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Less than one-fifth of patients with diabetes receive certain recommended lab tests to monitor diabetes care

Diabetes is a devastating chronic disease that affects blacks more than whites. Regular lab tests can monitor diabetes care and identify early when interventions are needed to prevent and limit its many complications, which range from vascular and vision problems to kidney disease. Yet less than one in five persons with diabetes receives the minimum number of tests recommended by the American Diabetes Association (ADA), according to a study of patients with diabetes enrolled in a large urban health maintenance organization (HMO).

The study, supported by the Agency for Health Care Policy and Research (HS07386) through the Minority Research Center Program, shows that more than 40 percent of insulin-using patients with diabetes and more than 30 percent of noninsulin-using patients with diabetes did not have a single glycosylated hemoglobin test during the study year. This test measures blood sugar levels over a 2- to 3-month time period. Elevated blood sugar levels indicate poor diabetes control, which increases the risk of diabetes-related complications.

Many patients also did not receive other recommended tests that, when elevated, indicate increased risk for developing complications, according to the researchers from Henry Ford Health System, the University of Michigan Medical School, and the University of Nebraska Medical Center. They used computerized medical record and billing data to analyze receipt of diabetic screening tests for 2,312 patients with diabetes enrolled in an HMO during 1991; 57 percent of patients had between 6 and 16 visits to the doctor during the year. Overall, between 60 and 71 percent of patients had annual cholesterol testing (high cholesterol can complicate vascular problems), and between 67 percent and 73 percent of patients had annual creatinine tests (to check for kidney problems) performed as recommended by the ADA. It is unclear whether this failure to consistently meet guidelines was due to lack of physician knowledge, insufficient time to interact with the patient, the patients' lack of understanding of the importance of diabetes care, or some other factor.

No differences were detected by race in the overall rate of receipt of recommended tests. Although black patients had cholesterol and creatinine measures similar to white patients, blacks had higher glycosylated hemoglobin values. Less diabetic control among blacks may be explained by differences in diet, exercise, or body weight that are strongly linked to race, but more studies are needed to confirm this. Nevertheless, blacks who have diabetes remain at increased risk for premature death and disability, and they and their health care providers should be targeted for programs to help them improve diabetes control.

See "Comparison of laboratory test frequency and test results between African-Americans and Caucasians with diabetes: Opportunity for improvement," by Kimberlydawn Wisdom, M.D., M.S., Jon P. Fryzek, Ph.D., Suzanne L. Havstad, M.A., and others, in the June 1997 Diabetes Care 20(6), pp. 971-977.

Researchers examine variation in stroke rehabilitation practices and impact of patient knowledge on stroke prevention

Three million stroke survivors are living with varying degrees of neurological impairment due to stroke. The disabling effects of stroke can be lessened through timely provision of rehabilitation services and other followup care. However, the use and intensity of rehabilitation services for stroke patients vary dramatically nationwide. This practice variation is not due to patient characteristics but probably results from differences in physician choices, according to a study supported by the Agency for Health Care Policy and Research (contract 290-91-0085). Individuals at risk for stroke can help prevent stroke by not smoking, controlling blood pressure, following a low-fat diet, and taking other measures.

Individuals who recognize their increased risk for stroke are more likely to engage in stroke prevention practices than those who do not. Yet over half of patients at increased risk for stroke are unaware of their stroke risk, concludes a second AHCPR-supported study (Stroke Prevention Patient Outcomes Research Team [PORT] contract 290-91-0028).

Lee, A.J., Huber, J.H., and Stason, W.B. (1997, June). "Factors contributing to practice variation in post-stroke rehabilitation." Health Services Research 32(2), pp. 197-221.

One-half to two-thirds of the practice variation in post-stroke rehabilitation is unexplained by patient and market factors; because the practice differences observed in this study were so large, this finding is particularly troubling, according to A. James Lee, Ph.D., of the Center for Health Economics Research. The researchers analyzed post-stroke rehabilitation services provided to a 20 percent random sample of Medicare patients admitted for stroke to acute care hospitals in 151 metropolitan statistical areas (MSAs) during 1991. Analysis showed that patient factors, such as number and level of disabilities, ability to tolerate intensive rehabilitation, other complex medical conditions, and level of home support, rarely explained a third of practice variation and often explained substantially less than that. Market variables, such as number of physicians in the area and bed capacity of various types of facilities, tended to be relatively less important but still were more important than one would like to see, notes Dr. Lee.

