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1. Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com.
CHAPTER 28
Health Services
Research:
Finding What
Works

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©
2021
by
Jones
&
Bartlett
Learning,
LLC
an
Ascend
Learning
Company.
www.jblearning.com
Small-Area Analysis
 Small-area analysis revealed:
– Large variations in practice style by geographical area exist for many medical
conditions.
– Greatest care variation is in conditions with the least known about the effectiveness
and appropriateness of diagnostic and treatment approaches.
– Sometimes more than one therapy may be appropriate.
– Doctors may adjust behavior when informed of other doctors’ practice patterns.

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2021
by
Jones
&
Bartlett
Learning,
LLC
an
Ascend
Learning
Company.
www.jblearning.com
Field of Dreams Effect
 Availability of services leads to more use of these services.
– More back surgeons, more back surgeries
– More hospital beds, more hospitalizations
– More hospital beds, more patients dying in hospitals than homes
 There is evidence in some cases that financial considerations may affect
medical decisions.

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©
2021
by
Jones
&
Bartlett
Learning,
LLC
an
Ascend
Learning
Company.
www.jblearning.com
Outcomes Research
 Is the epidemiologic study of medical care
 Analyzes data generated by everyday practice of medicine, e.g., from Medicare
records
 Should allow patients to make informed decisions based on their own values
 Benign prostatic hyperplasia (BPH) was a high-variation procedure.
– Watchful waiting and prostatectomy are weighed.
– Prostatectomy benefits are overstated, and complications are understated.
– Patients need to be informed so they can choose.
– PSA screening for prostate cancer leads to more invasive tests.
• There is no evidence that it reduces mortality from cancer.

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2021
by
Jones
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Bartlett
Learning,
LLC
an
Ascend
Learning
Company.
www.jblearning.com
Agency for Health Care Research and Quality
 The agency was mandated by Congress in 1989 to develop guidelines for
treatment.
 When it recommended less back surgery (1994), political pressure from back
surgeons almost forced elimination of the agency.
 Now the agency has recovered.
 There is continued interest in improving medical outcomes while controlling
costs.

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2021
by
Jones
&
Bartlett
Learning,
LLC
an
Ascend
Learning
Company.
www.jblearning.com
Medical Errors
 Series of medication errors and wrong-side surgeries led to the 1999 Institute of
Medicine report.
– It estimated errors cause 44,000–98,000 deaths per year.
– It recommended shifting focus from blaming individuals to focusing on improving a
system decentralized, fragmented, and rife with poor communication and more.
 Detailed recommendations included:
– Create the Center for Patient Safety.
– Set national goals, track progress, do research.
– Report and investigate errors.
– Change drug naming, packaging, and labeling to minimize confusion.

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2021
by
Jones
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Bartlett
Learning,
LLC
an
Ascend
Learning
Company.
www.jblearning.com
Medical Care Report Cards
 Managed care plans are easier to evaluate than other plans.
– Data is available.
– Managed care organizations are accredited.
– Annual reports are created.
 Report cards can evaluate quality of care for some procedures.
– New York State measures outcomes of coronary bypass surgery.
• Outcomes of individual hospitals and surgeons are reported.
• Reports have led to improvement in outcomes.
• High volume surgeons and hospitals do better.

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2021
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Jones
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Learning,
LLC
an
Ascend
Learning
Company.
www.jblearning.com
Inequities in Medical Care
 Medical care is rationed by ability to pay.
 Racial inequities in care exist, even when ability to pay is the same.
 Blacks and Hispanics receive poorer treatment for many conditions.
– E.g., less likely to be recommended for mammograms.
 Institute of Medicine reports bias, prejudice, and stereotyping.

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2021
by
Jones
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Bartlett
Learning,
LLC
an
Ascend
Learning
Company.
www.jblearning.com
Relative Importance of Medical Care for Public Health
 International comparisons show health is proportional to wealth (national GDP).
 Health isn’t proportional to amount of physicians.
 More spending does not improve health and may even increase the mortality
rate.
 RAND Health Insurance Experiment revealed:
– For people with generous insurance, many healthcare services may be wasted.
– For the poor and chronically ill, free care does improve health status.

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Learning,
LLC
an
Ascend
Learning
Company.
www.jblearning.com
Discussion Question 1
 What are three or more reasons why treatments for some illnesses vary from
one geographic area to another?
 Do you think this is a problem and that the government should do more about
it?

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Learning,
LLC
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Ascend
Learning
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www.jblearning.com
Discussion Question 2
 Describe three or more ways in which outcomes research can improve the
health of the population.

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Learning,
LLC
an
Ascend
Learning
Company.
www.jblearning.com
Discussion Question 3
 Discuss the relative importance of human biology, lifestyle, the environment,
and medical care in contributing to the health of the population.

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2021
by
Jones
&
Bartlett
Learning,
LLC
an
Ascend
Learning
Company.
www.jblearning.com
Discussion Question 4
 Visit the website of the Agency for Healthcare Research and Quality (AHRQ),
www.ahrq.gov.
 Review press releases for the past few months.
 What issues is the AHRQ concerned about recently?

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2021
by
Jones
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Bartlett
Learning,
LLC
an
Ascend
Learning
Company.
www.jblearning.com
Discussion Question 5
 Visit Cochrane’s website, www.cochrane.org.
 The organization is an international, nonprofit organization that collects and
synthesizes evidence on outcomes research.
 Review the most recent newsletters.
 What new findings has the organization produced?