Announcements

AHCPR's World Wide Web site goes live

The Agency for Health Care Policy and Research has launched its World Wide Web site, making available a wealth of practical, science-based health care information in one convenient place. The new Web site—located at http://www.ahcpr.gov—features information to help consumers and their health care practitioners make informed health care decisions; research on what works best in health care; and other information and data central to AHCPR's mission to enhance the quality, cost-effectiveness, and delivery of health care services.

Visitors to the AHCPR home page (the "title" page of the Web site) can get an overview of the Web site by clicking on the "welcome" button. Six buttons correspond to major categories of available holdings on the Web site: Offices/Centers, News and Resources, Research Portfolio, Data and Methods, Guidelines and Medical Outcomes, and Consumer Health. There is also an electronic catalog of the more than 450 information products generated by AHCPR, with information on how to obtain these resources.

The Consumer Health section includes the consumer versions of AHCPR-supported clinical practice guidelines—information to help consumers and their families make informed decisions about preventing or treating common health conditions such as depression, pain after surgery, cataract, and acute low back problems. Consumers also have access to information to help them make decisions about whether and when to have elective surgery (from the recently released brochure Be Informed: Questions To Ask Your Doctor Before You Have Surgery).

Also featured on the new Web site are electronic versions of the 17 clinical practice guidelines AHCPR has supported and released thus far. These items were previously made available online only through the National Library of Medicine (NLM).

Recently, AHCPR has averaged about 100,000 electronic accesses to the text of these guidelines per month. In addition to usage across the United States, about 50 foreign countries also have accessed the guidelines on the Internet, according to AHCPR's Administrator, Clifton R. Gaus, Sc.D.

For policymakers, researchers, and health care payers, the Web site offers unique data from AHCPR's surveys and studies that relate to the use and cost of hospital care, HIV/AIDS, and national medical expenditures. In addition, online newsletters look at research activities in the areas of health services, medical outcomes, and health technology. General organizational information on the agency also is featured, including program contacts, research funding opportunities, fact sheets, speeches, and press releases. The Web site is a dynamic information outlet and will include new materials as they become available.

Researchers, policymakers, health care providers, consumers, and the media helped evaluate a test Web site and provided feedback on content, presentation, and ease of use. AHCPR Web site users can send technical questions and comments for agency staff via an E-mail address, info@ahrq.gov; or call Gerri Michael-Dyer at (301) 427-1898. This feedback will help to improve Web holdings as the site evolves.

AHCPR and HRSA announce new projects in pediatric emergency medicine

The Agency for Health Care Policy and Research, in collaboration with the Health Resources and Services Administration (HRSA), has awarded four grants totaling $2.5 million for research leading to improvements in the provision of emergency medical services to children. The awards were made in late fiscal year 1995, according to AHCPR Administrator Clifton R. Gaus, Sc.D.

Childhood injuries and illnesses constitute a major public health problem in the United States; more than 20,000 children under 19 years of age die each year as a result of injury, and an additional 30,000 suffer permanent disability as a result of brain injury. Moreover, for each death of a child due to injury in the United States, as many as 42 children are hospitalized and 1,120 children visit emergency rooms.

There are important differences in the emergency care needs of children and adults; differences in anatomy, physiology and psychology between children and adults mean there must be different and special equipment, different-sized instruments, different doses of different drugs, and different approaches to the psychological support and remedial care to be given to ill or injured children, noted Dr. Gaus.

HRSA Administrator Ciro V. Sumaya, M.D., M.P.H.T.M., emphasized the need for more research in the area of pediatric emergency care. Research topics in this field are outlined in a 1993 report by the Institute of Medicine (IOM), Emergency Medical Services for Children. The IOM study, which was funded by HRSA's Maternal and Child Health Bureau, also describes the ongoing deficiencies in pediatric emergency care and recommends a variety of steps to correct the problems.

