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<p><strong>You Are Here:</strong> <span class="crumb_link"><a href="/" class="crumb_link">AHRQ Archive Home</a> &gt; <a href="/research/resarch.htm" class="crumb_link"><em>Research Activities</em> Archive</a> &gt; <a href="." class="crumb_link">July 1997</a>
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<td><h1><a name="h1" id="h1"></a>AHCPR News and Notes </h1>
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<td><div id="centerContent"><div class="headnote">
<p>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 It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work.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: <a href="https://info.ahrq.gov/">https://info.ahrq.gov</a>. Let us know the nature of the problem, the Web address of what you want, and your contact information. </p>
<p>Please go to <a href="https://www.ahrq.gov/">www.ahrq.gov</a> for current information.</p></div>
<a name="head1"></a>
<a name="head2"></a><h2>Contracts awarded for 12 Evidence-based Practice
Centers</h2>
<p>The Agency for Health Care Policy and Research has awarded 12 5-year contracts to institutions
in the United States and Canada that will serve as Evidence-based Practice Centers (EPCs). This
new program is intended to help clinicians, providers, and health plans improve the quality of
health care by giving them state-of-the-art scientific information on common, costly medical
conditions and new health care technologies.</p> <p>
The EPCs will review all the relevant scientific literature on medical topics assigned to them by
AHCPR and conduct additional analyses when appropriate. Their findings will be produced as
"evidence reports" or technology assessments, which AHCPR will disseminate widely through
its site on the World Wide Web and as printed documents. The evidence reports will serve as the
scientific foundation for public- and private-sector organizations to develop tools and strategies
for improving the quality of health care services they provide and pay for. Technology
assessments produced by the EPCs will give health plans and payers information they need to
make informed decisions about covering new and changing medical devices and procedures.</p>
<p>AHCPR's Evidence-based Practice Program, which includes the EPCs, and the recently
announced National Guideline Clearinghouse&#8482; will help clinicians, health plans, and other providers make critical health care decisions using
the best scientific knowledge available. AHCPR's goal is to use the Internet and every other
means of dissemination to ensure that this information is used to provide high quality health care
services and achieve the best value possible for the money spent on health care.</p><p>
The EPCs will tackle specific topics within broad areas such as adult health, child and adolescent
health, maternal health, geriatrics, rehabilitation, dental health, mental health and substance
abuse, alternative care, and preventive care. The first set of topics, nominated by public- and
private-sector organizations in response to a solicitation published by AHCPR in November
1996, will be announced this summer. </p>
<p>AHCPR expects this initiative to be invaluable not only to individual clinicians, health plans,
providers, and purchasers, but also to the health care system as a whole by providing important
information to help reduce inappropriate variations in medical practice.</p> <p>
To bring the broadest range of experts into the development of evidence reports and health
technology assessments, the EPCs are encouraged to form partnerships and enter into
collaborations with other medical and research organizations. The EPCs will work with partner
organizations to ensure that the evidence reports and technology assessments they produce will
become building blocks for health care quality improvement projects throughout the country.</p>
<p>AHCPR's Evidence-based Practice Centers and their collaborators are: </p>
<ol>
<li> <strong>Blue Cross/Blue Shield Technical Evaluation Center, Chicago IL.</strong> Collaborators
include:
Kaiser Permanente and, through members of the TEC Medical Advisory Panel, the American
College of Physicians; the University of Washington; the Massachusetts Institute of
Technology; the Wisconsin School of Medicine; the University of Pittsburgh; and Johns
Hopkins University.</li>
<li><strong> Duke University, Durham, NC.</strong> Subcontractor, Health Economics Research,
Inc., Waltham,
MA.</li>
<li> <strong>ECRI, Plymouth Meeting, PA.</strong> Collaborators include the Leonard Davis
Institute
and the
Philadelphia School of Pharmacy and Science.</li>
<li> <strong>Johns Hopkins University, Baltimore, MD.</strong> Collaborators include the University
of
Maryland and the Baltimore Cochrane Center.</li>
<li> <strong>McMaster University, Hamilton, Ontario, Canada.</strong> Collaborators include the
Canadian
Cochrane Center and St. Josephs Hospital.</li>
<li> <strong>MetaWorks, Inc., Boston, MA.</strong> Collaborators include the Leonard Davis
Institute
and the
