Research Activities, December 2010, No. 364
Acri, T.L., Grossberg, R.M., and Gross, R. (2010). "How long is the right interval for assessing antiretroviral pharmacy refill adherence?" (AHRQ grant HS16946). Journal of Acquired Immune Deficiency Syndrome 54(5), pp. e16-e18.
Near-perfect adherence to highly active antiretroviral therapy (HAART) results in the highest likelihood of successful HIV outcomes. The pharmacy refill measure of adherence has been validated against change in viral load over the time interval in which individuals have a 90-day supply of HAART. The researchers aimed to determine if short (i.e., 30-day and 60-day supply) intervals of medication adherence measured by refills were as well correlated with virologic response as the previously validated 90-day measure. The test subjects were 110 patients on a stable HAART regimen for at least 3 months prior to the study. The study found that the three 30-day estimates were equally likely to correlate with adherence over the 90-day interval, but differed in their ability to predict change in viral load. The same was true for the two 60-day estimates. One drawback to this approach is that clinicians might detect nonadherence that would never lead to significant virologic failure and thus might intervene unnecessarily.
Bardach, N.S., Chien, A.T., and Dudley, A. (2010, July/August). "Small numbers limit the use of the inpatient pediatric quality indicators for hospital comparison." (AHRQ grant HS17146). Academic Pediatrics 10(4), pp. 266-273.
Low event rates and inadequate numbers of relevant pediatric inpatients at many hospitals limit the usefulness of AHRQ's inpatient pediatric quality indicators (PDIs), according to a new study. The researchers used 2005-2007 data on California hospital discharges for pediatric patients. They calculated statewide rates for nine hospital-level PDIs, excluding events present on admission. Event rates varied greatly among the PDIs, the researchers report. They calculated that none of 401 hospitals had sufficient patient volume to detect a doubling of the statewide average event rate (0.2 per 1,000 discharges) for iatrogenic pneumothorax in nonnewborns, while only 11 of 44 hospitals (25 percent) doing pediatric heart surgery had sufficient patient volume to detect doubling of the statewide average (38 per 1,000 discharges) for heart surgery-related mortality.
Berdahl, T., Owens, P.L., Dougherty, D., and others (2010, March/April). "Annual report on health care for children and youth in the United States: Racial/ethnic and socioeconomic disparities in children's health care quality." Academic Pediatrics 10(2), pp. 95-118. Reprints (AHRQ Publication No. 10-R057) are available from the AHRQ Publications Clearinghouse.
This report explores the joint effect of race/ethnicity and insurance status/expected payer or income on children's health care quality. Across a set of 23 quality indicators, chosen broadly, the researchers found that racial and ethnic disparities varied by income levels and type of insurance. A key finding is that for the same income level or type of insurance/payer, some racial/ethnic groups had more pronounced differences in quality of care than others. The report uses data from both the Medical Expenditure Panel Survey (MEPS) covering 2004 and 2005, and from the State Inpatient Databases of the Healthcare Cost and Utilization Project (HCUP).
Brookhart, M.A., Rassen, J.A., and Schneeweiss, S. (2010, June). "Instrumental variable methods in comparative safety and effectiveness research." (AHRQ Contract No. 290-2005-0016). Pharmacoepidemiology and Drug Safety 19(6), pp. 537-554.
This paper discusses the use of instrumental variable (IV) methods in studies that compare the safety or effectiveness of medical interventions, to avoid the problem of systematic differences between a group of patients exposed to the intervention and the group chosen for comparison (uncontrolled confounding). Because data on the confounding factors (such as clinical indications and prognostic variables that can guide treatment choice) is often missing or unavailable, researchers cannot use statistical modeling to equalize the two groups. Use of an IV factor that is related to the treatment, but not to the outcome, allows analysis of a study's findings without confounding. For example, assignment to the treatment or placebo arm of a randomized, controlled trial can serve as an IV. Because such assignment is random, it will be unrelated to patient characteristics. The authors discuss other IV examples, how to report analyses that use IVs, and work through some numeric examples in an online appendix.
Carr, B.G., Conway, P.H., Meisel, Z.F., and others (2010, July). "Defining the emergency care sensitive condition: A health policy research agenda in emergency medicine." (AHRQ grant HS17960). Annals of Emergency Medicine 56(10), pp. 49-51.