Following are descriptions of the newly funded research projects on emergency medical services (EMS) for children, with the names of grant recipients, principal investigators, and amounts of the awards:

• Harbour-UCLA Medical Center, Torrance, CA, Marianne Gausche, M.D., principal investigator ($415,000): This 2-year project will compare the use of two technologies, endotracheal intubation (ETI) and bag-valve-mask (BVM) ventilation, in providing emergency respiratory care to pediatric patients en route to the hospital. The most common cause of death in children is respiratory failure, and there is much controversy regarding the need for teaching thousands of paramedics the skills of ETI vs. airway management with simple BVM ventilation. Preliminary data have indicated that BVM might be as effective as intubation in achieving survival of pediatric cardiac arrest victims.
• University of Utah, Salt Lake City, Anthony J. Suruda, M.D., M.P.H., principal investigator ($612,000): This 3-year population-based epidemiologic study will link data from existing sources—EMS data, aeromedical data, hospital inpatient and outpatient data, police crash data, and poison control data—to determine the effect of EMS for children (EMSC) on patient outcomes. The epidemiology of pediatric emergencies and the cost of EMSC, including the cost and nature of EMSC aeromedical transport, will be described. Researchers will determine the effect of poison control center telephone consultation on subsequent EMSC and hospital care. The outcomes of EMSC delivered by providers before and after EMSC training will be compared. Information from this study will be useful to public health officials and providers of emergency services for decisionmaking on preventive programs and for determining EMSC policies.
• Arkansas Children's Hospital Research Institute, Little Rock, John M. Tilford, Ph.D., principal investigator ($747,000): This 3-year project will investigate the relationship between cost-containment efforts and quality of care in pediatric intensive care units (PICUs). As managed care and cost-reducing measures alter the delivery of care in PICUs, knowledge of the relationship between resource utilization and patient outcomes will be important in assuring quality care for critically ill infants and children. Researchers will evaluate the usefulness of a severity of illness measurement system designed and validated specifically for prediction of PICU outcomes, and they will determine the effect of patient characteristics such as insurance status and race on resource utilization.
• Joseph Stokes, Jr., Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA, Flaura K. Winston, M.D., Ph.D., principal investigator ($749,000): During this 3-year project, the researchers will develop a biomechanical survey technique and "prediction score" for evaluating pedestrian and bicycling injuries. Pedestrian injuries are the leading cause of injury death in children 4 to 8 years of age. Biomechanical factors related to an injury (speed,energy delivered to the body, direction of impact, body rotation, etc.) are of key importance in determining the nature and severity of the injury. The score will be useful to prehospital-care providers in determining the appropriate mode of transport for the patient; to clinicians who must decide whether to perform emergency surgery for a suspected intra-abdominal bleed; to researchers evaluating the efficacy of new therapies; and to health economists evaluating the cost-effectiveness of care.

AHCPR funds major study of outpatient treatment for pelvic inflammatory disease

The Agency for Health Care Policy and Research has awarded a $6 million grant to study the effectiveness of outpatient treatment for pelvic inflammatory disease (PID), an infection of the pelvic tract caused by sexually transmitted pathogens. The 5-year study, to be conducted by researchers at the University of Pittsburgh, will involve the first clinical trial to compare directly the effectiveness and cost-effectiveness of outpatient and inpatient therapies recommended for treating PID.

Pelvic inflammatory disease affects over 1 million American women every year and frequently results in infertility, ectopic pregnancy, and chronic pelvic pain. The costs associated with PID and its consequences have been estimated at over $4 billion per year, according to AHCPR's Administrator, Clifton R. Gaus, Sc.D.

Treatment for more than three-quarters of the women diagnosed with PID currently consists of antibiotics to be taken on an outpatient basis. However, the effectiveness of outpatient treatment compared with antibiotic treatment administered parenterally (by injection) to patients who remain hospitalized has not been tested. Outpatient treatment is initially less costly than inpatient treatment, but there has been no systematic assessment of the long-term costs of PID relative to the effectiveness of each treatment.

Roberta B. Ness, M.D., Assistant Professor at the University of Pittsburgh's Department of Epidemiology, will lead the study. According to Dr. Ness, clinicians currently often work under the untested assumption that intensive inpatient therapy for PID, while more expensive, may be more effective in treating the disease. By focusing on both clinical outcomes and quantification of costs associated with each treatment, this study will permit the development of rational treatment guidelines.

Twelve hundred women at five medical centers who are suspected of having PID will be randomly assigned to parenteral or oral antibiotic therapy provided in either inpatient or outpatient settings. The primary comparison of interest between the two treatment groups will be the time it takes for women to attain fertility and the rates of involuntary infertility. Women assigned to the two treatment groups also will be compared from the standpoint of disease-related direct and indirect costs, taking into account the benefits and burdens of each of the outcomes.

