Improving the Health and Health Care of Older Americans

A Report of the AHRQ Task Force on Aging (continued)

Appendix A: Recent Aging-Related Grants in AHRQ's Portfolio

Title: AHRQ (formerly AHCPR) UI Guidelines: Application in Nursing Homes
Principal Investigator: Nancy Watson, University of Rochester; R01 HS08491
Description: Evaluates urinary incontinence (UI) management practices in 32 nursing homes in New York State to determine staff knowledge and attitudes about UI and the UI guideline and to assess the nature of in-service training activities relevant to the guideline.

Title: Assisted Living and Health System Use
Principal Investigator: Charles Phillips, Myers Research Institute; R01 HS10606
Description: Examines how the characteristics of assisted living facilities (ALFs) affect the ways in which ALF residents interact with the health and long-term care systems, specifically their utilization of Medicare-covered health services and transitions to other care settings.

Title: Benefit of CEA in Patients With Contralateral Occlusion
Principal Investigator: Ronda Pindzola, University of Pittsburgh; R03 HS09021
Description: Assesses the potential role of cerebrovascular hemodynamic measurements in determining which patients with a carotid blockage and high-grade constriction on the contralateral side would benefit from a carotid endarterectomy (CEA).

Title: Benefits of Regionalizing Surgery for Medicare Patients
Principal Investigator: John Birkmeyer, Dartmouth College; R01 HS10141
Description: Investigates whether altering patterns of care from low-volume (high-risk) to higher volume (lower risk) hospitals affects overall mortality of Medicare patients.

Title: Biofeedback and Urinary Incontinence in Older Women
Principal Investigator: Elizabeth Dugan, Bowman Gray School of Medicine; R03 HS10663
Description: Aims to determine the effectiveness of pharmacological and behavioral interventions in the treatment of urinary incontinence in women ages 50-65.

Title: Cardiac Arrhythmia PORT
Principal Investigator: Mark Hlatky, Stanford University; R01 HS08362
Description: Develops a comprehensive decision model for the screening and treatment of patients at risk for sudden cardiac death that incorporates information about a range of outcomes (mortality, morbidity, functional status, quality of life, and cost) as well as patient preferences.

Title: Care, Cost, and Outcomes of Local Breast Cancer
Principal Investigator: Jeanne Mandelblatt, Georgetown University; R01 HS08395
Description: Identifies the determinants of and calculates cost-effectiveness ratios for three alternative treatments for local breast cancer in the elderly: modified radical mastectomy, breast conserving surgery (BCS) with radiotherapy (RT), and BCS without RT.

Title: Comprehensive Outcomes of Frail Elders in the Community
Principal Investigator: Kenneth Covinsky, University of California, San Francisco; K02 HS00006
Description: Identifies determinants of health outcomes—e.g., mortality, functional change, hospitalization, quality of life—in frail, nursing home-eligible patients who continue to live in community settings.

Title: Consequences of Drug Cost Sharing in the Elderly
Principal Investigator: Sebastian Schneeweiss, Brigham and Women's Hospital; R01 HS10881
Description: Assesses the impact of differential cost sharing applied to two pharmaceuticals (angiotensin converting enzyme inhibitors and calcium channel blockers) on patterns of utilization and medication use among the elderly.

Title: A Detailed Profile of the End-of-Life Care in Medicare
Principal Investigator: Dorcas Lynn, George Washington University; R01 HS 10561
Description: Documents cost and use patterns of end-of-life care for Medicare beneficiaries in five broad disease categories.

Title: Determinants of Nursing Home Resident Hospital Use
Principal Investigator: Orna Intrator, Brown University; R01 HS09723
Description: Examines facility and organizational characteristics associated with the decision to hospitalize nursing home residents.

