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AHCPR invites contract proposals for evidence-based centers and nominations of topics for reports and assessments

As part of its program to strengthen the scientific evidence base used by health care organizations to improve clinical practice, the Agency for Health Care Policy and Research is accepting proposals to fund Evidence-based Practice Centers (EPCs). The EPCs will produce evidence reports and technology assessments for use by systems of care, professional societies, purchasers, and others. These groups will be able to use the reports and assessments as the scientific foundation for developing and implementing their own clinical practice guidelines, performance measures, and other clinical quality improvement tools, and for making decisions related to the effectiveness or appropriateness of specific health care technologies.

In addition, AHCPR is seeking nominations of topics for the evidence reports and technology assessments to be produced by the EPCs. These reports and assessments will involve the prevention, diagnosis, treatment, and management of common diseases and clinical conditions, and where appropriate, the use of alternative/complementary therapies, as well as specific medical procedures or health care technologies. The reports and assessments will be based on comprehensive reviews and rigorous analyses of the relevant scientific evidence—emphasizing explicit and detailed documentation of methods, rationale, and assumptions—and peer reviews.

Until the new centers are established, AHCPR will convert the work of the last two panels under its former guideline program into the first evidence reports to be issued under the new program. These reports will address screening for colorectal cancer and the diagnosis and management of chronic headache pain. AHCPR also expects to produce two additional evidence reports during this transition phase in cooperation with public- and private-sector partners. The topics for these reports will be announced in the near future.

The solicitation for Evidence-based Practice Centers was published in the November 22, 1996, Commerce Business Daily. The Request for Proposals (RFP) will be released no sooner than December 6, 1996, and the closing date for proposals will be 90 days after release of the RFP.

For copies of the Evidence-based Practice Centers RFP (RFP no. AHCPR-97-0001), send a written request to the Agency for Health Care Policy and Research, Contracts Management Staff, Attention: Al Deal, Executive Office Center, Suite 601, 2101 East Jefferson Street, Rockville, MD 20852; telefax (301) 443-7523. Include the requestor's name, affiliation, address, and telephone and fax numbers.

An announcement regarding the nomination of topics for the EPCs will be published shortly in the Federal Register. To be considered for the first group of evidence reports, topic nominations should be submitted within 60 days of the date of publication of the notice to: Douglas B. Kamerow, M.D., M.P.H., Director, Office of the Forum for Quality and Effectiveness in Health Care, Agency for Health Care Policy and Research, 6000 Executive Boulevard, Willco Building, Suite 310, Rockville, MD 20852.

AHCPR funds studies on hysterectomy and alternative treatments for uterine conditions

The Agency for Health Care Policy and Research recently funded three research projects to determine the outcomes of surgery versus other treatments for dysfunctional uterine bleeding (DUB), as well as patient treatment preferences for women with endometriosis, chronic pelvic pain, fibroids, uterine prolapse and DUB. Each year in the United States, 590,000 women have hysterectomies for various conditions. The majority of hysterectomies are performed before menopause, often for abnormal uterine bleeding.

U.S. hysterectomy rates are much higher than in other Western nations, and rates vary by geographic region, race/ethnicity, and socioeconomic status. Although alternative treatments are available, there are few data comparing these treatments to hysterectomy or one form of hysterectomy to another. This lack of information makes it more difficult for women to choose the treatment option that is best for them.