Guide helps consumers make decisions about elective surgery

Each year, millions of Americans have surgery, and most are elective procedures—that is, they are not emergency operations. This means there is time to ask doctors and/or surgeons questions about the operation, look into the surgeon's and hospital's experience with similar surgeries, and make a decision about whether to have the operation and when or where to have it.

Be Informed: Questions To Ask Your Doctor Before You Have Surgery—a new consumer brochure from the Agency for Health Care Policy and Research—helps consumers make decisions about elective surgery by posing 12 key questions for patients to ask their doctors, including:

• Why do I need the operation?
• Are there alternatives to surgery?
• What are the benefits and risks of having the operation?
• How long will it take me to recover?
• What happens if I don't have the operation?

The guide encourages readers to get a second opinion and play an active part in the decisionmaking process. It points out the need to understand the approximate recovery time and costs associated with the procedure and notes that well-informed patients tend to be more satisfied with the outcomes or results of their treatment. The guide lists additional sources of information on topics such as surgeons' qualifications and second opinions, as well as other publications that are designed to help patients make good health care decisions. Be Informed: Questions to Ask Your Doctor Before You Have Surgery is available from the AHCPR Clearinghouse (AHCPR Publication No. 95-0027). Bulk copies of the surgery guide may be purchased from the U.S. Government Printing Office (stock number 017-026-00145-0; $11.00 per package of 20).

Select to to access the guide on the Internet at http://www.ahrq.gov/consumer/surgery.htm.

New publications available from NTIS

The following publications and final reports of research projects funded by the Agency for Health Care Policy and Research are now available from the National Technical Information Service (NTIS). Refer to the NTIS accession number when ordering.

Caregiving Needs of HIV-Positive Minority Women. AHCPR grant HS07265, 9/30/92 to 9/29/95. Eugene Litwak, Ph.D., Columbia University School of Public Health, New York, NY.

Sixty HIV-positive minority women were interviewed at an out-patient HIV/AIDS clinic in a New York inner-city neighborhood. They were in the early asymptomatic stage of the illness, with 62 percent reporting no needs pertaining to activities of daily living. Their caregiving needs revolved around normal social goals, e.g., sociability and child care. They were young (average age of 35.5), single (76 percent), and involved with men (74 percent). Fifty-seven percent of the women were sexually active, and 47 percent were not practicing safe sex. Heterosexual sex was the prevalent risk factor (63 percent). Forty-four percent did not adhere to medical regimens, and 33 percent did not keep clinic appointments. Seventy-six percent had children under 16, and 56 percent had children under 10. Ninety-two percent chose kin as future guardians, and 40 percent already had children under guardianship. Grandmothers were chosen 50 percent of the time, and other relatives were chosen 42 percent of the time. The women who had positive social supports were more likely to adhere to medical regimens and practice safer sex and were less likely to be substance abusers, have problem children, or have children being raised by others than women who had mixed supports. (Abstract, executive summary, and final report; NTIS accession no. PB96-130125, 54 pp; $19.50 paper, $9.00 microfiche)

Cognitive Impairment and Medication Appropriateness. AHCPR grant HS07819, 3/1/93 to 5/31/95. Joseph T. Hanlon, Ph.D., Duke University Medical Center, Durham, NC.

Using data from Duke University's longitudinal Established Populations for Epidemiological Studies of the Elderly (EPESE) database, the researchers examined whether drug use patterns in community-dwelling elderly differ by cognitive status. They found that cognitively impaired subjects (including demented individuals) are less likely to use over-the-counter medications and analgesics than cognitively intact, community-dwelling elderly. Using the same database and a prospective population-based cohort design, they also examined the risk of cognitive impairment in elders associated with the use of nonsteroidal antiinflammatory drugs (NSAIDs) and benzodiazepines. The researchers found no compelling evidence to suggest that NSAID use is associated with either deterioration or improvement in level of cognitive function among community-dwelling elderly. However, they did find that current use of benzodiazepines was associated with memory impairment, and use of higher doses of benzodiazepines was associated with increasingly worsened memory function. These study findings are significant because they are the first to describe medication use by cognitive status; further, this study is the first to address the risk of cognitive impairment associated with the use of specific medication classes in a representative sample of community-dwelling elders. (Abstract, executive summary, and final report; NTIS accession no. PB96-116223, 26 pp; $17.50 paper, $9.00 microfiche)

Content of Obstetric Care for Rural, Medicaid, and Minority Women. AHCPR grant HS07412, 9/30/92 to 9/29/94. Lawrence G. Hart, Ph.D., M.S., University of Washington, Seattle, WA.

