MEDTEP at Work

Section Contents (Spring 1995)

Introduction
Guideline Use
Dissemination of AHCPR Guidelines
Medical Effectiveness Research
Health Technology Assessment

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Introduction

As the following examples demonstrate, MEDTEP clinical practice guidelines, research, and health technology assessments add to the understanding of problems in health care delivery. This can mean a better quality of life for millions of Americans undergoing treatment for health problems and the reduction or elimination of the use of ineffective or inappropriate procedures and treatments.

Two clinical practice guidelines supported by AHCPR—acute low back problems in adults, released December 8, 1994, and pressure ulcer treatment, issued December 21, 1994—are good examples of MEDTEP products.

Acute (nonchronic) low back problems affect 70 to 80 percent of all American adults sometime in life and cost an estimated $20 billion a year in medical care. Workers' compensation payments, lost productivity, and other societal costs add another $30 billion annually for a total annual estimated cost of $50 billion.

But widespread use of the guideline on low back problems could save an estimated $5 billion annually (one-tenth of the overall cost), according to Agency projections. Estimated savings would come mainly from avoiding therapies not proven to be effective and using fewer imaging tests. The guideline's developers found that many treatments for acute low back problems have little or no evidence of effectiveness. They also found that the use of highly sophisticated, expensive tests such as magnetic resonance imaging is not justified unless an underlying problem is suspected. The guideline recommends treating most acute low back problems with nonprescription painkillers and mild exercise such as walking or swimming and, later, conditioning exercises.

Pressure ulcers (bed sores) wounds caused by unrelieved pressure on the skin are another prevalent and costly problem. They afflict an estimated 1 million Americans, including as many as a quarter of all nursing home residents and 1 in 10 hospital patients. AHCPR estimates that the use of its guideline for pressure ulcer treatment could save payers—mainly Medicaid and Medicare—more than $40 million annually. This would be in addition to savings realized from widespread adoption of AHCPR's earlier guideline for preventing pressure ulcers.

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Guideline Use

The following examples demonstrate how AHCPR-supported guidelines are being used across the country.

• Pressure Ulcer Prevention Guideline
• Urinary Incontinence Guideline
• Acute Pain Management Guideline
• Other Uses of Guidelines

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Pressure Ulcer Prevention Guideline

Cost effectiveness

Intermountain Health Care, a Salt Lake City-based health care system, tested the AHCPR pressure ulcer prevention guideline in 1 of its 24 hospitals for 6 months and found that it reduced the incidence of pressure ulcers significantly, saving the system $240,000. Intermountain is implementing the guideline in its 23 other hospitals.

Abbott-Northwestern Healthcare System in Minneapolis estimated that it would save $288,000 annually by using AHCPR's pressure ulcer prevention guideline and has since expanded its use throughout its system of medical facilities.

Improved quality of care

At South Suburban Hospital, a 225-bed facility in Hazel Crest, lL, the incidence of hospital-acquired pressure ulcers decreased by more than half since the AHCPR-supported guideline was introduced 2 years ago. The hospital says greater awareness of pressure ulcers—attained by widely disseminating the guideline's Consumer Version—contributed to the improvement.

The pressure ulcer prevention guideline is also being used to help high-risk patients at home. Panhandle Home Health, Inc., which serves a three-county region in West Virginia, reports that in using the guideline, its field nurses are better able to help patients prevent pressure ulcers.

State government use

In Texas, State surveyors are using the pressure ulcer prevention guideline, as well as AHCPR's urinary incontinence guideline, to help identify and correct problems in institutions that fall under the jurisdiction of the Texas Department of Human Services. The institutions include 1,200 nursing homes, 380 personal care homes, and 798 facilities for the mentally retarded.

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Urinary Incontinence Guideline

Urinary incontinence—involuntary loss of enough urine to be a problem—affects as many as 13 million American adults and costs an estimated $10.3 billion annually. But 80 percent of all cases can be controlled or cured. For most cases, the AHCPR guideline recommends relatively low-tech treatment methods, including special exercises.

Improved quality of care

The Heritage Manor Nursing Home in Chattanooga, TN, says AHCPR's urinary incontinence and pressure ulcer prevention guidelines have helped reduce the incidence of both problems among its residents. In just 1 year, the facility was able to reduce the number of incontinent patients from 52 to 18 and reduce the number with pressure ulcers from 14 to 5.

State government use

The Maryland Health Resources Planning Committee has established policies "to ensure widespread knowledge and use" of AHCPR's urinary incontinence guideline as a model for the guidelines of other institutions, as a public education tool, and as a standard for licensing nursing homes. The policies call on medical and surgical faculty, local medical societies, hospitals with outpatient clinics, health maintenance organizations, and nursing homes to establish guidelines consistent with AHCPR's guideline on urinary incontinence.

