Research Activities, August 2010, No. 360
Al-Khatib, S.M., Calkins, H., Eloff, B.C., and others (2010, January). "Planning the Safety of Atrial Fibrillation Ablation Registry Initiative (SAFARI) as a collaborative pan-stakeholder critical path registry model: A cardiac safety research consortium "incubator" think tank." American Heart Journal 159, pp. 17-24el. Reprints (AHRQ Publication No. 10-R054) are available from the AHRQ Publications Clearinghouse.
Atrial fibrillation (AF) is the most common arrhythmia seen in clinical practice. The treatment of AF by percutaneous catheter ablation is expanding rapidly. However, randomized clinical trials can only partially determine the safety and durability of the effect of the procedure in routine clinical practice. There is a need to address the limitations of such studies and other key concerns regarding the safety of AF ablation with the help of a national registry. This is the intention of the Safety of Atrial Fibrillation Ablation Registry Initiative (SAFARI).To consider the development of SAFARI, a "think tank" meeting was convened by a number of public and private bodies, including the Cardiac Safety Research Consortium, the Duke Clinical Research Institute, and the U.S. Food and Drug Administration. This report summarizes the issues and directions discussed at the meeting.
Berdahl, T.A., and Torres Stone, R.A. (2009). "Examining Latino differences in mental health use: The roles of acculturation and attitudes towards healthcare." Community Mental Health Journal 45, pp. 393-403. Reprints (Publication No. 10-R006) are available from the AHRQ Publications Clearinghouse.
The authors of this study analyzed differing patterns of use for mental health services by the three largest Latino groups (Mexicans, Cubans, and Puerto Ricans) to determine the influence of medical self-reliance and acculturation on mental health care use. Mexicans (4.5 percent) and Cubans (5.7 percent) were less likely than whites (9.3 percent) to use any mental health service, but Puerto Ricans' use (8.3 percent) was not significantly different from that of whites. Self-reliance regarding health care was associated with lower use of mental health services among all groups, but this finding did not explain the various gaps identified for each ethnic group. The lowest mental health use by Mexicans was partly explained by less English language proficiency and less time spent in the United States. The findings were based on data on 30,234 individuals taken from the 2002-2003 Medical Expenditure Panel Survey.
Bozikis, M.R., Braun, B.I., and Kritchevsky, S.B. (2010, March). "How accurately are starting times documented in the medical record? Implications for surgical infection prevention performance measurement." (AHRQ grant HS11331). Infection Control and Hospital Epidemiology 31(3), pp. 307-309.
Public reporting of hospital-level performance measure rates is an effective national strategy for improving care. Yet little is known about the reliability and validity of most efforts at performance measure data collection. Since 2007, public reporting of a surgical-site infection prevention measure that assesses the time interval between administration of prophylactic antibiotics and surgical incision has been called for. The researchers undertook a prospective study to assess whether starting times of antimicrobial prophylaxis administration and surgical incision were being accurately documented in the medical record. Twenty-five hospitals participated in the study with at least two types of surgical procedures (cardiac procedure, hip or knee replacement, hysterectomy) being observed in each hospital. A total of 96 procedures were observed. Observer records were then compared with the patient record documented by operating suite personnel. Documented times exactly matched observed times in 50 cases. In only four cases were documented times different from observed times by 30 minutes or more.
Byrd, K.K., Holman, R.C., Bruce, M.G, and others (2009, October). "Methicillin-resistant Staphylococcus aureus-associated hospitalizations among the American Indian and Alaska native population," Clinical Infectious Diseases 49(7), pp. 1009-1015. Reprints (AHRQ Publication No. 10-R016) are available from the AHRQ Publications Clearinghouse.
