The vigorous intramural and extramural research program of the Agency for Healthcare Research and Quality (AHRQ) focuses principally on health care quality and the outcomes of health care services. Examples of AHRQ's current and completed research projects concerning conditions especially important to women are described below.
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Introduction
Cardiovascular Disease
Cancer Screening and Treatment
Hysterectomy and Alternative Treatments
Urinary Incontinence
Reproductive Health
Health Care Access and Quality
Medical Expenditure Panel Survey
Violence Against Women
HIV/AIDS
Clinical Preventive Services
Pregnancy, Birth Outcomes, and Family Planning
Hormone Replacement Therapy
Other Research
Complementary/Alternative Medicine
More Information
The life expectancy of U.S. women has nearly doubled in the past 100 years, from 48 in 1900 to nearly 80 in 2000, compared with a 2000 average of 74 for men. Although women have a longer life expectancy than men, they do not necessarily live those extra years in good physical and mental health. On average, women experience 3.1 years of disability at the end of life.
In 1900, the leading causes of mortality among U.S. women included infectious diseases and complications of pregnancy and childbirth. Today, the chronic conditions of heart disease, cancer, and stroke account for 63 percent of American women's deaths and are the leading causes of mortality for both women and men.
The Agency for Healthcare Research and Quality (AHRQ) supports research on all aspects of health care provided to women, including quality, access, cost, and outcomes. This summary presents highlights from a cross-section of AHRQ's current and recently completed research projects on women's health.
Select to access more detailed information on AHRQ's research programs, including grant announcements and application kits.
Heart disease is the number one killer of women in the United States. More than one-third of all deaths among U.S. women are due to heart disease, which usually occurs about 10 years later in life in women than in men. There are substantial differences in heart disease mortality between white and black women; the heart disease mortality rate is about two-thirds higher for black women than white women. However, heart disease mortality is lower among Hispanic, American Indian, and Asian/Pacific Islander women compared with white women.
In this 3-year project underway at Olmsted Medical Center in Rochester, MN, researchers are taking a "look-back" approach to compare the assessment and treatment of potentially modifiable risk factors for coronary disease in the 10 years prior to first heart attack. In addition, they are comparing the experiences of men and women in terms of the duration of diagnosed coronary disease prior to heart attack, the presence of specific signs and symptoms associated with coronary disease, the use of specific diagnostic evaluations and referrals, and the reporting of symptoms immediately prior to first heart attack. Barbara Yawn, Principal Investigator (AHRQ grant HS10239).
Although coronary heart disease (CHD) causes more than 250,000 deaths in women each year, much of the research in the last 20 years on CHD has either excluded women entirely or included only limited numbers of women. Two reviews conducted by AHRQ's Evidence-based Practice Center (EPC) at the University of California, San Francisco/Stanford examined the usefulness of beta-blockers, aspirin, and ACE inhibitors in reducing risk among women with known heart disease; the use of exercise EKG and exercise thallium testing for CHD in women; the efficacy of nitrates to reduce risk for CHD events in women with known heart disease; the role of high cholesterol, diabetes, and high homocystine levels as risk factors for CHD in women; and, the extent to which smoking cessation after heart attack, along with treatment of high blood pressure and high cholesterol, can lower risk for CHD events in women.
Copies of the two reports, Results of a Systematic Review of Research on Diagnosis and Treatment of Coronary Heart Disease in Women, Evidence Report/Technology Assessment No. 80 (AHRQ Publication No. 03-E035, full report; 03-E034, summary) and Diagnosis and Treatment of Coronary Heart Disease in Women: Systematic Reviews of Evidence on Selected Topics, Evidence Report/Technology Assessment No. 81 (AHRQ Publication No. 03-E037, full report; 03-E036, summary) are available from AHRQ (contract 290-97-0013).*
Researchers at AHRQ's Southern California EPC examined evidence on pharmacologic management of heart failure and found that treatment with ACE inhibitors was beneficial in women, but it did not reduce mortality in women with asymptomatic left ventricular systolic dysfunction. They also found that both women and men with symptomatic heart failure have reduced mortality when treated with beta-blockers.
