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PEDIATRICS Vol. 111 No. 1 January 2003, pp. 171-178

REVIEW ARTICLE

Outcomes Research in Pediatric Settings: Recent Trends and Future Directions

Christopher B. Forrest, MD, PhD*,{ddagger}, Scott A. Shipman, MD, MPH*,{ddagger}, Denise Dougherty, PhD§ and Marlene R. Miller, MD, MSc{ddagger},§

* Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Maryland
{ddagger} Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, Maryland
§ Agency for Healthcare Research and Quality, Rockville, Maryland

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   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 APPENDIX A.
 APPENDIX B.
 REFERENCES
 
Objective. Pediatric outcomes research examines the effects of health care delivered in everyday medical settings on the health of children and adolescents. It is an area of inquiry in its nascent stages of development.

Methods. We conducted a systematic literature review that covered articles published during the 6-year interval 1994–1999 and in 39 peer-reviewed journals chosen for their likelihood of containing child health services research. This article summarizes the article abstraction, reviews the literature, describes recent trends, and makes recommendations for future work.

Results. In the sample of journals that we examined, the number of pediatric outcomes research articles doubled between 1994 and 1999. Hospitals and primary care practices were the most common service sectors, accounting for more than half of the articles. Common clinical categories included neonatal conditions, asthma, psychosocial problems, and injuries. Approximately 1 in 5 studies included multistate or national samples; 1 in 10 used a randomized controlled trial study design. Remarkably few studies examined the health effects of preventive, diagnostic, long-term management, or curative services delivered to children and adolescents.

Conclusions. Outcomes research in pediatric settings is a rapidly growing area of inquiry that is acquiring breadth but has achieved little depth in any single content area. Much work needs to be done to inform decision making regarding the optimal ways to finance, organize, and deliver child health care services. To improve the evidence base of pediatric health care, more effectiveness research is needed to evaluate the overall and relative effects of services delivered to children and adolescents in everyday settings.

Key Words: outcomes research • effectiveness • child • healthcare financing • organization of health care

Abbreviations: CHIP, Child Health and Illness Profile • CT, computed tomography


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 APPENDIX A.
 APPENDIX B.
 REFERENCES
 
Pediatric outcomes research examines the effects of health care delivered in everyday medical settings on the health of children and adolescents. It is 1 of several areas of inquiry within the broad field of health services research.1 Clancy and Eisenberg2 defined outcomes research as "the study of the end results of health services that takes patients’ experiences, preferences, and values into account." Health care services include "any organized effort whose primary purpose is to improve the health of children and families."3 They may take the form of specific interventions—such as preventive care procedures, drugs, medical devices, long-term management, curative procedures, and doctor-patient communication—or programmatic interventions, such as delivery system models. End results refer to clinical measures of health—eg, mortality, morbidity, and physiologic change—as well as individuals’ perceptions of their well-being, feelings and symptoms, and functioning. Additional outcomes of interest among pediatric populations include developmental change and family well-being.4

The 4 Ds of childhood—developmental change, dependence on adults for accessing care and implementing treatments, different disease epidemiology from adults, and demographic characteristics unique to childhood—create methodologic problems for pediatric outcomes research.4 Such challenges as the low association between parental and child perspectives, the need for developmentally appropriate measures, low rates of medical conditions, long intervals needed to detect treatment effects, and the need for case-mix adjustment have stymied growth of the field.4–6

Findings from effectiveness research, a subcategory of outcomes research, can inform policy and clinical practice by determining the effects of clinical interventions applied in everyday medical settings on child health. This type of research has been difficult to perform because some pediatric interventions optimize health rather than reduce disease, health measures are not routinely collected in clinical practice, and the end results of some health care services may not be realized for many years.3 Much of what we have learned from outcomes research comes from disease-specific studies among adults. Many disease-specific outcomes particular to children are relatively rare in adulthood.