Title: Determining/Understanding Barriers to Adult Immunization
Principal Investigator: Richard Zimmerson, University of Pittsburgh; R01 HS09874
Description: Investigates the principal barriers to influenza and pneumococcal vaccination in a set of primary care practices by determining vaccination rates and the provider and patient characteristics that predict immunization status.

Title: Effects of Differential Cost Sharing in the Elderly
Principal Investigator: Stephen Soumerai, Harvard Medical School; R03 HS09855
Description: Examines how a change in drug pricing policy ("reference pricing") for certain anti-hypertensive drugs affects their use by people age 65 and older in British Columbia.

Title: Evaluation of Inappropriate Psychotropic Use in Elderly
Principal Investigator: Rajender Aparasu, South Dakota State University; R03 HS10813
Description: Uses data from AHRQ's Medical Expenditure Panel Survey to examine factors associated with inappropriate utilization of psychotropic drugs among a cohort of persons ages 65 and older.

Title: Evaluation of Safety Data Reporting in Randomized Trials
Principal Investigator: Joseph Lau, New England Medical Center; R03 HS10345
Description: Assesses qualitative and quantitative adequacy of safety reporting in different clinical fields, including nonsteroidal anti-inflammatory drugs for rheumatoid arthritis and treatment of hypertension in the elderly.

Title: Evidence Based Practice: From Book to Bedside
Principal Investigator: Marita Titler, University of Iowa; R01 HS10482
Description: Evaluates a multidimensional, model-based approach to implementation of an evidence-based guideline for acute pain management of elderly patients (65 years and older) hospitalized for hip fracture in nonintensive settings.

Title: Facility Effects on Racial Differences in NH Quality
Principal Investigator: Mary Fennell, Brown University; R01 HS10322
Description: Examines how nursing home (NH) structure and the local community contexts interact to affect the quality of care experienced by white and minority nursing home residents.

Title: For-Profit Hospital Ownership and Medicare Spending
Principal Investigator: Elaine Silverman, Dartmouth College; R03 HS11012
Description: Examines the relationship between hospital ownership and Medicare expenditures for health care (e.g., hospital, home health, physician, and skilled nursing facility).

Title: Functional Outcomes in Patients with Hip Fractures
Principal Investigator: Albert Siu, Mount Sinai School of Medicine; U18 HS09459
Description: Investigates the feasibility and validity of using functional status outcomes as a measure of quality for patients with hip fracture.

Title: Health Care Markets and Vulnerable Populations
Principal Investigator: Jose Escarce: RAND Corporation; P01 HS10770
Description: One project of this multiproject grant investigates how the structure of the Medicare managed care market affects economic and clinical outcomes, including insurance choice, health status, and out-of-pocket expenses for chronically ill elderly persons.

Title: Health Education in an HMO: Effectiveness and Efficiency
Principal Investigator: Ronald Toseland, State University of New York at Albany; R01 HS08641
Description: Assesses short- and long-term effectiveness of a multicomponent, group health education program for spouse caregivers and frail elderly care recipients in a health maintenance organization (HMO); includes emotion-focused and problem-focused coping strategies and support.

Title: Health Outcomes for Uninsured Older Adults
Principal Investigator: David Baker, Case Western Reserve University; R01 HS10283
Description: Examines the effect of lack of insurance and changes in insurance status over time on self-reported overall health; physical functioning; and occurrence of stroke, myocardial infarction, or death among participants in the National Institute of Aging's Health and Retirement Survey who were ages 45-61 at the time of the initial survey.

Title: Helping Elders Include Quality in Health Plan Choice
Principal Investigator: Lauren Harris-Kojetin, Research Triangle Institute; R18 HS11008
Description: Aims to develop and evaluate an integrated information and decision-support strategy for use by employee benefits staff in counseling employees ages 60-64 about their Medicare plan options.

Title: Hospitalization of Nursing Facility Residents
Principal Investigator: Joan Buchanan, Harvard University; R01 HS10645
Description: Develops a comprehensive model of the determinants of nursing facility hospitalization rates that takes into account facility and resident characteristics as well as economic and environmental incentives.

