Research Activities, July 2010, No. 359
Bernstein, S. L. (2009). "The clinical impact of health behaviors on emergency department visits." (AHRQ grant HS18601). Academic Emergency Medicine 16, pp. 1054-1059.
The emergency department (ED) represents an ideal clinical laboratory to study the epidemiology of risky health behaviors and design interventions to modify them. ED patients drink, smoke, use illicit drugs, have unsafe sex, and sustain injuries more than the general population. Use of licit and illicit substances constitutes the largest single modifiable set of health risks among ED patients. Alcohol accounts for 7.9 percent of all ED visits and tobacco accounts for 4.9 percent of all adult ED visits. In 2006, there were 1.74 million visits related to illicit and prescription drugs. The author discusses future challenges in ED research in health behaviors. He briefly reviews some problems with secondary prevention programs. Finally, he discusses models of health behavior, challenges in dissemination and implementation of ED-based interventions, and multimodal interventions.
Billinger, M. E., Olivier, K. N., Viboud, C., and others (2009, October). "Nontuberculous mycobacteria-associated lung disease in hospitalized persons, United States, 1998-2005." Emerging Infectious Diseases 15(10), pp. 1562-1569. Reprints (AHRQ Publication No. 10-R038) are available from the AHRQ Publications Clearinghouse.
Clinical and laboratory-based studies since the 1980s have shown an increased prevalence of persons with nontuberculous mycobacteria-associated lung disease. Using data from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project, the researchers estimated the prevalence, demographic characteristics, and trends of pulmonary nontuberculous mycobacteria (NTM)-associated hospitalizations. The data were from 11 States with continuous reporting from 1998 to 2005. Among persons older than 70 years of age, the relative prevalence was higher for women than for men. The prevalence for persons 70-79 years of age compared with those 40-49 years of age was 15-fold higher for women and 9-fold higher for men. Annual prevalence increased significantly among men and women in Florida (3.2 percent and 6.5 percent, respectively), and among women in New York (4.6 percent).
Broderick, K. B., Ranney, M. L., Vaca, F. E., and others (2009). "Study designs and evaluation models for emergency department public health research." (AHRQ grant HS17526). Academic Emergency Medicine 16, pp. 1124-1131.
This article is a product of the 2009 Academic Emergency Medicine consensus conference titled "Public Health in the ED: Surveillance, Screening, and Intervention." The authors reported on the findings of a conference workshop intended to review study designs and evaluation models specific to ED-based public health research. They reviewed concepts related to ED-based public health research such as study designs, participant selection and retention, and measurement and analyses. The key concepts raised in discussion of these topics are framed within a broader goal of educating researchers and providing a more focused foundation for performing high-quality ED-based public health research. The authors also formulated a set of 10 study design and program evaluation recommendations for future ED-based public health research.
Carlson, J. N., Mayrose, J., and Wang, H. E. (2010, January-March). "How much force is required to dislodge an alternate airway?" (AHRQ grant HS13628). Prehospital Emergency Care 14(1), pp. 31-35.
Airway management is a core intervention in the resuscitation of out-of-hospital critically ill patients. While most advanced-level practitioners provide airway management using endotracheal intubation (ETI), many newer airway devices provide alternatives to ETI. A key task in ETI is securing the endotracheal tube (ETT) to prevent inadvertent dislodgment, a potentially catastrophic event. To prevent this from happening, practitioners typically secure the ETT in place using adhesive tape or a commercial tube holder. The researchers tested a standard ETT against three newer airway devices to determine which one took the most force to dislodge. Three of the devices�the standard ETT, the King laryngeal tube airway, and the laryngeal mask airway�required similar dislodgment force. The esophageal-tracheal Combitube (ETC) required almost twice as much dislodgment force as the ETT.
Clancy, C. M. (2009, December). "Physician leadership for high-quality care." Chest 136(6), pp. 1452-1454. Reprints (AHRQ Publication No. 10-R043) are available from the AHRQ Publications Clearinghouse.