Despite the importance of outcomes research to policy and clinical practice, the boundaries of the field are ill-defined. It is an area of inquiry in its nascent stages of development. As a consequence, it has been difficult to catalog previous research in this field and the questions that should be addressed in the future. In this article, we examine recent studies to elucidate trends in outcomes research done in pediatric settings and identify areas for future inquiry. Specifically, we discuss findings from a systematic literature review that covered articles published in a select group of journals during the 6-year interval 1994–1999.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 APPENDIX A.
 APPENDIX B.
 REFERENCES
 
Search Strategy
The emphasis of our literature review was on identifying trends in pediatric outcomes research, rather than describing the totality of work done in the field. To obtain a manageable set of articles, we limited our review to published studies that appeared between January 1, 1994, and December 31, 1999, in 39 journals (Appendix A). The journals were selected because our pilot testing showed that they contained studies that pertained to child health services research conducted in the United States. All journals were indexed in the National Library of Medicine’s PubMed search engine.

We selected MESH headings and subheadings that identify articles in 5 health services research content areas: access to care, use of services, health care costs, quality, and outcomes (Appendix B). Because of inconsistencies in how MESH terms are assigned to articles in the PubMed database, we found that using only the outcomes terms (Appendix B) resulted in inappropriately low rates of identification of outcomes research articles. To obtain our initial database, we cross-referenced the health services research search terms with children or pediatrics, year of publication in 1994–1999, the selected journals, and the requirements that the article was neither an editorial nor a letter. The search strategy was pretested by comparing articles obtained from the computerized search with manual review of 2 years of a subset of journals. We pretested our search strategy until manual review failed to identify any new articles beyond those that our computerized search yielded. The final computerized search resulted in 4138 citations.

Article Abstraction
An article had to meet 5 criteria to be included: 1) study was conducted in the United States; 2) study population included children or adolescents; 3) study addressed access to care, utilization, costs, quality, or outcomes; 4) study addressed personal medical services; and 5) mental health studies were limited to those done in general health care settings. To apply these selection criteria consistently across the 4138 articles, a single reviewer examined titles and abstracts of the full set, which yielded 1160 child health services research articles.

Each of the 1160 articles was reviewed by 2 of 4 coders. Coders were randomly assigned to review each abstract. The abstraction form was pretested and modified to improve its clarity and reliability. Explicit coding instructions and definitions were used by the reviewers to reduce subjectivity in coding. Overall interobserver agreement for all items contained in all abstract forms ranged between 91% and 94% across the 6 reviewer pairs. An additional 186 articles were excluded during this phase of abstract review, because the coder pair identified an exclusion criterion. This resulted in a data set of 974 child health services research articles. Discrepant conclusions about excluding an article were reconciled by the 2 reviewers for that article. Data entry of the abstraction forms was performed in duplicate.

Literature Synthesis
The operational definition for outcomes was that the study address the "end results of health care and include any or all of the following types of measures: morbidity, mortality, disability, development, and health-related quality of life." A total of 314 articles (32% of the total child health services research articles) were designated as pediatric outcomes research.

We used implicit criteria to select a subset of articles with the highest potential research impact. The criteria included 1) generalizability of findings; 2) strength of research design to minimize bias; and 3) likelihood that the study would influence future research, medical or public health practice, or health care policy. After reviewing the full text of the 314 child health services articles, 2 reviewers agreed on a group of articles that had the highest potential impact. This subset of articles forms the basis of the literature synthesis presented in this article.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 APPENDIX A.
 APPENDIX B.
 REFERENCES
 
Table 1 summarizes characteristics of the 314 outcomes research articles published in the 39 selected journals from 1994–1999. During this interval, the number of pediatric outcomes research articles doubled. In rank order, articles in our search most commonly appeared in Pediatrics, Journal of the American Medical Association, Journal of Perinatology, Journal of Pediatrics, and Archives of Pediatrics and Adolescent Medicine.


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  		TABLE 1. 314 Pediatric Outcomes Research Studies Published in 39 Journals, 1994–1999

 
Hospitals and primary care practices were the most common service sectors studied, accounting for more than half of the articles. The majority of articles focused on specific pediatric diseases, primarily chronic conditions. Almost 1 in 3 pediatric outcomes research articles dealt with neonatal clinical conditions. Other common clinical categories included asthma, psychosocial problems, and injuries. Approximately 1 in 5 studies was either a multistate or a national sample, and 1 in 10 included a randomized, controlled trial study design.

