Research Activities, August 2011, No. 372
Anderson, W.G., Chase, R., Pantilat, S.Z., and others (2011, April). "Code status discussions between attending physicians and medical patients at hospital admission." (AHRQ grant HS10597). Journal of General Internal Medicine 26(4), pp. 359-366.
When interviewed by a hospitalist for hospital admission, few seriously ill patients are informed about their code status options (e.g., cardiopulmonary resuscitation [CPR] or not in certain circumstances), prognosis, and goals of care, despite years of recommendations by bioethicists and professional associations, found this study. Only 19 of the 80 patients had these discussions with the admitting hospitalist at two hospitals in the same system. Discussions were more frequent with older or seriously ill patients (terminal illness or likely to die or be admitted to an intensive care unit in the next year). Yet 66 percent of seriously ill patients had no discussion of code status, CPR, or prognosis. Also, existing conversations were brief. The researchers suggest that hospitalists discuss these issues with patients most likely to need CPR during their hospitalization or those likely to have a worse-than-average outcome.
Atkins, D., Chang, S., Gartlehner, G., and others (2011, April). "Assessing applicability when comparing medical interventions: Agency for Healthcare Research and Quality and the Effective Health Care Program." Journal of Clinical Epidemiology [Epub ahead of print]. Reprints (AHRQ Publication No.11-R052) are available from the AHRQ Publications Clearinghouse.
Existing guidance on conducting comparative effectiveness systematic reviews has focused insufficient attention to applicability, assert the authors of this study. They define applicability as the extent to which the effects observed in published studies are likely to reflect the expected results when a specific intervention is applied to the population of interest under "real-world" conditions. The authors outline specific steps to ensure that systematic reviews describe and characterize the evidence so that users of a review can apply it appropriately in their decisions. In identifying the characteristics of individual studies that may affect applicability, they develop The Patient, Intervention, Comparator, Outcome, Setting framework as a useful way of organizing the review.
Beukelman, T., Patkar, N.M., Saag, K.G., and others (2011, April). "2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: Initiation and safety monitoring of therapeutic agents for the treatment of arthritis and systemic features." (AHRQ grant HS16956). Arthritis Care & Research 63(4), pp. 465-482.
Juvenile idiopathic arthritis (JIA) is one of the more common chronic diseases of childhood, with a prevalence of approximately 1 per 1,000. In developing recommendations for the safest and most effective treatment of JIA on behalf of the American College of Rheumatology, the authors focused on the initiation and safety monitoring of various agents such as nonsteroidal antinflammatory drugs, intraarticular glucocorticoid injections, nonbiologic disease-modifying antirheumatic drugs (DMARDs), biologic DMARDs, and systemic glucocorticoids for the treatment of the systemic features of systemic arthritis. The evidence and consensus-based recommendations offered in this article are meant as a guide to health care providers caring for children with JIA and are not meant to take the place of individualized care or to serve as health care coverage guidelines.
Crandall, W., Kappelman, M.D., Colletti, R.B., and others (2011, January). "ImproveCareNow: The development of a pediatric inflammatory bowel disease improvement network." (AHRQ grant HS16957). Inflammatory Bowel Disease 17(1), pp. 450-457.
Inflammatory bowel disease (IBD) is estimated to account for more than 700,000 physician visits and 100,000 hospitalizations each year. Data from studies of pediatric IBD patients show significant variations in care, including variation in diagnostic interventions such as stool tests for pathogens and imaging of the small intestine. In addition, treatments were not started at the recommended doses and many underweight patients did not receive nutritional interventions. The authors report on the design and development of an approach to overcome these gaps. The ImproveCareNow Network model includes three components: (1) creating multicenter collaborative networks of pediatric subspecialists, (2) sharing of performance data collected in patient registries, and (3) training in quality improvement methods. As of 2010, patients are being enrolled at 24 sites. Results will be reported separately in future publications.
Davies, S., McDonald, K.M., Schmidt, E., and others (2011, April). "Expanding the uses of AHRQ's Prevention Quality Indicators. Validity from the clinician perspective." (AHRQ Contract No. 290-04-0020). Medical Care [Epub ahead of print].
