Impact on Clinical Decisionmaking, Access, and Quality

To what extent do managed care arrangements influence a clinician's decisions, such as the decision to refer patients to specialists? How is access to services, such as preventive screenings, changed by managed care? What effect does managed care have on quality of services delivered? The studies in this section describe how both the process and results of the health care system have been affected by managed care.

Health Care Utilization and Recurrence of Abdominal Pain. Alan M. Adelman, Principal Investigator. Although abdominal pain is one of the most common reasons for visiting a physician, little is known about it as a reason for a doctor's visit. Using subjects selected from the rosters of a large HMO, this study provided descriptive information on the natural history of abdominal pain, assessed factors associated with the recurrence and resolution of abdominal pain, assessed factors associated with seeking medical care for the problem, and described the health utilization patterns of these patients. (Project Officer: Carolyn Clancy. Project dates: 5/1/90-4/30/94)

Nephrologist Care and Outcomes in Renal Insufficiency. Jerome L. Avorn, Principal Investigator. This study will measure (1) utilization of nephrologist services in the year prior to hemodialysis and/or transplantation (HD/Tx); (2) how use of specialist care varies by age, gender, socioeconomic status, and race; and (3) whether absence of nephrologist referral in the year prior to HD/Tx is associated with differences in clinical course and outcome in the year after HD/Tx begins. Findings will help inform ongoing discussions at both the policy and clinical levels concerning the appropriate mix of generalist and specialist care. (Project Officer: David Lanier. Project dates: 9/30/96-9/29/98)

Medicaid HMO Enrollee Non-Urgent Emergency Room Use. Patricia A. Butler, Principal Investigator. This project tested models predicting the use of emergency rooms in non-emergency situations by Medicaid managed care enrollees. Colorado Medicaid households enrolled in an independent practice association were randomly sampled. (Project Officer: David Lanier. Project dates: 8/1/95-3/31/96)

Specialty Care in Closed vs. Open Access HMOs. Jose Escarce, Principal Investigator. This project aims to examine (1) whether use of primary care physicians (PCP) services differ between patients in gatekeeper and point of service (POS) HMOs, (2) whether use of specialists' services on referral from a PCP and overall use of specialists' services differ between patients in gatekeeper and POS HMOs, (3) whether PCPs refer gatekeeper and POS patients at different rates, and (4) whether specialist efficiency affects the choice of specialist in gatekeeper and POS HMOs. This project will enhance our understanding of the effect of alternative managed care models on the use of primary and speciality care. (Project Officer: David Lanier. Project dates: 9/30/96-9/29/98)

Referrals in Primary Care. Peter Franks, Principal Investigator. This project aims to (1) examine variations in referral rates among primary care physicians; (2) examine physician and physician practice factors affecting referral rates; (3) examine the relationship between physician referral rates and costs; and (4) explore the possible relationships between under-referral and avoidable hospitalizations, health status, and satisfaction. This study, conducted in an Individual Practice Association (IPA) model HMO, will inform policymakers, educate physicians, and permit monitoring of strategies to change referral behavior. (Project Officer: David Lanier. Project dates: 9/30/96-9/30/98)

Medicaid Managed Care and Access to Health Services. P. Joseph Gibson, Principal Investigator. Across the United States, managed care systems are replacing FFS systems in providing Medicaid services. This study examined how access to medical services for Medicaid clients is affected by the change from a FFS system to a capitated, gatekeeper system. Results from this study will be used to help guide future State health reform measures and guide improvements to the Medicaid system. (Project Officer: David Lanier. Project dates: 9/30/94-9/29/96)

Managed Care, Physician Referral, and Medical Outcomes. David E. Grembowski, Principal Investigator. To increase the understanding of managed care's influence on physician referral behavior and health outcomes, this study examines the effect of managed care on (1) the probability of referral among patients suffering from pain and depression, and (2) health outcomes of both referred and nonreferred patients. (Project Officer: Carolyn Clancy. Project dates: 5/1/95-10/31/98)

