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AHCPR funds new studies

Appropriate and effective use of right heart catheterization, home care of infants with neonatal chronic lung disease, medical and surgical superspecialization, and the effects of the market structure on HMOs are among the topics to be studied in a series of 12 new grants awarded by the Agency for Health Care Policy and Research.

The following descriptions of the 12 new projects include the principal investigator's name and affiliation, first-year funding, and project period.

Adoption of Cancer Pain Guidelines in Managed Care. Mildred Z. Solomon, Ed.D., Education Development Center, Inc., Newton, MA; $581,087, 6/01/96 to 5/31/00.

To conduct a randomized controlled study of cancer patients and their providers in managed care clinics to determine the effectiveness of a two-tiered (organizational and individual) dissemination strategy of the AHCPR-sponsored cancer pain guideline.

AHCPR UI Guideline: Application in Nursing Homes. Nancy M. Watson, M.S., Ph.D., University of Rochester, Rochester, NY; $201,635, 6/1/96 to 5/31/99.

To evaluate the impact of the AHCPR-supported clinical practice guideline on urinary incontinence in adults in the nursing home setting.

Assessing Pediatric Quality of Life in a Clinical Trial. Robert D. Annett, Ph.D., University of New Mexico, Albuquerque; $36,329, 6/1/96 to 5/31/98.

To examine the relationship between a disease-specific pediatric quality-of-life measure and (1) current asthma symptom severity as measured in the Childhood Asthma Management Program (CAMP), (2) sociodemographic variables as measured in the CAMP study, and (3) the general multidimensional measures of quality of life utilized in the CAMP study. Additionally, to determine the best clinical and psychosocial predictors of disease-specific quality of life.

Cardiac Procedure Use: A Prospective Cohort Study. Thomas H. Lee, M.D., M.S.C., Brigham and Women's Hospital, Boston, MA; $654,677, 7/1/96 to 6/30/99.

To evaluate the reasons for the racial differences and differences among male and female patients in the use of cardiac tests and procedures. The study group will be identified at the time of emergency room presentation with chest pain and subsequently followed for all procedures, both invasive and noninvasive, for 1 year.

Community-Based Pharmaceutical Care: A Controlled Trial. Morris Weinberger, M.D., Indiana University, Indianapolis; $590,656, 6/1/96 to 5/31/00.

To develop algorithms, materials, and an educational program to facilitate pharmaceutical care and, subsequently, conduct a randomized, controlled trial of the effects of providing pharmacists with these materials and patient-specific information.

Effects of Health Care Market Structure on HMOs. Jack Hadley, M.D., Georgetown University, Washington, DC; $307,437, 7/01/96 to 6/30/97.

To analyze the impact of the recent growth and concentration of HMOs on employers, health insurance coverage decisions, health care premiums, and employees' health insurance choices.

Facilitating Home Care of Neonatal Chronic Lung Disease. Thomas Michael O'Shea, M.D., Bowman Gray School of Medicine, Winston-Salem, NC; $266,967, 7/1/96 to 6/30/01.

To measure the outcomes and expenses associated with two interventions that facilitate home care of infants with chronic lung disease.

Impact of Prospective Drug Use Review on Health. Frank A. Ahern, Ph.D., Pennsylvania State University, University Park; $184,099, 8/1/96 to 7/31/98.

To (1) conduct a descriptive epidemiological analysis of psychotropic drug use, prescribing patterns, and yield of Prospective Drug Utilization Review (ProDUR) screen failures. The study will examine two 24-month periods, before and after interventions, and compute estimates of drug-related outcome measures; and (2) evaluate the independent effects of two different procedures on health outcomes including both outcomes from changes in prescribing practices and differential mortality, morbidity, and health services utilization.

Right Heart Catheterization: Appropriate/Effective Use. Alfred F. Connors, Jr., M.D., Case Western Reserve University, Cleveland, OH; $372,595, 7/1/96 to 6/30/98.

