AHCPR teams with the AAHP Foundation and HRSA to improve care for people with chronic illnesses

Millions of chronically ill Americans who depend on managed care plans for their care will benefit from new studies announced recently by the Agency for Health Care Policy and Research. AHCPR and the American Association of Health Plans Foundation (AAHPF)—the research arm of the nation's largest managed care trade association—together with AHCPR's sister agency, the Health Resources and Services Administration (HRSA), have awarded six research teams a total of $8.5 million over 3 years.

These newly funded projects will examine how particular managed care policies and practices, such as protocols governing the referral of patients to medical specialists and arrangements for paying physicians, affect the quality of care for patients living with chronic illnesses. An estimated 90 million Americans—or one of every three people in the United States—are affected by one or more chronic conditions, which account for $1 of every $6 spent on health care.

The six teams, which were selected through AHCPR's peer review process from a pool of over 30 applicants, will include scientists working at some of the top research institutions in the country. In announcing the awards, AHCPR administrator John M. Eisenberg, M.D., and AAHP president and CEO Karen Ignagni noted that the studies will provide health plan executives and purchasers, including government, with the first comprehensive findings regarding which policies and procedures managed care organizations can adopt to optimize health outcomes.

The last generation of research in this area focused on general comparisons between managed care and traditional fee-for-service plans. The main lessons learned from those studies are that both types of plans can do a better job in taking care of people with chronic conditions and that what is needed most is evidence on how specific strategies for managing and financing care affect quality. According to Dr. Eisenberg, the question that puzzles Americans today is not whether fee-for-service or managed care is better, but whether there are some aspects of managed care that are helpful and some that are harmful, especially to people with chronic diseases. The new studies will provide evidence-based research to help us answer these kinds of questions.

The new projects represent a groundbreaking research effort that is built upon a public and private partnership dedicated to furthering the goal of developing evidence-based care. Ms. Ignagni offered thanks to AAHP's affiliated health plans for their commitment, as well as the Prime Health Foundation in Kansas City, an early partner in this unique research effort. The research teams will examine data and patient records from 32 health plans, over 50 local medical group practices affiliated with one of the Nation's largest health care purchasing cooperatives—organizations funded by employers to negotiate health coverage for workers—and several government-sponsored programs. Together these groups provide health care for over 10 million Americans from California to Massachusetts.

The study populations represent a cross-section of Americans, including low-income people who are living with chronic illnesses. Poor, uninsured Americans—especially racial and ethnic minorities—are the people most likely to have chronic illnesses, and they are least likely to have access to care needed to manage their condition, according to Claude Earl Fox, M.D., M.P.H., administrator of HRSA.

The following grants were awarded:

• Jose Escarce, M.D., Ph.D., RAND, Santa Monica, CA, will study the care given to working-age members of seven United Health Care plans in different parts of the country for diabetic retinopathy and open-angle glaucoma—both of which are leading causes of blindness.
• Edward Guadagnoli, Ph.D., Harvard Medical School, Cambridge, MA, will examine care for diabetic and hypertensive patients enrolled in the plans of Health Partners, Preferred One, and Allina in the Minneapolis-St.Paul, MN, area.
• Katherine Kahn, M.D., University of California, Los Angeles, will analyze the quality of care provided to patients with chronic heart and lung diseases by 58 group practices serving companies who belong to the Pacific Business Group on Health.
• Tracy Lieu, M.D., Kaiser Permanente of Northern California, Oakland, CA, will examine the quality of care given to asthmatic children enrolled in Medicaid managed care plans in California, Massachusetts, and Washington State.
• Barbara McNeil, M.D., Harvard Medical School, Cambridge, MA, will focus on members of Prudential, Allina, United Health Care, and Pacificare treated for heart attack, congestive heart failure, or hypertension.
• Elizabeth Shenkman, Ph.D., University of Florida, Gainesville, FL, will study the quality of care for low-income children in Florida's Healthy Kids Program who suffer from asthma, diabetes, or other problems. Participating groups include the Health Insurance Plan of Florida, Health Option/Blue Cross-Blue Shield of Florida, Humana, Florida Health Care Plans, Florida First, PCA Family (Physicians' Corporation of America-Family), JMH Health Plan of Florida (Jackson Memorial Trust Plan of Florida), Av-Med Health Plan, and Physicians' Health Plan.

