Research Activities, July 2011, No. 371
Annett, R.D., Bender, B.G., Skipper, B., and Allen, C. (2011). "Predicting moderate improvement and decline in pediatric asthma quality of life over 24 months." (AHRQ grant HS09123). Quality of Life Research 19, pp. 1517-1527.
Because quality of life reflects disease control from the patient's perspective, its measurement has become an important objective of asthma management and research. The authors of this study examined factors associated with moderate improvement in quality of life over a 24-month period for 1,041 children and parents who participated in a Childhood Asthma Management Program. Medication treatment did not contribute to changes (either improvement or decline) in child or parent quality of life during the study period. However, the single determinant of moderate improvement in physical activities was the use of steroid therapy in the preceding 4 months. The factors most strongly associated with moderate decline in child-reported quality-of-life score were reports of asthma interfering with the child's life and specific child psychological functioning.
Andrews, R.M. (2011). "Race and ethnicity reporting in Statewide hospital data: Progress and future challenges in a key resource for local and State monitoring of health disparities." Journal of Public Health Management Practice 17(20), pp. 167-173. Reprints (AHRQ Publication No. 11-R033) are available from the AHRQ Publications Clearinghouse.
Statewide hospital discharge data are an important resource for identifying and tracking racial and ethnic disparities at the local, State, and national levels. This study examined the extent of race-ethnicity coding in statewide hospital discharge data systems, compared the collection to national standards, and assessed the completeness and accuracy of race-ethnicity data collected in these systems. Information from the Healthcare Cost and Utilization Project State Inpatient Databases, sponsored by the Agency for Healthcare Research and Quality, was the primary source of data for the study. Race data collection increased from 14 to 43 States between 1991 and 2008. In 2008, 20 States conformed to the 1997 Office of Management and Budget directive standard, 19 used the 1977 standard, 10 collected multi-racial data, 4 did not collect Hispanic ethnicity, and 3 collected detailed data by racial-ethnic categories.
Brokel, J.M., Schwichtenberg, T.J., Wakefield, D.S., and others (2011, February). "Evaluating clinical decision support rules as an intervention in clinician workflows with technology." (AHRQ grant HS15196). CIN: Computers, Informatics, Nursing 29(1), pp. 36-42.
Clinical information systems in rural hospitals lag 40 to 50 percent behind urban hospitals. The high cost of implementing the electronic health records (EHRs) has been a significant obstacle in rural areas. The clinical decision support (CDS) applications within the EHR are powerful information technology tools to foster efficiencies and affect outcomes. This study describes the process of validation of one of the complex types of CDS interventions, the CDS rule (CDSR). Since 2005, the study hospital has added specific CDSRs for catheter-acquired urinary tract infections, deep venous thrombosis, heart failure, and more. The findings validate the use of CDSRs across sites and the ability to use existing indicators to measure outcomes. The authors present a model for design and validation of CDSRs into workflow processes. They plan further research to test the effectiveness of more CDSRs across facilities.
Brown, T.T., Mehta, S.H., Sutcliffe, C., and others (2010). "Hepatic steatosis associated with increased central body fat by dual-energy X-ray absorptiometry and uncontrolled HIV in HIV/hepatitis C co-infected persons." (AHRQ grant HS07809). AIDS 24(6), pp. 811-817.
Only a subset of HIV/hepatitis C (HCV) patients will progress to end-stage liver disease, and the risk factors associated with disease progression are not fully understood. The researchers evaluated the relationship between regional body composition and liver disease (fibrosis or steatosis) in HIV/HCV co-infected patients. Whole body dual-energy X-ray absorptiometry (DXA) was performed in 173 HIV/HCV co-infected persons within 12 months of a liver biopsy. In this group, who underwent both DXA and histologic evaluation of liver biopsy specimens, hepatic steatosis was significantly associated with increased central fat, whereas hepatic fibrosis was not correlated with any measure of body composition. Another finding was that steatosis was associated with uncontrolled HIV replication rather than the use of antiretroviral therapy or specific antiretroviral therapy.
Clancy, C. (2011, April). "Patient engagement in health care." HSR: Health Services Research 46(2), pp. 389-393. Reprints (AHRQ Publication No. 11-R043) are available from the AHRQ Publications Clearinghouse.
In this issue of the journal, the author briefly introduces four papers addressing distinct tasks of patient engagement in health care, and one paper presenting a patient-centered approach to assessing health care expenditures. One paper on the tasks of patient engagement in health care is a discrete-choice experiment among Dutch consumers eliciting their willingness to switch general practitioners or pharmacists in response to different copayments and information on quality of care. A second paper assesses how financial incentives and quality information from multiple sources affect consumer choice of physicians. A third paper assesses the psychometric properties of Hibbard's Patient Activation Measure. Finally, a fourth paper assesses the extent to which racial/ethnic differences in ratings of patient experience represent true differences or perceptions. The author concludes that a focus on the interactions between new models of care and patients' engagement will be an indispensable component of research illuminating which models are most effective.
