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Felix-Aaron, K.L., Bone, L.R., Levine, D.M., and Rubin, H.R. (2002). "Using participant information to develop a tool for the evaluation of community health worker outreach services." Ethnicity & Disease 12, pp. 87-96.

Health care providers and managed care organizations use community health workers/advisors (CHWs) for outreach programs in underserved communities. CHWs work in clinics and have access to homes, community centers, and the streets, tackling health issues ranging from cancer screenings and childhood immunizations to management of HIV/AIDS. These researchers used interviews with clients of CHWs to develop and administer an in-person survey measuring the importance of 57 aspects of CHW services to 84 clients in 3 programs that were using CHWs to help control hypertension or diabetes. The aspects of CHW care that ranked highest were: CHW knows their job; keeps client alive; gives information on high blood pressure; shows respect to the client; blood pressure is lowered; CHW pays attention; client gets better medical care; CHW speaks understandably; and client gets needed care. Such questionnaire-elicited information may be helpful to providers and managed care organizations who want to evaluate the CHWs they use.

Reprints (AHRQ Publication No. 02-R057) are available from the AHRQ Publications Clearinghouse.

Fowler, F.J., Gallagher, P.M., Stringfellow, V.L., and others (2002). "Using telephone interviews to reduce nonresponse bias to mail surveys of health plan members." (AHRQ grant HS09205). Medical Care 40(3), pp. 190-200.

Surveying members of health insurance plans is an increasingly popular approach to measuring quality of care in the United States. However, responses to mail surveys are likely to be related to survey content and hence are potentially biased. Nonresponse to phone surveys is less directly related to survey content. In fact, telephone interviews with mail nonrespondents not only increase survey response rates but also can produce less biased samples than mail-only protocols, according to this study. The investigators conducted a mail survey about health care experiences with 800 members in each of four health plans. They attempted to interview nonrespondents by telephone. Response rates for the mail surveys averaged 46 percent; the telephone effort raised the average to 66 percent. Based on administrative data, telephone interviews of mail nonrespondents also improved the demographic representativeness of the responding samples.

Hermann, R.C., and Palmer, R.H. (2002, March). "Common ground: A framework for selecting core quality measures for mental health and substance abuse care." (AHRQ grant HS10303). Psychiatric Services 53(3), pp. 281-287.

Stakeholders in the mental health care system—from delivery systems and payers to managed care organizations, regulators, and accreditors—have implemented ways to assess quality of care delivered to patients. These diverse approaches to measuring quality of care have increased the burden on health care providers, limited the comparability of results, and hindered efforts to focus limited resources on further development of the most promising measures, assert these researchers. They present a framework for the selection of a core set of measures and point out that differences in priorities among stakeholders complicate the selection process. They clarify divergent perspectives of various stakeholders, such as the technical clinical processes that physicians focus on, personal experience relied on by consumers and families, and utilization measures favored by managed behavioral health organizations. Finally, the researchers make recommendations for further development of core quality measures for mental health care.

Koroukian, S.M., and Rimm, A.A. (2002). "The Adequacy of Prenatal Care Utilization' (APNCU) index to study low birth weight: Is the index biased?" (AHRQ National Research Service Award training grant T32 HS00059). Journal of Clinical Epidemiology 55, pp. 296-305.

The period from 1981 to 1995 showed increasing trends toward use of more prenatal resources but worsening trends in birth outcomes, according to a recent nationwide study of 54 million births that used the Adequacy of Prenatal Care Utilization (APNCU) index to measure resource use. However, this study demonstrates that there is a bias in the APNCU index and that more intensive resource use is in fact associated with improved birth outcomes. The index categorizes use of prenatal care services as follows: adequate plus (A+), adequate, intermediate, and inadequate based on the ratio of observed to expected or recommended (O/E) number of prenatal visits. Preterm births were disproportionately represented in the A+ category: 61 percent of births prior to 37 weeks were A+, whereas only 19 percent of term births were A+. This apparent bias results from the fact that the schedule of prenatal visits recommended by the American College of Obstetricians and Gynecologists allocates nearly one-third of the total visits to the last 4-5 weeks of gestation, suggesting falsely that women grouped in the A+ category were most likely to deliver low birthweight infants. The authors recommend discontinuing use of the APNCU index to study the association between low birthweight and prenatal care use.

