This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://info.ahrq.gov. Let us know the nature of the problem, the Web address of what you want, and your contact information.
Please go to www.ahrq.gov for current information.
Balas, E.A., Stockham, M.G., Mitchell, J.A., and others
(1995, October). "The Columbia registry of information and
utilization management trials." (AHCPR grant HS07715). Journal
of the American Medical Informatics Association 2(5), pp.
307-315.
The authors describe the development of The Columbia Registry of
Information and Utilization Management Trials. The Registry
located, registered, and abstracted 600 reports from 24 countries
on randomized controlled trials that examined management
interventions—ranging from patient or physician education to
telephone followup, patient or physician reminders, and home care
services—their effects on the process and/or outcomes of
patient care. Frequently reported effects included
hospitalization rate, length of stay, and immunization and
mortality rates. The registry has been used already for several
meta-analyses, for example, assessing the clinical value of a
physician reminder in increasing compliance with cervical cancer
screening and tetanus immunizations. Conventional abstracts by
investigators provide useful synopses but lack the detail and
standardization provided by the Columbia Registry, according to
the authors.
Barry, M.J., Fowler, F.J., Chang, Y., and others (1995,
September). "The American Urological Association symptom index:
Does mode of administration affect its psychometric properties?"
(AHCPR grants HS06336 and HS08397). The Journal of Urology 154, pp. 1056-1059.
The American Urological Association (AUA) symptom index is a
seven-item questionnaire designed to measure the severity of
lower urinary tract symptoms among men with benign prostatic
hyperplasia (BPH). It was designed to be self-administered and
has been validated as such. However, some men who are visually
impaired or illiterate cannot complete the index by themselves.
This study compared self-administration and interviewer
administration to 41 visually impaired or illiterate men. There
was no significant difference between group mean scores. The
researchers conclude that, although the AUA symptom index should
be self-administered when possible, interviewer administration
appears to be acceptable.
Carlson, B.L., Kemper, P., and Murtaugh, C.M. (1995).
"Constructing a lifetime nursing home use data base from a sample
of discharges." Journal of Economic and Social Measurement 21, pp. 187-211.
This paper, authored by researchers formerly with the Agency
for Health Care Policy and Research's Center for Health Insurance
and Expenditure Studies, describes the method used to select and
re-weight discharge data from the 1985 National Nursing Home
Survey so that the data represent a sample of decedents who used
nursing homes at some point during their lives. The derived
sample greatly expands the amount of information on lifetime
nursing home use available to include information on the full
distribution of use, its timing, and the source of payment at the
beginning and end of episodes. An important part of the
information is based on facility records, which are supplemented
by information obtained from the decedent's next-of-kin. Analysis
of the derived sample showed that 68 percent of decedents who
used nursing homes were either discharged dead, or died on the
day of discharge, and were represented directly in the discharge
sample. Another 25 percent died within a year of discharge and
were represented after a minor adjustment to the weights. Only
the remaining 7 percent of decedents, who used a nursing home but
not in the last year of life, were imperfectly represented in the
derived sample. Estimates of lifetime nursing home use from this
derived sample were similar to those from the Mortality
Followback Survey. However, changes in both surveys could be made
to improve the ability to address questions concerning lifetime
nursing home use.
Colditz, G.A., Burdick, E., and Mosteller, F. (1995).
"Heterogeneity in meta-analysis of data from epidemiologic
studies: A commentary." (AHCPR grant HS05936). American
Journal of Epidemiology 142(4), pp. 371-382.
Epidemiologic studies that appear to be similar in design can
vary greatly in results (heterogeneity). The authors of this
paper review the approaches taken to identify, deal with, and
interpret heterogeneity in meta-analyses of epidemiologic data
and suggest methods that may be used in future studies. They
emphasize quantifying and reporting the magnitude of among-study
variance and using meta-analysis to describe factors that
contribute to variation among study results. They cite two
examples showing that analysts sometimes identify heterogeneity
and deal with it by excluding studies until a satisfactory degree
of homogeneity is achieved. Researchers sometimes exclude 25
percent of the data and still generalize to the total
population.
Cooper, J.K. (1995). "Accountability for clinical preventive
services." Military Medicine 160(6), pp. 297-299.
