Research Activities, June 2011, No. 370
Calderon, J. L., Bazargan, M., and Sangasubana, N. (2010). "A comparison of two educational methods on immigrant Latinas' breast cancer knowledge and screening behaviors." (AHRQ grant HS14022). Journal of Health Care for the Poor and Underserved 21, pp. 76-90.
Although the United States has made great strides educating women about breast cancer screening, such is not the case when it comes to immigrant Hispanic women (Latinas). Many of these women do not get yearly mammograms or perform breast self-examination. The researchers studied two interventions to address these problems. In the first intervention, 200 Latinas participated in focused discussion groups alone. These moderated sessions assessed the women's knowledge about breast cancer and asked about barriers to breast self-examination and mammograms. In the second intervention, another group of 200 Latinas participated in the same discussion groups and also viewed an animated video on breast self-examination and received training in the technique using latex models. Both interventions were successful in increasing the Latinas' knowledge and screening behaviors and were cost-effective.
Calvillo-King, L., Xuan, L., Zhang, S., and others (2010). "Predicting risk of perioperative death and stroke after carotid endarterectomy in asymptomatic patients. Derivation and validation of a clinical risk score." (AHRQ grant HS 09754). Stroke 41, pp. 2786-2794.
National guidelines on carotid endarterectomy (CEA) for asymptomatic patients state that the procedure should be performed with a 3 percent or less risk of perioperative death or stroke. The researchers developed a multivariable model to predict the risk of death and stroke for asymptomatic patients and to create a practical clinical prediction rule that could be used by physicians and patients. Analyzing the results of CEA on 6,555 asymptomatic patients, the researchers found that the perioperative risk of death or stroke was 3 percent. Eight variables were independent predictors of death or stroke: two were sociodemographic, three were nuerologic, and three were cardiac comorbidities. The CEA-8 risk score developed by the researchers stratified patients with a predicted probability of death or stroke rate from 0.6 percent (0 risk score) to 9.6 percent (risk score of 5+).
Cho, A. H., Arar, N. H., Edelman, D. E., and others (2010). "Do diabetic veterans use the Internet? Self-reported usage, skills, and interest in using My HealtheVet web portal." (AHRQ grant T32 HS00079). Telemedicine and e-Health 16(5), pp. 595-602.
Glycemic control for patients with diabetes treated within the Veterans Health Administration continues to be suboptimal. A new study finds that when given the opportunity, many older veterans with diabetes are willing to try using the Internet to help manage their disease. The researchers mailed surveys and received responses from 201 veterans with diabetes who were receiving care at 1 of 5 primary care clinics run by the Veteran Affairs (VA) health care system. Veterans were asked about their Internet usage in the past 30 days. They were also asked about their use of the VA's own Web-based portal, called "My HealtheVet," where vets can enter blood glucose and blood pressure readings, along with other health data.
Chou, R., and Dana, T. (2010, October). "Screening adults for bladder cancer: A review of the evidence for the U.S. Preventive Services Task Force." (AHRQ Contract No. 290-07-0057). Annals of Internal Medicine 153(7), pp. 461-468.
Bladder cancer is the fourth most commonly diagnosed cancer among men and the ninth among women in the United States. For 2009, about 71,000 new cases of bladder cancer are estimated to have been diagnosed, and more than 14,000 patients are estimated to have died of the disease. Risk factors for the disease include older age, male sex, white race, smoking, occupational exposures to carcinogens, certain parasitic infections, and a family or personal history of the disease. A systematic review was conducted to help the United States Preventive Services Task Force update its 2004 evidence review for this condition. The review found that the lack of high-quality controlled studies comparing clinical outcomes of adults screened for bladder cancer with those who were not makes it impossible to recommend use of this screening in primary care without additional research.
Clancy, C. (2011). "As obesity epidemic escalates, need for more screening and counseling grows." Journal of Nursing Care Quality 26(1), pp. 1-3. Reprints (AHRQ Publication No. 11-R039) are available from the AHRQ Publications Clearinghouse.
Despite rising obesity rates, reports from the Agency for Healthcare Research and Quality (AHRQ) show that fewer adults were told by a health care professional that their weight classified them as obese or overweight. Data from AHRQ's National Healthcare Disparities Report show that disparities in access to counseling exist for blacks, Hispanics, the poor, and the uninsured. The new Patient Protection and Affordable Care Act contains provisions that make it easier for Medicare beneficiaries to receive obesity counseling. These expanded benefits are welcome given that Americans now use preventive services at about half the recommended rate, notes the author, director of AHRQ. Bariatric surgery provides one option for reversing the negative effects of obesity and AHRQ-funded research has found that complications from this surgery declined by 21 percent between 2002 and 2006.
