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New publications now available from NTIS

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

Financial and Nonfinancial Barriers to Prenatal Care After Major Medicaid Eligibility Expansions. Paula A. Braveman, M.D., M.P.H., University of California, San Francisco. AHCPR grant HS07910, project period 3/1/94 to 2/28/97.

The researchers interviewed a representative sample of 10,132 postpartum women at 19 randomly selected delivery hospitals in California during 1994 and 1995 to identify barriers to prenatal care 5 years after major Medicaid eligibility expansions. Although only 2 percent of women remained uninsured throughout pregnancy, 36 percent of Medi-Cal-covered and 18 percent of privately insured, low-income women did not receive first trimester care. The principal barrier to timely care appeared to be delayed coverage, even after adjusting for multiple characteristics and other potential barriers. Factors related to family planning and connections with care systems pre-pregnancy, along with unspecified factors related to absolute poverty or being unmarried, also appeared to be significant independent barriers among low-income women. Problems with Medi-Cal provider availability, transportation, child care, and language were not significantly associated with untimely care, after adjusting for other factors. Universal coverage unlinked to pregnancy may be required to substantially improve prenatal care utilization, given remaining personal and systems barriers. Furthermore, because 65 percent of the sample overall and 35 percent of privately insured women were low-income and most low-income women received care at private sites, both private and public maternity services need to address low-income women's needs, according to this report.

Abstract, executive summary, and final report are available from the National Technical Information Service (NTIS accession no. PB97-203475; 144 pp, $31.00 paper, $14.00 microfiche).

Impact of Risk Management on Liability Claims Experience. Laura L. Morlock, Ph.D., Johns Hopkins University, Baltimore, MD. AHCPR grant HS06735, project period 9/1/91 to 9/31/95.

The objectives of this project were to: (1) describe the clinical risk management programs and activities of Maryland hospitals after such activities were mandated by State law; (2) compare the current clinical risk management programs among Maryland hospitals with different types of liability insurance coverage; (3) compare current risk management activities among hospitals in three States with varying levels of risk management regulation; and (4) examine relationships between clinical risk management activities and risk-adjusted liability claims experience. Study results indicate that risk management efforts vary widely among Maryland hospitals. On average, hospitals have approximately two-thirds of the minimum recommended risk management programs and activities in place. In a three-State comparison, risk management regulation does not appear to motivate greater program efforts among hospitals. Although self-insurance is associated with risk management program activity among Maryland hospitals, stronger predictors of risk management effort include hospital location in a metropolitan area and previous claims experience.

Abstract, executive summary, final report, and selected appendixes are available from the National Technical Information Service (NTIS accession no. PB97-199762; 156 pp, $35.00 paper, $14.00 microfiche).

Minority Capacity Building in Health Services Research. Herbert W. Nickens, M.D., Association of American Medical Colleges, Washington, DC. AHCPR grant HS06772, project period 9/30/91 to 6/30/96.

Health services research is the field that should provide the knowledge base for rational health reform measures designed to improve the efficiency and equity of the U.S. health care system. However, to accomplish this, it is essential to increase the degree to which the field of health services research specifically addresses questions related to minority and disadvantaged populations. This project focused on two mechanisms to address the problem. First, by diversifying the pool of investigators by increasing the number of underrepresented minority faculty (black, American Indian/Alaska Native, Mexican American and Puerto Rican) at U.S. medical schools that are involved with health services research by creation of the AAMC Health Services Research Institute. Since its inception, the Institute has worked with 52 faculty members. Second, by broadening the field of research enquiry through a national conference, "The Role of Class, Race and Ethnicity in Health Services Research," which was held in December 1993.

Abstract, executive summary, final report, and selected appendixes are available from the National Technical Information Service (NTIS accession no. PB97-188783; 128 pp, $31.00 paper, $14.00 microfiche).

Primary Care Physician Job Satisfaction and Turnover. Modena E. Wilson, Johns Hopkins University, Baltimore, MD. AHCPR grant HS08984, project period 9/30/95 to 3/31/97.

