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Berliner, E., Ozbilgin, B., and Zarin, D.A. (2003). "A systematic review of pneumatic compression for treatment of chronic venous insufficiency and venous ulcers." Journal of Vascular Surgery 37, pp. 539-544.

Available data cannot be relied on to inform the optimal choice of compression therapy or optimal protocol for patients with chronic venous insufficiency (CVI) or venous ulcers, according to a technology assessment on the use of pneumatic compression devices for these problems. As a result of the assessment, the Centers for Medicare & Medicaid Services issued a decision that pneumatic compression will be covered only for patients with refractory edema with significant ulceration of the lower extremities after a 6-month trial of standard therapies, such as compression stockings, has failed. The researchers reached their conclusions following a systematic review of the literature and selection of eight pertinent studies for more in-depth review. Three studies showed that the devices could alleviate symptoms of CVI, but none of the studies directly measured whether the devices could prevent the occurrence of venous ulcers. Some studies of the treatment of venous ulcers did not show a benefit for pneumatic compression, but others showed that pneumatic compression healed long-standing chronic ulcers that had not healed with other methods.

Reprints (AHRQ Publication No. 03-R032) are available from the AHRQ Publications Clearinghouse.

Berner, E.S., Baker, C.S., Funkhouser, E., and others (2003). "Do local opinion leaders augment hospital quality improvement efforts?" (AHRQ grant HS08843). Medical Care 41(3), pp. 420-431.

The influence of physician opinion leaders was positive for only one of five quality of care indicators for unstable angina (UA) examined in this study. To maximize adherence to best practices through physician opinion leaders will require more research on how these physicians influence health care delivery in their organizations, suggest the researchers. They compared the impact on five quality indicators with no intervention (NI), a traditional Health Care Quality Improvement Program (HCQIP), and a physician opinion leader (OL) in addition to the HCQIP. Quality indicators included electrocardiogram within 20 minutes, antiplatelet therapy within 24 hours and at discharge, and heparin and beta-blockers during hospitalization among 2,210 patients with UA from 21 hospitals. The only significant postintervention difference in compliance with UA guidelines was greater improvement for the OL group in the use of antiplatelet therapy at 24 hours in both hospital-level and patient-level analyses compared with the HCQIP and NI groups.

Croskerry, P. (2003, January). "Cognitive forcing strategies in clinical decisionmaking." (AHRQ grant HS11592). Annals of Emergency Medicine 41(1), pp. 110-121.

All disciplines of medicine are subject to pitfalls in clinical reasoning, as well as caveats for avoiding them. Examples of typical pitfalls affecting emergency department (ED) physicians include: abandoning the reading of an x-ray of an ED patient after identifying one fracture, since there may be more; failure to look for coingestants in the context of a self-poisoning; and failure to look for medical problems once a psychiatric diagnosis has been made. Cognitive forcing strategy is a form of cognitive debiasing designed to help clinicians make better decisions by recalling vivid lessons they have learned from past errors that have harmed patients. In the first step, the clinician is taught the value of stepping back from the immediate situation and reflecting on the thinking process. The second step is knowledge of particular cognitive errors. The third step requires identification of the particular scenario in which the cognitive error is likely to occur, and the fourth step is the selection of a cognitive forcing strategy. The adoption of this method provides a systematic approach to cognitive root-cause analysis in the avoidance of adverse outcomes associated with delayed or missed diagnoses and with the clinical management of specific cases.

Fink, K.S., Phillips, R.L., Fryer, G.E., and Koehn, N. (2003, March). "International medical graduates and the primary care workforce for rural underserved areas." Health Affairs 22(2), pp. 255-262.

International medical school graduates (IMGs) do not appear to be the solution to physician shortages in U.S. rural underserved areas (RUAs), concludes this study. The authors found that IMGs who came to the United States for postgraduate training were no more likely than U.S. medical school graduates (USMGs) to practice primary care in RUAs. The researchers analyzed the 2000 American Medical Association Masterfile and Area Resource File to calculate the percentage of primary care IMGs, relative to USMGs working in RUAs. They found that 2.1 percent of both primary care USMGs and IMGs were in RUAs. USMGs were more likely to be family physicians than IMGs but less likely to be internists or pediatricians. Given the belief by many groups that physicians are oversupplied but poorly distributed, the focus of future policies should be directed at increasing the percentage of primary care physicians who locate in RUAs. However, attention should be given to the appropriate primary care specialty distribution.

Mukamel, D.B., Weimer, D.L., Zwanziger, J., and Mushlin, A. (2002). "Quality of cardiac surgeons and managed care contracting practices." (AHRQ grant HS09803). Health Services Research 37(5), pp. 1129-1144.

These researchers examined the association between the contracts managed care organizations (MCOs) had with cardiac surgeons and the quality of care provided by the surgeons using data from the New York State Cardiac Surgery Reports. The study included all cardiac surgeons offering coronary artery bypass graft surgery and 78 percent of MCOs in New York State in 1998. The association between surgeon quality and MCO contracts did not vary significantly by MCO type and ownership, but it did vary by region and type of quality measure. MCO contract probability showed a tendency to decrease with a surgeon's risk-adjusted mortality rates (RAMR), low volume of bypass surgery (usually associated with poorer quality), and low-quality outlier status (RAMR higher than the State average) and to increase with high-quality outlier status (RAMR lower than the State average). Low-volume surgeons were more likely in Downstate New York (40 percent) than Upstate New York (23.7 percent), and the existence of contracts with high-quality outliers was more than twice as likely in Downstate areas as in Upstate areas (35.6 vs. 17.6). These regional differences in MCO contracting behavior suggest that MCO contracting with cardiac surgeons depends to some extent on local market conditions, such as competition among MCOs and sophistication of individual consumers or employers.

