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<a name="head1"></a>
<a name="head2"></a><h2>Availability of free vaccine and other factors affect
likelihood of timely childhood immunizations</h2>
<p>The United States experienced a major measles epidemic between 1989 and 1991, and there was a
resurgence of whooping cough in 1993. Experts predict that future outbreaks of other
vaccine-preventable diseases will occur. Thus, a national priority for the year 2000 is full
immunization of at least 90 percent of children by age 2. In 1996, the combined vaccination rate
for children 19 to 35 months of age was 78 percent, although 91 percent had received measles
vaccine.</p> <p>
Two recent studies, supported by the Agency for Health Care Policy and Research (HS08068)
and led by Richard K. Zimmerman, M.D., M.P.H., of the University of Pittsburgh School of
Medicine and Graduate School of Public Health, looked at reasons for low immunization rates.
Dr. Zimmerman and his colleagues found that uninsured children are less likely to be immunized
than insured children, especially if their doctors don't receive free vaccines. Cost isn't the only
factor; physicians' practice policies and beliefs about the risks associated with immunizations also
determine whether children receive timely immunizations. The two studies are summarized
below.</p>
<p><strong>Zimmerman, R.K., Medsger, A.R., Ricci, E.M., and others (1997, September 24). "Impact
of free vaccine and insurance status on physician referral of children to public vaccine
clinics." <em>Journal of the American Medical Association</em> 278(12), pp. 996-1000.</strong></p><p>
Uninsured children are less apt to be immunized when they see their primary care physician than
are insured children, particularly if their doctor does not receive free vaccines, according to this
study. The Federal Government provides free vaccines to States for distribution to public health
departments and participating physicians' offices through the Vaccines for Children (VFC)
program. The VFC program provides the free vaccines to be used for uninsured children, those
eligible for Medicaid, and American Indian/Alaska Native children. The VFC program also
provides free vaccines to insured children if their insurer does not cover vaccines and they are
vaccinated at a public health clinic.</p>
<p>Of the 1,236 physicians surveyed in this study, most (66 percent) said they would refer an
uninsured child to the health department for vaccination. However, 90 percent of physicians who
did not receive free vaccines, compared with 44 percent who did, said they would refer an
uninsured child to a public health clinic. Only 11 percent of doctors not receiving free vaccines
said they would refer an insured child to a clinic. It appears that physicians who receive free
vaccines are more willing to absorb other uncovered immunization costs, including the cost of the
office visit, according to Dr. Zimmerman.</p><p>
Overall, 36 percent of physicians surveyed would refer to a public health clinic a child with
insurance that did not cover vaccines, 26 percent would refer a child with Medicaid, but only 8
percent would refer an insured child with coverage for the vaccines. Referral of children from
primary care physicians' offices to public clinics results in delayed immunization (and often no
immunization) and fragmented care, with parents having the added expense and burden of taking
the child to one site for vaccines and another for other services, note the researchers. </p>
<p><strong>Zimmerman, R.K., Schlesselman, J.J., Baird, A.L., and Mieczkowski, T.A. (1997, July). "A
national survey to understand why physicians defer childhood immunizations." <em>Archives of
Pediatric and Adolescent Medicine</em> 151, pp. 657-664.</strong></p><p>
The continuing vulnerability of U.S. children to potential outbreaks of vaccine-preventable
diseases is due in part to suboptimal vaccination practices of health care providers, according to
this study. For example, contrary to national recommendations, many physicians are less apt to
vaccinate a child with an upper respiratory infection (URI) because they think it will increase the
vaccine's side effects or decrease its efficacy. </p>
<p>Lack of vaccination during acute care visits (compared with well-child visits), overly cautious
interpretation of contraindications (such as a URI), and lack of simultaneous administration of all
needed vaccines (sometimes because of parental objection to multiple shots during one visit) are
