Better assessment of chest pain patients in
the ER could reduce unnecessary CCU admissions
Chest pain patients who could be suffering a heart attack (acute
myocardial infarction, AMI) are
usually sent from the emergency department to the coronary care
unit (CCU), even though only
about 30 percent of these patients are ultimately found to have
suffered a heart attack.
Unnecessary and costly CCU admissions could be reduced if these
units were reserved for
patients with a moderate probability (21 percent or more,
depending on the patient's age) of heart
attack, unless patients need intensive care for other reasons,
concludes a study supported in part
by the Agency for Health Care Policy and Research (HS06452).
Patients at moderate risk of an
AMI typically are those with electrocardiographic changes
indicative of coronary blood
deficiency (ischemia) and tissue damage (infarction) that appear
to be recent, explain the
researchers from Dartmouth Medical School, the University of
California, San Francisco,
Brigham and Women's Hospital, and Harvard Medical School. They
used clinical data from over
12,000 emergency department patients with acute chest pain at
seven hospitals and resource use
data from 900 patients in a decision-analytic model to identify
cost-effective recommendations
for initial admission to a CCU versus an intermediate care (or
stepdown) unit, based on the
probability of AMI.
Assuming a 15 percent relative increase in death when patients
with AMI were admitted to the
intermediate unit instead of the CCU, the costs per
year-of-life-saved for triage to the CCU
varied markedly, depending on the age of the patient and the
probability of AMI. For 55- to
64-year-old patients with a 1 percent probability of heart attack
determined in the emergency
department, the cost per year-of-life-saved was $1.4 million.
When the probability of heart attack
was 99 percent, the cost per year-of-life-saved was $15,000. The
CCU had a cost-effectiveness
comparable to other accepted medical interventions (less than
$50,000 per year-of-life-saved)
when the initial probability of AMI was greater than 57 percent
among patients 30 to 44 years of
age but only 21 percent among patients 65 to 74 years of age. The
researchers found that initial
triage to the CCU is generally more cost effective for older
patients who have higher
age-specific mortality rates and for patients with ECG changes of
ischemia who have a moderate
to high probability of AMI.
Details are in "Cost-effectiveness of a coronary care unit versus
an intermediate care unit for
emergency department patients with chest pain," by Anna N.A.
Tosteson, Sc.D., Lee Goldman,
M.D., I. Steven Udvarhelyi, M.D., and Thomas H. Lee, M.D., M.Sc.,
in the July 15, 1996, issue
of Circulation 94, pp. 143-150.
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Healthcare Marketplace Research
Marketplace demand for specialists
declines
Anecdotal reports suggest that medical school graduates in
certain specialties are having
difficulty finding employment, while their primary care
colleagues are being recruited with
lucrative incentive packages. Also, a recent study found that in
1990, there were four
advertisements recruiting specialist physicians for every one for
generalist physicians, but by
1995, the market for specialists had declined steeply to two
advertisements for specialists for
every one generalist ad.
Despite recommendations to train more generalists, the demand for
internists and pediatricians
appears to be flat or declining, perhaps due to increased use of
physician assistants and nurse
practitioners. On the other hand, the demand for family
physicians is rising, according to the
study (supported in part by the Agency for Health Care Policy and
Research, T32 HS00026).
Based on analysis of the number of physician positions advertised
in the September issue (peak
month for physicians to conduct job searches and for recruitment
advertising) of key specialty
and general medical journals in select years from 1984 through
1995, researchers in California
and Washington found steep declines in the number of advertised
positions for specialist
physicians over the past 5 years, with the exception of pediatric
specialists. The most dramatic
changes occurred in the number of internal medicine specialist
positions, which declined by 75
percent from 1990 to 1995, compared with a 9 percent decline in
general internist positions.
During the same period, anesthesiology positions declined 65
percent, pulmonary positions 50
percent, and orthopedic surgery positions 50 percent. For
physicians as a whole, there were four
specialist positions for every generalist position advertised in
1990; by 1995, this ratio dropped
to 1.8.