As policymakers grapple with reforming the U.S. health care system, a common theme is the urgent need to assure that all Americans receive high-quality, affordable care. An article in the same issue of Chest provides a clear summary of the Medicare physician quality reporting initiative (PQRI) for chest physicians. This presents an important opportunity for physician leadership, notes the author, director of the Agency for Healthcare Research and Quality. Physicians will need to work together to address issues ranging from reconciling different values from different sources to the incorporation of standard data collection at the point of care. Transitioning from leisurely to rapid improvements will require timely feedback, clinical decision support, and broad engagement by physicians and organizations to design systems and strategies that encourage and reinforce a culture of learning.
Dellon, E. P., Shores, M. D., Nelson, K. I., and others (2009, December). "Caregivers' perspectives on decisionmaking about lung transplantation in cystic fibrosis." (AHRQ grant HS10397). Progress in Transplantation 19(4), pp. 318-325.
Cystic fibrosis is the most common lethal genetic disease among whites. Lung transplantation is a therapeutic option that may improve survival and quality of life for selected patients. The researchers' objective was to describe the current decisionmaking process for lung transplantation from the perspective of caregivers of patients who faced the transplant decisions before dying of complications of cystic fibrosis (9 patients) or lung transplantation (19 patients). They interviewed 28 caregivers (mostly mothers) of patients with cystic fibrosis who received care at their center and died between 1996 and 2006. Ten caregivers reported that the patient did not fully understand the alternatives. Five thought that the patient did not fully understand potential risks. Thirteen reported that the patient thought that declining transplantation was not an option.
Do, Y. K., Carpenter, W. R., Spain, P., and others (2010). "Race, healthcare access and physician trust among prostate cancer patients." (AHRQ grant HS10861). Cancer Causes Control 21, pp. 31-40.
Prostate cancer mortality is more than twice as high for black men as it is for white men in the United States. A previous study had suggested that health care access, not culturally biased attitudes or lack of knowledge, is the key factor to explain black-white disparities in prostate cancer care. The researchers examined the relationship between physician trust and health care access among black and white prostate cancer patients. Their survey included 1,370 interviews with 474 patients over 3 time periods. They found that black men had generally lower levels of trust in their physician than white men. However, much of this effect can be explained by substantially lower trust levels within the subgroup of black men who reported having failed to seek medically necessary care, note the authors.
Haukoos, J. S., Mehta, S. D., Harvey, L., and others (2009). "Research priorities for human immunodeficiency virus and sexually transmitted infections surveillance, screening, and intervention in emergency departments: Consensus-based recommendations." (AHRQ grant HS17526). Academic Emergency Medicine 16(11), pp. 1096-1102.
The journal Academic Emergency Medicine convened a consensus conference on "Public Health in the ED: Surveillance, Screening, and Intervention" as part of its 2009 annual meeting. The authors describe the results of a conference breakout session on HIV and sexually transmitted infections (STIs) in the emergency department (ED). They used a four-step group technique that involved the generation, sharing, and discussion of ideas related to the problem, followed by voting and ranking to prioritize the ideas relative to the objective. The 21 session participants agreed on 11 priority knowledge gaps and 14 research questions as the highest ranked research priorities. The overarching themes of the research priority questions were related to effectiveness, sustainability, and integration of HIV and STI prevention in the ED.
Haukoos, J. S. and Lyons, M. S. (2009). "Idealized models or incremental program evaluation: Translating emergency department HIV testing into practice." (HS17526). Academic Emergency Medicine 16(11), pp. 1044-1048.
In 2006, the Centers for Disease Control and Prevention revised their recommendations for performing HIV testing with a significant focus on emergency departments (EDs). Going back over the last 2 decades, the authors show, through a systematic search of several publication search engines, that ED-related HIV research efforts have increased considerably. They also discuss three articles in the same issue that describe different aspects of performing HIV testing in EDs. In discussing the next steps in translating HIV testing into practice for all EDs, the authors emphasize the need for substantial external administrative, financial, and political support. They conclude that incremental investigation and implementation are the best ways to proceed in expanding HIV testing in EDs.
