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Plans underway to streamline AHCPR's grant review process

Consistent with the Government Performance and Results Act and Vice President Al Gore's charge to streamline or "reinvent" government processes, the Agency for Health Care Policy and Research has undertaken a comprehensive and careful assessment of the submission and peer review of research grant applications assigned to its standing study sections and special emphasis panels. Several members of AHCPR's National Advisory Council, chairs of the study sections, and agency staff have met and examined in depth key components of the process and made recommendations for streamlining, keeping in mind the perspectives of grant applicants, peer reviewers, and staff.

Specific issues under discussion include acceptance of "just-in-time" applications (adopted in limited circumstances at several NIH Institutes) whereby components of a grant application are submitted only if the application is likely to be funded; pilot testing of a quick-turnaround process for review of a limited number of deferred applications that lack information about one or two critical issues; providing more technical assistance for potential applicants; pilot testing the use of preapplications for screening purposes in designated review circumstances (such as for applications submitted in response to requests for applications); identification of mechanisms to guide and enhance percentile rankings to facilitate funding decisions; the use and role of flexible appointments for members of standing study sections and special emphasis panels; and convening an annual meeting of study section members.

The following requirements, which are current National Institutes of Health (NIH) policy, are also under consideration by AHCPR: instituting a limit on the number of times an application can be resubmitted to AHCPR for review; the need for applicants to receive prior approval from Agency staff for submission of applications requesting direct costs of $500,000 or more in a year; triaging grant applications for review purposes; and streamlining preparation of summary statements.

Over the coming months, Agency staff will refine the recommendations emanating from recent discussions with Advisory Council members and study section chairs, prepare implementation and evaluation plans, formally announce streamlining initiatives (at a minimum in the NIH Guide to Contracts and Grants, at AHCPR's Web site, in Research Activities, and in other appropriate media), and proceed to receive and review applications according to the recommendations. Watch upcoming issues of Research Activities for more information on this streamlining initiative.

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AHCPR and private-sector groups form partnerships to develop pilot evidence reports

The Agency for Health Care Policy and Research has entered into partnerships with medical professional groups to develop two pilot evidence reports under its new evidence-based practice program, according to AHCPR Acting Administrator Lisa A. Simpson, M.B., B.Ch. AHCPR is working with the American Academy of Pediatrics (AAP) to develop an evidence report on attention deficit hyperactivity disorder (AD/HD) and with the American College of Cardiology (ACC) and the American Heart Association (AHA) to develop an evidence report on valvular heart disease. AHCPR will develop the reports in consultation with the professional groups.

These collaborations typify AHCPR's new role as "science partner" with public and private groups. In this role, AHCPR will work to provide the scientific foundation needed by these groups and by other organizations for use in developing their own quality improvement tools.

The evidence reports on ADHD and valvular heart disease, along with evidence reports on screening for colorectal cancer and the diagnosis and management of chronic headache pain—topics under development by AHCPR-sponsored guideline panels when AHCPR discontinued its practice guideline program—will be the prototypes for the evidence reports to be developed by AHCPR's Evidence-based Practice Centers (EPCs). The EPCs will produce evidence reports and technology assessments based on comprehensive reviews and rigorous analyses of the relevant scientific evidence.

The ADHD evidence report is being produced in partnership with the AAPs Subcommittee on AD/HD, headed by AAPs James M. Perrin, M.D., Head of the Division of General Pediatrics at Massachusetts General Hospital and Associate Professor of Pediatrics at Harvard; and Martin T. Stein, M.D., Professor of Pediatrics at the University of California, San Diego. The report will focus on the initial evaluation and diagnosis of ADHD in the primary care setting.

The evidence report on valvular heart disease will result from a partnership with the ACC/AHA Task Force on Practice Guidelines, Committee to Develop Guidelines for Valvular Heart Disease, chaired by Robert Bonow, M.D., Head of the Division of Cardiology at Northwestern University, Chicago. Topics to be included in the evidence report include initial evaluation of cardiac murmurs and evaluation of tests used in the workup/evaluation of newly diagnosed heart murmurs.

