Register now for outcomes research conference

The 2-day conference, "Outcomes Research: Engine for Quality Improvement," will be held October 30 and 31, 1997, in Washington, DC. The Agency for Health Care Policy and Researchs Center for Outcomes and Effectiveness Research is sponsoring the conference, which is designed for public- and private-sector health care providers, policymakers, purchasers, and health services researchers.

The conference will celebrate AHCPR's accomplishments in outcomes and effectiveness research and identify critical gaps and future research needs. Specific conference goals are to:

• Present selected accomplishments and challenges from previous outcomes and effectiveness research.
• Discuss the role of cost and economics in outcomes research.
• Explore the future of outcomes and effectiveness research in both the public and private sectors.

Space is limited, and registrations will be accepted on a first-come, first-served basis. For more information or to register for the conference, contact Maureen Ball at Health Systems Research, Inc., (202) 828-5100. The conference will be held at the Holiday Inn Capitol Hill, 550 C Street, S.W., Washington, DC (telephone 202-479-4000; fax 202-479-4353). Contact the hotel directly to inquire about reservations.

Proceedings from Kaiser/AHCPR quality conference now available

The conference, "Value and Choice: Providing Consumers with Information on the Quality of Health Care," was cosponsored by the Henry J. Kaiser Family Foundation and the Agency for Health Care Policy and Research and held in Arlington, VA, October 29-30, 1996. The conference brought together more than 250 participants of diverse backgrounds and interests to share their expertise and knowledge on this increasingly important topic.

The conference was organized around four central themes:

1. What information about quality of care do Americans want and use?
2. What are the unique information needs of particular groups?
3. Who is helping consumers with their decisions?
4. What is the goal of providing consumers with information about quality of care?

An overview and four key articles from the conference were published recently in the May 1997 issue of The Joint Commission Journal on Quality Improvement. The publication includes the following articles:

• "Patient's Perspective: Conference Overview," by Lisa A. Lang, M.P.P., formerly with the Henry J. Kaiser Family Foundation and now with the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and Terry E. Shannon, M.P.H., of AHCPR's Center for Health Information Dissemination.
• "Understanding the Quality Challenge for Health Consumers: The Kaiser/AHCPR Survey," by Sandra Robinson, M.S.P.H., of AHCPRs Center for Quality Measurement and Improvement, and Mollyann Brodie, Ph.D., of the Henry J. Kaiser Family Foundation.
• "The Total Customer Relationship in Health Care: Broadening the Bandwidth," by Donald M. Berwick, M.D., President and CEO of the Institute for Healthcare Improvement, Boston, MA.
• "Health Online and the Empowered Medical Consumer," by Tom Ferguson, M.D., of the Center for Clinical Computing, Boston, MA.
• "How Will We Know if We Got It Right? Aims, Benefits, and Risks of Consumer Information Initiatives," by Shoshanna Sofaer, Dr.P.H., of the George Washington University Medical Center, Washington, DC.

Copies of the journal are available from AHCPR (Publication No. OM-97-0011).

AHCPR funds new grants

The following grants 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.

Cost and quality in the treatment of hypertension Project director: Randall S. Stafford, M.D.
Organization: Massachusetts General Hospital, Boston, MA
Project number: AHCPR grant HS09538
Period: 9/1/97 to 8/31/98
Funding: $84,958

Quality of dying and death in persons with AIDS
Project director: Donald L. Patrick, Ph.D.
Organization: University of Washington, Seattle, WA
Project number: AHCPR grant HS09540
Period: 9/1/97 to 8/31/99
First year funding: $31,058

Severity of lower respiratory tract illness in infants
Project director: Kenneth M. McConnochie, M.D.
Organization: University of Rochester, Rochester, NY
Project number: AHCPR grant HS09062
Period: 7/1/97 to 6/30/00
First year funding: $269,144

Final reports 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.

Controlled Trial of Telephone Care in Medicine. John H. Wasson, M.D., Dartmouth College, Hanover, NH. AHCPR grant HS07350, project period 9/30/93 to 11/30/96.

The objective of this randomized trial was to examine the impact of clinician-initiated telephone "house calls" on the care of Medicare patients who were in poor health. The study was conducted in 16 primary care practices (21 physicians) and involved 290 patients (average age 75). Prescheduled telephone calls were substituted for some routine office visits. Intervention patients overall satisfaction with care and the value of telephone calls were the only measures that were significantly better than control patients. Control patients reported a similar number of telephone calls from their physicians (2.3 vs. 2.2, respectively) and similar numbers of office visits (2.4 vs. 2.1). Because of this, the analysis was restricted to the 13 physicians whose ratio of intervention/control telephone calls was greater than average. For this subgroup of 172 patients, the intervention made patients feel better, and they reported improved physician awareness of functional limits and more treatment received for functional problems. However, the intervention did not change the use of medical services, resolve important clinical problems, or improve patient function. Although this study demonstrated some positive effects of clinician-initiated telephone "house calls" in Medicare patients, it did not replicate the many previously reported benefits of this approach.

Abstract, executive summary, and final report, are available from the National Technical Information Service (NTIS accession no. PB97-191969; 19 pp, $19.50 paper, $10.00 microfiche).