Title: Impact of Early Discharge Following Bypass Surgery
Principal Investigator: Patricia A. Cowper, Ph.D. Duke University Medical Center; R01 HS10279
Description: Determines how decreased lengths of stay after coronary artery bypass graft (CABG) surgery affects clinical outcomes and identifies patient and hospital factors associated with good outcomes following early discharge. Outcomes in high-risk patients such as the elderly will be specifically examined.

Title: Impact of Physician Specialty on Post-MI Care and Outcomes
Principal Investigator: John Ayanian; Harvard Medical School; R01 HS09718
Description: Investigates the effect of receiving ambulatory care from primary care physicians and/or cardiologists for Medicare beneficiaries who have had an acute myocardial infarction (AMI).

Title: Improving Pain Management in Nursing Homes
Principal Investigator: Katherine R. Jones, University of Colorado Health Sciences Center; U18 HS11093
Description: Develops and implements a culturally competent, evidence-based educational and behavioral intervention to improve the quality of pain assessment and management in two nursing homes.

Title: Improving Utilization of Ischemic Stroke Research
Principal Investigator: Catherine Borbas, Minneapolis Medical Research Institute; U18 HS11073
Description: Assesses the effectiveness of a model for accelerating the use of evidence-based treatment guidelines for acute ischemic stroke in 24 urban and rural hospitals in Minnesota.

Title: Medicare Managed Care: Selection/Competition/Quality
Principal Investigator: Glenn Melnick, RAND Corporation; R01 HS10256
Description: Estimates the extent of selection bias from enrollment in and disenrollment from Medicare Risk HMOs and compares alternative measures of plan quality.

Title: Measuring and Improving Quality: Carotid Endarterectomy
Principal Investigator: Mark Chassin, Mount Sinai School of Medicine; R01 HS09754
Description: Investigates quality of care in carotid endarterectomy by measuring appropriateness, risk-adjusted complications (e.g., death, stroke), and relationship of specific surgical processes to outcomes in a sample of Medicare cases from New York State.

Title: A Model for Use of the Urinary Incontinence Guideline in U.S. Nursing Homes
Principal Investigator: Nancy M. Watson, University of Rochester School of Nursing; U18 HS11064
Description: Tests the effectiveness of a model of care implemented by nurse practitioners collaborating with nurses and physicians to translate AHRQ's Urinary Incontinence Guideline into practice in 10 nursing homes.

Title: More Disease: How Major a Factor in Higher Utilization
Principal Investigator: Michael Shwartz, Boston University; R03 HS09832
Description: Examines variation in Medicare hospital admissions for 22 medical conditions in 70 small geographic areas using rates of outpatient treatment as proxies for prevalence of underlying disease in each of the areas.

Title: Nursing Home Care at the End of Life: Cost and Quality
Principal Investigator: Susan C. Miller, Brown University; R01 HS10549
Description: Examines the cost and quality of care of terminally ill nursing home residents, both in hospice care and regular nursing home care settings.

Title: Nursing Home Quality Indicators
Principal Investigator: Carol Hegeman, Foundation for Long-term Care; R13 HS10085
Description: Conference to disseminate information to nurse managers on how to use quality indicators based on the Minimum Data Set to improve quality of care in nursing homes.

Title: Optimal Antithrombotic Therapy in Atrial Fibrillation
Principal Investigator: Brian Gage, Barnes-Jewish Hospital; R01 HS10133
Description: Investigates how prescribing antithrombotic therapy affects the rates of death, stroke, and hemorrhage in a cohort of Medicare beneficiaries with atrial fibrillation.

Title: Optimizing Antibiotic Use in Long-term Care
Principal Investigator: Mark B. Loeb, McMaster University; U18 HS11113
Description: Assesses whether an evidence-based clinical algorithm for managing urinary tract infections in older adults in residential long-term care facilities (LTCFs) can reduce the overall use of antibiotics in LTCFs.

