Performance Improvement 1996. Office of Public Health and Science

02/01/1996

Contents

Baseline Data on the Delivery of Clinical Preventive Services Provided by Nurse Practitioners

Breast and Reproductive Cancer Screening Project for Women 40 Years of Age and Older

Consequences of Whistleblowing for the Whistleblower in Misconduct in Science Cases

Evaluation and Enhancement of Primary Care Research in Community, Migrant, and Homeless Health Centers in the Public Health Service, Region VI

Federal Regulation of Methadone Treatment

Financing of Academic Medical Centers and Graduate Medical Education Under Competitive Systems With Managed Care (Two Volumes)

HIV and the Blood Supply: An Analysis of Crisis Decisionmaking

Improving the Supply, Training, and Distribution of Primary Care Providers Under Federal Health Care Reform

Measuring Expenditures for Essential Public Health Services

Minority HIV/AIDS Programs Community-Based Organization Evaluation: HIV/AIDS Education/Prevention Grant Program 1988-89, A Cross-Site Evaluation

Region IX Hepatitis B Project Final Report

Review of the Fialuridine (FIAU) Clinical Trials

TITLE: Baseline Data on the Delivery of Clinical Preventive Services Provided by Nurse Practitioners

ABSTRACT NUMBER: 136

ABSTRACT: This report obtains baseline data on the disease-prevention activities of nurse practitioners as primary care providers and compares the findings with target goals from 17 objectives of Healthy People 2000: National Health Promotion and Disease Prevention Objectives. The study surveyed 1,310 nurse practitioners. The 892 respondents reported spending 50 percent or more of their time providing primary care, and it appears that nurse practitioners are closer to the Healthy People 2000 target percentages for assessment services than for intervention services (that is, nurse practitioners exceeded assessment goals with regard to preconception care, family planning, and emotional and behavioral functioning; however, they exceeded the intervention goals only in the areas of preconception care and family planning). With regard to the provision of screening and immunization services, nurse practitioners working in pediatrics and family medicine exceeded the target percentages for scheduled hemoglobin and hematocrit testing; blood pressure monitoring; height and weight checks; and diphtheria, pertussis, and tetanus vaccinations. Concerning the provision of cancer screening services, nurse practitioners in obstetrics/gynecology and family medicine exceeded the objectives for breast exams, Pap smears, and mammograms. See also PIC ID 4962.1-4962.3. (Final report 42 pages, plus appendixes.)

AGENCY SPONSOR: Office of Disease Prevention and Health Promotion

FEDERAL CONTACT: Deborah R. Maiese

PHONE NUMBER: 202/401-5809

PIC ID: 4962

PERFORMER ORGANIZATION: National Alliance of Nurse Practitioners, Washington, DC

TITLE: Breast and Reproductive Cancer Screening Project for Women 40 Years of Age and Older

ABSTRACT NUMBER: 137

ABSTRACT: This project evaluated the impact of factors that impede the implementation of breast and reproductive cancer prevention efforts at nine C/MHCs located in California. This report reviews screening, referral, diagnosis, treatment, and case management protocols in the nine C/MHCs. Federal funding requires that C/MHCs file programmatic assurances stating that such protocols are on file. Two sources of established guidelines, the American College of Obstetricians and Gynecologists clinical guidelines and the California State Breast and Cervical Cancer Control Program clinical guidelines, were used as the basis of comparison for the C/MHC guidelines. Eight of the nine C/MHCs submitted protocols; the ninth submitted a letter listing the routines they followed for women over 40. The report finds that, of the protocols submitted, all are either developed by other organizations or developed specifically for the C/MHC. All included information on women over the age of 40. However, several weaknesses existed: (1) community education and outreach was lacking among the majority of C/MHCs; (2) only one of the nine C/MHCs designated staff in the protocols who would be performing the different care duties; (3) no ethnic, culturally specific barriers were addressed in protocols submitted by any of the C/MHCs; and (4) the C/MHCs fail to understand the content of protocols or their importance. (Final report 16 pages, plus appendix.)

AGENCY SPONSOR: Public Health Service, Regional Office IX

FEDERAL CONTACT: Irene Reed

PHONE NUMBER: 415/556-7009

PIC ID: 5625

PERFORMER ORGANIZATION: Associated California Health Centers, Inc., Lamont, CA

TITLE: Consequences of Whistleblowing for the Whistleblower in Misconduct in Science Cases