The ADHD and valvular heart disease evidence reports are expected to be completed by mid-1997. AHCPR will obtain feedback from the AAP, ACC, and AHA on the usefulness and effectiveness of these reports to inform subsequent efforts by the EPCs.

Both the AAP and the ACC/AHA teams will use the evidence reports to develop clinical practice guidelines on their respective topics. The AHCPR evidence reports also will be available to other groups, including professional societies and health plans, for their use in creating guidelines or for other quality improvement activities.

AHCPR funds projects to foster collaboration between medicine and public health

The Agency for Health Care Policy and Research recently funded three new projects that will foster a closer working relationship between medicine and public health. These projects support the efforts of the Medicine/Public Health Initiative, a national consortium involved in efforts to improve the working relationship between the two disciplines.

In the past, medicine and public health usually worked separately, with medicine concentrating on the physical health of the individual and public health focusing on the health of whole populations and communities. As the needs of individuals and populations have diverged, the separation between public health and medicine has grown wider.

To bridge this gap, the Medicine/Public Health Initiative was started in 1994. Co-chaired by the American Medical Association and the American Public Health Association, it brought together leaders from the main professional, medical, and academic organizations; representatives from government entities involved with both public health and medicine; and individuals from the private sector.

In March 1996, a 3-day national conference, cosponsored by AHCPR, the Centers for Disease Control and Prevention, and the W. K. Kellogg Foundation, was held in Chicago. The goal of the conference was to develop opportunities for collaboration in health and health care provision, education, and research that could be undertaken at regional and local levels of the country. The conference was attended by nearly 400 delegates from all 50 States.

In conjunction with this initiative, AHCPR and the Robert Wood Johnson Foundation joined together to contribute funds for grants that will enhance these cooperative activities. AHCPR has funded the following three projects through its small project grant program:

  • The Massachusetts General Hospital (MGH)/City of Chelsea Asthma Collaborative. AHCPR grant HS09357. Elisha Atkins, M.D., Massachusetts General Hospital Community Health Associates, Boston. Project period 9/30/96 to 9/29/97. Award $25,199.
    This project will provide support, education, and access to primary care and preventive services for individuals presenting with an acute asthmatic episode within the Chelsea school system or at the MGH Urgent Care Center. Project goals include: increasing access to primary care for patients who do not have an identified provider, facilitating public health intervention within the home environment, providing ongoing education and support to individuals with asthma, and providing followup to insure necessary services are obtained.
  • Developing an Ongoing Collaboration Between the Metropolitan Nashville/Davidson County Health Department and Vanderbilt University Medical Center Clinicians. AHCPR grant HS09359. Anthony Chapdelaine, M.D., M.S.P.H., Metropolitan Nashville/Davidson County Health Department, Nashville, TN. Project period 9/30/96 to 9/29/97. Award $34,902.
    The Davidson County Health Department will be a training site for doctoral-level students enrolled in the Vanderbilt University Department of Preventive Medicines inaugural Masters in Public Health Program. The goals of this project are to acquaint students with public health practice at the local level, form an alliance between Vanderbilt clinicians and the Metropolitan Health Department (MHD) to better monitor key conditions, provide technical assistance from the Department of Preventive Medicine to the MHD, and generate projects of public health importance to become the topic of larger collaborative research activities.
  • Evaluation of Ischemic Heart Disease in Monroe County. AHCPR grant HS09358. Alvin Mushlin, M.D., Sc.M., University of Rochester, Rochester, NY. Project period 9/30/96 to 9/29/97. Award $39,481.
    This project aims to bring together representatives from the community, hospitals, and health care plans of Monroe County for strategic planning to improve the treatment of ischemic heart disease. It will examine community-level data to better define patterns of illness, mortality, and service utilization within Monroe County; analyze patient-specific and aggregate variables with regard to in-hospital procedures and mortality for myocardial infarction; and formally integrate and disseminate the results of the study to improve overall planning and consensus-building for managing this condition.