Copies of Evidence Report/Technology Assessment No. 82, Pharmacologic Management of Heart Failure and Left Ventricular Systolic Dysfunction: Effect in Female, Black, and Diabetic Patients, and Cost-Effectiveness (AHRQ Publication No. 03-E044, summary; 03-E045, full report), are available from AHRQ (contract 290-97-0001).*
According to this study of more than 327,000 men and women who suffered heart attacks between 1994 and 1997, women clearly received fewer cardiac treatments and procedures and had worse outcomes than men, but insurance status did not appear to explain these disparities. Regardless of insurance status, women generally were less likely than men to receive aspirin, beta-blockers, intravenous heparin, or nitrate therapies within the first 24 hours of hospital admission. Also, women were much less likely than men to undergo coronary angiography, angioplasty, or coronary bypass surgery, and they were significantly more likely than men to die in the hospital.
Canto, Rogers, Chandra, et al., Arch Int Med 162:587-93, 2002 (AHRQ grant HS08843).
Researchers at the Johns Hopkins Evidence-based Practice Center examined the available evidence on the utility of blood pressure (BP) monitoring outside of the clinic setting. Although they found some support for the use of ambulatory BP monitoring, in general, the evidence was insufficient to compare clinic BP monitoring with BP monitoring elsewhere. Evidence on BP monitoring among population subgroups was rarely stratified by race or sex. The only notable subgroup finding was a higher prevalence of white-coat hypertension in women. However, the evidence was insufficient to determine whether the risks associated with white-coat hypertension are sufficiently low to consider withholding drug therapy in this large subgroup of hypertensive patients.
Copies of Evidence Report/Technology Assessment No. 63, Utility of Blood Pressure Monitoring Outside of the Clinic Setting (AHRQ Publication No. 03-E003, summary; 03-E004, full report), are available from AHRQ (contract 290-97-0006).*
In an editorial accompanying study findings on male and female mortality rates after heart attack, this researcher notes that the interaction of age and sex remains a significant predictor of heart attack-related death, even after adjustment for demographic factors, clinical characteristics, and cardiac treatment while hospitalized. The study reported an 11 percent, 2-year mortality rate for women before age 60 (vs. 7 percent for men) and a lower mortality rate for women after age 79 (46 vs. 51 percent for men).
Ayanian, Ann Intern Med 134(3):239-41, 2001 (AHRQ grant HS09718).
Emergency room (ER) doctors miss diagnosing about 2 percent of patients with heart attack or unstable angina because they do not have chest pain or other symptoms typical of cardiac emergency. When these patients are mistakenly sent home from the ER, they are twice as likely to die from their heart problems as similar patients who are admitted to the hospital. The patients in this study who were misdiagnosed tended to be women under the age of 55 or minorities, to report shortness of breath as their chief symptom—instead of chest pain—and/or to have apparently normal electrocardiograms. The study involved more than 10,500 patients seen in the ERs of 10 U.S. hospitals.
Pope, Aufderheide, Ruthazer, et al., New Engl J Med 342(16):1163-70, 2000 (AHRQ grant HS07360).
Most of the 1 million U.S. patients who suffer a heart attack each year are candidates for reperfusion therapy—either thrombolytic (clot-busting) drugs or primary angioplasty. In a study of nearly 27,000 Medicare beneficiaries who met the strict criteria for reperfusion therapy between February 1994 and July 1995, only 44 percent of eligible black women received the treatment, compared with 59 percent of white men, 50 percent of black men, and 56 percent of white women.
Canto, Allison, Kiefe, et al., New Engl J Med 342(15):1094-100, 2000 (AHRQ grants HS08843, HS09446).
Coronary artery disease risk is elevated in certain women with angina, particularly women who have a poor cardiovascular risk profile and symptoms such as shortness of breath. Researchers used the Rose Questionnaire to examine correlates of angina in men and women aged 35 to 55.
Nicholson, White, MacFarlane, et al., J Clin Epidemiol 52(4):337-46, 1999 (AHRQ grant HS06516).
In this study of 454 Rochester, MN, residents who had a first ischemic stroke between 1985 and 1989, the risk of stroke due to atherosclerosis with narrowing of the blood vessel was four times greater in men than in women (47 vs. 12 per 100,000 population). This could help to explain why U.S. rates of carotid endarterectomy (surgical opening of a blocked carotid artery) are 30 to 60 percent higher in men than in women.
Petty, Brown, Whisnant, et al., Stroke 30:2513-16, 1999 (Stroke Prevention PORT, contract 290-91-0028).
