Improving Public Health

Extending Insurance Coverage to the Nation's Uninsured

RAND Health researchers are conducting an ongoing project to examine the costs and effectiveness of a variety of state and federal policies intended to increase insurance coverage. Among the most important findings from this work is an estimate of how the 1997 Children's Health Insurance Program (CHIP) would affect access to care for uninsured children.

The researchers found that, across the country, CHIP promises to raise the number of low-income children who will be newly insured and to substantially increase their access to physician services. But the magnitude of the effects will vary greatly from one state to another, with the biggest improvements in access to care likely to occur in states that have traditionally provided the scantiest health safety nets.

The research was reported in "Geographic Variation in Physician Visits for Uninsured Children: The Role of the Safety Net" (Journal of the American Medical Association, June 1999). This article received the Sixth Annual Health Care Research Award from the National Institute for Health Care Management Research and Educational Foundation.

Treating Depression

Depression is one of the three leading causes of disability worldwide. Although effective medication and psychotherapy treatments exist, depression is often not detected or treated appropriately in primary-care settings. Yet a team of RAND Health researchers found that it doesn't take expensive, elaborate, mandatory treatment protocols or highly trained specialists operating in academic settings to make a big difference in the mental health, daily functioning, and job-holding ability of depressed patients.

The researchers conducted a study that involved more than 27,000 patients, 125 health care providers, and 46 primary care clinics located in counties ranging from the poorest to one of the wealthiest in the nation.

Each practice nominated leaders (a doctor, a nursing supervisor, and a mental health specialist), and the study team trained them to educate other staff in implementing programs to improve quality of care. The team also provided them with written and videotaped materials for this purpose.

Physicians and patients were given enriched opportunities to be informed about both medication and therapy, but they were free to make their own choices. In effect, both practices and patients were trained to improve themselves.

One year after program implementation, the results were striking. The interventions greatly increased rates of counseling and of appropriate use of antidepressant medication compared with that of patients in the "care-as-usual" clinics. Patients in the intervention programs were also less likely to be clinically depressed over the year, and they had better quality of life.

Even more striking from a policy perspective, a substantially higher number of patients in the program remained in the work force at 12 months than did their care-as-usual counterparts. Thus, the program significantly mitigated the detrimental effect of depression on employment. No other quality-improvement evaluation for any condition in primary care has shown the same level of positive employment boost.

The team's report appears in a January 2000 issue of the Journal of the American Medical Association, which also prepared a video news story to make the results of this research available to a wider audience.

Identifying Possible Causes of Gulf War Illnesses

In late 1996, the Department of Defense's Special Assistant for Gulf War Illnesses asked RAND to summarize the scientific literature on the health effects of eight possible causes of illness among Gulf War veterans, including pretreatment against nerve agents.

Pyridostigmine bromide (PB) is a drug that was taken during the Persian Gulf War by an estimated 250,000 U.S. troops as a pretreatment to protect against the nerve agent soman. The Department of Defense (DoD) knew that Iraq had weaponized certain nerve agents and feared that soman might be one of them.

PB had been approved in 1955 for treatment of myasthenia gravis, an autoimmune disease that affects the muscles, and it was also approved for certain post-anesthesia applications. During the Gulf War, PB was designated an "investigational new drug" in nerve-agent pretreatment, and it was supplied to U.S. forces under an FDA waiver of informed consent.

A researcher in RAND's Center for Military Health Policy Research conducted an exhaustive study of the PB literature and concluded that PB "cannot be excluded" as a contributor to illness in veterans of the Gulf War. More research into the effectiveness and safety of PB for humans is needed. The issue is a complex one that involves trading off uncertain, but biologically plausible, health risks against uncertain benefits from use of PB in a warfare setting.

The study has been briefed at the highest levels in DoD. In late 1999 it was presented in testimony to the Sub-Committees on Health and Oversight and Investigations, Committee on Veterans' Affairs, U.S. House of Representatives. The research results have also attracted considerable media attention, including press briefings on Capitol Hill and appearances of the author on network news programs.

Assessing the Quality of Health Care in Europe

For nearly two decades, RAND has conducted pioneering work in assessing the quality of medical care. One of its most important contributions has been the development of the RAND/UCLA Appropriateness Method, a tool for identifying overuse or underuse of specific medical procedures.

The method has three key elements. First, a literature review identifies patient characteristics relating to a specific treatment and generates a comprehensive list of descriptions--or indications--for possible use of a procedure. Second, a panel of experts rates the indications on the basis of their appropriateness--the likelihood that the benefits of a procedure will greatly outweigh its potential harm, or vice versa. Third, panel results are applied to actual practice, either retrospectively or prospectively. Retrospectively, quality of care can be assessed by comparing panel judgments to records of actual patients who received (or did not receive) the procedure. This determines the extent of appropriate and necessary care. Prospectively, panel ratings are used to design guidelines for patient management.

For the past three years, RAND Europe analysts have coordinated an effort by eleven health services research centers in seven European countries to promulgate, refine, and expand the use of the Appropriateness Method. In 1999, this approach was applied in a multi-national context for the first time. Contrary to the fears of many observers, it was found that differences in culture, language, and health care financing systems need not be a barrier to reliable and valid use of the method. The work was described in the Autumn 1999 issue of Eurohealth.The project has been greeted with enthusiasm in European health policy circles because of its ability to help improve health care delivery within resource-constrained budgets.

Contents

---

1999 RAND Research Highlights