Two Aspects of Medicaid: Acute and Long-term Care Usage. Anthony T. Losasso, Principal Investigator. This research looked at (1) the effect on medical service utilization when people eligible for Medicaid are switched from FFS medical care to capitated health plans, and (2) the effect of Medicaid subsidies on the decision of the frail elderly to enter a nursing home, and the role of their adult children in the decision. The goal was to explore six specific issues in order to inform policymakers about how the incentive schemes and delivery systems constructed by the Government affected utilization of medical care services and therefore program cost. (Project Officer: David Lanier. Project dates: 8/1/95-7/31/96)

Unmet Need and Use of Vision Care by Medicare Beneficiaries. Carol Mangione, Principal Investigator. This study examines how the organization of Medicare affects the use of referrals and outcomes of care. Findings from this study should deepen our understanding of the influence of risk-sharing on use of services that are routinely performed by specialists but, in the managed care setting, are increasingly paid for by primary care providers. Data will be collected directly from Medicare beneficiaries in two types of managed care plans and in FFS Medicare in Southern California. (Project Officer: David Lanier. Project dates: 9/30/96-9/29/98)

The Detection and Treatment of Depression in a Large HMO. Gregory A. Nichols, Principal Investigator. This study explored differences between internal medicine and family practice physicians in detecting and treating patients with major depression. The specific aims of this study were to compare differences between the two types of physicians in (1) detection rates of depression, (2) treatment methods, (3) health care resource use by depressed patients, and (4) health care resource use of detected versus nondetected depressed patients. (Project Officer: David Lanier. Project dates: 8/1/93-7/31/95)

Doctor/Patient/System Relationship and Perception of Quality. Roy Penchansky, Principal Investigator. From five HMOs, investigators examined undesirable outcomes and other functions that influence the possibility of a malpractice claim. Analysis showed that injury and the doctor-patient relationship were more important than patient or provider attributes. The widespread perception among providers that Medicaid and minority patients are more litigious was not supported. A low-cost way of identifying critical occurrences and incidents in ambulatory care that affect the probability of malpractice claims (hospitalization with selected combinations of diagnoses and procedures) was found, permitting risk management activities to be focused. (Project Officer: James Carmody. Project dates: 4/1/90-2/28/94)

Patterns of Referral and Care for Children on Medicaid. James M. Perrin, Principal Investigator. This research focuses on the effects on resource use and quality of care of referrals to pediatric specialists compared to adult specialists for common and uncommon chronic health conditions among children enrolled in Medicaid. This study should shed light on the important and controversial question of the consequences for children who fail to receive pediatric specialist attention. (Project Officer: David Lanier. Project dates: 9/30/96-9/29/98)

Effect of Specialty on Primary Care Practice in an HMO. Joseph V. Selby, Principal Investigator. Three groups are usually thought of as primary care providers: family physicians, general internists, and subspecialty internists. Previous studies suggested that the level of training received by primary care physicians has a marked impact on practice style, resource utilization, and costs of care, with subspecialty internists using more medical resources than general internists or family physicians. This was the first study to assess the independent effect of physician training on the cost and quality of primary care. To examine differences in resource utilization and total costs, this prospective study used the automated data systems of the Kaiser Permanente Medical Care Program of Northern California. (Project Officer: Linda Siegenthaler. Project dates: 9/1/94-12/30/96)

Specialty Referrals Among California Physician Groups. Joseph V. Selby, Principal Investigator. This study examines the determinants of referral among 6,300 adult patients with one of three common chronic conditions (congestive heart failure, benign prostatic hyperplasia, and peptic ulcer disease). The principal objectives are to (1) examine the possible effect of financial arrangements and utilization management techniques on referral decisions, and (2) to evaluate the possible association between referral patterns and quality of care. The effects of managed care plan type on specialty referrals for these conditions will also be assessed. (Project Officer: David Lanier. Project dates: 9/30/96-9/29/98)

Managed Care and the Primary-Specialty Care Interface. Barbara Starfield, Principal Investigator. The objective of this research is to study (1) how primary care physicians make referrals, (2) consumers' experiences with referrals, and (3) how new managed care financing and organizational arrangements affect both the occurrence and content of referrals. When completed, this study will represent one of the most comprehensive analyses of the primary-speciality care interface and the effect of managed care on these linkages. Data will be collected from physicians in the Ambulatory Sentinel Practice Network (ASPN), a national practice-based research network of physician practices. (Project Officer: David Lanier. Project dates: 9/30/96-9/29/98)

