Components of Prenatal Care and Low
Birthweight
Grant/Contract Number: HS06785
Project Period: 08/91-04/93
Principal Investigator: Shirley A. Beresford, Ph.D.
Institution: University of Washington
Seattle, WA 98195
Purpose: To provide information on the relative effectiveness of
different components of care in preventing poor pregnancy
outcomes. The study verified or revised components of care by
using a modified Delphi technique. A population based case
control study was carried out to compare medical/obstetrical,
behavioral, social, and nutritional components of prenatal care.
The results led to a better understanding of the preventive role
of prenatal care.
Measuring Outcomes and Costs in High Risk
Obstetrics
Grant/Contract Number: HS08830
Project Period: 08/95-07/96
Principal Investigator: Susan Berman, M.D.
Institution: Brigham and Women's Hospital
Boston, MA 02115
Purpose: To develop tools to quantitate initial obstetric risk
upon entry to a perinatal center. The study also examines the
utility of an established newborn severity of illness score, the
Score for Neonatal Acute Physiology (SNAP), as an obstetric
outcome measure. By characterizing initial risk and validating
an outcome measure that reflects the immediate condition of the
newborn, this project will provide tools for comparison of high
risk obstetric services, identification of effective practice
styles, and evaluation of resource use.
Effectiveness of Prenatal Care: Two
Approaches
Grant/Contract Number: HS06605
Project Period: 08/90-05/92
Principal Investigator: Betsy J. Brach, Ph.D., M.S.N., M.P.H.
Institution: Johns Hopkins University
Baltimore, MD 21205
Purpose: To determine the extent to which comprehensiveness,
continuity, and coordination in the delivery of prenatal care
affect maternal and infant morbidity. The study used a sample
consisting of low income pregnant women who were given perinatal
care according to two different approaches, namely, the
traditional medical model of specialty care and the
multidisciplinary team approach. By identifying effective
approaches and remaining gaps in patient care delivery, the study
provided information to policy makers and planners for continuing
development of maternal and child health programs.
Hospital and Regional Factors in C-Section
Rate
Variations
Grant/Contract Number: HS06642
Project Period: 03/91-02/93
Principal Investigator: Laura B. Gardner, M.D., Ph.D., M.P.H.
Institution: Axiomedics Research, Inc.
Los Altos, CA 94022-3611
Purpose: To assess the relationship between hospital and
regional characteristics and variations in Caesarean section
rates in California. The study analyzed 5 years of California
hospital discharge abstract data, hospital specific data, and
regional data. It observed changes in regional, hospital, and
patient related variables over time. Because it used pooled
cross sectional and time series data, the study minimized the
problem of multicollinearity among the independent variables.
Low Birthweight in Minority and High Risk
Women (PORT)
Grant/Contract Number: 282-92-0055
Project Period: 09/92-09/97
Principal Investigator: Robert L. Goldenberg, M.D.
Institution: University of Alabama
Birmingham, AL 35233-7333
Purpose: To (1) identify and understand practice variations
prior to and during pregnancy that aim to prevent low birthweight
and related negative sequelae; (2) determine the overall
effectiveness of different practices by examining their
association with pregnancy outcomes; and (3) develop and
disseminate clinical, client, and care system recommendations to
maximize improvements in the use of effective practices for
minority and high risk women.
Decision Making in Prenatal Genetic
Testing
Grant/Contract Number: HS06945
Project Period: 09/93-08/96
Principal Investigator: Paul S. Heckerling, M.D.
Institution: University of Illinois
Chicago, IL 60680
Purpose: To determine the value perceived by patients and
physicians for the outcomes that follow prenatal diagnostic
testing (chorionic villus sampling and amniocentesis), and to
understand how these values affect their decision making. Linear
rating scales will be used to assess patients' and physicians'
values. Sociodemographic, obstetric, and health care provider
data will be analyzed in relationship to formal decision analytic
models.
The Impact of Specialty on Caesarean Section
Rates
Grant/Contract Number: HS07012
Project Period: 01/92-09/93
Principal Investigator: William J. Hueston, M.D.
Institution: Eau Claire Family Medicine Clinic
Eau Claire, WI 54701-3832
Purpose: To expand on the hypothesis that Caesarean section
rates differ for family physicians and obstetricians by examining
physician specialty along with other variables that are known to
influence Caesarean section rates. Maternal and neonatal
outcomes for patients of varying risk status were compared
between the two specialties to determine if physician specialty
influences the quality of obstetric care. Differences in
Caesarean section rates between family physicians and
obstetricians may suggest alterations in physician training,
which may be useful in curtailing the rapid rise in Caesarean
section rates.
