Effectiveness and Outcomes in Health Care -- Copyright -- ACKNOWLEDGMENTS -- PREFACE -- EFFECTIVENESS VERSUS EFFICACY -- METHODOLOGIES -- IMPACT UPON COSTS -- RISK ADJUSTMENTS AND OUTCOMES -- CONCLUSIONS -- Contents -- PART I INTRODUCTION -- 1 Genesis of the Effectiveness Initiative and IOM's Role -- THE BROADER CONTEXT -- The Institute of Medicine's Contribution -- The IOM Clinical Workshop -- The Condition-Specific Workshops -- Effectiveness and Outcomes Conference -- Proceedings -- 2 Promise and Limitations of Effectiveness and Outcomes Research -- IMPORTANCE OF EFFECTIVENESS RESEARCH -- Medicare Data Bases -- KEY ASPECTS OF EFFECTIVENESS RESEARCH -- Reliability and Validity of Data -- Longitudinal Studies -- Tracking the Patient -- Health Status Assessment -- Risk Stratification -- Prevention -- The Aging Process -- PRINCIPLES TO GUIDE FEDERAL EFFORTS -- Range of Study Designs -- Funding -- Balance of Approaches -- Coordination -- Technology Assessment -- Influencing Provider Behavior -- The Confluence of Biomedical, Health Services, and Effectiveness Research -- PART II OVERVIEW -- 3 Research on the Effectiveness of Medical Treatment: New Challenges and Opportunities -- Medical Treatment Effectiveness Program -- Implementation of the Program -- Priorities for Research -- New Patterns of Collaboration -- References -- 4 The Health Care Financing Administration and the Effectiveness Initiative -- HCFA'S INTEREST IN EFFECTIVENESS -- THE EFFECTIVENESS INITIATIVE -- FUTURE ACTIVITIES -- ACKNOWLEDGEMENTS -- 5 The Effectiveness Initiative: Retrospective and Prospects -- THE GOVERNMENT'S ROLE IN EFFECTIVENESS RESEARCH -- PROSPECTS -- 6 The Social Perspective -- THE PRESENT SCENARIO -- COSTS OF HEALTH CARE -- VARIATIONS IN MEDICAL COSTS AND PRACTICE -- REASONS FOR THE EFFECTIVENESS INITIATIVE -- HOW TO PROCEED IN EFFECTIVENESS AND OUTCOMES RESEARCH.

7 The Clinical Perspective -- ISSUES IN THE USEFULNESS OF EFFECTIVENESS RESEARCH -- MEETING PHYSICIANS' NEEDS -- Accessibility of Results -- Aiding Patient Invol Vement -- Relation to Payment Mechanisms -- Unbalanced Regulation -- IMPACT OF THE EFFECTIVENESS INITIATIVE -- Reference -- 8 The Legislative Perspective -- UNMET HEALTH CARE NEEDS -- GROWING AWARENESS OF EFFECTIVENESS RESEARCH -- THE CHALLENGE TO SCIENTISTS -- CONCLUSION -- PART III THE IOM CLINICAL CONDITION WORKSHOPS -- The IOM Condition Workshops: Introduction -- 9 Breast Cancer -- THE PROBLEM OF POOR COMPLIANCE -- CONTROVERSIES -- Screening -- Treatment -- THE ROLE OF EFFECTIVENESS STUDIES IN BREAST CANCER -- References -- 10 Hip Fracture -- PREVENTION -- TREATMENT -- IN-HOSPITAL CARE -- REHABILITATION -- CONCLUSION -- 11 Claims Data and Effectiveness: Acute Myocardial Infarction and Other Examples -- STRENGTHS OF CLAIMS DATA -- GENERAL LIMITATIONS -- Limitations for Diagnostic Devices -- Limitations for Drugs -- Limitations for Therapies -- CONCLUSION -- References -- PART IV METHODOLOGICAL ISSUES AND WORK IN PROGRESS -- Use of Large Data Bases: Introduction -- 12 The Role of Large Data Bases in Effectiveness Research -- SIZE OF LARGE DATA BASES -- USES OF LARGE DATA BASES -- MEDICARE DATA BASES -- MEDICAID DATA BASES -- 13 Administrative Data in Effectiveness Studies: The Prostatectomy Assessment -- OVERVIEW OF THE PROSTATECTOMY ASSESSMENT -- OVERVIEW OF METHODS -- Case Identification and Variables -- Outcomes -- Patient Covariables -- Treatment Variables -- USES OF ADMINISTRATIVE DATA IN PROSTATECTOMY ASSESSMENT -- Variations in Utilization Rates -- Population-Based Estimates of Adverse Outcome Rates -- Comparisons of Transurethral and Open Prostatectomy -- IMPROVING THE USEFULNESS OF ADMINISTRATIVE DATA BASES -- Strengths -- Limitations -- Suggestions -- References.

