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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">October 1996</a>
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<td><h1><a name="h1" id="h1"></a>Announcements </h1>
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<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 It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work.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><h2>New publications now available from AHCPR and
NTIS</h2>
<p>The following publications and final reports are now available
from either the <a href="https://www.ahrq.gov/research/publications/order/order-research-activities.html">AHCPR Publications Clearinghouse</a> or the
<a href="https://www.ahrq.gov/research/order.htm#ntis">National Technical Information Service</a> (NTIS). Select hot links for
ordering information.</p>
<p>
<strong><em>Conference Summary Report&#8212;Moving Toward International
Standards in Primary Care Informatics: Clinical Vocabulary</em>.
AHCPR Publication No. 96-0069. October 1996.</strong>
</p>
<p>In November 1995, the Agency for Health Care Policy and Research
and the American Medical Informatics Association cosponsored an
international conference in New Orleans, LA, which was the
beginning of a process to move toward international standards in
the clinical vocabulary used in primary care. Standards for
coding primary care data and a clinical vocabulary are needed to
increase the research usefulness of documentation from primary
care practitioners. Conference participants determined that no
existing vocabulary is sufficient for the many needs of primary
care, health statistics, billing, and health services research.
In this report, the strengths and weaknesses of the current
primary care vocabularies are identified, and targets are set for
future research. Conference participants agreed on three
vocabularies&#8212;the International Classification of Primary
Care
(ICPC), the Read Codes, and the Systematized Nomenclature of
Human and Veterinary Medicine (SNOMED)&#8212;to use as building
blocks
for the standard. In addition, the group recommended that all
primary care vocabularies be added to the Unified Medical
Language System (UMLS). The group developed a framework to
further efforts toward a standardized vocabulary and a plan to
integrate clinical vocabularies into other ongoing public- and
private-sector efforts.</p>
<p>
<strong><em>Prospective Evaluation of Enigmatic Meningitis</em>. AHCPR
grant HS07682. 4/1/94 to 3/31/96. Vincent J. Quagliarello, M.D.,
Yale University, New Haven, CT.</strong>
</p>
<p>This purpose of this pilot study was to determine whether
clinical features at presentation can identify the high-risk
subgroup of patients with enigmatic meningitis (fever, headache,
and cerebrospinal fluid [CSF] inflammation, with a negative CSF
Gram stain) who warrant hospitalization and urgent antibiotic
therapy and which patients are at low risk and can be safely
managed as outpatients. The researchers identified and followed
118 patients presenting with enigmatic meningitis to the two
emergency rooms serving New Haven, CT. They found that most
patients were young and healthy, and almost half presented during
nonsummer months. The majority of patients (76 percent) were
hospitalized and had a mean length of hospital stay of over 7
days, underwent cranial imaging (53 percent) and were treated
with empiric intravenous antibiotics for presumptive bacterial
meningitis (67 percent). According to the researchers, only 36
percent of patients benefited from their hospitalization, and
only 10 percent benefited from empiric antibiotic therapy. In
fact, only 15 percent of these patients had an established cause
of their meningitis that was treatable. Patients most likely to
benefit from admission and empiric antibiotic therapy presented
with a focal neurological exam, abnormal mental status, and
extreme abnormalities in the initial CSF formula (i.e., CSF
granulocyte count greater than 50 percent, CSF glucose level less
than 50 mg/dl).</p> <p>To order abstract, executive summary, and final
report, contact the <a href="https://www.ahrq.gov/research/order.htm#ntis">National
Technical Information Service</a>. NTIS
accession no. PB96-198171; 8 pp, $6.50 paper; $10.00 microfiche.</p>
<p>
<strong><em>Public Policy and Prevention of AIDS at the State
Level</em>. AHCPR grant HS07981, 7/1/94 to 6/30/95. James N.
Schubert, Ph.D., Northern Illinois University, Dekalb.</strong>
</p>
<p>This study was designed to explore the consequences and origins
of competing policy models of AIDS prevention at the State level.
The researchers focused on States because of key role States play
in the formulation and implementation of public preventive
policies. Three broad theoretical objectives were addressed: (1)
the systematic description of State AIDS policies, (2)
explanation of State policies, and (3) assessment of their
preventive effects on the AIDS epidemic within States. The
original texts of 750 pieces of State legislation enacted during
the period 1983 to 1992 were acquired and coded. The researchers
assessed whether legislation reflected the appearance of policy
models of contain-and-control or cooperation-and-inclusion for
responding to the epidemic in the United States. These models
were found to describe the policy choices made by the States.