Variations in Management of Childbirth and
Patient Outcomes
(PORT)
Grant/Contract Number: 282-90-0039
Project Period: 09/90-09/96
Principal Investigator: Emmett Keeler, Ph.D.
Institution: RAND
Santa Monica CA 90401-2138
Purpose: To (1) examine the use and outcomes of Caesarean
section versus its alternatives (oxytocin, trial of labor, normal
and assisted vaginal delivery); (2) analyze variations and
correlates of specific diagnostic and treatment procedures
utilized in the course of labor and delivery; and (3) develop
clinical recommendations and a series of interventions for
disseminating information to distinct audiences of patients and
physicians. Final steps include evaluating the impact of these
interventions on practice and preparing public use data files to
support further research.
The Effects of Rural Obstetric Care Provider
Shortages
Grant/Contract Number: HS07321
Project Period: 07/92-12/94
Principal Investigator: Wayne A. Ray, Ph.D., M.S.
Institution: Vanderbilt University
Nashville, TN 37232-2637
Purpose: To test the hypothesis that women residing in rural
areas with obstetric care provider shortages receive less
prenatal care and have more adverse pregnancy outcomes than other
women. The study used data from a statewide review of primary
health care services, a linked vital records maternal Medicaid
enrollment database, and the Perinatal Risk Factor Surveillance
Program database. It explored risk factors associated with
adverse perinatal outcomes, such as maternal life style, maternal
medical problems, complications of labor and delivery, transport
of mother and infant, and newborn complications.
Practice Variations in Prenatal and
Intrapartum Care
Grant/Contract Number: HS06166
Project Period: 07/89-06/93
Principal Investigator: Roger A. Rosenblatt, M.D., M.P.H.
Institution: University of Washington
Seattle, WA 98195
Purpose: To study the variations in obstetrical care for women
with low risk pregnancies in Washington State. The dependent
variables in this study were the charges (as a proxy for cost)
associated with the prenatal and obstetric protocols; the
independent variables included the training and experience of
physician or midwife attending the birth, the characteristics of
the birth setting, the malpractice experience of the provider,
and the characteristics of the patient.
This study contributed information to reduce the cost of routine
obstetrical care for women with low risk pregnancies without
impairing patient outcomes.
A Prospective Study of an Out-Of-Hospital
Birth Center
Grant/Contract Number: HS07161
Project Period: 09/93-09/97
Principal Investigator: William H. Swartz, M.D.
Institution: Primary Care Perinatal Services, Incorporated
San Diego, CA 92103
Purpose: To evaluate whether the out of hospital birth center
model is a safe and cost effective alternative for the delivery
of prenatal and perinatal services for underserved, low income
women. The study assesses the maternal and infant outcomes and
costs of care at the out of hospital birth center and compares
them with the traditional model using physician providers and
hospital delivery. Data are being collected primarily through
medical and financial record abstraction and questionnaires. The
findings of this study could have significant implications for
the delivery of perinatal services nationwide. Study subjects
primarily are low risk, Medicaid-eligible, Hispanic women.
Determinants of Oral Health in Older
Persons
Grant/Contract Number: HS07084
Project Period: 07/91-06/96
Principal Investigator: Ronald M. Andersen, Ph.D.
Institution: University of California
Los Angeles, CA 90024-1772
Purpose: To provide a description and better understanding of
the oral health status of older persons by employing a generic
model of health service use and health status and by using
findings from the gerontological and dental care literature. The
results of this study will be used to suggest policies to improve
the oral health status of older persons in general as well as
specific groups of this population with special problems.
Evaluation of Guidelines for Prescribing
Dental X-Rays
Grant/Contract Number: HS06670
Project Period: 08/90-07/94
Principal Investigator: Kathryn A. Atchison, D.D.S., M.P.H.
Institution: University of California
Los Angeles, CA 90095-1668
Purpose: To assess the effectiveness of clinical guidelines for
ordering selected radiographs to detect dental disease. Using a
blinded comparison group study design, the study evaluated
whether clinical application of these guidelines reduced patient
exposure and whether their use introduced unacceptable levels of
undiagnosed disease. The results of this experiment enhanced
the refinement of selection criteria for ordering dental
radiographs and may thereby lead to a substantial savings in
patient exposure.