obstacles to age-appropriate vaccination, notes Dr. Zimmerman. Dr. Zimmerman and his
colleagues conducted telephone interviews with primary care physicians across the United States
to determine the likelihood that they would recommend vaccination in common clinical scenarios
and to probe the reasons behind their decisions.</p><p>
Only 4 percent of physicians who thought the risk for side effects was increased by URI were
likely to vaccinate a child with a URI, compared with 55 percent of physicians who thought there
would be no increased risk. Also, 83 percent of those who thought the efficacy of measles,
mumps, and rubella vaccine would not be affected by a URI recommended vaccination, compared
with only 8 percent of physicians who thought efficacy would decrease. Some physicians (11
percent) would not administer three injectable vaccines simultaneously based on beliefs about side
effects, parental objections, and vaccine efficacy. These findings have implications for both
provider education and the development of practice policies, conclude the researchers. </p>
<p class="size2"><a href=".">Return to Contents</a></p>
<a name="head3"></a><h1>Primary Care/Managed Care</h1>
<a name="head4"></a><h2>Routine use of antibiotics may not be the best way to
manage children's middle ear infections</h2>
<p>Except in the Netherlands, antibiotics are standard treatment for acute otitis media (AOM), that
is, middle ear infection, in most developed countries&#8212;indeed, this is the most frequent use of
antibiotics in the United States. However, routine use of antibiotics to prevent and treat children's
middle ear infections has uncertain benefits and contributes to the growing worldwide problem of
antibiotic resistance. Clinical trials provide only weak evidence that routine use of antibiotics
decreases the duration and severity of symptoms and prevents complications, according to Jack
Froom, M.D., of the State University of New York at Stony Brook, and Larry Culpepper, M.D.,
M.P.H., of Boston University, and their colleagues, authors of a recent study supported by the
Agency for Health Care Policy and Research (HS07035).</p> <p>
In reviewing the scientific literature, the researchers found that more than 80 percent of children
with AOM recover without antibiotics. They suggest that physicians use analgesics to treat AOM
symptoms and observe children to make sure their condition improves. Children less than 2 years
of age who are not treated with antibiotics require frequent re-evaluation. If antibiotics are used,
they should be given for less than 10 days. Physicians also should work with parents to eliminate
modifiable risk factors for AOM such as tobacco smoke. The most important risk factors for poor
outcomes are young age and attendance at day care centers. </p>
<p>More than 70 percent of AOM cases are immediately preceded by viral respiratory infections, and
there is evidence that contaminated hands and surfaces are more important than airborne
respiratory droplets in viral transmission. According to the researchers, increased hand washing by
staff and children at day care centers and the use of virucidal agents to wipe surfaces might reduce
this risk. For instance, in Iceland, penicillin-resistant pneumococci appeared in 1988 and increased
to nearly 20 percent of pneumococcal infections by 1993. After a campaign to decrease antibiotic
use, particularly for AOM, and to control spread of infections in day care centers, this rate
declined to 17 percent in 1994. This improvement was accomplished without compromising
clinical outcomes, note the researchers.</p><p>
These findings are reported in detail in two recent articles. See "Routine antimicrobial treatment
of acute otitis media. Is it necessary?" by Drs. Culpepper and Froom, in the November 26, 1997
<em>Journal of the American Medical Association</em> 278(20), pp. 1643-1645; and
"Antimicrobials for
acute otitis media? A review from the international primary care network," by Drs. Froom,
Culpepper, Max Jacobs, M.D., and others, in the July 1997 <em>British Medical Journal</em> 315,
pp.
98-102. </p>
<a name="head5"></a><h2>NSAIDs greatly increase risk of GI bleeding in
patients with dyspepsia</h2>
<p>If you suffer from dyspepsia&#8212;with symptoms ranging from stomach pain or discomfort, to
heartburn, nausea, and vomiting&#8212;you should minimize your use of nonsteroidal
antiinflammatory
drugs (NSAIDs). NSAIDs such as aspirin, ibuprofen (e.g., Advil, Motrin) and naproxen (e.g.,
Aleve) are available over-the-counter; many others are available with a doctors prescription.