Policies of the cooperation-and-inclusion variety were
significantly and substantially affected by economic and
government capabilities. Cooperation-and-inclusion policy,
containment policy, and prevention spending had statistically
significant effects associated with lower than predicted
incidence of AIDS among States with smaller caseloads. Inclusion
policy showed much stronger effects than containment policy.
There were no significant preventive effects associated with AIDS
policy among States with high caseloads. </p> <p>To order abstract,
executive summary, and final report, contact the <a
href="https://www.ahrq.gov/research/order.htm#ntis">National
Technical Information Service</a>. NTIS accession no.
PB96-176888,
196 pp; $38.00 paper, $14.00 microfiche.</p>
<p>
<strong><em>Regional Conference on Local Adoption of Guidelines</em>.
AHCPR grant HS07967, 9/1/94 to 5/31/96. Christel Mottur-Pilson,
Ph.D.</strong>
</p>
<p>This project supported a 1-day research conference, held April 8,
1995 in Chantilly, VA, on local guideline adoption. Three
hypotheses were tested: (1) guideline use and adoption are
subject to regional variation; (2) interactive learning promises
behavior change; and (3) guideline use is subject to
institutional constraints. In general, information learned at the
conference supported the above hypotheses. However, there were a
number of unexpected results. For example, local variation in
guideline adoption is always institution-specific. Thus,
guideline adoption is a function of the particular institutional
culture in a given region. Although institutions may share
general structural similarities, there still may be fundamental
differences between them. These differences have a strong impact
on guideline adaptation and adoption. Professional
responsibilities and functions predispose individuals to adapt
guidelines. These professional roles cut across medical
disciplines and age groups. This research suggests that guideline
dissemination should not be separated out from adaptation and
adoption. Furthermore, unless an institutional fiat decrees
guideline use, a certain degree of guideline familiarity and
acceptance must be present for a guideline to be adapted/adopted.
Finally, institutional policy is the primary determinant of
guideline use and adaptation. To order abstract, conference
proceedings, and final report, contact the <a
href="https://www.ahrq.gov/research/order.htm#ntis">National
Technical Information Service</a>. NTIS accession no. PB96-203468; 145 pp,
$31.00 paper, $14.00 microfiche.</p>
<p>
<strong><em>Retention of Physicians in Community Health Centers</em>.
AHCPR grant HS07053, 2/1/92 to 10/31/94. Stephen M. Davidson,
M.S.W., Ph.D., John Snow, Inc., Research and Training Institute,
Boston, MA.</strong>
</p>
<p>The inability of community health centers (CHCs) to retain
physicians has been a perennial problem and was the focus of this
three-phase study. The components of the study were to: (1)
determine how long primary care physicians stay in CHCs; (2)
pinpoint when in their tenure physicians are most likely to leave
CHCs; and (3) identify factors that affect a physician's
likelihood of remaining in a CHC, emphasizing those items which
are under the control of CHC management. In phase one, the
researchers found that physicians with an obligation to the
National Health Service Corps (NHSC) are less likely to leave
during the first 2 years on the job but are at much greater risk
of leaving after that time than physicians without an NHSC
obligation. At the end of 5 years, 16.8 percent of physicians
with an NHSC obligation remained at a CHC, compared with 35.6
percent of other physicians. In phase two, a national survey was
conducted of two representative samples of primary care
physicians who had practiced in CHCs: group one was still there,
while group two had left. Survey results suggest that physicians
who stay tend to be more satisfied with a wide range of factors
associated with the CHCs than physicians who leave, and the
strongest and most consistent predictor of physicians'
satisfaction was their perception of the CHC's management. As
might be expected, a more positive perception was associated with
greater satisfaction and retention. In the third phase of the
study, site visits were made to eight CHCs with different
physician retention rates. Corresponding differences in both the
behavior of CHC executives and the attitudes of their physicians
were found. According to the researchers, their
findings&#8212;detailed in the final report&#8212;provide specific
guidance
to center managers who are seeking actions they can take to
extend the tenure of their physicians. </p><p>To order abstract,