Table 2 lists specific outcomes examined in the articles chosen for in-depth review. The table illustrates the wide variety of clinical endpoints and health-related quality-of-life measures that investigators use in pediatric outcomes research.


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  		TABLE 2. Outcomes Examined in 314 Pediatric Outcomes Research Articles, 1994–1999

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 APPENDIX A.
 APPENDIX B.
 REFERENCES
 
An overarching theme in our review related to the need for a common framework of child health and its determinants and relationship to health care services. A conceptual model of child health that finds widespread acceptance must clearly explicate those outcomes that constitute child health and those factors that determine child health. Not all health outcomes are equally amenable to medical care, and some outcomes may be appropriate targets for other health-oriented but nonmedical services. A comprehensive pediatric outcomes model should define the relationships between health and such "suprasystems" as the family, schools, peer networks, public health, juvenile justice, and medical care, all of which occur within the context of children’s physical and sociopolitical environments.

An important limitation in our methods is that we did not include the totality of outcomes research published during 1994–1999. We reviewed a select group of 39 journals and chose a subset of articles. Thus, the themes that we describe here should be considered a "snapshot" of research trends.

We organized the discussion of our literature synthesis into 3 categories of outcomes research. The first deals with development of health status and other outcome measures. The second is concerned with the linkages between the structure of the health care system (ie, its organization and financing) and outcomes. The third summarizes effectiveness research, the relationship between clinical interventions (processes of care) and outcomes.

Outcome Measure Development
The development of measurement tools that obtain the perspectives of children or parents on child health is 1 of the best concrete examples of the recent progress in pediatric outcomes research. Most studies in our review used single survey items to assess health, which are not as responsive to true changes in health as scales and indexes.7 Several new health status instruments have been developed for children and adolescents. The Child Health and Illness Profile (CHIP) uses a conceptualization of health that includes well-being, self-esteem, the burden of emotional and physical symptoms, risk behaviors, family involvement, resilience factors, and achievement in developmentally appropriate social activities.8–10 A new version of the CHIP has been developed for children 6 to 11 years of age.11 Developed for children with chronic conditions, the core module of the Pediatric Quality of Life Inventory assesses physical functioning, emotional symptoms, and peer relationships.12 Including the Child Health Questionnaire13 and the Functional Status IIR,14 these instruments provide several options for assessing the generic health of children. Although their content and domain structure have recently been contrasted,15 studies should be done to compare these measures to determine their relative strengths and potential applications.

Asthma is not only the most prevalent chronic condition in childhood but also the most common condition for which disease-specific health status measures have been developed.16,17 Juniper18 provided preliminary evidence on the reliability and validity of a health status measure for children and adolescents19 with rhinoconjunctivitis. Despite sample size limitations, researchers have begun to develop measures for patients with rare conditions, such as congenital agranulocytosis,20 spina bifida,21 and short stature.22 Research is needed to assess whether the combination of a generic health status instrument (which measures a broad set of health domains and can be compared across conditions) with a disease-specific measure (which may be more sensitive to changes in health as a result of a specific condition) improves the accuracy of health assessments of individuals with specific conditions.

Our literature search revealed scant research that elicited parents’ or children’s preferences for various outcomes when confronted with specific clinical situations or choices. The report by Kramer et al23 that compared parents’ and physicians’ values for alternative clinical outcomes among febrile young children is a notable exception. Developing a better understanding of child and parent preferences for alternative health states and health care choices is a necessary step toward making pediatric health care more responsive to its clients’ desires.

Progress has been made toward developing new measures of pediatric case mix and disease severity, which enable investigators to reduce some of the selection bias associated with observational study designs. Richardson et al24 provided a cogent analysis of the methodologic considerations involved in designing and interpreting case-mix and severity-of-illness measures in studies of neonatal outcomes. New approaches for assessing acute physiologic stability have been developed for critical care medicine25–27 and general hospital care.28 Injury severity measures are available so that alternative methods of organizing and delivering trauma services can be compared.29,30

Clinical endpoints such as mortality, morbidity, and development were commonly assessed among studies in our review. However, few studies examined physiologic and biochemical variables (eg, pulmonary function, glycosylated hemoglobin, hemoglobin level). Because childhood rates of mortality and morbidity are so low, expanding the range of these "intermediate" clinical outcome measures should be an avenue of further methodologic development.