The Agency for Healthcare Research and Quality's Patient Quality Indicators (PQIs) are measures of potentially preventable hospitalizations. The 12 indicators for adult patients span both chronic and acute conditions. Each indicator was evaluated for 3 potential uses based on 3 potential levels of analysis and reporting (residents of geographic areas, enrollees of health plans, and patients of large physician organizations). Sixty-four clinician panelists were split into Delphi and Nominal Groups. Panelists showed more support of the usefulness of the PQIs for internal quality improvement within large physician groups than for other applications. Three indicators (diabetes short-term complications, asthma, and congestive heart failure) earned "full support for use" from both groups. Panelists fully supported the usefulness of two indicators for comparative reporting (asthma, congestive heart failure) and no indicators for pay-for-performance applications.
Dougherty, D., and Clancy, C. (2011, May/June). Transforming children's health care quality and outcomes - A not-so-random non-linear walk across the translational continuum." Academic Pediatrics 11(3S), pp. S91-S93. Reprints (AHRQ Publication No.11 R047) are available from the AHRQ Publications Clearinghouse.
The authors discuss the contributions that the Children's Health Insurance Program Reauthorization Act (CHIPRA) makes to overcoming what they have characterized as the third translational block between sufficient knowledge of clinical effectiveness and reliable delivery of safe and effective services at every patient's bedside. They suggest that for substantial improvements to be made in children's health care and health, additional attention must be paid to all components of the translational continuum. The authors suggest that the quality portions of CHIPRA contribute greatly to overcoming the third translational block between clinical knowledge and improved care quality and outcomes. But that to make even more substantial improvements in children's health care and health, more attention to children's clinical research is needed.
Dougherty, D., Schiff, J., and Mangione-Smith, R. (2011, May/June). "The Children's Health Insurance Program Reauthorization Act Quality Measures Initiatives: Moving forward to improve measurement, care, and child and adolescent outcomes." Academic Pediatrics 11(3S), pp. S1-S10. Reprints (AHRQ Publication No.11-R045) are available from the AHRQ Publications Clearinghouse.
This article introduces a journal supplement on quality measures initiatives for the Children's Health Insurance Program Reauthorization Act. The supplement aims to make available useful information about issues surrounding the initial core set and key concepts for moving toward improvement of children's health care quality measures, children's health care quality, and children's health outcomes. Included in the set of articles is a detailed description of how the identification of a balanced, grounded, and parsimonious core set of children's health care quality measures was accomplished by an open, public process combined with an evidence-informed evaluation methodology. The introduction briefly summarizes the content of other articles in the supplement. Finally, it focuses on setting priorities for measurement in the areas of inpatient care, specialty care, health outcome measures, and inequities in health.
Finkelstein, J., Barr, M.S., Kothari, P.P., and others (2011). "Patient-centered medical home cyberinfrastructure. Current and future landscape." American Journal of Preventive Medicine 40(5S2), S225-S233. Reprints (AHRQ Publication No. 11-R055) are available from the AHRQ Publications Clearinghouse.
The efforts to promote patient-centered medical home (PCMH) principles are especially important in the light of recent health care reform initiatives that call for greater emphasis on health promotion and disease prevention. The major aspects of PCMH related to its information infrastructure were discussed at a panel organized by the Agency for Healthcare Research and Quality. The authors summarize the panel discussions along four major domains: (1) PCMH as the evolving model of health care delivery; (2) health information technology (IT) applications to support the PCMH; (3) Current health IT Landscape of PCMH; and (4) future health IT landscapes of PCMH: Federal initiatives on health informatics, legislation, and standardization. They conclude that health IT has enormous potential to improve primary care delivery, and will play a pivotal role in implementing the PCMH model.
Gerhard, T. (2011). "Clopidogrel and proton pump inhibitors: A clinically meaningful interaction?" (AHRQ grant HS16097). Pharmacoepidemiology and Drug Safety 20, pp. 214-218.
