California hospitals shifted costs from public to private payers during the 1980s

During the 1980s, California acute care hospitals compensated for the low reimbursement they received for care provided to Medicare- and Medicaid-insured patients by charging privately insured patients more. However, this cost shifting decreased slightly over time as private payers revised their payment methods to control costs, concludes a study supported by the Agency for Health Care Policy and Research (HS07983). It shows that private payers paid from 12 percent more net revenue markup over cost in 1983 to 30 percent by 1992. The average markup to private payers exceeded the markups paid by Medicare and Medicaid during the same time period.

In 1983, when Medicare reimbursed hospitals on the basis of costs, the Medicare markup averaged .55 percent. Even though Medicare continued to pay hospitals slightly more than the average full cost per patient day through the 1980s, Medicare markups steadily decreased from an average of 11 percent in 1986 to 6 percent in 1989 to 0.6 percent in 1992. California Medicaid, on the other hand, consistently paid hospitals less than the average cost per day, declining from 79 percent to 55 percent of daily average costs from 1983 to 1992. This circumstance drove hospitals to shift costs to private payers.

Hospitals that were financially strong at the beginning of a 3-year interval increased their markup to private patients less. Low-profit hospitals raised their markup to private patients more. Surprisingly, this dynamic cost shifting was not influenced by hospital competition or market penetration by health maintenance organizations, notes the study's author, Jan P. Clement, Ph.D., of Virginia Commonwealth University. She used California annual hospital financial data for 1983, 1986, 1989, and 1992 to examine hospital cost shifting.

See "Dynamic cost shifting in hospitals: Evidence from the 1980s and 1990s," by Dr. Clement, in the Winter 1997/98 Inquiry 34, pp. 340-350.

Multiple births raise neonatal intensive care charges 250-400 percent over singleton births

Due in part to more widespread use of fertility drugs, the number of twin births in the United States from 1973 to 1990 increased at twice the rate of single births (65 percent vs. 32 percent). Triplets and higher-order multiple births increased at a rate seven times that of single births (222 percent vs. 32 percent). These typically low birthweight and premature infants dramatically increase neonatal hospital costs, finds a study supported in part by the Agency for Health Care Policy and Research (HS07118). The Harvard Medical School researchers analyzed computerized medical and billing records of 13,206 women who delivered at Brigham and Women's Hospital in Boston between 1986 and 1991.

They found that twins were born almost 3 weeks earlier than singletons and weighed nearly one-third less. Higher order multiples were born more than 5 weeks earlier and weighed only about half as much as singletons. On average, the singletons were born at 39.27 weeks gestation and weighed 3,212 grams (7 lbs), whereas twins were born at 36.30 weeks and weighed 2,279 grams (5 lbs), and higher order multiples were born at 33.91 weeks and weighed only 1,808 grams (almost 4 lbs).

Neonatal charges for twins ranged from about 250 percent to 350 percent of the charges for singletons, while charges for higher order multiples ranged from 300 percent to 400 percent of singleton charges. The predicted probability of any neonatal intensive care use increased from 15 percent to 47 percent if the baby was a twin and reached 77 percent for higher-order multiples. About 50 percent of the increase in total charges for multiple births was due to lower gestational age, and a further 40 percent was due to lower birthweight. Delaying birth by an extra week would have reduced total neonatal charges by $669, and increasing birthweight by 500 grams would have reduced total charges by $900.

See "How low birthweight and gestational age contribute to increased inpatient costs for multiple births," by Susan L. Ettner, Ph.D., Cindy L. Christiansen, Ph.D., Tamara L. Callahan, M.D., M.P.P., and Janet E. Hall, M.D., in the Winter 1997/98 Inquiry 34, pp. 325-339.