To determine: (1) variation in the use of right heart catheterization (RHC) in seriously ill patients; (2) the effectiveness of RHC in terms of survival, quality of life, and satisfaction with care; (3) the cost of RHC; and (4) the appropriateness of RHC use.

Selective Cervical Spine Radiography in Blunt Trauma. William R. Mower, M.D., M.E., M.S., University of California, Los Angeles; $621,570, 8/1/96 to 7/31/98.

To determine whether clinical criteria can reliably exclude cervical spine injury in "no risk" blunt trauma victims without misidentifying any injured patient; if so, the use of radiographic cervical spine imaging could be reduced.

Superspecialization of Medical and Surgical Subspecialists. Jose Escarce, M.D., University of Pennsylvania, Philadelphia; $271,721, 6/1/96 to 5/31/98.

To examine the patterns and determinants of superspecialization, the phenomenon in which physicians narrow their scope of practice to a small set of services chosen from the larger set of services for which they are trained.

Understanding Health Values of HIV-Infected Patients. Joel Tsevat, M.D., M.P.H., University of Cincinnati Medical Center, Cincinnati, OH; $160,160, 9/1/96 to 8/31/97.

To use focus groups and interviews to gain an understanding of the health values of 100 HIV-infected patients and to develop and test a conceptual model of their health values.

AHCPR publishes two HCUP-3 Research Notes

The following two Research Notes are part of an ongoing series of publications derived from research conducted by the Agency for Health Care Policy and Research using data from the Healthcare Cost and Utilization Project. This series provides the results of analyses on health policy issues important to the Nation's health care providers and patients.

Elixhauser, A. (1996). Clinical Classifications for Health Policy Research Version 2: Software and User's Guide (AHCPR Publication No. 96-0046). Healthcare Cost and Utilization Project (HCUP-3) Research Note 2.

Clinical Classifications for Health Policy Research (CCHPR) Version 2 provides a way to classify diagnoses and procedures into a limited number of categories. CCHPR aggregates individual hospital stays into larger diagnosis and procedure groups for statistical analysis and reporting. This product provides information required to use CCHPR:

  • A description of the CCHPR categorization scheme.
  • Electronic files containing the translation of ICD-9-CM diagnosis and procedure codes into CCHPR categories.

CCHPR Version 2 is based on ICD-9-CM codes that are valid for January 1980 through October 1995. There is one classification scheme for diagnoses (260 categories) and one classification scheme for procedures (231 categories).

Duffy, S.Q., Elixhauser, A., and Sommers, J.P. (1996). Diagnosis and Procedure Combinations in Hospital Inpatient Data (AHCPR Publication No. 96-0047). Healthcare Cost and Utilization Project (HCUP-3) Research Note 3.

This Research Note contains information on the most frequent combinations of diagnoses and procedures for hospital inpatients. It helps to answer the questions "What is this procedure used for?" and "How is this diagnosis managed?" The analysis is based on data from the 1992 Nationwide Inpatient Sample, a component of AHCPR's Healthcare Cost and Utilization Project. For each of the 100 most frequently performed principal procedures, the authors list the five principal diagnoses most commonly recorded on discharge abstracts of patients who had that procedure during the hospitalization. For each of the 100 most frequent diagnoses, they also list the five principal procedures most commonly performed. Median charges and length of stay for each diagnosis-procedure combination also are provided, along with estimates of standard errors.

Examples of findings cited in this Research Note include:

  • More than one-quarter of all cesarean sections are performed for a principal diagnosis of previous C-section.
  • Charges for amputation of lower extremity vary from $14,930 for diabetes mellitus with complication to $28,499 for aortic and peripheral arterial embolism or thrombosis.
  • Median charges are $20,237 for hospitalized heart attack patients who undergo angioplasty as their principal procedure, compared with $47,244 for patients who undergo bypass surgery.
  • About one-half of all patients with cancer of the prostate received open prostatectomy, and 29 percent received transurethral resection of the prostate.