In this paper, James K. Cooper, M.D., of AHCPR's Center for
Primary Care Research, reviews civilian approaches to
accountability for clinical preventive services and suggests a
possible approach for military systems. He evaluates four
civilian accountability models: DEMPAQ, a program developed for
Medicare that collects data both from claims records and from
office medical records; PROSPER, which uses patient
questionnaires to collect information; HEDIS, which produces
"report cards" on health care services and relies on
administrative data generally available in managed care
organizations; and Passports, a developmental program. None of
these civilian models is directly applicable to today's military
care system, according to Dr. Cooper. However, adding a
preventive services module to the Composite Health Care
System, a computer system widely used in military treatment
facilities, is one way to provide accountability for clinical
preventive services within military health care systems, and
probably would lead to higher adherence to recommended standards.
Cooper, J.K. (1995). "Managed care and rural America." The
Journal of Family Practice 41(2), pp. 115-117.
In this essay, James K. Cooper, M.D., of the Center for
Primary Care Research, Agency for Health Care Policy and
Research, discusses trends in rural health maintenance
organization (HMO) growth and the forces stimulating this growth:
efforts to preserve or increase availability of health care
services, expansion of urban managed care organizations (MCOs) to
adjacent rural communities, and pressure on States to control
Medicaid costs. Dr. Cooper also points out the advantages and
disadvantages of physician participation in rural managed care
and discusses the legal issues involved in joining or
establishing managed care networks in rural areas.
Dikmen, S.S., Machamer, J.E., Donovan, D.M., and others
(1995). "Alcohol use before and after traumatic head injury."
(AHCPR grants HS04146, HS05304, HS06497). Annals of Emergency
Medicine 26(2), pp. 167-176.
University of Washington researchers studied 197 hospitalized
adult head-injury survivors at a trauma center and followed them
for 1 year. They found that pre-injury alcohol abuse was
frequent, with 42 percent of the patients legally intoxicated
while in the emergency department (ED). Forty-five percent of the
head-injured patients reported two or more problems with alcohol
prior to their injury, such as missing work or inability to stop
drinking. About 25 percent of patients had been arrested for
driving while intoxicated. Alcohol problems had decreased sharply
1 month after injury, but after 1 year, drinking was almost to
the level of the year preceding injury. During the immediate post
injury period, patients often lack access to alcohol (are in the
hospital or living with family), are rethinking their lifestyle,
and are advised to stop drinking to minimize the chance of
posttrauma seizures. This period may be a natural window of
opportunity in which to treat alcohol problems, according to the
researchers. In this study, patients who received treatment for
alcohol abuse after head trauma decreased the amount they drank
per sitting from 6.4 to 3.0 drinks compared with 3.5 to 2.0
drinks for patients who did not receive treatment.
Farrow, D.C., Hunt, W.C., and Samet, J.M. (1995, September).
"Biased comparisons of lung cancer survival across geographic
areas: Effects of stage bias." (AHCPR grant HS06897).
Epidemiology 6, pp. 558-560.
This paper illustrates the phenomenon of stage bias as it
affects comparative analyses of lung cancer survival across
geographic areas in the United States included in the
Surveillance, Epidemiology, and End Results (SEER) Program of the
National Cancer Institute. The SEER Program collects demographic
and clinical data on all incident cancers diagnosed in nine
regions of the United States. The researchers examined the stage
distributions of lung cancer cases (local, regional, metastatic,
and all others), and calculated the proportion of local stage
cases receiving surgery for each SEER area. They found that there
was marked variability between the SEER areas in both 1- and
3-year survival following the diagnosis of local stage lung
cancer. In SEER areas where more local-stage surgery was
performed, the surgery provided an opportunity to identify
regional and metastatic disease and remove those cases from the
local stage group. These findings illustrate that patients within
a stage category will not be homogeneous with respect to extent
of disease, if staging is accomplished more aggressively
(identified by surgery) in one geographic area than in another.
As a result, stage-specific survival differences across
geographic areas may be artifactual.
Fine, M.J., Hanusa, B.H., Lave, J.R., and others (1995).
"Comparison of a disease-specific and a generic severity of
illness measure for patients with community-acquired pneumonia."
(AHCPR grant HS06468). Journal of General Internal
Medicine 10, pp. 359-368.
This study compares the accuracy of the pneumonia severity of
illness index (PSI) with a generic measure of severity of illness
for identifying illness severity in patients with
community-acquired pneumonia. The researchers retrospectively
studied adult patients in 78 Medisgroups Comparative Database
hospitals. Results showed that 14,199 patients had
community-acquired pneumonia, and nearly 11 percent died during
hospitalization. Compared with the generic severity measure, the
PSI more accurately identified patients at extremely low risk of
death (low outliers). Among the 11 low-outlier hospitals, six
patients were classified by the generic severity measure alone,
two by the PSI alone, and three by both systems. Among the six
high-outlier hospitals, one patient was classified by the generic
measure alone, three by the PSI alone, and two by both systems.
