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Most low-risk patients with pneumonia prefer
to be treated at
home, but few are given the option
One-third of the 3 million U.S. adults diagnosed with
community-acquired pneumonia (CAP) each year are initially
hospitalized. However, most patients who are at low risk of death
from CAP prefer to be treated at home rather than the hospital.
Even though the majority of low-risk patients fare well with
outpatient treatment, few clinicians offer them this option,
according to a study supported in part by the Agency for Health
Care Policy and Research (HS06468). Identifying which patients
are candidates for home treatment is one goal of the Pneumonia
Patient Outcomes Research Team (PORT), which conducted the study.
Christopher M. Coley, M.D., of Massachusetts General Hospital and
Harvard Medical School, PORT leader Wishwa N. Kapoor, M.D.,
M.P.H., of the University of Pittsburgh, and their colleagues
explored preferences for home or hospital treatment among 159
patients diagnosed with low-risk CAP and enrolled in the
multiple-site Pneumonia PORT study, for whom outpatient therapy
would be a reasonable option. The team evaluated the patients'
responses to seven low-risk pneumonia scenarios. These ranged
from progressive return to usual health within 6 weeks, whether
initially treated at the hospital or not, to slower rate of
recovery with no improvement in fever or symptoms after 1 week,
to serious complications after initial treatment with usual
health returning after 12 weeks.
When asked, 80 percent of the patients preferred home-based care
for the present episode of low-risk CAP, including 60 percent of
those who were initially hospitalized. Nearly three-quarters of
the patients were willing to pay an average of 24 percent of 1
month's household income to be assured of this preference.
Nevertheless, 69 percent of patients felt that the attending
physician alone made the decision for home or hospital treatment.
Only 9 percent of patients felt that they alone, or in concert
with family, made the decision. Fifteen percent felt the decision
was made jointly with their physicians,and 7 percent said that
"other determinants" played a key role.
Only 11 percent of patients recalled being asked if they had a
preference for either site of care. The researchers conclude that
most persons with low-risk CAP should be informed of their
favorable prognosis and encouraged to play an active role in the
decision for hospital or home care.
More details are in "Preferences for home vs. hospital care among
low-risk patients with community-acquired pneumonia," by
Christopher M. Coley, M.D., Yi-Hwei Li, Ph.D., Anne R. Medsger,
M.S.Hyg., and others, which appears in the July 22, 1996,
of Internal Medicine 156, pp. 1565-1571.
Women and the elderly are less likely to
receive life-saving drugs for heart attacks
Evidence-based guidelines issued by the American College of
Cardiology and the American Heart Association advise physicians
to treat patients suffering from heart attack (acute myocardial
infarction, AMI) with medications such as thrombolytics
(clot-dissolving drugs), beta blockers, and aspirin, in order to
reduce complications and death. The guidelines advise against use
of lidocaine hydrochloride to prevent the likelihood of primary
ventricular fibrillation because it can lead to an increased risk
of death, especially in uncomplicated AMI. Nevertheless,
lidocaine is still used inappropriately in many patients with
AMI, and appropriate medications are still underused in elderly
patients and women, according to a study supported in part by the
Agency for Health Care Policy and Research (HS07357).
Physicians need to follow AMI clinical practice guidelines more
closely, especially for elderly patients and women, asserts
Thomas J. McLaughlin, Sc.D., lead author of a recently published
report of an ongoing study from Harvard Medical School and
Harvard Pilgrim Health Care. The study was designed to test the
dissemination of national evidence-based guidelines through use
of local opinion leaders. Stephen B. Soumerai, Sc.D., the study's
principal investigator, Dr. McLaughlin, and their colleagues
reviewed the medical records of nearly 2,500 patients admitted to
37 Minnesota hospitals for suspected AMI during 1992 and 1993.
Among patients eligible for effective, life-saving drugs, they
observed moderately high rates of use of aspirin (81 percent),
moderate use of thrombolytic agents (72 percent), and low use of
beta blockers (53 percent). Twenty percent of patients with no
indication for needing lidocaine received this potentially
For all four drugs, patients 75 years or older were significantly
less likely to be treated than those aged 64 years or younger,
regardless of whether the agent was likely to be beneficial or
ineffective (lidocaine). This level of undertreatment of elderly
patients was most pronounced for thrombolytic agents. Use of all
study drugs was consistently lower for women than for men. After
adjusting for age and hospital type, women were less likely than
men to be treated with aspirin and thrombolytic agents. A similar
trend was observed for the use of beta blockers and lidocaine.