This study showed that blacks and women, particularly black women, have statistically significant lower odds of being referred for cardiac catheterization than whites and men. The study involved 720 primary care doctors and 8 patient actors (2 each black men, black women, white men, and white women) who used the same scripts to report the same symptoms, wore identical gowns, used similar hand gestures, and had the same insurance and professions.
Schulman, Berlin, Harless, et al., N Engl J Med 340:618-26, 1999 (AHRQ grant HS07315).
Breast cancer continues to be the most commonly diagnosed cancer among women in the United Sates. In 2002, an estimated 203,500 U.S. women were newly diagnosed with breast cancer, and nearly 39,000 women died from the disease.
The good news is that breast cancer deaths have declined recently among white women in this country; the bad news is that over the same period, survival has decreased among black women. Although between 12 and 29 percent more white women than black women are stricken with breast cancer, black women are 28 percent more likely than white women to die from the disease. The 5-year breast cancer survival rate is 69 percent for black women, compared with 85 percent for white women.
In 2002, there were an estimated 13,000 newly diangosed cases of invasive cervical cancer in U.S. women, and about 4,100 women died from the disease. Cervical cancer occurs most often among minority women, particularly Asian-American (Vietnamese and Korean), Alaska Native, and Hispanic women. Although deaths from cervical cancer have declined substantially over the past 30 years, the cervical cancer death rate for black women continues to be more than twice that of white women. The chance of dying of cervical cancer increases as women get older. Worldwide, cervical cancer is the second or third most common cancer among women, and in some developing countries, it is the most common cancer.
Women who have never had a Pap test or who have not had one for several years have a higher than average risk of developing cervical cancer. Many women still do not have regular Pap tests, particularly older women, uninsured women, minorities, poor women, and women living in rural areas. About half of the women with newly diagnosed invasive cervical cancer have not had a Pap test in the previous 5 years.
Strengthening preventive programs that promote women's health is critical. For example, early diagnosis and treatment through regular checkups, yearly mammograms for women over age 50, and Pap smears every 1 to 3 years for women over age 18 substantially increase the odds of surviving breast or cervical cancer.
Using the Medical Expenditure Panel Survey and Surveillance Epidemiology and End Results databases, researchers are conducting a three-step study to identify adverse effects of screening mammography. They will identify a population and categorize participants into false-positive or true-negative mammogram status; compare both groups, according to days off work, perceived health status, physician visits, and medical expenditures; and analyze outcomes and their associations with race, age, socioeconomic status, and comorbidity.
Geoffrey C. Lamb, Principal Investigator (AHRQ grant HS11755).
These Yale University researchers are studying psychosocial influences on regular use of screening mammography by women of different races.
Lisa Calvocoressi, Principal Investigator (AHRQ grant HS11603).
Two recent studies conducted by researchers at Georgetown University examined the cost-effectiveness of surgical treatments for early-stage breast cancer and patients' quality of life after surgery. In the first study, the researchers concluded that the current practice of giving older women with early stage breast cancer a choice of breast-conserving surgery (lumpectomy) followed by radiation treatment or mastectomy is cost effective. In the second study, they demonstrated that, with the exception of surgical removal of armpit lymph nodes to determine cancer spread, how older women are treated during their care, not the therapy itself, is the most important determinant of long-term quality of life.
Polsky, Mandelblatt, Weeks, et al., J Clin Oncol 21(5):1139-46, 2003; Mandelblatt, Edge, Meropol, et al., J Clin Oncol 21(5):855-63, 2003 (AHRQ grant HS08395).
Radiologists who examine more than 5,000 mammograms a year are more likely to accurately interpret them than radiologists who read a low volume of mammograms. Factors other than volume also influence radiologists' accuracy in mammogram interpretation, including fear of medical malpractice, differences in the women screened, having women return to the same facility year after year, and having prior films available for comparison.
Elmore, Miglioretti, and Carney, J Nat Cancer Inst 95(4):250-52, 2003 (AHRQ grant HS10591).
Researchers surveyed 683 older women with localized breast cancer at 5 months, 1 year, and 2 years following breast cancer surgery at 1 of 29 hospitals in Massachusetts, Texas, Washington, DC, and New York. The investigators found that women aged 67 and older who participate with their doctor in choosing which treatment they receive recover faster and have a more positive short-term outlook than women who are not given a choice.