This information can be used as a starting point by medical professionals to compare their own practices with a nationwide sample and by third-party payers and managed care organizations to examine the impact of payment policies on practice patterns. Health services researchers can use this information to generate hypotheses for future research on the treatment of specific conditions.

New publications available from NTIS

The following publications and final reports are now available from the National Technical Information Service (NTIS).

Cardiac Rehabilitation: Secondary Prevention. Guideline Technical Report, Number 17. Wenger, N.K., Froelicher, E.S., Smith, L.K., et al.

Cardiac rehabilitation programs are long-term programs that include medical evaluation, prescribed exercise, cardiac risk factor modification, education, counseling, and behavioral interventions. They are tailored to meet the needs of each patient and are intended to limit the physiologic and psychological effects of cardiac illness, reduce the risk for future problems, control symptoms, stabilize or reverse the atherosclerotic process, and enhance selected patients' psychosocial and vocational status. In October 1995, the Agency for Health Care Policy and Research released a clinical practice guideline on cardiac rehabilitation. This report presents the background materials and supporting documentation used by the expert panel in developing the guideline. (NTIS accession no. PB96-168307, 726 pp; $92.00 paper, $25.00 microfiche)

Consequences of Variation in Treatment for Acute MI. Final Report of the Patient Outcomes Research Team. AHCPR grant HS06341, 9/30/89 to 2/28/95. Barbara J. McNeil, M.D., Ph.D., Harvard Medical School, Boston, MA.

The Acute Myocardial Infarction Patient Outcomes Research Team (AMI PORT) focused its research on the effectiveness of invasive procedures (specifically angiography, bypass surgery, and angioplasty) and medical therapies (including the use of thrombolytic agents and other cardiac drugs). The PORT found that, although survival of AMI patients has improved concurrent with a dramatic increase in the use of invasive procedures, the aspects of treatment most affecting long-term survival are related to care received within the first day of admission. The higher usage rates of invasive procedures do not appear to confer any advantage, on average, with respect to health-related quality of life. With respect to medical therapies, the PORT found that: (1) use of thrombolysis and other beneficial drugs in AMI was proven to be effective years before widespread acceptance of their use by "experts"; (2) thrombolytic agents and beta blockers are underutilized; (3) thrombolysis with streptokinase is beneficial and cost effective for elderly patients in many clinical settings; and (4) cardiologists appear more knowledgeable than generalist physicians about the benefits of drug therapies. This last finding is particularly important, given the attention currently being focused on the role of primary care providers as gatekeepers in the managed care environment.

A Dynamic Stochastic Model of Medical Care Use and Work Absence. AHCPR grant HS07964, 8/1/93 to 8/31/95. Donna L. Boswell, M.A., University of Minnesota, Minneapolis, MN.

The author uses data from the 1987 National Medical Expenditure Survey (NMES) to focus on one aspect of health care demand: the medical care consumption and absenteeism behavior of employed individuals with acute illnesses. The theoretical framework models the decision to visit a doctor and/or to miss work during an episode of acute illness. The author uses structural estimation to examine the parameters of the individual's decisionmaking process. This estimation technique allows for the introduction and evaluation of the impact of new public policy initiatives relating to health care. The estimates also allow for predictions of the change in use of physician services and illness-related absenteeism that would arise with improvements in access to health care through more complete health insurance and sick leave coverage and with changes in consumer cost sharing.

Enhanced Accuracy of MRI for Staging Prostate Cancer. AHCPR grant HS07027, 9/1/92 to 12/31/95. Barbara J. McNeil, M.D., Ph.D., Brigham & Women's Hospital, Boston, MA.

