Oral rehydration therapy improves outcomes for children with acute gastroenteritis

There appears to be great potential for improving the medical treatment of American children with acute gastroenteritis by the increased use of oral rehydration therapy (ORT), according to a recent study supported by the Agency for Health Care Policy and Research (contract 282-90-0043). Acute gastroenteritis is a major cause of death among children in developing countries, where for two decades ORT has been used to treat dehydration caused by vomiting and diarrhea. In the United States and other developed countries, when acute gastroenteritis results in dehydration, it is usually treated by readily available intravenous therapy.

Physicians in this country have been reluctant to use ORT in part because of the vomiting that frequently accompanies gastroenteritis, resistance by some non- or mildly dehydrated patients, fear of possible hypernatremia (excess sodium in the blood caused by the salt-containing ORT solution), perceived inconvenience in administering ORT in a practice setting, and lack of third-party reimbursement for ORT and over-the-counter solutions. According to principal investigator Nancy Merrick, M.D., M.S.P.H., of the MEDSTAT Group in Santa Barbara, CA, these concerns may be unwarranted and inhibit the use of this important medical treatment. The researchers conducted a meta-analysis of 13 randomized, controlled trials in developed countries, comparing the safety and efficacy of ORT with intravenous rehydration treatment in children with mild or moderate dehydration.

The researchers found that only 3.6 percent of well-nourished children with gastroenteritis who received ORT had to be rehydrated intravenously (due to failure of ORT), including children seen in inpatient and outpatient settings and regardless of the sodium content of the ORT solution. Also, children treated with ORT did not have a higher risk than those rehydrated intravenously of developing either hyponatremia (low sodium blood levels) or hypernatremia. In fact, ORT-treated children had diarrhea of shorter duration, greater weight gain at discharge, and shorter length of hospital stay than those rehydrated intravenously.

See "Efficacy of glucose-based oral rehydration therapy," by Norma Gavin, Ph.D., Dr. Merrick, and Bruce Davidson, Ph.D., M.P.H., in the July 1996 issue of Pediatrics 98(1), pp. 45-51.

Earlier referral to hospice care may benefit terminally ill elderly patients

Many elderly patients who enter hospice care do so when they have only a few weeks left to live. They may resist being told that their illness is terminal, and physicians may want to preserve hope by postponing hospice referral. However, earlier referral by physicians to hospice care may improve the quality of the remaining life of these elderly patients, allow them to receive Medicare-covered noncurative medicine and support services that would not be covered in the hospital, and reduce costs for more expensive hospital care, according to a recent study supported in part by the Agency for Health Care Policy and Research (National Research Service Award training grant T32 HS00009).

Nicholas A. Christakis, M.D., Ph.D., M.P.H., of the University of Chicago, and Jose J. Escarce, M.D., of the University of Pennsylvania analyzed 1990 Medicare claims data for the characteristics and survival time of 6,451 hospice patients who had been followed for a minimum of 27 months. About 80 percent of the patients had some form of cancer.

Median survival time after the patients entered hospice care was 36 days. However, survival time varied substantially, with 16 percent of patients surviving for less than 1 week and 15 percent for longer than 6 months. As might be expected, diagnosis strongly affected survival time. For instance, patients with renal failure survived a median of 17 days compared with 77 days for patients with chronic obstructive pulmonary disease. Finally, there was substantial variation in survival according to the type of hospice provider, even after adjustment for patient characteristics.

Although earlier referral of patients to hospice care would increase Medicare costs for such care, these increased costs might be more than offset by the savings realized through reducing more expensive hospital costs. For example, 63 percent of the total hospital days in the 9 months prior to hospice enrollment were during the 30 days just before hospice admission. Moreover, patients who were hospitalized for many days during the month before hospice enrollment tended to have relatively short survival after enrollment. These patients may have received costly and perhaps unnecessarily aggressive care for an unduly long period before entering a hospice, according to the researchers, who conclude that, to the extent possible, earlier hospice referral might have been more beneficial to these patients.

Details are in "Survival of Medicare patients after enrollment in hospice programs," by Drs. Christakis and Escarce, in The New England Journal of Medicine 335 (3), pp. 172-178, 1996.

Electrostimulation helps stroke patients recover muscle strength

Each year, 500,000 persons suffer a stroke in the United States. Electrostimulation significantly aids recovery of muscle strength following stroke, according to a recent study conducted by William Stason, M.D., and his colleagues from the Harvard School of Public Health (supported by the Agency for Health Care Policy and Research, contract 282-91-0085). Dr. Stason was project director for the AHCPR-supported Post-Stroke Clinical Practice Guideline Panel.

Muscle strength enables muscles to efficiently contract, allowing movement and improved function. However, muscle strength is only one aspect of neurological deficit that occurs with stroke-induced upper motor neuron injury. Proprioceptive input (receiving stimuli in muscles and tendons), level of spasticity, and coordination of antagonistic muscle groups involved in complex activities such as walking also determine functional recovery from a stroke.

Functional electrostimulation (FES) is a technique that applies short, programmed bursts of electrical current to the neuromuscular region affected by the stroke, either to the partially paralyzed (paretic) muscles directly or to the associated peripheral nerves. The researchers conducted a meta-analysis of four studies of middle-aged men and women who had suffered strokes 1.5 months to 2.5 years earlier and were treated with FES for 3-4 weeks to achieve extension of the wrist or knee or bending of the ankle. They compared the change in muscle force of contraction following FES compared with no FES.