The new studies are part of a broad AHCPR effort to build a foundation of scientifically sound evidence that can be used to help make clinical, public policy, and health care system decisions related to the quality of care.

Gregg Meyer, M.D., to head AHCPR's Center for Quality Measurement and Improvement

John M. Eisenberg, M.D., Administrator of the Agency for Health Care Policy and Research, has announced the appointment of Gregg S. Meyer, M.D., as the new director of AHCPR's Center for Quality Measurement and Improvement (CQMI). As director of CQMI, Dr. Meyer will lead AHCPR's efforts to develop new and more effective quality measures and improvement strategies to help public- and private-sector organizations provide, organize, and purchase high-quality health care services.

One of CQMI's principal initiatives is the Consumer Assessment of Health Plans (CAHPS®) project, which involves a series of questionnaires used by health plans, employers, and other organizations to survey their members and employees. The Medicare program is using CAHPS® to survey its beneficiaries in managed care plans, and the Federal Employees Health Benefits Program will begin using CAHPS® in 1999.

Dr. Meyer is leaving his position as an Associate Professor in the Departments of Medicine and Preventive Medicine and Biometrics at the Uniformed Services University of the Health Sciences (USUHS), where he coordinated design and analysis of the Department of Defense's Cardiovascular National Quality Management Project and developed curricula for senior military medical leaders in quality improvement. Dr. Meyer also served as Division Director for General Medicine at USUHS. While at the University, Dr. Meyer was an active-duty Medical Corps officer and Lieutenant Colonel in the United States Air Force.

Dr. Meyer's responsibilities at USUHS also included serving as principal investigator for health services research in quality of care, managed care, and physician workforce modeling. In addition, he served as liaison between health services research and clinical care delivery for the military health services system. Dr. Meyer is the author of over 45 articles, editorials, book chapters, and monographs and is board certified in internal medicine. He is a Phi Beta Kappa graduate of Union College and magna cum laude graduate of Albany Medical College. Dr. Meyer was a Rhodes Scholar and earned a master's degree from Oxford University. While in England, He worked in a community-based general medical practice in the National Health Service. Upon returning to the United States, Dr. Meyer completed a residency in primary care internal medicine at Massachusetts General Hospital. After residency he completed fellowship training in general internal medicine at Massachusetts General Hospital and Harvard Medical School and received a master's degree from the Department of Health Policy and Management at the Harvard School of Public Health. In addition, Dr. Meyer served as a fellow in the health office of the U.S. Senate Labor and Human Resources Committee.

AHCPR announces two clinical prevention centers

Agency for Health Care Policy and Research Administrator John M. Eisenberg, M.D., has announced the selection of two Clinical Prevention Centers to support the work of the soon-to-be reconvened U.S. Preventive Services Task Force (USPSTF). The Centers, already under contract to AHCPR as two of 12 Evidence-based Practice Centers, are Research Triangle Institute (RTI) in collaboration with the University of North Carolina at Chapel Hill (UNC) and Oregon Health Sciences University (OHSU).

RTI/UNC and OHSU have many years prior experience in evidence-based activities, according to Dr. Eisenberg. Under AHCPR's evidence-based practice initiative, they are part of a network of centers that produce comprehensive evaluations of medical treatments and technologies in collaboration with outside partners such as professional organizations, health plans, and consumer groups. Their reports provide the foundation for public and private efforts to improve the quality of health care.

The USPSTF, an independent panel of preventive health specialists, was first convened in 1984 by the U.S. Public Health Service to evaluate the scientific evidence for the effectiveness of a range of clinical preventive services (screening, immunizations, and counseling for health behavior change) and to produce age- and risk-factor specific recommendations regarding the use of clinical preventive services by primary care clinicians. The Task Force recommendations were issued in 1989 in the Guide to Clinical Preventive Services; revised recommendations by a reconvened panel were issued in 1996 in a second edition of the Guide.

The newly designated Clinical Prevention Centers will provide hands-on support to all USPSTF activities, including: identifying high-priority topics; reviewing and synthesizing research to assist the USPSTF in making new recommendations; drafting new chapters for inclusion in the third edition of the Guide; and marshaling appropriate clinical and methodologic staff for topics across the spectrum of clinical preventive services.