NSAIDs increase the risk of gastrointestinal (GI) bleeding seven-fold in persons with dyspepsia,
according to a study supported in part by the Agency for Health Care Policy and Research
(HS07257). NSAIDs are mainstay medicine for those with arthritis and musculoskeletal problems,
making these dyspeptic patients at most risk for GI complications, explain John H. Kurata, Ph.D.,
M.P.H., of the University of California Los Angeles School of Medicine, and colleagues.</p> <p>
The researchers studied 545 patients visiting a family medicine clinic for dyspepsia to identify
predictors of GI bleeding and use of medical services for GI-related conditions after the initial
dyspepsia visit. They used initial and 1-year followup data to examine the impact on GI bleeding
and other GI problems of cigarette smoking, alcohol use, and NSAID use; existence of chronic
medical conditions; and patient demographic characteristics. Results showed that 52 percent of
patients were later seen for GI-related followup visits. The most important predictor of these
visits was use of NSAIDs. </p>
<p>Prior use of NSAIDs doubled the odds for any followup GI problem and increased the risk of GI
bleeding by a factor of 7. Seventy-eight percent of bleeders used NSAIDs compared with 33
percent of nonbleeders. In fact, current use of NSAIDs was the only significantly different variable
between patients who returned with a GI-related problem and those who did not. Forty-one
percent of patients with a followup GI-related service used NSAIDs compared with 26 percent of
patients with no GI followup. There was a moderate association between alcohol use and
bleeding; 44 percent of bleeders used alcohol compared with 16 percent of nonbleeders.</p> <p>
See "NSAIDs increase risk of gastrointestinal bleeding in primary care patients with dyspepsia,"
by Dr. Kurata, Aki N. Nogawa, M.S., and Dean Noritake, M.D., in the September 1997 issue of
<em>The Journal of Family Practice</em> 45(3), pp. 227-235. </p>
<a name="head6"></a><h2>Practice-based research project documents effects of
low education on women's mammography decisions</h2>
<p>The cost of a mammogram and lack of insurance are not the most prevalent barriers to
mammography screening among poor New England women who receive care at community
health centers (CHCs). Instead, thinking the test is not important ("don't need it" or "don't want
it") is the most common reason for not receiving a mammogram. These women simply don't think
a mammogram is necessary, according to a practice-based research project supported by the
Agency for Health Care Policy and Research and the Bureau of Primary Health Care.</p> <p>
As increasing numbers of patients become enrolled in managed care plans, concerns about
cost&#8212;historically the greatest barrier to mammography&#8212;will cease to be an issue. The
challenge then
will be to improve patient acceptance, according to Anthony Valdini, M.D., M.S., of Tufts
University Medical School, and Lucia C. Cargill, B.S.N., Ph.D., of Marlboro College, authors of
the study.</p>
<p>For the study, questionnaires were administered in 1995 by staff of 32 community health centers
in 6 New England States to 2,943 low-income women; 932 of the women were 40 to 49 years of
age, and 2,011 women were 50 years of age or older. Seventy percent of these women reported
having had a breast examination by a provider within the preceding 2 years; 87 percent reported
that mammography was recommended. More women 50 years of age or older (55 percent) had
undergone mammography during the previous 2 years than women in the 40 to 49 age group (45
percent). Most women who had not had a mammogram said it was because they thought that "the
test was not important." Expense was a secondary reason within the community health center
population, where a majority of patients have mammography costs covered by insurance.</p> <p>
The national goal by the year 2000 is to have 60 percent of women 50 years of age and older
receive a mammogram every 2 years. It is estimated that this approach could reduce breast cancer
death rates by 30 percent. This study's results show that progress is being made toward this goal
among low-income New England women seen in community health centers.</p>
<p>For more information, see "Access and barriers to mammography in New England community
health centers," by Drs. Valdini and Cargill, in the September 1997 <em>Journal of Family
Practice</em>
45(3), pp. 243-249.</p>
<p class="size2"><a href=".">Return to Contents</a></p>
<a name="head7"></a><h1>Outcomes/Effectiveness Research</h1>
<a name="head8"></a><h2>Managing infants at risk for group B streptococcal
disease, although costly, is cost effective</h2>
<p>Group B streptococcus (GBS) is the most common cause of neonatal sepsis and a major cause of
neonatal disease and death in the United States. The Centers for Disease Control and Prevention
(CDC) recently recommended two strategies to treat pregnant women suspected of being infected