Analysis of Physician Referrals of Medicare Patients. Bruce C. Stuart, Principal Investigator. This study has three major aims: (1) to characterize patterns of physician referral and paid consultations in the treatment of noninstitutionalized elderly and disabled Medicare beneficiaries from 1992-1994, (2) to identify correlates of the referral and consultation patterns found in the course of addressing the first study objective, and (3) to identify differences in costs and clinical outcomes associated with specialist referrals for the treatment of cardiovascular disease in the Medicare population. The study will link information from the Medicare Beneficiary Survey with Medicare claims data for cardiovascular conditions. (Project Officer: David Lanier. Project dates: 9/30/96-9/29/98)

Quality and Cost Containment in Pediatric Intensive Care. John M. Tilford, Principal Investigator. This multi-site study examines the effect of managed care on outcomes of pediatric intensive care units (PICUs). Prospective data will be collected on 4,800 patients in three university PICUs serving populations with managed care penetration rates of 6 to 39 percent. A severity model predicting functional outcomes will be developed, and the relationship of utilization and outcomes to characteristics such as race and insurance status will be examined. (Project Officer: Elinor Walker. Project dates: 9/1/95-8/31/98)

Women's Use of Preventive Screening Services: A Comparison of HMO vs. FFS Enrollees. Robin M. Weinick and Karen M. Beauregard, AHCPR Investigators. Using the 1987 National Medical Expenditure Survey and the 1992 National Health Interview Survey, the investigators explored whether HMO enrollment is associated with the use of preventive screening services for nonelderly, privately insured women. The study found that women who were enrolled in HMOs in 1987 were more likely to have received Pap smears and breast exams within the last year, and to have ever received a mammogram when compared to women with FFS coverage. By 1992, however, HMOs had lost this comparative advantage. (Project dates: 11/4/94-12/31/97)

Primary Care Physician Job Satisfaction and Turnover. Modena E. Wilson, Principal Investigator. The purpose of this study is to examine the relationship between primary care physician (PCP) job satisfaction and likelihood of turnover. The relative contributions made to the relationship between PCP job satisfaction and the likelihood of turnover by (1) the individual PCP, (2) the organization or practice setting, and (3) the interaction between the individual PCP and the organization or practice setting will be investigated. Because the demand for PCPs in managed care organizations (MCOs) is increasing, it is important for physician employers, in general, and MCO plans in particular, to be cognizant of the impact of PCP job satisfaction on PCP turnover. (Project Officer: Linda Siegenthaler. Project dates: 9/30/95-3/31/97)

Out-of-Plan Medical Use in a Prototypical Managed Care Plan: A Case Study. Herbert Wong, AHCPR Investigator. This study will use claims data from a large, mature IPA-type HMO with a PPO option to examine the extent of enrollees' use of out-of-plan providers. The objectives of the study are to 1) determine the prevalence of out-of-plan medical use, 2) examine the financial impact of out-of-plan use, 3) identify characteristics of out-of-plan users, and 4) document the types of procedures and providers most often used out of plan. (Project dates: 3/1/94-4/30/97)

Determinants of Physician Practice Styles: Does HMO Coverage Matter? Herbert Wong, AHCPR Investigator. To explore whether managed care plans' incentives for providers to limit the amount of care are strong enough to alter physician treatment patterns, this study will: (1) explore whether physicians treat HMO patients differently than their FFS counterparts, and (2) determine if physicians develop a particular practice style during the course of their training (medical school, residency training, and through associations with colleagues at patient care centers), and maintain that style regardless of their patients' insurance coverage. (Project dates: 7/1/96-12/31/97)

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Interventions that Improve Outcomes

Interventions designed to improve outcomes have often been developed or tested in managed care settings. These studies are designed to further knowledge about "what works." Included are studies in which HMOs have served as laboratories for translating AHCPR's clinical practice guidelines into medical review criteria.