The researchers used a complex survey design to study the prenatal and intrapartum care received by a random sample of low-risk pregnant women who were cared for by a random sample of obstetrical providers in Washington State. The provider group included urban obstetricians, family physicians, and nurse midwives and rural obstetricians and family physicians. The results were reported for three groups: white non-Hispanic vs. all other racial/ethnic groups, Medicaid vs. privately insured patients, and rural vs. urban women. The pattern of care received and the total amount of resources used were remarkably similar across groups. The only significant difference in total resource use was for rural women, who used about 7 percent fewer total resources than their urban counterparts. This was largely because of lower rates of anesthesia during delivery. After controlling for other factors, African-American women actually used significantly more resources than their counterparts. Medicaid status had no meaningful association with overall resource use. (Abstract, executive summary, and final report; NTIS accession no. PB95-264552, 50 pp; $17.50 paper, $9.00 microfiche).

Content of Obstetrical Care Project: Practice Variation in Prenatal and Intrapartum Care. AHCPR grant HS06166, 7/1/89 to 6/30/93. Roger A. Rosenblatt, M.D., M.P.H., University of Washington School of Medicine and Public Health, Seattle, WA.

There are over 4,000,000 births annually in the United States, making this the most common hospital discharge and one of the most common reasons that patients visit physicians. Despite the ubiquity of this event, there is little consensus as to what constitutes optimal or even appropriate prenatal and intrapartum care. As a result, there are wide variations in medical practice patterns in obstetrics, variations that lead to major differences in the cost of care, much of which is borne by public financing programs such as Medicaid. This study was performed to determine the content of obstetrical care provided by a random sample of obstetrical providers in one State (Washington) and to determine the causes for postulated variations in the patterns of care. This report summarizes the study and its major findings. (Abstract, executive summary, and appendixes A and B; NTIS accession no. PB96-129176, 24 pp; $17.50 paper, $9.00 microfiche)

Continuity of Care for Chronically Ill Maryland Medicaid Patients. AHCPR grant HS06986, 9/1/92 to 8/31/93. Andrea S. Gerstenberger, Sc.D., Johns Hopkins School of Hygiene and Public Health, Baltimore, MD.

In this study, data from the Medicaid claims files of 7,200 chronically ill Maryland Medicaid patients, and data from the medical records of a subset of these patients, were analyzed to determine the extent of continuity and coordination of their care. Various subpopulations of patients were compared in terms of achieved continuity; multivariate analyses were performed to examine the relationships between continuity score and selected patient and provider characteristics, and the relationships between continuity scores and total costs and overall quality of care. Findings indicate that continuity of care within the chronically ill Maryland Medicaid population (for this study, hypertensive and diabetic patients) is on a par with and sometimes exceeds the continuity found in other research on non-Medicaid, nonchronically ill populations.

Study findings also suggest that physicians in primary care-oriented specialties (e.g., family practice, general practice, and internal medicine) deliver significantly higher levels of continuity than physicians in other specialty groups. The study also found that patients with more severe burdens of illness received less continuity of care, and "usual source of care" providers of different types were found to deliver differing levels of continuity of care. (Dissertation thesis; NTIS accession no. PB95-264537, 240 pp; $36.50 paper, $17.50 microfiche)

Costs and Characteristics of Health Insurance Plans. AHCPR grant HS06732, 8/1/92 to 7/31/95. Gary A. Zarkin, Ph.D., Research Triangle Institute, Research Triangle Park, NC.

The researchers examined the characteristics of employer-provided health insurance using data from the 1989 Survey of Health Insurance Plans (SHIP). The specific aims of the 18-month research project were to answer the following research questions: What factors determine who offers health insurance? For those firms that do not offer health insurance, what reasons influence their decision? Is there a relationship between employer health insurance characteristics and the firm's decision to provide an employee assistance program? Among those that offer a fee-for-service (FFS) plan, what factors explain the decision to self-insure? In designing a survey of employer-provided health insurance, what are the sampling and statistical issues that arise? Results provide new insights into the determinants of employer-provided health insurance and will aid policymakers in evaluating the impact of new legislative initiatives designed to increase firms' provision of health insurance coverage to their workers. (Abstract, executive summary, and final report; NTIS accession no. PB96-130117, 16 pp; $17.50 paper; $9.00 microfiche)

Cultural Values and Health Research: A Methods Conference. AHCPR grant HS08105, 2/1/94 to 7/31/95. Pamela K. Pletsch, Ph.D., R.N., University of Wisconsin, Milwaukee, WI.