with GBS to minimize the risk of early-onset GBS in newborns.</p> <p>
Total costs are substantial for managing infants at risk for GBS whose mothers are treated in line
with the CDC strategies, according to a study supported in part by the Agency for Health Care
Policy and Research (PORT contract 290-92-0055). Nevertheless, these costs do not negate the
value of a GBS neonatal prevention strategy, concludes the Patient Outcomes Research Team on
Low Birthweight in Minority and High-Risk Women, which is led by Robert L. Goldenberg,
M.D., of the University of Alabama at Birmingham. </p>
<p>The researchers estimated the costs of pediatric care provided to full-term asymptomatic infants
when pediatricians followed either of the CDC strategies for managing infants whose mothers
received intrapartum antibiotics to treat suspected GBS infection. One strategy is based on
positive maternal culture screening (as recommended by the American Academy of Pediatrics),
and the other is based on maternal risk factors for GBS (as recommended by the American
College of Obstetricians and Gynecologists). The CDC recommends that pediatricians observe
asymptomatic infants for at least 48 hours if their mothers received more than 4 hours of
antibiotics. If mothers at risk received less than 4 hours of intrapartum antibiotics, physicians
should order a complete blood count and blood culture; asymptomatic infants with normal results
should be observed for at least 48 hours.</p> <p>
The research team found that the cost of managing an annual U.S. birth cohort of 3.95 million
asymptomatic full-term infants in this way would be $41 million for a culture-based approach and
$33 million for a risk-factor-based approach. Hospital and physician costs account for more than
78 percent of this total. Incorporating pediatric costs into previous PORT cost-effectiveness
analyses of obstetrical strategies increased the cost per sepsis case averted by as much as 51
percent for culture-based strategies and 112 percent for risk- factor-based strategies. </p>
<p>For more details, see "The pediatric costs of strategies for minimizing the risk of early-onset
Group B streptococcal disease," by Crayton A. Fargason Jr., M.D., M.M., Myriam
Peralta-Carcelen, M.D., M.P.H., Dwight J. Rouse, M.D., and others, in the September 1997
<em>Obstetrics &amp; Gynecology </em>90(3), pp. 347-352.</p>
<a name="head9"></a><h2>ACE inhibitors are more effective than other blood
pressure medicines at slowing kidney disease</h2>
<p>Diabetes is the single largest cause of end-stage renal disease in the United States, accounting for
about 30 percent of new cases. Over the past decade, many clinical trials have shown that
angiotensin-converting enzyme (ACE) inhibitors are effective in slowing the progression of
diabetic renal disease. A recent study supported in part by the Agency for Health Care Policy and
Research (HS07782 and HS08532) shows that ACE inhibitors also are more effective than other
antihypertensive medications in delaying the onset of end-stage renal disease in individuals who do
not have diabetes. It is not clear, however, whether this beneficial effect is due to the greater
decline in blood pressure or to other effects of ACE inhibition, notes Joseph Lau, M.D., of Tufts
University School of Medicine.</p><p>
The researchers used a meta-analysis of 10 randomized studies (1,594 patients) to compare the
impact of ACE inhibitors with other antihypertensive agents on the development of end-stage
renal disease caused by factors other than diabetes. Among 806 patients receiving ACE inhibitors,
6 percent developed end-stage renal disease, and 2 percent died; in the 788 controls who received
other antihypertensive agents, the respective values were 9 percent and 1.5 percent. The pooled
relative risks were 0.70 (95 percent confidence interval [CI], 0.51-0.97; 1 is equal risk) for
end-stage renal disease and 1.24 (95 percent CI; 0.55-2.83) for mortality. Patients who received
ACE inhibitors had 4.9 mm Hg greater decrease in mean systolic and 1.2 mm Hg greater decrease
in mean diastolic blood pressure than control patients during followup. Therefore, the greater
decline in systolic blood pressure may have been large enough to account for the clinically
significant beneficial effect on progression of renal disease, according to the researchers. </p>
<p>Most study patients were men aged 44 to 66 years. Renal function was mildly impaired in patients
in three studies, moderately impaired among patients in five studies, and severely impaired in
patients in two studies. In most studies, the proportion of men who had hypertensive
nephrosclerosis, glomerular and interstitial diseases, and polycystic kidney disease was similar to
that of patients with nondiabetic end-stage renal disease. The researchers estimated decline in
renal function from serum creatinine level, creatinine clearance, or glomerular filtration rate.