Organization and Financing Studies
A robust literature has accrued on the importance of health insurance to use of health care services. Less is known about the effects of insurance on child and adolescent health status. The importance of this type of outcomes research grows as more children obtain coverage through publically financed programs. In a quasi-experimental evaluation of the State Child Health Insurance Program in western Pennsylvania, Lave et al31 found that enrollees reported fewer limitations in their activities and that their families had fewer stressors as a result of the child’s insurance status than a comparison group that was not enrolled in the program. These outcome findings were strengthened by demonstrating that the State Child Health Insurance Program also led to higher rates of service use (ie, by linking processes of care with health outcomes). We need more information on the mechanisms by which specific types of insurance coverage influence care-seeking behavior, practitioner decision making, and patient participation in the treatment process.

The Medicaid program finances 1 in 3 births in the United States,32 which has led to great interest in assessing the impact of Medicaid on perinatal outcomes. Implementation of Medicaid managed care in Tennessee compared with traditional Medicaid did not alter rates of prenatal service delivery or perinatal outcomes.33 In an analysis of the 1988 National Maternal and Infant Health Survey, higher rates of low birth weight infants found among women who were enrolled in Medicaid compared with those who had private financing had little to do with differences in receipt of prenatal care.34 The authors of that study concluded that expansions in Medicaid will be insufficient to improve outcomes of infants among low-income women.

Few studies in our literature search examined long-term outcomes of health care services. Two reports from the Infant Health and Development Study, a longitudinal study of the effects of early intervention services for low birth weight survivors, were notable exceptions.35,36 The intervention took place during the first 3 years of life and consisted of center-based and home-visiting components that provided education and other services to families. Better developmental outcomes were associated with the intervention among heavier low birth weight infants but not lighter ones, and these effects attenuated over time.36

For vulnerable subpopulations, primary care services are commonly provided outside of physicians’ offices in hospital outpatient departments and community health centers.37 For children, these sites include schools, which may include medical care clinics (ie, school-based health centers) and may provide health services that typically are not available in general medical settings. An innovative, school-based, randomized, controlled trial designed to reduce obesity was conducted by Gortmaker et al.38 The program was associated with reduced prevalence of obesity in girls but not in boys. The program effect seemed to be mediated by reduced television watching. More research is needed on the effectiveness of service delivery for school-based health care clinics and the role that schools can play in improving the health of children.

Home care services have proliferated in pediatrics to promote healthy child development, to improve child and family health, and to provide health care services. Nurse home visitation programs to prevent child abuse and neglect have been associated with positive effects on parenting and reduced rates of injury but no impact on child development.39,40 The evaluation by Duggan et al41 of Hawaii’s Healthy Start Program, also designed to prevent child abuse, found no overall impact on children’s health and development. This null finding may have been a consequence of differences in how the program was implemented by the 3 administering agencies. Compared with pediatric patients who received chemotherapy in a hospital, children with home chemotherapy reported (by parental proxy response) better appetite, more independence, higher levels of overall well-being, and better performance in school work.42

Evaluations of health care policies, particularly when they include a focus on health outcomes, can provide policy makers with empirical evidence to underpin their decision making. Following the American Academy of Pediatrics’ recommendation that infants sleep in nonprone positions, rates of sudden infant death syndrome declined in urban areas43 and nationally.44 Colleges and universities in states with mandated prematriculation immunization requirements had fewer outbreaks of measles in 1988–1991, compared with states without such requirements.45

Studies that examine how procedure volume influences outcomes have provided one of the most compelling links between health services and outcomes of care. Although most of these studies have focused on adult conditions, particularly those that involve high-cost procedures, some recent studies have been done with child populations. Jenkins et al46 used a hospital discharge abstract database to examine the effects of hospital caseloads on in-hospital mortality for children who were undergoing surgery for congenital heart disease. The chances of in-hospital death were increased 8-fold in hospitals with fewer than 10 cases of congenital heart disease surgery compared with those that had >300 cases per year. Phibbs et al47 reported that neonatal mortality was lower among high-volume level III neonatal intensive care units compared with low-volume level III and all level I and II neonatal intensive care units. Conversely, the study by Horbar et al48 on very low birth weight infants found no association between volume and neonatal outcome.