The authors conclude that the PSI more accurately estimated
hospital mortality and classified different hospital outliers for
mortality than the generic severity of illness measure for
patients with community-acquired pneumonia.
Friedman, B., and Elixhauser, A. (1995). "The changing
distribution of a major surgical procedure across hospitals: Were
supply shifts and disequilibrium important?" Health
Economics 4, pp. 301-314.
In this paper, researchers with the Agency for Health Care
Policy and Research's Center for Delivery System Research
describe and analyze the changes in performance of total hip
replacement (THR) among U.S. hospitals from 1980 to 1987. Using
data for all hip replacement patients in a large sample of
hospitals, the researchers found that hospitals where a large
number of hip replacements were performed did not have a higher
percentage of older, sicker, and lower income patients. Moreover,
there was little evidence that hospitals responded to financial
incentives inherent in the Medicare payment system after 1983 to
select among hip replacement candidates in favor of those with
below-average expected costs. The observed increased
concentration over time of hip replacement procedures in
hospitals with a high volume of THRs did suggest plausible demand
shifts towards hospitals with a priori quality and cost
advantages or hospitals that obtained those advantages with a
high volume of patients.
Gold, M., and Wooldridge, J. (1995). "Surveying consumer
satisfaction to assess managed-care quality: Current practices."
(AHCPR contract 282-91-0027). Health Care Financing Review 16(4), pp. 155-173.
A growing number of managed care health plans are using
consumer surveys to monitor and improve the quality of care they
deliver and to promote informed consumer choice. However, there
is no consensus on survey content or approach. This article
synthesizes information about consumer satisfaction surveys
conducted by managed care plans, government and other agencies,
community groups, and purchasers of care. The authors discuss
survey content, methods, and use of consumer survey information.
The content of instruments appears to be better developed than
the methods for using them. The researchers conclude that
differences in the use of consumer surveys preclude one
instrument or methodology from meeting all needs. They suggest
that the effectiveness of plan-based surveys could be enhanced by
increased information on alternative survey instruments and
methods and new methodological studies.
Greene, V.L., Lovely, M.E., Miller, M.D., and Ondrich, J.I.
(1995). "Reducing nursing home use through community long-term
care: An optimization analysis." (AHCPR grant HS06757).
Journal of Gerontology: Social Sciences 50B(4), pp.
S259-S268.
The authors explore the capability of community long-term
care (CLTC) services to reduce nursing home use when services are
allocated strategically for this purpose. Using an actual CLTC
clientele—the population of persons screened into the
National Long-Term Care Channeling Demonstration--they noted the
existing use of CLTC services and costs and nursing home use. The
authors then simulated reallocation of the existing budget so
that the CLTC service packages received by each individual
minimized long-term nursing home use. A comparison of the two
scenarios revealed that use of CLTC services could significantly
reduce nursing home use without increasing total community
expenditures, according to the authors.
Hennessy, S., Strom, B.L., Berlin, J.A., and Brennan, P.J.
(1995). "Predicting cutaneous hypersensitivity reactions to
cotrimoxazole in HIV-infected individuals receiving primary
Pneumocystis carinii pneumonia prophylaxis." (NRSA Fellowship F32
HS00066). Journal of General Internal Medicine 10, pp.
380-386.
Cotrimoxazole is currently advocated by the U.S. Public
Health Service as the preferred agent for Pneumocystis carinii pneumonia (PCP) prophylaxis for individuals infected with the
human immunodeficiency virus (HIV), whose CD4 cell counts are
below 200 or who experience symptoms. However, many HIV-infected
patients are unable to tolerate the drug, most frequently because
they develop a cutaneous hypersensitivity reaction that is
characterized by rash, fever, and itching. In this study, the
researchers measured the incidence of this reaction among 236
HIV-infected patients receiving cotrimoxazole for primary PCP
prophylaxis. They found that 20 percent developed cutaneous
hypersensitivity reactions, with 12.5 percent of these being
severe, that is, resulting in hospital admission or systemic
treatment with a corticosteroid. Being male, having a higher CD4
percentage, a history of syphilis, and having higher total
protein have at least borderline associations with these
reactions. However, clinical and laboratory variables do not
appear sufficiently associated with the reactions to permit a
clinically useful rule that would predict the reaction in these
patients.