ABSTRACT NUMBER: 138

ABSTRACT: Whistleblowers in scientific misconduct cases are highly likely to experience one or more negative consequences as a result of their whistleblowing. This report presents the results of a mail survey of those individuals listed in the Office of Research Integrity files as having made allegations of scientific misconduct. Only individuals involved in closed cases were contacted for the study. Of the 127 individuals eligible to be surveyed, 105 whistleblowers were located and mailed a survey. Of these, 89 responded, of whom 68 completed the surveys. Survey results show that (1) most whistleblowers believe that the negative consequences they have experienced as a result of their actions have had a neutral impact on their careers, professional activities, and personal lives; (2) 69 percent report experiencing at least one or more negative outcomes, while 31 percent experienced none; (3) 25 percent report serious consequences, such as the loss of position or denial of tenure, promotions, or salary increases; (4) whistleblowers attribute negative consequences to institutional officials, respondents, colleagues, and professional societies; (5) most consequences were experienced during the response to the allegations and after the inquiry was completed; and (6) despite the negative consequences cited, 68 percent of respondents said they would make another allegation, 10 percent were uncertain, and 10 percent would not. (Final report 61 pages, plus appendixes.)

AGENCY SPONSOR: Office of Research Integrity

FEDERAL CONTACT: Lawrence J. Rhoades, Ph.D.

PHONE NUMBER: 301/443-5300

PIC ID: 5659

NTIS ACCESSION NUMBER: PB 96-200449

PERFORMER ORGANIZATION: Research Triangle Institute, Research Triangle Park, NC

TITLE: Evaluation and Enhancement of Primary Care Research in Community, Migrant, and Homeless Health Centers in the Public Health Service, Region VI

ABSTRACT NUMBER: 139

ABSTRACT: This project assessed the level of interest in primary care practice-based research in PHS Region VI. The project (1) ascertained and evaluated past and present activities and potential sources for primary care research in Region VI; (2) developed and enhanced primary care research linkages; and (3) promoted interest in primary care research and clinical networking in Region VI. Surveys were mailed to the medical director and the executive director in each of nine sites chosen from C/MHCs in Region VI. Analysis of survey responses shows that (1) clinicians are interested in primary care research, electronic mail, and clinical bulletin board systems; (2) respondents are more interested in research on preventive and lifestyle factors than on clinical diseases; and (3) only a minority of clinicians have access to computer lists of patient diagnoses and ordered tests. Significant barriers to research include (1) lack of research skills and expertise; (2) too many clinical responsibilities; and (3) lack of access to research consultation. The report recommends that (1) further evaluation of PHS and non-PHS clinic sites in Region VI be carried out to determine topics of interest; (2) collaborative arrangements with academic researchers be developed; and (3) possible electronic forums for clinician use be investigated. (Final report 10 pages, plus appendixes.)

AGENCY SPONSOR: Public Health Service, Regional Office VI

FEDERAL CONTACT: Robert A. Sappington

PHONE NUMBER: 214/767-3719

PIC ID: 5914

PERFORMER ORGANIZATION: Migrant Clinicians Network, Austin, TX

TITLE: Federal Regulation of Methadone Treatment

ABSTRACT NUMBER: 140

ABSTRACT: Methadone hydrochloride (methadone) has been used to treat opiate addiction since 1972. Unlike other controlled substances, methadone use is controlled by a many-tiered system of regulations. FDA, the Drug Enforcement Administration, NIDA, and SAMHSA provide Federal oversight to methadone programs, while State and local agencies may also regulate them. This report examines current HHS standards for methadone programs and evaluates the effects of Federal regulations on the provision of methadone treatment services. The report also explores options for modifying these regulations. It finds that the underlying ideology of methadone regulations is that the societal risks of methadone outweigh the benefits to such an extent that its use must be extraordinarily regulated. The report contends that this belief is not valid in the current environment and that the stringent regulation of methadone removes power from the hands of clinicians in determining the best course of a patient's treatment and causes unintended negative impacts. The report recommends that the scope of Federal regulations be scaled back to allow greater clinical discretion, and that opiate-addicted patients be regarded holistically by methadone programs and other health and human services providers. (Final report 237 pages.)

AGENCY SPONSOR: Office of Public Health and Science

FEDERAL CONTACT: Carol Roddy

PHONE NUMBER: 202/205-0152

PIC ID: 5627

PERFORMER ORGANIZATION: National Academy of Sciences, Institute of Medicine, Washington, DC

TITLE: Financing of Academic Medical Centers and Graduate Medical Education Under Competitive Systems With Managed Care (Two Volumes)

ABSTRACT NUMBER: 141

ABSTRACT: This report examines how the growth of competitive health care financing and service delivery systems based on managed care have affected or could affect the financial support available to academic medical centers (AMCs) and graduate medical education (GME). Case studies of AMCs in Minneapolis/St. Paul, San Diego, and Washington, D.C., and a review of the literature, as well as the results of an ongoing study of the related financial performance of AMCs nationwide, produce several findings. These findings include the following: (1) AMCs tend to be more expensive than other hospitals, although the extent to which this higher cost is attributable to GME is unclear; (2) implicit subsidies for these higher costs through patient care revenues are becoming less available; (3) relatively few short-term adverse effects on AMCs from the growth of competitive systems can be found, but AMCs are concerned that long-term effects will arise; (4) to the extent that managed care penetrates more heavily into the Medicare market, impacts on AMCs are likely to be intensified; and (5) AMCs are attempting to reduce costs and develop affiliations useful to a managed care environment, even though they are concerned that doing so will detract from their unique missions. The report concludes that, while there is considerable support for pooled funding for GME among diverse parties, AMCs have not reached a consensus about its details. (Volume One final report 15 pages; Volume Two appendixes variously paginated.)