Editor's Note: A print copy of the conference summary and information about participating in the initiative can be obtained by contacting Stanley J. Reiser, M.D., M.P.A., Ph.D., National Coordinator, Medicine/Public Health Initiative, University of Texas-Houston, 6431 Fannin, P.O. Box 20708, Houston, TX 77225.

Final reports now available from NTIS

The following grant final reports are now available from the National Technical Information Service (NTIS). Each listing identifies the project, principal investigator and his or her affiliation, grant number, project period, project objective, and methods used. Findings and other information are detailed in the individual reports.

Access to Ambulatory Care by the Indigent. Barry G. Saver, M.D., M.P.H., University of Washington, Seattle. AHCPR grant HS07253, 9/30/93 to 9/29/96.

The researchers present their findings on access to and use of ambulatory care by adults 18 to 64 years of age. They used data from the National Medical Expenditure Survey (NMES) for this study and controlled for income, insurance status, race, education, employment, age, sex, health status, and other factors.

Abstract, executive summary, and final report, are available from the National Techincal Information Service (NTIS accession no. PB97-134456; 45 pp, $21.50 paper, $10.00 microfiche).

Cancer Prevention for Minority Women in a Medicaid HMO. Alan L. Hillman, M.D., M.B.A., University of Pennsylvania, Philadelphia. AHCPR grant HS07720, 9/30/93 to 9/29/96.

This randomized controlled trial evaluated the impact of feedback and financial incentives on physician compliance with cancer screening guidelines for women 50 years of age and older seen in 54 primary care sites in a Medicaid managed care program.

Abstract, executive summary, and final report, are available from the National Technical Information Service (NTIS accession no. PB97-134449; 25 pp, $19.50 paper, $10.00 microfiche).

Cognitive Impairment and Medication Appropriateness. Joseph T. Hanlon, P.H.R.D., Ph.D., Duke University Medical Center, Durham, NC. AHCPR grant HS07819, 3/1/93 to 5/31/95.

Data from the longitudinal Duke Established Populations for Epidemiological Studies of the Elderly (EPESE) were used to examine whether drug use patterns in community-dwelling elderly differed by cognitive status and to determine the risk of cognitive impairment in elders associated with use of nonsteroidal antiinflammatory (NSAID) drugs and benzodiazepine.

Abstract, executive summary, and final report, are available from the National Technical Information Service (NTIS accession no. PB96-116223; 26 pp, $19.50 paper, $10.00 microfiche).

Concentration of AIDS-Related Inpatient Care. Jesse Green, M.B.A., Ph.D., New York University Medical Center, New York.

The researchers examined hospitalization patterns for inpatient care of AIDS patients for 27 metropolitan statistical areas across the country—accounting for half the Nation's AIDS cases between 1983 and 1992—and discuss the pros and cons of concentration vs. dispersion of care across many hospitals.

Abstract, executive summary, and final report, are available from the National Technical Information Service (NTIS accession no. PB97-126601; 20 pp, $19.50 paper, $10.00 microfiche).

Diagnostic Accuracy of Community Physicians Performing Colposcopy. Paul R. Gordon, M.D., University of Arizona College of Medicine, Tucson. AHCPR grant HS07162, 7/1/93 to 6/30/96.

This study assessed the diagnostic skill and accuracy of 25 community-based physicians in Arizona, each of whom performed 20 to 50 colposcopy examinations (microscopic examination of the cervix used as followup to an abnormal Pap smear). The physicians' visual diagnosis was compared with subsequent histologic diagnosis to assess accuracy.

Abstract, executive summary, and final report, are available from the National Technical Information Service (NTIS accession no. PB97-106470; 17 pp, $19.50 paper, $10.00 microfiche).

Directed Counseling: Effects on Contraceptive Behavior. Valerie J. Sedivy, M.H.S., Johns Hopkins School of Public Health, Baltimore, MD. AHCPR grant HS08923, 8/1/95 to 7/31/96.