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Acute Pain Management Guideline

About 23 million surgeries are performed in the United States each year, and half the patients who receive conventional pain therapy experience moderate-to-severe pain. Unrelieved pain results in needless suffering and often additional health care costs by causing further illness, delaying recovery from surgery, and lengthening hospital stays. These problems could be avoided through pain management that is more aggressive, as recommended by the AHCPR-sponsored guideline.

Cost effectiveness

Nurses at Memorial Medical Center in Modesto, CA, credit AHCPR's acute pain guideline with helping shorten surgical patients' hospital stays. Compared with data for 1991—before the AHCPR guideline was available—the average stay for patients undergoing total knee replacement surgery has fallen from 7 to 5.5 days, stays for total hip replacement patients have declined from 10 to 6.5 days, and stays for hysterectomy are down from 5 to 3 days. In 1991, the average daily charge in California hospitals was $1,962, according to AHCPR data.

San Francisco General Hospital reports that AHCPR's acute pain guideline has helped increase the scope and effectiveness of its pain management program. The hospital's pain management committee has selected less costly equivalents for some of the drugs recommended by the guideline to help it meet cost-containment goals while still aggressively treating pain. Other recommendations adopted by San Francisco General include increasing the use of epidural injections and patient-controlled analgesia.

UCLA Medical Center surgery patients whose pain is managed according to the principles of AHCPR's acute pain guideline recover faster and in some cases are discharged days sooner than patients with similar conditions but different pain management, according to the hospital's director of pain management. He said, "By moving away from traditional pain treatment, we're seeing a shift from [typically] 8- to 10-day stays in the hospital to 3-day stays" for chest surgery patients.

Improved quality of care

At Community Memorial Hospital in Menomonee Falls, WI, the effects of AHCPR's acute pain guideline are measured in the drop in patients' self-reported pain levels. Since introduction of the AHCPR guideline, the average pain score in the hospital's postanesthesia care unit has fallen from nearly 6 on a scale of 10 (with 10 being the most severe pain) to about 2. Use of the guideline has also helped reduce postanesthesia nausea.

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Other Uses of Guidelines

Improved quality of care

The Island Peer Review Organization (IPRO), the Medicare peer review organization for New York State, is using various AHCPR guidelines to help it assess quality of care for Medicare and Medicaid patients. IPRO has distributed hundreds of copies of AHCPR's guidelines on cataract management, early human immunodeficiency virus (HIV) care, cancer pain, sickle cell disease, and other conditions to its peer-review physicians and nurse consultants throughout the State.

State government use

Florida's Agency for Health Care Administration has endorsed several AHCPR guidelines, including sickle cell disease, pressure ulcer prevention, and urinary incontinence. In effect, the endorsed guidelines are required to be made available to the public and to all hospitals and health professionals throughout Florida.

By State law, the Medical Board of California is required to notify all licensed physicians in the State of the existence of AHCPR's acute pain guideline.

Prompted by AHCPR's sickle cell disease guideline, North Carolina has adopted a policy of universal screening for sickle cell disease in all infants born in the State.

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Dissemination of AHCPR Guidelines

AHCPR has released 15 clinical practice guidelines to date in versions for both medical practitioners and consumers. As of January 1995, the Agency had disseminated more than 15 million copies, and private-sector entities—mainly pharmaceutical firms and health insurance companies—had reprinted and distributed another 7.5 million copies. The most widely disseminated AHCPR guidelines to date are acute pain management (3 million), urinary incontinence (2.2 million), prediction and prevention of pressure ulcers (2.1 million), evaluation and management of early HIV illness (1.7 million), and management of cancer pain (1.7 million).

More recent AHCPR guidelines are also in great demand. For example, AHCPR has disseminated nearly 400,000 copies of its guideline for diagnosing and treating unstable angina since March 1994 and more than 300,000 copies of its otitis media with effusion guideline since July 1994. When AHCPR announced the release of its acute low back problem guideline in December 1994, it received nearly 15,000 calls in 3 days asking for copies.

A column by syndicated newspaper columnist Ann Landers concerning the AHCPR urinary incontinence guideline produced more than 100,000 requests for the Consumer Version of the guideline.

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Medical Effectiveness Research

In its first 5 years, AHCPR's medical effectiveness research has made major contributions to improving the quality and value of health care. Perhaps the most important contribution so far is the discovery that established treatments for many common health problems have no or only weak evidence to support their effectiveness. AHCPR-funded researchers have made and are continuing to make other important discoveries.

The following are just a few of the contributions that AHCPR's research has made in advancing the health care field.

