Research on Health Care Costs, Quality and Outcomes (HCQO)

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Performance Budget Submission for Congressional Justification

Research on Health Care Costs, Quality and Outcomes (HCQO)

Purpose and Method of Operation
Improving Clinical Practice
   Patient Outcomes Research Teams (PORTS)
   Improved Outcomes for Vulnerable Populations
   Evidence-based Practice Centers
   The National Guideline Clearinghouse™
   Clinical Preventive Services
Improving Capacity to Deliver Quality Health Care
   The Quality Initiative
   Ongoing Research to Measure and Improve the Quality of Health Care
   Help for Patients and Consumers of Health Care
   Managed Care
Tracking the Nation's Progress
   The Medical Expenditure Panel Survey
   Building on the HIV Cost and Service Utilization Study (HCSUS)
   The Health Care Costs and Utilization Project
Activities in Support of All Goals
   Health Services Research Training
   Dissemination Activities
Prior Year Funding
Rationale for the Fiscal Year 2000 Request    Priority I: New Research on Priority Health Issues
   Priority II—New Tools and Talent for a New Century
   Priority III—Translating Research into Practice

Purpose and Method of Operation

The purpose of the Research on Health Care Costs, Quality and Outcomes (HCQO) program is to support and conduct research that improves the outcomes, quality, and cost, use, and accessibility of health care. To achieve this purpose, the HCQO budget activity has four main areas of focus: (1) Improving clinical practice, (2) Improving capacity to deliver quality health care, (3) Tracking the Nation's progress by providing policy makers with the capability to monitor and evaluate the impact of system changes on cost, use, and accessibility of health care, and (4) Activities that support all areas of focus.

In the last 12 months, the Agency for Health Care Policy and Research (AHCPR) has made important strides toward meeting its goals and addressing the needs of its customers. Specific achievements in the Agency's core programs are reviewed here, as well as activities initiated in response to the $25 million increase in the Agency's budget in fiscal year 1999.

The first section, Improving Clinical Practice, reviews the Agency's progress on several initiatives:

Patient Outcomes Research Teams (PORTS)—Outcomes research on vulnerable populations, including minorities, children, the chronically ill, and women.
Evidence-based Practice Centers.
The National Guideline Clearinghouse™.
Clinical Preventive Services.

The second section, Improving Capacity to Deliver Quality Health Care provides updates on the following programs:

The Quality Initiative.
Research to Measure and Improve the Quality of Health Care.
Consumer Focused Activities.
Managed Care.

The third section, Tracking the Nation's Progress encompasses three critical sources of data and information for policymakers:

The Medical Expenditure Panel Survey.
The HIV Cost, Services, and Utilization Study.
The Health Care Costs and Utilization Project.

The final section, Activities that Support All Goals include a discussion of training and dissemination activities which have been notably enhanced in the last year.

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Improving Clinical Practice

One of AHCPR's most important priorities is to translate and disseminate research findings into tools and information that can be used to improve outcomes of care and enable providers and consumers to make good health care decisions. AHCPR's research concentrates on conditions that are common, costly, and for which there is substantial variation in practice. This research focuses on many of the conditions that represent a major expenditure for Medicare. AHCPR's research helps to close the gap on variation and provides information on what care is appropriate, how much is enough, and what is cost-effective.

For example, of the four million adults diagnosed with community acquired pneumonia each year in the United States, nearly 1 million are hospitalized at a cost of more than $4 billion. Of those who are hospitalized, 14 percent die, making pneumonia the sixth leading cause of death overall, and the fifth leading cause for Americans 65 years of age or older. The challenge facing physicians is identifying which patients need to be hospitalized and which patients can be treated safely at home.

To address this problem, AHCPR-funded researchers at the University of Pittsburgh developed a prediction method that physicians can use to identify high and low-risk patients. When they compared current practice in three cities with the results of this prediction model, they concluded that 26 to 31 percent of those hospitalized could have been treated safely at home and another 13 to 19 percent could have been hospitalized only briefly for observation. Widespread application of this prediction method will improve the quality and appropriateness of care for Medicare beneficiaries as well as reduce Medicare spending for inappropriate hospitalization.

A brief description of AHCPR's current work to improve clinical research for selected areas of research follows.

Patient Outcomes Research Teams (PORTS)

Patient Outcomes Research Teams (PORTS) are 5-year research grants that include the elements of formal literature synthesis (meta-analysis), data acquisition and analysis, development of clinical recommendations, dissemination of findings, and evaluation of the effects of findings on change in clinical practice.