Patient characteristics should be the driving force behind choice of rehabilitation setting. Inpatient rehabilitation hospitals (IRHs) provide the most intensive rehabilitation and are appropriate for patients who are at least moderately disabled and can tolerate at least 3 hours per day of rehabilitation. Skilled nursing facilities (SNFs) generally provide less intensive rehabilitation and are appropriate for patients who have minimal disabilities but require more medical monitoring or lack sufficient home support to receive outpatient rehabilitation. Ambulatory rehabilitation is appropriate for people with minimal to moderate levels of disability and with adequate home support.

Some differences in use of post-stroke rehabilitation services across metropolitan areas were found to be related to differences in patient characteristics, consistent with recommendations contained in the AHCPR guideline for post-stroke rehabilitation. To the extent that practice variations are not attributable to differences in patient needs, clinical practice is inconsistent and possibly inappropriate, according to the researchers. They conclude that to the extent clinical guidelines correct misinformation and provide a common understanding of clinical practice for post-stroke rehabilitation, otherwise unexplainable practice differences should begin to disappear.

Samsa, G.P., Cohen, S.J., Goldstein, L.B., and others. "Knowledge of risk among patients at increased risk of stroke." (1997, May). Stroke 28(5), pp. 916-921.

Over one-half of patients at increased risk of stroke because of conditions such as atrial fibrillation, hypertension, smoking, cardiovascular disease, diabetes, and congestive heart failure are unaware of their risk, finds this study. These patients are less apt to engage in stroke prevention practices, such as undergoing carotid endarterectomy (for clogged carotid artery), attempting to control blood pressure, following a low-cholesterol diet, and taking the anticoagulant warfarin or aspirin.

The Stroke Prevention Patient Outcomes Research Team (PORT), led by David Matchar, M.D., of Duke University, recruited 621 patients from the Academic Medical Center Consortium (five academic medical centers), 321 from the Cardiovascular Health Study, and 319 from United Health Care (five health plans). These patients were identified from inpatient records as having one or more codes indicating stroke or transient ischemic attacks (TIAs, mini-strokes) or as asymptomatic but at increased risk for stroke. The patients were interviewed about their health status, functional status, cerebrovascular symptoms, medical conditions, prevention practices, and knowledge of stroke risk.

The results indicated that only 41 percent of respondents were aware of their increased risk for stroke and less than one-half of patients with previous minor stroke acknowledged any increase in stroke risk. About 74 percent of patients who recalled being told of their increased risk of stroke by a physician acknowledged this risk compared with 28 percent of patients who did not recall being informed by a physician. Young patients, depressed patients, those in poor current health, and those with a history of TIA were most likely to be aware of their stroke risk. The researchers conclude that by communicating information about stroke risk to their patients, health care providers can encourage adoption of stroke prevention practices. In addition, clinicians should recognize that patients tend to misunderstand risk, underestimate their risk for stroke, and assume that adverse events will not happen to them. This underscores the need for increasing public awareness about stroke prevention, particularly in the at-risk population.

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HIV/AIDS Research

Use of formal home care is concentrated at later stages of HIV infection

Persons with AIDS are much more likely to use home care than individuals who are HIV-positive but have not yet developed AIDS. Limited ability to carry out ordinary daily tasks and higher levels of fatigue are related to receipt of formal home care, according to a study by John A. Fleishman, Ph.D., of the Agency for Health Care Policy and Research.

The study was based on data obtained in four interviews over a 12-month period with 1,727 HIV-infected adults cared for by major medical providers in 10 U.S. cities. The interviews revealed that nearly 30 percent of persons with AIDS received home care from nurses, compared with 3 percent of HIV-infected individuals without AIDS; 20 percent were cared for by aides or helpers (3 percent for HIV-infected individuals); and 12 percent of AIDS patients received care from other professionals, such as social workers or case managers (4 percent for HIV-infected persons).

Overall, 39 percent of people with AIDS received any formal (paid) home care, and 38 percent received any informal (unpaid) care from family, friends, or more rarely from community volunteers. Use of formal home care services was negligible among asymptomatic HIV-infected persons and was only slightly higher among those with symptoms.

The likelihood of service use increased with the level of physical impairment, level of fatigue, and prior hospitalization. Individuals with both AIDS and limitations in their ability to carry out routine activities of daily living (ADLs), such as dressing or eating, were most likely to use formal services. Thirty-two percent of this group received nursing care and 28 percent received paraprofessional care, compared with 2 percent and 12 percent, respectively, among people with AIDS but no ADL limitations. In addition, higher levels of fatigue significantly increased the likelihood of receiving care from nurses and other professionals but not from paraprofessionals.

Respondents with public insurance, such as Medicaid, were more likely than those with private insurance to receive home care from paraprofessionals. A person with AIDS may be capable of performing ADLs or other activities, but the effort required may be exhausting, prompting the need for home-delivered meals, aides, or homemakers. However, many private insurers do not pay for services such as paid helpers at home. Medicaid may be more likely than private insurers to cover personal care attendants and homemakers.