Polsky, Keating, Weeks, et al., Med Care 40(11):1068-79, 2002 (AHRQ grant HS08395).
In this study, investigators examined results from 24 community radiologists' interpretations of 8,734 screening mammograms from 2,169 women over 8 years. They found wide variation in how frequently different radiologists noted masses, calcifications, and other suspicious lesions. The rate of false-positive readings ranged from 2.6 to 15.9 percent.
Elmore, Miglioretti, Reisch, et al., J Natl Cancer Inst 94(18):1373-80, 2002 (AHRQ grant HS10591).
Data from 984 black and 849 white Medicare-insured women aged 67 years or older who had local breast cancer were analyzed, and a subset of 732 surviving women were interviewed 3 to 4 years after treatment. Black women were 36 percent more likely than white women to receive mastectomy versus breast-conserving surgery and radiation, say researchers. Further, when black women received BCS, they were 48 percent more likely than white women to not have radiotherapy.
Mandelblatt, Kerner, Hadley, et al., Cancer 95:1401-14, 2002 (AHRQ grant HS08395).
Using medical records for 464 elderly women with stage 1-2 breast cancer who had breast-conserving surgery and 158 surgeon surveys, investigators examined patient, clinical, and surgeon characteristics associated with the non-use of axillary lymph node biopsy. Older age was strongly associated with decreasing odds of undergoing node biopsy. Women who were cared for by surgeons with training in surgical oncology were 60 percent less likely to undergo node dissection than women cared for by other surgeons.
Edge, Gold, Berg, et al., Cancer 94:2534-41, 2002 (AHRQ grant HS08395).
Researchers analyzed data from 613 surgeons and their patients who had been diagnosed with localized breast cancer. According to the study results, older women who are told about treatment options by their surgeons are more likely to receive breast-conserving surgery with radiation than other types of treatment. These women also are more likely to be satisfied with the care they receive.
Liang, Burnett, Rowland et al., J Clin Oncol 20(4):1008-16, 2002 (AHRQ grant HS08395).
This study examined mammography use among 2,059 HIV-positive and 569 HIV-negative socioeconomically disadvantaged women involved in the Women's Interagency HIV Study. Mammography use was also compared with U.S. women in the general population using data from the National Health Interview Survey. The HIV-positive women were 60 percent more likely than HIV-negative women to be screened for the first time while in the study. And, more HIV-positive than HIV-negative women reported having health insurance (82 vs. 59 percent); having a primary care provider (93 vs. 67 percent); and visiting a doctor in the past 2 months (84 vs. 54 percent).
Preston-Martin, Kirstein, Pogoda, et al., Prev Med 34:386-92, 2002 (sponsored by AHRQ, NIH, CDC).
Researchers examined the quality of life of 571 elderly women who were diagnosed with stage I or II breast cancer between 1995 and 1997 from 29 hospitals in five regions. They interviewed the women at 3 months, 12 months, and 24 months after surgery about problems with arm functioning, physical and mental functioning, overall impact of breast cancer on their lives, and worry about cancer recurrence. Sixty percent of the women reported arm problems at some time in the 2 years after surgery (83 percent had axillary lymph nodes removed and 17 percent did not). Women with arm problems used significantly more physical therapy services than other women, and arm problems were the primary determinant of reduced physical and mental functioning.
Mandelblatt, Edge, Meropol, et al., Cancer 95(12):2445-54, 2002 (AHRQ grant HS08395).
To determine the impact of mammography screening on elderly breast cancer patients, data were examined on 718 patients newly diagnosed with stage I and II disease at 29 hospitals. Researchers found that 96 percent of women with cancer diagnosed with a mammogram had stage I lesions compared with 81 percent of women diagnosed by other means.
Kerner, Mandelblatt, Silliman, et al., Breast Cancer Res Treat 69(1):81-91, 2001 (AHRQ grant HS08395).
Investigators assessed the correlations between five measures of illness burden, global health, and physical function and evaluated how each measure correlated with breast cancer treatment patterns in a group of 718 older women with early-stage breast cancer. All of the measures were significantly correlated with each other and with physical function and self-rated health.
Mandelblatt, Bierman, Gold, et al., Health Serv Res 36(6):1085-107, 2001 (AHRQ grant HS08395).
