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appropriate also to study prevention and how to increase efforts at early detection?

Answer. Breast cancer is among the conditions identified by the Institute of Medicine and the Agency for Health Care Policy and Research (AHCPR) as a priority for study under MEDTEP. However, from our discussions with the National Cancer Institute (NCI), we believe that NCI is in a better position to explore better techniques for treating breast cancer. We do expect to contribute to this important issue by facilitating the development of guidelines to ensure the quality of mammograms. This work would be undertaken with the full collaboration of the Food and Drug Administration, the National Cancer Institute, and the Centers for Disease Control,

Question. Breast cancer is a perfect example of a condition whose treatment is enhanced enormously through early detection. Does it make sense to you that AHCPR might meet its mandate to disseminate information about effective treatments by undertaking to educate women about the new Medicare coverage of mammography?

Answer. Generally, AHCPR is focusing its attention on the dissemination of the guidelines, publications, and clinical effectiveness information generated under its own auspices. This does not preclude participation in the dissemination of pertinent information from other sources in the future. The Health Care Financing Administration disseminates Medicare coverage information to beneficiaries through the Medicare Handbook. Information about its mammogram coverage policy will be published in the 1991 revision of the Medicare. Handbook. Further, our guideline activity regarding quality determinants for mammograms will have the additional advantage of focusing attention on this clinical issue.

MEDTEP RESEARCH

Question. The FY 90 Labor-HHS report directed that a conference be held to develop a research agenda for MEDTEP.

What is the status of that conference and the agenda ?

Answer. The National Agenda Setting Conference on Outcomes and Effectiveness Research will be held April 14 · 16, 1991 in the Washington, D.C. metropolitan area. There will be ten workshops within the conference addressing a wide range of outcomes and effectiveness research issues.

Question. What has the agency learned so far from the medical treatment effectiveness research portfolio, and how will this knowledge be used to improve health care?

Answer. MEDTEP research is designed to produce several different products, which will have either direct or indirect effects on health care. These include specific findings relating treatment to outcomes or describing variations in treatment, syntheses of literature, identification of unresolved issues

warranting study, new measures and methods for conducting outcomes research, new protocols or materials for involving patients in health care decisionmaking, methods for disseminating findings and other products, and, ultimately, clinical guidelines.

MEDTEP research will improve health care by producing and disseminating information to replace untested assumptions and unsettled questions regarding what treatment is effective and appropriate. Information needed by health care providers, patients, policymakers, and health services researchers will take the form of professional publications, presentations, and educational materials; patient-oriented tools such as interactive videodiscs for "shared decisionmaking ; " policy-relevant data and projections on costs, utilization, and effectiveness; and improved research tools and databases.

Some of these products will require significant time to create; however, interim products of many MEDTEP grants are noteworthy. Specific examples of contributions already resulting from the Patient Outcomes Research Teams (PORTs) follow:

After extensive review of the literature, the Cataract PORT reports finding no studies to support the hypothesis that visual acuity, significant astigmatism, visual function, or health status are different for patients undergoing phacoemulsification versus standard extracapsular cataract extraction.

The PORT on Benign Prostatic Hypertrophy (Wennberg, Dartmouth University) has introduced its "Shared Medical Decision Making Process" videodisc into several clinical practices, and uses it routinely for measuring patient preferences regarding risks and outcomes of alternative treatment for this common prostate problem.

The PORT on low back pain (Deyo, University of Washington)
already has 21 articles published or in press; and 6 more
under review. These include a state-of-the-art review on
clinical research methods in low back pain, a scientific-
analysis on the usefulness of thermography in detecting
lumbar nerve radiculopathy, and articles evaluating a
physician education intervention to improve primary care for
low back pain, which has been published in medical,
surgical, chiropractic, and public health publications.

The PORT on acute myocardial infarction (McNeil, Harvard
University) has described wide variations in rates of
cardiac catheterization and revascularization.

Question. What MEDTEP studies will be undertaken in 1991, and what studies are planned for FY92?

Answer. New MEDTEP studies approved for funding since the start of FY 1991 include the following:

Outcomes Following Community Interventions for Acute
Myocardial Infarction

Nursing Effectiveness in Preventive Child Health Program
Breast Cancer Screening Policy and Practice
Head Injury Outcomes ..
Effectiveness and Outcomes of Non-Cardiac Surgery
Implementing Practice Guidelines
Refining the Measurement of Quality of Care
Clinical Decisionmaking in Medical Adverse Events
Comparison of Surgery vs Drug for Epilepsy
A Physician Insurer's Impact on Early Cancer Detection
Variations in the Process/Outcomes of Care/Depression
A Model of Patients' Preferences in Serious illness
A Clinical Decision Aid for Genital Chlamydia in Women
Components of Prenatal Care and Low Birthweight
Computer-Based Access to Guidelines for Clinical Care
Diabetic Retinopathy Education Study

Additional grants for FY 1991 will be made in the summer, subsequent to review of the National Advisory Council for Health Care Policy, Research and Evaluation. Expected new grants include studies on back pain in ambulatory settings, epilepsy, prostate cancer, and hysterectomy. In addition, AHCPR anticipates supporting during FY 1991, PORTs dealing with chronic obstructive pulmonary disease, congestive heart failure, and prevention of stroke.

