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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">March 1996</a>
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<td><h1><a name="h1" id="h1"></a> Patient Care/Clinical Decisionmaking </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 It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work.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="s1"></a>
<h2>Combined anticoagulant/antiplatelet therapy reduces risk of
stroke after mechanical heart-valve replacement</h2>
<p>It is known that patients with prosthetic heart valves are at
increased risk for sudden blockage of an artery by a blood clot,
known as an arterial embolism. These patients are at particular
risk for stroke. This stroke risk can be reduced by long-term
treatment with oral anticoagulant therapy (usually warfarin).</p>
<p>Joseph Lau, M.D., and colleagues at the New England Medical
Center, Tufts University School of Medicine, and Boston
University School of Medicine performed a meta-analysis of five
randomized controlled trials that compared the efficacy and
safety of combined anticoagulant and antiplatelet therapy with
that of anticoagulant therapy alone after prosthetic heart-valve
replacement.</p><p>
The investigators were able to show that the risk of stroke may
be further reduced by adding antiplatelet agents such as aspirin
(500 to 1,000 mg daily) or dipyridamole (400 mg daily) to the
anticoagulant therapy of these patients. The combined regimen
reduced embolism by approximately two-thirds (67 percent). Less
than 3 percent of patients had an embolism when treated with the
combined therapy compared with about 9 percent of patients
treated with oral anticoagulants alone.</p>
<p>Although the combined regimen decreased overall mortality by 40
percent, it resulted in a 2.5-fold increase in major
gastrointestinal hemorrhage. For every 1.6 patients in whom
stroke was prevented by combination therapy, there was an excess
of one major gastrointestinal bleed. Nevertheless, the
researchers conclude that the benefits derived from the combined
therapy outweigh its toxic effects. Lowering the dose of aspirin
to between 75 and 100 mg per day may decrease the risk of
hemorrhage, noted Dr. Lau, who led the study. This research was
supported in part by the Agency for Health Care Policy and
Research (HS07782).</p><p>
For more information, see "Efficacy and safety of combined
anticoagulant and antiplatelet therapy versus anticoagulant
monotherapy after mechanical heart-valve replacement: A
meta-analysis," by Joseph C. Cappelleri, Ph.D., M.P.H., M.S.,
Louis D. Fiore, M.D., Mary T. Brophy, M.D., and others, in the
<em>American Heart Journal</em> 130(3), pp. 547-552, 1995.</p>
<a name="s2"></a>
<h2>Experts examine the relationship between early newborn
discharge and neonatal jaundice</h2>
<p>Some insurance plans require hospital discharge of mothers and
newborn infants within 24 hours of the infant's birth if there
are no recognized complications. Currently 1-4 percent of term
infants are readmitted to the hospital in the first week of
life&#8212;85 percent of these readmissions are for jaundice
(hyperbilirubinemia). Many other complications or indicators of
high risk for adverse outcomes also have been associated with
early discharge.</p>
<p>Furthermore, there is some evidence that pediatric care providers
have not adjusted adequately to new neonatal discharge policies.
For example, early discharge policies have sometimes been applied
inappropriately to groups such as premature infants. In addition,
early-discharge infants usually are not scheduled for a pediatric
appointment until 2 weeks after discharge. Thus undetected
hyperbilirubinemia (excess of bilirubin, a byproduct of
hemoglobin breakdown, in the blood) can result in neurotoxicity,
a condition called kernicterus. Anecdotal reports have recently
begun to surface of a reemergence of kernicterus, a condition
that had virtually disappeared in the United States.</p><p>
Participants at a recent workshop examined the potential impact
of early discharge on newborn outcomes. The workshop was convened
by the Agency for Health Care Policy and Research and the
National Institute of Child Health and Human Development in March
1995. According to Lisa Simpson, M.B., B.Ch., a pediatrician and
Deputy Administrator of AHCPR, conference participants found that
there is an inadequate science base to determine the safety and
appropriateness of discharge strategies, either new or old.