The collaboration between UNC and RTI brings the combined expertise of two institutions with distinguished records in prevention research and evaluation. UNC is home to nationally recognized Schools of Medicine and Public Health, the Cecil Sheps Center for Health Services Research, and a CDC-funded Center for Research and Demonstration in Health Promotion and Disease Prevention. RTI is an independent, nonprofit organization that works with private, Federal, and State partners on a wide range of research and development initiatives in health policy, public health, medicine, and environmental protection.

Russell Harris, M.D., M.P.H., of UNC, and Kathleen Lohr, Ph.D., of RTI, will co-direct the USPSTF activities for RTI/UNC. Dr. Harris is an internist with broad expertise in prevention, and cancer screening in particular. He is principal investigator on a National Cancer Institute grant to improve cancer prevention activities in primary care practice. Dr. Lohr directs RTI's health services and policy research. She also has served as Director of the Division of Health Care Services at the Institute of Medicine, National Academy of Sciences, where she oversaw a variety of projects analyzing quality of care and health care policy.

The Clinical Prevention Center at OHSU represents a partnership between the OHSU School of Medicine, the Kaiser Permanente Center for Health Research (KPCHR), the Portland Veterans Affairs Medical Center, and the Center for Outcomes Research and Education at the Providence Health System, Portland, OR. The successful history of collaboration between OHSU—a leading managed care research center—and the VA health system will allow the Task Force to examine some of the effects of implementing new preventive services in different systems of care.

Mark Helfand, M.D., M.P.H., who will direct the Clinical Prevention Center at OHSU, is a primary care internist with a distinguished career in the evaluation of medical technology and screening tests. He has authored screening recommendations developed by the American College of Physicians, as well as analyses for panels of the Institute of Medicine. Dr. Helfand also was a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar. Working with Dr. Helfand will be Heidi D. Nelson, M.D., M.P.H., a general internist whose clinical and research interests are in women's health and substance abuse. Evelyn Whitlock, M.D., M.P.H., will lead the work at KPCHR, which has extensive experience in developing and implementing clinical preventive services in such areas as health behavior change, cancer screening, and chronic disease management.

According to Dr. Eisenberg, the USPSTF will be reconvened in the fall of 1998 to update previous recommendations and to evaluate prevention interventions not previously assessed. To speed implementation of new and updated recommendations, the Task Force will release individual reports and recommendations as they are completed. The third full edition of the Guide is anticipated for release in late 2002.

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Announcements

AHCPR grantees honored

Congratulations to Harold S. Luft, Ph.D., of the University of California, San Francisco, and Joanne Wolfe, M.D., M.P.H., of the Dana-Farber Cancer Institute, who were honored recently with awards. Both Dr. Luft and Dr. Wolfe have been the recipients of grant support from the Agency for Health Care Policy and Research.

Dr. Luft received the Health Services Research Prize, sponsored by Baxter Allegiance Foundation, during the June 1998 meeting of the Association of University Programs in Health Administration held in Washington, DC. The annual award, begun in 1986, recognizes significant and demonstrable contributions to the improved health of the public through innovative health services research. Dr. Luft's research on health maintenance organizations has become the standard reference tool in education and the industry. He has authored or coauthored 18 books and monographs and more than 90 articles in refereed journals.

Currently, Dr. Luft is Director of the Institute for Health Policy Studies at the University of California, San Francisco. In 1995 he was named the Caldwell B. Esselstyn Professor of Health Policy and Health Economics at the university. He is co-principal investigator of an AHCPR National Research Service Award training grant that provides training to health services researchers at both the pre- and postdoctoral levels at the University of California, Berkeley, and the University of California, San Francisco.

Joanne Wolfe, M.D., M.P.H., of the Division of Hematology/Oncology at Dana-Farber Cancer Institute and Children's Hospital, Boston, is a fellow in the pediatric health services research program (funded by an AHCPR National Research Service Award training grant). Dr. Wolfe received the combined Pain Merit and Brigid Leventhal Award presented by the American Society of Clinical Oncology at their 34th annual meeting in May 1998 in Los Angeles, CA.

Dr. Wolfe was the fellow who submitted the highest ranking abstract on the subject of pain and pediatric oncology treatment. Her paper, "Medical problems and suffering experienced by pediatric oncology patients in the last month of life," was based on her AHCPR-supported research.

Dr. Wolfe received an M.D. from Harvard Medical School and an M.P.H. from the Harvard School of Public Health. Her major research interests are end-of-life care, medical decisionmaking, and ethics.