Methicillin-resistant Staphylococcus aureus (MRSA) infections, which can be deadly, have become prevalent in recent years. This study used data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality to examine MRSA infection outbreaks among the American Indians and Alaskan Natives (AI/ANs). It found that nationwide hospitalization rates for MRSA swelled between 1996 and 2005 for AI/ANs. In fact, rates went from 4.6 to 51 hospitalizations per 100,000 AI/ANs from the 1996-1998 period to the 2003-2005 period. Hospitalization rates for MRSA were highest for young AI/AN children and nonelderly adults, and skin and soft tissue infections were the most commonly diagnosed. Indian Health Service regions with the highest prevalence of MRSA infections were Alaska and the Southwest.
Calonge, N., Green, N.S., Rinaldo, P., and others (2010, February). "Committee report: Method for evaluating conditions nominated for population-based screening of newborns and children." Genetics in Medicine [Epub ahead of print]. Reprints (AHRQ Publication No. 10-R055) are available from the AHRQ Publications Clearinghouse.
The Advisory Committee on Heritable Disorders in Newborns and Children is charged with evaluating conditions nominated for addition to the uniform newborn screening panel and making recommendations to the Secretary of the U.S. Department of Health and Human Services. This report describes the framework the committee uses to approach its task. Initially, a condition is nominated for consideration via a structured nomination process. Once complete, the nomination package is assessed by a committee workgroup for the likelihood of sufficient information to conduct a systematic evidence review (SER). If the advisory committee agrees to move the nomination forward, the nomination package is assigned to an external review workgroup. Once the SER is completed, the workgroup's draft report is submitted to the decision process workgroup and the full committee. After full discussion, including consideration of six key questions outlined in this report, the committee makes its recommendations to the Secretary.
Cannon, E.A., Bonomi, A.E., Anderson, M.L., and Rivara, F. P. (2009). "The intergenerational transmission of witnessing intimate partner violence." (HS10909). Archives of Pediatric and Adolescent Medicine 163(8), pp. 706-708.
Children whose mothers saw domestic violence during their childhoods may also be at risk for witnessing abuse. After conducting 1,288 telephone surveys in Seattle, researchers found that children of mothers who saw abuse up close had 1.29 higher odds of also viewing abuse than children whose mothers never witnessed abuse. They suggest that mothers who witnessed abuse may view violence as normal and may not shield their children from it. Just over 56 percent of the abused women reported that their children had never seen domestic violence firsthand. However, because mothers were answering questions on their children's behalf, they could have been mistaken about what their child had or had not seen. The researchers state that their findings support the need for domestic violence prevention strategies.
Christensen, K.L.Y., Holman, R.C., Steiner, C., and others (2009). "Infectious disease hospitalizations in the United States." Clinical Infectious Diseases 49(7), pp. 1025-1035. Reprints (AHRQ Publication No. 10-R010) are available from the AHRQ Publications Clearinghouse.
Hospitalizations for infectious diseases rose slightly over a 9-year period, particularly for patients aged 40 to 59, a new study finds. In fact, infectious diseases led to about 4.5 million days of hospitalizations at a cost of $865 billion from 1998 to 2006. The most common infectious diseases were lower respiratory tract infections (34 percent), which often struck young children and older adults. Kidney, urinary tract, and bladder infections took second place (10 percent) and most often affected women. Men were hospitalized more frequently with bone, abdominal, and rectal infections; HIV/AIDS; and tuberculosis. Black patients had the highest hospitalization rates for infectious diseases. The authors suggest that socioeconomic factors and risk factors, such as smoking, may explain this disparity. The researchers used inpatient data from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality.
Conway, P.H., and Clancy, C. (2010). "Charting a path from comparative effectiveness funding to improved patient-centered health care." Journal of the American Medical Association 303(10), pp. 985-986. Reprints (AHRQ Publication No. 10-R048) are available from the AHRQ Publications Clearinghouse.