The second generation of PORT projects continues in fiscal year 1999. Like the initial PORTS, they address important clinical and policy-relevant questions on the effectiveness and cost-effectiveness of different clinical approaches for common clinical conditions, and will advance methods for outcomes research. (Select to access a table listing the PORT-II projects.) Because PORT projects are usually funded over a 5-year period, findings from these projects come out over time. Below are the summaries of research findings released over the entire project period of two PORT projects.

Stroke Prevention PORT Findings. Stroke is the leading cause of serious, long-term disability in the United States. Thirty-one percent of brain attack survivors need help caring for themselves, 20 percent need help walking, and 71 percent have an impaired vocational capacity when examined an average of 7 years later. In addition, 16 percent are institutionalized. Atrial fibrillation (AF) occurs in 1.9 million Americans over the age of 65 and causes 80,000 strokes annually in Medicare patients.

The Stroke PORT helped establish anticoagulation ("blood-thinning") drug therapy was the treatment of choice to prevent strokes in certain categories of patients, and, if used properly, less dangerous than many physicians previously believed.
However, anticoagulation is underutilized, and when used, monitoring may be inadequate according to a survey of 2,000 physicians across the country.
Subsequently, Peer Review Organizations (PROs) implemented projects in 42 States to increase anticoagulation rates in these patients. Data from 20 of these States showed that the frequency with which eligible patients were discharged on anticoagulation therapy increased to 71 percent from 58 percent before the projects began. Researchers estimate that this quality intervention may have prevented over 1,200 strokes.
The stroke PORT was influential in the development of guidelines from the American College of Physicians, American Heart Association and the Joint Council of Vascular Surgeons.
The Managing Anticoagulation Services Trial (MAST) is the major implementation effort of the Stroke PORT. In it, each site creates its own approach to increasing anticoagulation rates for atrial fibrillation.
The investigators have provided consultative assistance to Illinois and North Carolina to promote appropriate and effective use of anticoagulation and to Georgia to promote the appropriate use of carotid endarterectomy.
The National Committee for Quality Assurance (NCQA) was encouraged to include anticoagulation for atrial fibrillation as a test measure in HEDIS 3.0.
United Health Care has started a national profiling project in which one of their measures is the use of anticoagulants for AF.
AHCPR has signed an agreement with Duke and DuPont Merck to extend the work of the stroke PORT to examine the most effective way to prevent stroke in high-risk patients.

Research Finding. Stroke killed an estimated 157,991 people in 1995 and is the third largest cause of death. Interventions based on AHCPR research are successful at reducing the risk of stroke.

Low Birthweight PORT Findings. The Low Birthweight PORT focuses on the multiple causes of both full-term and pre-term low birthweight. The PORT is led by University of Alabama at Birmingham and the Albert Einstein College of Medicine. Over the years, this PORT has issued a number of important findings related to low birthweight.

In the first stage of the grant, the investigators reviewed the literature on commonly used interventions. They found that the following did not reduce pre-term births: prenatal care, bed rest, risk screening, nutrition counseling, caloric supplementation, iron supplementation, most labor inhibiting drugs, drug/alcohol/tobacco cessation programs, IV hydration for premature labor and home uterine activity monitoring. The finding regarding bed rest alone is startling. The investigators reviewed the literature discussing bed rest in pregnancy and found that there is no clear indication for its use including spontaneous abortion, pre-term labor, fetal growth retardation, edema, chronic hypertension and preeclampsia.
The PORT also demonstrated that vaginal infection is more closely related to pre-term birth in black versus white women, accounting for 40 percent of the excess pre-term birth in black women.
The investigators also reviewed the clinical use of antenatal steroids and found that the therapy is being underused, with only 20 percent of eligible newborn who arrived before 34 weeks receiving the medication. Corticosteroids have been shown to reduce the incidence and severity of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis and neonatal mortality.
In 1994, the National Institutes of Health (NIH) convened a Consensus Development Panel on the use of corticosteroids to improve the outcomes of pre-term infants. The PORT's involvement in this Consensus Conference significantly influenced the Panel's recommendations. The PORT helped define the gestational ages when corticosteroid use was most effective. The PORT conducted research on physicians' opinions to determine why this highly effective intervention was only rarely used. The PORT worked with the NIH to define the way corticosteroids should be used and helped the NIH evaluate the effectiveness of its Consensus Conference.
The use of corticosteroids by obstetricians increased from less than 20 percent of premature newborns prior to 1994 to almost 70 percent by 1996. This increased use has contributed to the continued reduction in infant mortality in the United States.
The Low Birthweight PORT's dissemination strategy to improve the use of corticosteroids was modeled by United HealthCare, a large national managed care organization, as a pilot project to improve the use of corticosteroids among their obstetrician provider networks. The PORT is also providing assistance to ACOG's New York State District, which is collaborating with the New York State Health Planning Agency to mount a dissemination project to increase corticosteroid use among the State's obstetrical providers.
PORT findings have led to specific screening and treatment recommendations by the Centers for Disease Control and Prevention (CDC) for management of group B streptococcal infection—a major infectious killer of newborns.
PORT findings have confirmed the value of the use of zinc as part of the daily vitamin and mineral supplement for use in pregnancy. Zinc supplementation is now recommended for all pregnant women.