Job lock due to loss of employer-related health insurance is smaller than previously thought

Most Americans under the age of 65 are covered by employer-provided health insurance that is not portable across jobs. A provision of the 1985 Consolidated Omnibus Budget Reconciliation Act (COBRA) was intended to reduce temporary portability problems by requiring employers to provide employees with the option to continue coverage for up to 18 months after termination of employment. In 1996, additional legislation was passed, which limits the length of time for which preexisting condition clauses can restrict health care coverage. The goal of this legislation is to prevent so-called job lock, that is, reluctance to leave a job because of loss of health insurance. But job lock may not be as prevalent as previously thought, according to a study supported in part by the Agency for Health Care Policy and Research (HS09333).

Workers who are sick or have sick family members should be more prone to job lock than other workers, since they are likely to face preexisting condition exclusions if they change jobs. In addition, they are more likely to find burdensome such factors as waiting periods for coverage on a new job and lack of insurance during a job search. Using proxy factors for sickness, such as data on medical conditions, health use, and medical expenses, Kanika Kapur, Ph.D., of RAND, developed a consistent estimate of job lock using data from the 1987 National Medical Expenditure Survey and compared a job-locked experimental group (based on proxy factors for sickness) with a comparable control group less subject to job lock. In contrast to other studies that have shown evidence of job lock, Dr. Kapur found that job lock was insignificant, suggesting that legislation aimed at enhancing the portability of employer-provided health insurance may be unlikely to have a large impact on job mobility.

For more information, see "The impact of health on job mobility: A measure of job lock," by Dr. Kapur, in the January 1998 Industrial and Labor Relations Review 51(2), pp. 282-297.

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Health Care Access and Quality

Reasons vary for lacking a usual source of health care

Almost 18 percent of the U.S. population did not have a usual source of health care in 1996, according to a recent article by Robin M. Weinick, Ph.D., and Susan K. Drilea, M.S., of the Agency for Health Care Policy and Research's Center for Cost and Financing Studies. They used data from the Medical Expenditure Panel Survey (MEPS) to describe the segment of the American population that lacked a usual source of care and the reasons survey respondents gave for not having a regular health care provider. The authors also discuss the usual sources of health care for people in the United States, changes in the usual source of care, and barriers to health care. The 1996 MEPS collects nationally representative data on health care use, expenditures, source of payment, and insurance coverage for the U.S. civilian noninstitutionalized population.

Overall, two-thirds of Americans without a usual source of care reported seldom or never getting sick as their main reason for having no usual source of care, but variations existed among population groups. Among those without a usual source of care, Hispanics (16.4 percent), uninsured persons under age 65 (18.4 percent), and people living in the West (15.2 percent) were substantially more likely than people in other racial/ethnic groups, other insurance categories, or other parts of the country to report cost as a reason they did not have a usual source of care.

Males were substantially more likely than females (71.8 percent compared with 59.2 percent) to report having no usual source of health care because they seldom or never get sick. Americans living in the Midwest were more likely than people living in other parts of the country to report having recently moved to the area or not knowing where to go to receive health care as a reason for lacking a usual source of care (9.3 percent).

For more information, see "Usual sources of health care and barriers to care, 1996," by Dr. Weinick and Ms. Drilea, in the January-March 1998 Statistical Bulletin pp. 11-17. Reprints (AHCPR Publication No. 98-R024) are available from the AHCPR Publications Clearinghouse.

Editor's note: See the November 1997 issue of Research Activities for a more detailed summary of MEPS information on access to care. Or, request a free copy of Access to Health Care in America—Sources and Barriers, 1996, MEPS Research Findings No. 3 (AHCPR Publication No. 98-0001) from the AHCPR Publications Clearinghouse.

Discharge abstract data may not be a reliable indicator of hospital quality of care for bypass surgery

Abstracting medical record data on coronary artery bypass (CABG) surgery patients to assess their risk of death from bypass surgery versus actual death rates is an expensive way for States to measure hospitals' quality of care for this procedure. Some States have begun to use less costly, readily available hospital discharge data instead. It's not clear, however, that this approach to obtaining hospital "report cards" for bypass surgery provides an accurate picture, cautions a study supported by the Agency for Health Care Policy and Research (HS06742).