These results correspond with other studies that show less use of
invasive cardiac procedures for women and the elderly compared
with men and younger patients.
See "Adherence to national guidelines for drug treatment of
suspected acute myocardial infarction," by Drs. McLaughlin and
Soumerai, Donald J. Willison, Sc.D., and others, in the
Archives of Internal Medicine 156, pp. 799-805, 1996.
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Hospital Use/Quality of Care
Neonatal ICU admission of normal weight
infants could be
avoided if intensive monitoring were available elsewhere
Half of infants admitted to neonatal intensive care units (NICUs)
are of normal weight (5.5 pounds or heavier). Yet many of them
could avoid the NICU if they could receive intensive monitoring
in alternative care settings, conclude James E. Gray, M.D., M.S.,
and Marie C. McCormick, M.D., Sc.D., of the Joint Program in
Neonatology of the Harvard Medical School, and their colleagues.
They found that of normal-birthweight (NBW) infants admitted to
ne NICU, only 59 percent received active therapy, such as
intravenous infusions, respiratory support, or tube feeding. The
remainder received only intensive monitoring and probably did not
need to be admitted to an NICU if they could have been monitored
in a less costly setting, explain the researchers.
They examined the medical records of 521 NBW infants admitted to
a single NICU during 1989 and 1990, mostly for respiratory
problems, jaundice, and congenital anomalies, and determined the
infants' health status 6 months later via telephone interviews.
The researchers found that the median length of hospitalization
for NBW infants was 7.7 days (ranging from 1 to 110 days), and
median hospital charges were $5,222 (ranging from $565 to
$317,820). Overall, about 10 percent of NBW infants required
rehospitalization, but 30 percent of those with congenital
anomalies were readmitted to the hospital. Infants with
congenital anomalies had significantly higher charges and longer
hospital stays than other NBW infants.
The major determinants of NICU admission among NBW infants were
congenital anomalies (21.6 percent), prematurity despite NBW (22
percent), and acute complications of the neonatal period.
Congenital malformations accounted for 22 percent of NBW
admissions, 35 percent of hospital days, and 45 percent of total
charges in the newborn period.
Details are in "Normal birth weight intensive care unit
survivors: Outcome assessment," by James E. Gray, M.D., M.S., Dr.
McCormick, Douglas K. Richardson, M.D., M.B.A., and Steven
Ringer, M.D., Ph.D., in the June 1996 issue of Pediatrics 97(6),
Race and sex influence use of hospital-based
Women and minorities in California receive fewer hospital-based
procedures than men and whites in that State, according to a
study supported by the Agency for Health Care Policy and Research
(HS07558). It found that men had much better odds than women of
undergoing seven of nine high-technology medical procedures.
Whites had greater odds for undergoing five of the nine
procedures than blacks, three of the nine procedures compared
with Latinos, and two of the nine compared with Asians, even
after controlling for patients' insurance status, age, diagnosis,
and number of medical conditions.
Analysis of California hospital discharges in 1989 and 1990
showed that the odds ratio favored men over women for seven of
the nine procedures studied, which included hip replacement,
pacemaker implant, endarterectomy (that is, removal of plaque
deposits from coronary arteries), angioplasty, defibrillator
implant, heart transplantation, and coronary bypass surgery.
Whites showed higher odds than blacks of undergoing angioplasty,
endarterectomy, coronary bypass surgery, defibrillator implant,
and kidney transplantation. Whites also had greater odds than
Latinos of undergoing coronary bypass surgery, kidney
transplantation, and angioplasty. Finally, whites showed higher
odds than Asians for receipt of angioplasty and endarterectomy.