Individualized Feedback to Implement Clinical Guidelines. E. Andrew Balas, Principal Investigator. This project resulted in a Quality Feedback Expert System (QFES) that generates reports to primary care providers integrating individual practice pattern data with pertinent research evidence. The feasibility of using QFES to implement clinical practice guidelines and analyze practice variation was demonstrated in samples of (1) 182 urinary tract infection cases from a primary care clinic and (2) 152 cases of chronic renal failure at 5 dialysis centers, in collaboration with Humana Health Care Plans of Kansas City. This quality management intervention should have practical application in a variety of managed care settings since it appears to be able to detect overutilization and underutilization and to identify non-random differences in practice patterns. (Project Officer: David Lanier. Project dates: 1/1/94-12/31/95)

Lipid-Lowering Medications and Risk of Injury. Viktor E. Bovbjerg, Principal Investigator. Trials of lipid-lowering drugs have not demonstrated overall reductions in mortality, because reductions in fatal cardiac deaths are offset by deaths from other causes. In this study, using Group Health Cooperative (GHC) enrollees with at least one total cholesterol measurement at or above 200 mg/dL, investigators examined the relationships between use of lipid-lowering medication and injury. Injury cases were identified using GHC computerized hospitalization files and death tapes; GHC pharmacy and laboratory data were used to collect information on exposure to lipid-lowering agents. The study also examined the utility of large HMO databases for the postmarketing surveillance of adverse drug effects. (Project Officer: David Lanier. Project dates: 9/1/94-8/31/95)

Chiropractic Versus Physical Therapy—A Randomized Trial. Daniel C. Cherkin, Principal Investigator. Using subjects recruited from two primary care clinics in a large HMO, this study compared the effectiveness of two popular and expensive nonsurgical treatments for low-back pain: spinal manipulation performed by chiropractors versus the McKenzie method of physical therapy. The results of this study are providing patients, physicians, managed health care systems, and insurers with valuable information on the relative benefits and costs of these commonly used treatments for patients with low-back pain. (Project Officer: Mary Cummings. Project dates: 8/1/93-7/31/97)

Alternative Therapies for Back Pain: A Randomized Trial. Daniel C. Cherkin, Principal Investigator. The effectiveness of two "alternative" therapies (traditional Chinese acupuncture and therapeutic massage) for low-back pain are compared with each other and with the use of relatively inexpensive self-care educational materials. This study will evaluate pain and functional outcomes of 300 enrollees of a large health maintenance organization who are randomly assigned to each treatment group. (Project Officer: Mary Cummings. Project dates: 9/30/96-9/29/98)

Back Pain Outcome Assessment Team. Richard A. Deyo, Principal Investigator. Back problems result in frequent hospitalizations, surgery, and use of expensive diagnostic tests; wide geographic variations in the use of these services are well documented. One site for this study of low-back pain was the Group Health Cooperative of Puget Sound. Investigators found no evidence that spinal fusion—one of the most common operations for low back problems—is superior to other surgical procedures for common degenerative conditions of the spine, but they did find more complications with spinal fusion. Evidence was also found to be growing against bed rest as therapy (even for 1 to 2 weeks) and against conventional spinal traction for treatment of sciatica or herniated disks. (Project Officer: Mary Cummings. Project dates: 9/7/89-2/28/95)

MEDTEP Study on Hysterectomy and Dysfunctional Uterine Bleeding. Sarah E. Fowler, Principal Investigator. Three clinical centers, including managed care settings, and a data coordinating center will conduct a clinical trial to compare patient outcomes and relative costs of hysterectomy, endometrial ablation, and gonadotropin-releasing hormone agonist therapy for women with refractory dysfunctional uterine bleeding. A common protocol will be used to recruit and randomize 375 patients, who will be followed for a minimum of 2 years (Project Officer: Henrietta Hubbard. Project dates: 9/30/96-9/29/01)