Research Finding. Bed rest costs have been estimated at $1.03 billion yearly or $1,417 per resting women in 1993 dollars. Doctors traditionally recommended bed rest for one out of every five women for at least 1 week. AHCPR researchers found that bed rest is not effective at reducing pre-term births.

Improved Outcomes for Vulnerable Populations

Nearly one-quarter of the U.S. population today are members of racial or ethnic "minority" groups. By the middle of the next century, this percentage will increase to nearly 47.5 percent. Research, a substantial portion sponsored by AHCPR, has clearly demonstrated differences in the use of medical care services, even when income and insurance status are taken into account. Clinicians and policymakers will need to take into account the epidemiologic and cultural sensitivities involved in treating patients of different ethnic and racial groups. Their patterns of disease may differ, as may their belief systems, and their preferences for types of care.

The scope of the disparities for the six areas identified in the Department's Race and Health Disparities Initiative, infant mortality, cancer screening and management, cardiovascular disease, diabetes, HIV/AIDS, and immunizations, is striking. Infant death rates among blacks, American Indians and Alaska Natives, and Hispanics in 1996 were all above the national average of 7.2 deaths per 1,000 live births. The greatest disparity exists for blacks, whose infant death rate is nearly 2 and one-half times that of white infants. Cancer mortality rates are 35 percent higher in blacks than those for whites. While much can be done to reduce the burden of cancer in the United States through population- and community-based prevention, improving the effective delivery of services in the clinical setting, both preventive and treatment, is also critical to eliminating these disparities.

The age-adjusted death rate for coronary heart disease for the total population declined by 20 percent from 1987 to 1995; for blacks, the overall decrease was only 13 percent. AHCPR research has consistently shown that blacks received fewer cardiac procedures, including bypass grafts and carotid endarterectomies. The prevalence of diabetes in blacks is approximately 70 percent higher than whites and the prevalence in Hispanics is nearly double that of whites. HIV infection/AIDS is a leading cause of death for all persons 25 to 44 years of age. Racial and ethnic minorities constitute approximately 25 percent of the total U.S. population, yet they account for nearly 54 percent of all AIDS cases. While the epidemic is decreasing in some populations, the number of new AIDS cases among blacks is now greater than the number of new AIDS cases among whites. Finally, variation by race in immunization rates continue with Hispanic children having the lowest rates of immunization at 73 percent compared with whites at 80 percent.

Science Advance. AHCPR-funded researchers have found that hypertensive black women had three times the risk of hemorrhaging before delivery than black women whose blood pressure was within normal limits, an association not seen among other U.S. women. Pregnant black women have more than twice the rate of chronic hypertension of women of other races. Investigators suspect that this may contribute to the greater incidence of low birthweight, pre-term deliveries, and infant morbidity and death among black women in the United States.

Children's Health Research. Adequate access to health care services continues to be a challenge for many Americans, including children. This is particularly so for the poor, the uninsured, members of minority groups, rural residents, and other vulnerable populations (see chart [3 KB]).

The Agency has significantly enhanced its child health activities in the last year through the funding of new studies and participation in the Department's implementation of Title XXI, the new State Children's Health Insurance Program (SCHIP). Examples of funded studies include:

"Study of Functional Outcome after Trauma in Adolescents." This study will determine a prospective epidemiologic study of the incidence and determinants of functional limitation after major trauma in adolescent children ages 12 to 17 years.
"Quality of Care for Newborn Jaundice." This 5-year study will test adherence to the American Academy of Pediatrics (AAP) guidelines in two managed care organizations in Texas and Michigan.
"Health, Health Insurance and Welfare Dynamics." This study will investigate the relationship between welfare dependents transitioning off of welfare and health insurance.
"Children's Use of Services." This study will test an innovative model of nurse managed primary care for low-income minority children.

