Form #7 Form #7 Educational Materials

Attachment B:
Educational Materials

Preparing for the
Community Forum:
Thinking about
quality health care

Preparing for the Community Forum

Thank you for agreeing to take part
in the Community Forum project!
This handout tells you about the Community Forum and what you can expect to do
during this exciting project. This handout also gives some background information on
quality health care and medical research.

What is the Community Forum?
The Community Forum is your opportunity to be part of a group that tells government
decision-makers your ideas about how medical research can be used to improve the
quality of health care for everyone. Your group’s ideas will help federal government
agencies make better decisions about how to improve health care.

Who is sponsoring the Community Forum?
The Community Forum is a project sponsored by a federal government agency called
the Agency for Healthcare Research and Quality, or AHRQ. AHRQ works to improve the
quality and safety of health care in the United States.
The American Institutes for Research (also called A-I-R) is a non-profit research
organization that is leading the groups on behalf of AHRQ.

Why do we want to hear from you?
AHRQ often hears from doctors and researchers about health care. Even so, AHRQ
feels that there is an opinion that is just as important as those of health care
professionals—Yours!

:: 2 ::

AHRQ Community Forum

Preparing for the Community Forum

What will happen during the group?
[Tailored to each method] You will learn about and discuss how medical research can
be used to make health care safer and better. The group takes place over three days.
This may sound like a long time, but there will be breaks and lots of chances to talk and
learn new information. A facilitator will lead the group, making sure everyone gets a
chance to talk. You will get the chance to ask questions of experts such as doctors and
researchers too.

What do I need to do?
•

Come to the discussion with an open mind and be ready to listen, learn, ask
questions, and share your ideas.

•

AHRQ wants to know what you think is best for everyone in your community or
society overall. It may be natural to think about yourself and your family first—
that’s important—but we also want to hear what you think is best when you think
about everyone.

•

We ask that you give reasons for your opinions or feelings, so everyone in the group
can understand why you feel the way you do. Remember – your input is really
important!

•

Some of the issues we discuss may be new to you. Don’t worry! We will help you
understand the health topics, so you can be part of the discussion. There will also
be plenty of time to ask questions.

Who is taking part in the group?
The group will include all types of people from your community to allow for a rich
discussion and many different points of view.

What happens after the group?
We will put together the ideas we get from all of the groups across the country and
write a report for AHRQ and other people who make decisions about health care.
They will use everyone’s input to make decisions about the use of medical research to
improve the quality of health care.

:: 3 ::

AHRQ Community Forum

Preparing for the Community Forum

Quality Health Care
What is good quality health care?
Good quality health care is care that gets people the best possible results for their health and
well-being. Getting good quality health care can help people stay healthy and recover faster
when they get sick.
1
According to the Institute of Medicine , good quality health care is:

1

:: 4 ::

•

Safe. Safe health care is health care without medical errors. Doctors, nurses, and hospitals
work hard to prevent medical errors, but mistakes still happen. A report by the Institute of
Medicine estimates that as many as 98,000 people in the United States die in hospitals each
year as the result of medical errors.

•

Effective. Effective health care means patients get health care based on the latest
evidence from medical research about what health care works best.

•

Patient-centered. Patient-centered health care is when doctors, nurses, and other health
care professionals respect and respond to the preferences, needs, and values of patients
and their families.

•

Timely. Timely health care is when patients get the health care they need at a time when
it will do them the most good.

•

Efficient. Efficient health care is health care that does not waste the patient’s time or
money—or cost more than it needs to.

•

Equitable. Equitable health care is when everyone has the same chance to get good
quality health care. It means people are not treated differently because of their gender,
ethnicity, where they live, or how much money they make.

The Institute of Medicine is an independent, non-profit research organization that is part of the National Academies of Sciences.

AHRQ Community Forum

Preparing for the Community Forum

⌃ This figure shows the different parts of good quality health care, as described by the Institute of Medicine.

:: 5 ::

AHRQ Community Forum

Preparing for the Community Forum

Medical Research
and Medical Evidence
The Community Forum will get your ideas about how medical research and
medical evidence can be used to make sure everyone gets good quality health care.

What is medical research?
Medical research is when doctors and researchers study groups of people to find out what
types of health care work best for most people.
Everyone is different. But if medical research is done well, then doctors and researchers can feel
sure that they have enough information to say if a treatment will work for most people.

What is medical evidence?
Medical evidence is when doctors and researchers have enough information from the results of
medical research to say how well a treatment will work for most people.

Using medical evidence is part of good quality health care
When medical research is done well, it leads to medical evidence.
When there is medical evidence to show which health care
works best, then using medical evidence is part of good quality health care.

:: 6 ::

AHRQ Community Forum

Preparing for the Community Forum

Does everyone get health care based on medical evidence?
No. It may surprise you to learn that often Americans do NOT get health care based on the
latest medical evidence.
Here are just two examples of research that have shown problems with quality of health care:
•

Americans receive appropriate health care when they need it only 55% of the time. All
Americans are at risk of receiving poor health care—no matter where they live, how much
money they have, or their race, education or health insurance.

•

Over 90,000 Americans with conditions such as high blood pressure, diabetes, and heart
disease die each year because they don’t receive the type of health care that research has
2
shown to work best for their condition .