The purpose of this project was to further understanding of primary care physician (PCP) turnover (job exit). A panel of 533 postresident, employed, non-Federal PCPs younger than 45 years of age who had been in practice between 2 and 9 years participated in two national surveys on physician practice patterns in 1987 and 1991. Individual PCP and organizational variables from 1987 were the independent variables, and turnover from 1991 was the dependent variable. PCPs who believed that third-party-payer influence would decrease in the future were 1.5 times more likely to leave their jobs than PCPs who believed that such influence would remain the same. Pediatricians were 1.4 times more likely to leave than general/family practitioners. Board-certified PCPs were 1.3 times more likely to exit than non-board-certified PCPs. Sex, age, race, and type of practice setting were not predictive of PCP turnover.

Abstract, executive summary, and final report are available from the National Technical Information Service (NTIS accession no. PB97-197123; 40 pp, $21.50 paper, $10.00 microfiche).

Quality of Life Subscale for Terminally Ill Cancer Patients. Anthony J. Grisinger, M.A., University of Texas, Houston, TX. AHCPR grant HS08421, project period 9/30/94 to 12/31/96.

The Functional Assessment of Cancer Therapy-End of Life (FACT-EOL) was developed to assess the quality of life of cancer patients with a life expectancy of 6 months or less. Phase one of this study identified the major concerns of 74 terminally ill cancer patients (breast, lung, colorectal, renal cell, and prostate cancer) at the University of Texass M.D. Anderson Cancer Center and the Hospice at the Texas Medical Center in Houston. In phase two, 120 patients rated the importance of their concerns for quality of life. In phase three, 356 patients were interviewed to determine the subscales reliability and sensitivity to change in clinical status. Patients who scored lower in functional status had lower scores in the spiritual, existential, social/family, and emotional domains and higher scores in the symptom domain. The results of this study support use of the FACT-EOL in assessing quality of life and the outcomes of palliative treatment for terminally ill cancer patients.

Abstract and executive summary of dissertation are available from the National Technical Information Service (NTIS accession no. PB97-200141; 13 pp, $19.50 paper, $10.00 microfiche).

Twelve-Hour Observation Unit Diagnosis of Tuberculosis. Daniel Murphy, M.D., University of Illinois at Chicago, Chicago, IL. AHCPR grant HS08427, project period 9/30/94 to 9/29/96.

This study compared the predictive value of direct microscopic detection of tuberculosis (TB) using three serial sputum samples obtained within 12 hours in an emergency department observation unit (EDOU) versus three early morning sputum samples obtained during consecutive hospital days. The researchers also examined the accuracy of a standardized clinical assessment obtained in the ED in predicting the diagnosis of active TB. And finally, they compared the sensitivity and specificity of the diagnosis of TB in the EDOU versus an inpatient isolation unit and assessed the capability of the EDOU to rapidly identify new TB cases. Eighty-seven patients, aged 16 to 87, were seen in a municipal inner-city hospital ED and admitted to an isolation bed with possible active TB. The study group was 86 percent male, 79 percent black, and 35 percent HIV-positive. All patients had active symptoms, a positive chest x-ray, and a decision to admit and isolate made by an ED physician and corroborated by a pulmonary medicine consultant. Sputum was collected at times 0 hours, 4 hours, and 8 hours after EDOU presentation and again in the morning of the following 3 days.

A standardized historical data collection form was completed and a PPD/anergy battery was placed. All samples were evaluated independently in a blinded manner. Twenty-eight patients (32 percent) had sputum positive for TB, and eight patients (9 percent) had sputum positive for a pathogen other than TB. There was no difference in sensitivity, specificity, or predictive values between the 12-hour EDOU sampling method and inpatient methods in detecting TB; use of the EDOU method could permit more precise indications for hospitalization and the use of respiratory isolation beds.

