As many as 40 percent of men and 20 percent of women have high serum cholesterol levels (over
240 mg/dL). Programs in California and Finland have shown that population-wide educational
programs emphasizing the importance of a low-fat diet have been effective in reducing cholesterol
levels from 1 to 4 percent. A nationwide effort in the United States could yield similar rates of
cholesterol reduction and be cost effective as well, concludes a study supported in part by the
Agency for Health Care Policy and Research (HS06258).
A slight reduction in cholesterol levels may have relatively small effects on the risk of heart attack
and other coronary problems in an individual patient. On the whole, however, such a reduction
has probably contributed to as much as one-third of the decline in coronary heart disease deaths in
the United States since the mid-1960s, points out Milton C. Weinstein, Ph.D., of the Harvard
School of Public Health, the study's principal investigator.
The researchers estimated the costs, life-years saved, and costs per year of life saved for a
cholesterol reduction education program across the range of actual cholesterol reductions (1
percent to 4 percent) and costs ($4.95 to $9.00 per person per year) of the Finnish and California
programs. The cholesterol reduction education program would consist of media campaigns and
direct education through community activities and face-to-face instruction.
Based on cost-effectiveness analyses, the researchers estimated that a population-wide program
costing $4.95 per person per year that accomplished an average 2 percent reduction in serum
cholesterol levels (as in the Stanford Five-City Project) would prolong life at an estimated cost of
only $3,200 per year of life saved. If the program affected persons with preexisting heart disease
or altered other coronary risk factors, it would be even more cost effective. A program cost of
about $16.55 per person in year one and $8.28 per year thereafter to achieve a 3 percent
reduction in cholesterol levels would cost about $6,100 per year of life saved. Even more
expensive programs that resulted in 2 percent cholesterol lowering would still be cost effective
compared with most accepted medical interventions.
Based on these findings, the researchers conclude that population-wide approaches should be part
of any comprehensive program undertaken in the United States to reduce coronary heart disease.
See "Cost-effectiveness of population-wide educational approaches to reduce serum cholesterol
levels," by Anna N.A. Tosteson, Sc.D., Milton C. Weinstein, Ph.D., Maria G.M. Hunink, M.S.,
Ph.D., and others, in the January 7, 1997, Circulation 95(1), pp. 24-30.
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Rural hospitals are especially vulnerable to competitive pressures because of their small size,
aging facilities, and limited strategic opportunities, which is evidenced by the increasing number of
rural hospital closures. Rather than engaging in direct price competition with hospitals in the same
market, which usually requires substantial capital outlay, rural hospitals may respond more
effectively to scarce resources
and market uncertainty through differentiation. Rural hospitals
may gain a competitive advantage through differentiation by establishing a viable market niche
and reducing the actual number of competitors, concludes a study supported by the Agency for
Health Care Policy and Research (HS07047).
Researchers at the University of Michigan used longitudinal data collected on U.S. rural
community hospitals from
1984 through 1991 (data from American Hospital Association annual surveys, Health Care
Financing Administration cost reports, and other sources) to examine the effects of competition
and market position on rural hospital closures during a period of intense competitive pressures on
these hospitals. They selected three attributes to evaluate the market position of a hospital in a
given market area: geographic distance from other similar facilities, size, and service
configuration.
The researchers found that hospital size, market population density and per capita income,
government control, and multihospital system membership did not influence risk of closure. Rural
hospitals that were not-for-profit, that had a higher cash flow, were at greater distance from other
hospitals, and that offered more basic and high-tech services than the market average were at
lower risk of closure than other rural hospitals in the same market area. This was not true of
hospitals offering more outpatient/outreach services than the market average. It may be that the
low profits often associated with outpatient/outreach services did not improve the viability of
rural hospitals, note the researchers. These findings indicate that distinct market positions can
offer rural hospitals better prospects for survival and provide support for programs that encourage
differentiation among rural hospitals.
See "Effects of market position and competition on rural hospital closures," by Melissa J. Succi,
Ph.D., Shoou-Yih D. Lee, M.S., and Jeffrey A. Alexander, Ph.D., in the February 1997
Health
Services Research 31(6), pp. 679-699.