The following studies resulted from a "Request For Application" issued March 1, 1996, by AHCPR. The awards total $17.4 million over 5 years for the following studies:

  • Surgical Treatment Outcomes Project for Dysfunctional Uterine Bleeding. Principal investigator Kay Dickersin, University of Maryland at Baltimore, AHCPR grant HS09506, project period 1996 to 2001. The purpose of this study is to determine the equivalence of two therapies for DUB—hysterectomy and endometrial ablation—using two randomized controlled trials. The researchers will examine the natural history of DUB, the effectiveness of treatment, and cost.
  • MEDTEP Study on Hysterectomy and Dysfunctional Uterine Bleeding. Principal investigator Sarah E. Fowler, Case-Western/Henry Ford Health Sciences Center, Detroit, MI, AHCPR grant HS09502, project period 1996 to 2001. Using collaborative, multisite, randomized controlled trials, this study will compare the effectiveness, relative costs, and patient outcomes of hysterectomy, endometrial ablation, and hormone therapy for women with dysfunctional uterine bleeding.
  • Medicine Or Surgery? Principal investigator Stephen B. Hulley, University of California at San Francisco, AHCPR grant HS09478, project period 1996 to 2001. The researchers will conduct two randomized controlled trials: one to compare the effects (including quality of life) and costs of medical therapy versus hysterectomy; the other to compare the effects of supracervical versus total hysterectomy on function and well-being in women who undergo abdominal hysterectomy. The study also will determine rates and patient preferences for management options for women with diagnoses of fibroids, dysfunctional uterine bleeding, chronic pelvic pain, endometriosis, or uterine prolapse.

AHCPR announces opportunity for senior nurse investigators

The Agency for Health Care Policy and Research, in conjunction with the American Academy of Nursing, is seeking applicants for the position of Senior Scholar in Residence for 1997-1998. This program was developed in collaboration with the American Nurses Association and the National Institute of Nursing Research to encourage a senior nurse scientist to develop areas of investigation that integrate clinical nursing care questions with critical issues of health care quality, costs, and access. The Federal agencies will pay up to half of the candidate's salary during the course of the assignment, but fringe benefits (e.g., insurance, retirement) will be maintained and paid by the candidate's home institution. Nominations will be accepted from individuals or institutions. Individual nominations require an endorsement of the application by the candidate's home institution.

Candidates should be experienced nurse investigators with an advanced degree in health services research or a related area, preferably with clinical experience in the delivery of primary care or experience in performing policy analyses related to primary care. Competitive candidates will have experience in writing, publication, and teaching and, on completion of the Senior Scholar in Residence program, will be prepared to return to an enhanced research career and facilitate the development of research capabilities in others.

The successful candidate will serve as an integral member of the agencies' extramural research programs, with a primary focus within AHCPR. As part of the program, the scholar will undertake a research project that assists AHCPR in fulfilling its mission and produce a paper for publication on the project. The assignment will begin on or after July 1, 1997.

Applications are due by January 15, 1997, and should include a curriculum vitae and a letter of intent describing the research project the applicant would like to undertake, as well as a cover letter describing career objectives, experience, and future potential relating to the senior scholar experience. The most highly qualified candidates may be interviewed.

Applications should be submitted to Janet Heinrich, Dr.P.H., R.N., Director, American Academy of Nursing, 600 Maryland Avenue, S.W., Washington, DC 20024; phone (202) 651-7238; fax (202) 554-2641; E-mail jheinrich@ANA.org.

Conference on minorities and cancer planned for spring 1997

Washington, DC, will be the site of the 6th Biennial Symposium on Minorities, the Medically Underserved, and Cancer. The conference will be held April 23-27 at the Hyatt Regency, Capitol Hill, and will feature scientific and educational general sessions, technical assistance and demonstration workshops, student mentoring programs, educational exhibits, a library and resources center, an awards program, and networking opportunities. The Agency for Health Care Policy and Research is a cosponsor of the conference, which will be particularly relevant for cancer survivors, specialists, primary care clinicians, scientists, educators, community leaders, students, and others interested in community-based cancer prevention and control programs for minorities and the medically underserved.

Participants will exchange the latest scientific and treatment information and share strategies for reducing the disproportionate incidence of cancer morbidity and mortality among minorities and the medically underserved in the United States. Conference sessions will enhance the knowledge of participants in the areas of primary and secondary cancer prevention, early detection, and treatment. An overall goal is to promote culturally competent cancer care and services and ethnically balanced research, especially clinical trials.

