Research Activities, April 2011, No. 368
Abdus, S. (2010). "A game-theoretical interpretation of guaranteed renewability in health insurance." Risk Management and Insurance Review 13(2), pp. 195-206. Reprints (AHRQ Publication No. 11-R024) are available from the AHRQ Publications Clearinghouse.
The author describes a game-theoretical model that explains why health insurance premiums do not vary that much over time, even when there is no legal restriction on premium prices. He next considers a finite period model and shows that no guaranteed renewal premium schedule can be supported as equilibrium in a finite period model. Finally, he considers an infinite period model and shows that some level premium schedules can be supported as equilibria. The threats of punishments in case of deviations force both the insurer and the individuals to stay on a constant premium path. This model does not presume the commitment of the insurer.
Castor, D., Pilowsky, D. J., Hadden, B., and others. (2010, January). "Sexual risk reduction among non-injection drug users: Report of a randomized controlled trial." (AHRQ grant HS16097). AIDS Care 22(1), pp. 62-70.
Non-injection drug users (NIDUs), those who use drugs such as crack cocaine, are likely to engage in high-risk sexual behaviors, particularly while under the influence. Recently, a study looked at how well a sexual risk-reduction intervention that promoted condom use worked in this population. The study included 264 NIDUs and 170 individuals identified by the users as their sexual partners or fellow users of drugs. Designed to promote condom use, the intervention consisted of four 1.5 hour sessions. While the intervention initially reduced high-risk sexual behaviors, there was an eventual return to the same level of risky behavior a year later. The researchers did not find any significant difference in high-risk sexual behaviors between the active intervention group and the control group. The findings show how difficult it is to reduce high-risk behaviors in these individuals. They also suggest that NIDUs may require more intensive sexual-risk reduction strategies.
Dimick, J. B., Staiger, D. O., and Birkmeyer, J. D. (2010, December). "Ranking hospitals on surgical mortality: The importance of reliability adjustment." (AHRQ grant HS17765). HSR: Health Services Research 45, 6(Part I), pp. 1614-1629.
Surgical mortality rates are widely used to measure hospital-level quality of care for high-risk surgery. Using hierarchical modeling, the researchers adjusted hospital mortality for reliability using empirical Bayes techniques. Three procedures (pancreatic resection, abdominal aortic aneurysm, and coronary artery bypass graft or CABG) were included in the study. The researchers found that reliability adjustments resulted in more stable estimates of mortality for the first two procedures by improving the ability to identify hospitals with lower future mortality. For CABG, the benefits were limited to the lowest volume hospitals.
Eden, K. B., McDonagh, M., Denman, M. A., and others. (2010, October). "New insights on vaginal birth after cesarean." (AHRQ Contract No. 290-07-1005). Obstetrics and Gynecology 116(4), pp. 967-981.
The authors sought to evaluate existing vaginal birth after cesarean (VBAC) screening tools and to identify additional factors that may predict VBAC or failed trial of labor. They conducted a systematic review of the literature and identified 16 articles on scored models and 28 on individual VBAC predictors that met the inclusion and quality standards. Accuracy remained high across all models for predicting VBAC, but accuracy for predicting failed trial of labor was low, ranging from 33 percent to 58 percent. None of the models provided consistent ability to identify women at risk for failed trial of labor. The authors concluded that a scoring model is needed that incorporates known antepartum factors and labor patterns to allow women and clinicians to better determine individuals most likely to require repeat cesarean delivery.
Fifield, J., McQuillan, J., Martin-Peele, M., and others. (2010). "Improving pediatric asthma control among minority children participating in Medicaid: Providing practice redesign support to deliver a chronic care model." (AHRQ grant HS11068). Journal of Asthma 47, pp. 718-727.