Kravitz, R.L., Bell, R.A., Franz, C.E., and others (2002, February). "Characterizing patient requests and physician responses in office practice." (AHRQ grant HS09812). Health Services Research 37(1), pp. 217-238.

The Taxonomy of Requests by Patients (TORP) is a refined system for characterizing patient requests and physician responses in office practice. These researchers assessed the reliability, applicability, and validity of TORP based on independent ratings by two coders using TORP of audiotaped recordings of 131 patient visits (71 to general internists and 60 to cardiologists). Intercoder agreement on the sorting of requests into categories (reliability) and intercoder agreement on the labeling of elements of discourse as patient requests and subsequent classification into categories (unitizing reliability) were substantially beyond chance. The researchers conclude that TORP should be a useful tool for understanding the clinical negotiation between doctors and patients and should be applicable to both generalist and specialist practices.

McCormack, L.A., Garfinkel, S.A., Hibbard, J.H., and others (2002, February). "Health insurance knowledge among Medicare beneficiaries." (AHRQ grant HS09218). Health Services Research 37(1), pp. 43-63.

The objective of this study was to assess the effect of new consumer information materials about the Medicare program on beneficiary knowledge about their health coverage under Medicare. These investigators randomly assigned Medicare beneficiaries in the Kansas City area to a control group and three treatment groups each receiving a different set of Medicare informational materials: the handbook only; a bulletin (abbreviated version of the handbook); or a survey report, which compared the quality of health care provided by the five local Medicare HMOs. The researchers then conducted a 15-item Medicare knowledge survey of 2,107 beneficiaries. For both new and experienced beneficiaries, all three treatment groups had modestly higher knowledge scores relative to the control group, including the critical areas of cost, coverage, and supplemental insurance options. Compared with controls, experienced beneficiaries in the bulletin group scored 7 percentage points higher and those who received either the handbook or the survey report scored 9 percentage points higher. Among new beneficiaries, members of all three treatment groups scored about 9 percentage points higher than the controls.

Okkes, I.M., Polderman, G.O., Fryer, G.E., and others (2002, January). "The role of family practice in different health care systems. A comparison of reasons for encounter, diagnoses, and interventions in primary care populations in the Netherlands, Japan, Poland, and the United States." Journal of Family Practice 51(1).

These researchers compared the content of family practice in different countries using databases containing information on reasons for encounter, diagnoses, and interventions. They found important differences and striking similarities. Differences in the numbers of episodes and of encounters per patient per year were small compared with differences in use per episode of care, including both diagnostic and therapeutic interventions. Substantial differences were found in prescribing antibiotics, oral contraceptives, cardiovascular medications, and gastrointestinal therapies. Prescribing behavior in the Netherlands and the United States was similar, while very different patterns were found in Japan and Poland. Similarities were much higher in patients' reasons for encounter than in diagnoses. Nevertheless, even under very different conditions in the four countries studied, there was substantial overlap in the top 30 symptom/complaint reasons for encounter, incidence rates, and encounters per diagnosis.

Patton, L.L., Shugars, D.A., and Bonito, A.J. (2002, February). "A systematic review of complication risks for HIV-positive patients undergoing invasive dental procedures." (Contract 290-97-0011). Journal of the American Dental Association 133, pp. 195-203.

These investigators reviewed the research literature to determine the strength of the evidence regarding whether HIV-infected patients are at higher risk of developing complications—such as infection, bleeding, or delayed healing—from invasive oral procedures than similar patients without HIV. They found no studies involving surgery on the jaw, periodontal therapy, prophylaxis, dental implants, or scaling and root planing and only one study reporting a few immediate endodontic therapeutic complications. They conclude that the evidence is insufficient with respect to any additional risk associated with these procedures among people with HIV/AIDS. They also consider the evidence to be too poor to rule in or out a meaningful relationship between HIV status and complications from tooth extractions.