Determinants of Oral Health in Older Persons. Ronald M. Andersen, Ph.D., University of California, Los Angeles. AHCPR grant HS07084, project period 7/1/91 to 6/30/96.

This project examined the determinants of oral health and how environmental factors, dental care delivery systems, population characteristics, and oral health behaviors may be linked to oral health outcomes for diverse ethnic groups and age cohorts in Baltimore, MD, San Antonio, TX, and two American Indian reservations. Respondent information was obtained by household interviews, and clinical examinations were conducted by an oral epidemiologist. Female sex, higher education, positive oral health beliefs, higher income, and having a usual source of care were generally related to positive oral hygiene practices for most racial-ethnic groups. Minority individuals reported fewer dental visits than whites; having a regular source of care and experiencing oral pain were important determinants of a dental visit for all ethnic groups. White individuals in Baltimore and San Antonio had less unrestored tooth decay and required less dental treatment than their minority counterparts. In almost every age cohort, individuals who were less likely to brush and floss teeth experienced more active dental decay. The most important predictors of positive perceived oral health were race/ethnicity, having higher educational attainment, better general health status, fewer oral symptoms, and having a dental visit in the past 12 months. Generally, people from all age and ethnic groups were satisfied with their last dental visit. A typology of oral health promotion priorities suggested that older American Indian populations are most in need of additional efforts, followed in order by Hispanics, blacks, and non-Hispanic whites.

Abstract and executive summary, are available from the National Technical Information Service (NTIS accession no. PB97-186696; 8 pp, $10.00 paper, $10.00 microfiche).

Health Care Barriers Among the Elderly in Eastern North Carolina. James P. Mitchell, M.A., Ph.D., East Carolina University, Greenville, NC. AHCPR grant HS08779, project period 7/1/95 to 12/31/96.

Data from in-home interviews with 604 white and black elderly individuals (aged 66 to 95) provide evidence of significant barriers to health care use among elderly blacks. Although there is no difference by race in physician visits for ongoing care, black males were found to be significantly less likely than whites to see physicians in response to serious medical symptoms. Elderly blacks also were less likely than whites to discuss the history or the cause of their medical problems, alternative treatments, or self-treatment strategies during physician visits. Blacks were less likely than whites to receive selected preventive health measures, including flu shots and cholesterol checks. Elderly blacks in this study were more likely to be taking no prescription medicines, while whites were more likely to be taking five or more prescription drugs. Black elders who were taking prescription medicines were more likely than whites to use prescription medicine cost management strategies. There was no evidence that blacks were less likely to be referred to specialists than whites or that elderly blacks preferred other long-term care arrangements over nursing homes.

Abstract, executive summary, final report, and interview guide, are available from the National Technical Information Service (NTIS accession no. PB97-186688; 76 pp, $25.00 paper, $10.00 microfiche).

The Making and Meaning of Difficult Patients: Doctors' and Nurses' Subjective Understandings and Experience of Difficulty. Norman Fineman, Ph.D., Regents University of California, San Francisco. AHCPR grant HS06984, project period 9/1/91 to 6/30/93.

In this dissertation, the author investigates how health care providers in their everyday practices with patients and with each other construct meaningful understandings of difficult patients. Data were derived from detailed long-term observations of three clinical settings in an urban community hospital; a series of in-depth interviews with doctors, nurses, and patients; and investigation of patient case studies. This study found providers' understanding of difficult patients is complex and often (but not always) shared. Such understanding is marked by regular and systematic differences that relate to the providers' status, level of training, self-perceptions of their roles and responsibilities, and expectations of appropriate patient behavior. This finding reveals as unreliable the common presumption in medical research that health care providers view difficult patients in essentially the same ways. Finally, this study found that doctors experience behaviorally difficult patients as a threat to their sense of professional entitlement and empowerment.

Abstract and executive summary, are available from the National Technical Information Services (NTIS accession no. PB97-191985; 15 pp, $19.50 paper, $10.00 paper).

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Research Briefs

Berg, A.O., Atkins, D., and Tierney, W. (1997, April). "Clinical practice guidelines in practice and education." Journal of General Internal Medicine 12(S2), pp. S25-S33.

In this commentary on implementing clinical practice guidelines, David Atkins, M.D., M.P.H., of the Agency for Health Care Policy and Research, and his colleagues present an overview of the methods used to construct clinical guidelines and discuss the use of guidelines in practice and education. The authors emphasize that guidelines and other clinical decisionmaking tools need to distinguish those measures for which there is clear and compelling evidence of important benefits (for example, childhood vaccinations), measures that should be encouraged but not required (for example, sigmoidoscopy), and interventions for which the best strategy depends largely on clinician judgment and patient preference (for example, hormone replacement therapy), thus giving levels of flexibility. Local implementation of guidelines includes not only adopting those that the providers intend to follow but also modifying them to make them compatible with the exigencies of each practice. Treatment recommendations in guidelines generally emphasize evidence of effectiveness, but clinicians must consider other factors as well, including patient preferences, costs, competing health priorities, and magnitude of the benefit to the individual patient. The authors describe several AHCPR-supported research initiatives to study the most effective ways to implement guidelines and other quality-improvement tools.