executive summary, and final report, contact the <a
href="https://www.ahrq.gov/research/order.htm#ntis">National
Technical Information Service</a>. NTIS accession no. PB96-203450; 77
pp, $25.00 paper, $10.00 microfiche) </p>
<p class="size2"><a href=".">Return to Contents</a></p>
<a name="head2"></a> <h1>Research Briefs</h1>
<a name="head3"></a><p><strong>Albertsen, P.C., Fryback, D.G., Storer, B.E.,
and others (1996, July). " The impact of co-morbidity on
life expectancy among men with localized prostate cancer." (AHCPR
grant HS06770). <em>The Journal of Urology</em> 156, pp. 127-132.</strong></p>
<p>
This paper explores the extent to which coexisting medical
conditions (comorbidity) decrease survival among men with
prostate cancer. The researchers evaluated three indexes of
comorbidity, not originally designed for use in prostate cancer
patients, to determine whether they could predict patient death
more accurately than those based on patient age alone. The
indexes were used to retrospectively predict length of survival
among elderly men identified by the Connecticut Tumor Registry
who were diagnosed with prostate cancer sometime during 1971 to
1976. The Kaplan-Feinstein index identifies 12 categories of
comorbid illnesses, the index developed by Charlson and
colleagues defines two groups of diseases with varying weights
for severity of the condition, and the index of coexistent
disease evaluates 14 medical conditions that are graded into four
severity levels. Nearly all men with severe comorbidities
according to these indexes had died within 10 years. Since life
expectancy greater than 10 years is frequently cited as a
criterion for recommending aggressive intervention, the indexes
should assist clinicians who advise patients 65 to 75 years of
age at diagnosis concerning appropriate treatment options for
newly diagnosed, localized prostate cancer.
</p>
<p><strong>Clancy, C.M., and Kamerow, D.B. (1996, July). "<a
name="gen20">Evidence-based medicine meets cost-effectiveness
analysis</a>." <em>Journal of the American Medical Association</em> 276(4), pp. 329-330.</strong></p>
<p>
In this editorial, Carolyn Clancy, M.D., Director of the Center
for Primary Care Research and Acting Director of the Center for
Outcomes and Effectiveness Research, and Douglas B. Kamerow,
M.D., M.P.H., Director of the Office of the Forum for Quality and
Effectiveness in Health Care, Agency for Health Care Policy and
Research, note current efforts to narrow the gap between research
evidence and medical practice. These efforts include clinical
practice guidelines and other evidence-based recommendations that
should reduce inappropriate variation in practice and associated
expense. However, the ultimate impact of these efforts for
practicing physicians is not clear. Physicians who consider these
guidelines and adjust them to fit their particular practice
setting refute charges offered by skeptics of "cookbook
medicine." But whether physicians' interpretations of practice
guidelines lead to reduced practice variation, better patient
outcomes, and cost savings is an open question. Dr. Clancy points
out that evidence-based recommendations and cost-effectiveness
analysis are implicitly intended for different target audience:
clinicians and policymakers, respectively. She concludes that, if
the goal is to move practice toward evidence-based medicine, it
is necessary to study and clarify the information needs of
practitioners and determine how relevant information is best
delivered to them.
</p>
<a name="head4"></a><p><strong>Freedman, V.A., and Kemper, P. (1996).
"Designing home care benefits: The range of options and
experience." <em>Journal of Aging &amp; Social Policy</em> 7(3/4),
pp. 129-148.</strong></p>
<p>Public funding for home care services in the United States has
been increasing over the past decade. The authors, Vicki
Freedman, Ph.D., of RAND, and Peter Kemper, Ph.D., formerly of
the Agency for Health Care Policy and Research and now with the
Center for Studying Health System Change in Washington, DC,
present a framework for identifying important home care benefit
design decisions and review the experience of 55 home care
programs where existing designs have been adopted into practice.
Fundamental home care benefit design questions include what type
of benefits are provided, how the benefit level is determined,
what services are covered and who can provide the services, who
has the authority over the mix of services used, and who chooses
the provider. The authors describe and provide examples of three
basic benefit designs that predominate: service entitlements,
managed-service benefits, and cash disability allowances.