The researcher presents a time-efficient strategy for improving the consistency of contraceptive use through use of a client-administered risk-assessment tool to assess attitudes toward pregnancy and contraception. To validate the tool, study participants (n=525) were divided into three groups and received either standard counseling, counseling by specially trained staff, or individualized counseling based on the risk-assessment tool. Participants were interviewed after 3 months to assess contraceptive behavior and attitude changes.

Abstract and executive summary of dissertation, are available from the National Technical Information Service (NTIS accession no. PB97-123913; 15 pp, $19.50 paper, $10.00 microfiche).

Do Public Hospitals Affect Private Insurance Choice? Kimberly J. Rask, M.D., Ph.D., Emory University School of Medicine, Atlanta, GA. AHCPR grant HS07665, 1/1/94 to 6/30/96.

The researchers used NMES data on respondents under age 65 to examine the effect of providing subsidies to public hospitals and health care providers for providing care to the uninsured and whether the proximity of free or subsidized care decreases individuals incentive to purchase private health insurance.

Abstract, executive summary, and final report, are available from the National Technical Information Service ( NTIS accession no. PB97-131817; 28 pp, $19.50 paper, $10.00 microfiche).

Effectiveness of an Early Postoperative Feeding Protocol. Ann Marie Hedberg, Ph.D., University of Texas Health Sciences Center, Houston. AHCPR grant HS08440, 9/1/94 to 8/31/96.

The use of a standardized early jejunal feeding protocol for patients following bowel resection was evaluated for its effects on patient outcomes and cost. The protocol involved insertion of a jejunal feeding tube at the time of surgery and initiation of feeding within 12 hours postsurgery. The researcher compared length of hospital stay, costs, nosocomial infection rate, and health status for 81 treatment patients and 159 control patients, who received standard care.

Abstract, executive summary, and dissertation, are available from the National Technical Information Service (NTIS accession no. PB97-127286; 64 pp, $21.50 paper, $10.00 microfiche).

Emergency Medicine Diagnostic and Treatment Units. Robert J. Zalenski, M.A., M.D., University of Illinois, Chicago. AHCPR grant HS07103, 8/1/92 to 7/31/96.

This two-pronged study involved patients with asthma and chest pain seen treated in the Emergency Department (ED). Accelerated therapy in an Emergency Observation Unit was compared with hospitalization for 224 patients aged 18 to 55 with moderately severe asthma who were randomly assigned to a 9-hour ED-based protocol of hospital admission. The chest pain study evaluated an accelerated diagnostic ED protocol for accuracy, patient satisfaction, and cost, compared with hospitalization, for 317 patients who were 54 percent male, 65 percent black, and had a mean age of 46.6.

Abstract, executive summary, and final report, are available from the National Technical Information Service (NTIS accession no. PB97-134423; 16 pp, $19.50 paper, $10.00 microfiche).

Hierarchical Statistical Modeling in Health Policy Research. Carl Morris, Ph.D., Harvard Medical School, Boston, MA. AHCPR grant HS07118, 8/1/92 to 7/31/96.

Hierarchical statistical models and random effect meta-analysis models were developed for use in health policy research applications. These models expand the set of policy questions that can be answered in data settings where problems of clustering, heterogeneity, random effects, or several levels of variation exist.

Abstract, executive summary, and final report, are available from the National Technical Information Service (NTIS accession no. PB97-115992; 25 pp, $19.50 paper, $10.00 microfiche).

Management of Acute Asthma in Pediatric Practice (MAAPP). Anthony J. Alario, M.D., American Academy of Pediatrics, Elk Grove Village, IL. AHCPR grant HS07418, 9/30/92 to 9/29/94.

The goal of this project was to determine the range of variability in pediatric office-based management of acute asthma, how this management differed from the national guidelines promulgated by the National Heart, Lung, and Blood Institute (NHLBI) and the American Academy of Pediatrics (AAP), and whether variability in care affected short-term clinical outcomes. Over a 12-month period, 55 community-based providers from the AAP's Pediatric Research in Office Settings (PROS) Network—recruited from 26 PROS practices from 17 States—recorded information on clinical findings and management plans for 363 consecutive children, 4 to 17 years of age, presenting with an acute exacerbation of asthma. Parents completed one questionnaire at enrollment and another 5 to 7 days after the initial clinical encounter to document short-term clinical and functional outcomes.