There have been several recent proposals to control Medicare inpatient expenditures for each
hospital admission. How these policies would affect actual expenditures depends on the
relationship between hospital facility services—such as nursing care, room and board, and
use of
specialized equipment—and inpatient physician services. Apparently these services do not
substitute for, but rather complement one another, according to a recent study conducted by
researchers at the Urban Institute, the Congressional Budget Office, and the Agency for Health
Care Policy and Research.
The study shows, for example, that a 10 percent increase in physician services is associated with
at least a 3 percent increase in facility services. Thus, proposals that reduce inpatient physician
expenditures also would reduce hospital expenditures in the long run, concludes Herbert S.
Wong, Ph.D., of AHCPR's Center for Organization and Delivery Studies. Dr. Wong and his
coauthors used Medicare data from the Medicare hospital cost reports, the Medicare Patient
Analysis and Review (MedPAR) file, and the National Claims History System to measure
physician services and facility costs per hospital admission.
Generally, several physician claims were linked to a typical hospital stay. A 10 percent increase in
physician services per admission was associated with a 3.4 percent to 8.5 percent increase in
facility services per admission. In fact, physician services were the single most important factor in
determining facility services per admission. Facility services were a less important determinant of
physician services.
These findings of complementarity suggest that proposals to reduce Medicare inpatient physician
expenditures could yield more savings in facility than physician expenditures in the long run, given
that inpatient facility services account for a much larger expenditure base. For instance, a policy
that would result in a 10 percent decrease in physician services (and costs) would decrease facility
costs by 3 percent, based on the authors' lower estimate. The policy impact is larger than the
percentage figure might suggest because Medicare's Prospective Payment System facility
payments (standard payment based on a patient's diagnosis) are almost six times those for
inpatient physician services. Hence a 10 percent decrease in physician costs might result in a
decrease in facility costs equal to 18 percent of physician costs.
For more details, see "Exploring the relationship between inpatient facility and physician
services," by Mark E. Miller, Ph.D., W. Pete Welch, Ph.D., and Dr. Wong, in the February 1997
issue of Medical Care 35(2), pp. 114-127. Reprints (AHCPR Publication No.
97-R045) are
available from the AHCPR Publications Clearinghouse.
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The number of malpractice claims filed against physicians nationwide rose at an average annual
rate of 10 percent in the years 1982 to 1986. Malpractice premiums rose over the same period by
81 percent for all physicians and by 113 percent for specialists in obstetrics and gynecology.
Malpractice suits are not only costly, but they damage physicians' reputations. In response, some
obstetricians have begun to practice "defensive medicine," that is, use of diagnostic tests and
procedures and sometimes medical and/or surgical procedures that they would not have used if
they didn't fear malpractice suits. In fact, about one-fourth of the cesarean sections (c-sections)
examined in this study were the result of defensive medicine, according to a study of deliveries in
New York State. Mothers with prior c-sections and cases with dystocia (abnormal or slow labor)
were excluded from the study. The study was supported in part by the Agency for Health Care
Policy and Research (HS05964).
If just one-eighth, rather than
one-fourth, of all such c-sections performed in the United States could be attributed to defensive
medicine, the number of excess c-sections would be 100,000 annually, at a cost of hundreds of
millions of dollars, explain A. Dale Tussing, Ph.D., of Syracuse University, and Martha A.
Wojtowycz, Ph.D., of the State University of New York Health Sciences Center at Syracuse.
They linked 1986 data from the New York State live birth file with data from the New York State
hospital discharge data abstracts to determine use of procedures. They focused primarily on
deliveries diagnosed with fetal distress. The researchers used cumulative obstetric malpractice
suits by county for 1975 through 1986 as a proxy for physician fear of malpractice in those
counties.
The analysis revealed that nearly 7 percent of an overall c-section rate of 28 percent was due to
fear of malpractice suits. Slightly more than 4 percent of this increase was a direct effect; 2.2
percent was an indirect effect of increased electronic fetal monitoring (EFM) and increased
diagnosis of fetal distress and resulting c-sections.
Of the 57 counties in the study (New York City was not included),
7 small counties, altogether accounting for fewer than 1 percent of c-sections, had no reported
malpractice suits. On the other hand, 10 counties, accounting for 42 percent of the c-sections,
exceeded the mean number of suits. These results suggest a small positive effect of malpractice
suit exposure on EFM use, diagnosis of fetal distress, and use of c-sections, indicating the practice
of defensive medicine, conclude Drs. Tussing and Wojtowycz.