What does it mean when medical research is done well?
In general, medical research is done well when:
The study has enough people to say what the chances of the same thing happening to
other people.
The study lasts for a long enough time to make sure all the benefits and risks of a
treatment can be known. For example, one study may last for 6 months, but another study
may last for 5 years.
Doctors and researchers design the study to reduce bias so that they know the
benefits and risks are due to the treatment and not to other factors.
More than one study shows the same results. If more than one study shows the
same results, then researchers can feel sure that the same thing will happen to other
people.

2

For details, see The Essential Guide to Health Care Quality) and State of Health Care Quality by the National Committee for Quality Assurance
(www.ncqa.org/tabid/203/Default.aspx).

:: 7 ::

AHRQ Community Forum

Preparing for the Community Forum

Comparative Effectiveness Research
Medical research helps make sure people get good quality health care. There are different types
of medical research. For this project, we will learn and talk about one type of medical research
called comparative effectiveness research.

What is comparative effectiveness research?
•

Comparative effectiveness research, sometimes called CER (C-E-R), is a type of
medical research that compares treatments for the same health problem to see which one
works best.

•

For example, researchers might compare two different asthma medicines to
see which one helps patients breathe more easily. Or, researchers might compare
whether surgery or radiation works best to treat cancer.

•

CER does not help discover new treatments or services because it looks at
treatments that are already available. Researchers do other types of medical
research to find new treatments.

•

Sometimes, there is not enough medical evidence from CER to say which
kind of health care works best. More research may be needed to find the answers.

Who does comparative effectiveness research?
Doctors and other medical experts do CER. These researchers work at different independent
organizations, such as universities and public or nonprofit research centers. Government
agencies, such as the Agency for Healthcare Research and Quality (AHRQ), pay to have much
of this research done.
A Note About the FDA
The FDA (Food and Drug Administration) decides if a new drug or medical device can go
on the market. The FDA makes sure that the drug or device does what it is supposed to do
and is safe. But the FDA does not compare drugs or devices to find out which one works
best for a specific health condition.
That’s why it is important to look at the results of CER.

:: 8 ::

AHRQ Community Forum

Preparing for the Community Forum

How can medical evidence
from comparative effectiveness
research be used?
Medical evidence from CER can be used in different ways. For example:
•

Doctors and patients can use the results of CER to choose the treatment that
works best for the patient. CER helps doctors and patients understand the facts about
different treatments, such as what works well and what the problems may be.

•

Groups of doctors, who are experts in their field, may make quality
recommendations for good patient health care. These recommendations help
doctors and other health care professionals know the best way to care for patients in most
situations. Quality recommendations may also be called clinical practice guidelines or
quality standards.
Health care that follows quality recommendations is sometimes called “evidence-based
care” because it is based on medical evidence that says what type of health care works well.

•

:: 9 ::

Health insurance plans may use the results of CER to help decide what the
cost of the treatment will be for patients. For example, when medical evidence
shows that one treatment works better than another, health insurance plans may set a
lower cost to patients for that treatment to encourage patients to use it.

AHRQ Community Forum

Preparing for the Community Forum

Health Care Costs
The costs of health care to society are important when thinking about the use of medical
evidence to improve the quality of health care. After all, the wrong kind of health care can not
only harm people, we also often spend more money than we need to.

Are health care costs increasing a lot?
Health care costs are increasing much faster than other parts of the economy. In 2009, health
care spending in the United States totaled $2.5 trillion. Health care spending in 2009 was 22
times more than in 1970. In comparison, prices for household goods were only 5.5 times more
than in 1970.

Health Care and Household Goods Spending Rates, 1975–2009

*Health care spending data is determined by the National Health Expenditures per capita.
**Household goods data is determined by the Consumer Price Index.
Sources: Centers for Medicare and Medicaid Services (CMS), Office of the Actuary; Bureau of Labor Statistics (CPI-U, U.S. city average, annual figures).

:: 10 ::

AHRQ Community Forum

Preparing for the Community Forum

Who pays for our health care?
All of us play a role in paying for health care.
Individuals and families–even those who have health insurance–paid 28% of the costs
of all health care in 2009. Individuals and families pay this amount in different ways.
For example, they pay:
•

Part or all of their insurance premiums

•

Out-of-pocket costs for their medical care

•

The portion of their salary that goes to support Medicare for seniors.

Also, the federal, state, and local government paid 43% of all health care costs in 2009.

Contributors To Health Care Payments in 2009*

*Estimates of spending by contributor are organized according to the underlying entity (business, households, and government) financing the health
care bill payer. CMS refers to these contributors as “sponsors.” Figure does not add to 100 percent due to rounding.
**Other includes philanthropic giving, worksite healthcare, and revenues received by some health care providers for non-health activities.
Sources: Centers for Medicare and Medicaid Services (CMS), Office of the Actuary

:: 11 ::

AHRQ Community Forum

For more information
If you would like more information about the group
or any part of this project, please contact Dierdre Gilmore
at [email protected].

Case Study Descriptions

Part 1: Case Study: Comparing Hospital Quality

Comparing Hospital Quality
What is the health problem?
Many serious health problems require treatment in the hospital. This treatment can be surgery or
intensive medical treatment. As medical technology improves, hospitals can save more lives and
treat more serious health problems. But doing more complicated medical work also puts more
pressure on hospitals to have highly skilled and experienced doctors and support teams.