Abstract, executive summary, final report, and appendixes A-C, are available from the National Technical Information Service (NTIS accession no. PB97-131825; 85 pp, $25.00 paper, $10.00 microfiche).

Natural History of Blood Lead and Effects of Intervention. Helen J. Binns, M.D., Children's Memorial Hospital, Chicago, IL. AHCPR grant HS08764, 5/1/95 to 4/30/96.

The objective of this project was to describe the natural history of blood lead levels in children aged 6 months to 5 years seen in three inner-city clinics and evaluate the effectiveness of a clinic-based intervention to decrease their exposure to lead.

Abstract, executive summary, and final report, are available from the National Technical Information Service (NTIS accession no. PB97-118855; 45 pp, $21.50 paper, $10.00 microfiche).

Patient and Physician Decisionmaking in Prenatal Genetic Testing. Paul S. Heckerling, M.D., University of Illinois, Chicago. AHCPR grant HS06945, 9/1/93 to 3/1/96.

The researchers examined the relationship between preferences for prenatal outcomes and prenatal test choice among 372 pregnant women who chose either amniocentesis (n=288) or chorionic villus sampling (n=84) who were being tested because of maternal age and the 92 physicians who referred them for testing. Preferences were assessed using written scenarios describing potential prenatal testing outcomes, responses were recorded on linear rating scales, and adjustments were made for sociodemographic and obstetric variables.

Abstract, executive summary, and final report, are available from the National Technical Information Service (NTIS accession no. PB96-212329; 53 pp, $21.50 paper, $10.00 microfiche).

Pediatric Preventive Care Incentives in a Medicaid HMO. Alan L. Hillman, M.B.A., M.D., University of Pennsylvania, Philadelphia. AHCPR grant HS07614, 4/1/93 to 9/30/96.

This randomized controlled trial assessed the impact of feedback and financial incentives on physician compliance with pediatric preventive care guidelines in a Medicaid managed care organization. Fifty-three primary care sites were assigned to one of three study groups: feedback reports and financial incentives, feedback reports only, or control (no feedback or financial incentive). Compliance with guidelines for immunizations and other preventive services was evaluated through semiannual chart audits in 1994 and 1995.

Abstract, executive summary, and final report, are available from the National Technical Information Service (NTIS accession no. PB97-136048; 26 pp, $19.50 paper, $10.00 microfiche).

Physician Insurer's Impact on Early Cancer Detection. Stuart J. Cohen, Ed.D., Bowman-Gray School of Medicine, Winston-Salem, NC. AHCPR grant HS06992, 6/1/91 to 5/31/96.

This project was a randomized trial to increase breast, cervical, skin, and prostate cancer screening by primary care physicians throughout Colorado. Practices were stratified by location (urban or rural) and by readiness to change cancer screening practices (most to least ready) and randomized to either usual care, care package (self-help materials mailed to the practice), external training (attend one regional workshop and have one in-office followup), or continuing contact (external training plus monthly telephone calls and return visits every 6 months). Chart reviews were obtained at baseline and 1 and 2 years later on a random sample of 22 male and 22 female patients aged 42 to 74.

Abstract, executive summary, and final report, are available from the National Technical Information Service (NTIS accession no. PB97-131833; 9 pp, $10.00 paper, $10.00 microfiche).

Practice Guidelines in Primary Care. W. Scott Schroth, M.D., M.P.H., George Washington University, Washington, DC. AHCPR grant HS07069, 7/1/93 to 8/31/96.