Details are in "Malpractice, defensive medicine, and obstetric behavior," by Drs. Tussing and
Wojtowycz, in the February 1997 issue of Medical Care 35(2),
pp. 172-191.
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About half of nursing home residents are impaired in their ability to make decisions. But even
residents who are alert and oriented often don't receive information about advance directives for
end-of-life treatment wishes, are excluded from such discussions, and don't make the final
decisions. Frequently, it is family members or other responsible parties who complete and sign
these advance directives, concludes a study supported by the Agency for Health Care Policy and
Research (National Research Service Award training grant T32 HS00052).
The study found that nearly half (48 percent) of residents judged to be alert and oriented at the
time of admission did not receive the information required by the Patient Self Determination Act
(PSDA), which became effective in 1991. On the other hand, 34 percent of residents judged to be
either partly or totally confused did receive the PSDA information.
Thus, some residents were inappropriately excluded from the PSDA process, while others were
included even though they did not have a full understanding of the
consequences of their decisions. Judgments about which patients to involve in advance care
planning often depend on staff perceptions of complex circumstances, such as the resident's level
of emotional distress, personal autonomy values (for example, the perception that the resident
wants a son or daughter to make the decision), and degree of cognitive impairment. But there is
no clear process or procedure to determine the resident's decisionmaking capacity, explain the
researchers.
They retrospectively studied patients at six Connecticut nursing homes, who were admitted before
(1990) and after (1994) implementation of the PSDA. The good news is that nearly 35 percent of
persons admitted to nursing homes after passage of the PSDA had a documented advance
directive in their medical records in contrast to only 5 percent in the pre-PSDA group. Also,
nearly twice as many residents participated in discussions of medical treatment wishes in 1994
compared with 1990 (37 percent vs. 20 percent). Nevertheless, in nearly 40 percent of cases in
which residents were judged alert and oriented, someone other than the resident signed the form
in 1994. This suggests that, despite important efforts to elicit resident wishes for end-of-life
treatment, family members are often those most involved in communicating and documenting this
information.
Details are in "Assessing capacity to participate in discussions of advance directives in nursing
homes: Findings from a study of the Patient Self Determination Act," by Elizabeth Bradley,
M.B.A., Ph.D., Leslie Walker, M.P.H., Barbara Blechner, J.D., and Terrie Wetle, Ph.D., in the
January 1997 Journal of the American Geriatrics Society 45, pp. 79-83.
Even though Hispanic women, and in particular Mexican-American women, tend to be poorer,
less educated, and medically underserved compared with non-Hispanic white women, their rates
of infant mortality are half those of black women and are similar to those of non-Hispanic white
women. This "paradox of Hispanic health" was underscored in a recent study by the Patient
Outcomes Research Team (PORT) on the Prevention of Low Birthweight Among High-Risk and
Minority Women.
In this study, white women had 1.5 times and black women had 2 times the prevalence of preterm
delivery of Hispanic women, according to the PORT, which is supported by the Agency for
Health Care Policy and Research (PORT contract 290-92-0055). The overall prevalence of
preterm delivery (less than 37 weeks of gestational age) was 8 percent: 10 percent in black,
7 percent in white, and 5 percent in Hispanic women.
Maternal thinness and poor maternal nutrition as reflected in low prepregnancy body mass index
(weight divided by height squared) and low pregnancy weight gain are associated with preterm
labor and premature rupture of membranes, according to Robert L. Goldenberg, M.D., of the
University of Alabama at Birmingham, the PORT's lead investigator. The researchers therefore
examined the association between prepregnancy body mass index (BMI) and preterm delivery
among black, white, and Hispanic women (12,459 total) enrolled in a large multicenter trial of
preterm birth prevention.
Only 12 percent of Hispanic women had a low prepregnancy BMI, which is associated with
preterm birth, compared with 20 percent of black women and
29 percent of white women. Among black and white women, there was an inverse relationship
between prepregnancy BMI and late preterm deliveries (33 to 36 weeks' gestation), but this was
not found among Hispanic women. Only prior spontaneous preterm delivery was associated with
preterm delivery among Hispanic women.