For more information or to register, contact Ruth Sanchez, 6th Biennial Symposium, 1720 Dryden, Suite C, Houston, TX 77030; telephone (713) 798-5383; fax (713) 798-3990; or visit the conference Web site at http://icc.bcm.tmc.edu/symposium/.

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Research Briefs

Maas, W.R. (1996, June). "Demands and opportunities or development of self-reported assessments of oral health outcomes." Journal of Dental Education 60(6), pp. 508-513.

This paper describes the larger social, political, and economic environment in which individual dental research efforts and collective research agendas are advanced. The author, a senior dental consultant in the Agency for Health Care Policy and Research, points out that, despite concerns about constrained support for dental research, there is reason to be optimistic that environmental forces may encourage development of self-assessed oral health outcome measures. For example, dental care may soon represent a significant health plan benefit for which performance measures are lacking. Also, there is anecdotal information that some people who have a choice of health plans, such as Federal civilian employees, choose their medical plan on the basis of the dental coverage it affords. Dental plans serving younger members will be under pressure to adopt comprehensive preventive health standards and measure performance against them. Dental plans serving older members also may need to consider patient perceptions of oral health outcomes.

Reprints (AHCPR Publication No. 96-R130) are available from the AHCPR Publications Clearinghouse.

Mayfield, J.A. (1996, July). "A foot risk classification system to predict diabetic amputation in Pima Indians." (AHCPR grant HS07238). Diabetes Care 19(7), pp. 704-709.

Several risk classification systems to predict amputation risk in diabetic patients have recently been developed and widely disseminated. These classification systems usually include measures of neuropathy, bone deformities, and a history of prior foot ulceration, with one including vascular status. However, all of these systems were developed from expert opinion. This study quantifies the contribution of various factors to the risk of amputation in diabetic patients to develop a foot-risk scoring system based on clinical data. The population-based, case-control study included adult diabetics, half of whom were Pima or Tohono O'odham Indians. Case patients had undergone a lower extremity amputation between 1983 and 1992; control subjects had not undergone amputation by 1992. The researchers reviewed medical records to determine patient risk and health status before the pivotal event that led to the amputation and found that male sex, end-organ complications of eye, heart, and kidney, and poor glucose control were associated with a higher amputation rate. Peripheral neuropathy, peripheral vascular disease, deformity, and a prior ulcer also were associated with an increased risk of lower extremity amputation.

O'Connor, P.W., Tansey, C.M., Detsky, A.S., and others (1996, July). "The effect of spectrum bias on the utility of magnetic resonance imaging and evoked potentials in the diagnosis of suspected multiple sclerosis." (AHCPR grant HS05427). Neurology 47, pp. 140-144.

Magnetic resonance imaging (MRI) has revolutionized the practice of neurology and is particularly useful for detecting the subtle white matter lesion used to diagnose multiple sclerosis (MS). However, these abnormalities are frequently found at a stage of disease when the clinical findings are inconclusive. All patients with MS do not have an abnormal brain MRI, and all patients with multiple small cranial lesions on MRI do not have MS. "Spectrum" is a term coined to describe the range of features (clinical, pathologic, and comorbid) that are found in patients and control subjects. Spectrum bias is the tendency for the effectiveness of a test (or treatment) to vary as a function of these variables, including disease severity. In this study, neurologists evaluated 303 patients with suspected MS and also scanned them with MRI; 204 patients also received evoked potential (EP) testing. Both EP and MRI results demonstrated an association between disease frequency, disease severity, and test sensitivity, with greater disease frequency and intensity suggesting more impressive diagnostic test performance. The distorting effect of clinical severity on MRI and EP sensitivity in suspected MS underscores the fact that diagnostic tests perform differently in different groups of patients.