Evaluation of Guidelines in Large Group Practices. Harold I. Goldberg, Principal Investigator. The effectiveness of academic detailing (AD) and continuous quality improvement (CQI) in implementing clinical practice guidelines for the primary care of depression and hypertension was studied at two sites: Kaiser in Portland, Oregon, and several large group practices in Seattle, Washington. A combined analysis of the results from both sites of this randomized controlled trial helped explain how guideline implementation methods differentially affect subgroups of providers and patients. Qualitative information about the implementation process at each site was also compared. (Project Officer: David Lanier. Project dates: 12/1/92-11/30/96)

Pediatric Preventive Care Incentives in a Medicaid HMO. Alan L. Hillman, Principal Investigator. This randomized controlled trial assessed the impact of a system of periodic feedback and financial incentives on compliance with pediatric preventive care clinical guidelines in HealthPASS, a mandatory Medicaid program in Philadelphia. The 53 primary care sites were assigned to 3 groups: Feedback reports and financial incentives, feedback reports only, and no feedback or financial incentives. Although compliance with guidelines increased during the study period for all three groups, the interventions did not increase compliance. (Project Officer: Linda Siegenthaler. Project dates: 4/1/93-9/30/96)

Cancer Prevention for Minority Women in a Medicaid HMO. Alan L. Hillman, Principal Investigator. In this randomized controlled trial, investigators assessed the impact of a system of periodic feedback and financial incentives on physician compliance with cancer screening guidelines in HealthPASS, Philadelphia's Medicaid program. The study investigated whether providing feedback to primary care sites and a financial bonus program improved primary care provider attention to cancer prevention for women aged 50 and over. (Project Officer: James Cooper. Project dates: 9/30/93-9/29/96)

Develop, Apply, and Evaluate Review Criteria and Education Programs Based upon Practice Guidelines. Carole J. Magoffin, Principal Investigator. The Center for Clinical Quality Evaluation (formerly the American Medical Review Research Center) developed quality and utilization review criteria and clinical practice guidelines based on three AHCPR-supported clinical practice guidelines. As part of this project, review criteria and performance measures based on the guideline Benign Prostatic Hyperplasia: Diagnosis and Treatment (AHCPR Pub. No. 94-0582) were tested for use in two staff model HMOs (Geisinger Medical Center in Danville, Pennsylvania, and Henry Ford Health Systems in Detroit, Michigan) and in two multispecialty clinics (Lahey Clinic in Burlington, Massachusetts, and Jackson Hospital and Clinic in Montgomery, Alabama). (AHCPR Contact: Marge Keyes. Project dates: 9/30/91-3/31/96)

Chiropractic Versus Medical Care for Low-Back Pain. Hal Morgenstern, Principal Investigator. By randomizing 200 patients, the efficacy and cost-effectiveness of four popular management strategies used in the treatment of low-back pain will be studied in a multi-specialty group practice. Along with chiropractic care and medical care, both with and without physical therapy, the effects of self-care will be studied. Measures of effectiveness will include pain reduction, functional status improvement, and patient satisfaction. Additionally, the relationship between patient satisfaction with care and other outcomes measures will be examined. (Project Officer: Mary Cummings. Project dates: 5/1/95-4/30/00)

Health and Cost Impact of Maternal Child Advocate Services. Kathleen F. Norr, Principal Investigator. Researchers are comparing the impact on health outcomes of an innovative home visit program targeting inner city mothers and infants with enrollees in Chicago's Medicaid managed care program. (Project Officer: Linda Siegenthaler. Project dates: 6/1/93-5/31/97)

Pharmacy-Based Patient Monitoring in an IPA HMO. L. Douglas Ried, Principal Investigator. The feasibility of modifying physician prescribing has not been clearly shown in a network-style HMO. This study evaluated the effectiveness of providing pharmaceutical information about asthma treatment to community practitioners in an individual practice association (IPA). Results will be valuable to IPA HMO drug benefit administrators in determining whether they can manage the cost and care of their patients in ways similar to staff model HMOs. (Project Officer: Linda Siegenthaler. Project dates: 4/1/95-10/31/97)