However, Asians showed favorable odds compared with whites for
The findings from this study have tremendous policy implications.
Providing insurance and admission to high technology hospitals
may not ensure equal access to high technology treatments for
women and minorities. In order to equalize utilization of these
procedures, it may be necessary for policymakers to address not
only financing, but also the social and clinical issues that
affect allocation of technologies.
It is not yet clear which roles, if any, referral patterns,
patient preferences, or evidence of clinical effectiveness play
in a provider's selection of candidates for various procedures,
comments Mita K. Giacomini, M.P.H., Ph.D., of McMaster
University, author of the study. A more disturbing implication is
possible discrimination on the part of the provider. A critical
question is how well sophisticated technologies—often
by public funding but developed and tested primarily on whites
and men&3151;serve the needs of minority and female patients with
target diseases, concludes Dr. Giacomini.
More details are in "Gender and ethnic differences in
hospital-based procedure utilization in California," by Dr.
Giacomini, in the June 10, 1996, Archives of Internal Medicine
156, pp. 1217-1224.
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Elderly persons' attitudes toward nursing
homes predict their
future use of these facilities
Health and financial status are two of the factors that determine
whether an elderly person will be admitted to a nursing home, but
attitude plays an important role as well. Elderly persons who
feel that there is lots to do in a nursing home are more likely
to later use a nursing home and to stay longer at a home than
elderly persons who do not share this opinion, concludes a study
supported in part by the Agency for Health Care Policy and
Research (T32 HS00032). It shows that those with favorable
attitudes toward nursing homes had 1.5 times increased odds of
subsequently using nursing home services and 17 percent longer
nursing home stays than other elderly persons. Prior nursing home
use did not directly affect subsequent attitudes toward nursing
Planners and policymakers need to recognize the importance of
these attitudes as a predictor of subsequent nursing home use.
They also need to develop opportunities to include patient
preferences and attitudes in long-term care treatment plans,
suggests Donna J. Rabiner, Ph.D., of the National Center for
Health Promotion, VA Medical Center, Durham, NC, author of the
study. She analyzed data from the National Long-Term Care Survey
of impaired elderly adults living at home in 1982, who were
reinterviewed in 1984. This survey provides data on the health
and functional status of chronically disabled elderly persons in
the United States and their use of hospital, medical, home
health, community-based, and institutional care, as well as
attitudes regarding this use.
Survey analysis pointed to four "predisposing" factors that
predicted the likelihood of any nursing home stay from 1982-1984:
black race, being married, advanced age, and the belief that
there is lots to do in a nursing home. This attitude increased
the odds of nursing home use. Being black or married reduced the
odds by 76 and 42 percent, respectively. Each additional year of
age increased the odds of having a nursing home stay and the
total months spent in a nursing home. Being married reduced total
length of stay by 24.3 percent.
Two "enabling" factors predicted the likelihood of any nursing
home stay from 1982 to 1984: the number of children and residence
in either the north central region or the west. The presence of
each child reduced the odds by 11 percent, while living in the
north central or western regions of the United States increased
the likelihood of nursing home use. Finally, three "need" factors
were significant predictors in the model. Each limitation in an
activity of daily living (e.g., bathing, feeding oneself, or
using the toilet) or instrumental activity of daily living (e.g.,
using the telephone, driving a car, or preparing a meal)
increased the odds of a nursing home stay. In addition, those
reporting their health to be good (as opposed to fair) were 17
percent less likely to have any subsequent nursing home stay.
See "Attitudes toward and use of subsequent nursing home services
among a national sample of older adults," by Dr. Rabiner, in the
August 1996 Journal of Aging and Health 8(3), pp. 417-443.