AGENCY SPONSOR: Office of Public Health and Science

FEDERAL CONTACT: Carol Roddy

PHONE NUMBER: 202/205-0152

PIC ID: 5722

PERFORMER ORGANIZATION: Mathematica Policy Research, Inc., Plainsboro, NJ

TITLE: HIV and the Blood Supply: An Analysis of Crisis Decisionmaking

ABSTRACT NUMBER: 142

ABSTRACT: FDA has regulatory authority over blood plasma collection establishments, blood banks, and all blood products. The Centers for Disease Control and Prevention is responsible for surveillance, detection, and warning of potential public health risks within the blood supply. NIH supports these efforts through fundamental research. These Federal entities, as well as the plasma fractionation industry, community blood banks, and other groups, have responsibilities to protect the supply of blood from communicable disease. This report examines the behavior of these entities in response to a threat to the blood supply that emerged in the early 1980's--HIV. The report relates the history of the disease and the bureaucratic response to it in four areas: (1) blood product treatment; (2) donor screening and referral; (3) regulation of the removal of contaminated products from the market; and (4) communication to physicians and patients. The report concludes that (1) the system did not deal well with blood safety issues such as hepatitis and was not prepared for the much greater threat of HIV; (2) strong leadership must counteract legal and competitive concerns that may inhibit effective agency action when a crisis is not well-defined; and (3) agencies need to formulate a systematic approach to advisory committees and should not rely on the entities they regulate for data analysis or modeling.

AGENCY SPONSOR: Office of Public Health and Science

FEDERAL CONTACT: Carol Roddy

PHONE NUMBER: 202/205-0152

PIC ID: 5896

PERFORMER ORGANIZATION: National Academy of Sciences, Institute of Medicine, Washington, DC

TITLE: Improving the Supply, Training, and Distribution of Primary Care Providers Under Federal Health Care Reform

ABSTRACT NUMBER: 143

ABSTRACT: This project analyzes issues related to proposals for improving the supply, training, and distribution of primary care providers as part of health care reform. Many reform proposals considered by Congress include provisions that would change the mechanism used in decisions to fund graduate medical education, thus changing the numbers and types of new physicians. Information provided in this report includes (1) a chart book on the supply, training, and distribution of physicians; (2) technical papers providing background on the need for increased numbers of generalist physicians; (3) the rationale for proposals to control the supply of new physicians; (4) proposals for an all-payer pool for GME; (5) estimates of the number of physicians in research training tracks funded by NIH and elsewhere; and (6) preliminary estimates of the number of advanced practice nurses and physician assistants that would be needed to substitute for physicians if the number of physician residents were reduced.

AGENCY SPONSOR: Office of Public Health and Science

FEDERAL CONTACT: Carol Roddy

PHONE NUMBER: 202/205-0152

PIC ID: 5666

PERFORMER ORGANIZATION: Center for Health Policy Research, Washington, DC

TITLE: Measuring Expenditures for Essential Public Health Services

ABSTRACT NUMBER: 144

ABSTRACT: The purpose of this project is to develop a tool for collecting data on Federal, State, and local public health expenditures that uses the terminology of the essential services of public health. The goal of this effort is to document the relative investment in public health in the United States, laying the groundwork for a system to track these expenditures over time and across agencies and levels of Government. Another purpose of this project is to provide the financial data to relate to public health outcomes, public health infrastructure, and work force measurement. Nine States participated in this effort: Arizona, Illinois, Iowa, Louisiana, New York, Oregon, Rhode Island, Texas, and Washington. On June 29, 1995, 75 State, local, and Federal officials met to discuss and plan the collection of data on public health expenditures. After a plenary session with presentations on several public health initiative projects, the participants from public health, mental health, substance abuse, and environmental agencies met in separate work groups to discuss the tools for estimating expenditures for the essential services of public health. Data collection instruments were distributed to State health officials in September 1995. State health officials coordinated the data collection for State and local public health, substance abuse, and environmental agencies. At the request of the mental health agencies, data collection was coordinated using 1993 data from the National Association of State Mental Health Program Directors.