Researchers led by Lisa I. Iezzoni, M.D., of Harvard Medical School, used the 1992 MedisGroups Comparative Database of 7,764 CABG patients from 38 hospitals to find out how individual severity measures rated severity of illness differently for identical patients. Two severity measures (MedisGroups and physiology scores) rated patients using clinical data taken from the first two hospital days. Three measures used diagnoses and other information coded on standard, computerized hospital discharge abstracts.

Results showed that code-based measures were statistically more predictive of death for individual CABG patients than clinical measures and that hospital rankings were similar for the two types of measures. However, this superior predictive power of code-based measures may reflect their reliance on diagnosis codes for life-threatening conditions that may occur late in hospitalizations. Drawing conclusions about quality from severity-adjusted death rates requires adjustment for preexisting or preoperative conditions only, and most code-based measures may owe their high predictive performance to occurrences that have nothing to do with quality of care. Another factor that compromises their usefulness is lack of credibility in the clinical community. These, according to the researchers, are compelling reasons not to rely exclusively on code-based measures.

More details are in "Predicting in-hospital deaths from coronary artery bypass graft surgery," by Dr. Iezzoni, Arlene S. Ash, Ph.D., Michael Schwartz, Ph.D., and others, in Medical Care 36(1), pp. 28-39, 1998.

Linking published evidence with practice data can change physicians' practice behavior

Physicians who receive clinical reports combining practice data and patient information from the literature are more likely to use peritoneal dialysis (PD) than hemodialysis (HD) for their dialysis patients than physicians who do not receive such reports, finds a study supported in part by the Agency for Health Care Policy and Research (HS07715). The researchers, led by Andrew Balas, M.D., Ph.D., of the University of Missouri School of Medicine, conducted a randomized controlled clinical trial at five dialysis centers. Five of the ten study physicians were randomized to receive 12 center-specific clinical reports encouraging the consideration of PD; five physicians were assigned to the control group and received usual information but no reports. The physicians monitored 52 new dialysis patients.

More than six times as many patients treated by doctors who received the reports were treated with PD than patients seen by physicians in the control group (15.3 percent vs. 2.4 percent). Also, use of PD increased significantly among physicians who received the reports but decreased among control physicians. Patient metabolic status, complications, and satisfaction with choice of dialysis mode were similar for both groups of patients.

The simple clinical reports compared a physician's center with other dialysis centers in the State on percentage of patients on CAPD (continuous ambulatory peritoneal dialysis) or CCPD (continuous cyclical peritoneal dialysis). The reports also noted that scientific studies show no important medical differences in outcomes of most patients on center-based HD or PD. These simple reports could result in substantial cost savings, conclude the researchers. Many studies have shown that PD is more cost effective than HD, saving an average of $6,000 to $8,000 per patient each year. In this study, the intervention resulted in an additional 14 individuals using CAPD/CCPD rather than HD, a potential cost savings of $267,862.

Details are in "Effect of linking practice data to published evidence: A randomized controlled trial of clinical direct reports," by Dr. Balas, Suzanne Austin Boren, M.H.A., Lanis L. Hicks, Ph.D., and others, in Medical Care 36(1), pp. 79-87, 1998.

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Elderly/Long-term Care

Attitudes toward medical care and risk affect demand by elderly for Medigap insurance

Cost-sharing requirements and benefit limitations in the Medicare program can leave elderly Medicare beneficiaries exposed to large out-of-pocket medical costs. As a result, many Medicare beneficiaries purchased supplemental—or Medigap—coverage in 1987 through insurance companies or associations.

Those with a negative attitude toward medical care and physicians were less likely to buy supplemental insurance than elderly individuals with a positive attitude, according to researchers in the Agency for Health Care Policy and Research's Center for Cost and Financing Studies. In fact, those who responded with negative attitudes on all five questions of a five-item scale—for example, they said that home remedies were often better than prescribed medicines or that they could overcome most illness without help from a medically trained professional—were 10 percentage points less likely to purchase supplemental insurance.