The scientific basis of comparative effectiveness (CE) research has not been clearly defined. In this editorial, the authors argue that an article in the same issue represents an important step in articulating criteria for published studies that assess the CE of medications. That article analyzed CE research studies from six general and internal medicine journals. Only 32 percent of the 104 medication studies met their criteria for CE research. There are several next steps to disseminate and translate CE research into practice, suggest the authors. One is the construction of an inventory of CE research to be undertaken by the U.S. Department of Health and Human Services. Another is the dissemination of CE research to clinicians, patients, and others in a way that informs decisions, improves health, and enhances the performance of the health care system. Under the American Recovery and Reinvestment Act, CE research is included in the segment of the strategic framework entitled "Dissemination, Translation, and Adoption."
Hasan, O., Meltzer, D.O., Shaykevich, S.A. "Hospital readmission in general medicine patients: A prediction model." (HS10597). Journal of General Internal Medicine 25(3), pp. 211-219.
The researchers sought to identify predictors of early hospital readmission in a diverse patient population and derive and validate a simple model for identifying patients at high readmission risk. Using data gathered for the Multicenter Hospitalist Study, a prospective multi-center trial that assessed the impact of hospitalist care on patients admitted to the general medical services of six academic medical centers, they were able to identify seven easily available patient-level predictors of early readmission. Next, they derived and internally validated an easy-to-use model for assessing readmission risks in patients hospitalized for a variety of medical conditions. Using the predictors, the model was able to identify 5 percent of patients with an approximately 30 percent risk of readmission within 30 days of discharge. Among the predictors were the number of hospital admissions in the previous year, the Charlson comorbidity index, marital status, having a regular physician, and having Medicare as primary insurance.
Ho, K., Moy, E., and Clancy, C. (2010, February). "Can incentives to improve quality reduce disparities?" HSR: Health Services Research 45(1), pp. 1-5.
Disparities associated with individual race, ethnicity, socioeconomic position, and other factors remain pervasive despite a continuing improvement in quality of care. Some quality improvement in preventive care, chronic care, and access to care significantly reduced disparities in mammography and counseling for smoking cessation. Yet much quality improvement tracked in the Agency for Healthcare Research and Quality's National Healthcare Quality Report and National Healthcare Disparity Report is not associated with significant decreases in care disparities across populations. The authors of this editorial also discuss a paper in the same issue of this journal on the impact on disparities of a hospital-based pay-for-performance demonstration. This program had only a minimal impact on access to care for racial and ethnic minority Medicare beneficiaries. The authors conclude that explicitly recognizing disparities reduction as a quality metric under pay for performance and financially rewarding providers that achieve equity in health care may be the most direct path to ensuring high-quality health care for all Americans.
Ip, S., Chung, J., Raman, G., and others (2009, October). "A summary of the Agency for Healthcare Research and Quality's evidence report on breastfeeding in developed countries." (Contract No. 290-02-0022). Breastfeeding Medicine 4 (Suppl.1), pp. S17-S30, 2009.
A recent evidence report from the Agency for Healthcare Research and Quality finds that breastfeeding offers health benefits for both infants and mothers. Babies who are breastfed have lowered risks for ear infections; stomach problems; lower respiratory tract infections, such as pneumonia, croup, and bronchiolitis; asthma; dermatitis; obesity; diabetes; leukemia; and sudden infant death syndrome. However, the evidence did not support claims that breastfed babies have superior cognitive performance than formula-fed infants, nor did breast milk affect the rates of cardiovascular disease or infant mortality. Mothers who nurse their infants have a lowered risk of type 2 diabetes as well as breast and ovarian cancer. Further, women who did not breastfeed their babies or who breastfed for a short time had higher risks of postpartum depression. Researchers from the Tufts Medical Center Evidence-Based Practice Center reviewed more than 9,000 abstracts for the evidence report.
Landon, B.E., O'Malley, A.J., and Keegan, T. (2010). "Can choice of the sample population affect perceived performance: Implications for performance assessment." (AHRQ grant HS13653). Journal of General Internal Medicine 25(2), pp. 104-109.