The Agency's work on SCHIP has been carried out in partnership with the Health Care Financing Administration (HCFA) and the Health Resources and Services Administration (HRSA). Emphasis has been placed on activities that support States in their design of programs that can provide high quality care for children. These include technical assistance, the development of tools (such as new measures of quality of care for adolescents and chronically ill children), and research to understand the impact of SCHIP on quality and access to care. Funded studies will examine how the features of insurance programs and the organization of the health care delivery systems associated with these programs affect access to services and the quality of care received by low-income children, particularly minority children or those with special health care needs. Studies will fall into one of two categories: (1) those examining the impact on low-income children enrolled in these insurance programs, and (2) those examining the impact on a low-income community's health care delivery system and all children that it serves.

Grants totaling $2.1 million, funded jointly by AHCPR, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institute of Mental Health (NIMH) have been awarded to researchers at three universities and a hospital to study treatments for depression, attention deficit disorder and oppositional defiant disorder in children and adolescents. At present, millions of children receive treatment everyday for these three complex illnesses—yet there is almost no scientific evidence showing whether or not these interventions are working. Considering the substantial impact these conditions have on so many children and their families, this scientific gap must be addressed. This cluster of research projects is designed to improve mental health interventions in primary care settings such as clinics, schools and doctors' offices. The research also will develop ways to improve the efficiency and cost-effectiveness of treatments for this population.

The four new grants for children's mental health research follow:

"Youth Partners in Care" (University of California, Los Angeles, CA). This study will evaluate the impact of a quality-improvement intervention in a managed care setting. The treatment intervention focuses on educating the patient and the primary care provider about depression treatment and the best use of clinic resources. It will measure outcomes such as satisfaction with care, clinical symptoms, daily functioning, service use and costs, indirect costs and parental psychological distress.
"Treating Oppositional Defiant Disorder in Primary Care" (Children's Memorial Hospital, Chicago, IL). Oppositional Defiant Disorder (ODD) is the most common psychiatric disruptive behavior disorder among preschool-aged children, with long-term social consequences ranging from delinquency and substance abuse to high-risk sexual behavior in adolescence. This study will examine the effectiveness of using a psychological intervention in primary care pediatric settings to help identify and treat pre-school children with ODD. It also will evaluate how well a 10-week training program on parenting skills reduces the incidence of ODD.
"Enhancing ADHD Treatment Effectiveness by Pediatrics and Schools" (Vanderbilt University, Nashville, TN). This study is designed to implement a model program for children with attention deficit hyperactivity disorder (ADHD) in the "real world" setting of school and physicians' practices. The model program will enhance communications between general medical and educational professionals regarding the evaluation and management of these children. ADHD is considered to be one of the most important problems in the pediatric age group and a pressing problem for schools.
"Effectiveness of Interpersonal Psychotherapy (IPT-A) in School-Based Health Clinics" (Columbia University, New York, NY). This research will test the clinical and cost-effectiveness of providing Interpersonal Psychotherapy for Adolescents (IPT-A) for adolescents with depression in a poor urban area. IPT-A is a guideline-based mental health treatment focusing on improved social function, interpersonal problem-solving skills as well as symptom reduction. Mental health professionals working from three Manhattan public school-based health clinics will be trained to deliver IPT-A as a short-term intervention. The research will measure such outcomes as clinical status, social functioning, school performance and attendance, and use of other medical and psychiatric services.

Science Advance. Each year, more than 200,000 children under age 5 are hospitalized needlessly for gastroenteritis (stomach flu), and about 300 children—mostly infants—die from the preventable dehydration that untreated gastroenteritis can cause. Either their physicians are unaware of the efficacy of oral rehydration therapy—a simple but very effective, over-the-counter treatment—the physicians choose not to use it for some other reason, or the children's parents cannot pay for the treatment. Addressing these three factors could reduce unnecessary hospitalizations and save health care dollars, according to an AHCPR-funded study.