This project was a randomized controlled investigation of the implementation of a clinical practice guideline for the care of acute low back pain. The setting was two group-model HMO practices in Washington, DC, where researchers used retrospective chart review and a telephone survey of patients to assess the impact of guideline implementation on the appropriateness of care, resource utilization, patient satisfaction, patient beliefs, functional status at 9 months, days of work missed, and the cost of care.

Abstract, executive summary, and final report, are available from the National Technical Information Service (NTIS accession no. PB97-127328; 76 pp, $25.00 paper, $10.00 microfiche).

Preference Assessment for Pharmaceutical Evaluation. Alan M. Garber, A.M., M.D., Ph.D., Stanford University, Stanford, CA. AHCPR grant HS07818, 3/1/93 to 9/20/96.

The researchers developed methods to assess patient preferences toward alternative states of health for use in cost-effectiveness analysis of pharmaceutical therapies. The methods they developed were multimedia, with tests of validity, reliability, and acceptability. These methods should improve subjects understanding of health states and result in preference assessments that are similar between patients with and without disease.

Abstract, executive summary, and final report, are available from the National Technical Information Service (NTIS accession no. PB97-134431; 37 pp, $21.50 paper, $10.00 microfiche).

Restorative Oral Health Status Outcome Measure. James D. Bader, D.D.S., M.P.H., University of North Carolina, Chapel Hill. AHCPR grant HS06669, 9/1/90 to 6/31/96.

The objective of this project was to determine how dentists make restorative treatment decisions and to develop and validate a measure of normative treatment needs for restorative dental care. Determinants of treatment decisions and variations in those decisions were identified through analysis of multiple dentists treatment decisions for the same group of patients.

Abstract, executive summary, and final report, are available from the National Technical Information Service (NTIS accession no. PB97-123905; 30 pp, $19.50 paper, $10.00 microfiche).

Risk Factors, Utilization, and Dental Outcomes in the Older-old. Teresa A. Dolan, D.D.S., M.P.H., University of Florida College of Dentistry, Gainesville. AHCPR grant HS08124, 2/1/94 to 1/31/95.

The researchers analyzed data collected between 1988 and 1993 in conjunction with a health promotion randomized trial to determine whether functional impairment interferes with dental service use. Participants were 331 community-dwelling men and women older than 75 years of age who were the subjects of in-home assessments at baseline and at 12, 24, and 36 months.

Abstract, executive summary, and final report, are available from the National Technical Information Service (NTIS accession no. PB97-118590; 25 pp, $19.50 paper, $10.00 microfiche).

Social Factors Influencing Medical Outcome Measures. Michael G. Marmot, M.B.B.S., Ph.D., University College of London, United Kingdom. AHCPR grant HS06516, 9/30/90 to 3/31/96.

In conjunction with the Whitehall II study of 8,000 male and female office workers, this project investigated the association between socioeconomic status and health functioning applying the SF-36, one of the most widely used measures of health status. The goal was to determine the utility of the SF-36, which was originally designed to assess the outcomes of medical care, for measuring health in a general population study.

Abstract, executive summary, and final report, are available from the National Technical Information Service (NTIS accession no. PB97-109417; 12 pp, $19.50 paper, $10.00 microfiche).

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Research Briefs

Balas, E.A., Boren S.A., Brown, G.D., and others (1996, October). "Effect of physician profiling on utilization." (AHCPR grant HS07715). Journal of General Internal Medicine 11, pp. 584- 590.

Physicians must continually adjust the way they practice medicine as new information becomes available via journal reports, practice guidelines, and clinical research results. Another approach to changing the practices of physicians is profiling reports that directly compare their performance with that of their colleagues. The purpose of this meta-analysis of 12 studies was to assess the effectiveness of profiling for changing clinical practice patterns and to examine its effect on the use of procedures ranging from colorectal, breast, and other cancer screening tests to tests to detect hypertension or high blood cholesterol. Analysis revealed that profiling had a statistically significant but minimal effect on the use of clinical procedures and is unlikely to be the right type of feedback for performance improvement, according to these researchers. On the other hand, feedback strategies—such as computerized reminders—seem to have the potential for changing physician practices.