Asthma, a leading chronic disease of children, currently affects about 6.2 million children in the United States. Poor, minority children have worse asthma rates, severity, and outcomes. The researchers assessed the effectiveness of practice redesign and computerized provider feedback in improving provider adherence to professional guidelines and improving outcomes for 295 poor minority children in four federally qualified health centers. They found that providers at intervention sites were more than twice as likely on average to prescribe guideline-appropriate medications after exposure to the computerized feedback system during the first phase of enrollment. In the second phase, asthma control improved significantly on average during each of four quarterly asthma visits.
Galanter, W. L., Moja, J., and Lambert, B. L. (2010, November). "Using computerized provider order entry and clinical decision support to improve prescribing in patients with decreased GFR." (AHRQ grant HS16973). American Journal of Kidney Diseases 56(50), pp. 809-812.
A high rate of medication errors affect hospitalized patients with decreased glomerular filtration rate (GFR), an indication of kidney problems. The authors comment on a paper by McCoy, et al. in the same issue of the journal that found that computerized physician order entry (CPOE) interruptive alerts improve the rate of order modification of potentially kidney-toxic medications or medications cleared by the kidneys from 35 to 56 percent during the first 24 hours after the detection of acute kidney injury (AKI). The refinements studied by McCoy et al., namely, using both passive and interruptive alerts and allowing clinicians to stop alerts for patients receiving dialysis, should improve the ability to design clinical decision support that helps clinicians care for hospitalized patients with AKI.
Goeschel, C. A., Holzmueller, C. G., Berenholz, S. M., and others. (2010, November). "Executive/senior leader checklist to improve culture and reduce central line-associated bloodstream infections"; Goeschel, C. A., Holzmueller, C. G., and Pronovost, P. J., "Hospital board checklist to improve culture and reduce central line-associated bloodstream infections." (AHRQ Contract No. 290-06-0022). The Joint Commission Journal on Quality and Patient Safety 36(11), pp. 519-524, 525-528.
Two articles by the same group of authors focus on the use of checklists by senior hospital officers to improve culture and reduce central line-associated blood stream infections (CLABSIs). The first article focuses on the role of hospital executives and senior leaders and the second discusses the role of the chair of a hospital board of trustees in reducing CLABSIs. The first article assumes that the hospital has already worked on CLABSI reduction, but that the CLABSI rate could still be lower. To get CLABSI rates down and keep them there, the authors propose that executives and senior leaders use the Executive/Senior Leader Checklist. This checklist emerged from the authors' experiences in working with hundreds of hospitals and chief executives in Michigan and other States to improve patient safety. The checklist is a one-page list of tasks for the Comprehensive Unit-based Safety Program (CUSP) and CLABSI components of the Stop BSI national program. The checklist describes ways that hospital leaders can comply with the Leadership Standards established by the Joint Commission. The second article directed at the hospital board chairperson is structured much the same as the first. It discusses the checklist as a project support tool that the chair of the board of trustees can use to facilitate CEO efforts and coordinate CUSP/CLABSI efforts for the Stop BSI program.
Hickner, J., Zafar, A., Kuo, G. M., and others. (2010, November/December). "Field test results of a new ambulatory care medication error and adverse drug event reporting system—MEADERS." (AHRQ Contract No. 290-88-0008). Annals of Family Medicine 8(6), pp. 517-525.
To become an effective safety tool in office practice, event reporting systems must be tailored to meet the needs of busy primary care practices, note these authors. They developed and tested a Medication Error and Adverse Event Reporting System (MEADERS)—an easy to use, Web-based reporting system. During the 10-week field test, 220 physicians and staff from 24 urban, suburban, and rural primary care practices in 4 States were able to identify and report 507 medication events with little difficulty and minimal time demand. The most frequent contributors to the medication errors and adverse drug events were communication problems (41 percent) and knowledge deficits (22 percent).
Karsh, B-T., Weinger, M. B., Abbott, P. A., and Weaver, R. L. (2010). "Health information technology: Fallacies and sober realities." (AHRQ grants HS17899, HS16651). Journal of the American Medical Informatics Association 17, pp. 617-623.