Improving Care for the Chronically Ill. AHCPR, the American Association of Health Plans Foundation, and the Health Resources and Services Administration have awarded seven research teams a total of $8.5 million over 3 years to determine how particular managed care policies and practices, such as protocols governing the referral of patients to medical specialists and arrangements for paying physicians, affect the quality of care for patients living with chronic illnesses.

The seven teams will examine data and patient records from 32 health plans, over 50 local medical group practices affiliated with one of the nation's largest health care purchasing cooperatives (organizations funded by employers to negotiate health coverage for workers) and several government-sponsored programs. Together, these groups provide health care for over 10 million Americans from California to Massachusetts. The study populations represent a cross-section of Americans, including persons of low income, who live with chronic illnesses.

The following grants were awarded:

RAND (Santa Monica, CA) will study the care given to working-age members of seven United Health Care plans in different parts of the country for diabetic retinopathy and open-angle glaucoma—both of which are leading causes of blindness.
Harvard Medical School (Cambridge, MA) will examine care for diabetic and hypertensive patients enrolled in the plans of Health Partners, Preferred One, and Allina in the Minneapolis-St. Paul area.
University of California (Los Angeles) will analyze quality of care provided to patients with chronic heart and lung diseases by 58 group practices serving companies who belong to the Pacific Business Group on Health.
Kaiser Permanente of Northern California (Oakland, CA) will examine the quality of care given to asthmatic children enrolled in Medicaid managed care plans in California, Massachusetts, and Washington State.
Harvard Medical School (Cambridge, MA) will focus on members of Prudential, Allina, United Health Care and Pacificare treated for heart attack, congestive heart failure, or hypertension.
University of Florida (Gainesville, FL) will study the quality of care for low-income children in Florida's Healthy Kids Program who suffer from asthma, diabetes, or other problems. Participating groups include the Health Insurance Plan of Florida, Health Option/Blue Cross-Blue Shield of Florida, Humana, Florida Health Care Plans, Florida First, PCA Family (Physicians' Corporation of America-Family), JMH Health Plan of Florida (Jackson Memorial Trust Plan of Florida), Av-Med Health Plan and Physicians' Health Plan.
University of Maryland at Baltimore (Baltimore, MD) will study the impact of managed care organization policies on the quality of pediatric asthma care for Medicaid recipients.

An estimated 90 million Americans—one of every three persons in the United States—has one or more chronic conditions, which account for 1 of every 6 dollars spent on health care.

Race and Health Disparities. Several ongoing AHCPR activities can contribute to the goals of the Race and Health Disparities Initiative:

AHCPR recently completed funding for the MEDTEP Research Centers on Minority Populations Program. Several of the 11 original centers have been successful in obtaining outside funding, and continue to contribute to the knowledge base regarding outcomes and effectiveness research for minority populations. Research findings from these centers have a potential role in focusing planned Agency initiatives aimed at eliminating the disparities. This program also is being viewed as a model for a new program, Minority Health Care Research Centers of Excellence, which will continue to target research to eliminate disparities experienced by minority populations.
A collaborative project between the Morehouse School of Medicine and the National School of Public Health at the Medical University of South Africa will conduct research on a major health issue faced by both African-American and African populations, affording a unique opportunity to investigate issues of race and culture. Current discussions center on exploring the impact of chronic hypertension on pregnancy, thought to be a factor in infant mortality.
Technical assistance activities for faculty at Historically Black Colleges and Universities (HBCUs) and Hispanic Serving Institutions (HSIs) planned for later this year will emphasize the importance of investigators focusing attention on the clinical areas identified in the Race and Health Disparities Initiative.
Funds provided in support of the Meharry Demonstration Project will permit AHCPR's active encouragement of research on these health disparities by Meharry's Minority Health Services Research Center.

Three solicitations issued early in January 1999 will fund up to $7 million in projects addressing minority populations and/or to be conducted by minority institutions alone or in collaboration with majority institutions. These three initiatives are:

Quality Measurement for Vulnerable Populations to develop and test new quality measures which can be used in the purchase or improvement of health care services for populations identified as vulnerable in the commission report.
Translating Research Into Practice to generate new knowledge about approaches, both innovative and established, which are effective and cost effective in promoting the use of rigorously derived evidence in clinical settings and lead to improved health care practice and sustained practitioner behavior change (with particular interest in studies that implement AHCPR-supported evidence-based tools and information).
Assessment of Quality Improvement Strategies in Health Care to rigorously evaluate strategies for improving health care quality which are currently in widespread use by organized quality improvement systems. These projects will expand the conceptual and methodologic basis for improving clinical quality and analyze the relative utility and costs of various approaches to quality improvement.