Dual antiplatelet therapy (DAT) with clopidogrel and aspirin has been shown effective and is widely used for patients with acute coronary syndrome or percutaneous coronary intervention. Because both drugs increase the risk of bleeding, current guidelines generally recommend proton pump inhibitors (PPIs) to manage the risk for serious gastrointestinal bleeding in patients treated with DAT. Some studies suggest that PPIs diminish the effectiveness of clopidogrel, but these and studies suggesting otherwise are the subject of controversy and debate. The author provides a brief overview of the evidence and takes an epidemiological perspective to discuss alternative potential causes for the conflicting findings reported in the literature. He concludes that the question whether the interaction between clopidogrel and PPIs is clinically meaningful is not yet conclusively answered.
Glance, L.G., and Dick, A.W. (2011). "In reply." (AHRQ grant HS16737). Anesthesiology 114, pp. 1243-1255.
The researchers reply to a letter raising a question about their earlier article on perioperative outcomes in patients with modified metabolic syndrome (mMetS) who undergo cardiac surgery. The author of the letter raises the issue about whether their study proves the increased risk of mMetS or simply proves "that the perioperative presence of two independent risk factors (and one protective factor) is more significant than having one protective factor." They respond that their analysis does not indicate whether the increased risk for cardiac, pulmonary, renal, and central nervous system complications associated with the mMetS is due simply to the additive effects of diabetes, hypertension, and obesity. Furthermore, they believe that whether their findings represent an additive effect or an interaction effect is less important than the simple recognition that mMetS is associated with a significantly higher risk of major postoperative complications.
Groeneveld, P.W., Polsky, D., Yang, F., and others (2011). "The impact of new cardiovascular device technology on health care costs." (AHRQ grant HS18403). Archives of Internal Medicine 114, pp. 1243-1255.
The researchers assessed the overall impact of drug-eluting coronary stents (DESs) on Medicare expenditures in a nationally representative cohort of 1,981,088 Medicare beneficiaries with coronary artery disease. In this group, 4.5 percent had a recent acute myocardial infarction (AMI or heart attack), 3.4 percent had a recent noninfarction acute coronary syndrome (ACS), and 92 percent had no recent ACS. The authors' estimates implied a DES-attributable increase in annual expenditures on patients with AMI of $657, on patients with noninfarct ACS of $999, and on patients without ACS of $146. This observational study could not establish whether the association between increased DES use and cost growth was causal. DESs added $1.57 billion in annual Medicare expenditures among beneficiaries aged 66 to 85 years.
Harrison, T.R., Morgan, S.E., King, A.J., and others (2011). "Promoting the Michigan Organ Donor Registry: Evaluating the impact of a multifaceted intervention utilizing media priming and communication design." (AHRQ grant HS08577). Health Communication 25, pp. 700-708.
Michigan has the fifth lowest rate of joining the organ donation registry, despite being the eighth most populous State in the country. In order to increase this rate, an intervention was focused on Secretary of State branch offices (the Department of Motor Vehicles equivalent in Michigan) in three Michigan counties in 2008. The campaign consisted of a mass media component (billboards and radio), point-of-decision materials, and an interpersonal component (volunteers staffing branch offices and interacting with customers). The successful campaign accounted for an increase of over 14,672 new registrants on the organ donor registry, compared with baseline data from the previous year. The rest of the State in the same time period experienced an increase of only 6,600 new registrants.
Holden, R.J. (2011). "Lean thinking in emergency departments: A critical review." (AHRQ grant T32 HS00083). Annals of Emergency Medicine 57, pp. 265-278.
The need for improvement in emergency departments (EDs) with respect to the cost of care, the speed of service, crowding, and patient safety is now widely accepted. Lean thinking is a bundle of concepts, methods, and tools derived from the Toyota Production System, the production philosophy of the Toyota Motor Corporation. Its success in manufacturing and in the British National Health Service and other health care systems has led to a strong push for introducing it to the ED. The author critically reviewed 18 articles describing the implementation of Lean in 15 EDs in the United States, Australia, and Canada. Patient care usually improved after implementation, with many EDs reporting decreases in length of stay, waiting times, and proportion of patients leaving the ED without being seen. Also, there were some indications of positive effects on employees and organizational culture.