Antihypertensive agents studied were enalapril, captopril, cilazapril, and benazepril.</p> <p>
Details are in "Effects of angiotensin-converting enzyme inhibitors on the progression of
nondiabetic renal disease: A meta-analysis of randomized trials," by Ioannis Giatras, M.D., Dr.
Lau, and Andrew S. Levey, M.D., in the September 1997 <em>Annals of Internal Medicine</em> 127(5), pp. 337-345. </p>
<a name="head10"></a><h2>Debate continues over appropriate treatment of BPH
and localized prostate cancer</h2>
<p>New technologies have become available over the past few years to diagnose and treat benign
prostatic hyperplasia (BPH, enlarged prostate) and prostate cancer, including drug therapies,
devices, and new surgical procedures, such as nerve-sparing prostatectomy (surgical removal of
the prostate). Dramatic increases in the incidence of prostate cancer are largely attributable to
increasing intensity of early detection efforts with digital rectal exams and prostate specific
antigen (PSA) testing. However, this has been accompanied by controversy about the best way to
treat clinically localized disease, ranging from watchful waiting (no treatment unless there is
evidence of disease progression) to radical prostatectomy, which can cause impotence and
incontinence, among other problems.</p> <p>
Three articles on BPH and prostate cancer research (supported by the Agency for Health Care
Policy and Research) were recently published and are summarized here. The first study,
conducted by the Prostate Patient Outcomes Research Team-II (PORT-II), reports results of a
nationwide survey on current management practices for both problems. The second study
(AHCPR grant HS06824) focuses on the rate of impotence and incontinence after nerve-sparing
radical prostatectomy. The third study describes the first 3 years of the Prostate Cancer
Intervention Versus Observation Trial (PIVOT) to find out whether watchful waiting or radical
prostatectomy results in better survival and quality of life for men with localized prostate
cancer.</p>
<p><strong>Barry, M.J., Fowler, Jr., F.J., Bin, L., and Oesterling, J.E. (1997). "A nationwide survey of
practicing urologists: Current management of benign prostatic hyperplasia and clinically
localized prostate cancer." (HS08397). <em>The Journal of Urology</em> 158, pp. 488-492.</strong> </p><p>
This nationwide survey of 394 practicing urologists provides insight into the current
treatment of
patients with BPH and localized prostate cancer. Not surprisingly, urologists reported seeing
many BPH patients, and while they commonly prescribed medication, many patients did not
require active treatment. Alpha-blockers were prescribed more than four times as often as
finasteride. Standard transurethral prostatectomy was by far the most common surgical procedure,
with variations such as transurethral incision or laser prostatectomy performed much less often.