Clinical Performance Measures for Dental Care Plans
Grant/Contract Number: HS09453
Project Period: 09/96-09/98
Principal Investigator: James D. Bader, D.D.S.
Institution: University of North Carolina
Chapel Hill, NC 27599-7450
Purpose: To describe the development and evaluation of clinical performance measures with
which to assess the provision of dental care. The measures will assess outcomes of the prevention
and treatment of the two major dental diseases, dental caries, and periodontal diseases. The
development of a comprehensive set of standardized, tested measures will permit valid
comparisons of managed care plan performance as well as to strengthen plans' internal quality
improvement activities.
A New Multicarrier Database for Dental Care Evaluation
Grant/Contract Number: HS06786
Project Period: 07/91-06/95
Principal Investigator: William J. Hayden, Jr., D.D.S., M.P.H.
Institution: University of Missouri
Kansas City, MO 64108-2795
Purpose: To develop a multipayer database from dental claims data provided by an electronic
claims service company and to investigate its usefulness for dental health services research. The
purpose of the database was to examine provider and practice variation of charges and to explore
provider treatment behaviors.
Developing a Dental Implant Patient Satisfaction Survey
Grant/Contract Number: HS06826
Project Period: 07/91-06/93
Principal Investigator: Mary A. Tavares, D.M.D., M.P.H.
Institution: Forsyth Dental Center
Boston, MA 02115
Purpose: To develop and validate a self-reporting instrument to assess patient satisfaction with
dental implant procedures and outcomes. The validation consisted of (1) a review of the survey
by clinical and measurement experts; (2) a prepilot study of a small group of implant patients;
(3) a revised draft of the instrument that will be used in a large-scale pilot study; and (4) a factor
analysis that will be used to determine which items are the strongest predictors.
Diabetic Retinopathy Education Study
II
Grant/Contract Number: HS06798
Project Period: 04/91-09/93
Principal Investigator: Lawrence P. Chong, M.D.
Institution: Doheny Eye Institute
Los Angeles, CA 90033
Purpose: To evaluate the effectiveness of five different
educational strategies in improving primary care physicians'
ability to recognize vision threatening diabetic retinopathy. By
increasing the physicians' awareness, it is believed that the
number of new cases of legal blindness may be decreased through
education and early detection. The educational process
included one or more of the following: independent study
materials, slide script program, and direct ophthalmoscopy on
model eyes. A randomized multicentered evaluation was
conducted.
Diabetic Retinopathy Education Study
I
Grant/Contract Number: HS06799
Project Period: 04/91-09/93
Principal Investigator: Howard P. Cupples, M.D.
Institution: Georgetown University Medical Center
Washington, DC 20007
Purpose: To evaluate the effectiveness of educational strategies
in improving primary care physicians' ability to recognize
vision-threatening diabetic retinopathy and to develop a
standardized educational program. The study tested the
hypothesis that through the proposed education, more physicians
will appropriately refer patients with diabetic retinopathy. A
multicenter investigation compared the effect of five educational
strategies on the diagnostic accuracy, clinical knowledge, and
practice patterns of groups of physicians. The cost
effectiveness of each strategy also was evaluated.
Variations in the Management and Outcomes of
Diabetes
(PORT)
Grant/Contract Number: HS06665
Project Period: 09/90-03/96
Principal Investigator: Sheldon M. Greenfield, M.D.
Institution: New England Medical Center
Boston, MA 02111
Purpose: To develop a comprehensive, prospective, longitudinal
database that is tailored to the special requirements for
addressing the medical effectiveness questions related to type 2
diabetes. The database will monitor the costs, quality, and
outcomes of care for patients with type 2 diabetes in three
large health care delivery organizations. The study utilizes a
quality of life scale to measure the medical effectiveness, as
well as study the financial costs to the health system and to the
patient. The results will then be translated into intervention
strategies that target change in physician behaviors with respect
to utilization, expenditures, and ultimately, increased quality
of care for the patient.
Research in Trauma Outcomes Using the MTOS Database
Grant/Contract Number: HS06721
Project Period: 07/91-01/94
Principal Investigator: Howard R. Champion, F.R.C.S., F.A.C.S.