This report summarizes the conference, "Cultural Values and Health Research Methods," held in Milwaukee, WI, in September 1994. The purpose of the conference was to address health disparities among Americans by providing health intervention researchers with increased knowledge and skills in cross-cultural research methods. During the 2-1/2 day conference, speakers addressed the methodological issues of designing culturally appropriate health intervention research. (Abstract, executive summary, and final report; NTIS accession no. PB96-130075, 15 pp; $17.50 paper, $9.00 microfiche)

Determinants of Dental Malpractice. AHCPR grant HS06554, 7/1/91 to 6/30/95. Peter M. Milgrom, D.D.S., University of Washington, Seattle, WA.

The purpose of this study was to examine the relative contribution of the legal environment, individual claims experience and liability insurance coverage, and the market on the structure and process of care of dental practice. A cross-sectional design was employed to estimate from a survey of 4,278 general dentists (77 percent response rate, 3,048 dentists) the prevalence of claims and to investigate the severity distribution of resolved claims. In addition, a survey of insurance firms and State insurance commissioners was conducted. The final report contains prevalence and payment data, findings on the determinants of professional liability claims, and the instrumentation used in the study. (Abstract, executive summary, and final report; NTIS accession no. PB96-116249, 74 pp; $19.50 paper, $9.00 microfiche)

Evaluation of Quality of Life in Asthma Patients. AHCPR grant HS07969, 9/1/93 to 8/31/95. Miriam L. Isola, Dr.P.H., University of Illinois, Chicago, IL.

Among inner-city patients, asthma mortality rates have been rising at a greater rate than the national average. This controlled clinical trial examined quality of life in 180 acute asthmatics aged 18-55, who presented at Cook County Hospital's emergency room with acute asthma. Patients were randomized to standard inpatient therapy (control) or 12-hour emergency department observation unit treatment. Tests on the quality-of-life (QOL) subscales revealed significantly higher scores among the experimental group. This study emphasized the need to move beyond measuring outcomes to get new information on how to improve the process of medical care and the quality of life of asthma patients. The examination of QOL is meaningful because it conveys the patients' point of view about their own health, not just that of clinical indicators. These results indicate that treatment type and clinical status variables differentially effect QOL in some areas. (Executive summary and final report of doctoral dissertation; NTIS accession no. PB96-116702, 190 pp; $27.00 paper, $12.50 microfiche)

Followup After Discharge from an Urban Public Hospital. AHCPR grant HS08930, 6/1/93 to 5/31/95. Catarina I. Kiefe, M.D., Ph.D., University of Alabama, Birmingham, AL.

Appointment-keeping after hospitalization is a poorly understood link between inpatient and outpatient care. The researchers studied how health care system and patient characteristics influence this aspect of compliance with medical treatment. All 372 consecutive eligible patients admitted to Medicine wards in an urban public teaching hospital were interviewed on hospitalization and after the date of their first appointment following discharge. The hospital's electronic databases were searched and charts were reviewed. Data included sociodemographics, diagnosis, comorbidity, medications, health care access and use, previous compliance behavior, and recommended followup appointments. Self-perceived health status was assessed on admission and on followup. Followup contact rate was 80 percent. Patients were primarily black (67 percent), uninsured (62 percent), female (53 percent), and had a mean age of 48 years; 68 percent of first appointments ordered were kept. Patients who kept their first followup appointment had significantly lower self-perceived physical functioning both on admission and at followup. Compliant patients were more likely to be older and to have received a written appointment at the time of discharge. (Abstract, executive summary, final report, and appendixes; NTIS accession no. PB96-101894, 77 pp; $19.50 paper, $9.00 microfiche)

Head Injury Outcomes. AHCPR grant HS06497, 8/1/91 to 7/31/95. Sureyya S. Dikmen, Ph.D., University of Washington, Seattle, WA.

