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Blewett, L.A., Kane, R.L., and Finch, M. (1995/1996, Winter). "Hospital ownership of post-acute care: Does it increase access to post-acute care services?" (AHCPR grant HS06604). Inquiry 32, pp. 457-467.

Patients with stroke or chronic obstructive pulmonary disease are more likely to use a post-acute care (PAC) facility after hospital discharge if the hospital owns the facility, it is a teaching hospital, or the hospital serves a large proportion of Medicare patients. However, patient characteristics—such as whether the patient lives alone, is older, or has functional impairments—are much more consistent predictors of PAC use. In the other three diagnosis-related groups studied (congestive heart failure, hip joint procedures, and hip fracture procedures), patients discharged from hospitals that owned PAC facilities were as likely to receive PAC as patients discharged from hospitals that did not own PAC facilities. Almost two-thirds of the patients studied were discharged to PAC services. Patients discharged from hospitals that owned PAC facilities and served a high volume of Medicare patients were more apt to receive PAC. The researchers suggest this may be because these hospitals benefit by reducing inpatient length of stay, where costs are paid by Medicare on a fixed-price basis, to the PAC setting, where services are paid for on a cost-plus basis. Also, these hospitals may be financially dependent on Medicare and thus face additional incentives to discharge patients sooner, leaving the patients more in need of PAC services. This analysis was based on data collected as part of a large-scale study on the course of post-acute care among more than 2,500 Medicare patients in five DRGs who were discharged from 52 hospitals in three urban areas (Minneapolis/St. Paul, Houston, and Pittsburgh) between March 1988 and March 1989.

Escalante, A., Galarza-Delgado, D., Beardmore, T.D., and others (1996, January). "Cross cultural adaptation of a brief outcome questionnaire for Spanish-speaking arthritis patients." (AHCPR grant HS07397). Arthritis & Rheumatism 39(1), pp. 93-100.

These researchers adapted a brief self-assessment questionnaire to measure health outcomes among English- and Spanish-speaking patients with arthritis. They translated the items into Spanish about 8 activities of daily living, duration of morning stiffness, and a 10-point pain scale. They tested the questionnaire among English- and Spanish-speaking arthritis patients from four clinical centers. Results showed that the English-Spanish equivalence and test-retest reliability of the questionnaire were almost perfect. Questionnaire scores compared with an occupational therapists' evaluation also were near-perfect in both languages. Both versions of the questionnaire correlated well with functional class, amount of pain, grip strength, and walking velocity. The researchers conclude that the questionnaire is suitable for studying Spanish-speaking subjects with arthritis in the United States and elsewhere.

Gaudier, F.L., Goldenberg, R.L., Nelson, K.G., and others (1996, February). "Influence of acid-base status at birth and Apgar scores on survival in 500-1000-g infants." (AHCPR Low Birthweight PORT contract 282-92-0055). Obstetrics & Gynecology 87(2), pp. 175-180.

Gestational age at delivery and birthweight are considered the most important predictors of survival in very low birthweight (VLBW) infants. However, the predictive value of other maternal and neonatal risk factors, especially cord blood acid-base status and Apgar scores, remain unclear. These researchers evaluated the influence of acid-base status at birth and Apgar scores on the survival of 1,073 VLBW infants during 1979 to 1991. Survival of infants in every gestational age grouping was higher in infants with an umbilical artery pH of 7.05 or higher compared with infants with a pH lower than 7.05, significantly so at 27-28 weeks. There was no consistent relationship between umbilical artery PCO2 or bicarbonate and survival. With the exception of the 1-minute Apgar score at 23-24 weeks, the relationship of Apgar score to survival was significant in all gestational age periods (23 to 29 weeks or more). The only significant relationships between any of the cord blood gases, Apgar scores, and mortality involved low 1-minute and low 5-minute Apgar scores and a bicarbonate less than 21 mEq/L. The researchers conclude that 1-minute and 5-minute Apgar scores are better predictors of survival than umbilical artery blood gases in neonates weighing 500-1,000 grams (approximately 1-3/4 to 3-1/2 pounds) at birth.

Knaus, W.A., Harrell, F.E., LaBrecque, J.F., and others (1996). "Use of predicted risk of mortality to evaluate the efficacy of anticytokine therapy in sepsis." (AHCPR grant HS07137). Critical Care Medicine 24(1), pp. 46-56.