More research is needed to determine the mechanisms that are responsible for the linkages between procedure volume and pediatric outcomes. Can the procedure-volume effect be decomposed into components related to practitioners (eg, training, skill level, experience) and institutions (eg, specialized teams and facilities)? A better understanding of how high-volume centers achieve their outcomes could lead to important changes in how health care is delivered to sick children.

The organization of pediatric specialty services has garnered national attention as pediatric societies have championed the notion that the specialty care of children and adolescents should be provided by pediatric-trained specialists. Patients with diabetes who made more visits to a pediatric endocrinology clinic had lower glycosylated hemoglobin values than those who made fewer visits.49 In a single hospital, patients who were treated by pediatric urologists for ureteroneocystostomy had lower hospital charges and similar rates of postoperative complications as those who were treated by general urologists.50 In a randomized, controlled trial, a master’s-level social worker functioning as an asthma counselor provided advice to inner-city families of children with asthma and helped them obtain referrals to appropriate community resources.51 The intervention was associated with fewer asthma symptom days. Shared responsibility between primary care physicians and pediatric oncologists for the administration of chemotherapy was associated with similar survival rates as care delivered exclusively by pediatric oncologists.52 Evidence regarding the impact of pediatric specialized services on outcomes will provide policy makers and managers with the necessary information for organizing the existing and future physician workforce to provide child health care of the highest quality within the system’s economic constraints.

Effectiveness Research
Effectiveness research determines the effects of clinical intervention delivered in everyday medical settings on patient outcomes. Efficacy refers to the success of an intervention under ideal circumstances. The effectiveness of an intervention is always lower than its efficacy because of patient, provider, and system barriers to implementation. Our literature search uncovered remarkably few studies that examined the overall and comparative health effects of preventive, diagnostic, long-term management, and curative services delivered to children and adolescents. Despite the uncommon occurrence of long-term disorders in childhood, pediatric effectiveness research has tended to focus on chronic conditions. More attention should be given to evaluations of care for patients with acute and recurrent conditions and those with multiple co-occurring conditions.

A few articles in our search provide empirical evidence for the effects of primary prevention activities for children and adolescents. An analysis of disease rates attributable to Haemophilus influenzae type b in Southern California demonstrated impressive downward temporal trends associated with introduction of the Haemophilus influenzae type b vaccine.53 Decision analysis techniques were used to estimate the risk and costs of vaccine-preventable disease, such as hepatitis B,54 associated with different immunization strategies. Studies estimated identification and treatment rates for a school-based scoliosis screening program55 and a statewide neonatal hearing screening program.56 However, our search did not reveal studies that linked screening programs with population health or studies that assessed the effects of health education or anticipatory guidance on outcomes.

A large number of high-cost diagnostic tests—eg, advanced imaging studies, gastrointestinal and pulmonary endoscopy, and cardiac catheterization—have found widespread use in pediatric specialty care, yet there is very little evidence to support the benefits of these procedures on children’s health status and thus little evidence documenting their cost-effectiveness. The study by Pena et al57 on the use of computed tomography (CT) in the treatment of patients with suspected appendicitis is a step in the right direction. This study of patients with suspected appendicitis found that diagnostic evaluations using CT were associated with a more favorable profile of costs and complications than those without CT.57 Linking use of the CT scan to reduced rates of complications associated with appendicitis among children would provide important data necessary to support the effectiveness of CT scans.

Health care practitioners need much more information on the effectiveness of diagnostic tests and therapeutic procedures as they are applied to children and adolescents. Many of the newer diagnostic modalities are likely to improve diagnostic accuracy. Whether improvement in diagnostic accuracy in clinical samples translates into improvements in population health is the sort of information that health care practitioners and delivery systems require to practice cost-effective medicine.

The dramatic proliferation of new drugs has heightened the need to study their effects on not just clinical endpoints but also health from the perspectives of patients themselves. Multiple medications within the same therapeutic class may have similar effects on patients’ physiologic status but dissimilar effects on symptoms, functioning, and well-being. An example of such a study is the analysis by Mahajan et al58 of the effect of fluticasone propionate on the health status of children with asthma. Using previously validated measures of health status, the study found beneficial effects of the drug compared with placebo. More work is needed to compare the health effects of one drug with another to determine the "relative effectiveness" of medications.