Details are in "Utilization of home care among people with HIV infection," by Dr. Fleishman, in the June 1997 Health Services Research 32(2), pp. 155-175. Reprints (AHCPR Publication No. 97-R082) are available from the AHCPR Publication Clearinghouse.

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Quality of Care

More research is needed to monitor the impact of health system changes on children's health and health care

The U.S. health system is undergoing unprecedented changes in its organization, financing, and delivery of care. There is very little information on the impact of these changes—in particular the rapid growth of managed care—on child health.

Unfortunately, child health services research (CHSR) currently lacks the tools necessary to monitor the impact of health system change on children's health and health care, compare the effectiveness of alternative treatments, or assess quality of care delivered, according to Christopher B. Forrest, M.D., Ph.D., of the Johns Hopkins School of Public Health, Lisa Simpson, M.B., B.Ch., Deputy Administrator of the Agency for Health Care Policy and Research, and Carolyn Clancy, M.D., Director of AHCPR's Center for Outcomes and Effectiveness Research and Acting Director of the Center for Primary Care Research. In a recent commentary on the topic, they point out that ignoring or minimizing attention to CHSR is both shortsighted and ultimately costly for families and the entire nation.

Children merit a separate research focus for several reasons, assert the authors. Since children's cognitive, emotional, and social development is constantly changing, outcome measures must be sensitive to the interplay between change in development and change in health. Moreover, alterations in the rate of development are themselves important outcomes for children and should be part of studies on children's health-related quality of life. Fewer than 5 percent of children are affected with one of the conditions usually addressed by outcomes research in adults, for example, diabetes, heart disease, and arthritis. Yet one in three medically underserved persons in the United States is younger than 18 years of age.

The authors propose six strategies for increasing the quantity and improving the quality of CHSR: expand the disease orientation of health services research to include a focus on child health development; establish child-sensitive standards for setting research priorities; increase the size and capacity of the CHSR workforce; develop appropriate laboratories to study child health care; improve coordination of research funding across the Federal government, foundations, and the private sector; and enhance the research function of health care delivery in the private sector.

For more information, see "Child health services research: Challenges and opportunities," by Drs. Forrest, Simpson, and Clancy, in the June 11, 1997, Journal of the American Medical Association 277(22), pp. 1787-1793. Reprints (AHCPR Publication No. 97-R071) are available from the AHCPR Publications Clearinghouse.

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AHCPR News and Notes

AHCPR's CAHPS® initiative focuses on what consumers want to know about health plans

CAHPS®, which stands for Consumer Assessment of Health Plans Study, is an easy-to-use kit of survey and reporting tools for use by organizations—such as employers, purchasing coalitions, unions, and Medicaid programs—that purchase health coverage for their employees, members, or beneficiaries. The kit contains a set of questionnaires that ask consumers about their experiences with their health plans, sample formats for reporting results to the consumers, and a handbook to help sponsors implement the surveys and produce the reports. Using CAHPS®, sponsors can provide consumers with reliable information to help them assess and choose among health plans based on the experiences of plan enrollees.

CAHPS® surveys and reports have been tested to ensure that they will accurately and clearly report the experiences of a wide range of respondents. CAHPS® yields results that are applicable to all plan types and a wide range of respondents. Surveys are provided in formats for mail and telephone administration. Questionnaires are included for Medicare beneficiaries, Medicaid recipients, and for consumers with children. Users of the surveys also can form their own questionnaires by combining core and supplemental items in a customized questionnaire. For example, supplemental items are included for persons with chronic conditions.

CAHPS® users maintain ownership of their data. Users may engage a survey vendor or conduct the surveys themselves; free technical assistance is available to facilitate the use of CAHPS® surveys and reports.

CAHPS® is sponsored by the Agency for Health Care Policy and Research. CAHPS® materials were developed by a consortium led by Harvard Medical School, RAND, and the Research Triangle Institute.

The CAHPS® Survey and Reporting Kit includes the survey kit, the reporting kit, and an implementation handbook. It will be available in late fall 1997. The CAHPS® Preview Kit (AHCPR Publication No. 97-0012) is available now. To find out if CAHPS® is right for your organization, request the Preview Kit from the AHCPR Clearinghouse.

Is CAHPS® right for you?

  • If you are an employer or the representative of a health plan or other interested organization, call 800-358-9295 to order the CAHPS® Preview Kit. It will help you determine whether CAHPS® is right for your group.
  • If you are an individual consumer and you have health insurance through your employer or another group, be sure to tell your benefits manager about CAHPS®.

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