Elixhauser, A., and Andrews, R. (2011). "A tool for reporting hospital data on care." Health Affairs 30(3), p. 538. Reprints (AHRQ Publication No. 11-R040) are available from the AHRQ Publications Clearinghouse.
A current project at the Agency for Healthcare Research and Quality (AHRQ) seeks to address the challenges and burdens faced by local and State data organizations in publicly reporting hospital-based quality of care. This project is called MONAHRQ®, short for "my own network, powered by AHRQ." MONAHRQ® 1.0 was released in June 2010. It efficiently analyzes, summarizes, and presents hospital-level information on use and quality of care (using AHRQ quality indicators). MONAHRQ® 2.0 is to be released in 2011. It will add information from the Centers for Medicare & Medicaid Services' Hospital Compare data on 30-day mortality, readmissions, process-of-care measures, and patient assessments, based on the Hospital Consumer Assessment of Healthcare Providers and Systems.
Etchegaray, J. M., and Throckmorton, T. (2010). "Barriers to reporting medication errors: A measurement equivalence perspective." (AHRQ grant HS11544). Quality and Safety in Health Care 19, pp. 1-4.
The Medication Administration Error Reporting (MAER) survey was developed to better understand why medication errors are not reported. The researchers extend previous research on the MAER by examining whether it demonstrates measurement equivalence, an important psychometric property of surveys that health services researchers need to examine prior to making comparisons between groups. Their study involved administering the survey to 435 nurses who were divided into two groups, those with more than 20 years of experience and those with less than 20 years of experience. The results indicate that with the exception of one of the four factors included in the MAER, the MAER appears to measure the factors equivalently across groups. Specifically, more and less experienced nurses disagreed on the definition of medication errors.
Goeschel, C. A., Holzmueller, C. G., Cosgrove, S. E., and others (2010, December). "Infection preventionist checklist to improve culture and reduce central line-associated bloodstream infections." (AHRQ Contract No. 290-06-0002). Joint Commission Journal on Quality and Patient Safety 36(12), pp. 571-575.
Infection preventionists (IPs) play a crucial role in supporting the unprecedented national momentum to reduce healthcare-associated infections. This checklist tool provides explicit activities that IPs should perform to enhance teamwork and collaboration with frontline staff, and to eliminate preventable infections. The checklist includes eight activities representing the Comprehensive Unit-Based Safety Program and nine representing the central line-associated bloodstream infections intervention. The checklist is appropriate for any clinical setting. It is best applied during the initial phase of a national program to align the activities undertaken in the infection control department with the chief executive officer and board of trustees' tasks.
Gordon, J. A., Alexander, E. K., Lockley, S. W., and others (2010, October). "Does simulator-based clinical performance correlate with actual hospital behavior? The effect of extended work hours on patient care provided by medical interns." (AHRQ grant HS12032). Academic Medicine 85(10), pp. 1583-1588.
In 2004, the Harvard Intern Sleep and Patient Safety Study demonstrated that medical interns working in intensive care units committed fewer medical errors when they got more sleep and did not work long (24- to 30-hour) shifts. A simulator-based study of intern performance has yielded very similar results, providing strong evidence for simulation's usefulness in testing medical performance. Boston researchers used an 8-point scale (with 8 representing top marks) to evaluate 17 medical interns' performance on cardiac or pulmonary scenarios in a simulator laboratory, when the interns were well-rested and again after they completed 24- to 30-hour shifts. The authors found that the 17 interns averaged a score of 6 when they were rested, but that score dropped to 5 after they pulled a long shift.
Gregory, P. C., Lam, D., and Howell, P. (2010). "Osteoporosis treatment following hip fracture: How rates vary by service." (AHRQ grant HS17956). Southern Medical Journal 103(10), pp. 977-981.
The National Osteoporosis Foundation guidelines recommend that clinicians consider initiating treatment for osteoporosis (loss of bone mass) in patients who have had a hip or vertebral fracture, to lower the risk of subsequent fractures. However, only 35 percent of patients started any form of osteoporosis treatment during their hospitalization for the fracture, according to this study. A team of researchers examined the medical charts of 191 elderly patients at an academic medical center. They found that both the medicine (58 percent) and rehabilitation services (44 percent) were much more likely than the orthopedic service (12 percent) to initiate osteoporosis treatment. The researchers recommend instituting an osteoporosis consultative service to improve the likelihood of starting osteoporosis treatment in patients who have suffered a fragility fracture.
Guise, J.-M., Lowe, N. K., Deering, S., and others (2010, October). "Mobile in situ obstetric emergency simulation and teamwork training to improve maternal�fetal safety in hospitals." (AHRQ grant HS15800). The Joint Commission Journal on Quality and Patient Safety 36(10), pp. 443-453.
