, pp. 1129-1139.

Bacterial vaginosis (BV) and Trichomonas vaginalis (TV) infection may increase the risk of acquiring or reactivating human papillomavirus (HPV) infection, concludes this study. This conclusion is consistent with the hypothesis that the local cervicovaginal milieu plays a role in susceptibility to HPV infection. The finding that BV did not affect persistence of HPV infection and that TV infection may shorten the duration of HPV infection helps explain the lack of effect that BV and TV infection have on development of squamous intraepithelial lesions (SIL). These findings are based on semiannual assessment of 1,763 HIV-infected and 494 high-risk HIV-uninfected women for BV, TV, type-specific HPV, and SIL.

Current as of July 2005
AHRQ Publication No. 05-0093

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