Reading and decision aids were refined and applied to staging of prostate cancer (limited vs. extensive disease) by magnetic resonance imaging (MRI). The reading aid was a checklist of relevant perceptual features of an image, each with a scale to elicit a quantitative rating. The decision aid was a statistical prediction rule, which merged the ratings with optimal weights into a diagnostic probability. The aids provided substantial increases in the diagnostic accuracy of MRI considered by itself. Aided MRI provided an increase in accuracy beyond prostate specific antigen and biopsy Gleason grade for radiologists specializing in MRI of the prostate but not for general body radiologists.

Is Coronary Angiography Underused by Poor and Uninsured Patients? AHCPR grant HS06916, 7/1/91 to 9/30/93. Marianne Laouri, Ph.D., RAND Corporation, Santa Monica, CA.

Prior studies have documented significant geographic variations in the use of health services, as well as substantial levels of inappropriate use. Other studies have shown differences in the use of medical care, and cardiac procedures in particular, among ethnic and socioeconomic groups and men and women. This study is an investigation of the underuse of coronary angiography among poor and uninsured patients who receive medical care at Los Angeles County medical centers. Explicit criteria, based on a set of indications for the clinical necessity of coronary angiography, were used to measure underuse. Patients who underwent exercise stress testing and had a positive stress test at three Los Angeles County hospitals or at the private university hospital between January 1, 1990 and June 3, 1991 were eligible for inclusion in the study. Data were collected using medical record abstraction and followup phone interviews. Of the 352 patients who met necessary indications, 56 percent underwent coronary angiography within 12 months following the exercise stress test. A higher proportion of patients from the private hospital than from the county hospitals underwent necessary coronary angiography 3 months after the stress test. The same was true at 12 months. Women were significantly less likely than men to have undergone necessary coronary angiography at 3 and 12 months after the stress test. No differences were observed between African Americans or Latinos and non-Latino whites. These findings demonstrate that a medical procedure for which overuse has been demonstrated is also underused in both public and private hospitals and in women. The author points out that efforts to enhance the effectiveness of the Nation's health care system should consider not only the elimination of inappropriate care but also the underuse of needed medical services.

Methods for Survival Analysis in Outcomes Research. AHCPR grant HS07137, 9/30/92 to 9/29/95. William A. Knaus, M.D., George Washington University, Washington, DC.

This project investigated and extended understanding and use of survival analysis in outcomes research by addressing seven objectives or targets: the handling of missing values, interaction among major predictive variables, the role of variations in patient selection, updating of survival estimates, confidence intervals and minimum data sets, the integration of objective and subjective estimates, and estimation and validation procedures. These seven targets represent methodologic challenges that must be addressed if survival analysis is to have a major impact on research design, clinical investigation, clinical practice, and national health policy. By using clinically accurate databases containing detailed disease, physiological, and other patient characteristics, as well as short- and long-term survival outcomes data, progress was made in all seven targets.

Variations in Cataract Management: Patient and Economic Outcomes. Final Report of the Cataract Patient Outcomes Research Team.

Cataract surgery is the most common surgical procedure performed on Medicare beneficiaries. The Patient Outcomes Research Team (PORT) performed a literature review; analyzed Medicare claims data; surveyed ophthalmologists, optometrists, anesthesiologists, and internists; performed a prospective observational study of over 750 patients undergoing first-eye cataract surgery; analyzed patient preferences on potential outcomes of cataract surgery and watchful waiting; and developed a decision analysis and epidemiologic policy model. Substantial variation was documented in the management of patients undergoing cataract surgery, and several associated factors were identified. A reliable and valid measure of a cataract's impact on a patient's functional status was developed. This, combined with Snellen visual acuity, was found to be a better measure of patients' need for and outcomes of cataract surgery than Snellen visual acuity alone. Cataract surgery's impact on patient functioning and satisfaction was characterized. Associations were defined between patient outcome and each of four factors: an ophthalmologist's annual volume of surgery, intra-operative technique, patient characteristics, and use of YAG-laser capsulotomy. The national impacts of alternative strategies for managing cataract were projected.

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AHCPR Publication No. 96-0061
Current as of June 1996

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