El-Kareh, R.E., Gandhi, T.K., Poon, E.G., and others (2011). "Actionable reminders did not improve performance over passive reminders for overdue tests in the primary care setting." (AHRQ grant HS15226). Journal of the American Medical Informatics Association 18, pp. 160-163.
Many primary care patients do not receive recommended preventive or chronic disease care. Actionable reminders (electronic reminders linked to computerized order entry) might improve care by facilitating direct ordering of recommended tests. The researchers created a set of such reminders that appeared each time a clinician opened an electronic patient chart. These reminders targeted performance of annual mammography, one-time bone-density screening, and diabetic testing. The intervention was implemented in 2007-2008 in four primary care clinics employing 25 primary care physicians. Among these physicians, 79 percent almost never used the system or were unaware of the functionality. Actionable reminders in the primary care setting did not affect the performance of overdue testing compared with passive reminders. The limited effect of these reminders was likely strongly influenced by inefficiencies in the test-ordering process.
Flaherman, V.J., Chien, A.T., McCulloch, C.E., and Dudley, R.A. (2011). "Breastfeeding rates differ significantly by method used: A cause for concern for public health measurement." (AHRQ grant HS17146). Breastfeeding Medicine 6(1), pp. 31-35.
The Centers for Disease Control and Prevention (CDC) has reported that rates of initial breastfeeding in the immediate post-partum period are close to the Healthy People 2010 goal of 75 percent of mothers initiating breastfeeding. But rates of "exclusive" breastfeeding through 3 and 6 months are estimated to be 30.5 percent and 11.3 percent, respectively. Researchers compared the estimates of "any" and "exclusive" breastfeeding from two different data sources, the National Immunization Survey (NIS) used by CDC and the California Newborn Screen (CNS) used by the California Department of Public Health. They found that the rates for "any" breastfeeding were similar using NIS and CNS data for the State as a whole, and for most racial/ethnic groups and geographic areas. In contrast, "exclusive" breastfeeding rates as reported by the two sources differed significantly, with the NIS reporting 60.4 percent and the CNS reporting 41.6 percent. This suggests that either or both sources are flawed measures of "exclusive" breastfeeding.
Mark, B.A., and Harless, D.W. (2011, April). "Adjusting for patient acuity in measurement of nurse staffing." (AHRQ grant HS10153). Nursing Research 60(2), pp. 107-114.
This study concludes that until a standardized system for measuring patient acuity (patient requirements for nursing care) is developed, tested, implemented widely in hospitals, and adopted by researchers, the power of the evidence base about nurse staffing to drive practice will not reach its full potential. The frequently used Medicare case mix index (CMI), a physician- and medical-diagnosis-oriented measure, is not really intended for this purpose. The researchers examined the unadjusted measures of registered nurse (RN) staffing (RNs per 1,000 adjusted patient days) and CMI-adjusted nurse staffing as well as nurse staffing adjusted with nursing intensity weights (NIW), a measure of patients' needs for nursing care. They drew on secondary data from 579 hospitals in 13 States from 2000 to 2006 that included three measures of nurse staffing and hospital characteristics. The study found statistically significant differences between NIW-adjusted staffing and CMI-adjusted staffing for ownership, teaching status, hospital size, and proportion of Medicare inpatient days.
Meyers, D., Quinn, M., and Clancy, C. (2011). "Health information technology: Turning the patient-centered medical home from concept to reality." American Journal of Medical Quality 26, pp. 154-156. Reprints (AHRQ Publication No. 11-R044) are available from the AHRQ Publications Clearinghouse.
The nation's primary care infrastructure is under great strain. The patient-centered medical home (PCMH) has emerged as a model of care that would restore order to the nation's primary care system. The PCMH is more necessary now than ever before because of skyrocketing medical costs, an aging and growing population, advances in the science of diagnostic and treatment procedures, and the rapid expansion of chronic care needs. Health information technology (IT), such as electronic health records can facilitate the development of and implementation of PCMHs by collecting and managing personal health information, enhancing communication among providers and patients, supporting providers' decisionmaking on tests and treatments, and in other ways. Research by the Agency for Healthcare Research and Quality is supporting the effort to apply the best features of health IT to create a PCMH that will improve care for all Americans.