Attitudes toward medical care and risk played as important a role in plan selection among these elderly people as self-reported health measures, education, and asset income, note Jessica P. Vistnes, Ph.D., and Jessica S. Banthin, Ph.D. Attitudes also affected decisions on specific benefits. For instance, respondents who said they were more apt to take risks than the average person were 7.5 percentage points less likely to purchase coverage for Medicare's Part A deductible (hospitalization).

In addition, beneficiaries' attitudes toward medical care affected decisions for prescription drug coverage and Part B (physician coverage) benefits. Finally, the researchers found that Medicare beneficiaries appeared to make reasonable decisions about whether to supplement coverage obtained from current or previous employers. For instance, if they had plans with more generous hospital and physician coverage, they were less likely to purchase additional insurance. These findings were based on analysis of data from the 1987 National Medical Expenditure Survey.

Details are in "The demand for Medicare supplemental insurance benefits: The role of attitudes toward medical care and risk," by Drs. Vistnes and Banthin, in the Winter 1997/98 issue of Inquiry 34, pp. 311-324.

Use of long-term care varies according to race

Long-term care policy has evolved with little attention to racial differences in the need for and use of these services. Due to their higher rate of disease and disability, the need for long-term care is higher among blacks and Latinos than whites, but their use of some long-term-care services is substantially lower. Two studies supported by the Agency for Health Care Policy and Research (HS07672) and summarized here examine racial differences in use of long-term care.

Wallace, S.P., Levy-Storms, L., Kington, R.S., and Andersen, R.M. (1998). "The persistence of race and ethnicity in the use of long-term care." Journal of Gerontology: Social Sciences 53B(2), pp. S104-S112.

Some blacks who probably would be in nursing homes if they were white are instead living in the community using paid home care, unpaid care only, or occasionally no care at all. This suggests that formal (paid) in-home community care is not fully compensating for the racial differences in nursing home use, concludes this study. The researchers analyzed data from the 1987 National Medical Expenditure Survey (NMES) to compare long-term care use by both institutionalized and noninstitutionalized older persons. The survey included 5,886 people aged 65 and older living in the community, including 1,148 with functional impairments and 4,995 individuals residing in nursing homes.

The researchers found that older blacks have higher needs for long-term care than whites as measured by difficulties in daily living activities as well as rates of stroke, diabetes, and hearing difficulties. Even among those who were dependent for help in three to five activities of daily living (ADLs), there were racial differences: 34 percent of older blacks and 53 percent of older whites were in nursing homes, whereas 45 percent of blacks and 32 percent of whites had only unpaid community care. Overall, older blacks had lower rates of nursing home care despite higher levels of need and higher levels of Medicaid insurance, which can pay for long-term care.

Elderly Latinos had similar levels of need as non-Latino whites, higher rates of Medicaid insurance, and no significant differences in the rates of long-term care use. Even after adjusting for age, sex, marital status, and education, as well as need, black race predicted less nursing home care and less paid home care. State-level policy and supply variables also predicted long-term care use, but controlling for these variables did not eliminate the race effect for nursing homes. These racial differences could be due to inequity of access, institutionalized discrimination, or cultural preferences, conclude the researchers.

Wallace, S.P., Levy-Storms, L., Andersen, R.M., and Kington, R.S. (1997). "The impact by race of changing long-term care policy." Journal of Aging & Social Policy 9(3), pp. 1-20.

Policy initiatives in the area of long-term care typically focus on race-blind issues, contend the authors of this study. Using data from the 1987 NMES, they developed a model to show how different races would use each type of long-term care in three scenarios: if a universal home-care benefit was established; if existing Medicaid home-care benefits were ended; or if the income level for Medicaid eligibility was substantially reduced (for example, as might happen if Medicaid were made a block grant to States).

The researchers concluded that expanded community care benefits would primarily serve severely disabled elderly whites. Since only 28 percent of this group had public coverage for long-term care, most would gain a new benefit.

