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New AHRQ-funded studies focus on quality improvement in diabetes, atrial fibrillation, and end-of-life care

Thousands of Medicare patients with diabetes mellitus or atrial fibrillation—a rapid, erratic heart beat—could benefit from two new quality improvement tools developed with the support of the Agency for Healthcare Research and Quality. The test results for these tools were published recently in the Journal of the American Medical Association. Findings from a third AHRQ-funded study, also published in JAMA, could improve care at the end of life by encouraging more end-of-life discussions between HIV patients and their doctors. The three studies are described here.

Kiefe, C.I., Allison, J.J., Williams, O.D., and others. (2000, June 13). "Improving quality improvement using achievable benchmarks for physician feedback. A randomized controlled trial." (AHRQ grants HS09446, HS11124, HS/GM10389). Journal of the American Medical Association 285(22), pp. 2871-2879.

University of Alabama at Birmingham researchers found that physicians who received periodic feedback reports based on chart reviews of their care of Medicare fee-for-service patients with diabetes mellitus, plus performance goals called "achievable benchmarks of care," significantly outperformed similar doctors who received only the chart reviews and standard performance feedback. Patients of doctors who were provided the benchmarks had 33 percent to 57 percent higher odds of receiving long-term glucose control measurement, serum cholesterol testing, foot exams, and influenza vaccinations than patients of the other physicians. Achievable benchmarks of care are standards of excellence attained by top performers among peer physicians, which provide a reference for doctors to assess their own performance.

The prevalence of type 2 diabetes is estimated to be 15.6 million in the United States, and approximately 18 percent of all patients dying with influenza and pneumonia—between 20,000 and 40,000 deaths per year between 1994 and 1997—are estimated to have diabetes. If achievable benchmarks of care were used widely for improving the quality of medical care for people with diabetes, the estimated increase in influenza vaccinations would prevent as many as 584 deaths per year and substantially more episodes of influenza and pneumonia among Medicare patients, concludes study leader Catarina I. Kiefe, Ph.D., M.D.

Gage, B.F., Waterman, A.D., Shannon, W., and others. (2001, June 13). "Validation of clinical classification schemes for predicting stroke. Results from the National Registry of Atrial Fibrillation." (AHRQ grant HS10133). Journal of the American Medical Association 285(22), pp. 2864-2870.

Researchers led by Brian F. Gage, M.D., of Washington University School of Medicine, found that their new CHADS2 method for predicting risk of stroke in patients with this condition is more accurate than existing methods. CHADS2 is an acronym for the risk factors for stroke—congestive heart failure, hypertension, advanced age, diabetes, and prior stroke—in patients with atrial fibrillation (AF).

Although physicians agree that warfarin therapy is favored when the risk of stroke is high and aspirin when risk is low, there has been little agreement on how to predict the risk of stroke. By more accurately estimating the risk of stroke in a patient with AF, doctors and their patients can make better decisions about which antithrombotic therapy to use. CHADS2 may be especially helpful for identifying low-risk patients who by taking aspirin can avoid the office visits, expense, and risks of taking warfarin, which has to be closely monitored because it may cause bleeding.

Wenger, N.S., Kanouse, D.E., Collins, R.L., and others. (2001, June). "End-of-life discussions and preferences among persons with HIV." (AHRQ grant HS08578). Journal of the American Medical Association 285(22), pp. 2880-2887.

These researchers found that half of all HIV-infected people in the United States—especially blacks, Hispanics, IV drug users, and people with less education—never talk about end-of-life care with their doctors. Such discussions could give physicians a better understanding about the types of care patients want when they are very ill and close to death. In addition, such discussions may lead to a patient designating a surrogate to make decisions if he or she is unable to do so.

End of life discussions occurred more often in a continuous, trusting patient-physician relationship. Advance directives—documents that can specify a surrogate decisionmaker and/or describe a person's wishes for care at the end of life—were completed much more often when doctors and patients discussed these issues.

Lead author Neil S. Wenger, M.D., of the University of California at Los Angeles, suggests that given the low rate of end-of-life discussions, clinicians and other providers should take the lead in initiating this kind of dialogue with patients.

Data for this study were from the HIV Cost and Services Utilization Study (HCSUS), which is conducted by a consortium led Martin F. Shapiro, M.D., of RAND. HCSUS, which is jointly funded by AHRQ and RAND through a cooperative agreement, provides data on a nationally representative probability sample of HIV-infected adults receiving care in the contiguous United States.

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