Compared with the other generalist fields, only family medicine
showed sustained growth, with
advertised positions more than doubling over the study period.
The researchers conclude that
these trends in recruitment advertisements reflect the shift to
increasingly managed and capitated
systems of care that use fewer specialists.
More details are in "Changes in marketplace demand for
physicians," by Sarena D. Seifer, M.D.,
Barbara Troupin, M.D., M.B.A., and Gordon D. Rubenfeld, M.D., in
the September 4, 1996,
Journal of the American Medical Association 276(9), pp.
695-699.
Return to Contents
Women's Health
Uterine fibroids occur more often among
black women than
white women undergoing hysterectomy
From one-fourth to one-half of women of childbearing age will
suffer from uterine fibroids at
some point. Among women undergoing hysterectomy, uterine fibroids
(leiomyomas) develop at
an earlier age in black women than they do in white women, are
larger and more numerous, and
cause more severe symptoms, according to a study supported in
part by the Agency for Health
Care Policy and Research (HS06865). The study also suggests that
being overweight may
increase a woman's risk of developing fibroids, since both black
and white leiomyoma patients in
this study were overweight compared with women in the general
population.
Uterine fibroids can cause abnormal bleeding, pelvic pain,
limited activity, anemia, fatigue,
urinary and bowel problems, miscarriage, and infertility. These
benign tumors of the uterine
smooth muscle are the leading indication for hysterectomy in the
United States, notes Kristen H.
Kjerulff, Ph.D., of the University of Maryland School of
Medicine, the study's lead author.
The researchers found that, of 409 black women and 836 white
women who underwent
hysterectomy for noncancerous conditions at 28 Maryland
hospitals, 89 percent of black women
and 59 percent of white women were found to have leiomyomas.
Interviews shortly before
surgery with patients who had a presurgical diagnosis of
leiomyoma, hospital records, and
pathology reports obtained after discharge showed that black
women were more likely than
white women to have seven or more leiomyomas (57 percent vs. 36
percent), to be anemic (56
percent vs. 38 percent), and to have severe pelvic pain (59
percent vs. 41 percent). Black women
were diagnosed with leiomyomas on average at an earlier age (38
years vs. 42 years) and
underwent hysterectomy at a younger average age (42 years vs. 45
years). Among women with
leiomyomas undergoing hysterectomy, black women had substantially
larger uteri than white
women; the average uterine weight was 421 g for black women with
leiomyomas and 319 g for
white women (average uterine weight for pregnant women at 12
weeks gestation is 280 g).
Body mass index (BMI) was significantly associated with uterine
weight. An increase of one
point in BMI was associated with an increase in uterine weight of
5 g. Forty-one percent of white
women and 67 percent of black women were classified as
overweight—with BMI values more
than 27.3, equivalent to 120 percent of desirable body
weight—compared with 33 percent of
white women and 49 percent of black women in the general
population. The researchers point
out, however, that body weight is only one factor in the
development and growth of leiomyomas;
various hormones and other factors also play a role in this
process.
Details are in "Uterine leiomyomas: Racial differences in
severity, symptoms, and age at
diagnosis," by Dr. Kjerulff, Patricia Langenberg, Ph.D., Jeffrey
D. Seidman, M.D., and others, in
the July 1996 Journal of Reproductive Medicine 41, pp.
483-490.
PORT researchers link bacterial infection
with many preterm
births
Preterm births, on the increase since the mid-1980s, are
responsible for nearly 75 percent of
newborn deaths and as much as half of long-term neurological
damage in children. Uterine
infection is the key to many of these preterm births, asserts
Robert L. Goldenberg, M.D., of the
University of Alabama (Birmingham), in a recent editorial. Dr.
Goldenberg is principal
investigator of the Low Birthweight Patient Outcomes Research
Team (PORT), which is
supported by the Agency for Health Care Policy and Research (PORT
contract 282-92-0055).