Are some hospitals better than others?
Yes. Hospitals that do a specific surgery or treatment for lots of patients are called high-volume
hospitals. Hospitals that do a specific surgery or treatment for a fewer number of patients are called
low-volume hospitals. High-volume hospitals often have greater success for that surgery or
treatment than low-volume hospitals. A hospital that is high-volume for one health problem (for
example, heart surgery) may not be high-volume for a different one (for example, cancer surgery).
For common health problems like pneumonia, low-volume hospitals are just as skilled as high-volume
hospitals.

What does the medical evidence show?
Over the years, researchers have studied the difference in care between high-volume and low-volume
hospitals for a variety of serious health problems. Hospital volume does not affect every health
problem. But, for some health problems, patients do better if they receive care at a high-volume
hospital. For example:
Pediatric heart surgery: In low-volume
hospitals, 15 percent of the children on average
will die from the surgery. In high-volume hospitals,
4 percent will die. This means that of 100 children
having this surgery, 11 more would die in a lowvolume hospital than in a high-volume hospital.
Surgery for cancer of the esophagus (the tube
between the mouth and stomach): In low-volume
hospitals, 17 percent will live for more than 5 years
after surgery. In high-volume hospitals, 34 percent
will live for more than 5 years after surgery. This
means that of 100 people having this surgery, 17
more people will live for more than 5 years after
surgery in a high-volume hospital than in a lowvolume hospital.

:: 1 ::

Artificial knee surgery: Sometimes this knee
surgery has to be done over again. The need to redo an artificial knee is necessary 50 percent more
often when surgery is done in low-volume
hospitals. This means that if 10 patients need their
surgery redone in a high-volume hospital, 15 will
need it redone in a low-volume one.
Surgery for aortic aneurysms (when the major
blood vessel from the heart needs to be repaired):
In low-volume hospitals, nearly 7 percent will die
from this surgery. In high-volume hospitals, 3
percent will die. This means that of 100 people
having this surgery, 4 more would die in a low
volume hospital than in a high-volume hospital.
Hip replacement surgery: The risk of death for
patients who get their hip replaced is only about 1
in a 100. Even so, the risk of death in a low-volume
hospital is nearly twice as high as the risk of death
in a high-volume hospital.
AHRQ Community Forum

Part 1: Case Study: Comparing Hospital Quality

Comparing Hospital Quality
What do you think?
Given the significant differences in results for patients in these low- and
high-volume hospitals, people might have different responses, such as:
This seems normal — some hospitals get better results than others and that is to be
expected.
The high-volume hospital is the only one I would go to, and I cannot imagine why
anyone would do anything else.
Makes me wonder how many people know which hospitals are the better ones.

Does one of these statements reflect your opinion? Has something else
occurred to you?

:: 2 ::

AHRQ Community Forum

Part 2: Case Study: Comparing Hospital Quality

Comparing Hospital Quality
A closer look
While researchers and health care leaders are primarily concerned about providing the highest quality
care to patients regardless of which hospitals they use, they also wonder if there are cost differences. In
other words, when patients get better results (such as fewer complications or higher number who
survive certain surgeries), does this cost more, less, or the same as for patients who do not do as well or
are less likely to survive?

Comparing the cost
Some studies compare the actual cost difference between low-volume and high-volume hospitals for
particular surgeries. For example, a complex abdominal surgery costs $27,000 in a high-volume hospital
and $33,000 in a low-volume. Cost differences like this are because patients recover faster with fewer
problems when they are at a hospital that performs many of these operations over time. Yet better
hospital care is not always less expensive. For example, patients with heart failure had better results at
high-volume hospitals but the cost of the care was greater than at a low-volume hospital.
Another research study compared patients who had major surgery and whether or not they had
complications such as an infection, excessive bleeding, or blood clots that would slow down the
patient's recovery or even cause their death. With this comparison, the cost difference was
considerable:
•

Patients without complications cost an average of $28,000.

•

Patients with complications cost an average of $159,000.

These results suggest that patients in low-volume hospitals have more medical problems from their
surgery, and the cost of dealing with these problems can be significant.
Although patients who have health insurance may be protected from much of the extra costs that can
come with less skilled care, these costs can have an impact on other people. That is because when more
dollars are spent on health care, health insurance rates can increase for everyone.

:: 3 ::

AHRQ Community Forum

Part 3: Case Study: Comparing Hospital Quality

Comparing Hospital Quality
The community of Springview
Knowing that low-volume and high-volume hospitals can get different results, imagine there is a small
community, Springview, with just one hospital. This small hospital is low-volume for almost anything it
does except delivering babies. The county government is the largest employer in town. Half the county
residents are in the families of county employees. Because of the poor economy, the county can only
offer employees just one health plan.
The county has to decide which of the two health plans it will offer:
Health Plan A. To support the needs of the
local community, this plan covers all the
services available at Springview Community
Hospital, the local, low-volume hospital. The
only time services are approved for the highvolume University Medical Center 50 miles
away is for specialized care that is not
available at Springview Community Hospital.

Health Plan B. To get the best clinical
results possible, this plan covers almost all
services at the high-volume University
Medical Center 50 miles away. This plan pays
for services at Springview Community
Hospital only for two situations: 1) maternity
care and 2) emergency care before
transferring patients to University Medical
Center.

Employees’ response
This was a difficult issue for county employees.
Many employees supported keeping their medical care at the local, low-volume Springview
Community Hospital because patients want their family and friends close to give them emotional
support and stay up to date on their progress. Also, patients and families feel more comfortable with
local doctors, nurses, and other staff who they know and trust.
Other employees supported getting medical care at the high-volume University Medical Center
because they did not want to jeopardize their health and that of their loved ones by agreeing only to
get medical services at a hospital that got worse results. They felt that having a better chance of
surviving a serious medical problem was more important than convenience and 'loyalty.'