Researchers interviewed 67 physicians, nurses, and support staff practicing at 6 hospitals about hospital-and office-based approaches to coordinating care for breast cancer patients. At high-coordination hospitals, 88 percent of women with breast-conserving surgery received recommended radiotherapy, and 84 percent of those with tumors larger than 1 cm received recommended systemic chemotherapy compared with 76 and 73 percent of women, respectively, at low-coordination hospitals.
Bickell and Young, J Gen Intern Med 16:737-42, 2001 (AHRQ grant HS09844).
The U.S. Preventive Services Task Force updated its recommendation by calling for screening mammography, with or without clinical breast exam, every 1 to 2 years for women 40 and over. The recommendation acknowledges some risks associated with mammography, which will lessen as women age. The strongest evidence of benefit and reduced mortality from breast cancer is among women ages 50 to 69.
The recommendation and materials for clinicians and patients are available at www.ahrq.gov/clinic/uspstf/uspsbrca.htm.
These researchers reviewed hospital inpatient and outpatient discharge records for all women who were treated for cancer with a breast procedure (lumpectomy, partial mastectomy, or complete mastectomy) between 1990 and 1996 in Colorado, Maryland, New Jersey, and New York and between 1993 and 1996 in Connecticut. They found that two key factors influence whether a woman gets a complete mastectomy in the hospital or in an outpatient setting: the State where she lives and who is paying for it. For example, women in New York were more than twice as likely, and in Colorado nearly nine times as likely, as women in New Jersey to have an outpatient complete mastectomy. Nearly all Medicaid and Medicare enrollees were kept in the hospital after their surgery, as were 89 percent of women enrolled in HMOs.
Case, Johantgen, and Steiner, Health Serv Res 36(5):869-84, 2001 (AHRQ Publication No. 01-R008).* (Intramural.)
Surveyors at the Georgetown University School of Medicine queried a random sample of 1,000 surgeons. Respondents were given three scenarios of older women with localized breast cancer and asked whether they would use breast-conserving surgery (BCS) or mastectomy and whether they would use radiation therapy after BCS. Surgeons' preferences were significantly associated with self-reported practice and treatments, and explained some of the variations in breast cancer treatment patterns among older women.
Mandelblatt, Berg, Meropol, et al., Med Care 39(3):228-42, 2001 (AHRQ grant HS08395).
Researchers conducted an extensive literature review and reported findings such as the evidence for performing an excisional biopsy following a stereotactic core needle biopsy, use of tamoxifen therapy, and sentinel lymph node biopsy. They suggest future research should examine breast disease risk factors, breast symptoms, and how these relate to cancer diagnoses.
Copies of Evidence Report/Technology Assessment No. 33, Management of Specific Breast Abnormalities (AHRQ Publication No. 01-E046, summary; 01-E045, full report), are available free from AHRQ (contract 290-97-0016).*
Researchers who studied the Los Angeles Mammography Program (LAMP) found that community-based and other approaches outside of the traditional purview of medicine could be an effective way to deliver mammography information and services to poor and minority women who have limited access to this kind of care. LAMP involved two interventions in 45 churches and generated 3.24 additional screenings among 56 women.
Siegel and Clancy, Health Serv Res 35(5):905-9, 2000 (AHRQ Publication No. 01-R032).* (Intramural.)
Knowledge of screening recommendations and access to free mammograms were not enough to get some low-income black women to keep their mammography appointments. Most of the women who skipped their appointments said they were embarrassed or believed that a mammogram was unnecessary if they did not have symptoms.
Crump, Mayberry, Taylor, et al., J Nat Med Assoc 92:237-46, 2000 (AHRQ grant HS07400).
This study involved more than 700 women aged 67 and older who were diagnosed with localized breast cancer between 1995 and 1997 and treated at 29 hospitals across the country. Women aged 80 and older were less likely than younger women to be referred to a radiation oncologist or to receive radiation therapy after breast-conserving surgery, placing them at significantly increased risk for recurrence.
Mandelblatt, Hadley, Kerner, et al., Cancer 89:561-73, 2000 (AHRQ grant HS08395).
This study involved 24 women who had been diagnosed with breast cancer in the previous 2 years. Many of the women found that as they adjusted to the negative consequences of the disease, they also found positive effects, ranging from a reappraisal of life, increased self-knowledge and change, and reordering of priorities.