Using a conceptual model derived from the development and widespread use of ambulatory care-sensitive conditions, the authors present a new concept, the emergency care-sensitive condition, as a framework on which to build emergency quality measures and through which to improve evolving emergency care delivery systems. Emergency care-sensitive conditions are those conditions for which rapid diagnosis and early intervention in acute illness or acutely decompensated chronic illness improve patient outcomes. An incomplete list of such conditions might include major trauma, ST-elevation myocardial infarction, acute ischemic stroke, sepsis, cardiac arrest, and congestive heart failure. These emergency care-sensitive conditions require a care delivery system to respond in a timely and appropriate manner.
Castle, N.G., and Ferguson, J.C. (2010). "What is nursing home quality and how is it measured?" (AHRQ grant HS16808). The Gerontologist 50(4), pp. 426-442.
The purpose of this commentary is to examine nursing home quality and indicators that have been used to measure nursing home quality. The authors first provide a brief review of the history of nursing home quality. Donabedian's structure, process, and outcome model is used to frame the discussion. The advantages and disadvantages of current quality indicators are noted. Although improvements in nursing home quality have likely occurred, empirical research studies still identify poor quality and government reports continue to find fault with care in nursing homes. The authors speculate on steps that need to be taken to address and potentially improve the quality of care provided by nursing homes, including report cards, pay for performance, market-based incentives, and policy developments in the certification process.
Cherepanov, D., Palta, M., and Fryback, D.G. (2010, August). "Underlying dimensions of the five health-related quality-of-life measures used in utility assessment." (AHRQ grant T32 HS00046). Medical Care 48(8), pp. 718-725).
Health-related quality-of-life (HRQoL), a broad and multi-dimensional construct, is measured as a single score by several generic indexes constructed to reflect community preferences for the health state reported by a person. The National Health Measurement study is unique in having simultaneously administered five HRQoL indexes commonly used in the U.S. to a population-based sample. The purpose of this study was to examine the latent health dimensions reflected in the HRQoL attribute scores of the five indexes. Three related underlying dimensions of HRQoL emerged - physical, psychosocial, and pain. The results were based on a U.S. nationally representative sample of adults aged 35 years and older.
Coeytaux, R.R., Williams, J.W., Gray, R.N., and Wang, A. (2010). "Percutaneous heart valve replacement for aortic stenosis: State of the evidence." (AHRQ Contract No. 290-02-0025). Annals of Internal Medicine 153, pp. 314-324.
Surgical aortic valve replacement (SAVR) is the only proven effective treatment of aortic stenosis. Percutaneous heart valve replacement (PHVR) is an emerging technology that allows implantation of a prosthetic heart valve without open heart surgery. The authors' review of the available literature on PHVR for aortic stenosis found 84 published reports representing 76 distinct studies and 2,375 patients. Successful implantation and 30-day survival rates for PHVR were found to be approximately 97 percent and 92 percent, respectively. However, differences between patients undergoing PHVR and those undergoing SAVR make comparisons difficult. The available evidence is inadequate to assess the most appropriate clinical role for percutaneous heart valves or the specific patient populations for whom these valves might be indicated.
Engelberg, R.A., Downey, L., Wenrich, M.D., and others (2010, June). "Measuring the quality of end-of-life care." (AHRQ grant HS11425). Journal of Pain and Symptom Management 39(6), pp. 951-971.
The researchers evaluated the usefulness of a questionnaire evaluating physician skill at end-of-life care. The questionnaire is to be used by patients with life-limiting illnesses (such as cancer, cardiovascular disease, congestive obstructive pulmonary disease, diabetes, and dementia), their families, and nurses. The study allowed the researchers to reduce the Quality of End-of-Life Care tool from an original 54-item questionnaire to a set of 29 items for patients, 30 items for families, and 31 items for nurses. This was further reduced to a common single-factor solution based on 10 items. Although the researchers concluded that their study showed the questionnaire's validity, they suggest that continued testing in heterogeneous samples may be necessary.
Fieldston, E.S., Hall, M., Sills, M.R., and others (2010, May). "Children's hospitals do not acutely respond to high occupancy." (AHRQ grant HS16418). Pediatrics 125(5), pp. 974-981.