Kaluzny, A.D., Konrad, T.R., and McLaughlin, C.P. (1995).
"Organizational strategies for implementing clinical guidelines."
(AHCPR grant HS07286). Journal on Quality Improvement 21(7), pp. 347-351.
CQI (continuous quality improvement, also known as total
quality management) and academic detailing represent significant
organizational strategies for facilitating the implementation of
clinical guidelines. CQI requires a systematic examination of the
internal operations of the organization and focuses on
identifying and implementing improvement in overall performance
and is best suited for handling interactions within, not across,
organizations. Academic detailing focuses on physician behavioral
change, including the use of market research, to develop an
understanding of motivational patterns of physicians' use,
sociometric identification of key decisionmakers, and use of
basic learning reinforcement techniques. The authors conclude
that, without a managerial commitment and organizational
strategy, guidelines may be perceived as a threat to the autonomy
of both the clinician and the organization.
Morise, A.P., Diamond, G.A., Detrano, R., and others (1995).
"Incremental value of exercise electrocardiography and
thallium-201 testing in men and women for the presence and extent
of coronary artery disease." (AHCPR grant HS06065). American
Heart Journal 130, pp. 267-276.
This study demonstrates that there is incremental value in
exercise testing for assessment of both the presence and extent
of coronary artery disease in men and women. The researchers
developed logistic algorithms and evaluated them in a separate
set of 865 patients from four centers. They included pretest risk
variables (age, sex, symptoms, diabetes, smoking, and cholesterol
concentration); exercise electrocardiogram (ECG); and
thallium-201 scintigram (to detect defect presence,
reversibility, and intensity of hypoperfusion). They assessed the
accuracy and incremental value by receiver operating
characteristic (ROC) curve analysis. Incremental ROC curve areas
for disease presence were pretest risk factors 0.75,
post-exercise ECG 0.82, and post-thallium scintigram 0.85 and for
disease extent were pretest risk factors 0.71, post-exercise ECG
0.76, and post-thallium scintigram 0.78.
Patrick, D.L., Deyo, R.A., Atlas, S.J., and others (1995).
"Assessing health-related quality of life in patients with
sciatica." (Back Pain PORT grant HS06344). Spine 20(17),
pp. 1899-1909.
This study analyzes health-related quality-of-life (HRQOL)
measures and other clinical and questionnaire data obtained from
the Maine Lumbar Spine Study, a prospective study of 427 persons
with low back problems. The SF-35 bodily pain questionnaire and
the modified Roland measure demonstrated the greatest amount of
change over the 3-month followup time and were the most highly
associated with self-rated improvement in HRQOL. A high
correlation between clinical findings or symptoms and the
modified Roland measure, SF-36, and disability days, indicated a
high degree of construct validity. The researchers conclude that
these measures performed well in measuring the HRQOL of patients
with sciatica.
Schwartz, M., Klimberg, R.K., Karp, M., and others (1995).
"An integer programming model to limit hospital selection in
studies with repeated sampling." (AHCPR grant HS06048). HSR:
Health Services Research 30(2), pp. 359-376.
The authors describe an integer programming model that could
be used by researchers to select a limited number of hospitals
for medical record review when repeated sampling is required. The
authors illustrate the model in the context of two studies, which
share these common characteristics: hospitals are classified into
categories, for example, high, medium, and low volume; the
classification process is repeated several times, for example,
for different medical conditions; medical records are selected
separately for each iteration of the classification; and for
budgetary and logistical reasons, reviews must be concentrated in
a relatively small subset of hospitals. The researchers found the
integer programming model to be useful for selecting a subset of
hospitals at which more intensive reviews would be conducted.
They caution, however, that limiting the number of hospitals at
which records are reviewed may compromise the independence of the
multiple analyses performed, since it ignores any overall
"hospital effect."
Selby-Harrington, M.L., Donat, P.L.N., Quade, D., and Farel,
A.M. (1995). "Facilitating random assignment in a community
health education project." (AHCPR grant HS06507). Health
Values 19(4), pp. 3-9.
The random assignment of individuals to intervention or
control groups is a common practice in clinical research.