Reynolds, C., Quan, V., Kim, D., and others (2011, January). "Methicillin-resistant staphylococcus aureus (MRSA) carriage in 10 nursing homes in Orange County, California." (AHRQ Contract No. 290-05-0031). Infection Control and Hospital Epidemiology 32(1), pp. 91-93.
Previous studies showed methicillin-resistant staphylococcus aureus (MRSA) prevalence ranging from 5 percent to 40 percent in nursing homes, but few explained this variation. The researchers measured MRSA prevalence among 10 nursing homes in 1 county and identified factors predicting carriage. MRSA carriage varied substantially across the nursing homes, with an overall point prevalence of 31 percent compared with 6 percent in hospitals and 9-24 percent in intensive care units. Overall, MRSA point prevalence was 67 percent higher than admission prevalence. MRSA carriage was associated with high proportions of Medicaid-insured residents. Limited resources may impact patient care and cleaning staff ratios, availability of single rooms, and cleaning and infection-control practices. The researchers concluded that MRSA burden was associated with admission of patients to the nursing home, but transmission from resident to resident was also evident and may relate to facility resources.
Richardson, T.M., He, H., Podgorski, C., and others (2010, December). "Screening for depression for aging services clients." (AHRQ grant T32 HS00044). American Journal of Geriatric Psychiatry 18(12), pp. 1116-1123.
Accurate and timely detection of major and subsyndromal depression is critical to reducing the burden of depression for the elderly. One setting that may offer a unique and important opportunity for elders at risk for affective illness is the Aging Services Network consisting of nearly 20,000 community services organizations. Yet systematic efforts to detect depression and other affective illnesses in this setting are rare. In primary care settings, the Patient Health Questionnaire (PHQ-9) is perhaps the most widely disseminated screening tool for depressive symptoms among adults, including the elderly. The PHQ-2, an abbreviated version of the PHQ-9, has similar properties. In a test including 378 persons, 60 years of age or older, who were clients of a single aging services provider, the researchers found that the PHQ-9 had greater specificity than the PHQ-2. This meant that its use would lead to fewer false positives and related higher costs.
Stevens, A.B., and Sanghi, S. (2010). "Emerging frontiers in healthcare research and delivery. The 16th Annual HMO Research Network Conference, March 21-24, 2010, Austin, Texas." (AHRQ grant HS18886). Clinical Medicine & Research 8 (3/4), pp. 135-137.
The purpose of this article is to provide information about the Health Maintenance Organization Research Network (HMORN) and its 16th annual conference held in March 2010. The HMORN is a collaboration of 16 nationally and internationally recognized research centers based within not-for-profit health care delivery systems. The theme of the conference was "Emerging Frontiers in Healthcare Research and Delivery." More than 320 researchers and health care professionals attended the conference. Some of the 16 session topics were cancer research, health and bioinformatics, virtual data warehouse, cardiovascular research, and genetics. The agenda included a new participant-directed group format in which small groups were formed based on topics of interest to the group, with facilitators provided by the organizing committee.
Strom, B.L., and Schinnar, R. (2011, February). "Evaluating health information technology's clinical effects." (AHRQ grant HS10399). LDI. Issue Brief. 16(4).
The researchers report on the experience of one hospital system that used its computerized physician order entry (CPOE) system to reduce the occurrence of a drug interaction between warfarin, an anticoagulant, and trimethoprim-sulfamethoxazole (TMP/Sulfa), an antibiotic. Patients who take both drugs are much more likely to develop bleeding from warfarin. The intervention consisted of using the CPOE system to introduce a hard-stop alert notifying the clinician that the order could not be processed due to a potential drug interaction. During the study period, clinicians ordered 8,826 prescriptions for warfarin or TMP/Sulfa, with 55 physicians triggering alerts in the intervention group. The trial was stopped for ethical reasons, because of three delays in prescribing one of the two drugs and one failure to prescribe TMP/Sulfa to a critically ill patient. The researchers conclude that their study illustrates why formal evaluation is needed in the implementation of health information technology.
Sun, F., Kosberg, J.I., Kaufman, A.V., and others (2010). "Coping strategies and caregiving outcomes among rural dementia caregivers." (AHRQ grant HS13189). Journal of Gerontological Social Work 53(6), pp. 547-567.
The researchers studied 141 family caregivers of persons with dementia in rural Alabama in order to learn about caregiver coping strategies and their relation to caregiver quality-of-life measures. Coping styles came from caregiver responses to the 60-item COPE Scale. Almost all of the rural caregivers used religious coping, followed by planning, growth, acceptance, and active coping. The least-used coping strategies included mental disengagement, behavioral disengagement, denial, and disengagement through alcohol or drug use—all considered dysfunctional coping styles. The researchers found a direct relationship between deliberate coping and education, and an inverse relationship between avoidance coping and both education and perceptions of having adequate income. They suggest that social workers in rural settings give particular attention to caregivers who use avoidance coping by using interventions to alter their coping styles.