Current research demonstrates that health information technology (IT) can improve patient safety and health care quality in certain circumstances. At the same time, other research shows that health IT adoption rates are low, and that health IT might not reliably improve care quality or reduce costs. The authors discuss 12 misguided beliefs about health IT and their implications for design and implementation. These include: the "HIT is not a device" fallacy, the "learned intermediary" fallacy, and the "use equals success" fallacy. They conclude by making a plea to accelerate and support the design and implementation of safer health IT.
Klabunde, C. N., Marcus, P. M., Silvestri, G.A., and others. (2010, November). "U.S. primary care physicians' lung cancer screening beliefs and recommendations." (Inter-agency agreement between AHRQ, National Cancer Institute, and The Centers for Disease Control and Prevention). American Journal of Preventive Medicine 39(5); pp. 411-420.
The lung cancer screening beliefs and recommendations of many primary care physicians (PCPs) are not consistent with current evidence and guidelines, according to a new study. The researchers surveyed a nationally representative sample of PCPs from September 2006 through May 2007. Overall, 25 percent of the respondents believed that at least one national expert group recommended lung cancer screening for patients without symptoms, although none of the groups cited in the survey currently does so. While only 17 percent of the PCPs would screen a healthy 50-year-old who never smoked for lung cancer, 67 percent would recommend screening for a healthy 50-year-old longtime (20 pack-years) smoker.
Kozower, B. D., Sheng, S., O'Brien, S. M., and others. (2010). "STS database risk models: Predictors of mortality and major morbidity for lung cancer resection." (AHRQ grant HS18049). Annals of Thoracic Surgery 90, pp. 875-883.
The objectives of this study were to create models for the perioperative risk of lung cancer resection using the Society for Thoracic Surgery's (STS) General Thoracic Surgery Database (GTSB). The study group consisted of 18,800 patients from 111 centers who had had surgery for lung cancer. Perioperative mortality occurred in 413 patients (2.2 percent). Major morbidity occurred in 1,491 patients (7.9 percent). Composite major morbidity or mortality occurred in 1,612 patients (8.6 percent). Predictors of mortality included pneumonectomy, American Society of Anesthesiology rating, Zubrod performance status, renal dysfunction, induction and chemoradiation therapy, among others. The models used will help surgeons and patients estimate perioperative risk and provide risk-adjusted outcomes for quality improvement.
Mardon, R. E., Khanna, K., Sorra, J., and others. (2010, December). "Exploring relationships between hospital patient safety culture and adverse events." (AHRQ Contract No. 233-02-0087). Journal of Patient Safety 6(4), pp. 226-232.
This study examined the relationship between 15 patient safety culture indicators and a composite measure of adverse clinical events based on 8 risk-adjusted Patient Safety Indicators (PSIs) from 179 hospitals. Higher patient safety scores were associated with fewer adverse events at the hospitals. Data sources were the Agency for Healthcare Research and Quality's (AHRQ's) 2007 Hospital Survey of Patient Safety Culture and AHRQ's Patient Safety Indicators, which measure rates of in-hospital complications and adverse events.
Meltzer, D. O., and Detsky, A. S. (2010, November). "The real meaning of rationing." (AHRQ grant HS16967). Journal of the American Medical Association 304(20), pp. 2292-2293.
To limit health care use, decisions have to be made about the circumstances under which insurance will cover certain types of health care. Coverage policies, therefore, are rationing from a practical perspective just as much as rationing systems that explicitly prevent consumers from acting on their preferences. The recent debate has centered around who should do the rationing: private enterprises or government officials. What is needed is intelligent discourse on what approaches to rationing work best and what values Americans most wish to express as a nation to address this problem. Acknowledging that the argument is not about whether rationing is required, but rather who should be trusted to ration care is a start, conclude the authors of this commentary.