Reductions in public programs for long-term care could result from eliminating Medicaid benefits for personal care or from restricting eligibility to those with incomes under $5,000. Reducing long-term care benefits would disproportionately affect older, severely disabled blacks, since 80 percent of black recipients of formal personal care are public pay, compared with 32 percent of older whites. Eliminating this benefit would likely cut formal personal care use in half among blacks, while creating a comparatively small reduction among whites. The net effect would be to shift the full social and economic costs of caring for about 10 percent of all severely disabled older blacks onto families and communities that already face high rates of poverty.

Lowering the eligibility income level for Medicaid would be the most far-reaching change and would most affect severely disabled blacks and whites. Both nursing home residents and formal home care recipients would lose coverage, increasing their reliance on informal care. In 1987, for example, 77 percent of severely disabled older blacks and 39 percent of similarly disabled whites in nursing homes had entered under Medicaid. Since the consequences of public policy changes are not color-blind, the researchers stress the need to make sure that policy changes do not disproportionately hurt those groups with the highest health needs and fewest financial resources.

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Special Populations

Asthma disproportionately affects blacks who often go to the ER for asthma care

Black Americans have proportionately more asthma, more hospitalizations for asthma, and die from asthma three to five times more often than white Americans. Asthma is a chronic inflammatory disease that should be treated with regular antiinflammatory medication to prevent life-threatening exacerbations that require emergency care.

Previous studies have suggested that low-income blacks rely almost exclusively on the emergency department (ED) for asthma care. However, in a recent study (supported in part by the Agency for Health Care Policy and Research, HS07386), 71 percent of the patients coming to the ED for asthma said they had a physician outside of the ED that they saw regularly for their asthma. The study was carried out by Carol Blixen, Ph.D., R.N., and other researchers at the MEDTEP Center for Minority Research at the Henry Ford Health System in Detroit, MI; the MEDTEP Center is led by Barbara Tilley, Ph.D. The study's findings suggest that availability of health care alone is not sufficient to reduce the burden of asthma for blacks seen in the ED.

One-third of the ED patients studied had one to three asthma-related hospital admissions in the previous 3 months with protracted lengths of stay. About 63 percent had made one to three asthma-related visits to the ED in the preceding 3 months; 21 percent had used the ED four to six times; and 8 percent had made more than six ED visits. Yet in the prior 3 months, 54 percent had not spoken on the telephone with their doctor or nurse about asthma-related problems, and 46 percent had not seen an office- or clinic-based physician for their asthma.

In addition, only 46 percent of patients who visited the ED were regularly using antiinflammatory medication to prevent complications, although 71 percent were taking prescribed beta agonists. Only 58 percent of patients were familiar with a home peak flow meter—a device into which the patient blows to measure air outflow, which is used for early detection of asthma-related problems.

The results of this study suggest the need to educate both providers and patients, concludes Dr. Blixen. The study was based on questionnaires filled out by black patients 18 to 50 years of age who were treated in three Detroit-area EDs with a primary diagnosis of asthma in July 1995.

For more information, see "Quality of life, medication use, and health care utilization of urban African Americans with asthma treated in emergency departments," by Dr. Blixen, Dr. Tilley, Suzanne Havstad, M.S., and Edward Zoratti, M.D., in the November/December 1997 Nursing Research 46(6), pp. 338-341.

Rural teens are just as likely as urban teens to become pregnant

The first study of U.S. rural adolescent pregnancy dispels the myth that teenage pregnancy is an inner-city problem. In the Southeast, rural teenage girls are as likely as urban teens to get pregnant. The difference is that they are less apt to have an abortion if they do conceive. The study shows that the overall regional abortion rate was more than twice as high in urban than in rural areas (20 vs. 9 per 1,000 women). For instance, the abortion rate for rural black teens aged 15 to 17 was 13 per 1,000 vs. 30 per 1,000 among same-aged urban black teens. The figures for white rural teens 15 to 17 years of age was 12 per 1,000 and 18 per 1,000 for white urban teens.