Up to 40 percent of women in spontaneous labor will have bacteria
in both the amniotic fluid and
the membranes. An additional 20 percent will have organisms in
the membranes but not in the
amniotic fluid, according to Dr. Goldenberg. Associated with
these microorganisms, some of
which are transmitted sexually, is an increased production of
inflammation-producing cytokines
that can be detected in the amniotic fluid. These cytokines
participate, both directly and
indirectly, in various reactions leading to the onset of uterine
contractions, changes in cervical
consistency, and rupture of the membranes that initiate labor.
Bacteria most commonly associated with spontaneous delivery
include Ureaplasma urealyticum,
Mycoplasma hominis, Bacteroides, and Gardnerella vaginalis. For
the most part, these strains of
bacteria are not very virulent and may exist in the vagina and
uterus for a long time without
producing symptoms. Previous studies by the Low Birthweight PORT
have shown up to a
three-fold increase in the odds of preterm birth with the
presence of bacterial vaginosis.
This type of infection also would explain why women who have one
early spontaneous birth are
so prone to have a second. There is no reason to believe that
after the infant is delivered, the
intrauterine bacterial colonization disappears spontaneously.
Chronic colonization of the uterine
lining with low virulence microorganisms has the potential to
explain most of the observations
related to early spontaneous preterm birth, notes Dr. Goldenberg,
including why black women
have more preterm births than white women. He concludes that
treatment strategies aimed at the
underlying disease (infection) seem far more promising than those
targeted to symptoms of
preterm labor or the psychosocial, behavioral, or nutritional
characteristics of the mother that
have been associated with, but not causally related to, preterm
birth. In fact, recently reported
randomized antibiotic treatment trials of women at high risk for
preterm birth, who also had
bacterial vaginosis, showed substantial reduction in spontaneous
preterm births.
See "Intrauterine infection and why preterm prevention programs
have failed," an editorial by
Dr. Goldenberg and William W. Andrews, M.D., Ph.D., in the
American Journal of Public
Health 86(6), pp. 781-782, 1996.
Women who have regular checkups appear to
live longer
Debate continues about which aspects of primary care are most
critical for improving patient
health. Is it having a usual doctor or clinic, regular checkups,
or better access to care? A recent
study points out the importance of regular checkups for women's
survival but also underscores
the difficulty of identifying which aspects of health care access
or use measured in population
surveys influence patient outcomes. The study was carried out by
Peter Franks, M.D., and
Marthe R. Gold, M.D., of the University of Rochester, and Carolyn
M. Clancy, M.D., Director of
the Center for Primary Care Research and Acting Director of the
Center for Outcomes and
Effectiveness Research, Agency for Health Care Policy and
Research.
The researchers found that women who have regular checkups have
better survival rates than
women who do not. However, no association was found between
checkups and men's survival
rates; instead, checkups among men are more likely to be a marker
for higher income. No
relationship was found between having a usual source of health
care (physician or clinic) or
forgoing care for perceived medical problems and subsequent
mortality for either men or
women.
These findings probably underestimate the relationship between
access to and use of health care
and survival, cautions Dr. Clancy. Better understanding of the
factors underlying differences
between the sexes in perceived health and health care use and
health outcomes could enhance the
development of more useful measures. For example, women are more
inclined to get a checkup
for preventive health reasons, such as screening mammograms and
pap smears. Men are more
apt to obtain a checkup if it is required for work or insurance.
Also, women generally have a
more positive attitude toward health and health care, and they
have been socialized to take more
responsibility for family health. So while they may be more
sensitive to symptoms of illness,
they also are less apt to adopt the sick role when ill. This may
explain why in this study twice as
many men as women did not have a usual source of care (17 percent
vs. 9 percent), but slightly
more women had chosen not to obtain care (16 percent vs. 13
percent).
These findings were based on data from the National Health and
Nutrition Examination Survey
Epidemiologic Follow-Up Study, which followed a representative
group of working-age U.S.
adults for up to 16 years. Dr. Clancy and colleagues measured the
impact on survival of
availability of a usual source of care, care not received for
perceived medical problems (forgone
care), and receipt of a general checkup (other than for illness).
For more information, see "Use of care and subsequent mortality:
The importance of gender," by
Drs. Franks, Gold, and Clancy, in the August 1996 HSR: Health
Services Research 31(3), pp.