Practice Guidelines in Primary Care. W. S. Schroth, Principal Investigator. To further the understanding of guideline dissemination and implementation, project investigators determined the effect of a clinical guideline for the treatment of acute low-back pain, a common condition associated with wide variations in evaluation and treatment. The implementation of a clinical practice guideline for acute low-back pain among primary care clinicians using an education, audit, and feedback intervention supported by peer-opinion leaders was unsuccessful in changing the appropriateness of clinical care or important patient outcomes. A formal cost analysis of the implementation methods was also undertaken. The study also evaluated alternative guideline implementation methods in a controlled comparison of primary care clinician practice groups in an HMO setting. The impact of guidelines on clinician practices, utilization of medical resources, patient satisfaction, and functional outcomes were the endpoints of interest in this study. (Project Officer: Lynn Kazemekas. Project dates: 7/1/93-8/30/96)

Improving Disease Prevention in Primary Care. Leif I. Solberg, Principal Investigator. This study is testing the hypotheses that (1) by promoting preventive services and by implementing continuous quality improvement (CQI), two HMOs—Blue Plus and HealthPartners—can stimulate contracted primary care clinics to routinely deliver the medical preventive services outlined in the Healthy People 2000 goals (e.g., breast exams and mammograms in women 50 and over, Pap smears in women 20 and over, tobacco cessation efforts, and hypertension and high cholesterol identification and treatment), and (2) that implementing these processes will improve overall quality of care for all clinic patients, including those who are not enrolled in the HMOs. Investigators are also measuring the developmental and operating costs for the HMOs, clinics, and patients and are assessing the potential for other clinics and HMOs to adopt a similar program. (Project Officer: James Cooper. Project dates: 7/1/93-6/30/97)

Pharmaceutical Care and Pediatric Asthma Outcomes. Andreas S. Stergachis, Principal Investigator. Although studies suggest that asthma education programs may improve knowledge and short-term outcomes, there have been no assessments of the impact on long-term outcome. This study assesses the changes in disease control, functional status, and cost associated with the introduction and delivery of a structured program of pharmaceutical care for pediatric and adolescent asthma patients. This randomized, controlled study is being conducted in the general community, including the Medicaid and King County, Washington, HMO settings, and will demonstrate the effect of pharmacists' cognitive services on the health outcomes and cost of care of this patient population. (Project Officer: Lynn Bosco. Project dates: 3/1/93-2/28/97)

Pediatric Asthma Care PORT II. Kevin B. Weiss, Principal Investigator. This test of the cost-effectiveness of recently developed practice guidelines for the care of childhood asthma will be conducted within 3 managed care settings for an estimated 400,000 children with moderate to severe disease. A pre- and post-test of an opinion leader training program to maximize adherence to the guidelines prescribing practices will be conducted. The effectiveness and cost-effectiveness of organizational change in primary care resulting from guideline implementation will be examined. In addition to symptom assessment, outcomes such as functional status, health care utilization, and patient satisfaction will be examined. (Project Officer: Lynn Bosco. Project dates: 9/30/96-9/30/01)

Improving the Cost-Effectiveness of Care for Depression. Kenneth B. Wells, Principal Investigator. The cost-effectiveness of alternative approaches to improving care for depression in prepaid group practices will be examined in this quasi-experimental study. Information on the linkages between process of care and patient outcomes in both primary care and mental health specialty settings will also be studied. The effects of three interventions will be compared with care as usual on quality of care, patient clinical and functioning outcomes, satisfaction with care, use of services, direct and indirect costs, and cost-effectiveness of care and cost-utilities (the assessment of the value of an intervention). Additionally, the effects on outcomes of specific depression treatments that are enhanced by the interventions will be examined. (Project Officer: Charlotte Mullican. Project dates: 4/1/95-3/31/00)

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Informing Consumers

As the number and type of managed care plans proliferate, consumers are clamoring for facts that will assist them in making choices. Furthermore, information can enable consumers to become active partners in their own health care. But what kind of information will be most valuable and what forms are most accessible? What factors explain the choices consumers make? Can computer software help consumers make decisions? Research sponsored by AHCPR is helping consumers make more informed decisions.