New starts in FY 1992 are mainly dependent on investigatorinitiated grants. These will be supplemented in FY 1992 with the initiation of a new program of research centers to concentrate on minority health issues. We will explore the potential of conducting studies of the effectiveness of pharmacologic interventions.

The AHCPR has issued a request for applications (RFA) on issues dealing with the ways in which scientific information can be presented and disseminated to foster its assimilation and use by health care providers and patients. The first deadline date for receipt of applications is April 26, 1991. Awards will be made late in FY 1991 and early FY 1992.

UNINSURED

Question. Depending on who's talking, there are either 31 million or 37 million uninsured Americans, or some number in between.

Can you give us a picture of the uninsured: who are they , are there geographic or socioeconomic factors affecting them, and what do we know about the health status of uninsured Americans?

Answer. The following are recent findings on the uninsured from the AHCPR 1987 National Medical Expenditure Survey (NMES):

Size. Growth, and Health Services of the Uninsured Population

Nearly 25 million people were uninsured throughout 1987. Another 23 million were uninsured for part but not all of the year, making a total of 48 million (1 out of 5

Americans) who were ever without coverage during a part of
1987.

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About 36 million people were uninsured in the first quarter of 1987. (This figure includes the 25 million who were uninsured all year and 11 million who were uninsured at the start of the year but obtained coverage before the end of the year.)

Seventeen percent of the population under 65 was uninsured
in the first quarter of 1987 compared to 14 percent (26.5
million) a decade earlier.

Only 64 percent of uninsured Americans under age 65 used any
health services in 1987, compared to 87 percent of those
with private insurance and 83 percent of those with public
coverage (Medicaid, CHAMPUS, or Medicare).

Average total health expenditures for uninsured persons less than 65 who used health services were $915 in 1987 compared to $1,316 for privately insured persons and $2,619 for persons with public health insurance.

Uninsured Minorities

The number of uninsured whites was 28 percent higher in the first quarter of 1987 than 1977. During the same time period, the number of uninsured blacks nearly doubled from 4 to 7 million and the number of uninsured Hispanics increased three-fold from 2 to 6 million.

Blacks and Hispanics accounted for half of the increase in
the uninsured over the decade.

Twenty-four percent of blacks under age 65 and 34 percent of Hispanics were uninsured in the first quarter of 1987, compared to 14 percent of whites.

Only 53 percent of uninsured blacks under age 65 and 55
percent of uninsured Hispanics used any health services in
1987, well below the national average (84 percent) and lower
than the percent of uninsured whites who used any services
(69 percent).

Average total health expenditures for uninsured blacks under
age 65 who used health services were $1,454 in 1987,
comparable to the national average of $1,420 for all persons
less than 65 who used health services. In contrast, average
total health expenditures for uninsured whites and Hispanics
were much lower, $896 on average for the former and $514
for the latter.

Uninsured Children

The proportion of children without insurance coverage increased from 13 percent in 1977 to 18 percent in 1987, almost entirely due to reductions in public coverage (mainly Medicaid).

Fully one-third of uninsured persons are under age 19.

While 93 percent of privately insured children under age 6 used any health services in 1987, only 81 percent of uninsured children used any services.

Average total health expenditures for uninsured children under age 6 who used health services were $954 in 1987. Average total health expenditures for privately insured children ($1,098) were somewhat higher. In contrast, average total health expenditures for publicly insured children ($2,566) were almost three times larger than uninsured children and two and a half times that of insured children.

Uninsured Poor (Poor = anything below poverty line)

The proportion of poor persons without insurance nearly doubled from 23 percent in the first quarter of 1977 to 39 percent in 1987.

The majority of the uninsured (62 percent) are in families with incomes equal to 200 percent of the poverty line or less. Those in poverty account for nearly one-third of all uninsured persons.

Only 63 percent of uninsured under age 65 persons in poverty used any health services in 1987, compared to 79 percent of the poor with either private or public coverage.

Average total health expenditures for uninsured persons under age 65 in poverty averaged $1,008 in 1987. In contrast, poor persons with private insurance had average total expenditures of $1,627, while those with public coverage had average total expenditures of $2,946, three times the average of the uninsured poor.

The Uninsured in Nonmetropolitan Areas

Persons who reside outside of metropolitan areas (outside of SMSAs) are slightly more likely to be without coverage (20 percent of the population under age 65) than residents of metropolitan areas (17 percent).

About a quarter of the uninsured live outside of SMSAs.

Only 65 percent of the uninsured under age 65 residing outside of metropolitan areas used any health services in 1987, compared to 86 percent of nonmetropolitan residents with private insurance and 85 percent of nonmetropolitan residents with public insurance.

Average total health expenditures for uninsured persons
under age 65 in nonmetropolitan areas were $579 in 1987
compared to $1,017 for privately insured persons in
nonmetropolitan areas and $2,336 for publicly insured
persons in nonmetropolitan areas.

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