It may be that Mexican immigrants bring a cultural orientation that includes protective behaviors
such as less smoking and alcohol consumption and a better diet, note the authors. For instance,
the Hispanic women in this study smoked much less, were less likely to be underweight, and were
more likely to have average prepregnancy weight—a theoretically protective
state—than either white
or black women.
Note: In the original study from which the data used in this investigation were derived, Hispanic
women were not classified as to their country of origin. However, given the location of the two
study centers that recruited the women (San Diego and Chicago), it can be assumed that a
considerable proportion of the women may have been Mexican-American.
See "Low pregravid body mass index as a risk factor for preterm birth: Variation by ethnic
group," by Carol A. Hickey, R.D., Ph.D., Suzanne P. Cliver, B.A., Sandre F. McNeal, B.S., and
Dr. Goldenberg, in the February 1997 issue of Obstetrics & Gynecology 89(2), pp.
206-212.
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Not surprisingly, persons with health insurance clearly perceive their access to health care as
much better than individuals without insurance. However, other primary care factors, such as
having a regular place for care and a regular provider, also influence how a person perceives
access to health care. Once a person has health insurance, these factors add cumulatively to the
perception of better access to care, according to a study supported in part by the Agency for
Health Care Policy and Research (HS07373).
The study was conducted by investigators at the MEDTEP Research Center on Minority
Populations at the University of California, San Francisco. Findings are based on a survey of
6,674 English- and Spanish-speaking adults with various levels of access to care who were
randomly sampled from 41 urban communities in California.
The researchers found that one-third of the variation in how persons perceived their access to care
was explained by four factors. Individuals rated their access to care better if they had "optimal"
primary care, health insurance, a regular place of care, and a regular health care provider.
Individuals were considered to have "optimal" primary care if they received the highest possible
score on the availability and comprehensiveness of care received, as well as the communication
measures employed, and if they had been coming to their regular place of care for 12 months or
more.
The biggest gap in perception of access to care was between those without health insurance and
those with insurance. If individuals had health insurance and a regular place of care, it didn't seem
to matter if they had a regular health care provider, as long as the group at the
care site provided optimal primary care. Over 20 percent of those surveyed reported at least some
difficulty in obtaining care, with access problems concentrated among those with low
socioeconomic status and no insurance.
The high level of unexplained variation suggests that there are many other important factors that
contribute to individual perceptions of the ability to obtain care, ranging from a patient's lack of
familiarity with the health care system and the amount of copayment or deductible they have to
pay to availability of physicians accepting Medicaid and poor patients.
See "Primary care and patient perceptions of access to care," by Anita L. Stewart, Ph.D., Kevin
Grumbach, M.D., Dennis H. Osmond, Ph.D., and others, in the February 1997 issue of the
Journal of Family Practice 44(2), pp. 177-185.
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As described in the March 1997 issue of Research Activities,
the Agency for Health Care Policy and Research is considering a series of refinements that are
intended to streamline AHCPR's grant application submission and review processes. Two of
these "streamlining" procedures have now been adopted formally by AHCPR. They involve:
- Limiting the number of times an application can be resubmitted to AHCPR for review.
- Streamlining preparation of summary statements.
The first policy provides that beginning with the October 1997 receipt date, AHCPR will no
longer consider any A3 or higher amendments to an application. Further, regardless of the number
of amendments, AHCPR will not accept a revised (amended) application that is submitted later
than 2 years beyond the receipt date of the initial, unamended application. This new policy applies
to all mechanisms (e.g., R01, R03, R18) and is consistent with the National Institutes of Health
policy on amended/revised applications announced in the NIH Guide to Grants and
Contracts,
volume 25, number 19, June 14, 1996.
A significant amount of applicant and review
resources are devoted to revised (amended) applications. Furthermore, AHCPR believes that after
2 years, the research issues may be less timely and relevant to AHCPR priorities. Thus, applicants
should reconsider their research plans in light of peer review comments and the timeliness and
relevance of research issues.
Questions/comments about this new policy should be directed to: Patricia Thompson, Ph.D.,
AHCPR Referral Office, (301) 427-1556, fax (301) 427-1561.
The second policy change involves the preparation of summary statements of reviews of grant
applications. The changes are designed to improve the timeliness of information for AHCPR
program decisions and for useful critiques to applicants.