Local hospital concerns
Springview Community Hospital was also worried. If it lost so many of its patients to University Medical
Center for treatment, this loss of services would affect the hospital's financial well-being. Without the
income from these treatments, other hospital services would be reduced. The hospital director started
worrying if the hospital could survive if it faced these major changes.

:: 4 ::

AHRQ Community Forum

Part 3: Case Study: Comparing Hospital Quality

Comparing Hospital Quality
Initial question:
Suppose all of you are on the Springview town council that has to make the
decisions for all the county employees and their families.

Which health plan would you pick and why?

:: 5 ::

AHRQ Community Forum

Part 1: Case Study: Comparing Hospital Quality

Comparing Hospital Quality
What is the health problem?
Many serious health problems require treatment in the hospital. This treatment can be surgery or
intensive medical treatment. As medical technology improves, hospitals can save more lives and
treat more serious health problems. But doing more complicated medical work also puts more
pressure on hospitals to have highly skilled and experienced doctors and support teams.

Are some hospitals better than others?
Yes. Hospitals that do a specific surgery or treatment for lots of patients are called high-volume
hospitals. Hospitals that do a specific surgery or treatment for a fewer number of patients are called
low-volume hospitals. High-volume hospitals often have greater success for that surgery or
treatment than low-volume hospitals. A hospital that is high-volume for one health problem (for
example, heart surgery) may not be high-volume for a different one (for example, cancer surgery).
For common health problems like pneumonia, low-volume hospitals are just as skilled as high-volume
hospitals.

What does the medical evidence show?
Over the years, researchers have studied the difference in care between high-volume and low-volume
hospitals for a variety of serious health problems. Hospital volume does not affect every health
problem. But, for some health problems, patients do better if they receive care at a high-volume
hospital. For example:
Pediatric heart surgery: In low-volume
hospitals, 15% of the children on average will die
from the surgery. In high-volume hospitals, 4% will
die. This means that of 100 children having this
surgery, 11 more would die in a low-volume
hospital than in a high-volume hospital.
Surgery for cancer of the esophagus (the tube
between the mouth and stomach): In low-volume
hospitals, 17 percent will live for more than 5 years
after surgery. In high-volume hospitals, 34 percent
will live for more than 5 years after surgery. This
means that of 100 people having this surgery, 17
more people will live for more than 5 years after
surgery in a high-volume hospital than in a lowvolume hospital.

:: 1 ::

Artificial knee surgery: Sometimes this knee
surgery has to be done over again. The need to redo an artificial knee is necessary 50 percent more
often when surgery is done in low-volume
hospitals. This means that if 10 patients need their
surgery redone in a high-volume hospital, 15 will
need it redone in a low-volume one.
Surgery for aortic aneurysms (when the major
blood vessel from the heart needs to be repaired):
In low-volume hospitals, nearly 7 percent will die
from this surgery. In high-volume hospitals, 3
percent will die. This means that of 100 people
having this surgery, 4 more would die in a low
volume hospital than in a high-volume hospital.
Hip replacement surgery: The risk of death for
patients who get their hip replaced is only about 1
in a 100. Even so, the risk of death in a low-volume
hospital is nearly twice as high as the risk of death
in a high-volume hospital.
AHRQ Community Forum

Part 1: Case Study: Comparing Hospital Quality

Comparing Hospital Quality
What do you think?
Given the significant differences in results for patients in these low- and
high-volume hospitals, people might have different responses, such as:
This seems normal — some hospitals get better results than others and that is to be
expected.
The high-volume hospital is the only one I would go to, and I cannot imagine why
anyone would do anything else.
Makes me wonder how many people know which hospitals are the better ones.

Does one of these statements reflect your opinion? Has something else
occurred to you?

:: 2 ::

AHRQ Community Forum

Part 2: Case Study: Comparing Hospital Quality

Comparing Hospital Quality
The community of Springview
Knowing that low-volume and high-volume hospitals can get different results, imagine there is a small
community, Springview, with just one hospital. This small hospital is low-volume for almost anything it
does except delivering babies. The county government is the largest employer in town. Half the county
residents are in the families of county employees. Because of the poor economy, the county can only
offer employees just one health plan.
The county has to decide which of the two health plans it will offer:
Health Plan A. To support the needs of the
local community, this plan covers all the
services available at Springview Community
Hospital, the local, low-volume hospital. The
only time services are approved for the highvolume University Medical Center 50 miles
away is for specialized care that is not
available at Springview Community Hospital.

Health Plan B. To get the best clinical
results possible, this plan covers almost all
services at the high-volume University
Medical Center 50 miles away. This plan pays
for services at Springview Community
Hospital only for two situations: 1) maternity
care and 2) emergency care before
transferring patients to University Medical
Center.

Employees’ response
This was a difficult issue for county employees.
Many employees supported keeping their medical care at the local, low-volume Springview
Community Hospital because patients want their family and friends close to give them emotional
support and stay up to date on their progress. Also, patients and families feel more comfortable with
local doctors, nurses, and other staff who they know and trust.
Other employees supported getting medical care at the high-volume University Medical Center
because they did not want to jeopardize their health and that of their loved ones by agreeing only to
get medical services at a hospital that got worse results. They felt that having a better chance of
surviving a serious medical problem was more important than convenience and 'loyalty.'