Immunization research has been successful in identifying barriers to effective delivery of vaccines and in showing the impact of vaccine policy on population health. Similar research should be done to examine the effectiveness of screening services (eg, hearing, vision, scoliosis, developmental screening) and health education (eg, anticipatory guidance, adolescent risk reduction). Child health care practitioners may need to devise new strategies for delivering preventive care, broadening the medical model to one that uses a multisector approach. For example, reducing rates of childhood overweight are likely to require the joint implementation of public health interventions, school-based interventions, and medical services designed to increase physical activity, reduce television watching, and promote healthful diets.38

The number of recommendations for preventive care has proliferated in recent years. Child health practitioners need guidance regarding the ones to which they should devote their energy and limited time. Effectiveness research can provide this type of information by studying alternative ways to deliver these services so as to maximize the health of children.


   CONCLUSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
APPENDIX A.
 APPENDIX B.
 REFERENCES
 
Pediatric outcomes research studies the end results of health care services in actual practice and takes into account children’s and their parents’ experiences, preferences, and values. Outcomes that are important to children include the symptoms that they experience; their ability to participate in physical activities and social activities such as school, play, and work; and their well-being. Parental and family outcomes are also considered in pediatric outcomes research because of their important influence on promoting adaptability and determining children’s health.

The evidence generated by outcomes research can reduce uncertainty regarding the linkages between services and health. The effects of clinical uncertainty on practice variation, higher costs of care, and variability in quality have been well-documented. However, the degree to which existing outcomes research has led to substantive changes in practice or policy is not well-established. Linking the "producers" of research with those who use it to inform their decision making will lead to more effective translation of research findings into actual practice.

Although conventional investigator-initiated research projects will be an important part of future outcomes research, other strategies are needed to fill the large gaps in our knowledge concerning the effects of health care on child health. We need to build data systems that include large populations of children, outcomes that are relevant to children and their families, and information on services that can modify those outcomes. These data systems should be updated regularly and as close to "real time" as possible. Harnessing information in electronic medical records is a promising avenue for meeting this goal.

This "snapshot" of pediatric outcomes research conducted from 1994–1999 revealed important advances in measure development, immunization research, and assessments of neonatal services. Outcomes research in pediatric settings is a rapidly growing area of inquiry that is acquiring breadth but has achieved little depth in any single content area. Much work needs to be done to inform decision making regarding the optimal ways to finance, organize, and deliver child health care. In our review, we found a surprising paucity of effectiveness research. Clearly, more effectiveness research is needed to evaluate the overall and relative effects of preventive, diagnostic, long-term management, and curative services delivered to children and adolescents. Our vision of an expanded role for outcomes research in the health care decision-making process has the potential to change practice, stimulate new health policy, and improve the health of the nation’s children.


   APPENDIX A.
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 APPENDIX A.
APPENDIX B.
 REFERENCES
 


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  		APPENDIX A. Journals Reviewed (N = 39)

 

   APPENDIX B.
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 APPENDIX A.
 APPENDIX B.
REFERENCES
 


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  		APPENDIX B. Health Services Research Search Terms

 


   ACKNOWLEDGMENTS
 
This project was funded by the Agency for Healthcare Research and Quality (AHRQ). Dr Shipman was supported by an National Research Service Award training grant from the AHRQ. Dr Forrest was funded in part by an Independent Scientist Award from the AHRQ.

Deidre Clements and Sarah von Schrader provided technical assistance with the creation of the article abstraction database. We thank Carolyn Clancy, MD, Greg Meyer, MD, and Steven Fox, MD, for review of and comments on the manuscript.


   FOOTNOTES
 
Received for publication Jan 17, 2002; Accepted Jun 4, 2002.

Reprint requests to (C.B.F.) Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Rm 689, Baltimore, MD 21205. E-mail: cforrest{at}jhsph.edu


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 APPENDIX A.
 APPENDIX B.
 REFERENCES
 

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