Hornberger, J., and Lenert, L.A. (1996). "Variation among quality-of-life surveys." Medical Care 34(12), pp. DS23-DS33.

Quality-of-life (QOL) assessments are increasingly being used to characterize treatment effectiveness in clinical studies. Although several QOL survey instruments are available, and there is growing interest in using them, a consensus has not been achieved on the types of survey instruments that should be used. Many sources of variation may affect the results of QOL surveys, and different surveys may yield different results about the effects of the same clinical strategy on quality of life. This article addresses whether there is sufficient consensus to begin establishing standards for assessing quality of life. The authors review sources of systematic and random variations in QOL survey responses that arise from disease- or treatment-specific experiences. They conclude that consensus on standard methods for assessing quality of life may be difficult to achieve at this time.

Moriarity, J.M. (1996, October). "A pound of cure." (AHCPR grant HS08091). Minnesota Medicine 79, pp. 8, 9, 60.

In this commentary, the author points out that despite widespread agreement about the benefits of preventive health measures, many patients have yet to receive these services routinely. But the results of the Twin Cities (Minneapolis-St. Paul, MN) greater metro area IMPROVE Project (Improving Prevention Through Organization, Vision, and Empowerment) point toward a solution. The goal of IMPROVE is to address the main barriers to delivery of preventive services by helping a team at each of 22 clinics use the techniques of continuous quality improvement (CQI). After agreeing to focus on eight preventive services, each clinic first created an interdisciplinary team responsible for developing a system to provide the services. The team at Chisago Health Services, a three-clinic system in Chisago, MN, developed a procedure to ensure that screening questions were asked routinely, as well as a uniform documentation system to show at a glance the status of each patient. The Chisago Health Services team followed a CQI process and developed an approach appropriate for each clinic. There was improvement in preventive care and increased awareness of preventive health among the patients at all three clinic sites. The article includes suggestions for other clinics interested in improving preventive services.

Peabody, J.W., Bickel, S.R., and Lawson, J.S. (1996, December). "The Australian health care system: Are the incentives down under right side up?" (NRSA training grant T32 HS00046). Journal of the American Medical Association 276(24), pp. 1944-1950.

Despite many similarities with the health care system in the United States, Australia has universal health insurance (introduced in 1975) and spends only $1,944 per capita, considerably less than the $3,299 per capita spent in the United States. There are similar numbers of physicians per capita in each country, but general practitioners make up 42 percent of Australian physicians compared with 11 percent in the United States. Australians have free choice of a general practitioner (GP), who acts as a gatekeeper for referrals to specialists. Hospital admissions are generally the responsibility of specialists, as few GPs have admitting privileges. The larger and more prestigious hospitals are public and often are associated with medical schools. Private hospitals are generally smaller and do not offer comprehensive services, nor do they usually have emergency or intensive care facilities. Health outcomes in Australia compare favorably with those in the United States. This leads the authors to conclude that Australia's health care system, while less expensive than that of the United States, is working.

Stineman, M.G., Shea, J.A., Jette, A., and others (1996, November). "The functional independence measure: Tests of scaling assumptions, structure, and reliability across 20 diverse impairment categories." Archives of Physical Medicine and Rehabilitation 77, pp. 1101-1108.

Clinicians use functional status to assess a patient's need for rehabilitation, set goals, and evaluate outcomes. Moreover, functional status at admission and/or at discharge from rehabilitation has been proposed as a basis for hospital payment. Because functional status is so essential, it is important that standard instruments meet established psychometric properties and that any subscale dimensions are consistent across diverse patient groups. The analysis presented here evaluated the psychometric properties of the Functional Independence Measure (FIM) as a summated rating scale within the context of the 20 impairment categories of the FIM-Function Related Group (FIM-FRG) system for 93,829 patients discharged from 252 freestanding rehabilitation hospitals and units during 1992. Factor analyses showed that psychometric properties of the summated FIM compare favorably to most standardized health measures used in medical practice.

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AHCPR Publication No. 97-0024
Current as of March 1997

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