More than one-third of Mexican Americans lack
Hispanics have the least health insurance coverage of any
ethnic/racial group in the United States. For instance, in 1980,
26 percent of Hispanics (including Mexican Americans) were
uninsured compared with 18 percent of blacks, and 9 percent of
whites. Currently, more than one-third of Mexican Americans are
without health insurance, according to a study supported by the
Agency for Health Care Policy and Research (HS07397).
Uninsured Mexican Americans—who are mostly poor and have low
levels of education—are those most in need of health care
the least likely to receive it, conclude researchers at the
Mexican-American Medical Treatment Effectiveness Research Center
at the University of Texas Health Science Center.
They interviewed a random sample of 501 Mexican Americans from
San Antonio about their sociodemographic characteristics,
perceived health status, health insurance coverage, and sources
of health care. The survey was conducted in the summer and early
fall of 1992.
More than one-third of those surveyed under the age of 65 years
were uninsured. Compared with privately insured Mexican
Americans, those who were uninsured or publicly insured were less
educated, poorer, and more likely to be unemployed. Uninsured or
publicly insured individuals were more in need of health care,
that is, they were more apt than privately insured persons to
consider themselves in fair or poor health. Yet, uninsured
Mexican Americans were least able to obtain health care. For
instance, 79 percent of publicly insured Mexican Americans
reported having personal physicians and making regular visits
compared with 36 percent of their uninsured counterparts. Persons
with private insurance, regardless of health care need (reporting
excellent to poor health), had similar access to personal
physicians (63 percent and 69 percent, respectively). Uninsured
persons, regardless of health care need, also had similar, but
substantially lower, access to personal physicians (33 percent and
40 percent, respectively).
The finding that poor Mexican Americans with health insurance did
use the health services available demonstrates that health care
access may improve health care outcomes for Mexican Americans.
But more comprehensive community-based campaigns to promote
health and better use of health services among underprivileged
groups should be developed, urge the researchers.
More details are in "Health care access among Mexican Americans
with different health insurance coverage," by Robert P. Trevino,
M.D., Fernando M. Trevino, Ph.D., M.P.H., Rolando Medina, M.D.,
M.P.H., and others, in the Journal of Health Care for the Poor
and Underserved 7(2), pp. 112-121, 1996.
Return to Contents
Symptoms such as fatigue and fever serve as
a barometer of
physical functioning in AIDS patients
Symptoms such as fatigue, fever, and neurologic problems are a
better guide to the physical functioning of AIDS patients than
biologic and physiologic factors such as current infections or
time since diagnosis. These symptoms explain more than half of
how well a patient with AIDS is functioning. Adding biologic and
physiologic factors only explains 2 percent more of the
differences in patients' physical functioning, according to a
study supported by the Agency for Health Care Policy and Research
Biologic and physiologic variables such as weight loss, lower
hemoglobin level, current non-pneumonia bacterial infections,
Mycobacterium avium complex infection, oral Pneumocystis carinii
pneumonia (PCP) prophylaxis, and cigarette smoking were
associated with worse physical functioning. Use of zidovudine
(ZDV) was associated with better physical functioning. These
factors explained 29 percent of variation in physical functioning
However, symptoms alone explained nearly twice (56 percent) the
variation. In each case, better mental health was associated with
fewer symptoms. Lower total white blood cell count, longer time
since diagnosis, weight loss in the last year, and more episodes
of PCP were all associated with more fatigue. Weight loss and
asthma were associated with more neurologic symptoms, and ZDV use
in the last month was associated with fewer neurologic symptoms.
This analysis by Massachusetts researchers was based on a
conceptual model which proposed that symptoms mediate the
relation between biologic and physiologic variables and physical
functioning. The researchers used the model, patient interviews,
and medical chart reviews to predict physical functioning in 305
persons with AIDS from three sites in Boston.
The researchers point out several limitations to their work.
First, as with all cross-sectional data, the direction of causal
effects could not be determined. Second, only one measure of
health-related quality of life—physical functioning—was
and these findings do not necessarily apply to other measures.