Honore, P.A., Wright, D., Berwick, D.M., Clancy, C., and others (2011). "Creating a framework for getting quality into the public health system." Health Affairs 30(4), pp. 737-745. Reprints (AHRQ Publication No. 11-R053) are available from the AHRQ Publications Clearinghouse.
Efforts to define, measure, and uphold quality have shaped health care delivery for individuals for more than a decade. Yet similar improvements have not extended to the broader realm of public health. The authors discuss a recent report by the Department of Health and Human Services (HHS), Consensus Statement on Quality in the Public Health System, which defines for the first time, what is meant by public health quality and clarifies its associated aims. They also review priority areas in need of quality improvement as identified in another HHS report, Priority Areas for Improvement of Quality in Public Health. Finally, they provide illustrations of applications for these aims and priorities, particularly in the context of implementing the Affordable Care Act.
Kappelman, M.D., Crandall, W.V., Colletti, R.B., and others (2011, January). "Short pediatric Crohn's Disease Activity Index for quality improvement and observational research." (AHRQ grant HS16957). Inflammatory Bowel Disease 17(1), pp. 112-117.
Crohn's disease (CD) is a chronic, relapsing disorder of the gastrointestinal tract that affects nearly 50,000 children in the U.S. Disease activity indices, such as the Pediatric Crohn's Disease Activity Index (PCDAI) have been developed and validated, but because the PCDAI requires the determination of height velocity, analysis of laboratory tests, and components of the physical exam that are not always completed during patient encounters, the feasibility of this index in observational studies has been called into question. The aims of this study were: (1) to determine the feasibility of completing the PCDAI, an abbreviated PCDAI, and their individual components in the context of routine clinical care, and (2) to create a Short PCDAI by retaining and reweighting the most practical and informative components. The study found that in 66.5 percent of visits, the Short PCDAI was completed (compared with 16.7 percent for the PCDAI and 44.1 percent for the abbreviated PCDAI). They concluded that it was a practical and valid tool to measure pediatric CD activity.
Kendall, B.A., Varley, C.D., Choi, D., and others (2011, March). "Distinguishing tuberculosis from nontuberculosis mycobacteria lung disease, Oregon, USA." (AHRQ grant HS17552). Emerging Infectious Diseases 17(3), pp. 506-509.
To determine whether tuberculosis (TB) and nontuberculous mycobacteria (NTM) infection patients could be distinguished from one another with limited information, the researchers conducted a population-based study comparing the demographic and clinical features of TB and NTM patients in a region of low TB incidence. They found that birthplace outside the United States, age, and the presence of chronic obstructive pulmonary disease can accurately categorize 98 percent of patients in whom NTM disease is suspected. Because definitive identification of mycobacterial species can take several weeks, the ability to quickly distinguish NTM from TB on clinical grounds could help public health officials make decisions regarding contact investigations and isolation.
Landman, M.P., Shelton, J., Kauffman, R.M., and Dattilo, J.B. (2010, November/December). "Guidelines for maintaining a professional compass in the era of social networking." (AHRQ grant T32 HS13811). Journal of Surgical Education 67(6), pp. 381-386.
The researchers studied the use of social networking by all faculty in the Department of Surgical Sciences and all general surgery residents at Vanderbilt Medical Center in November 2009. They found that of the 88 residents and 127 faculty, 56 (64 percent) and 28 (22 percent), respectively, have pages on Facebook. Of these, 50 percent are publicly accessible. Thirty-one percent of the publicly accessible pages had work-related comments posted, and of these comments, 14 percent referenced specific patient situations or were related to patient care. The potential for misuse of these Web sites suggests the need for expanding professional guidelines to address this situation. The authors present a number of guidelines to preserve a balance of personal freedom and individuality with professional responsibility.