Philadelphia VA Medical Center.</li>
<li><strong> New England Medical Center, Boston, MA.</strong> Collaborators include the San
Francisco
Cochrane Center, Blue Cross/Blue Shield of Massachusetts, and the Tufts Managed Care
Institute.</li>
<li> <strong>Oregon Health Sciences University, Portland.</strong> Collaborators include Kaiser
Permanente
Northwest and the Northwest VA Medical Center.</li>
<li> <strong>RAND Corporation, Santa Monica, CA.</strong> Collaborators include the University of
California,
Los Angeles; the University of California, San Diego; the University of Southern California;
Cedars Sinai Hospital; Value Health Sciences; and VA Medical Centers.</li>
<li> <strong>Research Triangle Institute and the University of North Carolina at Chapel Hill.</strong>
Collaborators include: the Morehouse Medical Treatment Effectiveness Center, Morehouse
School of Medicine; the Urban Health Institute, Harlem Hospital Center; and the Harvard
School of Public Health, Center for Quality of Care Research and Education.</li>
<li><strong>The University of California, San Francisco, and Stanford University.</strong>
Collaborators
include the San Francisco Cochrane Center, Kaiser Permanente, and VA Medical Centers in
San Francisco, Palo Alto, and Menlo Park.</li>
<li><strong>The University of Texas, San Antonio.</strong> Collaborators include the San Antonio and
San
Francisco Cochrane Centers and the American College of Physicians. </li>
</ol>
<a name="head3"></a><h2>AHCPR and the American Academy of Nursing
announce selection of second Senior Nurse Scholar</h2>
<p>The Agency for Health Care Policy and Research, in conjunction with the American Academy of
Nursing, has selected Lorraine Tulman, D.N.Sc., R.N., F.A.A.N., as the second Senior Nurse
Scholar in Residence. Under this program, senior nurse scientists help AHCPR develop areas of
investigation that integrate clinical nursing care questions with critical issues of quality, cost, and
access to health care.</p><p>
Dr. Tulman currently is an Associate Professor in the University of Pennsylvania's School of
Nursing. She will be on sabbatical from that position during her appointment as Senior Nurse
Scholar. For the past 10 years, Dr. Tulman's research has focused on the health of women during
life transitions, specifically during childbearing and following diagnosis of cancer. During her
tenure as Senior Nurse Scholar, Dr. Tulman plans to examine how clinical trial interventions not
specific to women have added to our knowledge of the functional status of women. She hopes to
study the relationship between clinical conclusions and national health care policy. </p>
<p>The Senior Nurse Scholar program is associated with AHCPR's Center for Primary Care
Research which supports studies of primary care and clinical, preventive, and public health
policies and systems. This includes studies of the effectiveness of education, supply, and
distribution of the health care workforce. Senior nurse scholars are appointed to serve for 1 year. </p>
<p>Dr. Tulman received a bachelor of arts degree from New York University's Washington Square
College and a bachelor of science degree, magna cum laude, from the State University of New
York Downstate Medical Center. She completed her master of science degree in nursing at
Russell Sage College in Troy, N.Y., and earned her doctorate in nursing science from the
University of Pennsylvania in Philadelphia. </p>
<p>Dr. Tulman has served as a nursing educator at several universities. She is a senior fellow at the
Leonard Davis Institute of Health Economics and is a research fellow with the Center for
Advancing Care in Serious Illness, both at the University of Pennsylvania. Dr. Tulman has
published numerous articles and book chapters.</p>
<p class="size2"><a href=".">Return to Contents</a></p>
<a name="head4"></a><h1>Announcements</h1>
<a name="head5"></a><h2>Five new projects focus on quality-of-life and
cost-effectiveness issues</h2>
<p>The Agency for Health Care Policy and Research has funded five new research projects designed
to improve health outcomes, patient satisfaction, and overall quality of care. These projects are
expected to provide important measures to help physicians and other providers assess patients'
well-being and improve outcomes of care.</p> <p>
The awards total $1.19 million for the first year of the projects. </p>
<p>The newly funded projects are:</p>
<ul>
<li> <strong>Quality of Well-Being Scale Revision Project (Grant HS09170). Principal
investigator:
Robert M. Kaplan, Ph.D., University of California, San Diego, La Jolla, CA. Project
period 1997 to 2000. First-year funding $231,035.</strong> This study will expand the application
and usefulness of the Quality of Well-Being (QWB) Scale, a widely used health status
measure that helps determine the quality of life. Specifically, the project will eliminate two
barriers to more widespread use: the fact that the QWB cannot be self-administered and its
lack of a profile of outcomes.</li>
<li><strong>Medical Intervention Effectiveness and Outcomes in COPD (Grant HS08774).