Ng, P.C., Barzilai, D.A., Ismail, S.A., and others (2003, March). "Evaluating invasive cutaneous melanoma: Is the initial biopsy representative of the final depth?" (NRSA training grant T32 HS00059). Journal of the American Academy of Dermatology 48, pp. 420-424.

Suspected melanoma (skin cancer) is often biopsied for diagnosis and then reexcised with appropriate margins based on the melanoma depth. Therefore, an accurate representative biopsy of the deepest portion of the lesion is important for further management. These researchers retrospectively examined the accuracy of preliminary biopsies performed by a group of predominantly experienced dermatologists on a total of 145 cases of cutaneous melanoma. They compared Breslow depth on preliminary biopsy with Breslow depth on subsequent excision to determine whether the initial diagnostic biopsy was performed on the deepest part of the melanoma. Of nonexcisional initial shave and punch biopsies, 88 percent were accurate, with Breslow depth greater than or equal to subsequent excision Breslow depth. Both superficial and deep shave biopsies were more accurate than punch biopsy for melanomas less than 1 mm. Excision biopsy was the most accurate method of biopsy. The researchers conclude that deep shave biopsy is preferable to superficial shave or punch biopsy for thin and intermediate depth (less than 2 mm) melanomas, when an initial sample is taken for diagnosis.

Wang, C., Schwaitzberg, S., Berliner, E., and others (2003, March). "Hyperbaric oxygen for treating wounds." (AHRQ contract 290-97-0019). Archives of Surgery 138, pp. 272-279.

Wounds often have a reduced oxygen supply that impairs infection fighting activities and wound healing. The use of hyperbaric oxygen therapy (HBO, intermittent inhalation of 100 percent oxygen in chambers pressurized about 1 atmosphere absolute) is based on the premise that raising tissue oxygen levels will enhance wound healing ability. However, this systematic review of the literature found that high-quality randomized controlled trials to evaluate the short- and long-term risks and benefits of HBO are necessary to better inform clinical decisions. They identified studies from technology assessment reports on HBO and a Medline search from mid-1998 to August 2001 that evaluated the use of HBO for wound care and reported clinical outcomes. Results suggested that HBO may be beneficial as an adjunctive therapy for chronic nonhealing diabetic wounds, compromised skin grafts, osteoradionecrosis, soft tissue radionecrosis, and gas gangrene compared with standard wound care alone. Serious adverse events associated with HBO included seizures and pressure-related traumas, such as pneumothorax.

Reprints (AHRQ Publication No. 03-R034) are available from the AHRQ Publications Clearinghouse.

Willging, C.E,. Semansky, R.M. Waitzkin, H. (2003, March). "New Mexico's Medicaid managed care waiver: Organizing input from mental health consumers and advocates." (AHRQ grant HS09703). Psychiatic Services 54(3), pp. 289-291.

States are required by Federal law to obtain waivers before they can enroll vulnerable populations, including people with serious mental illness, in Medicaid managed care programs. However, they are not obliged to elicit comments from community stakeholders, and each State determines the extent of public involvement in developing Medicaid managed care waivers. According to this study of the New Mexico waiver experience, there is a need to institutionalize formal structures for public consultation about waiver programs to ensure responsiveness to the concerns of vulnerable groups. In January 2000, New Mexico's Medicaid agency requested a renewal of its Medicaid managed care waiver, despite concern about increasing numbers of Medicaid-eligible children and adults with serious mental illnesses who needed intensive services but were unable to obtain them under managed care. Consumers, patient advocates, and providers developed coalitions throughout the State and with national organizations to lobby for Federal intervention by CMS. The resulting assessment of the State's Medicaid monitoring data revealed significant underuse of the intensive services effective for serious mental illness and linked Medicaid managed care to manpower shortages and decreased financial support for mental health safety-net institutions. Ultimately, State legislators required New Mexico's waiver renewal to include the creation of a provisional advisory committee, composed of State officials, consumers, patient advocates, and providers, to redesign Medicaid mental health services. This could be a model for other States that are establishing waiver programs for mental health services.

Wyrwich, K.W., Fihn, S.D., Tierney, W.M., and others (2003, March). "Clinically important changes in health-related quality of life for patients with chronic obstructive pulmonary disease." (AHRQ grants HS10234, K02 HS11635). Journal of General Internal Medicine 18, pp. 196-202.

The goal of treatment for patients with chronic obstructive pulmonary disease (COPD) is to relieve symptoms such as labored breathing and to enhance functioning. How patients view important changes in health-related quality of life (HRQOL) does not reflect an informed clinical evaluation. The goal of this study was to establish clinically important difference standards from the physician's perspective for use of two HRQOL measures among patients with COPD. The investigators assembled a nine-member expert panel of physicians familiar with the use of the Chronic Respiratory Questionnaire (CRQ), a disease-specific HRQOL measure, or the generic Medical Outcomes Study Short-Form 36-item Health Survey (SF-36) to assess patients with COPD. After several rounds of discussions, the expert panel established small, moderate, and large clinically important change levels for the CRQ and the SF-36. Levels for detecting clinically important differences on the CRQ were equal to or slightly higher than previous studies based on patient-reported differences. Clinically important differences on the SF-36 (Version 2.0) were noticeably larger than previous estimates based on cross-sectional differences between clinically defined patient groups.

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Current as of June 2003
AHRQ Publication No. 03-0035

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