347-363. Reprints (AHCPR Publication No. 97-R006) are available
from the AHCPR
Publication Clearinghouse.
Return to Contents
Patient Outcomes/Effectiveness Research
Benefits and costs weighed for specialty
versus primary care
for stroke patients
Stroke patients who are treated by neurologists may pay more, but
they often experience better
outcomes, according to a recent study by the Stroke Patient
Outcomes Research Team (Stroke
PORT). Led by David Matchar, M.D., of Duke University Medical
Center, and supported by the
Agency for Health Care Policy and Research (contract
290-91-0028), the Stroke PORT
researchers analyzed claims data for a random 20 percent sample
of Medicare patients admitted
to the hospital with nonhemorrhagic stroke between January 2 and
September 30, 1991.
Three months following the stroke, study patients treated by
neurologists had a 31 percent lower
death rate than study patients treated by internists and a 36
percent lower death rate than patients
treated by family practitioners. Patients cared for by
neurologists also appeared to be more
functional after their hospital stay. They were more likely to be
sent home or discharged to
inpatient rehabilitation facilities rather than to a nursing or
rest home.
Neurologists were 34 percent more expensive than family
practitioners and 22 percent more
expensive than internists or other specialists. If both a
neurologist and a primary care physician
treated a stroke patient, the costs increased another 5 percent.
Lead author Janet Mitchell, Ph.D., of Health Economics Research
in Waltham, MA, suggests
that several dimensions of stroke management by neurologists may
be relevant both to the
increased costs and the improved outcomes. Neurologists are
significantly more likely to order
diagnostic cerebrovascular tests, especially brain scans, which
often identify the
pathophysiologic mechanism of the stroke and may affect the
course of treatment. Also, they are
more likely to prescribe the anticoagulant warfarin and to begin
early rehabilitation.
These findings could warrant a broader dissemination to primary
care physicians of stroke
treatment guidelines that incorporate the methods used by
neurologists, Dr. Mitchell concludes.
However, further research, preferably by randomized trial, would
be needed first to provide
definitive answers.
For more information, see "What role do neurologists play in
determining the costs and
outcomes of stroke patients?" by Dr. Mitchell, David J. Ballard,
M.D., Ph.D., Jack P. Whisnant,
M.D., and others, in the November 1996 issue of Stroke 27,
pp. 1937-1943.
PORT researchers identify risk factors for
retinal detachment
after cataract surgery and confirm the reliability of the VF-14
index of visual function
Cataracts are the second leading cause of blindness in the United
States. About 18 percent of
persons 65-74 years of age and almost half of those aged 75-84
years have cataracts that impair
their everyday activities and ability to live independently. The
Cataract Patient Outcomes
Research Team (PORT) was funded by the Agency for Health Care
Policy and Research
(HS06280) to study variations in cataract management, patient
outcomes, and the economic
aspects of cataract treatment. PORT researchers, led by Earl P.
Steinberg, M.D., M.P.P., of The
Johns Hopkins University, recently published the results of two
studies, which are discussed
here.
Tielsch, J.M., Legro, M.W., Cassard, S.D., and others (1996).
"Risk factors for retinal
detachment following cataract surgery: A population-based
case-control study." Ophthalmology 103(10), pp. 1537-1545.
Performance of Nd:YAG laser posterior capsulotomy (incision of
the lens capsule with a laser)
after cataract surgery increases the risk of retinal detachment
nearly four-fold (3.8), according to
this study by the Cataract PORT investigators. This finding was
based on an analysis that
adjusted for other factors which can increase the risk of retinal
detachment, such as prior history
of retinal detachment and refractive error. Retinal detachment
occurs in 0.2 percent to 3.6
percent of persons following cataract surgery. However, given the
large number of cataract
surgeries performed, the number of these vision-threatening
complications becomes substantial.