Identifying the appropriate patient population for performance assessment is crucial to the design and implementation of pay-for-performance systems, because using various methods of identifying patient populations might lead to large differences in observed performance that are, in fact, spurious, suggest these authors. They examined the potential impact of using three alternative algorithms to define accountable patient populations for performance assessment of cancer screening rates. Regardless of sample design, there were large numbers of individuals eligible for each of the screening tests (breast, cervical and colorectal cancer) at each of the nine community health centers (CHCs) included in the study. However, there was a wide variation in the proportion of health center patients that would be included in the denominator (from 18 to 62 percent). Also, simulated performance data demonstrated that variations in eligible patient populations could lead to the appearance of large differences in expected rankings of CHCs when no such differences exist.
Martinez, E.A., Marsteller, J.A., Thompson, D.A., and others (2010, February). "The Society of Cardiovascular Anesthesiologists' FOCUS Initiative: Locating errors through networked surveillance (LENS) project vision." (AHRQ grant HS13904). Anesthesia and Analgesia 110(2), pp. 307-311.
The field of anesthesiology, although recognized for efforts to improve patient safety, has much work to do to reduce harm to patients having cardiac surgery. The Society of Cardiovascular Anesthesiologists (SCA) Foundation set the goal of attaining harm-free cardiac surgery through an initiative called Flawless Operative Cardiovascular Unified Systems (FOCUS). The authors describe a continuing collaboration between the Foundation and a research team at Johns Hopkins University. The approach of this project was to integrate the wisdom of diverse disciplines, including organizational sociology, human factors engineering, industrial psychology, and clinical medicine. The prospective identification of hazards through direct observation was the richest and most labor-intensive part of the program. The project also prioritizes hazards and seeks to develop risk-reduction interventions along the lines of eliminating or preventing mistakes, making mistakes visible, mitigating harm should it occur, educating clinicians, and creating policies.
Pittas, A.G., Chung, M., Trikalinos, T., and others (2010, March). "Systematic review: Vitamin D and cardiometabolic outcomes." (AHRQ Contract No. 290-07-1005). Annals of Internal Medicine 152(5), pp. 307-314.
The authors conducted a systematic review to determine if Vitamin D intake affected cardiometabolic outcomes (type 2 diabetes, hypertension, cardiovascular disease) in generally healthy adults. A total of 13 observational studies and 18 trials were eligible for the review. Some of the cohort studies reported that lower vitamin D status was associated with increased risk for hypertension and possibly cardiovascular disease. Data on associations with diabetes were unclear. Trials showed no consistent, statistically significant effect of vitamin D supplementation on blood pressure or glycemic or cardiovascular outcomes. Although lower vitamin D status seems to be associated with increased risk for hypertension and cardiovascular disease, it is not yet known whether vitamin D supplementation will affect clinical outcomes.
Rhee, M.K., Herrick, K., Ziemer, D.C., and others (2010, January). "Many Americans have pre-diabetes and should be considered for metformin therapy." (AHRQ grant HS07922). Diabetes Care 33(10), pp. 49-54.
The researchers sought to estimate the likelihood that Americans with previously unrecognized pre-diabetes would meet American Diabetes Association (ADA) consensus panel recommendations for the drug metformin in addition to change in lifestyle. They evaluated known risk factors for diabetes in a population of 1,581 relatively healthy patients who were recruited and screened for impaired glucose tolerance. Two additional groups of 2,014 and 1,111 respondents to the National Health and Nutrition Surveys (NHANES III and NHANES 2005-2006) were also evaluated. From one-quarter to one-third of the patients had pre-diabetes. Among those with impaired fasting glucose, nearly one-third met the criteria for consideration of metformin treatment to prevent diabetes in accordance with the recent ADA consensus statement. If these findings are representative of the U.S. population, close to 1 in 12 American adults may meet the recommended guidelines for consideration of metformin treatment for diabetes prevention or delay.