Turchin, A., and Conlin, P.R. (2011). "The doctor needs to see you now: Accelerating the care of patients with uncontrolled hypertension." (AHRQ grant HS17030). Expert Reviews. Cardiovascular Therapeutics 8(11), p. 1501-1503.
Barely half of hypertensive adults in the United States have their blood pressure under control (<140/90mmHg). Studies show that patients with elevated blood pressure are being seen much less frequently than the monthly or more frequent visits recommended by guidelines. This study of 5,042 hypertensive patients with diabetes found that patients who saw their physicians monthly or more often normalized their blood pressure within 1.5 months compared with 12.2 months for patients seen less frequently. They cite a number of other studies showing that earlier control of hypertension was correlated with a lower incidence of stroke, cardiovascular complications, and mortality. The authors conclude that clinicians should feel comfortable adopting treatment algorithms that actively and rapidly manage patients with uncontrolled hypertension using patient encounter intervals of 2 weeks or less.
Wagner, P.J., Howard, S.M., Bentley, D. R., Seol, Y-H., and Sodomka, P. (2010). "Incorporating patient perspectives into the personal health record: Implications for care and caring." (AHRQ grant HS17234). Perspectives in Health Information Management Fall 2010, pp. 1-12.
The purpose of this study was to examine patient perspectives on electronic personal health record (ePHR) use and functionality as part of the development process of an existing ePHR, to assess whether these ideas are technologically feasible, and to compare the patient views to the expectations of a collaborative team of providers, information technology professionals, patient- and family-centered care experts, and investigators. Patients participated in a semistructured interview after one to two weeks of using an ePHR. Seven technology themes with 40 specific questions were identified and were rank-ordered by importance and feasibility, and 20 suggestions were subsequently implemented into the ePHR. The researchers concluded that incorporating patient feedback on specific utilities and functionality into an existing ePHR is possible.
Wald, J.S., Businger, A., and Gandhi, T.K. (2010). "Implementing practice-linked pre-visit electronic journals in primary care: Patient and physician use and satisfaction." (AHRQ grant HS13362). Journal of the American Medical Informatics Association 17(5); pp. 502-506.
The previsit electronic journal (eJournal) was developed as a new feature of a large, integrated health system's electronic health record-connected patient portal. Patients who registered to use the portal could communicate securely with their doctor's office; view selected portions of their medical chart; make requests for prescriptions, appointments, and other matters; and search for health reference information. The researchers invited 2,027 patients at a large, integrated health system in Boston to fill out an eJournal before a primary care visit and surveyed the patients after the visit. Among the 806 patients responding to the survey who submitted eJournals, 55.9 percent reported feeling more prepared for the visit and 58 percent reported that the provider had more accurate information about them.
Woreta, T.A., Sutcliffe, C.G., Mehta, S.H., and others (2011). "Incidence and risk factors for steatosis progression in adults coinfected with HIV and hepatitis C virus." (AHRQ grant HS07809). Gastroenterology 140, pp. 809-817.
Hepatic steatosis (accumulation of triglycerides and other fats in liver cells) is a common finding in individuals coinfected with HIV and hepatitis C virus (HCV). The researchers examined the natural history of steatosis in 222 HIV/HCV coinfected patients who attended an urban HIV clinic between 1993 and 2008. Initial biopsy specimens from 88 percent of patients had either no fat or trivial amounts of fat. But the second biopsy samples showed 74 percent with little or no fat and 13 percent with significant amounts of fat. Fibrosis progression was observed more frequently in conjunction with an increase in steatosis. Fat progression was associated with the clinical diagnosis of alcoholism and a body mass index greater than 25kg/m2. Importantly, exposure to contemporary antiretroviral medications and higher baseline CD4 cell count (indicating better immune system function) appeared to be protective against progressive steatosis.
Wright, A., Sittig, D.F., Ash, J.S., and others (2011). "Governance for clinical decision support: Case studies and recommended practices from leading institutions." (AHRQ Contract No. 290-2008-10010). Journal of the American Medical Informatics Association 18, pp. 187-194.
Clinical decision support (CDS) represents a critical tool for improving the quality and safety of health care. Careful consideration of governance issues when developing and implementing CDS can be as important as the quality of the decision support itself. However, limited research exists about optimal and real-world CDS governance practices. The authors show how five diverse health care organizations developed their governance structures and discuss some of the tools they are using to support these activities. They identify six recommended practices in the area of governance and four in the area of content management. Many of these recommended practices may be nearly universal and all implementers of decision support should consider employing them.