Local hospital concerns
Springview Community Hospital was also worried. If it lost so many of its patients to University Medical
Center for treatment, this loss of services would affect the hospital's financial well-being. Without the
income from these treatments, other hospital services would be reduced. The hospital director started
worrying if the hospital could survive if it faced these major changes.

:: 3 ::

AHRQ Community Forum

Part 2: Case Study: Comparing Hospital Quality

Comparing Hospital Quality

Initial question:
Suppose all of you are on the Springview town council that has to make the
decisions for all the county employees and their families.

Which health plan would you pick and why?

:: 4 ::

AHRQ Community Forum

Part 1: Case Study: Upper Respiratory Infections

Upper Respiratory Infections in Children:
Antibiotics vs. Symptom Treatment
What is the health problem?
Children get colds with symptoms like coughs and sore throats throughout their childhood. These
conditions are called Upper Respiratory Infections (URIs).
URIs are most often caused by a virus. URIs caused by viruses will get better on their own within a
week or so. But, about 10 percent of URIs are caused by bacteria. Sometimes it is difficult to tell
whether the infection is viral or bacterial without a special test.

What to do about URIs?
There are two approaches to treating URIs.
•

Relieve symptoms. URIs have lots of uncomfortable symptoms. One approach to treatment
is to relieve these symptoms. This includes having a child drink plenty of fluids and when
necessary use common drugstore medicines to loosen congestion, decrease cough, and control
any fever.

•

Use antibiotics. A second approach to treat URIs is antibiotics. Although antibiotics have no
effect on a URI that is caused by a virus, antibiotics work against a URI caused by bacteria. URIs
caused by bacteria may lead to more serious illness if left untreated. When doctors prescribe
antibiotics, they usually recommend that parents also relieve symptoms, as noted above.

What does the medical evidence show?
When antibiotics are given to a child routinely, even with a good reason, bacteria can become
'resistant.' This means they are less likely to get rid of bacterial infections. Researchers believe
that if a child is given antibiotics when not needed, those antibiotics might not work to stop future
infections that the child may develop. This can put the child's health in danger.
Because of these concerns, the American Academy of Pediatrics established clinical practice
guidelines more than 10 years ago saying that to avoid over-using antibiotics, they should not be
prescribed unless the doctor is sure that it is a bacterial infection and not a virus.

What is actually done?
Most doctors follow the guidelines by the American Academy of Pediatrics. But some doctors still
prescribe antibiotics for URIs – even when they do not know for sure if the URI is caused by a bacteria
or virus – for various reasons:

:: 1 ::

•

Doctors may be concerned about sore throats caused by strep bacteria. These infections may
cause serious problems if not treated with antibiotics. If they suspect strep, then they may not
want to wait for test results before starting treatment.

•

Parents ask for them because they believe that the antibiotic make their child feel better. Parents
may also think that antibiotics will help them avoid missing work to stay home with their child.

•

Some doctors and parents think the antibiotics will not cause harm, so it does not to hurt to try.
AHRQ Community Forum

Part 1: Case Study: Upper Respiratory Infection

Upper Respiratory Infections in Children:
Antibiotics vs. Symptom Treatment

What do you think?
Which statement best reflects your view?
If the doctor thinks that an antibiotic will help the child and the parents, then that is
more important than what clinical practice guidelines say.
It is the parents’ decision about getting the antibiotic or not; they care the most for their
children and they should decide if they think the benefit of the antibiotic is worth it or
not.
If the clinical practice guidelines say that too many antibiotics might harm the child in
the long run, then doctors and parents should follow the guidelines.

:: 2 ::

AHRQ Community Forum

Part 2: Case Study: Upper Respiratory Infection

Upper Respiratory Infections in Children:
Antibiotics vs. Symptom Treatment
Community impact
As mentioned earlier, if antibiotics are used when not needed, they eventually become less able to
kill bacterial infections. This affects not only the individual patient who had taken antibiotics when
not needed, but it also affects the larger population. One example of this is a severe infection called
MRSA (“mersa”).
MRSA developed because a common antibiotic, a type of penicillin, was widely used, and now no
longer works against the MRSA infection. It takes stronger, more dangerous drugs to control the
MRSA bacteria. In 2005, the number of people hospitalized with the MRSA infection was more than
278,000, and about 5,500 people died that year due to this infection.
Because of examples like MRSA, public health experts have been trying for many years to help
doctors and patients understand the problems of antibiotics. If antibiotics are over-used, many
people – children and adults – who need an antibiotic in the future may be in danger of getting an
infection that cannot be controlled. But many parents find it difficult to put aside their current
worries about their child's health for a possible problem in the future that could impact the
population at large.

:: 3 ::

AHRQ Community Forum

Part 2: Case Study: Upper Respiratory Infection

Upper Respiratory Infections in Children:
Antibiotics vs. Symptom Treatment

What do you think?
Now that you’ve learned more about over-using antibiotics, which
statement best describes your view?
I think it is up to the doctor and family to decide if the antibiotic should be used in each
individual case. Families should not feel responsible for what might or might not happen
with future bacteria.
I think if everyone really understood this well, more doctors and parents would decide
not to take antibiotics unless they knew for sure that they had a bacterial infection.
To avoid this problem, there should be stricter rules for when a doctor can order an
antibiotic for a patient. We cannot always depend on people to do ‘the right thing’
voluntarily.