As a result, rural white teens had a higher birthrate than their urban counterparts (38 vs. 29 per 1,000 for ages 15 to 17 and 106 vs. 78 per 1,000 for ages 18 and 19). Black rural women 18 or 19 years of age had a higher birth rate than same-aged black urban women (162 vs. 154 per 1,000). What's more, 32 percent of white rural women and 45 percent of black rural women aged 18 or 19 who became pregnant during the study had been pregnant before. Also, 5 percent of those 10 to 14 years of age who had a live birth in 1990 had been pregnant at least once previously, according to the study. The study was carried out by the Rural Health Center at the University of North Carolina at Chapel Hill and supported by the Agency for Health Care Policy and Research (contract 290-93-0038).

Pregnancy prevention programs in rural areas must begin by addressing the pervasive denial of the problem, according to the researchers. They used 1990 census data and data from an interstate collaborative network of maternal and child health analysts to calculate population-based rates of pregnancy, abortions, and births in eight Southeastern states: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee.

See "Rural adolescent pregnancy: A view from the South," by Trude Bennett, Dr.P.H., Julia DeClerque Skatrud, Dr.P.H., Priscilla Guild, M.S.P.H., and others, in the November 1997 Family Planning Perspectives 29, pp. 256-260, 267.

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HIV/AIDS Research

Preventing AIDS-related opportunistic infections is cost effective

Opportunistic infections that take advantage of the weakened immune systems of AIDS patients worsen their quality of life and hasten their death. Prophylactic medications can reduce the occurrence of many of these infections. Preventive therapy for Pneumocystis carinii pneumonia (PCP) is the most cost effective, followed by prophylaxis for Mycobacterium avium complex (MAC). Prophylaxis for cytomegalovirus (CMV) infection is the least cost effective, according to a study supported by the Agency for Health Care Policy and Research (HS07317). State-based AIDS Drug Assistance Programs in the United States should make PCP prophylaxis available to all patients. The next priority should be MAC prophylaxis, where azithromycin is most cost effective as first-line therapy.

Only when patients have access to those medications is it reasonable, from a cost-effectiveness perspective, to consider fluconazole and then perhaps oral ganciclovir for CMV, suggests Kenneth A. Freedberg, M.D., M.Sc., of Boston Medical Center and Boston University School of Medicine. Dr. Freedberg and colleagues at the Harvard School of Public Health and Yale School of Medicine developed a simulation model to compare different prophylactic strategies for these opportunistic infections using data derived from the Multicenter AIDS Cohort Study, randomized controlled trials, and the AHCPR-supported national AIDS Cost and Services Utilization Survey. They projected a quality-adjusted life expectancy of 39 months and average total lifetime costs of $40,288 for patients beginning with CD4 cell counts of 200 to 300. Once cell counts near 200 and below, the risk of opportunistic infections increases dramatically.

Prophylaxis for PCP and toxoplasmosis with trimethoprim-sulfamethoxazole for patients with CD4 cell counts of 200 or less increased quality-adjusted life expectancy to 43 months, implying an incremental cost of $16,000 per quality-adjusted life year (QALY) saved. Prophylaxis for MAC for patients with CD4 cell counts of 50 or less produced smaller gains in life expectancy. Incremental cost-effectiveness ratios were $35,000 per QALY saved for azithromycin and $74,000 per QALY saved for rifabutin. Oral ganciclovir for the prevention of CMV infection was the least cost effective ($314,000 per QALY saved).

Details are in "The cost-effectiveness of preventing AIDS-related opportunistic infections," by Dr. Freedberg, Julie A. Scharfstein, M.S., Sc.D., George R. Seage III, D.Sc., M.P.H., and others, in the January 14, 1998, Journal of the American Medical Association 279(2), pp. 130-136.