Lazar, A. J. (2010, February). "Two takeaways for hospitals." Modern Healthcare.
Two takeaways for hospitals already are certain: costs must be managed, and daily operations need to be redesigned to focus on higher quality and better outcomes. Most U.S. hospitals have 200 or fewer beds and do not resemble the highly integrated systems, like Kaiser Permanente, that are often held up as models. Hospitals must use evidence-based data to improve outcomes and reduce readmissions and the Agency for Healthcare Research and Quality (AHRQ) has taken a leading role in offering tools to achieve these results. An AHRQ-funded Project RED (Re-engineered discharge) has transformed the way patients are discharged. The protocol developed from this project reduces readmissions and lowers costs. To address uncertainties about which treatment or intervention works best for patients, Congress created AHRQ's Effective Health Care Program in 2003. It highlights the pros and cons of different treatment options for a given condition. This type of analysis is known as comparative effectiveness research.
Mukamel, D. B., Glance, L. G., Dick, A. W., and Osler, T. M. (2010, February). "Measuring quality for public reporting of health provider quality: Making it meaningful to patients." (AHRQ grant HS16737). American Journal of Public Health 100(2), pp. 264-269.
Measuring the performance of medical care providers has become an important facet of the American health care system over the last 20 years. The accuracy of quality measures depends on a number of factors, including the use of shrinkage estimators rather than the traditional, nonshrinkage estimators. The researchers examined the advantages and disadvantages of shrinkage and nonshrinkage estimators from the perspective of a patient faced with choosing a local provider. In considering the quality of a provider, the nonshrinkage estimator is the mean for all patients treated by that provider; the shrinkage estimator is a weighted average of the unshrunk estimator and the average outcome rate calculated over all providers. The authors criticize the shrinkage estimator for its assumption that all providers are similar and for inaccurate interpretation of data comparing the mortality rates of six hospitals. They conclude that use of the shrinkage estimator may not serve the needs of individual patients.
Mularski, R. A., Campbell, M. L., Asch, S. M., and others (2010, March). "A review of quality of care evaluation for the palliation of dyspnea." (AHRQ Contract No. 290-05-0034). American Journal of Respiratory Critical Care Medicine 181(6), pp. 534-538.
Evaluation and management of dyspnea requires recognizing patients at risk for dyspnea and regularly assessing and characterizing the patient experience at clinical interactions. As part of an Agency for Healthcare Research and Quality symposium, the authors performed a dyspnea quality measure review. They sought to identify any publicly available process and outcome quality indicators. Only 5 operationalized quality measures, 14 quality indicators, and a number of other quality statements about recommended care for dyspnea could be identified. Dyspnea quality measurement and quality improvement efforts will likely expand in future years. The current field is young and most proposed dyspnea quality measures lack data on reliability, validity, and feasibility. The authors call for more research to understand the most appropriate symptom assessment instruments and how these link to patient-centered priorities for intervention.
Pincus, H. A. (2009). "From PORT to policy to patient outcomes: Crossing the quality chasm." (AHRQ grant HS16097). Schizophrenia Bulletin 36(1), pp. 109-111.
The reports from the Agency for Healthcare Research and Quality's Schizophrenia Patient Outcomes Research Team provide guidance on evidence-based clinical practice. In addition, a report from the Institute of Medicine (IOM) documents gaps in behavioral health care between the care Americans should be receiving and the care they are receiving. The IOM report also provides a set of aims, principles, and strategies to improve the quality of the mental health care system. The author offers a framework for applying these elements and suggests a series of additional steps. These steps include: making consumers, policy leaders, administrators, clinicians, and researchers part of the process; transforming guidelines into valid performance measures that can be feasibly measured; applying measures at multiple levels (consumer, clinical, etc.); applying strategies to improve performance more widely at the point of care; and evaluating the effectiveness of guidelines, measures, and quality improvement strategies.