:: 4 ::

AHRQ Community Forum

Part 1: Case Study: Obesity

Obesity treatment: Comparing
different approaches
What is the health problem?
Obesity is a widespread and growing problem throughout the country. More than one-third of
Americans are obese as defined by their “body mass index,” or BMI. BMI is a number that describes a
person’s weight in relation to their height. An adult who has a BMI of 30 and above is considered
obese.
Obesity often gives rise to other medical problems such as diabetes, heart disease, arthritis, stroke,
depression, and other long-term problems.
Compared to people
of normal weight,
people who are
severely obese, with
a BMI of 35 and
above, are:

normal
weight
BMI

•

Almost 2 times as likely to have heart
disease

•

Almost 4 times as likely to have high
blood pressure

•

6 times as likely to have diabetes

18.5-24.9

overweight
25-29.9

moderately

severely

obese

obese

30-34.9

35 and above

What are the treatments for obesity?

:: 1 ::

•

Supervised diet and exercise programs are highly recommended for those who are overweight
or obese. But, many people find it difficult to stay on these programs, especially programs with
little or no supervision.

•

More structured behavior change programs – such as residential treatment or weight-loss
'camps' –are much more successful in treating obesity than those that are offered only as outpatient programs, but they are expensive and often not covered by insurance.

•

Surgery provides the most effective short-term treatment for achieving significant weight loss.
There are different types of surgeries. Banding surgery is a type of surgery where a band is
surgically placed around the stomach to restrict its size, so individuals eat much less food than
before. Banding is being used more often now because it is less risky than other types of surgery.

AHRQ Community Forum

Part 1: Case Study: Obesity

What are the benefits of banding surgery?
The success of banding surgery has been measured in different ways for people who are severely
obese (a BMI of 35 and above).
•

Weight loss. When banding surgery is successful, people who are severely obese lose most of
their excess weight.

•

Number of prescriptions. People who are severely obese must often take a lot of prescription
medicines for various illnesses. One study showed that the number of prescription medicines
dropped from 21 to 13 for severely obese patients who had the banding surgery. This drop was a
sign that patients had fewer medical problems after the banding surgery.

What are the risks of banding surgery?
In a study of 299 patients, after 3 years of having the band, 88%,
or 263 people, had one or more side effects or complications –
mild, moderate, or severe. Most common were nausea and
vomiting, band slippage, or stomach blockage. In the study,
25%, or about 75 of the patients, had their band removed. This
often followed a complication of the procedure.
In a different study, the response of patients who had banding
surgery changed over time. After the surgery, many patients said
they were generally satisfied, but several years later almost 40%
had major complications and about half had to have their bands
removed.

Banding surgery made available to more people
In 2001, the FDA approved banding surgery for people who are severely obese (a BMI of 35 and
above) if they also had a related problem such as diabetes. FDA approval means that the banding
surgery was shown to be safe and effective. In February 2011, the FDA approved banding surgery for
moderately obese people (BMI of 30 to 34.9) if they also had a related problem, such as diabetes or
arthritis. This new approval meant that many more people could be eligible for banding surgery.

Concerns about research for the new approval
Many critics were concerned about the new FDA approval for people who are moderately obese.
They pointed out that this FDA approval was based on a small study of 149 people that was paid for
by the company that makes the bands. Of particular concern, the study results were based on
patients having the band for one year, rather than several years. Because banding surgery in severely
obese patients often did not create problems until several years after surgery, there were concerns
that people who are moderately obese may face risks from banding surgery that did not show up in
the one-year study.
Nevertheless, the FDA approval meant that millions of individuals would have access to a surgery
that could make a big difference in their health and well-being.
:: 2 ::

AHRQ Community Forum

Part 1: Case Study: Obesity

Obesity treatment: Comparing different
approaches

What do you think?
Imagine that you live in a community that is receiving government
funding to try to decrease the growing number of people who are obese.
You can devote these funds in any amounts to these three approaches to
obesity treatment:
Structured behavior change programs (no surgery). With this approach, patients do
not lose as much weight as they do with banding surgery, but they avoid the risks of
surgery. Patients average 15% weight loss and they are able to reduce the medical
problems that are associated with obesity.
Banding surgery for severely obese. This approach concentrates on those people
with the most severe health-threatening problems, and patients lose an average of
31% of their total weight. This is the most effective way to lose weight and reduce the
medical problems associated with obesity.
Banding surgery for moderately obese. This approach will reach patients before they
are severely obese, to help control the weight gain before it reaches the severe level.
Focusing efforts on the moderately obese may help them avoid the risk of other
diseases, but there is not enough research to say for sure.

:: 3 ::

AHRQ Community Forum

Part 2: Case Study: Obesity

Obesity and public policy: Comparing

prevention and treatment

Preventing obesity or offering treatment
Some policymakers believe that it is better to spend resources to prevent obesity than to treat
obesity and its related health problems. They use “stop smoking” efforts as an example. Over the
past couple of decades, "stop smoking" efforts in the community have reduced smoking rates by
half and saved resources. Although these efforts have been successful, changing eating habits may
be more difficult.

What does the evidence show?
Research has shown that certain factors will increase the risk of obesity for people living in a
community. These include:
•

Not having markets near them that provide fresh fruits and vegetables

•

The cost of fresh fruits and vegetables

•

Local stores having processed foods with high sugar, salt, and fat

•

Too many fast food restaurants

•

Not having “green space” or safe areas for leisure exercise

•

The cost of using private gyms and exercise clubs

Many of these factors are especially present in low-income communities, which have a higher
percentage of obese residents than higher-income communities.