Principal investigator: David R. Carter, M.S., Ph.D., University of Texas Health Center,
Tyler, TX. Project period 1997 to 2000. First-year funding $241,888.</strong> This project will
determine how variations in exercise training reduce mortality and increase quality of life for
patients suffering from chronic obstructive pulmonary disease (COPD). Documenting these
benefits could provide the needed justification for including exercise as part of a standard of
care for COPD patients.</li>
<li> <strong>Statistical Inference for Cost-Effectiveness Analysis (Grant HS09514). Principal
investigator: Joseph Gardiner, Ph.D., Michigan State University, East Lansing, MI.
Project period 1997 to 2000. First-year funding $198,162.</strong> This project will develop and
test new statistical procedures for cost-effectiveness analyses. It will address the development
of models that accurately reflect the experiences of patients in sustained and changing states
of health.</li>
<li><strong>Severity of Lower Respiratory Tract Illness in Infants (Grant HS09062). Principal
investigator: Kenneth M. McConnochie, M.D., M.P.H., University of Rochester School
of Medicine and Dentistry, Rochester, NY. Project period 1997 to 2000. First-year
funding $269,144.</strong> This study will develop a predictive measure of lower-respiratory tract
infections in infants that could serve as a guide to which infants should be hospitalized.
Lower-respiratory tract illness (LRI) is the most common reason infants are hospitalized after
the neonatal period and accounts for about $700 million in health care costs annually. </li>
<li><strong>Patient-Centered, Computer-Assisted Quality Improvement (Grant HS08823).
Principal investigator: Lisa E. Harris, M.D., Indiana University, Indianapolis, IN.
Project period 1997 to 1998. First-year funding $253,556.</strong> This project will extend the
techniques of computer-generated reminders to improving patient satisfaction and outcomes
of care. It will also conduct a randomized controlled trial testing the effect on patient
outcomes of a patient-centered, computer-assisted intervention targeted toward physicians and
nurses. </li>
</ul>
<h2><em>healthfinder&reg;</em></h2>
<p><a href="http://www.healthfinder.gov/">healthfinder&reg;</a> is your gateway to online consumer
health information produced by the
Federal Government and its many partners. healthfinder&reg; features a searchable index
and
locator aids for news, publications, online journals, support and self-help groups, online
discussions, and toll-free numbers. The site's coverage is broad and deep. You can locate
information on topics such as heart disease, breast cancer, infectious diseases, women's health,
aging, HIV/AIDS, and more. And best of all, it's free.</p>
<a name="head6"></a><h2>AHCPR funds new grants</h2>
<p>The following small project grants, conference grants, and National Research Service Awards
were funded recently by the Agency for Health Care Policy and Research. Readers are reminded
that the results of studies usually are not available or published until a project is completed or
nearing completion. </p>
<h3>Small Project Grants</h3>
<p><strong>Complements and substitutes in the production of health</strong></p>
<p>Project director: Michael L. Ganz, Ph.D.<br />
Organization: Columbia University, New York, NY<br />
Project no: AHCPR grant HS09610<br />
Period: 7/1/97 to 6/30/98<br />
Funding: $30,289</p>
<p><strong>Issue complexity in academic health centers</strong></p>
<p>Project director: Christopher E. Johnson, B.S.<br />
Organization: University of Minnesota,
Minneapolis, MN<br />
Project no: AHCPR grant HS09593<br />
Period: 6/1/97 to 5/31/98<br />
Funding: $29,122</p>
<p><strong>Risk-bearing arrangements and capital for financing integrated health systems</strong></p>
<p>Project director: Douglas A. Conrad, Ph.D.<br />
Organization: University of Washington,
Seattle, WA<br />
Project no: AHCPR grant HS09536<br />
Period: 7/1/97 to 6/30/98<br />
Funding: $73,013</p><p>