Nakamura, M.N., McAdam, A. J., Sandora, T. J., and others. (2010, August). "Higher prevalence of pharyngeal than nasal Staphylococcus aureus carriage in pediatric intensive units." Journal of Clinical Microbiology 48(8), pp. 2947-2959.
Healthcare-associated Staphylococcus aureus infections increase morbidity, mortality, and hospital costs. Although the nostrils have been considered the primary site of S. aureus colonization, recent studies indicate that pharyngeal carriage may be equally or more common. The researchers sought to determine the prevalence of pharyngeal carriage for methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) and to compare the sensitivities of pharyngeal and nasal screening among children admitted to a hospital intensive care unit (ICU). There were 122 children who were carriers of MSSA and/or MRSA in the nostrils and/or pharynx. Of these, 113 were pharyngeal carriers and 45 were colonized in the pharynx alone. Using culture-based methods, the sensitivity of pharyngeal screening for MSSA and MRSA was found to be 92.6 percent, compared to 63.1 percent for nasal screening.
Porterfield, D. S., Hinnant, L., Stevens, D. M., and others. (2010). "Diabetes primary prevention initiative interventions focus area. A case study and recommendations." (AHRQ Contract No. 290-20-0600). American Journal of Preventive Medicine 39(3), pp. 235-242. Reprints (AHRQ Publication No. 11-R009) are available from the AHRQ Publications Clearinghouse.
The researchers examined how diabetes prevention research was being translated into practice by conducting a case study of five State Diabetes Prevention and Control Programs (DPCPs). To gather information for the case study, the researchers conducted site visits to the five programs and interviewed State staff and partners. The programs implemented activities in diabetes primary prevention and prediabetes awareness, screening activities and lifestyle interventions, and prediabetes-related health policy efforts. The researchers found out how important it was for the DPCPs to partner with other organizations to extend the cooperative work into diabetes prevention. The challenges included recruiting participants, establishing links with providers for diagnostic testing of people screened for prediabetes, and offering a lifestyle intervention.
Shaw, S. J. (2010). "The logic of identity and resemblance in culturally appropriate health care." (AHRQ grant HS14086). Health 14(5), pp. 523-544.
Culturally appropriate health care programs that include provider and patient ethnic similarity are emerging to mobilize demands for cultural authenticity and produce new forms of expertise. Claims for the efficacy of patient-provider similarity in addressing disparities in quality of care are proposed as a means to expand access to health care. Yet, these programs perpetuate segregation in health care by relying on minority health care providers to care for the minority poor, asserts the author. Both patients and providers interviewed by the author perceived benefits associated with ethnic resemblance. However, they were also critical of notions of identity that render ethnicity automatically efficacious. The author argues that this approach may help obscure the relations of power and inequality that produce the very health disparities it is meant to solve.
Slutsky, J. (2010, October). "Guiding comparative effectiveness research—A U.S. perspective." Pharmacoeconomics 28(10), pp. 839-842. Reprints (AHRQ Publication No. 11-R025) are available from the AHRQ Publications Clearinghouse.
In this article, the Director of the Center for Outcomes and Evidence at the Agency for Healthcare Research and Quality is interviewed by Howard Birnbaum of Analysis Group, Inc., and guest co-editor of this issue. Ms. Slutsky discusses the impetus given to comparative effectiveness research (CER) by the $1.1 billion investment made by the American Recovery and Reinvestment Act of 2009. She next reviews the challenges faced by physicians and how CER can help by filling gaps in evidence that physicians need. She points out that the new investment in CER presents an opportunity to re-evaluate how we approach patient-centered care. She calls for a framework that explicitly links policy interventions to the most important outcomes and raises several issues that this approach should include. Finally, she emphasizes that the true value of CER will be improvements in the quality of care and health outcomes.
Swan, B. A., Haas, S. A., and Chow, M. (2010, October). "Ambulatory care registered nurse performance measurement." (AHRQ grant HS18885). Nursing Economics 28(5), pp. 337-342.