However, their review of U.S. and foreign government programs and
private long-term care insurance policies also identifies
examples of a wide variety of designs being used in practice.</p>
<p>Reprints (AHCPR Publication No. 96-R128) are available from the
<a href="https://www.ahrq.gov/research/publications/order/order-research-activities.html">AHCPR Publications
Clearinghouse</a>.</p>
<p>
<a name="head5"></a><strong>Humphreys, B.L., Hole, W.T., McCray, A.T., and
Fitzmaurice, J.M. (1996, August). "Planned NLM/AHCPR
large-scale vocabulary test: Using UMLS technology to determine
the extent to which controlled vocabularies cover terminology
needed for health care and public health." <em>Journal of the
American Medical Informatics Association</em> 3(4), pp. 281-287.</strong>
</p>
<p>This article, by J. Michael Fitzmaurice, Ph.D., Director of the
Center for Information Technology, Agency for Health Care Policy
and Research, and his colleagues from the National Library of
Medicine (NLM), describes the joint efforts of NLM and AHCPR to
sponsor a large-scale vocabulary test. The purpose of the test is
to determine the extent to which a combination of existing
health-related classifications and vocabularies covers vocabulary
needed in information systems supporting health care, public
health, and health services research. The test vocabularies are
the 30 that are fully or partially represented in the 1996
edition of the Unified Medical Language System (UMLS)
Metathesaurus, plus three planned additions: the portions of
SNOMED International not in the 1996 Metathesaurus, the Read
Clinical Classification, and the Logical Observations
Identifiers, Names, and Codes (LOINC) system. These vocabularies
are available to testers through a special interface to the
Internet-based UMLS Knowledge Source Server. The test will
determine the ability of the test vocabularies to serve as a
source of controlled vocabulary for health data systems and
applications.</p> <p>Reprints (AHCPR Publication No. 96-R126) are
available from the <a href="https://www.ahrq.gov/research/publications/order/order-research-activities.html">AHCPR
Publications Clearinghouse</a>.</p>
<p><a name="head6"><strong>McDowell, I., and Newell, C. (1996).
<em>Measuring Health: A Guide to Rating Scales and
Questionnaires</em>. (AHCPR grant HS06206). New York: Oxford
University Press.</strong></a>
</p>
<p>This reference book provides a critical overview of the field of
health measurement, with a technical introduction and discussion
of the history and future directions of health measurements. It
covers measurements of physical disability, social health,
psychological well-being, depression, mental status, pain,
general health status, and quality of life. The book is intended
for researchers from the medical and social sciences and for
health professionals wishing to evaluate the progress of their
patients. Its principal aim is to guide readers in choosing among
rival health measurement methods and to score the instrument
chosen. The authors give full descriptions and copies of over 80
health measurement methods, summarize the reliability and
validity of each, and provide the information readers need to
select the most appropriate measurement for their purposes and
then to apply and score the method chosen.</p>
<p>
<a name="head7"><strong>Pathman, D., Konrad, T.R., Freed, G.L., and
others (1996, September). "The awareness-to-adherence
model of the steps to clinical guideline compliance: The case of
pediatric vaccine recommendations." (AHCPR grant HS07286).
<em>Medical Care</em> 34(9), pp. 873-889.</strong></a>
</p>
<p>The model suggests the necessary steps that precede a physician's
adoption of a clinical practice guideline: (1) the physician must
first become aware of the guideline, (2) intellectually agree
with it, (3) decide to adopt it in his or her practice, and (4)
succeed in following it at appropriate times, that is, adhere to
it. The researchers used data on family physicians' and
pediatricians' use of national recommendations for selected
pediatric vaccines as a test case for assessing the model they
developed. They mailed questionnaires to 3,014 family physicians
and pediatricians in nine States. In the case of the
recommendation to provide hepatitis B vaccine to all infants,
guideline awareness among respondents was 98.4 percent;
agreement, 70.4 percent; adoption, 77.7 percent; and adherence,
30.1 percent. Data for 87.9 percent of physicians fit the model
at every step. Significant deviation from the model occurred only
for the 11 percent of physicians who adopted the hepatitis B
recommendation without agreeing with it. According to the
researchers, this model may prove useful in identifying ways to
improve physicians' adherence to a variety of guidelines by
demonstrating where physicians fall along the path to adherence,
which physicians are at greatest risk for not attaining each step
in the path, and factors associated with a greater likelihood of
attaining each step towards guideline adherence.</p>
<p>
<a name="head8"><strong>Weissman, J.S., Levin, K., Chasan-Taber, S.,
and others (1996). "The validity of self-reported
health-care utilization by AIDS patients." (HS06239). <em>AIDS</em> 10, pp. 775-783.</strong></a>
</p>
<p>These researchers examined the validity of self-reported health