Mangione-Smith, R., Schiff, J., and Dougherty, D. (2011). "Identifying children's health care quality measures for Medicaid and CHIP: An evidence-informed, publicly transparent expert process." Academic Pediatrics 11(3S), pp. S11-S21. Reprints (AHRQ Publication No.11-R046) are available from the AHRQ Publications Clearinghouse.
The authors present a brief summary of the processes used to identify an initial recommended core set of children's health care quality measures and the key steps that will need to be taken to successfully implement them on a widespread scale. This process was mandated by the Children's Health Insurance Program Reauthorization Act. The authors also provide an overview of the measures selected. Seventy of the 119 nominated measures met criteria for validity, feasibility, and importance, according to Delphi scoring. After further prioritization, 25 measures were recommended for the initial core set. Twelve of the recommended measures focus on preventive care and health promotion, including prenatal/perinatal care, well-child care, immunizations, screening for developmental delays, obesity, sexually transmitted infections, and receipt of preventive dental services.
McCormack, L.A., Treiman, K., Rupert, D., and others (2011). "Measuring patient-centered communication in cancer care: A literature review and the development of a systematic approach." Social Science & Medicine 72, pp. 1085-1095. Reprints (AHRQ Publication No.11-R054) are available from the AHRQ Publications Clearinghouse.
One of the more problematic aspects of assessing patient-centeredness is the conceptualization and measurement of patient-centered communication (PCC), which is arguably a primary means through which patient-centered care is accomplished. The authors present a brief critique of current approaches for measuring PCC in patient-clinician interactions. They then propose a conceptual framework for assessing PCC. Their study, which included a literature review, interviews with cancer patients, and consultations with experts, identified key domains and subdomains of PCC that can serve as the foundation for future PCC measure development. These domains are organized under the six core functions specified in the PCC conceptual framework: exchanging information, fostering healing relationships, recognizing and responding to emotions, managing uncertainty, making decisions, and enabling patient self-management.
Meyers, D. (2011). "Using the evidence: PCMH and patient-centered outcomes research." Journal of the American Pharmacists Association 51(2), p. 155. Reprints (AHRQ Publication No.11-R056) are available from the AHRQ Publications Clearinghouse.
The patient-centered medical home (PCMH) has emerged as an attractive model of care that holds the potential to improve the quality, safety, and effectiveness of health care. Patient-centered outcomes research helps patients confront everyday decisions about care under real-world circumstances. The Agency for Healthcare Research and Quality (AHRQ) supports PCMH by advancing its evidence base and by convening and working with government and private stakeholders to ensure that the best ideas are shared broadly. AHRQ's role in patient-centered outcomes research is also well-established. AHRQ has conducted and supported this research since the creation of the Effective Health Care Program in 2005. The program already has produced much research that is of great interest to pharmacists, such as guides on medications to reduce the risk of developing primary breast cancers and on the use of insulin analogs.
Pronovost, P.J., Marsteller, J.A., and Goeschel, C.A. (2011). "Preventing bloodstream infections: A measurable national success story in quality improvement." (AHRQ grant HS14246). Health Affairs 30(4), pp. 628-634.
The number of patients in U.S. intensive care units suffering a central-line infection declined by 63 percent between 2001 and 2009. The authors present information about the combined public-private effort to reduce bloodstream infections in U.S. hospitals. The effort serves as a case example to describe how multiple forces can align to effectively disseminate successful quality improvement interventions. They describe the lever of managing change and the efforts to channel external pressures to create accountability, including social pressure from withholding payment when complications from bloodstream infections arise, and regulatory pressure. Although each of these pressures may have a relatively weak association with improved outcomes, they can have a bigger impact when combined.
Sharkey, S., Hudak, S., Horn, S.D., and Spector, W. (2011, April). "Leveraging certified nursing assistant documentation and knowledge to improve clinical decision making: The on-time quality improvement program to prevent pressure ulcers." (AHRQ Contract No. 290-05-0020). Advances in Skin & Wound Care 24(4), pp. 182-188.