The researchers sought to determine how children's hospitals respond to high occupancy. Using midnight census data during 2006 from 39 children's hospitals participating in a national pediatric database, they constructed occupancy levels and measured responses to overcrowding. Overall, the participating hospitals reported 70 percent of midnights with at least 85 percent occupancy (including 42 percent of midnights with at least 95 percent occupancy). At this highest occupancy level, only a handful of the children's hospitals took active steps to reduce crowding through admissions cutoffs or transfers out. The researchers note that crowding has been associated with increases in patient safety events, including medical errors.
Gandhi, T.K., Seger, A.C., Overhage, J.M., and others (2010, June). "Outpatient adverse drug events identified by screening electronic health records." (AHRQ grant HS11169). Journal of Patient Safety 6(2), pp. 91-96.
Unlike adverse drug events (ADEs) for hospital inpatients, little is known about such events in patients in the community. The researchers used a rule-based screening program to identify ADEs among outpatients at clinics associated with two large health care systems. The scanning program looked at both structured patient data and unstructured physicians' free-text notes. The software used a set of rules that identified potential ADEs, including preventable ADEs (medical errors). In a 4-month study, the researchers found that preventable ADEs accounted for 10�12 percent of all ADEs identified. They found that the rules most likely to identify preventable ADEs were related to angiotensin-converting enzyme events or beta-blocker events.
Go, J.T., Vaughn-Sarrazin, M., Auerbach, A., and others (2010, March). "Do hospitalists affect clinical outcomes and efficiency for patients with acute upper gastrointestinal hemorrhage (UGIH)?" (AHRQ grant HS10597). Journal of Hospital Management 5(3), pp. 133-139.
Acute upper gastrointestinal hemorrhage (UGIH) is one of the most common hospital admissions. To explore the effects of hospitalists on care of patients with acute UGIH, the researchers examined data from the Multicenter Hospital Trial. They compared clinical outcomes (in-hospital mortality and complications) and efficiency (length of stay and costs) in hospitalized UGIH patients cared for by academic hospitalists and nonhospitalists in 6 academic centers in the United States during a 2-year period. Differences in adverse outcomes between providers were not seen after multivariable adjustments. Median length of stay was similar for hospitalists and nonhospitalists, but patients cared for by hospitalists had higher median costs ($7,359 vs. $6,181).
Gurses, A.P., Marsteller, J.A., Ozok, A., and others (2010). "Using an interdisciplinary approach to identify factors that affect clinician compliance with evidence-based guidelines." (AHRQ grant HS07908). Critical Care Medicine 38(Suppl. 8), pp. S282-S291).
Inadequate guideline compliance is a complex and difficult problem to tackle. To expand understanding of guideline compliance, what is needed is an interdisciplinary approach that uses multiple lenses to identify factors affecting compliance, suggest the authors. They identified 13 different models originating from disciplines that included medicine, rural sociology, psychology, human factors, and systems engineering. Clinician, guideline, system, and implementation characteristics were all identified as factors affecting compliance. The authors also developed the Barrier Identification and Mitigation (BIM) tool to provide a systematic, research-based approach to identifying barriers and reducing their effects. The authors believe that the combination of the interdisciplinary conceptual framework proposed in this paper along with the practical BIM tool provides a comprehensive systematic approach to improving guideline compliance.
Harrington, C.J., and Zaydfudim, V. (2010, April). "Buprenorphine maintenance therapy hinders acute pain management in trauma." (AHRQ grant HS13833). The American Surgeon 76(4), pp. 397-399.
The authors use a case study of a motorcycle trauma patient, who was being treated to wean him off of opioid addiction, to illustrate the problems in providing adequate pain relief to such patients. Because the opioid antagonist used, buprenorphine (Suboxone®), prevents opioids from acting through their receptors, pain management was compromised as long as the trauma patient remained on buprenorphine. Discontinuing the antagonist allowed appropriate pain management in this patient. The authors suggest that acute care clinicians need further training about buprenorphine pharmacology, and that each patient be evaluated individually, taking into account the patient's injury and pain level.
Hutt, E., Radcliff, T.A., Oman, K.S., and others (2010, June). "Impact of NHAP guideline implementation intervention on staff and resident vaccination rates." (AHRQ grant HS13608). Journal of the American Medical Directors Association 11(5), pp. 365-370.
Increasing the proportion of nursing home staff and residents who received influenza and pneumococcal vaccines has been judged to be important in reducing nursing home-acquired pneumonia, according to national consensus guidelines. In this study, the researchers attempted a multifaceted intervention trial at 16 nursing homes under common ownership to increase these vaccination rates. None of the interventions significantly improved vaccination rates among the nursing home residents. The researchers attributed the changes that were observed to external factors—some facility-specific and others related to national policy changes.