Abstract, executive summary, and final report are available from the National Technical Information Service (NTIS accession no. PB97-200158; 16 pp, $19.50 paper, $10.00 microfiche).

AHCPR funds new studies

The following new grants and National Research Service Award (NRSA) fellowships were funded recently by the Agency for Health Care Policy and Research. Readers are reminded that the results of studies usually are not available or published until a project is completed or nearing completion.

Research Projects

Efficacy of telemedicine colposcopy
Project director: Daron G. Ferris, M.D.
Organization: Medical College of Georgia, Augusta, GA
Project number: AHCPR grant HS08814
Period: 9/30/97 to 9/39/00
First year funding: $203,328

Optimal timing of liver transplantation
Project director: Mark S. Roberts, M.D.
Organization: University of Pittsburgh, Pittsburgh, PA
Project number: AHCPR grant HS09694
Period: 9/30/97 to 9/29/00
First year funding: $442,837

Conference Grant

Acute pain dissemination conference
Project director: Julie Morath, M.S.
Organization: Allina Health System, Minneapolis, MN
Project number: AHCPR grant HS09547
Period: 9/1/97 to 3/31/98
Funding: $15,000

Dissertation Grants

Fetal and infant mortality review: Health policy tool
Project director: Christine M. Layton, M.P.H.
Organization: Johns Hopkins University, Baltimore, MD
Project number: AHCPR grant HS09671
Period: 9/30/97 to 9/29/98
Funding: $29,934

Impact of data collection mode on low-literacy subjects
Project director: Cathy A. Coyne, M.P.H.
Organization: Johns Hopkins University, Baltimore, MD
Project number: AHCPR grant HS09693
Period: 9/30/97 to 9/29/98
Funding: $31,622

Small Project Grants

Alternative approaches for evaluation of fever in injection drug users
Project director: Richard E. Rothman
Organization: Johns Hopkins University, Baltimore, MD
Project number: AHCPR grant HS09555
Period: 9/30/97 to 3/30/99
Funding: $62,500

Analysis of micro costs of coronary artery bypass grafting
Project director: Chuan-Fen Liu, Ph.D.
Organization: Center for Health Economics Research, Waltham, MA
Project number: AHCPR grant HS09559
Period: 9/30/97 to 9/39/98
Funding: $64,401

Assessing match in child-clinician communications
Project director: Charles W. Kalish, Ph.D.
Organization: University of Wisconsin, Madison, WI
Project number: AHCPR grant HS09556
Period: 9/30/97 to 9/29/98
Funding: $72,000

Assessing outcomes of dental care with claims data
Project director: Stephen A. Eklund, Dr.P.H.
Organization: University of Michigan, Ann Arbor, MI
Project number: AHCPR grant HS09554
Period: 9/30/97 to 9/29/99
Funding: $36,185

Computer system to support Alzheimer's decisionmaking
Project director: David H. Gustafson, Ph.D.
Organization: University of Wisconsin, Madison, WI
Project number: AHCPR grant HS09567
Period: 9/30/97 to 9/29/98
Funding: $71,568

Consumer evaluation of health care
Project director: Gordon G. Bechtel, Ph.D.
Organization: Florida Research Institute, Gainesville, FL
Project number: AHCPR grant HS09550
Period: 9/30/97 to 9/29/98
Funding: $39,974

Evaluation of a home and community-based waiver for persons with AIDS
Project director: Jean M. Mitchell, Ph.D.
Organization: Georgetown University, Washington, DC
Project number: AHCPR grant HS09560
Period: 9/30/97 to 9/29/98
Funding: $80,500

Evaluation of performance measures for predictive models
Project director: John L. Griffith, Ph.D.
Organization: New England Medical Center, Boston, MA
Project number: AHCPR grant HS09561
Period: 9/30/97 to 9/29/98
Funding: $79,858

Financial burden of health care costs for the elderly
Project director: Stephen Crystal, Ph.D.
Organization: Rutgers University, Piscataway, NJ
Project number: AHCPR grant HS09566
Period: 9/30/97 to 9/29/98
Funding: $78,500