Weinger, M.B. (2010, February). "The pharmacology of simulation: A conceptual framework to inform progress in simulation research." (AHRQ grant HS16651). Simulation in Healthcare 5(1), pp. 8-15.
The author presents a framework for the design and evaluation of simulation research to assist pharmacologists in creating the empirical evidence on which to base decisions about curriculum design and implementation. Its purpose is to provide readers unfamiliar with pharmacology with the foundational knowledge of and an appreciation of the potential value of such an approach. Drawing on basic concepts in pharmacology, the author describes simulation learning experiences as analogous to a drug treatment. From this, he proceeds to a consideration of simulation pharmacokinetics (PK) and pharmacodynamics (PD), dose-time curves, dose-effect relationships, and drug-drug interactions. He concludes that the notions of simulation PK (the effects of an intervention on the knowledge, skills, abilities, and behaviors of trainees in the simulated environment) and simulation PD (effects on subsequent behavior during actual patient care) can help to guide the design simulation research.
Westrick S.C., and Mount, J.K. (2009). "Impact of perceived innovation characteristics on adoption of pharmacy-based in-house immunization services." (AHRQ grant HS14512). International Journal of Pharmacy Practice 17, pp. 39-46.
U.S. pharmacists and pharmacies have ample opportunities to expand traditional pharmacist responsibilities of dispensing pharmaceuticals to engage in preventing diseases. Immunization services are one example of such an opportunity. The researchers examined the impact of three specific characteristics (perceived benefit, perceived compatibility, and perceived complexity) of in�house immunization services on community pharmacies' adoption decisions. The study found that perceived benefit, perceived compatibility, and perceived complexity each predicted adoptions of in-house immunization services individually. However, when all three characteristics were included in logistic regression analysis, perceived benefit was the only significant predictor of in-house immunization service adoption. Pharmacies in Washington State were included in the survey with between 204 and 506 of the 1,143 pharmacies completing survey forms during the study's three stages.
Wu, A.W., Huang, I.-C., Stokes, S., and Pronovost, P. J. (2009). "Disclosing medical errors to patients: It's not what you say, it's what they hear." (AHRQ grant HS11902). Journal of General Internal Medicine 24(9), pp. 1012-1017.
Physicians agree that disclosing errors to patients is the right thing to do, but they often shy away from doing so for fear of being sued. Sincerely apologizing to a patient after an error occurs does not reduce the likelihood of being sued, a new study finds. Researchers surveyed 200 volunteers who watched three videotaped scenarios during which physicians told patients about mistakes they made with their care. Volunteers indicated having more trust and a willingness to have as their own doctor those physicians who offered apologies and accepted responsibility for their mistakes. When doctors were vague in taking responsibility or issuing apologies or when they offered neither apology nor acceptance of responsibility, patients' and family members' regard for the physician fell. Further, how volunteers perceived the physician turned out to be more important than what the doctor actually said.
Yan, M., Alejandro, G.D.V., Hui, W., and Tu, X.M. (2010). "A U-statistics-based approach for modeling Cronbach coefficient alpha within a longitudinal data setting." (AHRQ grant HS16075). Statistics in Medicine 29, pp. 659-670.
Cronbach coefficient alpha (CCA) is a classic measure of item internal consistency of an instrument and is used in a wide range of behavioral, biomedical, psychosocial, and health-care-related research. Methods are available for making inference about one CCA or multiple CCAs from correlated outcomes. However, none of the existing approaches effectively address missing data. As longitudinal study designs become increasingly popular and complex in modern-day clinical studies, missing data have become a serious issue, and the lack of methods to systematically address this problem has hampered the progress of research in the aforementioned fields. The authors develop a novel approach to tackle the complexities involved in addressing missing data (at the instrument level due to subject dropout) within a longitudinal data setting. Their approach is illustrated with both clinical and simulated data.