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Evidence-based Practice Centers

In December 1998, AHCPR released 4 of the first 12 evidence reports and technology assessments resulting from AHCPR's Evidence-based Practice Center program (select for list of reports). The remaining eight evidence reports and technology assessments are scheduled for release in January and February. In addition, the next 12 evidence reports topics have been assigned (select for list of second-round reports).

These reports facilitate translating evidence-based research findings into clinical practice. The reports will form the basis of other organizations' efforts to develop and implement their own practice guidelines, performance measures, review criteria, and other clinical quality improvement tools.

Potential users of the evidence reports and technology assessments include a wide range of health care providers, medical and professional associations, health system managers, researchers, and others who play key roles in the effort to improve the quality of health care services nationwide. In addition, the reports may give health plans and payers information needed to make informed decisions about coverage policies for new and changing medical devices and procedures. Already, the reports on Traumatic Brain Injury and Attention Deficit Hyperactivity Disorder have been successfully used by the NIH consensus conference process to inform the participants of the state of the published science on these two topics.

Results from AHCPR's third evidence report (on alcoholism) show that two relatively new medications, naltrexone and acamprosate, have promise for the treatment of patients with alcohol dependence. The medications appear to reduce the urge to drink, decrease the frequency with which a person drinks, and in some studies, improve abstinence. Naltrexone has been in use in the United States for the treatment of alcoholism only since 1994. Acamprosate is widely used in Europe and has been granted investigational drug status within this country by the Food and Drug Administration, and clinical trials are also underway.

The results were based on a systematic review of the best available evidence developed by North Carolina-based Research Triangle Institute (RTI) and the University of North Carolina (UNC) at Chapel Hill. This topic, The Pharmacotherapy for Alcohol Dependence, was recommended by the American Society of Addiction Medicine. AHCPR will now partner with several key health agencies with established alcohol research and treatment networks, including the National Institute of Alcohol Abuse and Alcoholism, to disseminate the report to a broad array of health care-related organizations and other interested groups in the United States and Canada.

The report suggests that future research address the effectiveness of long-term maintenance of patients on those medications proven to work alone, the effectiveness of combinations of medications, and the optimal combinations of drugs and psychosocial therapies.

Select for the Overview of Evidence-based Practice Centers.

Research Finding. Two new drugs, naltrexone and acamprosate, show promise in the treatment of alcoholism. Alcoholism afflicts approximately 9.6 percent of men and 3.2 percent of women in the United States over their lifetimes. Alcohol dependence costs the economy an estimated $166 billion annually.

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National Guideline Clearinghouse™ (NGC)

The National Guideline Clearinghouse™ (NGC), a new Internet resource for evidence-based clinical practice guidelines, became operational on December 15, 1998, at http://www.guideline.gov. The NGC was developed by AHCPR, in partnership with the American Medical Association (AMA) and the American Association of Health Plans (AAHP), to be a resource for physicians, nurses, and other health care professionals.

When NGC first became operational, it contained 200 evidence-based clinical practice guidelines submitted by over 50 health care organizations and other entities. When NGC was formally launched to the public in mid-January 1999, it had close to 300 clinical practice guidelines submitted by over 65 guideline developers. New guidelines are being added to NGC weekly.

All guidelines are abstracted into a standardized format that enables users to compare clinical practice guideline recommendations more quickly than ever before. After the first five years of operation, this Internet repository is expected to contain 3,500 clinical practice guidelines. NGC's electronic database will be updated continually to reflect the most recent clinical practice guidelines.

The NGC database can be browsed three different ways: by disease/condition; by treatment/intervention; or by the name of the submitting organization. In addition, NGC allows the creation of tabular comparisons of guideline abstracts and provides syntheses of guidelines that cover similar topics, noting areas of agreement and disagreement. Users may also obtain the full text of most NGC guidelines by simply clicking on a button that takes them to the World Wide Web site where the full text is located.

Recent Quote from an NGC User: "I am very impressed with the intended scope of this very important project ...[t]his is exactly the sort of site I need as a medical librarian in an active suburban hospital. It is also the sort of help and support I expect from my governmental dollars and from the professional associations. Please continue in this vein despite any setbacks and keep it all as current as possible. I am advertising the site to my physicians today; so be terrific tomorrow." —Continuing Medical Education Coordinator and Librarian.

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