<strong>Risk factors for early unscheduled visits in cancer patients</strong></p>
<p>Project director: Danna J. Kurtin, M.P.H.<br />
Organization: University of Texas Health Science Center,
Houston, TX<br />
Project no: AHCPR grant HS09613<br />
Period: 7/1/97 to 10/31/98<br />
Funding: $26,722</p><p>
<strong>Staff work in an urban medical rehabilitation hospital</strong></p>
<p>Project director: Diane R. Pawlowski, M.A.<br />
Organization: Wayne State University,
Detroit, MI<br />
Project no: AHCPR grant HS09603<br />
Period: 9/1/97 to 8/31/98<br />
Funding: $31,659</p>
<h3>Conference Grant</h3>
<p><strong>Developing standards of practice</strong></p>
<p>Project director: Lawrence J. Schneiderman, M.D.<br />
Organization: University of California, San Diego <br />
La Jolla, CA<br />
Project no: AHCPR grant HS09534<br />
Period: 7/1/97 to 6/30/98<br />
Funding: $30,075</p>
<h3>National Research Service Award Fellowships</h3>
<p><strong>Validity of computer-based utility elicitation</strong></p>
<p>Fellow: Jonathan R. Treadwell, Ph.D.<br />
Organization: Stanford University,
Stanford, CA<br />
Project no: AHCPR grant F32 HS00122 <br />
Leslie A. Lenert, sponsor<br />
Period: 2-year fellowship<br />
Funding: $25,420</p><p>
<strong>Utilizing primary care: Attitudes and barriers</strong></p>
<p>Fellow: Anna E. Plauth, M.D.<br />
Organization: Harvard Pilgrim Health Care,
Brookline, MA<br />
Project no: AHCPR grant F32 HS00119 <br />
Thomas S. Inui, sponsor<br />
Period: 1-year fellowship<br />
Funding: $33,500 </p>
<a name="head7"></a><h2>Managed care audiotapes now available</h2>
<p>The Agency for Health Care Policy and Research's User Liaison Program hosted a conference on
managed care March 24-26, 1997, in Boston, MA. The conference theme was "Integrated
Delivery Systems in Managed Care: Challenges to State Oversight," and its objective was to help
State and local health officials understand the function of provider-sponsored integrated delivery
systems within a system of managed care. In particular, the conference focused on the public
policy issues raised at the State level by the emergence of these systems, including licensing,
quality assurance oversight, public purchasing issues, and community accountability.</p><p>
Audiotapes containing a transcript of the conference are now available free from AHCPR's
Publications Clearinghouse. You may order the entire set of 14 tapes (AHCPR 97-AV02), or you
may order one or more individual tapes (see order numbers below). See the back cover of
Research Activities for ordering information, and please use the AHCPR AV number when
ordering. The tapes are organized by session, as follows:</p>
<p>Session 1: Welcome, Introduction and Overview; AHCPR 97-AV02(A)<br />
Session 2: The Evolving Managed Care Marketplace: Can the Empire Strike Back? AHCPR
97-AV02(B)<br />
Session 3: What Are Integrated Delivery Systems? Part I: Definitions; AHCPR 97-AV02(C)<br />
Session 4: What Are Integrated Delivery Systems? Part II: Models Action; (two tapes) AHCPR
97-AV02(D, E)<br />
Session 5: Managed Care Plan Contracts with Integrated Delivery Systems; AHCPR
97-AV02(F)<br />
Session 6: Challenges to Public Purchasers' Contracting with Integrated Delivery Systems;
AHCPR 97-AV02(G)<br />
Session 7A: IDSs and State Oversight: Square Pegs in Round Holes? AHCPR 97-AV02(H)<br />
Session 7C: State Oversight Issues Wrap-Up; AHCPR 97-AV02(I)<br />
Session 8: State Interagency Collaboration; AHCPR 97-AV02(J)<br />
Session 9: IDSs and Community Accountability; AHCPR 97-AV02(K)<br />
Session 10: Emerging Issues for Policymakers: A Roundtable Discussion; (two tapes) AHCPR
97-AV02(L, M)<br />
Session 11: Workshop Evaluation and Concluding Comments; AHCPR 97-AV02(N) </p>
<p class="size2"><strong>Note:</strong> Session 7B involved a series of break-out groups which were not taped.</p>
<p class="size2"><a href=".">Return to Contents</a></p>
<a name="head8"></a> <h1>Research Briefs</h1>
<a name="head9"></a><p><strong>Andrews, W.W., Lee, H.H., Roden, W.J., and Mott, C.W. (1997, April).