A community plan to prevent obesity
A group of community leaders put together a plan for a local prevention program. They want to:
•

Establish a local tax on foods that have little nutritional value

•

Provide calorie counts in restaurants

•

Work with schools to improve the nutritional value of the food served to children

•

Work with the school district to reinstate active gym classes for school-age kids

Which has priority?
But, others argue that the problem of obesity cannot be changed by this prevention plan. They
saw how banding surgery made a meaningful difference in the lives of individuals whose health is
affected by obesity. They want to make sure that the moderately obese also had the opportunity
to benefit.

:: 4 ::

AHRQ Community Forum

Part 2: Case Study: Obesity

Obesity and public policy: Comparing
prevention and treatment

What do you think?
Imagine that the local community has limited funding and has to decide
which of the two interventions to support: banding surgery for moderately
obese or community-based prevention.
Which approach is most important and why?

:: 5 ::

AHRQ Community Forum

Part 1: Case Study: Heart Disease

Heart Disease Treatment: Comparing

medicines only and stents plus medicines
What is the health problem?
Coronary heart disease is the leading cause of death for all Americans. Heart disease occurs when
the blood vessels in the heart become clogged, and blood and oxygen have a hard time getting to the
heart. Not getting enough blood or oxygen to the heart can cause a range of problems such as chest
pain (angina), shortness of breath, limitation of activities, a heart attack, and death.
Heart disease ranges from mild to severe. People with mild heart disease have some blockage in their
blood vessels, but the symptoms – mainly chest pain – are not severe. People with mild heart disease
need to be treated to relieve chest pain and to prevent blockages from becoming worse.

What are the treatments for mild heart disease?
There are two main ways to treat mild heart disease:
•

Medicines only. Doctors prescribe a combination of medicines, such as those that lower
cholesterol, control blood pressure, relieve chest pain, reduce blood clotting, and others.
Medicines relieve symptoms, such as chest pain or shortness of breath, but a small percent of
patients will not have as good relief from medicines as from a stent. Medicines pose possible risks
to the liver and kidney, which can be checked regularly with lab tests.

•

Stent plus medicines. A stent is a metal device that is placed into a narrowed or clogged heart
vessel to keep it open so that blood flow to parts of the heart is improved, or protected from
further damage. Stents relieve symptoms, such as chest pain and shortness of breath as soon as
they are put in place. But, stents have more risks than only taking medicines. For example, 1 out
of 100 patients will have a heart attack from getting the stent. And, 2 out of 1,000 patients will die
directly related to having the stent put in. Patients who get a stent also take medicines like those
described above.

All patients with mild heart disease are advised to make lifestyle changes, such as stopping smoking,
limiting salt and fat in their diets, and exercising regularly, as long as the patient can do so safely.

What does the medical evidence show about each treatment?
Researchers compared the two types of treatment:
•

The research showed no difference between the two treatments in the number of deaths or heart
attacks over a period of 5 years.

•

Getting a stent has more risks than medicines only, but stents bring faster relief from symptoms
than medicines only. People who get a stent have fewer symptoms and report a higher quality of
life than people who only take medicines. But, after 2 years, these differences go away.

Based on this research, only 1 out of 3, or 33%, of patients eventually will need a stent. The rest will
have comparable results from medicines only.
:: 1 ::

AHRQ Community Forum

Part 1: Case Study: Heart Disease

Research recommendation
Based on the medical evidence, medical experts recommend that medicines should be the first
treatment given to patients with mild heart disease. If patients continue to have chest pain and
other symptoms of mild heart disease, then experts recommend offering a stent.

What is actually being done?
A major study showed that 55% of patients were getting stents as the first treatment, rather than
getting medicines only as recommended. This number is significantly more than the 33% of
patients who need it.
This study raised concerns that many patients are getting stents that they do not need.

:: 2 ::

AHRQ Community Forum

Part 1: Case Study: Heart Disease

Heart Disease Treatment: Comparing

medicines only and stents plus medicines

What do you think?
Which statement below is closest to your view?
Patients should trust doctors, not the research, to do the best thing for them.
Patients should expect doctors to tell them about the risks and benefits of each
treatment before the patient decides what to do.
Patients should be wary if doctors are recommending a treatment that research says
is not useful.

:: 3 ::

AHRQ Community Forum

Part 2: Case Study: Heart Disease

Heart Disease Treatment: Comparing

medicines only and stents plus medicines
What are the costs of treatment?
With so many doctors doing stent procedures, researchers looked at the difference in what these
treatments cost. Assuming all patients were also on medicines, then the only difference in cost
would be the cost of performing the stent procedure in patients when there was no clear need for
them.
In 2004, there were more than 650,000 stents placed as the first treatment in patients with mild
heart disease. The average cost of placing a stent was $56,000. This means that in one year
(excluding those who would have needed a stent eventually), $37 billion was spent on this procedure
that research found to be ‘not necessary.'

:: 4 ::

AHRQ Community Forum

Part 2: Case Study: Heart Disease

Heart Disease Treatment: Comparing

medicines only and stents plus medicines

What do you think?
In what way does having this information about the cost of the stent
procedure influence your view?
Knowing the cost of the stent procedure makes no difference in how I think about it.
Knowing the cost of the stent procedure is one of several factors to consider when
comparing two different treatments but is not the most important.
You need to know the cost differences of the two treatments to make good decisions.