Pooled results of the four studies showed a change in force of .63 (0.20 is a small effect and 0.80 is a large effect), a statistically significant increase in strength. Although the results did not necessarily confirm sustained improvement in muscle strength or actual functional improvement, they nonetheless provide promising support for the use of FES, according to the researchers. They point out that FES units are relatively inexpensive (mean price, $1,250), extremely durable and reliable, and can be used by the patient or family member without the ongoing assistance of a professional. Also, there is little if any risk associated with their use. The researchers conclude that, given the large burden of stroke-related disability and the few effective therapies, the thoughtful and selective use of FES is warranted.

Details are in "Functional electrostimulation in poststroke rehabilitation: A meta-analysis of the randomized controlled trials," by Morton Glanz, M.D., Sidney Klawansky, M.D., Ph.D., William Stason, M.D., and others, in the June 1996 Archives of Physical Medicine and Rehabilitation 77, pp. 549-553.

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HIV/AIDS Research

Residency training can improve physicians' attitudes towards treating AIDS patients

One of every five physicians, residents, and medical students expresses unwillingness to treat people with AIDS (PWAs). Yet certain aspects of residency training can have a modest influence on improving physicians' willingness to treat PWAs and softening the negative impact of attitudes they may have toward homosexuals and intravenous drug users (IVDUs), who are the majority of PWAs. Homophobia and IVDU-phobia are more apt to originate in residents' broader social experiences, points out Michael J. Yedidia, Ph.D., of New York University.

Several aspects of residency training, however, were found to mute the impact of such attitudes on willingness to treat AIDS: the faculty's commitment to teaching, tolerance of differing viewpoints, and emotional supportiveness and the program's emphasis on democratic decisionmaking, student-centered training, and clear expectations. In addition, the researchers found that being acquainted socially with someone who has HIV infection also diminishes the effects of homophobia. They suggest that residents be involved in experiences that "put a human face on AIDS," emphasizing the individuality of people with HIV infection. The findings also support selection of faculty role models who regard treating PWAs as a positive learning experience, encourage residents to treat IVDUs and AIDS patients exactly as they would other patients, are very willing to treat AIDS patients.

Supported by the Agency for Health Care Policy and Research (HS06539), the researchers surveyed 383 physicians, first as students in their fourth and final year at six medical schools in New York State, and next as house staff (representing all major specialties) in their third year of residency at sites across the country. The researchers examined the change in attitudes toward treating PWAs over time and found an overall positive change in attitudes, which was driven primarily by a significantly increased perception of benefits associated with treating PWAs and decreased concern that treating PWAs interfered with other educational and patient-care activities.

However, willingness to treat PWAs increased only marginally, and concern about risk of exposure to the human immunodeficiency virus that causes AIDS decreased only slightly. Of the medical students who were somewhat or very willing to treat PWAs, 29 percent decreased in willingness, 57 percent remained equally willing, and 14 percent moved from somewhat to very willing. Conversely, of the medical students who were not very or not at all willing to treat PWAs, 58 percent became more willing, 35 percent maintained their initially negative attitudes, and 7 percent became even less willing.

More details are in "Changes in physicians' attitudes toward AIDS during residency training: A longitudinal study of medical school graduates," by Dr. Yedidia, Carolyn A. Berry, Ph.D., and Judith K. Barr, Sc.D., in the June 1996 Journal of Health and Social Behavior 37, pp. 179-191.

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Access to Care

Policies that reduce the number of minority physicians also may reduce access to health care for poor people and minorities

According to a recent study supported in part by the Agency for Health Care Policy and Research (HS07373), dismantling programs that facilitate training of minority physicians—as was recently done in the California State university system—may threaten health care for both poor people and members of minority groups. This is because black and Hispanic physicians are much more likely than other physicians in that State to treat poor, black, and Hispanic patients.

Despite the fact that black and Hispanic physicians play an important role in caring for poor and minority patients, they are markedly underrepresented among physicians. In 1990, blacks made up 12 percent of the U.S. population but only 4 percent of physicians; Hispanics made up 9 percent of the population but only 5 percent of physicians. Recent figures show that members of underrepresented minority groups now make up about 12 percent of all medical school students, due at least in part to affirmative action programs, suggest the researchers.

The researchers surveyed 718 primary care physicians and found that, on average, black physicians cared for nearly six times as many black patients and Hispanic physicians cared for nearly three times as many Hispanic patients as did other physicians. Also, black and Hispanic physicians cared for more patients covered by Medicaid (45 and 24 percent of their patients, respectively, compared with 18 percent of patients of non-Hispanic white physicians) than did other physicians. Hispanic doctors cared for more uninsured patients than did other doctors (9 percent of their patients compared with 3 to 6 percent for other physicians). In addition, black and Hispanic physicians tend to locate their practices in areas with large underserved groups, thereby increasing access to care for these groups.

These findings suggest that physicians who are black or Hispanic fill an important role in caring for poor people and members of minority groups. Changes that result in a decrease in the number of physicians from minority groups are likely to result in poorer access to health care and ultimately may lead to reduced health and well being for a substantial proportion of the population, conclude the researchers. They caution, however, that these findings are based on data from California and may or may not apply to other States.

See "The role of black and Hispanic physicians in providing health care for underserved populations," by Miriam Komaromy, M.D., Kevin Grumbach, M.D., Michael Drake, M.D., and others, in the May 16, 1996, New England Journal of Medicine 334, pp. 1305-1310.

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