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AHCPR News and Notes

From the Administrator: Academic health centers have an important role in improving health services research and health care

The mission of the Agency for Health Care Policy and Research is to generate and disseminate information that improves the Nation's health care system. Academic health centers can play a critical role in helping the Agency fulfill its mission, says AHCPR Administrator John M. Eisenberg, M.D., in a recent commentary. He points out that academic health centers provide the talent needed to conduct health services research, a testing ground for clinical and health services research innovations, and training for the clinicians who will put into practice evidence-based medicine. They also are the ones who will train the next generation of health services researchers, which the Institute of Medicine estimates will be in short supply by the year 2000.

As Dr. Eisenberg notes, AHCPR has several programs that provide support for training new health services researchers. The Agency also collaborates with academic and research communities to create "centers of excellence" on particular diseases such as cancer or arthritis. AHCPR's 22 Patient Outcomes Research Team (PORT) projects are an excellent example of this kind of effort. They involve teams of researchers in large-scale, multi-year studies about what works best for specific common diseases and conditions.

Another example is the Agency's evidence-based practice initiative, which is being implemented in 12 new AHCPR-supported evidence-based practice centers (EPCs). Most of these EPCs are housed in academic health centers and produce comprehensive evidence reports on specific clinical conditions ranging from AIDS to Alzheimer's disease.

For more information, see "AHCPR: Providing the foundation for improving health care," by Dr. Eisenberg, in the January 1998 issue of Academic Medicine 73(1), pp. 68-69. Reprints (AHCPR Publication No. 98-R023) are available from the AHCPR Publications Clearinghouse.

Editor's Note: See the July 1997 issue of Research Activities and the November 1997 issue for more information on the EPCs. Select to access press releases on the announcement of 12 EPCs, first report topics, and topic nominations.

AHCPR announces availability of prevention materials

The Agency for Health Care Policy and Research recently launched "Put Prevention into Practice" (PPIP), a new initiative that can help clinicians, health plans, and consumers work together to make prevention—screening, immunizations, and counseling for health behavior change—a part of every health care visit, in every clinical setting. AHCPR is the new home for PPIP, which was developed by the Federal Office of Disease Prevention and Health Promotion.

Research has shown that prevention can help people stay healthier and live longer. However, we know that for various reasons—such as confusion due to conflicting recommendations and lack of time—clinicians may not be providing all the clinical preventive services their patients need. Furthermore, patients continue to ask for preventive services that have been found to be ineffective or to have unproven benefits.

PPIP is the tool that will be used to move evidence-based findings about prevention—such as those developed by the U.S. Preventive Services Task Force—into the settings where patients receive their health care. PPIP materials are designed to make it easier for systems of care, clinicians, and their office staffs to deliver recommended prevention services and to perform them properly. The PPIP consumer materials help patients ask about and keep track of their preventive health care.

Research clearly shows the need for improvements in the provision of preventive care. In 1997 the National Committee for Quality Assurance released a report showing a wide range of performance by health maintenance organizations and other managed care plans nationwide in the delivery of preventive services and other health care. For example, the report shows that in 1996, 81 percent of New England children under age 2 received appropriate immunizations, but in the Mountain region the rate was only 59 percent. Health plans in the Mid-Atlantic region reported mammography screening ranging from 30 percent to 80 percent. Also, patients in some plans received advice to quit smoking as infrequently as 30 percent of the time; in other plans, stop-smoking advice was given as often as 85 percent of the time.

The PPIP materials were developed and evaluated with the cooperation of numerous public and private institutions, including the 31 members of the National Coordinating Committee on Clinical Preventive Services, Federal liaisons to the Committee, other Federal agency experts, and many other contributors from academic institutions, State departments of health, professional groups, and voluntary organizations.

The Clinician's Handbook of Preventive Services, 2nd Edition, includes summaries of recommendations on screening tests, immunizations, and counseling for children/adolescents and adults/older adults by major authorities, including the U.S. Preventive Services Task Force, Federal health agencies, national professional organizations, national voluntary health organizations, and the Canadian Task Force on the Periodic Health Examination. Instructions for performing the services are included, along with other information that will facilitate implementation of prevention in health care settings. Office materials include patient chart flow sheets, patient reminder postcards, a waiting room poster, and prevention care timeline posters.