care use by nearly 300 persons with AIDS at three provider sites
in Boston, based on personal interviews within 4 months of
hospitalization, ambulatory visits, and hours of home care during
1990 and 1991. They identified reporting error by differences
between self reports and medical/financial records. Results
showed that AIDS patients' overall reports of their use of health
care services were accurate. However, patients were somewhat
better at reporting major events, such as hospitalizations, than
they were at reporting more frequent, and perhaps less
emotionally and financially prominent events, such as ambulatory
visits or hours of home care. Biases may exist for persons with
high use, who underreported all types of services, and for those
identified by interviewers as having recall problems. The
researchers conclude that smaller studies of patients with AIDS
which analyze health care costs may rely on data provided
directly by patients.</p>
<p><a name="head9"><strong>Wong, H.S. (1996). "Market structure
and the role of consumer information in the physician services
industry: An empirical test." <em>Journal of Health Economics</em> 15, pp. 139-160.</strong></a>
</p>
<p>To draw reliable inferences about the effects of various health
care proposals and to explain economic phenomena observed in the
physician services industry, it is important to model the
physician services market structure properly. Using private and
public sources and applying Panzar and Rosse's econometric test
of market structure, Herbert S. Wong, Ph.D., of the Agency for
Health Care Policy and Research, presents two novel empirical
analyses. First, he provides an empirical test that
simultaneously evaluates three possible alternatives for the
market structure for physician services: monopoly, perfect
competition, and monopolistic competition. Second, he provides a
more direct test of the hypothesis which suggests that greater
physician density raises the search cost of obtaining consumer
information and leads to higher prices. For primary care and
general and family practice physicians, the monopolistically
competitive model prevailed over the competing hypotheses.</p>
<p>Reprints (AHCPR Publication No. 97-R005) are available from the
<a href="https://www.ahrq.gov/research/publications/order/order-research-activities.html">AHCPR Publications
Clearinghouse</a>.</p>
<p>
<strong>Zapka, J.G., Bigelow, C., Hurley, T., and others (1996,
July). "Mammography use among sociodemographically diverse women:
The accuracy of self-report." (AHCPR grant HS06874). <em>American
Journal of Public Health</em> 86(7), pp. 1016-1021.</strong>
</p>
<p>This study analyzed the accuracy of self-report of mammography
among 392 ethnically diverse women aged 50 to 74. Women were
randomly selected for telephone or mail surveys. Results showed
that 31 percent of women reported accurately the exact month and
year of their most recent mammogram, 54 percent reported
accurately within 3 months, and 83 percent reported accurately
within the year. Greater accuracy was associated with mammogram
recency, white race, and non-Hispanic ethnicity but not with age,
education, or income. Most women could correctly report the
reason for, the findings of, and the payer of their mammograms
but knew little about how much they or their insurance paid. The
authors conclude that clinical studies requiring more precise
information than the year of last mammogram should be cautious
when using self-reported data.</p>
<p>
<a name="head10"><strong>Zimmerman, J.E., Wagner, D.P., Seneff, M.G.,
and others (1996). "Intensive care unit admissions with
cirrhosis: Risk stratifying patient groups and predicting
individual survival." (AHCPR grant HS05787). <em>Hepatology</em> 23(6), pp. 1393-1401.</strong></a>
</p>
<p>This study examines the usefulness of the Acute Physiology, Age,
and Chronic Health Evaluation (APACHE III) prognostic system for
risk-stratifying groups of intensive care unit (ICU) patients
with cirrhosis and in predicting individual survival. The
researchers used data for 17,440 ICU admissions at 40 American
hospitals to select 117 of the 537 patients with a history of
cirrhosis who were ventilated on ICU day 1, a group known to have
a high mortality rate. The most important determinants of risk
for hospital death on ICU day 1 were the acute physiology score
of APACHE III, ICU admission diagnosis, and operative status.
Daily changes in the acute physiology score caused a rise or fall
in the probability of hospital death and were useful in assessing
individual response to therapy. According to the researchers,
APACHE III accurately risk-stratifies critically ill patients
with cirrhosis because it accounts for many of the factors known
to influence prognosis. This capability can be used to assess
severity of illness and risk-stratify patients with cirrhosis
during clinical trials. </p>
<p class="size2"><a href=".">Return to Contents</a></p>
<p class="size2"><em>AHCPR Publication No. 97-0003<br />
Current as of October 1996</em></p>
<!-- <hr />
<p class="size2"><strong>Internet Citation:</strong></p>
<p class="size2"><em>Research Activities</em> newsletter. October 1996, No. 197. Agency for Health Care Policy and Research, Rockville, MD. https://www.ahrq.gov/research/oct96/</p>
<hr /> -->
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