Highlights from AHCPR's June Research Activities

Media Advisory Date: July 3, 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 monthly publication, Research Activities.

Health Insurance Plans Vary Dramatically in Their Coverage of New Technologies

Persons covered by traditional indemnity insurance and for-profit insurers may be able to obtain coverage for a wider range of medical technology than persons covered by HMOs or nonprofit health plans, according to a study conducted by AHCPR researchers. Claudia A. Steiner, M.D., M.P.H., of AHCPR's Center for Organization and Delivery Studies, and her colleagues at the Johns Hopkins University, surveyed 231 medical directors of private HMO and indemnity insurance plans representing over two-thirds of the privately insured persons in the United States on their coverage of laser medical technologies. The survey found that coverage and the rationale for coverage varied dramatically among plans. Coverage for 13 of 15 laser technologies ranged from 20 to 90 percent with for-profit and indemnity plans covering two more of the different therapies than did nonprofit or HMO plans. In addition, HMOs are up to three times more likely than indemnity insurers to list the potential for decreased cost as a consideration in favor of new medical technologies. The researchers conclude that a proportion of the privately insured population is ineligible for medical technologies that are routinely available to others due to variation in coverage across plans because of the characteristics of private health care plans.

["Technology coverage decisions by health care plans and considerations by medical directors," by Dr. Steiner, Neil R. Powe, M.D., M.P.H., M.B.A., Gerard F. Anderson, Ph.D., and Abhik Das, M.S., in the May 1997 issue of Medical Care 35 (5), pp.472-489.]

Higher Dental Prices Often Denote Higher Quality of Care

People who pay more for dental services are probably receiving higher quality services, according to a study supported by AHCPR. Peter Milgrom, D.D.S., of the University of Washington, and his colleagues surveyed a random sample of 3,408 dentists in private practice, drawn from the 1991 to 1992 American Dental Association's Distribution of Dentists census of U.S. dentists. They examined demographic characteristics, dental practice characteristics, practice finances, and insurance. The researchers found that dentists who charge higher prices are more apt to have quality office practices, such as staff vaccinated against Hepatitis B and trained in CPR, and quality of care practices, such as head and neck exams, written treatment plans, autoclaving of handpieces, and use of rubber dams. The dentists surveyed estimated that the price of services increased by $21.38 for each quality policy implemented in the practice. Dr. Milgrom concludes that regulatory interventions to restrict dental fees may have the unintended effect of reducing quality of dental care.

["The relationship between price of services, quality of care, and patient time costs for general dental practice," by Coralyn W. Whitney, Ph.D., Dr. Milgrom, Douglas Conrad, M.H.A., M.B.A., Ph.D., and others, in the February 1997 issue of Health Services Research 31(6), pp. 773-790.]

Evidence Does Not Yet Support Annual Screening of Men Over 50 to Detect Prostate Cancer

A new study by the AHCPR-supported Prostate Disease Patient Outcomes Research Team (PORT) indicates there is insufficient evidence to support performing an annual digital rectal examination and prostate-specific antigen (PSA) screening in men over 50 years of age as recommended by the American Cancer Society. Using data from large studies and meta-analyses, the PORT constructed a model to estimate the risks, maximum benefits, and cost-effectiveness of a one-time screening in a hypothetical group of 100,000 men in their 50s, 60s, and 70s using both digital rectal exams and PSA tests. The researchers estimate that early detection would result in many biopsies of the prostate (10,752 to 27,064 men, depending on age), cause few surgical deaths (8 to 23), and render many men newly impotent (657 to 1,594), incontinent (131 to 317), or both (196 to 476) from prostatectomy (surgical removal of the prostate). Even when their model assumed effective treatment following confirmed local prostate cancer, screening added only 6 days to 2.5 weeks to the average life expectancy of older men. "The lack of direct evidence showing a net benefit of screening for prostate cancer mandates more clinician-patient discussion for this procedure than for many other routine tests," concludes team leader, Michael J. Barry, M.D., of Harvard Medical School.

["Early detection of prostate cancer: Part I: Prior probability and effectiveness of tests," and Early detection of prostate cancer: Part II: Estimating the risks, benefits, and costs," by Christopher M. Coley, M.D., Dr. Barry, Craig Fleming, M.D., and others, in the March 1 and 15, 1997, Annals of Internal Medicine 126(5), pp. 394-406, and 126(6), pp. 468-479.]

Broad Exposure to Other Children and Being Poor Are Linked to Increased Risk for Childhood Middle-Ear Effusion

Low socioeconomic status and repeated exposure to large numbers of children, whether at home or at day care, increase the risk of otitis media (middle ear inflammation), with or without effusion (fluid), among some children over others, says a new study supported by AHCPR and the National Institute of Child Health and Human Development. Researchers studied 2,253 healthy infants from age 2 months to 2 years of age who received primary care at one of two urban hospitals or one of two small town/rural and four suburban private pediatric practices. They found that 30 percent of children under 2 years of age, whose mothers had less than a high school education and Medicaid insurance had a mean 30 percent of days with middle ear effusion, compared with only 14 percent of infants of privately insured, college-educated mothers. Also, urban infants with four or fewer other children in the household had a mean 30 percent of days with middle ear effusion, compared with a mean 26 percent in infants in day care with less than five children and a mean 35 percent in children in day care with five or more children. Contrary to other studies, middle ear effusion appears to be at least as prevalent among black as among white lower-socioeconomic-status infants and certainly is more prevalent than in white middle-class infants.

["Otitis media in 2,253 Pittsburgh-area infants: Prevalence and risk factors during the first two years of life," by Jack L. Paradise, M.D., Howard E. Rockette, Ph.D., D. Kathleen Colborn, B.S., and others, in the March 1997 issue of Pediatrics 99(3), pp. 318-333]

Other articles in Research Activities include findings on:

• Drawbacks of current proposals to finance long-term care.
• Stroke prevention screening.
• Reasons for inappropriate variations in clinical practice.
• Differences in heart attacks among men and women.
• Heart attack patients who delay going to the hospital.
• Heart disease among non-insulin-dependent diabetics.
• Contributors to higher incidence of asthma among black children.
• Factors that affect hospital mergers.
• Inconsistency of dental treatment recommendations.
• Use of dental care by the elderly.
• Concurrent treatment of depression and coexisting illnesses.
• Factors that influence physicians' recognition of depressed patients.
• Assessment of HIV risk factors among primary care patients.
• Testing TB patients for HIV infection.
• High prevalence of tuberculosis among the homeless.

For additional information, contact AHCPR Public Affairs: Karen J. Migdail, (301) 427-1855 (KMigdail@ahrq.gov) or Salina Prasad (SPrasad@ahrq.gov).