Resnick, B. Galik, E., Pretzer-Aboff, I., and others (2009). "Treatment fidelity in nursing home research: The Res-Care Intervention Study." (AHRQ grant HS13372). Research in Gerontological Nursing 2(1), pp. 30-38.
Increasingly, investigators are addressing treatment fidelity when reporting research on interventions to change behavior. An intervention can be said to satisfy treatment fidelity requirements if the treatment provided is consistently given to all participants randomized to treatment, there is no evidence of non-treatment-related effects, and the intervention is true to the theories and goal underlying the research. The researchers describe how treatment fidelity was comprehensively evaluated in a two-tiered motivational intervention, the Res-Care Intervention Study, focused on restorative care interventions in 12 nursing homes. Six homes were exposed to the intervention and six received a placebo control intervention. The Res-Care Intervention was focused on teaching nursing assistants how to motivate residents to engage in restorative care activities. There was some evidence of treatment fidelity across the five areas of design, training, delivery, receipt, and enactment.
Schroy, P. C., Glick, J. T., Robinson, P., and others (2009). "A cost-effectiveness analysis of subject recruitment strategies in the HIPAA era: Results from a colorectal cancer screening adherence trial." (AHRQ grant HS13912). Clinical Trials 6, pp. 597-609.
Changes in regulation as a result of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule have made it more difficult to recruit subjects for clinical trials. The researchers evaluated three methods to recruit subjects for a trial on the impact of a computer-based decision aid on shared decisionmaking and patient adherence to colorectal cancer screening. The methods were: (1) a provider-initiated electronic referral opt-in (Click) method, (2) a provider-mediated referral letter opt-in (Letter) method, and (3) an investigator-initiated coordinator-mediated direct contact opt-out (Call) method. The Call method yielded substantially higher accrual rates (188 out of 531 subjects) than either the Click method (12 of 72) or the Letter method (17 of 816). The average cost per patient enrolled for the Call method was $156. This was competitive with the Click method ($129) and much lower than the Letter method ($1,967).
Schultz, D., Seid, M., Stoto, M. A., and Burstain, J. M. (2010). "The Agency for Healthcare Research and Quality's Children's Health Research Portfolio." (AHRQ Contract No. 282-00-0005). Maternal and Child Health 14, pp. 1-8.
The purpose of this study was to evaluate the Agency for Healthcare Research and Quality's (AHRQ's) children's health activities and determine the extent to which they reflected AHRQ's portfolios of research and resulted in publications in the peer-reviewed literature. The review assessed AHRQ-funded children's activities for the period 1990-2005 and related publications for the period 1996-2002. The evaluation showed that AHRQ's child health portfolio has changed over time with an increase in activities related to patient safety and health information technology, reflecting trends at AHRQ as a whole. Furthermore, AHRQ has contributed a substantial body of new knowledge as a result of its funding for children's health activities. The analysis also suggested that AHRQ's children's health activities have successfully disseminated research findings and new knowledge.
Zivin, K., Madden, J. M., Graves, A. J., and others (2009, December). "Cost-related medication nonadherence among beneficiaries with depression following Medicare Part D." (AHRQ grant HS10391). American Journal of Geriatric Psychiatry 17(12), pp. 1068-1076.
Despite increased prescription drug coverage with Medicare Part D, overall rates of cost-related nonadherence (CRN) and spending less on basic needs improved only somewhat since its implementation. Using data from the Medicare Current Beneficiary Surveys of 2004-2006, the researchers determined changes in CRN and forgoing basic needs to pay for drugs among Medicare beneficiaries with and without depressive symptoms before and after Part D implementation. The unadjusted, weighted annual prevalence of CRN among beneficiaries with depressive symptoms was 27 percent in 2004 and 2005, and 24 percent after Part D implementation in 2006, compared with 13 percent, 12 percent, and 9 percent, respectively, among beneficiaries without depressive symptoms. The annual prevalence of spending less on basic needs among depressed beneficiaries was 22 percent in 2004, 23 percent in 2005, and 19 percent in 2006, compared with 8 percent, 9 percent, and 5 percent, respectively, among beneficiaries without depressive symptoms.