Knudsen, A.B., Lansdorp-Vogelaar, Rutter, C.M., and others (2010). "Cost-effectiveness of computed tomographic colonography screening for colorectal cancer in the Medicare population." (Interagency Agreement between AHRQ and the National Cancer Institute). Journal of the National Cancer Institute 102(16), pp. 1238-1262.
Computed tomographic colonography (CTC) is a promising technique for colorectal cancer screening. To determine its cost-effectiveness, the researchers used three independently developed microsimulation models to assess the health outcomes and costs associated with CTC screening and with currently reimbursed colorectal cancer screening tests among the average–risk Medicare population. Assuming perfect adherence to all tests (annual fecal occult blood test [FOBT], flexible sigmoidoscopy every 5 years, flexible sigmoidoscopy every 5 years with annual FOBT, and colonoscopy every 10 years), the number of life-years gained from CTC every 5 years was similar to the number gained from colonoscopy every 10 years. If CTC were reimbursed at the same rate as colonoscopy, it would be the most costly of all the strategies. However, if the test cost was substantially lower than colonoscopy or if a large proportion of otherwise unscreened persons were to undergo CTC screening, it would be cost-effective.
Laiteerapong, N., and Huang, E.S. (2010, August). "Health care reform and chronic diseases: Anticipating the health consequences." (AHRQ grant T32 HS00084). Journal of the American Medical Association 304(8), pp. 899-900.
Because of it numerous provisions, the Patient Protection and Affordable Care Act (PPACA) has the potential to reshape the treatment and course of chronic diseases in America. Its effects will differ for individuals based on their insurance status before reform. Specific primary prevention provisions with the greatest potential influence include improved access to preventive services in Medicaid, private insurance without cost sharing, and improved access to evidence-based preventive services in Medicare without cost sharing. The PPACA also provides funding for community health teams to support the patient-centered medical home, the Medicare coverage gap discount program, medication management services, and other initiatives. The PPACA provides the opportunity to take advantage of recent discoveries that show the long-lasting health benefits of chronic disease prevention and treatment.
Lee, S. D., Stucky, B.D., Lee, J.Y., and others (2010, August). "Short assessment of health literacy: Spanish and English: A comparable test of health literacy for Spanish and English speakers." (AHRQ grant HS13233). HSR: Health Services Research 45(4), pp. 1105-1120.
The researchers sought to develop and validate a health literacy test that was comparable for both Spanish–speaking and English–speaking populations. The test, called the Short Assessment of Health Literacy—Spanish and English (SAHL–S&E), combines a word recognition test and a comprehension test using multiple–choice questions designed by an expert panel. They tested and compared it with other health literacy tests in a sample of 201 Spanish-speaking and 202 English–speaking persons recruited from an ambulatory care center. The researchers found that the SAHL–S&E displayed satisfactory reliability of 0.80 and 0.89 in the Spanish- and English–speaking samples. They concluded that the SAHL–S&E has good reliability and validity.
Lin, K.W., and Humphrey, M.E. (2010). "Screening of infants for hyperbilirubinemia to prevent chronic bilirubin encephalopathy." American Family Physician 82(4), pp. 411-412.
This article is a case study together with questions and answers published in conjunction with the U.S. Preventive Services Task Force (USPSTF) Recommendation Statement on this subject. The case study focuses on K.J., a full-term newborn Asian American male, born 24 hours ago with jaundice on his chest. The infant is exclusively breast feeding, has normal urine output, and the same blood type as his mother. The three questions focused on conditions which may or may not be complications of severe neonatal hyperbilirubinemia, identifying correct statements about hyperbilirubinemia, and whether or not to screen K.J. for the condition. The authors concluded that, given the USPSTF statement on this subject, which includes the risk factors for the condition, that K.J. should not be screened since the evidence in the case study is insufficient to recommend screening infants for hyperbilirubinemia to prevent chronic bilirubin encephalopathy.
Luo, Z., Gardiner, J.C., and Bradley, C.J. (2010, October). "Applying propensity score methods in medical research: Pitfalls and prospects." (AHRQ grant HS14206). Medical Care Research and Review 67(5), pp. 528-554.