14 Issues in the Use of Large Data Bases for Effectiveness Research -- DEFINING LARGE DATA SETS -- Population Base -- Original Purpose -- USES OF LARGE DATA BASES -- Sampling Frames -- Rates and Outcomes Surveillance -- Variations in Outcomes -- Linking Large Data Sets -- LIMITATIONS OF LARGE DATA BASES -- Data Quality -- Timeliness -- Access -- METHODOLOGICAL ISSUES -- Risk Adjustment -- Treatment Selection -- Provider-Procedure Interaction -- Statistical Issues -- Multiple Hypotheses -- Processes in Control -- RANDOMIZED CONTROLLED TRIALS VERSUS ANALYSIS OF LARGE DATA SETS -- PROSPECTS -- AN AGENDA -- References -- Collection of Primary Data: Introduction -- 15 Measuring Patient Function and Well-Being: Some Lessons from the Medical Outcomes Study -- CONCEPTS AND DATA SOURCES -- DISEASE-SPECIFIC VERSUS GENERIC MEASURES -- A MINIMUM SET OF GENERIC HEALTH CONCEPTS -- THE MEDICAL OUTCOMES STUDY -- FEASIBILITY AND COST -- STANDARDS FOR EVALUATING MEASURES -- USE OF HEALTH SURVEY DATA -- ACKNOWLEDGEMENTS -- References -- 16 The Uniform Clinical Data Set -- THE PRO CASE REVIEW PROCESS -- THE UNIFORM CLINICAL DATA SET AND PRO NEEDS -- Using the Uniform Clinical Data Set -- Application of Findings -- CONCLUSIONS -- Development and Use of Outcome Measures: Introduction -- 17 Assessing Health-Related Quality of Life Outcomes -- QUANTITY AND QUALITY OF LIFE -- SELECTION OF OUTCOMES -- Sources For Analysis -- Indexes -- Profiles -- Batteries -- GENERIC AND SPECIFIC MEASURES -- SHORT, RESPONSIVE MEASURES -- CHANGES IN MEASURES -- A THEORETICAL MODEL FOR HEALTH STATUS AND QUALITY OF LIFE -- CONCLUSIONS -- References -- 18 Using Patient Reports of Outcomes to Assess Effectiveness of Medical Care -- LINKING PROCESS AND OUTCOME -- Early Studies of Outcome -- The Need For Disease-Specific Measures -- SCOPE OF THE STUDY -- Patient Questionnaire -- Findings.

CONCLUSIONS -- References -- 19 Studying Outcomes for Patients with Depression: Initial Findings From the Medical Outcomes Study -- THE MEDICAL OUTCOMES STUDY -- Health Care Setting -- Initial Samples -- THE STUDY OF DEPRESSION -- Identifying Patients With Depression -- Assessing Outcomes -- RESULTS OF THE DEPRESSION STUDY -- Findings From the Baseline Data -- Preliminary Findings From the Longitudinal Data -- CONCLUSION -- References -- Application to Clinical Practice: Introduction -- 20 Effectiveness Research and Changing Physician Practice Patterns -- EFFECTS OF RESEARCH ON MEDICAL PRACTICE -- Clinical Trials -- Consensus Development Conferences -- WHAT SHOULD BE DONE -- References -- 21 Applying Effectiveness and Outcomes Research to Clinical Practice -- WHAT IS DIFFERENT ABOUT EFFECTIVENESS AND OUTCOMES RESEARCH? -- A CLINICAL EXAMPLE: OUTCOME PROBABILITIES IN DECISION MAKING -- SOURCES OF PROBABILITIES AND A ROLE FOR OUTCOMES RESEARCH -- VALUE JUDGMENTS IN DECISION MAKING -- VALUE JUDGMENTS AND THE ROLE OF OUTCOMES RESEARCH -- CONCLUSIONS -- References -- 22 An Attempt to Manage Variation in Obstetrical Practice -- THE HARVARD COMMUNITY HEALTH PLAN EXPERIENCE -- The Choice of Obstetrical Care -- Variations in Practice Between Two Hospitals -- Possible Causes of the Variations -- The Attempt to Change Process of Care -- Preliminary Results -- LESSONS -- A CAUTION -- ACKNOWLEDGMENTS -- 23 Using Outcome Measures to Improve Care Delivered by Physicians and Hospitals -- OUTCOMES MEASUREMENT/IMPROVEMENT SYSTEMS FOR MEDICAL PRACTICES -- The Coop Charts -- THE RUBENSTEIN FUNCTIONAL HEALTH STATUS APPROACH -- MEASUREMENT/IMPROVEMENT SYSTEMS FOR HOSPITALS -- HCA Patient Judgment System -- SOUTH SHORE HOSPITAL GERIATRIC ASSESSMENT AND PLANNING PROGRAM -- HALLMARKS OF MEASUREMENT/IMPROVEMENT SYSTEMS.

USE OF OUTCOMES MEASURES TO BENEFIT A PATIENT POPULATION -- CONCLUSION -- References -- PART V WHERE DO WE GO FROM HERE? -- 24 The Need for Reasonable Expectations -- THE LIKELIHOOD OF UNMET EXPECTATIONS -- WHAT EFFECTIVENESS RESEARCH CAN DO -- References -- 25 Use of Effectiveness Research in Managed Care Plans -- IMPORTANCE OF OUTCOMES RESEARCH -- CURRENT APPLICATIONS OF OUTCOMES RESEARCH -- Clinical Protocols -- Technology Assessment -- INSURERS' ROLE IN EFFECTIVENESS RESEARCH -- LIMITATIONS OF THE EFFECTIVENESS ''STRATEGY'' -- Reference -- 26 Gaining Acceptance for Effectiveness and Outcomes Research -- REASONS FOR PURSUING RESEARCH -- WHO MUST BE CONVINCED? -- WHO WILL PUSH FOR RESEARCH? -- References -- LIST OF AUTHORS.