Hospital use and costs by children with asthma, 1988-1994
Project director: John Richard Meurer, M.D.
Organization: Medical College of Wisconsin, Milwaukee, WI
Project number: AHCPR grant HS09564
Period: 9/30/97 to 9/29/98
Funding: $75,000

National alternative medicine ambulatory care survey
Project director: Daniel C. Cherkin, Ph.D.
Organization: Center for Health Studies, Seattle, WA
Project number: AHCPR grant HS09565
Period: 9/30/97 to 9/29/99
First year funding: $53,276

Outcomes and costs of inpatient antidepressant drugs
Project director: Deborah L. Ackerman, Ph.D.
Organization: University of California, Los Angeles, CA
Project number: AHCPR grant HS09551
Period: 9/30/97 to 9/30/99
First year funding: $55,966

Racial disparities in quality of nursing home care
Project director: Sally Zierler, Dr.P.H.
Organization: Brown University, Providence, RI
Project number: AHCPR grant HS09552
Period: 9/29/97 to 9/29/98
Funding: $79,986

Using data envelopment analysis (DEA) to profile surgeon efficiency
Project director: Jon A. Chilingerian, Ph.D.
Organization: Brandeis University, Waltham, MA
Project number: AHCPR grant HS09562
Period: 9/30/97 to 9/29/98
Funding: $59,577

NRSA Fellowships

Patterns of care and outcomes for colon cancer
Fellow: Maria R. Ferreira, M.D.
Organization: Northwestern University, Evanston, IL
Sponsor: Charles L. Bennett
Project number: F32 HS00125
Period: 1-year fellowship
Funding: $32,200

Quality of life in patients with emphysema
Fellow: Roger D. Yusen, M.D.
Organization: Washington University, St. Louis, MO
Sponsor: Benjamin Littenberg
Project number: F32 HS00124
Period: 1-year fellowship
Funding: $36,300

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Research Briefs

Dal Pan, G.J., Skolasky, R.L., and Moore, R.D. (1997, July). "The impact of neurologic disease on hospitalizations related to human immunodeficiency virus infection in Maryland 1991-1992." (AHCPR grant HS07809). Archives of Neurology 54, pp. 846-852.

Most neurologic complications occur in the advanced stages of HIV infection, usually after the person has already developed full-blown AIDS and AIDS-related illnesses. These HIV-related neurologic diseases, which range from primary lymphoma of the brain and dementia to encephalitis and psychosis, increase the length of hospital stay and total hospital charges for patients with AIDS. According to this study, 14 percent of 6,013 AIDS-related hospitalizations were associated with neurologic disease as a primary or secondary diagnosis. After controlling for age, sex, race, and stage of HIV infection, the presence of neurologic disease significantly increased the length of hospital stay by 3.3 days for all HIV-seropositive patients and 5 days for persons with AIDS and increased total charges by $2,552 and $1,500, respectively. These findings are based on data from HIV-related hospitalizations from all acute, non-Federal hospitals in Maryland in 1991 and 1992.

Messeri, P., Workman, S., Sanders, C., and Francis, C. (1997). "The application of meta-analysis in assessing racial differences in the effects of antihypertensive medication." (AHCPR grant HS07399). Journal of the National Medical Association 89(7), pp. 477-485.

Meta-analysis of clinical studies is an important and common technique for synthesizing research findings. In recent years, there has been increasing emphasis on the use of meta-analysis not only to summarize the central tendency of findings, but also to explain variation between studies. These researchers used meta-analysis of the antihypertensive efficacy of calcium channel blockers to illustrate how a comparative analysis can be applied to investigate racial variation in the effects of calcium channel blockers. They found a significant trend between the proportion of black hypertensive subjects and the mean reduction in blood pressure. The researchers also applied meta-analytic techniques to explore possible confounders due to differences in research design and patient characteristics.

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