"Detection of
genitourinary tract <em>Chlamydia trachomatis</em> infection in pregnant women by ligase chain
reaction assay." (AHCPR contract 290-92-0055). <em>Obstetrics and Gynecology </em>89, pp.
556-560.</strong></p><p>
<em>Chlamydia trachomatis</em>, the most common sexually transmitted bacterial pathogen in the United
States, has been linked to increased risk for preterm birth and low birthweight. But the
association remains controversial, suggesting the need for further investigation with more
sensitive techniques for <em>C. trachomatis</em> detection. These researchers compared the sensitivity and
specificity of a ligase chain reaction assay of cervical swabs and voided urine with those of
cervical swab tissue culture for the detection of genitourinary tract infection with <em>C. trachomatis</em> in 462 pregnant women during routine visits to prenatal clinics. The prevalence of infection was
6 percent by cervical culture, 18 percent by ligase chain reaction of cervical swab, and 17 percent
by ligase chain reaction of urine. Ligase chain reaction of cervical swabs and urine detected 89
percent and 82 percent, respectively, of women with a positive cervical culture. The researchers
conclude that ligase chain reaction testing of urine is a simple and effective means of screening
pregnant women for this genitourinary tract infection.</p>
<a name="head10"></a><p><strong>Black, M.M., and Teti, L.O. (1997, March). "Promoting mealtime
communication between
adolescent mothers and their infants through videotape." (AHCPR grant HS07392).
<em>Pediatrics</em> 99(3), pp. 432-437.</strong></p><p>
Adolescents gave birth to about one of every eight infants (13 percent) born in the United States
in 1993. This study shows that brief, culturally sensitive videotapes may be an effective way to
promote parenting skills among adolescent mothers. The researchers compared the mealtime
communication and attitudes of black adolescent mothers who viewed a short, fast-action
videotape with those of similar mothers who did not view the videotape. The tape included
real-life segments of urban, adolescent mothers feeding their babies, while modeling healthy
nutrition and loving communication. During baseline and followup, the young women were
viewed feeding their babies, and they completed a questionnaire on attitudes toward mealtime
behavior. The mothers who had viewed the videotape were more involved with their infants and
reported more favorable attitudes toward feeding and communication than mothers who had not
seen the videotape. </p>
<a name="head11"></a><p><strong>Markson, L.E., Turner, B.J., Cocroft, J., and others (1997, March).
"Clinic services for
persons with AIDS." (AHCPR grant HS06465). <em>Journal of General Internal Medicine</em> 12,
pp. 141-149.</strong></p><p>
In this study of services provided to Medicaid-insured HIV-infected patients in community-based
clinics in New York were significantly more likely to have longer hours, a physician on call, and
to accommodate unscheduled care than were hospital-based general medicine/primary care
clinics or other types of clinics. Compared with HIV-specialty clinics, hospital-based general
medicine clinics were less apt to have features that facilitate HIV-specific care, such as a director
of HIV care (98 percent vs. 72 percent of clinics studied), multidisciplinary conferences on HIV
care (83 percent vs. 32 percent), or a standard initial HIV workup for new patients (90 percent vs.
70 percent). In addition, community-based clinics offered more ancillary services than
hospital-based clinics&#8212;such as substance abuse treatment, psychological services, and case
managers. At least half of the clinics in the study integrated medical and social support services
in one setting by providing housing assistance and financial counseling services on site. Shifting
HIV-infected Medicaid enrollees into managed care arrangements might not support a similar
array of services, note the authors of the study. Their findings are based on a survey of services
available in 179 New York clinics from 1987 to 1992 based on data from the New York State
Medicaid HIV/AIDS Research Data Base.</p>
<a name="head12"></a><p><strong>McCormick, K., Renner, A.L., Mayes, R., and others (1997, April).
