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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 It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work.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="head1"></a>
<a name="head2"></a><h2>Oral rehydration therapy improves outcomes
for children with acute gastroenteritis</h2>
<p>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.</p>
<p>
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.</p>
<p>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.</p>
<p>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 <em>Pediatrics</em> 98(1), pp.
45-51.</p>
<a name="head3"></a><h2> Earlier referral to hospice care may benefit
terminally ill elderly patients</h2>
<p>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).</p>
<p>
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.
</p>
<p>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.</p>
<p>
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.</p>
<p>Details are in "Survival of Medicare patients after enrollment in
hospice programs," by Drs. Christakis and Escarce, in <em>The New
England Journal of Medicine</em> 335 (3), pp. 172-178, 1996. </p>
<a name="head4"></a><h2> Electrostimulation helps stroke patients
recover muscle strength</h2><p>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.</p>
<p>
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.
</p>
<p>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.</p>
<p>
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.
</p>
<p>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 <em>Archives of
Physical Medicine and Rehabilitation</em> 77, pp. 549-553.</p>
<p class="size2"><a href=".">Return to Contents</a></p>
<a name="head5"></a><h1> HIV/AIDS
Research</h1>
<a name="head6"></a><h2>Residency training can improve physicians'
attitudes towards treating AIDS patients</h2>
<p>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.</p>
<p>
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.
</p>
<p>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.</p>
<p>
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.
</p>
<p>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 <em>Journal of Health and Social
Behavior</em> 37, pp. 179-191.</p>
<p class="size2"><a href=".">Return to Contents</a></p>
<a name="head7"></a><h1>Access to Care</h1>
<a name="head8"></a><h2> Policies that reduce the number of minority
physicians also may reduce access to health care for poor people
and minorities</h2>
<p>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&#8212;as was
recently done in the California State university system&#8212;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.</p>
<p>
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.
</p>
<p>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.</p>
<p>
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.
</p>
<p>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, <em>New England Journal of Medicine</em> 334, pp.
1305-1310.</p>
<p class="size2"><a href=".">Return to Contents</a><br />
<a href="ra3.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>
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