Heart attack therapy

In a cardiac study, AHCPR-funded researchers found that the use of life-preserving thrombolytic therapy, which dissolves blood clots, increased dramatically for heart attack patients between 1988 and 1990—from 11 to 18 percent—but has since leveled off. The study points out that this is a serious shortfall, because a quarter to a third of all heart attack patients are likely to benefit from thrombolytic therapy.

Renal disease

Persons with underlying renal disease who take too much acetaminophen (more than two pills a day or 1,000 or more during a lifetime) for controlling pain may double the risk of damaging their kidneys and developing end-stage renal disease (ESRD), according to AHCPR-funded researchers. The investigators report that reducing acetaminophen consumption would probably decrease the national incidence of ESRD by 8 to 10 percent and save $500 million to $700 million a year in medical care costs. The study also found that very heavy use (5,000 or more pills during lifetime) of nonsteroidal anti-inflammatory drugs, such as ibuprofen or sulindac, increases the risk of ESRD fourfold. Consumption of aspirin does not raise the risk of ESRD. The researchers suggest advising people who need large amounts of analgesic medicines, and those at high risk of renal failure, to use aspirin for pain control.

Blindness prevention

Diabetic retinopathy is the leading cause of blindness in working-age Americans. Yet properly timed laser photocoagulation can substantially reduce the likelihood of blindness in such patients. If all Americans with type 2 (not insulin-dependent) diabetes received recommended care (screening and treatment), there would be a net annual savings of more than $472 million, according to AHCPR-funded researchers. Screening and treatment would also save 94,304 person-years of eyesight.

HIV therapies

African Americans infected with HIV who go to an HIV clinic for the first time may be only 59 percent as likely as a white person with HIV to receive antiretroviral drug therapy and 27 percent as likely to be given preventive drug therapy for Pneumocystis carinii pneumonia, a major killer of HIV-infected persons. The AHCPR-funded researchers state that the findings suggest the need for more culturally appropriate efforts to promote early preventive care among African Americans.

Research has shown that treating HIV-infected patients who have no or only mild symptoms with 500 mg of zidovudine (AZT) daily delays the progression of the disease. Other studies have found that early use of AZT does not help patients survive longer. Now AHCPR-supported researchers have found that the decline in quality of life for asymptomatic HIV-infected patients due to the severe side effects of AZT roughly equals the increase in quality of life associated with delaying progression of the disease. The researchers have concluded that it might be better to delay using AZT until there is evidence that HIV disease is progressing.

Managed care

As managed care continues to expand, more Americans obtain medical care from primary care physicians. In a recent study, AHCPR-funded researchers found that primary care physicians may be less aware of or less certain about key advances in treating heart attack patients than cardiologists. The specialists report being more likely to keep abreast of cardiac research and prescribe drugs known to improve survival rates. Whether the results of this study, which assessed physician-reported practices and attitudes, reflect actual practice is being actively investigated. AHCPR released guidelines for unstable angina and heart failure in 1994.

Depression

More than 11 million Americans suffer from depression, which can disrupt a person's ability to work or carry out other normal activities. A new AHCPR-funded study shows that improving the effectiveness of care for depression will increase health costs by an estimated $1,000 to $2,000 per patient, but also will increase the patient's income by $2,000 to $3,000 a year by reducing just one functional limitation (such as being unable to work at a paying job). AHCPR released a clinical practice guideline in 1993 to improve primary care providers' ability to detect, diagnose, and effectively treat depression.

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Health Technology Assessment

Technology assessment is yet another area in which AHCPR provides reliable, scientific information to the health care community. Although a guideline addresses all aspects of the management of a condition, a technology assessment is usually limited to a single, new technology.

Technology assessments can, for example, help managed care plans and hospital administrators decide whether to purchase a specific technology. Technology assessments can also aid medical insurers in deciding whether to cover the use of newly introduced or commonly performed medical tests and procedures in patients they insure.

The following examples illustrate AHCPR health technology assessments:

• A new AHCPR health technology assessment finds magnetic resonance angiography (MRA) a promising, but not yet standard, technology for visualizing large central blood vessels (for example, carotids) or peripheral vessels. MRA offers several advantages over the conventional technology. Patients are not exposed to ionizing radiation; they are not injected with contrast agents (dyes), which sometimes cause reactions; and MRA can be used in outpatient settings. On the other hand, MRA alone is not always sufficient for comprehensive evaluation of blood flow and blood vessel vasculature.
• An AHCPR health technology assessment found that various types of lymphedema pumps—used in treating cancer and other patients with excessive lymph fluid and swelling—are similarly effective in treating lymphedema, but differ sevenfold in Medicare reimbursement costs. For example, in 1991, Medicare allowed $198.15 for purchase of a single-chambered pump, $535.01 for a multichambered device, and $1,437.39 for a multichambered device with calibrated pressure gradients.

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