Based on over 500 representative cases, this project generated new and reliable information on the ranges of expected neurobehavioral outcomes in patients hospitalized with traumatic brain injury who survive and the means of predicting outcomes in individual cases. Outcomes are closely related to the severity of brain injury and also to preinjury characteristics of the individual, as well as other injuries sustained in the same accident. Disruptions are most prevalent early on, but with recovery, most of the mildly injured do well by 1 year; with increasing severity, the probability of permanent disability and partial or complete dependence on others increases. Important psychometric information related to reliability and practice effects for commonly used neuropsychological measures has also been generated. (Abstract, executive summary, and appendix A; NTIS PB96-130141, 12 pp; $17.50 paper, $9.00 microfiche)

Health Care Utilization and Recurrence of Abdominal Pain. AHCPR grant HS05705, 5/1/90 to 4/30/94. Alan M. Adelman, M.D., M.S., Pennsylvania State University, University Park, PA.

This study examined the natural history of abdominal pain and factors associated with health care utilization. A telephone survey was used to identify 624 adult HMO patients with abdominal pain. Demographics, characteristics of the pain, social support, psychological distress, and health status were measured. Utilization information was collected for the year prior to and following the interview. Subjects kept a diary of pain occurrence for 1 year. From the telephone survey, 27 percent reported more than three episodes of pain in the previous year, and 38 percent of these individuals sought care for their pain. Social support and the number of days of work missed due to pain were associated with both psychological distress and health status. Both mental health and office visits were positively associated with psychosocial distress and negatively associated with health status. The only clinical factor associated with office visits was the frequency of pain in the prior year. Few clinical factors were associated with psychological distress, health status, office visits, or medication use. Psychological distress and health status were important factors associated with utilization. (Abstract, executive summary, and final report; NTIS accession no. PB95-271979, 36 pp; $17.50 paper, $9.00 microfiche)

Impact of Physician Specialty on Cesarean Section and Site to Site Variation in the Factors Affecting Cesarean Rates. AHCPR grant HS07012, 4/1/92 to 9/29/93. William J. Hueston, M.D., St. Claire Medical Center, Morehead, KY.

Numerous factors have been linked with the likelihood of cesarean delivery. These include clinical factors (e.g., patient parity), nonclinical factors (e.g., insurance status), and provider factors (e.g., physician specialty). This study sought to evaluate if these factors are consistently associated with c-section when adjusted for potential confounders. The researchers selected a random sample of 8,647 women from five clinical centers and examined c-section frequency based on over 50 clinical and nonclinical factors. They found that a great deal of variability exists among sites in the types of factors associated with c-section. Only two risk factors (primiparity and multiple gestation) were associated with c-section in all five sites. Three factors (physician specialty, preeclampsia, and private insurance) were associated with cesarean delivery in four sites. In cases where physician specialty was associated with c-section, having an obstetrician as a provider increased risk of a cesarean delivery. Further analyses of other obstetric health services such as intrapartum epidural anesthesia and trial of labor also showed large variations across sites. These results suggest that factors influencing obstetric decisions are not consistent. (Abstract, executive summary, final report, and appendixes; NTIS accession no. PB96-107750, 48 pp; $17.50 paper, $9.00 microfiche)

Low Back Pain: Outcomes and Efficiency of Care. AHCPR grant HS06664, 8/1/91 to 7/31/95. Timothy S. Carey, M.S., M.P.H., University of North Carolina, Chapel Hill, NC.

The North Carolina Back Pain Project examined the following major research questions: (1) What kinds of health care providers do people with low back pain seek out? and (2) Which diagnostic and therapeutic strategies do practitioners use in evaluating and treating outpatients with acute low back pain? Do these strategies vary among differing types of practitioners? What is the effectiveness and cost-effectiveness of different diagnostic and therapeutic strategies? The researchers conducted a telephone survey of North Carolina adults; 7.6 percent had episodes of functionally disabling acute low back pain in a year, 39 percent sought any professional care, and 13 percent sought care from chiropractors. The study included 1,633 patients presenting to randomly sampled practitioners in six strata: urban and rural primary care, urban and rural chiropractors, orthopedic surgeons, and primary care in a staff-model HMO. Over 6 months, clinical outcomes (time to recovery, functional status, return to work) were very similar among the six strata. Significant differences were found in health care utilization and charges—greatest in orthopedic surgeon and chiropractic strata, least in primary care strata. Patient satisfaction was greatest in the chiropractic strata. Given the similar outcomes among strata, the potential for substantial cost savings exists in acute back pain care, according to the researchers. (Abstract, executive summary, final report, and appendixes; NTIS accession no. PB96-133954, 62 pp; $19.50 paper, $9.00 microfiche)

Nursing: Access to Rural Cardiac Rehabilitation Programs. AHCPR grant HS07688, 6/1/93 to 5/31/95. Julie E. Johnson, R.N., Montana State University, Bozeman, MT.

