Highlights from AHCPR's November Research Activities

Media Advisory Date: December 1, 1997

The Agency for Health Care Policy and Research (AHCPR) works to improve the quality of health care, reduce costs, and broaden access to essential services. Here are some of the findings described in the most recent issue of AHCPR's Research Activities.

More Prevalent Severe Obesity May Explain Black/White Difference in Stage at Diagnosis of Breast Cancer

Black women are typically diagnosed with breast cancer at a later stage than are white women, putting them at greater risk of dying from the disease. According to a study supported by AHCPR, higher rates of obesity among black women as compared with white women may explain some of the disparity. Researchers analyzed body mass index, socioeconomic status, and a number of other factors, including medical care variables, as possible predictors of stage and diagnosis of breast cancer among 145 black women and 177 white women diagnosed with new cases of breast cancer in Connecticut in the late 1980s. They found that severely obese women are more than three times as likely to be diagnosed with breast cancer at later, less treatable stages of the disease. The findings from this study did not support the prevalent belief that black women are diagnosed with breast cancer at later stages due to factors such as lower socioeconomic status and less access to health care and screening mammography.

["Severe obesity as an explanatory factor for the black/white difference in stage of diagnosis of breast cancer," by Beth A. Jones, Ph.D., M.P.H., Stanislav V. Kasl, Ph.D., Mary G. McCrea Curnen, M.D., Dr. P.H., and others, in the September 1997 American Journal of Epidemiology 146(5), pp. 394-404.]

People Over 45 with Pneumonia Report Fewer Symptoms than Younger People but May Be at Higher Risk of Death or Complications

Elderly patients with pneumonia generally report 3 fewer symptoms than pneumonia patients 44 years of age and younger (7 vs 10 symptoms). However, they are at higher risk of death and complications from pneumonia than younger individuals, and physicians should not be misled by their less severe symptoms, cautions the Pneumonia Patient Outcomes Research Team (PORT). Older patients may simply treat some symptoms, such as muscle aches and headache, as less bothersome and thus be less apt to mention them. On the other hand, their lower reporting of some symptoms, such as fever and chills, may reflect actual physiological changes that accompany aging, explains PORT leader, Wishwa N. Kapoor, M.D., M.P.H., of the University of Pittsburgh. The research team correlated age with 5 respiratory symptoms and 13 nonrespiratory symptoms in 1,812 adults with clinical or x-ray evidence of pneumonia treated at 5 different sites.

["Influence of age on symptoms at presentation in patients with community-acquired pneumonia," by Joshua P. Metlay, M.D., Ph.D., Richard Schulz, Ph.D., Yi-Hwei Li, Ph.D., and others, in the July 1997 Archives of Internal Medicine 157, pp. 1453-1459.]

Carotid Endarterectomy Outcomes May Not Be as Favorable Outside of Ideal Clinical Trial Conditions

Carotid endarterectomy (surgical removal of plaque from the carotid artery) has been shown to be more effective than medical therapy for reducing the risk of stroke when 70 percent or more of a person's carotid artery is blocked and he or she is experiencing stroke symptoms. Symptoms of an impending stroke include vision or speech problems and/or weakness or partial paralysis affecting one side of the body, often with a tingling sensation. A recent AHCPR-supported study shows that patients who have a carotid endarterectomy outside of clinical trials, where circumstances tend to be ideal, seem to have less favorable outcomes. Researchers analyzed Medicare claims data for 41,493 patients 65 years of age and older who underwent carotid endarterectomy during 1989. These data can be used to complement data from clinical trials to give a more realistic idea of the effectiveness of this procedure for the general population, concludes George J. Stukenborg, Ph.D., of Virginia Commonwealth University, author of the study. The study found that Medicare patients who had more coexisting illnesses than those who generally qualify for clinical trials had nearly twice the odds of death of trial participants. Also, non-trial patients, who underwent carotid endarterectomy at a hospital with a higher mortality rate than trial hospitals, had nearly 1.5 times the risk of death within 2 years after surgery than trial patients.

["Comparison of carotid endarterectomy outcomes from randomized controlled trials and Medicare administrative databases, by George H. Stukenborg, Ph.D., Archives of Neurology 54, pp. 826-832.]

HMO Primary Care Physicians Refer as Many Women as Men to Specialists

In general, men are more likely than women to be referred to specialists by their primary care physicians. However, men and women enrolled in health maintenance organizations are referred at equal rates, according to an AHCPR-supported study. Although pressures exist in HMOs for primary care physicians to reduce their referral rates, the findings of this study offer some assurance that enrollees may be at less risk of lower access to specialists based solely on sex or insurance status as compared with non-HMO patients, according to Peter Franks, M.D., of the University of Rochester, and Carolyn M. Clancy, M.D., director of AHCPR's Center for Outcomes and Effectiveness Research and acting director of the Center for Primary Care Research. They reviewed nearly 50,000 office visits of adult patients to primary care physicians reported in the National Ambulatory Care Survey for the years 1985 to 1992. They adjusted their analysis to account for patient factors (such as insurance status, diagnosis, and visit length), physician factors (such as age, sex, and specialty), and practice factors (such as location, study year, and proportion of HMO patients). The researchers found that overall, 4.5 percent of patients were referred to specialists compared with 7.5 percent HMO enrollees. Those more likely to be referred included males, patients with fewer prescribed medications, and patients with a longer visit. Among patients enrolled in an HMO, there was no difference in referral rates for men and women.

["Referrals of adult patients from primary care: Demographic disparities and their relationship to HMO insurance," by Drs. Franks and Clancy, in the July 1997 Journal of Family Practice 45(1), pp. 47-53.]

Other findings:

• Maternal hormone levels and fetal growth retardation.
• Factors associated with low pregnancy weight gain and low birthweight infants.
• Impact of vaginal infections on preterm labor.
• Assessing maternal psychosocial status during pregnancy.
• Obstacles to obtaining health care.
• Role of patient preferences in decisions about cataract surgery.
• The newly insured: Do they have pent-up health care needs?
• Changes in advance care planning in nursing homes.
• Impact of acculturation on risky behavior among pregnant Mexican-origin women.

Other AHCPR News:

Routine Use of Antibiotics for Acute Middle Ear Infections Not Recommended

Last week's Journal of the American Medical Association included an AHCPR-supported article which found that routine use of antibiotics to treat acute middle ear infections in children is not recommended because antibiotics don't work in all cases and may in fact be harmful. Overuse of antibiotics is linked to increased resistance to bacteria, and there is little evidence that routine use of the drugs is necessary to prevent complications. Researchers examined seven international studies, each involving a different treatment regimen. The findings indicate that there is very little difference in outcomes among each treatment regimen. The treatments ranged from a 2-day to a 10-day course of antibiotics. One treatment regimen, used in Holland, recommended only prescribing antibiotics if symptoms persist more than three days. The 10-day course of antibiotics has been the standard treatment in the United States, but this analysis suggests that routine use should be reconsidered.

[The analysis was conducted by Jack Froom, M.D., SUNY at Stony Brook Department of Medicine, and Larry Culpepper, M.D., M.P.H., Boston University School of Medicine, and funded by AHCPR. A description of the findings was published in the November 26 issue of JAMA, in the "Controversies in Medicine" section.]

For additional information, contact AHCPR Press Office: Salina Prasad, (301) 427-1864 (SPrasad@ahrq.gov).