Urologists used diagnostic practices consistent with published BPH guidelines, such as digital
rectal exams and PSA tests for men with suspected BPH. </p>
<p>However, urologists should more routinely use the American Urological Association symptom
index to gauge symptom severity and less routinely use upper tract imaging and cystoscopy,
according to the Prostate Patient Outcomes Research Team led by Michael J. Barry, M.D., of
Massachusetts General Hospital. The use of urinary flow and residual volume measurements,
which are optional according to the guidelines, varied among urologists.</p> <p>
The typical U.S. urologist performs about two prostate biopsies weekly and about one radical
prostatectomy per month. Whether this low surgical volume provides enough experience to result
in optimal outcomes is unknown, but higher volume often equates with better outcomes for many
surgical procedures. Cancer staging practices varied considerably. This is not surprising, given the
general lack of evidence relating particular staging practices to outcomes. However, recent
studies have suggested that bone scan and pelvic lymph node dissection have relatively low yields
in men with clinically localized cancer and low preoperative PSA levels. Also, pelvic
computerized tomography or magnetic resonance imaging may be insufficiently sensitive and
specific to guide therapeutic decisionmaking. The authors conclude that a more selective
approach to the use of these tests would decrease the costs of treatment for men with clinically
localized prostate cancer.</p>
<p><strong>Talcott, J.A., Rieker, P., Propert, K.J., and others (1997). "Patient-reported impotence
and incontinence after nerve-sparing radical prostatectomy." (HS06824). <em>Journal of the
National Cancer Institute</em> 89(15), pp. 1117-1123.</strong></p><p>
The rate of radical prostatectomy increased almost six-fold between 1984 and 1990, due in
part to
reported improvement in postoperative sexual potency after use of newly developed nerve-sparing
techniques, which prompted many men to choose surgery over radiation therapy. However, a new
study suggests that this approach, especially when nerves are spared on only one side, does not
improve postoperative sexual function nearly as much as had been thought. In nerve-sparing
radical prostatectomy, the surgeon identifies for potential preservation one or both of the
neurovascular bundles that lie adjacent to each side of the prostate, based on how close the cancer
is to the nerves. Thus, the operation that the patient receives&#8212;bilateral nerve-sparing,
unilateral
nerve-sparing, or non-nerve-sparing prostatectomy&#8212;is in some cases unpredictable prior to
surgery.</p>
<p>This study of 94 men before and after they underwent radical prostatectomy for early prostate
cancer involved questionnaires of sexual and urinary function before surgery and at 3 and 12
months after surgery, which the researchers correlated with the surgical technique used.
Compared with men who had not been treated with a nerve-sparing procedure, men who
underwent nerve-sparing radical prostatectomy, particularly of the bilateral type, were younger
and had better prognostic features, indicating less advanced cancers. Before surgery, 75 percent
of men not treated with a nerve-sparing procedure reported erections that were usually inadequate
for sexual intercourse compared with 33 percent and 5 percent of men who underwent unilateral
and bilateral nerve-sparing prostatectomies, respectively.</p> <p>
One year after surgery, most men reported inadequate erections, including 79 percent of men who
had bilateral nerve-sparing surgery. Unilateral nerve preservation provided no apparent benefit.
</p>
<p>In general, nerve-sparing surgery was associated with more use of absorbent pads at 3 and 12
months following treatment, and this approach was associated with substantial urinary
incontinence at 3 months but not at 12 months following surgery. Because men with preoperative
impotence and more advanced cancers receive nerve-sparing surgery less often, some of the
previously reported benefit of nerve preservation may be the result of patient selection and not of
the technique itself, concludes James A. Talcott, M.D., of Massachusetts General Hospital, who
led the study.</p>
<p><strong>Wilt, T.J., and Brawer, M.K., and PIVOT Executive Committee (1997). "The prostate
cancer intervention versus observation trial (PIVOT)." (Interagency Agreement; AHCPR,
VA, NCI). <em>Oncology</em> 11(8), pp. 1133-1143.</strong></p> <p>
It is still not known whether radical prostatectomy or expectant management (watchful
waiting)
provides longer survival and better quality of life for men with localized prostate cancer. The
Prostate Cancer Intervention Versus Observation Trial (PIVOT) is the first national randomized
controlled trial to compare the two strategies in men under age 75 with newly diagnosed prostate
cancer. It began 3 years ago, enrolled over 400 men by the fall of 1997, and will eventually enroll
1,000 men and have results in the year 2008. PIVOT, supported in part by an interagency
agreement between the Agency for Health Care Policy and Research, the Department of Veterans
Affairs, and the National Cancer Institute, is being conducted at over 50 Department of Veterans
Affairs and National Cancer Institute medical centers across the country. The men are randomized
to radical prostatectomy, with additional intervention for subsequent disease persistence or
recurrence, or to surveillance (watchful waiting), with palliative therapy generally reserved for
symptomatic or metastatic disease progression.</p>
<p>Both early intervention and expectant management involve potential risks and benefits. Radical
prostatectomy and radiation therapy offer the possibility of complete tumor eradication and cure.