Sherman, K.J., Cherkin, D.C., and Hogeboom, C.J. (2001). "The diagnosis and treatment of patients with chronic low-back pain by traditional Chinese medical acupuncturists." (AHRQ grants HS09351, HS09989). Journal of Alternative and Complementary Medicine 7(6), pp. 641-650.

These researchers used data from two sources, an acupuncture teaching clinic and seven acupuncturists involved in a clinical trial, to examine more than 150 initial visits to acupuncturists using Traditional Chinese Medical (TCM) diagnoses and treatments for patients with chronic low back pain. They could not identify any clear and consistent set of diagnostic groups or acupoint prescriptions. Although three principal TCM diagnoses are outlined by TCM textbooks, acupuncturists studied classified only one-third of patients into a single one of these diagnostic categories. Instead, they often gave patients multiple diagnoses. Acupuncturists prescribed a wide variety of acupoints. However, only a handful of points were used regularly by most acupuncturists, and individual acupuncturists usually had favorite points rarely used by others. More than half of acupuncture patients with low back pain received additional treatments, including heat (36-67 percent) and cupping (16 to 21 percent). It is unknown whether these different approaches are equally effective.

Titler, M.G., and Everett, L.Q. (2001, December). "Considerations for critical care investigators." (AHRQ grant HS10482). Critical Care Nursing Clinics of North America 13(4), pp. 587-604.

Use of evidence-based guidelines in clinical practice is sporadic at best, and research continues to demonstrate that these guidelines are used inconsistently by nurses and physicians. This article describes a research model based on a model of diffusion of innovations to guide researchers in studying the adoption of evidence-based practices in critical care environments. The authors point out that the nature, credibility, and localization of the innovation (clinical practice guideline) and the use of "practice prompts" influence adoption of the innovation. Mass communication and didactic education are most appropriate during the initial stage of communicating with potential users about adopting the innovation. Interpersonal communication and trying out an innovation are appropriate during the persuasion and decisionmaking stages. Local opinion leaders, such as respected physicians, can aid adoption of guidelines by modeling, peer influence, and altering group norms. Outreach visits conducted by a trained person who meets one-on-one with practitioners also help spur adoption of evidence-based practices.

Valenta, Z., and Weissfeld, L. (2002). "Estimation of the survival function for Gray's piecewise-constant time-varying coefficients model." (AHRQ grant HS09694). Statistics in Medicine 21, pp. 717-727.

The Cox proportional hazards (PH) model has been widely used for the analysis of biomedical data from both longitudinal studies and clinical trials. This is mainly due to its appealing mathematical simplicity, as well as its general availability through most statistical packages. These authors demonstrate the usefulness of Gray's extension of the Cox's PH model for right-censored survival data. They provide an example of the estimated survival functions and the corresponding confidence limits derived from Cox's PH and Gray's PC-TVC model for a liver transplant data set.

Williams, J.W., Noel, P.H., Cordes, J.A., and others (2002, March 6). "Is this patient clinically depressed?" (AHRQ contract 290-97-0012). Journal of the American Medical Association 287(9), pp. 1160-1170.

These researchers reviewed studies that used depression questionnaires to evaluate at least 100 primary care patients and compared questionnaire results with accepted diagnostic criteria for major depression. The 28 published studies assessed 11 questionnaires, which ranged in length from 1 to 30 questions and took from 1 to 5 minutes to administer. All questionnaires were diagnostically accurate. Overall, a positive depression screen was 3.3 times as likely to be seen in someone with depression as in someone without the illness. A negative depression screen was much less (0.2 times) likely to be seen in a depressed person. Given the similar diagnostic accuracy of the questionnaires studied, the researchers recommend that physicians choose questionnaires based on brevity, response format, the desire to screen for other psychiatric illnesses, and the need to monitor response. In a clinic with an 8 percent prevalence of major depression or prolonged minor depression (dysthymia), a doctor seeing 100 patients a week can expect that 30 will screen positive for depression, of whom 7 would meet the criteria for clinical depression after a clinical interview.

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Current as of May 2002
AHRQ Publication No. 02-0026

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