In March 2010, a state-of-the-science invitational conference titled "Ambulatory Care Registered Nurse Performance Measurement" was held to focus on measuring quality of ambulatory care by registered nurses (RNs). The goal was to formulate a research agenda and develop a strategy to study the testable components of the RN role related to care coordination and care transitions, improving patient outcomes, decreasing health care costs, and promoting sustainable system change. Expert participants came from the fields of nursing, public health, managed care, research, practice, and policy. The speakers identified priority areas for a unified practice, policy, and research agenda. They focused on the issues and implications for nursing and interprofessional practice, quality, and pay-for-performance.
Vilhauer, R. P., McClintock, M. K., and Matthews, A. M. (2010). "Online support groups for women with metastatic breast cancer: A feasibility pilot study." (AHRQ grant HS10565). Journal of Psychosocial Oncology 28, pp. 560-586.
Women often experience significant psychosocial problems after being diagnosed with metastatic breast cancer (MBC). The researchers report on the development and implementation of pilot peer-to-peer online support groups for women with MBC. Thirty women with MBC were assigned to either an immediate online support group or a wait-listed control group. They were assessed monthly for a 6-month period. Intervention retention rates, assessment completion rates, and support group participation were high compared with other published studies on this population. Reported satisfaction was also high. However, small sample size and study design precluded definitive conclusions about the intervention's effectiveness.
Weinstein, J. R., and Anderson, S. (2010). "The aging kidney: Physiological changes." (AHRQ grant HS17582). Advances in Kidney Disease 17(4), pp. 302-307.
The authors review the characteristics of age-related changes in kidney function and structure, and how physiological and biochemical changes act to produce age-associated loss of kidney function that can lead to chronic kidney disease (CKD). The primary measure of loss of kidney function is the age-related decline per decade in glomerular filtration rate (GFR) from the adult maximum (140 mL/min/1.73 m ), which occurs around age 40. Renal blood flow also declines by 10 percent per decade (from about 600 mL/min) after this age. Diseases such as systemic hypertension and atherosclerosis are known to speed up the loss in renal function, the authors note. After pointing out some physical changes in kidney structure with age, the authors go on to discuss the possible role of several biochemical systems that affect the constriction and dilation of blood vessels in mediating the progression of CKD in the elderly.
Wen, K-Y., Gustafson, D. H., Hawkins, R. P., and others. (2010). "Developing and validating a model to predict the success of an IHCS implementation: The Readiness for Implementation Model." (AHRQ grant HS10246). Journal of the American Medical Informatics Association 17, pp. 707-713.
Interactive health communications systems (IHCS) are the operational software program or modules that interface with patients and their families. They include health information and support, Web sites, clinical decision-support, and risk-assessment software. More health care organizations are adopting IHCS, making it important to understand the factors that predict a successful implementation. The researchers describe two studies used to formulate and validate the Readiness for Implementation Model (RIM). The model consists of seven weighted factors. They measured the weights of the RIM with a sample of 410 experts. Two of the seven factors, "organizational motivation" and "meeting user needs," were found to be most important in predicting implementation readiness.
Zayas-Cab�n, T. and Dixon, B. E. (2010). "Considerations for the design of safe and effective consumer health IT applications in the home." (AHRQ Contract No. 290-04-0016). Quality and Safety in Health Care 19(Suppl. 3), pp. 233-271. Reprints (AHRQ Publication No. 11-R014) are available from the AHRQ Publications Clearinghouse.
Consumer health applications of information technology (IT) would benefit from the application of human factors and ergonomics methods in their design and evaluation, suggests this study. Because human factors and ergonomics allows the developers of IT projects to understand and improve the interaction between the users of an application and the application, the researchers analyzed how such issues were addressed during the development of five AHRQ-funded consumer health IT projects. Project proposals, progress reports, other documents, and discussions with the project teams were used to gather data. Key areas of focus in the analysis were design considerations; design approach, testing, and prototyping; implementation; training and support; use; provider interaction; and vendor support.