"The Federal and
private sector roles in the development of minimum data sets and core health data
elements." <em>Computers in Nursing</em> 15(2S), pp. S23-S32.</strong></p>
<p>This article describes Federal and private efforts to define minimum data sets and core data
elements for health care. This has been an ongoing Federal effort for more than 25 years. The
researchers report on 17 minimum data sets and core health data elements that are published or in
draft form in health care to date. They include regulated data elements that are needed for
reimbursement from the Health Care Financing Administration and core health data elements
from the Health Resources and Services Administration. They also include recommended data
elements for better reporting to the Government and private-sector initiatives that are under
development, being researched, or in use to standardize data collection for assessing access,
quality, and costs of health care. This framework can be used in furthering research on the
development of a computer-based patient record, the acceleration of data standards, and the
evaluation of vocabulary in health care.</p> <p>Reprints (AHCPR Publication No. 97-R054) are
available from the <a href="https://www.ahrq.gov/research/publications/order/order-research-activities.html">AHCPR Publications Clearinghouse</a>.</p>
<a name="head13"></a><p><strong>Shea J.A., Healey, M.J., Berlin, J.A., and others (1996, November).
"Mortality and
complications associated with laparoscopic cholecystectomy: A meta-analysis." <em>Annals of
Surgery</em> 224(5), pp. 609-620. </strong></p><p>
The researchers conducted a meta-analysis of 126 studies of laparoscopic (98 studies) and open
cholecystectomy (28 studies) published through 1995 to compare results concerning
complications, particularly bile duct injury, of the two procedures. Individual studies measured
rates of mortality, common bile duct injury (such as cuts and leaks), and conversion from
laparoscopic to open cholecystectomy (usually for technical problems, such as dense adhesions
or inflammation). Laparoscopic cholecystectomy resulted in lower mortality rates but higher
common bile duct injury rates than the open procedure. The researchers caution, however, that
the increased number of patients with uncomplicated gallstone disease after the introduction of
laparoscopic cholecystectomy in the United States in 1988 may explain the lower mortality rate
for the procedure, which was probably performed on less difficult patients. Also, rates of
common bile duct injury were higher in studies of inpatients (rather than in outpatients with
fewer difficulties) and in studies beginning in 1988 through the first half of 1990, suggesting an
association between injury and the surgeons' learning curve. Finally, types of complications
varied considerably between studies, making it difficult to draw conclusions about the true risks
associated with the procedure. However, risk of serious complications, such as pulmonary
embolism, pulmonary edema, bowel injury, and myocardial infarction, is less than 5 in 1,000 for
patients undergoing laparoscopic cholecystectomy.</p>
<a name="head14"></a><p><strong>Solberg, L.I., Mosser, G., and McDonald, S. (1997, March). "The three
faces of
performance measurement: Improvement, accountability, and research." (AHCPR grant
HS08091). <em>Joint Commission Journal on Quality Improvement</em> 23(3), pp.
135-147.</strong></p>
<p>There are increasing pressures from purchasers, legislators, and consumer advocates for public
disclosure of information on patient satisfaction and other health care outcomes. However,
clinicians often are wary of efforts to create quality measurement systems, in part because of the
difficulties involved in developing and collecting valid and reliable quality measures. This article
describes the efforts of the Institute for Clinical Systems Integration (ICSI), a quality
improvement organization that bridges a managed care organization and 19 medical groups in
Minnesota, to measure care for improvement purposes. The article also describes a randomized
trial involving more than 40 clinics of an intervention to use continuous quality improvement to
implement preventive services guidelines (the IMPROVE Project&#8212;Improving Prevention
Through Organization, Vision, and Empowerment). The authors discuss the difficulties
encountered and lessons learned about measuring quality during this 3-year study. In particular,
they cite the need to avoid confusing measurement for accountability or research with
measurement for improvement. Understanding these differences and respecting the
confidentiality of individual medical groups was crucial in helping these Minnesota clinicians
move past confusion and suspicion to genuine improvement actions involving multiple medical
groups and managed care plans.</p>
<p class="size2"><a href=".">Return to Contents</a></p>
<p class="size2"><em>AHCPR Publication No. 97-0064<br />
Current as of July 1997</em> </p>
<!-- <hr />
<p class="size2"><strong>Internet Citation:</strong></p>
<p class="size2"><em>Research Activities</em> newsletter. July 1997, No. 206. AHCPR Publication No. 97-0064. Agency for Health Care Policy and Research, Rockville, MD. https://www.ahrq.gov/research/jul97/</p>
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