A simulator initiative was developed, in part, to address a crisis in obstetric care in Oregon, where a 2002 survey indicated that a third of maternity providers (66 percent of whom were rural) planned to stop delivering babies in the next 1�5 years. While there are a number of permanently located simulation centers, the cost of travel, limitations on the number of team members who could be spared for training, and other factors made this option less attractive to teams from smaller hospitals. In contrast, a mobile simulation can run using two rooms (one housing the simulation setup and one for debriefing the team members) at the hospital, allowing team members to work in a familiar setting, with supplies organized in a recognizable way. The researchers found that mobile simulators can bring to rural and community hospitals hands-on experience in handling rare childbirth emergencies as well as an opportunity for improving teamwork skills.
Hersh, A. O., Trupin, L., Yazdany, J., and others (2010, August). "Childhood-onset disease as a predictor of mortality in an adult cohort of patients with systemic lupus erythematosus." (AHRQ grant 13893). Arthritis Care & Research 62(8), pp. 1152-1159.
Systemic lupus erythematosus (lupus) is a chronic, inflammatory disorder of the immune system that disproportionately affects women and minorities. Researchers analyzed data from the California Lupus Outcomes Study on 957 adults with lupus, including 98 individuals who were diagnosed with the disorder as children. After a median followup of 4 years, there were 72 deaths. Of these, nine individuals had been diagnosed with lupus in childhood. When they adjusted for age, the researchers found that the adults with childhood-onset lupus were at increased risk for mortality during the followup period. There was no association between mortality and ethnicity. Those who died tended to be older, male, and have a longer duration of disease. They also were more likely to have less education, be below the poverty line, and be covered by Medicare or Medicaid.
Johnson, K. B., Ho, Y.-X., Cala, C. M., and Davison, C. (2010). "Showing your work: Impact of annotating electronic prescriptions with decision support results." (AHRQ grant HS16261). Journal of Biomedical Informatics 43, pp. 321-325.
Electronic prescribing systems with decision support provide important safety features to patients, pharmacists, and clinicians. For example, the ability of physicians to annotate prescriptions automatically with explanatory notes can convey to the pharmacist such things as dose calculations and warnings. A recent study, using such a system, increased communication between physicians and pharmacists, resulting in improved patient safety. The study looked at the success of "Show Your Work" (SYW), a system at one institution that allows prescribers to add notes below each medication order. Researchers turned this feature on and off on various days. Three pharmacies were selected to complete and submit callback logs each day. When the SYW system was on, the callback rate was 45 callbacks/1,000 prescriptions and when SYW was off and unavailable, the callback rate was 40 callbacks/1,000 prescriptions. With 38 surveys returned, most pharmacies felt that the SYW had a favorable impact on callbacks (69 percent).
Kaufman, A. V., Kosberg, J. I., Leeper, J. D., and others (2010, April). "Social support, caregiver burden, and life satisfaction in a sample of rural African American and white caregivers of older persons with dementia." (AHRQ grant HS13189). Journal of Gerontological Social Work 53(3), pp. 251-269.
This study found that certain demographic factors and coping strategies improved the quality of life of 141 family caregivers of persons with dementia in rural Alabama. The researchers analyzed four dimensions of social support based on results for the widely used Interpersonal Support Evaluation List (ISEL). Female caregivers reported significantly higher mean scores than males for three of the four ISEL dimensions of social support (tangible support from others, belonging to a network of persons to talk to or socialize with, and obtaining self-esteem from others). Self-esteem and belonging accounted for 32 percent of the variance in the caregivers' reported quality of life.
Kim-Hwang, J. E., Chen, A. H., Bell, D. S., and others (2010). "Evaluating electronic referrals for specialty care at a public hospital." (AHRQ Contract No. 290-06-0017). Journal of General Internal Medicine 25(10); pp. 1123-1128.
Existing referral processes involve verbal or paper-based methods that often provide vague reasons for the specialist consult, inadequate pre-referral clinical or laboratory investigation of the patient's problems, and delayed communication between the primary care provider and specialist. The researchers developed and implemented eReferral, a Web-based program embedded in the electronic health record at San Francisco General Hospital, to allow a structured review process for new referrals to a hospital's specialty clinics. Specialists reported the reason for referral was difficult to determine in 19.8 percent of medical and 38 percent of surgical referrals using the paper-based system compared with 11 percent and 9.5 percent, respectively, after implementation of eReferral. The researchers concluded that the eReferral system increases the effectiveness of the specialty referral.
Leipzig, R. M., Whitlock, E. P., Wolff, T. A., and others (2010). "Reconsidering the approach to prevention recommendations for older adults." Annals of Internal Medicine 153, pp. 809-814. Reprints (AHRQ Publication No. 11-R038) are available from the AHRQ Publications Clearinghouse.