Infection is one of the most frequent causes of morbidity and mortality in severely ill, hospitalized patients. Although antibiotic therapy controls or limits the growth of bacteria, a high mortality rate persists, attributable in part to the patients' own systemic inflammatory response to the infection. The investigators applied an independent, sepsis-specific, regression model to predict the risk of mortality over 28 days to all patients with sepsis syndrome enrolled in the multicenter clinical trial of recombinant human interleukin-1-receptor antagonist (rhIL-1ra) therapy. Of the 893 patients, 302 received a placebo, 298 were treated with 1 mg/kg/hr of rhIL-1ra, and 293 were treated with 2 mg/kg/hr of rhIL-1ra. Results showed a significant increase in survival time for all patients treated with rhIL-1ra, but patients with a predicted risk of mortality of less than 24 percent derived little benefit. Retrospective examination of time-to-death demonstrated that rhIL-1ra reduced risk of death in the first 2 days for patients by 24 percent or more. This same effect was not present in patients with a predicted risk of mortality of less than 24 percent on entry into the study. There was a wide distribution of individual patient risks for 28-day mortality for all patients, as well as within categorical subgroups, such as shock and organ system dysfunction. The researchers conclude that individual risk or severity assessment may be useful for evaluating the clinical benefit of new therapeutic approaches to sepsis and for monitoring outcomes at the bedside.

Steinberg, S.H., Strickland, G.T., Pena, C., and Israel, E. (1996, January). "Lyme disease surveillance in Maryland." (AHCPR grant HS07813). Annals of Epidemiology 6(1), pp. 24029.

Lyme disease (LD) is a tick-borne infection caused by the spirochete Borrelia burgdorferi, which accounts for 90 percent of all reported vector-borne illnesses in the United States. The authors describe the incidence of LD reported to the Maryland Department of Health and Mental Hygiene during 1992 at 6.5/100,000 population, ranging from 29.3 cases/100,000 on the Eastern Shore (nearly 75 percent of all cases) to no cases in the mountains of western Maryland. Among the 317 reported patients, 44.4 percent gave a history of tick exposure and 78.9 percent had positive serologic test results. For the 59 percent of patients meeting the Centers for Disease Control and Prevention surveillance case definition, erythema migrans (EM) occurred in 69.5 percent, with arthritic (26.7 percent), neurologic (13.4 percent), and cardiac (2.1 percent) manifestations being less frequent. Patients not meeting the case definition were significantly more likely to have influenza-like symptoms, a smaller rash, and arthralgia. Patients meeting the CDC criteria were more likely to have an onset during the major transmission season in the summer, since this was the time that most patients with EM were detected. There was no difference in the treatment prescribed for patients who did and did not meet the case definition. These data show that physicians in Maryland are treating many patients for LD who are clinically diagnosed as having the disease and have positive serologic test results but do not meet the CDC case definition.

Zhu, B-P, Lemeshow, S., Hosmer, D.W., and others (1996). "Factors affecting the performance of the models in the Mortality Probability Model II system and strategies of customization: A simulation study." (AHCPR grant HS06026). Critical Care Medicine 24(1), pp. 57-63.

More than a dozen statistical models have been developed to estimate the probability of hospital mortality of intensive care unit (ICU) patients. These models need to be evaluated in order for them to accurately reflect mortality experience in diverse clinical settings. The researchers examined the impact of hospital mortality and ICU size on the performance of the Mortality Probability Model II system for use in quality assessment and examined the ability of model customization to produce accurate estimates of hospital mortality to characterize patients by severity of illness. They simulated model performance using data assembled from six adult medical and surgical ICUs in Massachusetts and New York and found the model to be sensitive to differences in hospital mortality and thus useful as a quality assurance tool.

Selected publications are available from the National Technical Information Service

Ordering Information. For copies of these publications, contact the National Technical Information Service (NTIS). Refer to the NTIS accession number when ordering.

Acute Pain Management. Guideline Technical Report, Number 1. Most of the 23 million operations performed each year in the United States involve some form of pain control. Acute pain management is also needed for most trauma patients and for patients undergoing certain medical procedures. The Guideline Technical Report presents scientific evidence tables, and discusses the results of peer and pilot reviews of guideline materials. (NTIS accession no. PB95-167391CEB; $44.50 bound copy; $17.50 microfiche.)

AHCPR Clinical Practice Guideline Program. Report to Congress. This congressionally mandated report summarizes findings and AHCPR's plans for streamlining and refining its clinical practice guideline activities. Methods for setting priorities for guideline topics, generating guidelines, and assessing the quality and impact of practice guidelines are discussed. (NTIS accession no. PB95-269148CEB; $27.00 bound copy.)

AHCPR's Program of Patient Outcomes Research and Related Activities. Report to Congress. This congressionally mandated report describes the progress of activities under the Agency's Medical Treatment Effectiveness Program, a multidisciplinary approach to addressing the complex issues of health care delivery through outcomes research, data development, clinical practice guidelines, and dissemination and evaluation of research findings. (NTIS accession no. PB95-261764CEB; $19.50 bound copy; $9.00 microfiche.)