Annapolis, MD 21403
Purpose: To use, for outcomes research, data collected at selected sites for the Major Trauma
Outcome Study (MTOS). Controlled site data were used to (1) evaluate TRISS norms and
compare TRISS and ASCOT outcome predictions; (2) determine the effect of preinjury illness on
outcome; and (3) develop relationships for predicting the occurrence of serious complications, for
patient disability at discharge from acute care, and for lengths of stay in hospitals and in the
intensive care units. The MTOS database enabled outcomes-related research to extend and
improve institutional care evaluations and quality assurance and to identify an improved basis for
trauma care reimbursement.
Head Injury Outcome
Grant/Contract Number: HS06497
Project Period: 08/91-07/95
Principal Investigator: Sureyya S. Dikmen, Ph.D.
Institution: University of Washington
Seattle, WA 98195
Purpose: To study the determinants of head injury outcome and
the factors that predict outcomes. Factors examined were
severity of head and other system injuries, preexisting
conditions, and basic demographics. The study examined the
sensitivity of the Abbreviated Injury Scale and the Injury
Severity Score—scales developed for major trauma—to
central nervous system injury. Secondary analyses based on three
longitudinal studies of head injury outcome were conducted. The
study also examined the reliability of neuropsychological tests
used to assess head injury outcomes.
Assessing the Technology of CPR Strategies:
A Randomized
Trial
Grant/Contract Number: HS08197
Project Period: 04/94-03/98
Principal Investigator: Alfred P. Hallstrom, Ph.D.
Institution: University of Washington
Seattle, WA 98105
Purpose: To determine whether a simplified form of
cardiopulmonary resuscitation (CPR) instruction (involving the
use of chest compressions only) provided by the dispatcher to the
person calling to report a potential cardiac arrest provides
greater survival rates than ABC instructions (involving airway,
breathing, and chest compression). A positive answer (1) would
prove that bystander CPR directly affects survival rates, (2)
would reduce the burden on the dispatcher by simplifying and
shortening the interaction with the caller while providing better
outcome, and (3) could have public health implications vis a vis
the concern about transmission of AIDS. Each episode is assigned
randomly, and paramedic field reports are reviewed.
Prospective Study of Functional Limitation
After
Trauma
Grant/Contract Number: HS07611
Project Period: 08/93-07/98
Principal Investigator: Troy L. Holbrook, Ph.D.
Institution: University of California
San Diego, CA 92103-8213
Purpose: To determine the incidence and determinants of
functional limitation after major trauma by using the
computerized San Diego County Regional Trauma System Registry
trauma patient database to identify patients for followup. A
questionnaire will be administered at 3 month intervals following
treatment at an emergency department. The study will also
determine the strength and independence of individual predictors
of functional limitation. This information will help facilitate
appropriate interventions for trauma patients dependent on their
predictors of functional limitation.
Outcomes Following Minor Head and Abdominal Trauma
Grant/Contract Number: HS07336
Project Period: 08/94-07/97
Principal Investigator: David H. Livingston, M.D.
Institution: University Hospital-New Jersey Trauma Center
Newark, NJ 07103-2406
Purpose: To evaluate the current practice of mandatory hospitalization for observation only,
following two specific types of injury: minimal closed head injury and blunt abdominal trauma;
and to develop practice guidelines that could reliably exclude significant injuries without
hospitalization. Attainment of these objectives will allow patients to be safely discharged from the
emergency department without hospital admission and result in a better utilization of health care
resources for these types of injuries. Prospective evaluations of the standard diagnostic workup,
construction of a diagnostic algorithm, and patient followup are being conducted.
Rural Emergency Medical Services and Trauma
Outcomes
Grant/Contract Number: HS06814
Project Period: 01/93-09/94
Principal Investigator: Michael A. Morrisey, Ph.D.
Institution: University of Alabama
Birmingha, AL 35294-2010
Purpose: To study the effects of the rural hospital emergency
department, the elements of the time to definitive treatment, and
the relative use of advanced life support versus basic life
support trained ambulance personnel on the outcomes of patients
suffering traumatic injuries in rural areas. The project
provided a multivariate statistical analysis of the likelihood of
trauma survival. It also described the clinical and demographic
characteristics of rural trauma patients, the types and frequency
of prehospital services provided, and the types of hospitals
used. The results provided insight on the advisability of
programs to promote the use of advanced life support personnel on
rural ambulances and transport protocols for rural trauma
victims. Ambulance trip data from rural Georgia in 1991 were
used.