However, barriers associated with the cost and complexity of
random assignment often preclude its use in evaluating community
health projects. This paper describes procedures that were
developed to facilitate the use of random assignment in a
community health project that tested educational interventions to
encourage parents to obtain well-child care through the Medicaid
program. A state-level Medicaid database was supplemented by
staff members from social service offices and the research
project to implement the procedures. A critical key to the
specific procedures used in this project was the ability to
generate a list of the target population and to arrange the list
in random order.
Stump, T.E., Dexter, P.R., Tierney, W.M., and Wolinsky, F.D.
(1995). "Measuring patient satisfaction with physicians among
older and diseased adults in a primary care municipal outpatient
setting." (AHCPR grant HS07632). Medical Care 33(9), pp.
958-972.
These authors examine the reliability and validity of three
instruments reported to be suitable for measuring patient
satisfaction with physicians among older and diseased adults in a
primary care municipal outpatient setting. The first two of these
instruments take a global approach to patient satisfaction: the
physician-behavior subscales of the Physician Satisfaction
Questionnaire (PSQ), and the American Board of Internal
Medicine's (ABIM) questionnaire, which evaluates the relationship
between patients and physicians in internal medicine residencies.
In contrast, the third instrument focuses on satisfaction with
the visit just made and consists of the nine items used in the
Medical Outcomes Study (MOS) visit-specific questionnaire. The
two general measures of patient satisfaction were found to be
highly correlated with the visit-specific measure. In contrast,
the ABIM was found to be shorter and to have a simpler and more
pristine factor structure.
Tierney, W.M., Overhage, J.M., Takesue, B.Y., and others.
(1995). "Computerizing guidelines to improve care and patient
outcomes: The example of heart failure." Journal of the
American Medical Informatics Association 2(5), pp.
316-322.
The researchers attempted to incorporate the AHCPR-sponsored
guideline, Heart Failure: Evaluation and Care of Patients with
Left-Ventricular Systolic Dysfunction, into a network of
microcomputer workstations at an urban teaching hospital to
facilitate use by physicians. The guideline was programmed into
the workstation software, using an automated version of the CARE
programming language. For all of the subsequent workstation
studies, the guideline suggested orders for drug therapy,
non-drug therapy, and diagnostic testing (with accompanying
explanatory text) that the physician could accept with a single
keystroke or mouse click. According to the authors, making the
guideline useful via computer proved difficult for several
reasons: one, the guideline frequently hinges on data that are
not routinely stored in most electronic record systems in a
useful format; two, heart failure usually is not an isolated
phenomenon, and dealing with a patient's coexisting conditions
often is the most difficult aspect of their care; three, the
guideline does not cover many of the coexisting conditions or
errors of commission (e.g., the inappropriate use of common
drugs).
Tu, S.W., Eriksson, H., Gennari, J.H., and others (1995).
"Ontology-based configuration of problem-solving methods and
generation of knowledge-acquisition tools: Application of
PROTEGE-II to protocol-based decision support." (AHCPR grant
HS06330). Artificial Intelligence in Medicine 7, pp.
257-289.
PROTEGE-II is a suite of tools and a method for building
knowledge-based systems and domain-specific knowledge-acquisition
tools. In this paper, the authors demonstrate how PROTEGE-II can
be applied to the task of providing protocol-based decision
support for treating HIV-infected patients. The general goal of
the PROTEGE-II approach is to produce systems and components that
are reusable and easily maintained. While conceding that their
evaluation of the PROTEGE-II system is still preliminary, the
authors show that the goals of reusability and easy maintenance
can be achieved. They discuss design decisions and the tradeoffs
that have to be made in the development of the system.
Yeaton, W.H., Langenbrunner, J.C., Smyth, J.M., and Wortman,
P.M. (1995, September). "Exploratory research synthesis:
Methodological considerations for addressing limitations in data
quality." (AHCPR grant HS06264). Evaluation & The Health
Professions 18(3), pp. 283-303.
Exploratory meta-analysis or research synthesis has been
advocated as a way to develop important hypotheses for further
study. These investigators conducted an exploratory research
synthesis on the carotid endarterectomy (CE) literature to
illustrate this method. The CE literature is similar to that of
many other new medical interventions because it contains numerous
limitations to data quality. Exploratory research synthesis of
such literature necessitates a number of methodological and
statistical considerations to address these limitations,
including the problems of missing data, appropriate unit of
analysis, nonnormal distribution of outcomes, and lack of
controlled studies. The authors discuss strengths and limitations
of the exploratory research synthesis approach within the context
of public policy decisions for assessing medical technologies.
AHCPR Publication No. 96-0032
Current as of November/December 1995