Final reports now available from NTIS

The following grant final reports are now available from the National Technical Information Service (NTIS). Each listing includes the name of the project, the principal investigator, his or her affiliation, the grant number and project period, and a brief description of the project.

Laboratory Testing for Preeclampsia. William M. Barron, M.D., Loyola University, Chicago, IL. AHCPR grant HS08598, project period 5/1/94 to 10/30/96.

Elevated blood pressure is a common problem in obstetrics, complicating 6 to 10 percent of the approximately 4 million pregnancies in the United States annually. Establishing the diagnosis of preeclampsia and determining its severity depend on the patient's history, a physical examination, and laboratory testing. The goal of this study was to improve the appropriateness of diagnostic testing used to evaluate pregnant women for preeclampsia. Specific objectives were to obtain an estimate of the magnitude of laboratory testing in the evaluation of hypertensive patients and determine if abnormalities in commonly ordered coagulation tests could be predicted from the results of other commonly obtained, less expensive tests. Results confirm that a substantial amount of diagnostic laboratory testing is performed at the two institutions studied to evaluate hypertension in pregnant women. This study found that measurement of prothrombin time (PT), activated partial thromboplastin time (aPTT), and fibrinogen are unnecessary in patients who have no clinical evidence of bleeding or of a condition that may produce a coagulation disturbance and whose platelet count and serum LDH are normal.

Executive summary and final report are available from the National Technical Information Service (NTIS accession no. PB98-131758; 42 pp, $25.50 paper, $12.00 microfiche).

Predictors of Urinary Tract Infection During Pregnancy. Lisa M. Pastore, M.S., University of North Carolina, Chapel Hill. AHCPR grant HS08901, project period 9/1/95 to 12/31/97.

Urinary tract infections (UTIs) are common during pregnancy and can have serious implications for maternal/fetal health. Infections that spread to the kidney (pyelonephritis) are one of the most serious complications of pregnancy and typically require hospitalization. Using a cohort of deliveries (8,037) at three North Carolina hospitals during 1990 to 1993, this study identified demographic, behavioral, and medical history predictors of UTIs during pregnancy. Statistical analyses revealed that history of UTI—both before pregnancy and during pregnancy prior to initiation of prenatal care—more than doubled a woman's risk of bacteriuria (i.e., high level of bacteria in the urine) at prenatal care initiation. African-American women with sickle cell versus normal hemoglobin were at nearly twice the risk for bacteriuria. The following factors at least double a woman's risk of symptomatic UTI after 20 weeks gestation (7,403 deliveries): antenatal UTI before 20 weeks gestation, prepregnancy history of UTI, nonprivate medical clinic, and among white women, history of chlamydia. The strongest predictor of pyelonephritis was any UTI diagnosis during the first 20 weeks gestation. Other suggestive risk factors for pyelonephritis were sickle cell hemoglobinopathy, nonprivate medical clinic, illicit drug use, prepregnancy history of chlamydia, unmarried status, and less than 12 years of education. Identification of these risk factors can influence clinic protocols for antenatal urine screening in order to avoid the most severe infections through early diagnosis and treatment.

Abstract, executive summary, and dissertation are available from the National Technical Information Service (NTIS accession no. PB98-140718; 22 pp, $23.00 paper, $12.00 microfiche).

Value-Based Health Care Purchasing by Employers. James D. Mortimer, Midwest Business Group on Health, Chicago, IL. AHCPR grant HS09368, project period 2/1/97 to 4/30/97.

The Midwest Business Group on Health convened invitational conferences in Washington, DC and Chicago, IL to present the findings and recommendations from an evaluation of health care purchasing initiatives in six markets across the country. Employer purchasers were found to be meeting their own goals, but they were urged to strengthen their programs by increasing market share, being more aggressive about picking the best providers, beefing up technical staff support, helping employees to be better consumers, and working with government employers and agencies as responsible purchasing partners.

Abstract, executive summary, and final report are available from the National Technical Information Service (NTIS accession no. PB98-140700; 34 pp, $25.50, paper $12.00).

New publications catalog now available

Your copy of the Spring/Summer 1998 AHCPR Publications Catalog (AHCPR Publication No. 98-0028) is now ready. The listings in this issue of the catalog have been reorganized into more useful categories to make it easier for you to quickly find what you're looking for. Call the AHCPR Clearinghouse (800-358-9295) to order your copy of the catalog.