The purpose of this study was to describe the factors that influence the use of cardiac rehabilitation programs by rural adults who have experienced a heart attack and/or undergone angioplasty or coronary artery bypass surgery. Data were collected on 286 adults at the time of hospitalization, 2 weeks postdischarge, and at the expected completion of a 12-week rehabilitation program. The study found that only 28 percent of the patients attended some portion of a rehabilitation program. Of those, only about 17 percent completed the entire program. Patients who attended more sessions were less dependent in carrying out daily activities, perceived themselves as less healthy, were not employed, experienced poorer mood states, and believed less in the influence of powerful others on health maintenance. (Abstract, executive summary, final report, and appendixes; NTIS accession no. PB95-271821, 93 pp; $19.50 paper, $9.00 microfiche)

Physician Liability Concerns and Use of Clinical Practice Guidelines. AHCPR grant HS07239, 5/1/93 to 8/31/94. Stephanie M. Spernak, J.D., M.A., George Washington University, Washington, DC.

The objective of this study was to determine if physicians report an inverse relationship between agreement with and use of a controversial clinical practice guideline and whether such respondents also report high malpractice concern. An anonymous survey was mailed to 1,000 board-certified pediatricians who provide direct patient care. Survey response rate was 38 percent (382 physicians completed and returned the survey). The 1992 NIH National Asthma Education Program (NAEP) practice guidelines were selected as the focus of the survey because they recommend aggressive use of beta-agonists and oral steroids. Due to medical disagreement about possible serious side effects of these treatment regimens in children, a decision to use the NAEP guidelines might raise liability issues for physicians. Most respondents (98 percent) reported they "agreed" or "strongly agreed" with the guidelines; 88 percent reported that they used them "frequently" or "always" in their practice. Agreement with the guideline was strongly related to use; only 36 respondents reported an inverse or negative relationship between agreement with and use of the guidelines. There was no difference in the mean malpractice concern of this group compared with the 228 respondents who reported a positive relationship between agreement and use of the guidelines. Respondents generally reported low malpractice concern. (Abstract, executive summary, final report, and appendix; NTIS accession no. PB95-256087, 20 pp; $17.50 paper, $9.00 microfiche)

Racial/Ethnic Differences in Utilization of Long-Term-Care Services Among the Elderly. AHCPR grant HS08034 (joint project with the National Institute on Aging). Naderah Pourat, Ph.D., University of California, Los Angeles, CA.

The researchers examined the existence of racial/ethnic differences in long-term-care use and found that after controlling for Medicaid status, African Americans use nursing homes less but have similar types of nursing home stays. Their higher use of home care, paid and unpaid, is explained by their greater needs. Hispanics show similar rates of nursing home use compared with whites but less home care. No significant Hispanic/white differences were found in type of nursing home stay or use of paid and unpaid home care. These findings show that racial/ethnic differences do exist and are alleviated partly by Medicaid coverage, suggesting that reductions in Medicaid coverage will adversely affect minority elderly. (Abstract and executive summary of dissertation; NTIS accession no. PB96-130083, 8 pp; $9.00 paper, $9.00 microfiche)

Strategies of HIV Prevention Programs in San Francisco. AHCPR grant HS07610, 8/1/93 to 8/31/95. James W. Dearing, Ph.D., M.A., Michigan State University, East Lansing, MI.

The extent to which the concepts of two behavioral change models, diffusion of innovations and social marketing, are represented in the HIV prevention strategies of San Francisco organizations was investigated. Data were collected through surveys and interviews with staff members from 100 prevention programs in 49 organizations over a 2-year period. Results suggest that the majority of HIV prevention programs in San Francisco operate on the basis of personal experience, direct observations, and shared anecdotes of program staff. Relatively more effective programs use a greater number of strategies associated with the two change models. Social marketing strategies are more common than diffusion of innovation strategies. More effective prevention programs emphasize cultural sensitivity in developing and refining program strategies. (Abstract, executive summary, and final report; NTIS accession no. PB96-130133, 138 pp; $27.00 paper, $12.50 microfiche)

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