Clinical Standards and Quality/Cost of
Emergency Care
Grant/Contract Number: HS06284
Project Period: 02/91-01/94
Principal Investigator: David L. Schriger, M.D., M.P.H.
Institution: University of California
Los Angeles, CA 90024-2924
Purpose: To develop a computerized charting system containing
clinical algorithms for five common problems (convulsions,
lacerations, back pain, pediatric fever, and exposure of health
care workers to body fluids) and to test for their effects on the
process, outcomes, and cost of care. The study tested the
hypothesis that the computerized charting system improves the
quality of care, reduces the cost of emergency care, and provides
education for physicians in training.
Sestamibi for ED Triage for Suspected Cardiac Ischemia
Grant/Contract Number: HS09110
Project Period: 08/96-07/99
Principal Investigator: Harry P. Selker, M.D., M.S.P.H.
New England Medical Center
Boston, MA 02111
Purpose: To assess the impact of Tc99m-sestamibi scanning on emergency department (ED)
triage decisions, that is, the degree to which those ED patients with acute cardiac ischemia (ACI)
are hospitalized and those without ACI are not hospitalized. This proposed multicenter
prospective controlled clinical trial will evaluate the ED use of sestamibi scanning to aid ED triage
of patients presenting with symptoms suggestive of ACI who have normal or nondiagnostic
electrocardiograms. The study will also assess the impact of the use of sestamibi scanning on
actual hospital costs.
Emergency Medicine Diagnostic and Treatment Units
Grant/Contract Number: HS07103
Project Period: 04/92-07/97
Principal Investigator: Robert J. Zalenski, M.D., M.A.
Institution: University of Illinois
Chicago, IL 60612
Purpose: To test whether an Emergency Diagnostic and Treatment Unit can provide equal or
improved quality of care and is a cost-effective alternative to hospital admission for two major
conditions: the diagnosis of low-risk cardiac chest pain and the treatment of acute asthma. This
study also aims to enable the establishment and utilization of such units by disseminating the
clinical, operational, and cost-effectiveness findings to physicians and
reimbursement agencies.
Cataract Extraction: An International
Comparison
Grant/Contract Number: HS07085
Project Period: 08/91-01/96
Principal Investigator: Gerard F. Anderson, Ph.D.
Institution: Johns Hopkins University
Baltimore, MD 21205
Purpose: To expand the U.S. PORT study of cataract management to
Manitoba, Canada; Denmark; and Barcelona, Spain. Collection of
parallel data will permit international comparisons of practice
patterns, physician attitudes and beliefs, patient expectations,
and outcomes.
Value of Medical Testing Prior to Cataract
Surgery (PORT II)
Grant/Contract Number: HS08331
Project Period: 09/94-08/98
Principal Investigator: Oliver D. Schein, M.D., M.P.H.
Institution: Johns Hopkins Hospital
Baltimore, MD 21287 9019
Purpose: To test the hypothesis that routine preoperative
medical laboratory testing for cataract surgery is not cost
effective and may provide no health benefit. This study will
randomize a large cohort of cataract surgical patients to receive
or not receive a routine battery of preoperative laboratory
tests. It is (1) comparing the rates of postoperative adverse
events in two groups, (2) assessing the cost effectiveness of a
routine battery of preoperative medical tests, and (3) developing
a practice guideline on the appropriate use of medical tests
before cataract surgery that is endorsed by the principal
relevant medical societies.
Variations in Cataract Management: Patient and Economic Outcomes (PORT)
Grant/Contract Number: HS06280
Project Period: 09/89-02/95
Principal Investigator: Earl P. Steinberg, M.D., M.P.P.
Institution: Covance Health Economics and Outcomes Services, Inc.
Washington, DC 20005-3934
Purpose: To (1) document variation in clinical outcomes, patient functioning, patient satisfaction,
and health care costs as a function of alternative strategies for cataract management; (2) define
"appropriate" or "optimal" management strategies for different categories of cataract patients; and
(3) develop a policy-relevant decision model and clinical recommendations. To achieve these
aims, the project's multidisciplinary team used four major data sources, namely, the clinical
literature, Medicare claims data, a national survey of ophthalmologists, and surveys of patients
and ophthalmologists in four geographic areas.
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