O'Dell, M.W., Hubert, H.B., Lubeck, D.P., and O'Driscoll, P. (1996). "Physical disability in a cohort of persons with AIDS: Data from the AIDS time-oriented health outcome study." (AHCPR grant HS06211). AIDS 10, pp. 667-673.

Severe disability is unusual among persons with AIDS (PWAs) living in the community, but mild to moderate disability is common. From 10 to 50 percent of these persons have some difficulty in daily activities, ranging from dressing themselves and rising from a chair to grocery shopping and doing household chores. The ability of a PWA to function is most influenced by the number of AIDS-related symptoms, level of fatigue, and general health status, especially the number of AIDS-related infections. A person's level of disability is not correlated with CD4 cell count, a marker of the disease's progression, or time elapsed since AIDS diagnosis, according to this study. The researchers analyzed a sample of 546 persons (528 men and 18 women). Study participants were predominantly white, well-educated, homosexual men (mean age of 37 years) who were evaluated 475 days following AIDS diagnosis. Between 50 and 90 percent of men and 33 to 88 percent of women had no difficulty functioning. Severe disability (inability to perform a task) ranged from 7 to 17 percent depending on sex and functional task. About half of the PWAs studied might have benefited from rehabilitation, yet less than 4 percent had recent contact with a physical therapist. Among the men, 17 percent had some difficulty gripping objects, 29 percent reaching, and 52 percent had problems carrying out other activities such as errands and household chores; 28 percent had some difficulty rising from a chair, and 38 percent had trouble walking; 11 percent had problems eating and 21 percent dressing/grooming. Of several factors studied, including treatment with antiretroviral drugs in the previous 3 months and educational level, symptoms contributed most to variations in disability (26.9 percent), followed by fatigue (3.7 percent) and number of AIDS-related infections (1.8 percent). The authors conclude that physical functioning varies among persons with AIDS living in the community, and a substantial number of these individuals experience mild to moderate deficits related to instrumental activities of daily living. They call for additional studies to address the need for and efficacy of appropriate rehabilitation interventions in persons with AIDS experiencing physical disability.

Palmer, R.H. (1996). "Measuring clinical performance to provide information for quality improvement." (AHCPR contract 282-92-0038). Quality Management in Health Care 4(2), pp. 1-6.

Clinical performance measures summarize the quality of care given to groups of patients by a practice, provider network, or health plan. Clinical managers can use these measures to drive and track internal quality improvements. Purchasers and accrediting organizations can provide benchmarks based on comparisons of performance in order to stimulate internal improvements. Whether a measure is suitable for a particular use depends in large part on the purpose of the user. For instance, a high degree of validity in measurement is desirable if an external agent intends to use the measure to sanction or deny payment to a provider. This article explains desired properties of such clinical performance measures and the AHCPR Typology of Clinical Performance Measures Project, whose goal is to promote the design, collection, retrieval, and evaluation of quality measure sets. The author points out that clinical performance measures should provide detailed specifications to ensure uniformity of application; testing for reliability and validity as measures of performance; consideration of patient differences in making comparisons; and well-planned graphic displays of comparisons.

Schmidt, J.R., and Deichert, J.A. (1996). "Predictions of county uninsured rates: Accuracy and stability." (AHCPR grant HS07397). Journal of Health Care for the Poor and Underserved 7(2), pp. 95-121.

Estimating the number of persons lacking health insurance and analyzing their characteristics has been an important research area during the past decade. Calculating uninsured rates is critical for this research. This study shows that uninsured rates of all counties in an area can be predicted by combining survey data from a subset of area counties and secondary data on economic indicators that are available for all counties. The authors present a set of indicators related to the uninsured rate and develop prediction models from surveys taken 2 years apart in the same counties. They assessed the accuracy and stability of the prediction models and found that accuracy levels are highest when contemporaneous rates are predicted. Accuracy deteriorates, however, when rates in a later time period are predicted using models from a prior period, according to the authors.

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