The On-Time Quality Improvement for Long-term Care Program (On-Time) was developed to embed health information technology into quality improvement at the frontline of care and incorporate culture change, workflow redesign principles, and current best clinical practices to prevent pressure ulcers (PrUs) in long-term care facilities. This paper describes the three main components of On-Time: (1) leveraging documentation and knowledge of certified nursing assistant (CNA) staff, who serve as primary informants to licensed staff; (2) supporting collaborative clinical decisionmaking of a multidisciplinary team using clinical decision support tools that summarize information from weekly reports; and (3) establishing practices for proactive risk identification and early intervention to prevent PrUs as part of a frontline caregivers' daily work.
Siminoff, L.A., and Step, M.M. (2011). "A comprehensive observational coding scheme for analyzing instrumental, affective, and relational communication in health care contexts." (AHRQ grant HS13152). Journal of Health Communication 16, pp. 178-197.
This article describes a computerized program to facilitate the analysis of health care conversations, the Siminoff Communications Content and Affect Program (SCCAP). This new program is designed to be adaptable to the goals and patterns of diverse health care contexts. The SCCAP builds on other well-known observational systems, but emphasizes verbal and nonverbal communication behaviors drawn from the communications research literature. Specifically, the program captures the following: (a) task-driven information exchange among multiple interaction partners, (b) the affective and relational communication activities of all communicators, and (c) the social-influence tactics used in health care settings that contribute to decisionmaking.
Sturmer, T., Funk, M.J., Poole, C., and Brookhart, M.A. (2011). "Nonexperimental comparative effectiveness research using linked healthcare databases." (AHRQ grant HS17950). Epidemiology 22(3), pp. 298-301.
The authors discuss the advantages and possible disadvantages of using large linked health care databases in performing nonexperimental comparative effectiveness research in pharmacoepidemiology. These databases have unique advantages for epidemiologic research. Most are population-based and therefore are less prone to the healthy selection that is virtually unavoidable when recruiting participants for randomized trials or cohort studies. Linked health care databases include continuous service dates rather than interval assessments. Continuous assessment of exposure and outcomes allows researchers to be specific about timing. Such databases contain information about almost all drugs prescribed or dispensed in an outpatient setting. On the downside, they lack data on important confounders, on drugs administered during hospitalization or purchased over the counter, and on sensitivity and specificity of various algorithms to define outcomes.
Tipton, K., Launders, J.H., Inamdar, R., and others (2011, June). "Stereotactic body radiation therapy: Scope of the literature." (AHRQ Contract No. 290-02-0019). Annals of Internal Medicine 154(11), pp. 737-745.
Stereotactic body radiation therapy (SBRT) is derived from the techniques of stereotactic radiosurgery used to treat lesions in the brain and spine. SBRT delivers a high dose of radiation to an extracranial target in the body in a single dose or a few fractions and requires fewer treatment sessions. Thus, it is likely to be attractive to patients. The authors' review of the SBRT literature identified a total of 124 relevant studies. No published comparative studies addressed the relative effectiveness and safety of SBRT versus other forms of external-beam radiation therapy. The review identified 50 ongoing SBRT trials, including metastatic breast cancer, as well as primary cancer of the biliary tract, kidney, liver, lung (principally non-small cell lung cancer), pancreas, prostate, and unidentified sites. Only one trial involved a direct comparison of SBRT with a different form of radiation therapy.
Wittenberg, E. (2011). "The effect of time of onset on community preferences for health states: An exploratory study." (AHRQ grant HS14010). Health and Quality of Life Outcomes 9(6), pp. 1-8.
Health utilities are cardinal values that represent the strength of the individual's preferences for specific health-related outcomes. This paper addresses one specific aspect of utility elicitation—the time of onset of illness—and how its inclusion in health state descriptions developed specifically for the elicitation of community perspective preferences affects how patients verbalize those preferences. The researcher conducted a survey of community-perspective preferences for hypothetical health states among a convenience sample of healthy adults recruited from a hospital's research volunteer pool. She found that the standard gamble scores from 368 completed surveys were not significantly different across times of illness onset described in the health-state descriptions, regardless of health condition severity and controlling for respondent characteristics.