This suggests the need for strong clinical and functional
justification for performance of
Nd:YAG laser capsulotomy, according to the researchers. Using
Medicare claims data, they
identified a group of Medicare beneficiaries who underwent this
surgery during 1988-1990 and
then compared 291 cases who had claims for retinal detachment
following surgery with 870
matched controls who did not. Data regarding clinical risk
factors, as well as clinical events (e.g.,
performance of capsulotomy or repair of retinal detachment), were
obtained directly from the
ophthalmologists who cared for the patients included in the
analysis—thus overcoming limitations
related to the Medicare claims data.
Cassard, S.D., Patrick, D.L., Damiano, A.M., and others (1995,
December). "Reproducibility
and responsiveness of the VF-14." Archives of
Ophthalmology 113, pp. 1508-1513.
The VF-14 is an index of functional impairment in patients with
cataracts. It was developed by
the cataract PORT researchers for use in routine clinical
practice and in research studies. The
Cataract PORT investigators have found that the VF-14 is three
times more responsive to small
but clinically important changes in vision following cataract
surgery than the Sickness Impact
Profile (SIP), a general health status measure.
The VF-14 is used to measure a cataract patient's ability to
perform 14 vision-dependent
activities such as reading small print, doing fine handwork, and
night and day driving. This study
also shows that the VF-14 elicits highly reproducible responses
over an 8-month period in
clinically stable patients.
Short-term improvement in carefully
selected patients with
sciatica and spinal stenosis appears better with surgery than
other treatments
When carefully selected, persons suffering from sciatica and
spinal stenosis may improve
substantially more with surgery than patients treated
nonsurgically, according to a study
conducted by the Maine Medical Assessment Foundation (MMAF),
directed by Robert B.
Keller, M.D. The study is a component of the Back Pain Patient
Outcomes Research Team
(PORT) led by Richard A. Deyo, M.D., M.P.H., of the University of
Washington.
Sciatica generally results from herniation or protrusion of an
intervertebral disc, which presses
on spinal nerve roots. It often results in leg pain, numbness or
tingling in the leg and/or foot,
weakness in the leg or foot, and back pain. The pain and loss of
mobility from sciatica may
severely reduce a person's ability to function at home and at
work. Spinal stenosis (constriction)
occurs predominantly among the elderly and is being diagnosed
more frequently due to
widespread use of sophisticated noninvasive imaging techniques.
It often causes leg pain,
numbness, and weakness and pain while walking. Physicians
continue to disagree about the best
approach to these problems, with surgery rates varying up to
15-fold among U.S. regions.
The Maine study showed that among 389 patients with sciatica and
148 patients with spinal
stenosis, outcomes of surgical patients were substantially better
at 1 year than for the patients
who underwent nonsurgical treatment (for example, back exercises,
physical therapy, and spinal
manipulation). Patients were recruited from orthopedic,
neurosurgical, and occupational
medicine practices across the state of Maine and, at the time of
study entry, had undergone at
least 2 weeks of conservative therapy within the previous 2
months without satisfactory
improvement.
Seventy-five percent of surgical sciatica patients had much less
or no back or leg pain compared
with 55 percent of nonsurgical patients, while 31 percent and 11
percent of patients, respectively,
reported that all symptoms were completely gone. Overall quality
of life was moderately
improved in 80 percent of surgical patients and 58 percent of
nonsurgical patients, while 60
percent and 40 percent, respectively, reported they would be
satisfied to spend the rest of their
lives in their current state. In fact, 86 percent of surgical
patients stated that they would elect
surgery again if they had to remake their decision. The benefits
of surgery were only modest for
the least symptomatic patients, resulting in symptoms, quality of
life, and satisfaction outcomes
similar to medically treated patients.
Of the 148 patients with lumbar spinal stenosis, 81 were treated
surgically and 67 were treated
nonsurgically. On average, patients undergoing surgery had more
severe imaging findings,
symptoms, and worse functional status than nonsurgical patients.
Twice as many
surgically treated patients reported near or complete relief of
leg or back pain 1 year after surgery
as nonsurgically treated patients (55 percent vs. 28 percent).
Even patients with moderate
symptoms improved compared with nonsurgically treated patients.
Days of disability during the
past month declined in both groups, but more so in surgical
patients. Overall quality of life was
at least moderately improved in 81 percent of surgical and 49
percent of nonsurgical patients.