The Clinician's Handbook of Preventive Services, 2nd Edition and the posters may be purchased from the Government Printing Office. Select to access online ordering information.

Two pocket-sized booklets—the Personal Health Guide for Adults (AHCPR Publication No. 98-0027) and the Child Health Guide (AHCPR Publication No. 98-0026)—include easy-to-use record forms to prompt patients to receive and keep track of timely care. These booklets are available free from the AHCPR Publications Clearinghouse.

The Personal Health Guide is available online. The Clinician's Handbook will be available in the near future.

Register now for AHCPR's second conference on evidence-based practice

The Agency for Health Care Policy and Research will host "Translating Evidence into Practice '98," July 27-29, 1998 at the Renaissance Washington Hotel, Washington, DC. For the latest information about the conference, call Hope Levy Kott at (301) 770-3153.

This second annual conference on evidence-based practice is being sponsored by AHCPR's Center for Practice and Technology Assessment. Conference participants will explore how health care research informs practitioner and consumer decisionmaking, as well as health policy development. Sessions will cover methodologies for synthesizing knowledge into products, strategies to enhance the usefulness of research evidence, and implementation strategies to achieve quality outcomes. The 3-day meeting will feature a dozen sessions that will be of particular interest to health care providers, educators, managers, policymakers, health services researchers, evidence-based guideline users and developers, and State and local health planners.

Early registration closes June 15. To register, contact Hope Levy Kott, Conference Management Group, Technical Resources International, Inc., 3202 Tower Oaks Boulevard, Rockville, MD 20852; phone: (301) 770-3153; fax: (301) 468-2245; E-mail: confdept@tech-res.com.

AHCPR invites guidelines for public/private clearinghouse

The Agency for Health Care Policy and Research is inviting health care organizations as well as other public- and private-sector entities to submit their clinical practice guidelines for inclusion in the National Guideline Clearinghouse™ (NGC), a comprehensive electronic data base. The request appeared in the Federal Register for April 13.

The NGC Web site will provide users with a science-based shortcut that offers one-stop access to thousands of clinical practice guidelines for anyone within reach of a computer. With guideline summaries in a standardized format, this unique resource will allow users to compare and contrast guideline recommendations on similar topics, according to AHCPR Administrator John M. Eisenberg, M.D.

The Clearinghouse was developed in partnership with the American Medical Association (AMA) and the American Association of Health Plans (AAHP) to promote widespread access to guidelines.

The NGC will make clinical practice guidelines available to the public via the World Wide Web, beginning in the fall of 1998. Each guideline entry in the NGC will include a structured abstract that describes how it was developed, a comparison of guidelines on similar topics, either the full text of the guideline or electronic links to the full text, and information on how to obtain the guideline. To be included in the NGC, guidelines must meet the following criteria:

1. The clinical practice guideline contains systematically developed statements that include recommendations, strategies, or information that assists physicians and/or other health care practitioners and patients in making decisions about appropriate health care for specific clinical circumstances.
2. The clinical practice guideline was produced under the auspices of medical specialty associations; relevant professional societies; public or private organizations; government agencies at the Federal, State, or local level; or health care organizations or plans. A clinical practice guideline developed and issued by an individual not officially sponsored or supported by one of the above types of organizations does not meet the inclusion criteria for the NGC.
3. Corroborating documentation can be produced and verified that a systematic literature search and review of existing scientific evidence published in peer reviewed journals was performed during guideline development. A guideline is not excluded from the NGC if corroborating documentation can be produced and verified detailing specific gaps in scientific evidence for some of the guideline's recommendations.
4. The guideline is English language, current, and the most recent version produced. Documented evidence can be produced or verified that the guideline was either developed, reviewed, or revised within the last 5 years.

The NGC will receive guidelines on an ongoing basis. If your organization is interested in submitting a guideline, please contact Vivian Coates, ECRI, NGC Project Director, 5200 Butler Pike, Plymouth Meeting, PA 19462-1298.

Select for the complete text of the Federal Register notice.

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