Third, too few patients had current CD4 cell counts, so this
important variable could not be included. Fourth, there are
limitations related to the size of the study and the constraints
of a natural experiment in which data were limited to what
physicians decided to order in the course of routine clinical
care. And finally, although the researchers enrolled a
sociodemographically diverse population, there is no way to know
if these findings also apply to other groups of persons with
AIDS, such as women. The researchers also point out that although
oral PCP prophylaxis was associated with worse physical
functioning, when the number of PCP episodes was added to the
model, oral PCP prophylaxis was no longer significant.
For more information, see "Clinical predictors of functioning in
persons with acquired immunodeficiency syndrome," by Ira B.
Wilson, M.D., M.Sc., and Paul D. Cleary, Ph.D., in the June 1996
issue of Medical Care 34(6), pp. 610-623.
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AHCPR News and Notes
Ten new members have been appointed to the
Ten new members have been appointed to the National Advisory
Council for Health Care Policy, Research, and Evaluation, and the
term of service of the council's Chairman, Walter J. McNerney,
M.H.A., has been extended to May 1997. The council, which
comprises 17 private-sector health care experts and consumers and
7 top Federal health officials, advises the Secretary of the
Department of Health and Human Services and the Administrator of
the Agency for Health Care Policy and Research on matters
elating to AHCPR's activities to enhance the quality,
appropriateness, and effectiveness of health care services and
access to such services.
The 10 new members of the council are:
- Richard E. Behrman, M.D., J.D, Managing Director, Center
the Future of Children, The David and Lucile Packard
Foundation, Los Altos, CA.
- Nancy Wilson Dickey, M.D., Chair, Board of Trustees,
American Medical Association, and Program Director, Family
Practice Residency Department of the Brazos Valley, and
Associate Professor, Department of Family and Community
Medicine, Texas A&M University, College Station, TX.
- Jose Julio Escarce, M.D., Ph.D., Senior Fellow, Leonard
Davis Institute and Assistant Professor, School of Medicine,
University of Pennsylvania, Philadelphia, PA.
- Sharon C. Kiely, M.D., Director of Health Services, Primary
Care Health Services, Inc., Pittsburgh, PA.
- Ada Sue Hinshaw, Dean and Professor, University of Michigan
School of Nursing, Ann Arbor, MI.
- Jeffrey P. Koplan, M.D., M.P.H., President, The Prudential
Center for Health Care Research, Atlanta, GA.
- Woodrow Meyers, Jr., M.D., M.B.A., Director, Health Care
Management, Ford Motor Company, Dearborn, MI.
- Martin Paris, M.D., M.P.H., Vice President, Medical
Tenet Healthcare Corp., Dallas, TX.
- Stephen M. Shortell, Ph.D., A.C. Buehler Distinguished
Professor of Health Services Management, J.L. Kellogg
Graduate School of Management, Northwestern University,
- W. Leigh Thompson, M.D., Ph.D., Chairman, Profound Quality
Resources, Ltd., Charleston, SC.
They will join six existing council members whose 3-year terms
will expire in May 1997. In addition to Walter McNerney, the
returning members of the panel are:
- Helen Darling, M.A., Manager, Health Strategy and Programs,
Corporate Benefits, Xerox Corporation, Stamford, CT.
- Robert M. Krughoff, J.D., President, Center for the Study
Services, Washington, DC.
- W. David Leak, M.D., Medical Director, Pain Control
Consultants, Columbus, OH.
- Harold S. Luft, Ph.D., Director, Institute for Policy
Studies, School of Medicine, University of California, San
- Edward B. Perrin, Ph.D., Professor, Department of Health
Services, School of Public Health, University of Washington,
The appointment of a 17th council member is expected within the
next several months. In addition to the private-sector members,
the following Federal officials serve as ex officio members of
the council: Director, National Institutes of Health;
Commissioner, Food and Drug Administration; Administrator,
Substance Abuse and Mental Health Services Administration;
Director, Centers for Disease Control and Prevention;
Administrator, Health Care Financing Administration; Assistant
Secretary for Defense (Health Affairs); and Chief Medical
Officer, Department of Veterans Affairs.
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