Taylor, Oncol Nurs Forum 27(5):781-88, 2000 (NRSA fellowship F32 HS00078).
Researchers recruited 123 healthy breast cancer survivors and 87 women who had not had cancer; they showed half of each group a standard videotape of two treatment options for metastatic cancer. The remaining women saw an "enhanced compassion" videotape in which the doctor was much more supportive. Anxiety scores were significantly lower for women in the enhanced compassion group.
Fogarty, Curbow, Wingard, et al., J Clin Oncol 17(1):371-79, 1999 (AHRQ grant HS08449).
Researchers examined the efficacy of telecolposcopy for women with abnormal Pap smears or other indications for colposcopy who were examined at rural clinics. Images of colposcopic examinations were transmitted to a tertiary care center for interpretation by an expert colposcopist, and another colposcopist (site expert) examined the same patients but did not share findings with the other colposcopists. Agreement ranged from 60, 56, and 53 percent for the local colposcopists, distant experts, and site experts, respectively.
Ferris, Macfee, Miller, et al., Obstet Gynecol 99(2):248-54, 2002 (AHRQ grant HS08814).
Researchers collected cervical smears during the Heart and Estrogen/Progestin Replacement Study of postmenopausal women who still had a uterus and were suffering from coronary artery disease. The researchers identified 2,561 women who had normal cervical smears at study entry and an abnormal smear at the first or second annual visit. Within 2 years of a normal smear, 110 women in the trial had a cytologic abnormality. Of these, all but one were false-positive.
Sawaya, Grady, Kerlikowski, et al., Ann Intern Med 133(12):942-50, 2000 (AHRQ grant HS07373).
A recent review of studies that compared conventional and newer Pap tests with a current reference standard found that conventional Pap tests were only moderately accurate and did not achieve concurrently high sensitivity and specificity. Nevertheless, the researchers maintain that serial Pap testing continues to be effective, and that a Pap test every 3 to 5 years will detect abnormalities missed in one screening because cervical cancer is usually a slow-growing disease, and many lesions regress spontaneously.
Nanda, McCrory, Myers, et al., Ann Int Med 132:810-19, 2000 (contract 290-97-0014).
Three new cervical cancer screening technologies may contribute to diagnostic accuracy in the detection of cervical cancer and reduce significantly the likelihood that premalignant and malignant cells will be misdiagnosed as normal. Duke University researchers examined the available scientific evidence on screening for cervical cancer and prepared an evidence report and summary on the topic.
Copies of Evidence Report/Technology Assessment Number 5, Evaluation of Cervical Cytology (AHRQ Publication No. 99-E009, summary; 99-E010, full report), are available free from AHRQ.*
These researchers analyzed responses to questionnaires completed by 11,435 women. Among women 18 to 75 years of age who had not had a hysterectomy, 78 percent of overweight and obese women compared with 84 percent of normal-weight women reported having a Pap smear in the previous 3 years. Likewise, fewer overweight and obese women than normal weight women had received a mammogram in the previous 2 years.
Wee, McCarthy, Davis, et al., Ann Int Med 132(9):697-704, 2000 (NRSA fellowship F32 HS00137).
A major reason women cite for not undergoing breast and cervical cancer screening is that their physicians never recommend it. Older women, in particular, are less likely to be screened. This may be due in part to conflicting professional recommendations for screening older women, the many competing causes of mortality as women age, and possible negative attitudes about screening held by doctors and their older female patients.
Mandelblatt and Yabroff, J Am Med Womens Assoc 55:210-15, 2000 (AHRQ grant HS08395).
The authors describe the development, use, and evaluation of a Web-based patient outreach program in a Seattle community screening facility. They conclude that customized Web-based programs can help public health programs with meager resources facilitate patient outreach.
Bush, Wooldridge, Foster, et al., Oncol Nurs Forum 26(5):857-65, 1999 (AHRQ grant HS09407).
This study found that elderly black and Hispanic women are screened less frequently for breast and cervical cancer than their younger counterparts. Women 65 years of age and older were 21 percent less likely than younger women to have ever had a Pap smear.
Mandelblatt, Gold, and O'Malley, Prev Med 28:418-29, 1999 (AHRQ grant HS08395).