Overall results were viewed as very good or excellent in 69
percent of surgical and 36 percent of
medical patients, and 88 percent of surgical patients said they
would make the same decision for
surgery again.
Although 1-year results appear better in surgical patients with
spinal stenosis, few nonsurgical
patients worsened or required subsequent surgery, and fully 20
percent of surgical patients
reported no improvement in back or leg pain. And, while surgery
provides a greater chance for
rapid relief of sciatica symptoms, nonsurgically treated patients
appear likely to gradually
improve. Ultimately, the decision to undergo surgery for either
condition is an individual
one,conclude the PORT researchers. Determining whether the
benefits of surgery for stenosis or
sciatica persist over time requires longer followup, which is
underway.
Additional support for portions of the Maine study came from
another AHCPR-funded project,
"Outcomes dissemination: The Maine Study Group Model." This
project has focused on methods
of dissemination and evaluation of the study group methodology
developed by the MMAF.
More details are in the following three articles: "The Maine
lumbar spine study: I. Background
and concepts," by Robert B. Keller, M.D., Steven J. Atlas, M.D.,
M.P.H., Daniel E. Singer,
M.D., and others; "The Maine lumbar spine study: II. 1-year
outcomes of surgical and
nonsurgical treatment of sciatica," by Dr. Atlas, Dr. Deyo, Dr.
Keller, and others; and "The
Maine lumbar spine study: III. 1-year outcomes of surgical and
nonsurgical treatment of lumbar
spinal stenosis," also by Dr. Atlas, Dr. Deyo, Dr. Keller, and
others. All three articles appear in
the August 1996 issue of Spine, 21, pp. 1769-1795.
Educating patients about prostate screening
and treatment
influences their medical decisions
When a videotape shown in clinical practice informs men about the
natural course of early-stage
prostate cancer and the medical uncertainty surrounding the
routine screening and treatment of
this condition, they are less likely to prefer screening and
treatment than men who don't see the
tape, concludes a study by the Prostate Patient Outcomes Research
Team (PORT). However,
even informed men varied in their decisions about prostate
screening. These findings underscore
the importance of incorporating individual preferences into PSA
screening decisions, conclude
the Prostate PORT researchers, whose work was supported by the
Agency for Health Care
Policy and Research (HS06336 and HS08397).
Routine prostate-specific antigen (PSA) screening for prostate
cancer is controversial because of
frequent false-positive results (the test shows cancer that does
not exist) and uncertainty
surrounding the benefits of treating early-stage prostate cancer.
Even if diagnosed early, the
majority of men with prostate cancer will not experience
significant symptoms and will die from
another cause. Moreover, it is questionable whether treatment,
usually with radical
prostatectomy or radiation therapy, improves survival over
watchful waiting or decreases
disease-related symptoms. Also, the side effects of treatment
range from impotence,
incontinence, and rectal injury to operative death.
The research team presented an educational videotape designed by
the team to inform men about
the uncertainty surrounding PSA screening and the treatment of
early-stage prostate cancer to
two groups of male patients 50 years of age or older who had no
history of prostate cancer who
were being seen at the Dartmouth-Hitchcock Medical Center in
Hanover, NH. Men seeking a
free screening were preassigned to view the videotape (184 men)
or another videotape (188).
Men scheduled to visit a general internal medicine clinic viewed
either the educational videotape
(103) or no videotape (93).
Men shown the educational videotape were more inclined to say
that they would choose
watchful waiting over active treatment if cancer were to be found
(63 and 86 percent vs. 26 and
40 percent) in two different clinic settings. They were also half
as likely as men who did not
view the videotape to have a PSA test (12 percent vs. 23 percent
of general internal medicine
clinic patients).
For more details, see "The importance of patient preference in
the decision to screen for prostate
cancer," by Ann Barry Flood, Ph.D., John E. Wennberg, M.D.,
M.P.H., Robert F. Nease, Jr.,
Ph.D., and others, in the Journal of General Internal
Medicine 11, pp. 342-349, 1996.
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