Title: Oral Health Intervention Trial in Older Adults
Principal Investigator: Mark Moss, University of Rochester; R01 HS10120
Description: Tests the effectiveness of three interventions on oral health promotion and dental disease prevention among functionally impaired, community living, Medicare-eligible patients at high risk for hospitalization.

Title: Outcomes of LRI in Nursing Home Residents
Principal Investigator: David Mehr, University of Missouri-Columbia; R01 HS08551
Description: Develops and validates a risk index for lower respiratory infection (LRI) and assesses the relative cost of initial management of LRI in an acute care hospital vs. initial nursing home care, particularly for low-risk residents.

Title: PORT-II for Prostatic Diseases
Principal Investigator: Michael Barry, Massachusetts General Hospital; R01 HS08397
Description: Continues the work of the Patient Outcomes Research Team (PORT-I) for prostate disease, including better defining and optimizing outcomes for men seen in primary care settings.

Title: Prescription Benefits as a Quality Measure
Principal Investigator: Barry Saver, University of Washington; R01 HS10318
Description: Examines whether the comprehensiveness of prescription drug coverage can serve as a useful measure of quality of care among elderly Medicare beneficiaries with chronic health conditions.

Title: Primary and Secondary Prevention of Coronary Heart Disease and Stroke
Principal Investigator: Steven M. Ornstein, Medical University of South Carolina; U18 HS11132
Description: Evaluates the impact of a quality improvement model using academic detailing and electronic medical records on adherence with clinical practice guidelines for prevention of cardiovascular disease and stroke in 22 primary care settings across the United States.

Title: Primary Care Performance and Outcomes in Medicare
Principal Investigator: Dana Safran, New England Medical Center; R01 HS09622
Description: Employs a longitudinal observational design to compare the primary care performance and outcomes of conventional Medicare with those of managed Medicare.

Title: Quality Factors in Nursing Home Choice
Principal Investigator: Joann Congdon, University of Colorado Health Center; R18 HS10926
Description: Develops and evaluates information strategies to assist consumers in using quality-related factors in choosing a nursing home.

Title: Quality Improvement in Nursing Homes
Principal Investigator: Francis Sainfort, University of Wisconsin; R01 HS09746
Description: Utilizes employee- and facility-level data to examine use and impact of quality improvement activities in nursing homes.

Title: Quality Measurement in Residential Care
Principal Investigator: M. Catherine Hawes, Menorah Park Center for the Aging; R01 HS10315
Description: Develops quality measures for residential care facilities for use in external quality-assurance systems, consumer report cards, and feedback systems for providers.

Title: Quality Outcomes in Subacute and Home Care Programs
Principal Investigator: John Morris, Hebrew Rehabilitation Center for the Aged; U18 HS09455
Description: Measures quality of postacute care for rehabilitative-restorative patients in two transitional settings—subacute long-term nursing home and home care—and sets benchmark values of longitudinal change for eight outcome measures.

Title: Reducing Adverse Drug Events in the Nursing Home.
Principal Investigator: Jerry Gurwitz, University of Massachusetts Medical Center; R01 HS10481
Description: Tests whether a computer-based clinical decision-support system can lower the rate of adverse drug events and potential adverse drug events in nursing homes.

Title: Resident Assessment of Pain Management
Principal Investigator: Joan Teno, Brown University; R01 HS10336
Description: Aims to develop and validate a strategy for measuring the quality of pain management in elderly nursing home residents.

Title: SES Differences in HMO Utilization by Older Americans
Principal Investigator: Jose Escarce, RAND Corporation; R01 HS09630
Description: Focuses on the role of socioeconomic status (SES) in determining hospitalization, length of stay, and readmissions, as well as ambulatory visits, among Medicare managed care enrollees.