Many U.S. Preventive Services Task Force (USPSTF) recommendations focus on prevention through the early identification of specific diseases with clearly defined risk factors or opportunities for early intervention. Using the current USPSTF approach for older adults has not been easy, because many geriatric disorders have multifactorial risk factors, interventions, and expected outcomes. The USPSTF is developing new methods to review evidence and make recommendations for the geriatric population: addressing aging-specific issues to disease prevention in older adults; expanding and adapting its typical analytic framework to better recognize the multifactorial nature of selected geriatric syndromes and their interventions; addressing the outcomes that are important to patients; and building recommendations on related topics.
Lomotan, E. A., Michel, G., Lin, Z., and others (2010). "How �should' we write guideline recommendations? Interpretation of deontic terminology in clinical practice guidelines: Survey of the health services community." (AHRQ grant HS10045). Quality and Safety in Health Care 19, pp. 509-513.
An understanding of how readers interpret deontic terminology (words such as "should," "may," "must," and "is indicated") may allow guideline developers to strengthen the connection between guideline language and expected adherence to guideline recommendations, suggest the authors of this study. They surveyed registrants at the 2008 annual conference of the Agency for Healthcare Research and Quality. Of the 445 respondents, 57 percent reported experience in developing clinical practice guidelines and 33 percent indicated that they provide health care. The results of the survey were that "must" conveyed the highest level of obligation and least amount of variability. "May" and "may consider" conveyed the lowest level of obligation. All other terms conveyed intermediate levels of obligation. These results suggest that three separate levels of recommendation strength should be available to guideline developers. As long as terms conveying distinct levels of obligation were chosen, guideline developers could take advantage of a natural ranking of deontic terms.
Makary, M. A., Clarke, J. M., Shore, A. D., and others (2010). "Medication utilization and annual health care costs in patients with type 2 diabetes mellitus before and after bariatric surgery." (AHRQ Contract No. 290-05-0034). Archives of Surgery 145(8), pp. 726-731.
A new study finds that bariatric surgery for obesity reduces medication use in patients with type 2 diabetes and lowers their overall health care costs. The majority of individuals (85.8 percent) studied were taking at least one diabetes medication for 3 months prior to having bariatric surgery. Six months after surgery, this fell dramatically to 25.3 percent. At the end of 3 years, health care costs per person were reduced by 70.5 percent. The researchers conclude that private and public insurers, including Medicaid, should pay for bariatric surgery in appropriate patient candidates. The researchers identified from commercial insurance claims 2,235 adults with type 2 diabetes who underwent bariatric surgery between 2002 and 2006.
Mukamel, D. B., Spector, W. D., Zinn, J., and others (2010, October). "Changes in clinical and hotel expenditures following publication of the Nursing Home Compare report card." Medical Care 48(10), pp. 869-874. Reprints (AHRQ Publication No. 11-R001) are available from the AHRQ Publications Clearinghouse.
Nursing homes have two large categories for spending. Hotel expenses include room, board, and building maintenance, while clinical service expenses cover all health-related care. Starting in 2002, when the Nursing Home Compare Web site began publishing report cards based on the less-observable clinical services, nursing homes increased funding for clinical services to attract future residents, a new study finds. A team of researchers determined that after the Nursing Home Compare report cards were published, the ratio of clinical to hotel services for 10,022 nursing homes increased 5 percent from 2001 to 2006. For instance, prereport card ratios were 1.71 and 1.72 in 2001 and 2002, respectively, but 1.76, 1.84, and 1.85 in 2003, 2004, and 2005, respectively. The increase in spending for clinical services was most notable in nursing homes that had poor reported quality, had low occupancy, were in competitive markets, were for profit, and were part of a chain of nursing homes.
Nishisaki, A., Donoghue, A., Ferry, S., and others (2010, December). "Just-in-time (JIT) tracheal intubation simulation training for pediatric residents phase II: Retention of resident participation and provider safety performance after discontinuation of JIT training." (AHRQ grant HS16678). Simulation in Healthcare 5(96), p. 405.
The researchers evaluated retention of resident tracheal intubation participation, success, and patient safety for 18 months after the Just-in-Time pediatric tracheal intubation training interventions were discontinued. During Phase I, pediatric intensive care unit residents received 20 minutes of multidisciplinary simulation-based tracheal intubation overtraining, and 10 minutes of psychomotor skill refresher training prior to their 24-hour on-call period. In their study, including 181 primary orotracheal intubations (Phase I) and 316 during Phase II, the researchers found that resident participation significantly decreased (from 36 to 27 percent). However, first attempt success and overall success rates did not significantly change.