Design of a Survey to Monitor Consumers' Access to Care, Use of Health Services, Health Outcomes, and Patient Satisfaction. Final Report. This book contains initial sets of questions and procedures for assessing consumer-supplied information that is useful to other consumers. The authors describe the method and results of the cognitive testing and how the items in the survey were chosen. The conceptual development process and description and rationale for the survey design also are included. (NTIS accession no. PB95-196036CEB; $36.50 bound copy; $17.50 microfiche.)

Effective Dissemination of Clinical and Health Information. Conference Summary This publication features presentations from a 1991 conference on dissemination of clinical and health information. Topics include disseminating evaluation findings, building network models of information dissemination, using mass media communications to enhance public health, designing message strategies, and using electronic dissemination. (NTIS accession no. PB95-123956CEB; $36.50 bound copy; $17.50 microfiche.)

Evaluation of a Comprehensive Hospital Information System. Project Summary. This report documents the differences and similarities in nearby hospitals, one of which has a 20-year history of computerization. It looks at a unique information system that was specifically designed to encourage physician data entry and thereby capture clinical data at the source. (NTIS accession no. PB95-269155CEB; $17.50 bound copy.)

Management of Functional Impairment Due to Cataract in Adults. Guideline Technical Report, Number 4. Cataract surgery is the most common surgical procedure performed on Americans age 65 and over. This report consists of recommendations for providing the highest quality of care for individual patients, based on an extensive review of the relevant literature and on expert opinion. (NTIS accession no. PB94-175809CEB; $44.50 bound copy; $17.50 microfiche.)

Maternity Care: Science, Guidelines, and Medical Practice. Conference Proceedings. This publication contains papers and presentations from a 1991 conference that examined the findings of a 10-year study on effective care in pregnancy and childbirth. (NTIS accession no. PB93-213692CEB; $19.50 bound copy; $12.50 microfiche.)

Otitis Media with Effusion in Young Children. Guideline Technical Report, Number 12. Otitis media with effusion (middle ear fluid) is one of the most common problems in infants and young children. The Guideline Technical Report presents recommendations based on extensive reviews of the relevant medical and health-related literature and on expert opinion and guideline panel consensus. (NTIS accession no. PB95-224523CEB; $44.50 bound copy; $17.50 microfiche.) An appendix detailing written testimony is also available. (NTIS accession no. PB95-170015CEB; $44.50 bound copy; $17.50 microfiche.)

Physicians, Nurses, and AIDS: Findings From a National Study. From a social perspective, acquired immunodeficiency syndrome (AIDS) revives longstanding issues about the willingness of health care professionals to treat people with a contagious, fatal, and stigmatized disease. This report presents responses to AIDS-related questions posed to 958 physicians and 1,520 registered nurses during 1990-1991. The author compares the responses of both groups and those from different regions in the United States. (NTIS accession no. PB95-129185CEB; $17.50 bound copy; $9.00 microfiche.)

Pressure Ulcers in Adults: Prediction and Prevention. Guideline Report, Number 3. Most pressure ulcers can be prevented, and early-stage pressure ulcers that do appear need not worsen. The Guideline Report contains a comprehensive literature review, details the methodology of the guideline, and presents exhaustive evidence tables and reference lists. (NTIS accession no. PB95-167383CEB; $36.50 bound copy; $17.50 microfiche.)

Prostate Disease: Final Report of the Patient Outcomes Research Team. This report discusses a 5-year study (1989-1994) conducted to better define the outcomes of health care for men with two very common diseases of aging: benign prostatic hyperplasia (enlargement) and early stage prostate cancer. Outcomes of care are assessed and made available to patients, clinicians, and policymakers. (NTIS accession no. PB95- 253811CEB; $19.50 bound copy; $9.00 microfiche.)

Putting Research Into Practice: Report of the Task Force on Building Capacity for Research in Primary Care. This report describes the critical need for primary care research and provides 10 recommendations that include national, institutional, collaborative, and individual career strategies for increasing support for research in primary care. (NTIS accession no. PB93-218584CEB; $17.50 bound copy; $9.00 microfiche.)

Understanding and Choosing Clinical Performance Measures for Quality Improvement: Development of a Typology. Three decades of research have yielded a scientific basis for research and development in clinical performance measurement and improvement. This book presents a literature review and results of a survey on instruments that estimate how well providers deliver appropriate clinical care. Information on a system for analyzing the instruments' properties and uses also is included. Attachments, (NTIS accession no. PB95-184784CEB; $27.00 bound copy; $12.50 microfiche.)

Use of Language in Clinical Practice Guidelines. This resource helps drafters of clinical practice guidelines express themselves with clarity and precision. Since guidelines not only affect clinical practice, but also may be used in litigation, drafters should be alert to the significance of language used. (NTIS accession no. PB93-213700CEB; $17.50 bound copy; $9.00 microfiche.)

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AHCPR Publication No. 96-0060
Current as of June 1996

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