Title: Structuring Markets and Competition in Health Care
Principal Investigator: Joseph Newhouse, Harvard Medical School; P01 HS10803
Description: One part of this multiproject effort examines whether the quality of care provided to traditional Medicare patients changes with increases in overall HMO penetration and Medicare HMO penetration.

Title: Testing the Effectiveness of Advance Medical Directives
Principal Investigator: Joseph Danks, Kent State University Foundation; R01 HS08180
Description: Compares the ability of three different methods of collecting advance directive information to improve the agreement between decisions made by elderly outpatients and their surrogates about the use of life-sustaining treatments.

Title: Timing Prophylactic Surgery for Diverticulitis
Principal Investigator: Robert Richards, University of Kansas; R03 HS10827
Description: Uses Markov modeling as the basis for evaluating the cost, years of life, and cost effectiveness of three strategies for dealing with diverticulitis (a common clinical condition among the elderly) for a hypothetical cohort of 65-year-olds.

Title: Understanding & Reducing Native Elder Health Disparities
Principal Investigator: Spero Manson, University of Colorado Health Sciences Center; P01 HS10854
Description: Aims to undertake a series of projects relating to reducing health care disparities among the American Indian/Alaska Native elderly population, specifically improving the quality of diabetes care and increasing participation in clinical preventive services such as cancer screening and management, immunizations, and smoking cessation programs.

Title: Using Cancer Registries To Assess Quality of Cancer Care
Principal Investigator: John Ayanian, Harvard Medical School; R01 HS09869
Description: Compares the quality of care for colorectal cancer among Medicare managed care plans and fee-fee-service care using data from the California Cancer Registry and a patient survey.

Title: Validating Guidelines for the Care of AMI Patients
Principal Investigator: Barbara McNeil, Harvard University; R01 HS08071
Description: Examines data from Medicare patients with acute myocardial infarction to assess each patient's appropriateness for three interventions—angiography, CABG, percutaneous transluminal coronary angioplasty—and compares the extent to which adherence to guidelines affects both health and financial outcomes.

Title: Value of Medical Testing Prior to Cataract Surgery
Principal Investigator: Oliver Schein, Johns Hopkins University; R01 HS08331
Description: Examines the cost effectiveness of a routine battery of preoperative medical tests for patients ages 50 and older undergoing elective ambulatory cataract surgery.

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Appendix B: AHRQ's Aging-Related Training Support

Institutional Training (T32) Grants

AHRQ supports the predoctoral and postdoctoral training of approximately 130 students annually through National Research Service Award institutional training (T32) grants. AHRQ currently funds more than 20 academic institutions that support students to develop research careers in the systematic examination of the organization, provision, and/or financing of health care. Among the programs which have a focus on gerontology are:

Institution: Brandeis University
Program Director: Stanley Wallack, Ph.D.
Description: Offers multidisciplinary training for predoctoral students in social science perspectives, research and statistics methods, and applied health services research, including health economics and health care organization and health policy. Aging-related areas of research include:

• Long-term care for the elderly (including alternative delivery systems and payment options).
• Ways to strengthen supportive services for older adults, including mental health.
• Mental health issues of women.
• Integrated acute and long-term care systems.
• Equity in long-term care access.
• Health care utilization.
• Quality of care.

Institution: Brown University
Program Director: Vincent Mor, Ph.D.
Description: Trains postdoctoral clinicians and nonclinicians for health services research emphasizing geriatrics/gerontology, enabling them to participate in ongoing research in four general thematic areas:

• Prevention services.
• Management of chronic disease.
• Long-term care quality.
• Organizational factors affecting health care delivery and quality.

Approximately 20 faculty are listed on grant, with major area of interest in gerontology. Aging-related areas of research include:

• Preventing the onset of disease and its sequelae of functional impairment and disability.
• Providing quality long-term care for severely disabled or demented individuals at an acceptable cost.
• Providing advanced care planning and quality of care to dying patients.
• Managing the complex and interacting health and social services needed by the chronically medically, physically, and mentally ill.
• Identifying and redressing social inequities in the delivery of services to this population.