AGENCY SPONSOR: Office of Disease Prevention and Health Promotion

FEDERAL CONTACT: Deborah R. Maiese

PHONE NUMBER: 202/401-5809

PIC ID: 6194

PERFORMER ORGANIZATION: Public Health Foundation, Washington, DC

TITLE: Minority HIV/AIDS Programs Community-Based Organization Evaluation: HIV/AIDS Education/Prevention Grant Program 1988-89, A Cross-Site Evaluation

ABSTRACT NUMBER: 145

ABSTRACT: This evaluation study uses a multiple case study approach to assess 9 of 38 projects awarded grants in 1988 and 1989. The study documents, describes, and assesses the effectiveness of community-based projects that address HIV and AIDS prevention within minority communities. The grant program was designed to support innovative approaches that minority programs use when targeting their communities and at-risk populations. This report assesses the effectiveness of these projects. The results and findings of this evaluation will be used by the Office of Minority Health and other agencies to identify successful practices and common themes that could be used as innovative community-based risk-reduction strategies. The study compares various community-based approaches to disease prevention and the impact of those approaches on minority communities. Results of the study show that successful prevention models include (1) funding agencies that give priority to community-based organizations (CBOs) with a history of meeting community needs; (2) CBOs with local representation at all levels of program decisionmaking; (3) funding agencies that provide site visits, responses to program reports, and ongoing communication with program managers; and (5) funding agencies that set aside resources for technical assistance. (Final report 121 pages, plus appendixes.)

AGENCY SPONSOR: Office of Minority Health

FEDERAL CONTACT: John Walker, III

PHONE NUMBER: 301/594-0769

PIC ID: 5618

PERFORMER ORGANIZATION: Tonya, Inc., Washington, DC

TITLE: Region IX Hepatitis B Project Final Report

ABSTRACT NUMBER: 146

ABSTRACT: Approximately 300,000 people are infected with the hepatitis B virus (HBV) each year, and about 1 million are infectious HBV carriers. Of these, over 50 percent are Asians or Pacific Islanders. Carrier rates for Asians range from 8 to 15 percent, and for Pacific Islanders, from 5 to 10 percent, while rates for the total U.S. population are 0.2 percent. This report assesses HBV education and outreach efforts among Region IX primary care centers serving Asians and Pacific Islanders. The report summarizes the programs at five centers. These centers completed and returned a self-assessment tool, the results of which show that staffing is the strongest component of HBV education and outreach programs. Programs with bilingual medical staff or medical interpreters, with materials written in patients' languages, and with a high-profile, integrated approach are generally more successful than others. The report finds that media-based outreach is the weakest aspect of the programs. Information gathered in two site visits is also presented. The report covers the following areas: clinic/client profiles; staffing; health education materials; clinic-based, media-based, and community-based outreach and education; and networking and linkages. The report also provides information on the barriers to effective HBV outreach and education, including cost, cultural health beliefs, and lack of personnel and awareness. It provides recommendations to improve HBV education and outreach for Asians and Pacific Islanders.

AGENCY SPONSOR: Public Health Service, Regional Office IX

FEDERAL CONTACT: George Nakama

PHONE NUMBER: 415/556-4926

PIC ID: 5681

PERFORMER ORGANIZATION: Association for Asian Pacific Community Health Organization, Oakland, CA

TITLE: Review of the Fialuridine (FIAU) Clinical Trials

ABSTRACT NUMBER: 147

ABSTRACT: In June 1993, 1 of 15 HBV outpatients taking part in an NIH clinical drug trial was hospitalized with liver failure. Shortly thereafter, six more patients also developed severe toxicity. Five patients eventually died, and two more were saved from death only by a liver transplant. All of these patients were taking the experimental drug fialuridine (FIAU). The Institute of Medicine (IOM) examined the clinical trials involving FIAU and its parent drug, fiacitabine, to determine whether any rules governing the trials process should be changed, and what burdens or costs these changes might place on future clinical trials. Their report presents the history of clinical trials of the drugs, beginning with trials that showed promise in the treatment of HBV and ending with the trial in which several people died from toxic effects of FIAU. It also carefully examines the clinical background for the trials, the informed consent process, and the conduct of the investigators. The IOM found that the entire set of trials reviewed was an ethically sound clinical research project designed and carried out by highly competent investigators who frequently exceeded requirements of regulations imposed by institutional review boards. Furthermore, the IOM report discusses conclusions and recommendations issued by the FDA. The IOM generally concurs with the recommendations without ascribing blame for the tragedy to any party.

AGENCY SPONSOR: Office of Public Health and Science

FEDERAL CONTACT: Carol Roddy

PHONE NUMBER: 202/205-0152

PIC ID: 5660

PERFORMER ORGANIZATION: National Academy of Sciences, Institute of Medicine, Washington, DC