Choice Card. Lisa Adatto, Principal Investigator. This project has developed a multimedia kiosk (Choice Card) to assist individuals in Oregon and Connecticut making health plan choices. It allows each individual to indicate what factors, values, and preferences are important; to review and compare the relevant information across plans; and to act on the information by making an informed health plan enrollment choice. The Choice Card is targeted to the Medicaid population, but can be easily adapted to meet the needs of other populations (e.g., Medicare, uninsured, employee). (Project Officer: Sandy Robinson. Project dates: 9/30/95-9/29/97)

Elder Care. Maureen Allen, Principal Investigator. This project is developing an interactive CD-ROM program to assist families in deciding on the best living/care arrangement for elderly relatives—home, personal care homes, nursing homes. The decision model will allow families to evaluate their elderly relatives' ability to function in each setting, as well as the families' ability to provide care. Decision factors address physical and cognitive ability, psychosocial and financial issues. (Project Officer: Sandy Robinson. Project dates: 9/30/96-3/31/97)

Randomized Trial of the SDP for Patients with BPH. Michael J. Barry, Principal Investigator. To evaluate the efficacy of the Shared Decision-Making Program (SDP), this study examined an interactive educational program to educate men about benign prostatic hyperplasia (BPH) and the available treatment alternatives. The study, conducted at the HMO Group Health Cooperative of Puget Sound, determined whether SDP use led to (1) improved health and well-being, (2) greater patient willingness to participate in treatment decisions, (3) a change in treatment decisions, (4) greater patient satisfaction with both the decisions made and the process of decisionmaking, and/or (5) more weight in decisionmaking placed on patient preferences. (Project Officer: Mary Cummings. Project dates: 8/1/91-7/31/95)

Internet Multimedia Cancer Patient Education System. Susan Bouma, Principal Investigator. This project, which develops a multimedia patient education system for the Internet, will use interactive technology to support patient education about cancer in a way that saves physician time and reduces health care costs. The contract involves an innovative use of Internet, CD-ROM, and Java programming language to provide patients with an interactive forum for obtaining information on breast cancer. (Project Officer: Sandy Robinson, 11/27/96-5/26/97)

Videodisc for Back Surgery Decisions: A Randomized Trial. Richard A. Deyo, Principal Investigator. Investigators are using study subjects drawn from a closed-panel HMO and a FFS academic surgical practice to evaluate the impact of a new educational program using interactive media (both computer and videodisc) to help patients with low back disorders make informed decisions about undergoing back surgery. The study will compare the interactive program with written materials and will evaluate the impact of this program on patient satisfaction with medical care, health perceptions and functioning, knowledge of low back problems relevant to informed decisionmaking, the proportion of patients selecting surgical therapy, and health care utilization. Because of the different practice sites used in the study, the results should be widely generalizable. (Project Officer: Mary Cummings. Project dates: 9/1/94-8/31/97)

Factors Affecting Premiums and Employee Choice of Health Plan. Bryan E. Dowd, Principal Investigator. In studying the strategy of managed competition, the project found that employees switch plans when faced with higher out-of-pocket premiums. Using data on Minnesota State employees from 1988 to 1993, the project established that high-cost plans lost market share while the lowest cost plan dramatically increased its market share. A second study, among five large Minnesota employers, indicated a high degree of consumer sensitivity to out-of-pocket premiums. (Project Officer: Melford Henderson. Project dates: 4/1/93-5/31/93)

Oregon Consumer Scorecard Project. Pam Hanes, Principal Investigator. This collaborative effort between AHCPR, the Regional Rural Health Center at the University of Washington, the Oregon Health Policy Institute, and the State of Oregon developed a consumer scorecard that allows enrollees of Oregons managed Medicaid program (the Oregon Health Plan) to obtain information concerning fees, morbidity rates, and other factors to assist in the selection of a health care provider or plan. Existing data were gathered, synthesized, and analyzed. The availability and validity of performance measures related to subpopulations of interest was assessed. Information and formats useful to and understandable by the target audience were identified through qualitative research. (Project Officer: Sandy Robinson. Project dates: 1/25/95-9/4/96)