The authors set out to review the use of propensity score (PS) methods in nonrandomized studies or nonexperimental (observational) data. The original aim of PS methods was to use observed preintervention characteristics to balance the treatment (or exposure) and comparison groups in such studies. An individual's PS is the probability of being treated (or exposed), conditional on the observed characteristics. The paper provides guidance to researchers in the analysis and reporting of PS methods, particularly for the estimation of treatment effects and for sensitivity analysis. They draw on examples published in the medical literature between 2000 and 2005 to discuss criteria for properly using PS methods.
Morgan, D.J., Lomotan, L.L., Agnes, K., and others (2010). "Characteristics of healthcare-associated infections contributing to unexpected in-hospital deaths." (AHRQ grant HS18111). Infection Control and Hospital Epidemiology 31(8), pp. 864-866.
Researchers at the Baltimore Veterans Affairs Medical Center, a 119-bed acute care hospital, conducted mortality reviews of all inpatient deaths from 2004 to 2008 to determine the contribution of healthcare-associated infections (HAIs) to mortality. They found that HAIs contributed to approximately one-third of the 179 unexpected in-hospital deaths. The most common HAIs were central line-associated bloodstream infection, surgical site infection, pneumonia, and gastrointestinal infections. The most common pathogens recovered were Enterobacteriaceae, S. Aureus, P. Aeruginosa, and C. difficile. Overall, 45 percent of bacterial isolates were multidrug- resistant. To reduce mortality due to HAIs, infection prevention efforts need to focus on measures that impact multiple types of infections and multidrug-resistant organisms.
O'Leary, T.J., Slutsky, J.R., and Bernard, M.A. (2010, June). "Comparative effectiveness research priorities at Federal agencies: The view from the Department of Veterans Affairs, National Institute on Aging, and Agency for Healthcare Research and Quality." Journal of the American Geriatrics Society 58(6), pp. 1187-1192. Reprints (AHRQ Publication No. 10-R078) are available from are available from the AHRQ Publications Clearinghouse.
Representatives from three Federal Agencies involved in comparative effectiveness research (CER) discuss the nature and goals of such research, which has grown greatly with funding from the American Recovery and Reinvestment Act. The article pays special attention to efforts concerning older adults. The focus is on what each of the Agencies involved (the Department of Veterans Affairs [VA], the Agency for Healthcare Research and Quality [AHRQ], and the National Institute on Aging [NIA]) see as priorities related to CER. The authors note the role of ARRA funding in increasing CER funding at AHRQ and NIA. The VA, in contrast, supports CER research as part of an overall intramural research program.
Pahel, B.T., Rozier, R.G., and Stearns, S.C. (2010, June). "Agreement between structured checklists and Medicaid claims for preventive dental visits in primary care medical offices." (AHRQ grant T32 HS00032). Health Informatics Journal 16(2), pp. 115-128.
Since 2000, North Carolina Medicaid has reimbursed pediatricians and family physicians for providing pediatric preventive oral health services. The researchers compared administrative records (Medicaid claims) for pediatric patients with structured checklists (physician encounter forms, or EFs) that become part of the child's medical record. Of the 41,252 EFs and 40,909 claims compared, the information on preventive oral health care services matched in slightly more than 80 percent (34,171 matches). Based on the researchers' findings, they concluded that structured checklists can be combined with claims to better assess provision of preventive dental services. Improving the completion rate of the EFs could allow their use with data beyond claims, the researchers suggest.
Palsbo, S.E., and Diao, G. (2010). "The Business case for adult disability care coordination." (AHRQ grant 16537). Archives of Physical Medicine Rehabilitation 91(2), pp. 178-183.
The researchers studied a capitated Medicaid care-coordination program to investigate the financial performance of physical-disability care coordination over a 3-year period. The study population of 245 beneficiaries included patients with stroke or other brain injuries, multiple sclerosis, cerebral palsy, and spinal cord or other paralytic injury. During this period, care coordination led to higher program expenditures, primarily in the first year, for enrollees with moderate physical impairments who encounter access problems. However, the program improved care access and reduced the cost per hospitalization (although not the hospitalization rate). Care coordination allows coverage of more disability-related services and can help people move from institutional care to less-expensive community settings, the researchers conclude.
Scanlon, M.C., and Karsh, B.-T. (2010, June). "Value of human factors to medication and patient safety in the intensive care unit." (AHRQ grant HS13610). Critical Care Medicine 38(6-Suppl.), pp. S90-S96.