They may reduce patient anxiety, the likelihood of cancer metastasis, and need for subsequent
interventions for disease progression. However, in individuals with poorly differentiated prostate
cancer, early intervention is less likely to completely eliminate cancer. These interventions also
may result in impotence and incontinence.</p><p>
In many men, treatment may not be necessary if expectant management is used. If men develop
symptoms due to local disease progression, relief can be provided by minor interventions
associated with minimal problems. The rate of metastasis may be similar regardless of whether
expectant management, surgery, or radiation is used. Therefore, expectant management may
improve quality of life compared with early intervention. On the other hand, expectant
management may miss an opportunity to prevent metastatic disease and prostate cancer-related
death. </p>
<p>The results from PIVOT will be useful, regardless of which strategy proves to be superior, since
randomized trials such as PIVOT can ensure that the treatment groups are balanced and that the
comparisons of outcomes are unbiased. The researchers stress the need for physicians to
encourage eligible men to enroll in PIVOT so that the preferred treatment approach for men with
clinically localized prostate cancer can be determined.</p>
<a name="head11"></a><h2>Elderly patients are unwilling to pay more to shorten
waiting time for cataract surgery</h2>
<p>Waiting lists for elective surgery are common in many countries. Because waiting lists are often
unpopular, countries have developed a variety of initiatives to reduce the total number of people
on the waiting lists, including subsidizing care in the private sector, priority-setting to identify
patients most in need, and other measures. A recent study, supported in part by the Agency for
Health Care Policy and Research (HS07085), investigated the preferences of patients in Denmark,
Manitoba, Canada, and Barcelona, Spain who were on waiting lists for cataract surgery.</p><p>
Despite dissatisfaction with long waits for cataract surgery, the majority of elderly people in this
study were unwilling to pay more to reduce the wait, according to Gerard F. Anderson, Ph.D., of
Johns Hopkins University, and colleagues. The researchers used a willingness-to-pay
questionnaire to interview 464 individuals in the three countries who had recently been placed on
waiting lists for cataract surgery. At the time they were placed on the list, these patients expected
to wait from 1 to 18 months for surgery. Subjects were interviewed three times: when they were
first put on the waiting list, upon completion of surgery, and 4 months later. </p>
<p>The majority of cataract surgery candidates in this study were unwilling to pay higher taxes to
reduce the length of the waiting list or to pay more out of pocket to have the surgery performed
earlier in the private sector&#8212;less than 2 percent of study participants actually had the
surgery done
in the private sector.</p> <p>
Willingness to pay was greater for persons with more education, lower visual acuity, more
problems with their vision, and longer anticipated waiting time. There was limited support for
higher taxation to reduce waiting time (12 percent of candidates from Spain, 24 percent from
Denmark, and 15 percent from Canada). The remainder either said they were unwilling or (in
Denmark) did not know if people should pay higher taxes for this option. </p>
<p>In all three countries, patients can go to a private clinic and pay an average of $1,000 out of
pocket for cataract surgery on one eye with a 1-month wait. As the out-of-pocket price increased
from $500 to $2,000, the percentage of candidates who would opt for private surgery declined.
For instance, 29 percent of those in Spain, 17 percent in Denmark, and 38 percent in Canada were
willing to pay $500 out of pocket; only 23 percent, 11 percent, and 7 percent, respectively, were
willing to pay $2,000. Patients waited an average of 0.2 months longer than they expected to wait
in Spain, 0.9 months longer in Denmark, and 0.6 months longer in Canada. When interviewed 4
months after surgery, about one-third of respondents said they waited longer or much longer than
they would have preferred.</p> <p>
The existence of waiting lists is often cited by U.S. policymakers as a reason why the United
States should not adopt the health care systems of other countries. Other countries have used
waiting lists to control the demand for services, with some success. Some managed care
organizations in the United States may begin to use waiting lists to constrain the demand for
services, although it is also possible that they would prove too unpopular in the marketplace,
conclude the researchers.</p>
<p>See "Willingness to pay to shorten waiting time for cataract surgery," by Dr. Anderson, Charlyn
Black, Elaine Dunn, and others, in the September/October 1997 <em>Health Affairs</em> 16(5), pp.
181-191.</p>
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