Consumer Comprehension of Quality-of-Care Indicators. Judith H. Hibbard, Principal Investigator. This study used a focus group methodology and content analysis to examine the degree to which consumers understand managed care and quality-of-care indicators, and the extent to which they find these indicators useful in making health care choices. The results showed that consumers are interested in having information about quality of care, but do not perceive the relevance of quality measures in choosing health plans. (Project Officer: Elinor Walker. Project dates: 7/1/94-12/31/95)

Smart Choice. Jeffrey Johnston, Principal Investigator. A software decision tool to assist Federal employees in selecting a health care plan is being developed; eventually the software program will be of use to both public- and private-sector employees. This builds on previous work wherein investigators developed an interactive decision assistance software program to train consumers about the meaning of important health plan features and help them clarify personal preferences about health care coverage. The program mathematically links the users preferences to externally available valuative data about available health plans. (Project Officer: Sandy Robinson. Project dates: 9/30/95-9/30/97)

Design of a Survey to Monitor Consumers' Access to Care, Use of Health Services, HealthOutcomes, and Patient Satisfaction. James Lubalin, Principal Investigator. Through this contract with the Research Triangle Institute, AHCPR has developed survey modules designed to collect key information on consumers' attitudes about access to health care, use of specific services, health outcomes, perceived quality of care, and satisfaction with care. One goal was to design a survey that could yield comparative data across types of health benefits plans (such as managed care versus FFS). (Project Officer: Sandy Robinson. Project dates: 9/30/94-3/30/95)

Consumer Assessment of Health Plans Study (CAHPS®). James Lubalin, Ron Hays, and Paul D. Cleary, Principal Investigators. In cooperation with AHCPR, the consortia of Research Triangle Institute, RAND, and Harvard University are developing a family of surveys and consumer report formats that will help consumers and purchasers select high-quality health care plans and services that meet their needs. The team will develop and test a health care consumer kit, user manual, and consumer reports in Phase 1 of the project. In Phase 2 the products developed will be implemented and evaluated. (Project Officers: Christine Crofton and Charles Darby. Project dates: 9/30/95-9/29/00)

Survey User Network (SUN). Samantha Sheridan, Principal Investigator. Westat, Inc., will ensure that the instruments and communication devices developed under CAHPS® get into the hands of consumers, employers, plans, unions, and other interested parties as quickly as possible. SUN will also provide technical assistance to users of the survey. (Project Officer: Charles Darby. Project dates: 9/28/95-9/27/00)

Health Education in an HMO: Effectiveness and Efficiency. Ronald W. Toseland, Principal Investigator. This study compares the short- and long-term effects of a health education program in a managed care setting to teach health education, coping, and other skills to individuals who care for their frail elderly spouses, and examines the impact of the training on caregivers and care recipients' health care utilization and costs. (Project Officer: Linda Siegenthaler. Project dates: 9/30/96-9/29/00)

Choosing and Using a Health Plan. Christina Zarcadoolas, Principal Investigator. In an effort to assist low-income, disadvantaged, low-literacy and/or ethnic minority consumers in Rhode Island who are choosing among health plans, this project developed two print guides (Choosing a Health Plan: A User's Guide and How to Assist Your Employees Choose and Use Their Health Plans) and a video in both English and Spanish (Choosing a Health Plan: No One Likes Surprises). The materials, presently being field tested with ADFC mothers and low-income workers, will help these individuals choose, as well as use, their health plan, whether the plans are offered under private or Government programs. These materials will be available for distribution in April 1998. (Project Officer: Sandy Robinson. Project dates: 9/30/95-3/31/97)

How to Evaluate Information from Providers: Tools for Nonmainstream Populations. Christina Zarcadoolas, Principal Investigator. This project will develop "low barrier' decision tools. The contractor will develop prototype print, video, and interactive voice response (IVR) telephone systems to assist consumers in communicating with plans and providers. The goal of the project is to help low-literate, minimally-English-proficient, minority, and low-income people understand and evaluate the information and advice they are given by providers with respect to illnesses and treatments, thus enabling more shared decisionmaking. (Project Officer: Sandy Robinson. Project dates: 12/20/96-6/20/97)

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