Institution: University of California at San Francisco and Berkeley
Program Directors: Harold Luft, Ph.D. (San Francisco) and Richard Sheffler, Ph.D. (Berkeley)
Description: Broad-based, interdisciplinary predoctoral and postdoctoral training in health services and health policy. Program includes: the Institute for Health and Aging (including about 40 faculty who serve as mentors from the Schools of Nursing, Medicine, Dentistry, Pharmacy, and Medical Anthropology). Its mandate is to: promote and strengthen multidisciplinary research, education, public service in aging, health services, and policy.

Institution: Case Western Reserve University
Program Director: Alfred Rimm, Ph.D.
Description: Offers interdisciplinary training for predoctoral students in urban health, medical outcomes and effectiveness, and health management policy; postdoctoral training for clinicians and health- related nonclinicians in statistics, epidemiology, and health services research methods; also training for those interested in a Ph.D./M.D. research career. Among the areas of aging research are:

• Geographic variation in hip fracture and cancer in the Medicare population.
• Relationship between hospital characteristics and outcomes.
• Validity of annual HCFA mortality studies.
• Studies of costs, efficiency, and appropriateness of medical care for elders.

Institution: Cornell University
Program Director: Mary Charlson, M.D.
Description: Trains postresidency physicians in research methods and design, including such areas as effectiveness and outcomes; cost-effectiveness; health systems; patient, community, and public education; and how to translate results of research into policy. Aging-related areas of research include:

• Evaluation of new and multiple systems now available to care for older adults (e.g., home care, assisted living facility, nursing home).
• Treatments designed to restore function and to forestall deterioration among the elderly.
• Late life mood disorders (depression in elderly).
• Elder mistreatment.
• Psychosocial factors in physical and social disability.

Institution: Duke University
Program Director: Eugene Oddone, M.D.
Description: Trains postdoctoral (M.D. and Ph.D.) students in health services research, primarily oriented towards clinical epidemiology, biostatistics, decision analysis, technology assessment, and meta analysis. Affiliated with the VA Center. Aging-related areas of research include:

• Access to care.
• End-of-life physician-patient interactions and treatment decisions.
• Processes, structures, and outcomes of post-stroke rehabilitation.
• Geriatric medicine.
• Health issues of older women (e.g., breast cancer risk factors, use of hormone replacement therapy among women in nursing homes, osteoporosis).

Institution: University of Michigan
Program Director: Jeffrey Alexander, Ph.D.
Description: Trains predoctoral students in health services organization and policy through an interdisciplinary approach; areas for postdoctoral program include research methodology in health services, statistical analysis, and health services management and policy. Affiliated with the VA Center. Aging-related areas of research include:

• Organizational links between the long-term and acute-care health care sectors.
• Nursing home to nursing home transfers.
• Whether elderly respond differently than non-elderly when choosing health plans.
• Ways to increase mammography in minority and rural older women.
• Changing roles of nursing homes.
• Development of resident assessment protocols.
• Well-being among the aged.

Institution: University of Minnesota
Program Director: John Kralewski, Ph.D.
Description: Trains predominantly predoctoral students to prepare for careers in health services research, policy, and administration. Smaller postdoctoral program provides research training for physicians. Emphasis on research methods, especially quantitative methods. Students take courses in a disciplinary area (e.g., economics, sociology, finance, epidemiology) and an applied area (e.g., women's health, aging). Aging-related areas of research include:

• Access to care and health status of elderly population.
• Outcome measures to assess costs to informal caregivers who care for those afflicted with chronic disease.
• Quality of care and long-term outcomes associated with long-term care in the elderly.
• Behavioral geriatrics and pharmaco-epidemiology.
• Impacts of payment policies and other regulations on nursing home costs, access, and quality.

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