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Research Briefs

Dolin, R.H., Huff, S.M., Rocha, R.A., and others (1998, March). "Evaluation of a 'lexically assign, logically refine' strategy for semi-automated integration of overlapping terminologies." (AHCPR grant HS08751). Journal of the American Medical Informatics Association 5(2), pp. 203-213.

Standardized definitions and standardized use of terminology in medical record systems are prerequisites for robust informatic applications such as automated decision support and outcomes analysis. Two proposed approaches to attain such standards and to formally define healthcare terminology are lexically based systems, which rely on analysis of morphemic patterns within the terms being defined to derive meaning, and logically based systems, which rely on axiomatic definition of concepts and subsequent classification of those definitions to derive meaning. This study evaluates a lexically assign, logically refine (LALR) strategy for merging overlapping healthcare terminologies. The researchers applied LALR strategy to 7,763 LOINC and 2,050 SNOMED procedure terms using a common set of defining relationships taken from the LOINC data model. They successfully defined 73 percent of LOINC and 56 percent of SNOMED procedure terms using a LALR strategy and appropriately placed more detailed LOINC terms underneath the corresponding SNOMED terms. The researchers conclude that LALR is a successful strategy for merging overlapping terminologies in a test case.

Selim, A.J., Ren, X.S., Fincke, G., and others (1998). "The importance of radiating leg pain in assessing health outcomes among patients with low back pain." (AHCPR grant HS08194). Spine 23, pp. 470-474.

Combining reports of the extent of radiating leg pain with the results of straight leg raising (SLR) tests correlates well with the intensity of localized low back pain (LBP), health-related quality of life (HRQL), disability, and use of medical services, concludes this study. The researchers mailed a HRQL questionnaire and interviewed 434 persons with LBP. They combined patients' reports of radiating leg pain and results of the straight leg raising tests into four hierarchical groups and correlated them with HRQL, LBP, disability, and use of medical services. Results showed that the intensity of LBP and disability increased from Group 1 (low back pain alone) to Group 4 (pain below the knee with positive straight leg raising test result), whereas HRQL decreased. Group 4 patients were five times more apt than Group 1 to use medications for LBP and four times more likely to have surgery.

Stineman, M.G., Escarce, J.J., Tassoni, C.J., and others (1998, March). "Diagnostic coding and medical rehabilitation length of stay." (AHCPR grant HS07595). Archives of Physical and Medical Rehabilitation 79, pp. 241-248.

The addition of diagnostic code information (ICD-9-CM) does not improve medical rehabilitation length-of-stay (LOS) prediction when used in combination with the Functional Independence Measure-Function Related Groups (FIM-FRGs) classification system, finds this study. The researchers analyzed 82,646 records from patients discharged in 1992 from 252 rehabilitation facilities and hospital units across the country.

They then used separate validation sets to quantify the incremental effect of diagnosis when combined with the FIM-FRG system. The addition of ICD-9-CM diagnostic information to the FIM-FRG classification system increased the variance in LOS explained by a maximum of only 2 percent, from 32 percent to 34 percent. The researchers attribute lack of improved prediction with the diagnosis codes to incomplete coding practices and to the effect of patients' diagnoses being absorbed in variables already expressed by the FIM-FRG system.

Welch, G., Kawachi, I., Barry, M.J., and others (1998). "Distinction between symptoms of voiding and filling in benign prostatic hyperplasia: Findings from the health professionals follow-up study." (AHCPR grant HS08570). Urology 51(3), pp. 422- 427.

There is debate about the validity of the clinical distinction between filling and voiding symptoms of benign prostatic hyperplasia (BPH). But these researchers found evidence to support the clinical conceptualization of lower urinary tract symptoms into filling and voiding problems. They analyzed responses to the American Urological Association Symptom Index (AUA SI) among 7,753 men and a subsample of 1,856 men with physician-diagnosed BPH. The results of factor analysis showed that responses to the AUA SI items could be grouped into one of two subscales: one describing voiding problems and the other filling problems. These findings provide support for using the total AUA SI score as a reliable measure of overall symptom severity in BPH as well as for separately summing the voiding and filling items to measure distinctive types of symptoms.

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AHCPR Publication No. 98-0045
Current as of July 1998