Furthermore, there is virtually no reliable information on
quality of care, health outcomes, impact on the public health,
socioeconomic impact, or consequences of early discharge or other
postpartum care strategies. Clearly, there is a pressing need for
appropriate research to shed light on these important aspects of
peri- and postnatal care, concluded Dr. Simpson.</p>
<p>In an article summarizing the conference, Dr. Simpson and her
colleagues offer a series of practice and research
recommendations, including epidemiologic and health services
research on various aspects of postdelivery care, prenatal and
perinatal education, strategies for postdischarge followup,
economic analyses of various discharge protocols, clinical trials
of specific treatments for hyperbilirubinemia, and studies of
other aspects of pre- and postdischarge management.</p><p>
See "Summary of workshop: Early discharge and neonatal
hyperbilirubinemia," by Charlotte Catz, M.D., James W. Hanson,
M.D., Dr. Simpson, and Sumner J. Yaffe, M.D., in <em>Pediatrics</em> 96(4), pp. 743-745, 1995.</p>
<a name="s3"></a>
<h2>Less than half of primary care physicians correctly diagnose
alcohol abuse</h2>
<p>The diagnosis of alcoholism or alcohol abuse is often missed by
physicians, even though asking just four questions (using the
CAGE questionnaire) is a reliable way of screening for alcoholism
in the primary care setting. The CAGE questionnaire is considered
a practical and reliable way to identify possible alcohol
problems among patients. The questions are simple: Have you ever
tried to Cut down on your drinking? Have you ever been Annoyed by
anybody criticizing your drinking? Have you ever felt Guilty
about your drinking? Have you ever had an Eye-opener (drink) in
the morning? Two positive answers is considered a standard
cutpoint for alcohol abuse.</p><p>
In a study supported by the Agency for Health Care Policy and
Research (HS06454), Paul G. Ramsey, M.D., and other University of
Washington researchers evaluated the performance of 134 primary
care doctors during a medical visit with 17 standardized patients
(SPs). SPs are trained to present a typical medical profile to
the physician.</p>
<p>The researchers found that more than 50 percent of the physicians
asked an initial alcohol screening question of three-fourths of
the patients they saw. However, few physicians further questioned
patients who reported drinking more than one drink per day. Also,
fewer than 50 percent of the doctors included alcohol abuse in
the diagnosis for patients who drank four or more drinks per day.</p><p>
The researchers conclude that many patients with moderate to
heavy alcohol use may be missed because physicians do not go
beyond an initial question about alcohol consumption to the brief
but sensitive further CAGE screening. These results suggest the
potential utility of using SPs to improve quality in primary care
practice.</p>
<p>More details are in "Do primary care physicians screen patients
about alcohol intake using the CAGE questions?" by Marjorie D.
Wenrich, M.P.H., Douglas S. Paauw, M.D., Jan D. Carline, Ph.D.,
and others, in the November 1995 <em>Journal of General Internal
Medicine</em> 10, p. 631-634.</p>
<p><strong>Attention Researchers:</strong> On March 15, 1996, AHCPR released a
Request for Applications (RFA HS-96-006) to conduct research related to
patient referrals from primary to specialty care. Applications
are sought for studies that (1) describe how changes in health
care organization affect referral practices, and/or (2) measure
quality of care or economic and other outcomes resulting from
decisions by primary care providers to refer, or not refer,
patients to specialty providers. Research under this RFA should
address issues related to referrals in the ambulatory care
setting.</p>
<p>Depending on the availability of funds, AHCPR expects to award up
to $1.5 million for the first year of projects under this RFA.
The deadline for applications is June 12, 1996. Direct
programmatic questions to: David Lanier, M.D., Center for Primary
Care Research, AHCPR (phone: 301-427-1567; E-mail: DLanier@ahrq.gov).</p>
<a name="s4"></a>
<h2>Inappropriate monitoring of antiepileptic drug levels may
result in higher hospital charges</h2>
<p>Although many doctors monitor antiepileptic drug levels in their
epileptic patients, a new study shows that only 27 percent of
these drug level measurements are appropriately indicated, and
half of the drug levels are not sampled correctly. Efforts to
decrease this inappropriate monitoring may substantially reduce
costs without missing important clinical results, conclude
researchers from Brigham and Women's Hospital.</p>
<p>In a study supported by the Agency for Health Care Policy and
Research (HS07107), the researchers assessed the drug levels at least 200
times for each of four antiepileptic drugs: phenytoin,
carbamazepine, phenobarbital, and valproic acid in 330 hospital
patients. Of the 624 antiepileptic drug level measurements
considered inappropriate (73 percent), only four (0.6 percent)
levels were potentially toxic, that is, more than 20 percent
higher than the upper limit of normal. Moreover, none of the four
patients had clinical signs of drug toxicity, and all four
samples had been drawn too soon after administration of the drug.</p><p>
Of the 27 percent of appropriate drug measurements, only 51
percent were sampled correctly, that is, drawn at the appropriate
interval between doses. This resulted in an overall
appropriateness rate of 14 percent. Most of the inappropriate
drug level measurements were part of a series of daily repeated
measurements performed after starting or changing the
antiepileptic drug regimen but before a pharmacological steady
state had been achieved, which can range from 3 days to 20 days
depending on the drug. If these inappropriate measurements had
not been performed, hospital charges would have decreased by
$302,740.</p>
<p>Details are in "Appropriateness of antiepileptic drug level
monitoring," by Ronald A. Schoenenberger, M.D., M.P.H., Milenko
J. Tanasijevic, M.D., Ashish Jha, and David W. Bates, M.D.,
M.Sc., in the November 22/29, 1995, <em>Journal of the American
Medical Association</em> 274(20), pp. 1622-1626.</p>
<p class="size2"><a href=".">Return to Contents</a><br />
<a href="dept2.htm">Proceed to Next Section</a></p>
<div class="footnote">
<p> The information on this page is archived and provided for reference purposes only.</p></div>
<p>&nbsp;</p>
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