Reprints (AHCPR Publication No. 97-R077) are available from the AHCPR Publications Clearinghouse.

McMillan, W.D., McCarthy, W.J., Lin, S.J., and others (1997, May). "Perioperative low molecular weight heparin for infrageniculate bypass." (AHCPR grant HS07184). Journal of Vascular Surgery 25, pp. 796-802.

Low molecular weight heparin (LMWH) is a safe, effective alternative to intravenous heparin (IVH) when needed for anticoagulation following lower extremity bypass procedures (infrageniculate bypass) performed with polytetrafluoroethylene (PTEE) grafts, concludes this study. In fact, LMWH may reduce the number of postoperative hospital days and coagulation studies by allowing discharge before therapeutic anticoagulation with warfarin. These findings are based on analysis of 68 lower extremity bypass operations performed at a single center over a 32-month period. The researchers compared 28 grafts completed in 16 months that were treated with LMWH with 41 consecutive control grafts treated with IVH from the previous 16-month period. There were similar percentages of composite bypasses (IVH, 50 percent; LMWH, 46 percent), patients with tissue loss or gangrene (IVH, 56 percent; LMWH, 61 percent), and patients with prior ipsilateral bypass (IVH, 57 percent; LMWH, 56 percent) in each group. Morbidity rates (IVH, 19 percent; LMWH, 11 percent) and mortality rates (IVH, 2.5 percent; LMWH, 4 percent) were not significantly different. There were no significant differences in the number of grafts that failed before discharge (IVH, 1; LMWH, 0), or percentage of hemorrhagic complications (15 percent vs. 7 percent). However, the mean number of postoperative hospital days (9.5 vs. 7.2) and coagulation monitoring studies (22 vs. 8.2) were significantly decreased in patients who were anticoagulated with LMWH.

Normand, S-L. T., Glickman, M.E., and Gatsonis, C.A. (1997). "Statistical methods for profiling providers of medical care: Issues and applications." (AMI PORT grant HS06341). Journal of the American Statistical Association 92, pp. 803-814.

There is a growing trend toward profiling medical care providers according to their use of health care resources and quality of care compared with a community or normative standard. For example, hospital profiles may be used to determine whether institutions deviate in important ways in the process of care they deliver. In this paper, the Acute Myocardial Infarction Patient Outcomes Research Team (PORT) proposes a class of performance indexes for use in profiling providers. The researchers applied the performance indexes to profile hospitals on the basis of 30-day mortality rates for a group of elderly heart attack patients, using data from 96 acute care hospitals located in one State. They compared the results of evaluating hospitals based on the performance indexes to those obtained using conventional measures. With 30-day risk-adjusted mortality rates ranging from 12 percent to 14 percent, one-quarter of the hospitals had a greater than 15 percent probability that hospital-specific mortality was 1.5 times the median mortality rate. The probability of a large difference between risk-adjusted and standardized mortality rates was less than 6 percent for three-quarters of the hospitals examined. The researchers conclude that, because profiling analysis can serve a number of purposes, the choice of performance measures and analytic strategy will have to be customized to fit the circumstances.

Seage, G.R., Gatsonis, C., Weissman, J.S., and others (1997, April). "The Boston AIDS Survival Score (BASS): A multidimensional severity instrument." (AHCPR grant HS06239). American Journal of Public Health 87(4), pp. 567-573.

Information on recent clinically significant events and measures of functional status substantially improve the ability of a physiologically based staging system to predict survival for persons with AIDS. This severity-of-illness system, the Boston AIDS Survival Score (BASS), combines information from sociodemographic, physiological, diagnostic, and functional status domains to predict long-term survival. It was developed based on interviews, medical records, and vital status of 305 persons with AIDS in Boston. It incorporates a staging system of three stages of increasing clinical severity and an opportunistic disease survival score. Adding measures on opportunistic diseases and functional status improved the ability of the physiological system to predict survival from 61 percent to 68 percent. Survival after initial interview varied significantly with functional status, neuropsychological symptoms, fatigue, sleep, fever, total symptoms, self-reported health status, and level of support from friends.

Stineman, M.G. (1997). "Measuring casemix, severity, and complexity in geriatric patients undergoing rehabilitation." (AHCPR grant H507595). Medical Care 35(6S), pp. JS90-JS105.

Geriatric rehabilitation is intended to maintain or restore function, maximize life satisfaction, enhance psychologic well-being, and maintain the social status of older persons. For clinical services to operate efficiently and equitably, payment must be based on rules that are clinically sound and thus reinforce the objectives of the services provided. This article presents a theoretical basis for casemix measurement in medical rehabilitation, contrasts the structure of the functional independence measure-function related groups (FIM-FRGs) intended for casemix measurement to the diagnosis-related groups (DRGs) and resource utilization groups (RUG) III systems designed for acute and long-term care settings. It focuses on special issues of relevance to the rehabilitation of older persons and provides four challenges in an effort to stimulate discussion.

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Current as of September 1997