Resource constraints make it difficult for AHCPR to continue providing comprehensive,
integrated summary statements of reviews in a timely manner. Effective with the October 1997
application receipt cycle, AHCPR will begin to implement a streamlined system for preparation of
summary statements. The transition phase is expected to take two review cycles; full
implementation will begin with the June 1998 application receipt cycle. During this transition,
reviewers will be oriented to the new process, and refinements to the system will be made as
needed.
The implementation of this process will not affect how applicants prepare or submit their
applications. Applicants should expect the summary statement of the review of applications to
appear in a different format than previously. The new format will consist of a summary of the
review group's discussion (when applicable), a description of the proposed project from the
investigator's abstract, and the reviewers' individual critiques.
The planned changes have been reviewed by AHCPR's internal and external grants streamlining
work groups and recommended for implementation. Changes in the AHCPR processes are
consistent with streamlined review systems implemented by NIH, which have been favorably
received by applicants and reviewers.
Notification of these new policies was published in the April 11, 1997, issue of the NIH Guide to Grants and Contracts, volume 26, number 12.
The Agency for Health Care Policy and Research will host the conference "Translating Evidence Into Practice: What Do We Know? What Do We Need?" at the Renaissance Hotel, Washington, DC, July 21-23, 1997. It will feature two major themes: (1) innovative strategies that work—health
care quality enhancement through use of evidence-based clinical guidelines and other quality
improvement tools, and (2) legal and ethical issues that help shape the purchase and delivery of
quality health care.
John M. Eisenberg, M.D., AHCPR's newly appointed Administrator, will speak on
"Evidence-based Practice: Key to Quality Care," and David M. Eddy, M.D., Senior Advisor,
Health Policy and Management, Kaiser Permanente, California, will speak on "Evidence-based
Medicine: What Have We Learned?" The international perspective on evidence-based health care
and the implementation of guidelines will be presented at a plenary session chaired by Steven
Woolf, M.D., Clinical Associate Professor, Medical College of Virginia.
Sessions and panel presentations on legal/ethical issues include the cost-quality interface; medical ethics—putting the patient first; ethical issues in health care delivery; learning from errors—what industry can teach us; using adverse events data to improve quality of care; ERISA—the interplay of State and Federal responsibilities in health care; scientific evidence and the courts; legislating clinical care; data needs for evidence-based practice; patient privacy versus the need for patient data; and the use of quality indicators for investigation, regulation, and accreditation.
Sessions on translating evidence into practice will include a panel on the implementation and use of technology assessments, the implementation of evidence-based medicine in managed care environments, implementation of guidelines in large health care systems, implementation and adaptation of nationally developed guidelines, use of evidence-based quality indicators,
implementation of guidelines in specific populations and settings, barriers to implementation, data
needs to support evidence-based practice, and differences in implementation goals.
In January, James J. Crall, D.D.S., Sc.D., began a
1-year appointment as the Agency for Health Care Policy and Research's first Dental
Scholar-in-Residence. This appointment was established in collaboration with the American
Association of Dental Schools and the American Association of Dental Research to help AHCPR
develop the capacity for research to improve the delivery of effective dental and oral health
services. Another goal of this initiative is to encourage and strengthen collaborative relationships
among the professional, educational, research, and business entities involved with dental care.
Dr. Crall will assist AHCPR in its efforts to foster increased communication, cooperation, and
collaboration among communities engaged in quality improvement efforts and the dental
profession. He also will use this year-long appointment to broaden the scope of his research
pursuits in the field of quality measurement
and improvement and examine issues related to the integration of oral health services into
comprehensive primary care systems.
Dr. Crall is on sabbatical leave from the School of Dental Medicine of the University of
Connecticut Health Center, Farmington, where he is Associate Professor, Head of the Department
of Pediatric Dentistry, and Associate Dean for Program Evaluation and Planning. He will
be working in AHCPR's Center for Quality Measurement and Improvement.
Dr. Crall received a D.D.S., M.S., and certification in pediatric dentistry from the University of
Iowa and master's and doctoral degrees in Health Policy and Management from Harvard
University. He was a Robert Wood Johnson Foundation Dental Services Research Scholar at
Harvard from 1984 to 1986 and conducted research on the basis of consumer choices among
health plans. His doctoral dissertation focused on assessments of dental practice quality and
price-quality relationships for dental services.
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