:: 5 ::

AHRQ Community Forum

Part 3: Case Study: Heart Disease

Preventing Heart Attacks: Comparing a

preventive medicine and no medicine

In the last discussion, we talked about ways to treat heart disease. In this discussion, we will talk
about ways to prevent a heart attack.

What is the health problem?
As we discussed before, coronary heart disease occurs when the blood vessels in the heart become
clogged, and blood and oxygen have a hard time getting to the heart. Not getting blood and oxygen
to the heart can cause a heart attack.
A risk factor for a heart attack is something that increases the chance of someone having a heart
attack. Some risk factors for a heart attack are family history, high levels of LDL or “bad” cholesterol,
being overweight and inactive, signs of inflammation in the blood, uncontrolled high blood pressure,
and smoking.
People who have already had a heart attack or people with many risk factors (for example a
combination of high blood pressure, smoking, and lack of physical exercise) are considered to be at
high risk for a heart attack.
People who have only one risk factor such as high levels of LDL or “bad” cholesterol are considered to
be at low risk for a heart attack.

What are approaches to prevent heart attacks?
To prevent heart attacks, doctors and patients try to reduce the number of risk factors a patient
faces. Two ways to reduce risk factors are:

:: 6 ::

•

Making lifestyle changes such as
stopping smoking, following a diet low in
salt and saturated fat, and exercising
regularly.

•

Taking a statin. Statins are a type
of medicine that decreases LDL or
“bad” cholesterol and signs of
inflammation in the blood, two risk
factors for a heart attack. It is
estimated that up to 25% of all
American adults take statins.

AHRQ Community Forum

Part 3: Case Study: Heart Disease

What does the medical evidence show?
About lifestyle changes: Some risk factors can be reduced by lifestyle changes. But, research has
shown that diet alone is not very effective in lowering levels of LDL (“bad”) cholesterol, a risk factor
for a heart attack.
About taking a statin:
•

Overall. Statins work well to lower LDL or “bad” cholesterol in both high-risk and low-risk
people. Statins have some side effects, such as mild muscle pain, that affect 1-10% of people
taking statins. Serious side effects, such as liver and kidney problems, generally affect only
one in several hundred people. And, many of these serious side effects can be reversed if the
medicine is stopped.

•

For people at high risk, taking statins reduces the chance of a heart attack.
When people have already had a heart attack, taking a statin reduces the chances of another
heart attack by 20-60%. Statins are also work well to prevent heart attacks for people with
many risk factors, but who have not had a heart attack.

•

For people at low risk, the medical evidence for taking statins is less clear than the
medical evidence for people at high risk.
When people only have one risk factor, the benefits of taking statins are not as clear as the
benefits for high-risk people. For example, one study discovered that 240 low-risk people
would have to take statins to save one life. Another study showed even less benefit: 1,400
low-risk people have to take statins to save one life.

Should statins be prescribed to people at low risk?
Although statins seem to work well to prevent a heart attack for people at high risk, the benefit for
people at low risk is not as strong.
Yet, doctors are now prescribing statins more and more to low-risk patients. Doctors do this
believing that they will help their patients avoid heart attacks, even though very few people actually
benefit.

:: 7 ::

AHRQ Community Forum

Part 3: Case Study: Heart Disease

Preventing Heart Attacks: Comparing a

preventive medicine and no medicine

What do you think?
Based on this information, which of the following is closest to your view?
If there is any chance that statins can lower the likelihood of a first time heart attack then
they should be prescribed to patients who want them.
It sounds like statins may be useful, but not for everyone. Doctors should be more
selective on who they prescribe statins to.
If 25% of adults are getting statins, this sounds like a lot of people are getting more
treatment than they need.

:: 8 ::

AHRQ Community Forum

Part 4: Case Study: Heart Disease

Preventing Heart Attacks: Comparing a

preventive medicine and no medicine
What are the costs?

Every year, about 785,000 people have a heart attack. About 25% of heart attacks are
immediately fatal.
In 2010, heart disease was estimated to cost the United States $316.4 billion dollars altogether,
including the cost of medical services, medicines, and lost work productivity. Knowing this was the
total cost, researchers also studied the cost of using statins.
One study estimated that if everyone with high levels of LDL cholesterol or signs of inflammation
in the blood took statins, including those with no other risk factors for heart disease, 80% of all
older adults in this country could be taking the medicine. The cost of statins ranges between
$120-$2,000 per year per person depending on the dose and whether the statin is generic or brand
name.
Prescribing statins to 80% of older adults, as noted above, would add between
$21 and $360 billion dollars to the cost of prescription medications. In addition, there would be
other costs associated with extra doctor visits and lab tests to monitor patients for side effects.
Although there could be savings from heart attacks that are prevented, overall costs would likely
increase for taxpayers, employers, employees, and all others who help pay for health insurance.

:: 9 ::

AHRQ Community Forum

Part 4: Case Study: Heart Disease

Preventing Heart Attacks: Comparing a

preventive medicine and no medicine

What do you think?
Does this cost information affect your views in any way?
Which is closest to your view?
If a few lives are saved with statins, then it is worth it, regardless of the cost.
We have to draw a line somewhere in prescribing statins to prevent a first heart attack; this
is too much money to spend on a medicine that many people may not need.

:: 10 ::

AHRQ Community Forum