The authors give an overview of how human factors engineering (HFE) is used to improve medication and patient safety. They note that the nontechnical use of the phrase "the human factor" tends to place blame for problems on clinicians. In contrast, HFE looks at how to take human cognitive and physical abilities—and limitations—into account when designing productive and safe tools, tasks, and environments for human use. The paper looks at five myths about the role of the human element in medication errors and other patient safety problems, focusing on the critical care environment.
Seifer, S.D., Michaels, M., and Collins, S. (2010, Spring). "Applying community-based participatory research principles and approaches in clinical trials forging a new model for cancer clinical research." (AHRQ grant HS16471). Progress in Community Health Partnerships: Research, Education, and Action 4(1), pp. 37-46.
Although an estimated 20 percent of United States adult cancer patients are eligible to participate in cancer treatment clinical trials, such participation remains under 3 percent. The authors address the use of community-based participatory research (CBPR) methods to increase the involvement of adult cancer patients in clinical trials. Their paper describes an initiative, partially funded by the Agency for Healthcare Research and Quality and the National Cancer Institute, to develop recommendations for employing CBPR approaches in multisite, phase III cancer clinical trials. The authors describe the background and rationale for the initiative, how the resulting report was developed and disseminated, and the challenges and opportunities in implementing the report's recommendations.
Simmons, D., and Sherwood, G. (2010, June). "Neonatal intensive care unit and emergency nurses' descriptions of working together: Building team relationships to improve safety." (AHRQ grant HS11544). Critical Care Nursing Clinics of North America 22(2), pp. 253-260.
The researchers report on a qualitative study of nurses' perceptions concerning working together in critical-care unit teams. The study was conducted at a large teaching hospital in an academic health center. They ran 4 focus groups, 2 with 11 volunteer participants from the neonatal intensive care unit (NICU) and 2 with 8 participants from the emergency department (ED) trauma resuscitation team. The researchers found three themes running through the nurses' descriptions of working together – one concerning their individual and collective personal and professional attributes, a second focusing on developing and maintaining relationships in the workplace, and a third emphasizing concurrence among team members.
Tsai, C.-L., Sullivan, A.F., Ginde, A.A., and others (2010, May). "Quality of emergency care provided by physician assistants and nurse practitioners in acute asthma." (AHRQ grant HS13099). American Journal of Emergency Medicine 28(4), pp. 485-491.
Unsupervised physician assistants and nurse practitioners (midlevel providers, or MLPs) provide poorer quality of emergency department (ED) care to patients with acute asthma than do physicians, a new study finds. The researchers also found that MLPs working under physician supervision provided quality of care similar to that of physicians. The study used data on ED visits for acute asthma selected from 63 EDs in 23 States. The level of asthma care quality was evaluated using 12 process-of-care measures based on asthma care guidelines, plus the number of hospital admissions, and how long asthma patients stayed in the ED.
Wakefield, D.S., Mehr, D., Keplinger, K., and others (2010, July). "Issues and questions to consider in implementing secure electronic patient-provider Web portal communication systems." (AHRQ grants HS17035 and HS17948). International Journal of Medical Informatics 79(7), pp. 469-477.
Providers of health care are finding increased patient interest in and expectations of electronic communications. The authors survey the literature and their collective experience to develop a framework that identifies key issues in development of a secure portal for electronic communication between patients and clinicians. This framework categorizes the specific issues involved in developing such a portal into seven areas: strategic fit and priority; selection process and implementation team; integration into communications and workflow; Health Insurance Portability and Accountability Act issues and clinic policies; systems implementation and training; marketing and enrollment; and ongoing performance monitoring.
Zayfudim, V., Rosen, M.J., Gillis, L.A., and others (2010, July). "Ciliated hepatic foregut cysts in children." (AHRQ grant T32 HS13833). Pediatric Surgery International 26(7), pp. 753-757.
This article is a case report of a teenage girl with a rare type of liver cyst (ciliated hepatic foregut cyst, or CHFC) that has been found to transform to squamous cell carcinoma, a malignant cancer, in about 3 percent of all cases. Although CHFC has been found in patients without symptoms in the course of certain imaging tests, the most common symptom is pain in the right upper quadrant of the abdomen or epigastric abdominal pain. When a hepatic cyst is identified, the researchers recommend its prompt excision.