This issue of CHP/PCOR's quarterly newsletter, which covers news from the winter 2006 quarter, includes articles about:

• a comprehensive review of worldwide anthrax cases from 1900 to 2005, conducted by CHP/PCOR researchers, which found that timely diagnosis and antibiotic treatment, along with pleural fluid drainage, are key to anthrax patients' survival;
• an early-stage research project in which CHP/PCOR core faculty member Grant Miller is collaborating with an NGO in Bangladesh to study whether villagers' traditional cooking practices are contributing to life-threatening respiratory infections;
• assertions by two CHP/PCOR health policy experts that health-savings accounts -- the cornerstone of President Bush's healthcare agenda -- won't save much money and won't address the fundamental problems of the U.S. healthcare system;
• the Agency for Healthcare Research and Quality's release of the Pediatric Quality Indicators, developed by CHP/PCOR researchers and collaborators. This is the first set of data-analysis tools specifically designed to help hospitals monitor their quality of care for hospitalized children; and
• a roundup of CHP/PCOR's 7th annual retreat, which featured panel discussions on improving healthcare quality, conducting health services research in developing countries, and health systems comparisons across industrialized nations.

Outcomes research often requires estimating the impact of a binary treatment on a binary outcome in a non-randomized setting, such as the effect of taking a drug on mortality. The data often come from self-selected samples, leading to a spurious correlation between the treatment and outcome when standard binary dependent variable techniques, like logit or probit, are used. Intuition suggests that a two-step procedure (analogous to two-stage least squares) might be sufficient to deal with this problem if variables are available that are correlated with the treatment choice but not the outcome.

This paper demonstrates the limitations of such a two-step procedure. We show that such estimators will not generally be consistent. We conduct a Monte Carlo exercise to compare the performance of the two-step probit estimator, the two-stage least squares linear probability model estimator, and the multivariate probit. The results from this exercise argue in favour of using the multivariate probit rather than the two-step or linear probability model estimators, especially when there is more than one treatment, when the average probability of the dependent variable is close to 0 or 1, or when the data generating process is not normal. We demonstrate how these different methods perform in an empirical example examining the effect of private and public insurance coverage on the mortality of HIV+ patients.

We sought to understand how diagnosis with HIV affects health-related quality of life. We assessed health-related quality of life using utility-based measures in a Department of Veterans Affairs (VA) clinic and a University-based clinic. Respondents assessed health-related quality of life regarding their current health, and retrospectively assessed their health 1 month prior to and 2 months after diagnosis with HIV infection. Sixty-six patients completed the study. The overall mean utilities for health 1 month before and 2 months after diagnosis were 0.87 (standard error 0.037), and 0.80 (0.043) (p0.005 by rank sign test), but the effect of diagnosis differed between the two clinics, with a substantial decrease in the university clinic and a small non-significant decrease in the VA clinic. The overall mean utility for current health was 0.85 (0.034), assessed on average 7.5 years after diagnosis. When asked directly whether diagnosis of HIV decreased health-related quality of life, 47% agreed, but 35% stated that HIV diagnosis positively affected health-related quality of life. Diagnosis with HIV decreased health-related quality of life at 2 months on average, but this effect diminished over time, and differed among patient populations. Years after diagnosis, although half of the patients believed that diagnosis reduced health-related quality of life, one-third reported improved health-related quality of life.

PURPOSE: Poor blood pressure control remains a common problem that contributes to significant cardiovascular morbidity and mortality, particularly among African Americans. We explored antihypertensive medication adherence and other factors that may explain racial differences in blood pressure control.

METHODS: Baseline data were obtained from the Veteran's Study to Improve The Control of Hypertension, a randomized controlled trial designed to improve blood pressure control. Clinical, demographic, and psychosocial factors relating to blood pressure control were examined.

RESULTS: A total of 569 patients who were African American (41%) or white (59%) were enrolled in the study. African Americans were more likely to have inadequate baseline blood pressure control than whites (63% vs 50%; odds ratio = 1.70; 95% confidence interval [CI] 1.20-2.41). Among 20 factors related to blood pressure control, African Americans also had a higher odds ratio of being nonadherent to their medication, being more functionally illiterate, and having a family member with hypertension compared with whites. Compared with whites, African Americans also were more likely to perceive high blood pressure as serious and to experience the side effect of increased urination compared with whites. Adjusting for these differences reduced the odds ratio of African Americans having adequate blood pressure control to 1.59 (95% confidence interval 1.09-2.29).

CONCLUSIONS: In this sample of hypertensive patients who have good access to health care and medication benefits, African Americans continued to have lower levels of blood pressure control despite considering more than 20 factors related to blood pressure control. Interventions designed to improve medication adherence need to take race into account. Patients' self-reports of failure to take medications provide an opportunity for clinicians to explore reasons for medication nonadherence, thereby improving adherence and potentially blood pressure control.

This issue of CHP/PCOR's quarterly newsletter, which covers news from the fall 2005 quarter, includes articles about:

• a study concluding that the implantable cardioverter defibrillator -- one of the most expensive medical devices on the market -- is worth its high cost, in appropriate patients, because it prevents sudden cardiac deaths;
• the evolution and broad application of the Quality Indicators, a set of practical tools developed by CHP/PCOR researchers that are used by hundreds of U.S. hospitals, medical groups, health insurers, state health agencies and business coalitions to screen for quality problems;
• a study finding that the Internet can be a valuable tool to help patients with stigmatized illnesses (such as mental illness) find information about and seek treatment for their illness;
• CHP/PCOR-hosted seminars on global health themes, given by Jack Chow of the World Health Organization -- who discussed combating malaria, TB and HIV/AIDS -- and Dean Jamison of the NIH's Fogarty International Center, who discussed evaluating countries' performance on health; and
• a prestigious national award won by two CHP/PCOR trainees at the annual meeting of the Society for Medical Decision Making.