Research Activities, March 2012, No. 379
Ash, J.S., Sittig, D.F., Wright, A., and others (2011). "Clinical decision support in small community practice settings: A case study." (AHRQ Contract No. 290-2008-10010). Journal of the Medical Informatics Association 18, pp. 879-882.
This case study describes an independent practice association that has implemented a commercial electronic health record system with clinical decision support (CDS). A multi-disciplinary team of investigators identified barriers and facilitators to CDS implementation. An eight-dimensional model proved useful as an organizing structure for the evaluation.
Brady, J., Ho, K., and Clancy, C.M. (2011). "The Quality and Disparity Reports: Why is progress so slow?" American Journal of Medical Quality 23, pp. 396-398. Reprints (AHRQ Publication No. 12-R029) are available from the
AHRQ Publications Online Store
The authors emphasize that the rate of quality improvement in American health care is modest and appears to be slowing. They note that the annual quality and disparity reports published by the Agency for Healthcare Research and Quality, which show variations in quality from State to State, reveal opportunities for improvement. They also emphasize that patient safety results show slow improvement and that significant disparities in care exist for minorities. In addition to geography and minority status, age, income, and insurance status are important factors in care disparities.
Chang, S.M. (2011). "The Agency for Healthcare Research and Quality Effective Health Care Program Methods Guide for Comparative Effectiveness Reviews: Keeping up-to-date in a rapidly evolving field." Journal of Clinical Epidemiology 64, pp. 1166-1167. Reprints (AHRQ Publication No. 12-R022) are available from the
AHRQ Publications Online Store
The Agency for Healthcare Research and Quality Methods Guide is a collaborative effort among participating scientists to identify the best methods for conducting systematic reviews on comparative effectiveness of medical interventions. The author introduces five papers in this issue of the journal that nearly completes version 1.0 of the guide. These articles address areas of unnecessary variation, uncertainty, and areas of controversy raised by peer or public review of early comparative effectiveness reviews.
Crabtree, B.F., Nutting, P.A., Miller, W.L., and others (2011, December). "Primary care practice transformation is hard work. Insights from a 15-year developmental program of research." (AHRQ grant HS8776). Medical Care 49(12), Suppl. 1, pp. S28-S35.
The authors highlight critical findings from a 15-year developmental program aimed at enhancing quality of care in primary care practice. Based on studying over 350 primary care practices, the program's results show that these practices are very complicated small organizations with multiple competing demands, dual hierarchies, and challenging relationship systems. The authors conclude that a theoretical framework guided by complexity science can help in the development of quality improvement strategies.
Curtis, J.R. (2011). "Improving osteoporosis care through multimodal interventions: Insights from the University of Alabama at Birmingham Center for Education and Research on Therapeutics." (AHRQ grants HS18517, HS20144). Osteoporosis International 22(9), Suppl. 3, S445-S450.
One aspect of translational research, sometimes called evidence implementation or implementation science, applies what has been learned about clinical medicine to achieve best practices across providers and health systems. The author describes evidence implementation as applied to osteoporosis care, drawing from several published or ongoing studies to illustrate challenges and potential solutions to improving the quality of osteoporosis care. He concludes that a systems-based team approach engaging patients and providers is likely to be most effective.
Dahabreh, I.J., Hadar, N., and Chung, M. (2011). "Emerging magnetic resonance imaging technologies for musculoskeletal imaging under loading stress: Scope of the literature." (AHRQ Contract No. 290-07-100551). Annals of Internal Medicine 155, pp. 616-624.
The authors review 57 studies about magnetic resonance imaging (MRI) for musculoskeletal conditions performed in an upright or sitting position or under axial load by using a compression device. They find that research on this type of MRI, known as a stress-loading MRI, is at an early developmental state with most studies focusing on non-clinically relevant endpoints. Therefore, its use should probably be considered experimental.
Ford, C.A., Davenport, A.F., Meier, A., and McRee, A.-L. (2011). "Partnerships between parents and health care professionals to improve adolescent health." (AHRQ grant HS16021). Journal of Adolescent Health 49, pp. 53-57.
The study objective was to combine the perspectives of parents, health care professionals (HCPs), and adolescents to develop a framework for future parent-HCP partnership research to improve adolescent health. Using focus groups and in-depth semi-structured interviews, the researchers explored the perceptions of HCPs and mothers regarding the roles of parents, HCPs, and parent-HCP partnerships in preventing and addressing adolescent health problems. Also discussed are a number of direct and indirect strategies to improve adolescent health.
Fu, R., Gartlehner, G., Grant, M., and others (2011). "Conducting quantitative synthesis when comparing medical interventions: AHRQ and the Effective Health Care Program." Journal of Clinical Epidemiology 64, pp. 1187-1197. Reprints (AHRQ Publication No. 12-R024) are available from the
AHRQ Publications Online Store
The article summarizes the authors' recommendations in conducting quantitative synthesis of comparative effectiveness research for therapeutic benefits and harms for the Effective Health Care Program with the goal to improve consistency and transparency. The recommendations cover recurrent issues in the Evidence-based Practice Center Program and focus on methods for combining study-level effect measures.
Giardina, T.D., and Singh, H. (2011, December). "Should patients get direct access to their laboratory test results? An answer with many questions." (AHRQ grant HS17820). Journal of the American Medical Association 306(22), pp. 2502-2503.
The U.S. Department of Health and Human Services has proposed a new rule allowing patients to access test results directly from the laboratory by request. Currently, there is a lack of consensus in the literature about best practices in direct patient notification of abnormal results. The authors of this commentary consider patient and clinician perspectives on the potential effects of this approach and lay the groundwork for issues to consider in the implementation of this proposed rule.
Groeneveld, P.W., Epstein, A.J., Yang, F., and others (2011). "Medicare's policy on carotid stents limited use to hospitals meeting quality guidelines yet did not hurt disadvantaged." (AHRQ grant HS18403). Health Affairs 30(2), pp. 312-321.
In 2005, Medicare began covering the use of carotid stents to treat arterial blockages under an innovative policy requiring hospitals to meet quality-of-care benchmarks before seeking reimbursement. The researchers' analysis shows that although 28-32 percent fewer hospitals offered stents than offered other types of interventional cardiovascular procedures, stents were no less available in areas with substantial poor, black, or rural populations than they were in other areas.
Guyatt, G.H., Oxman, A.D., Sultan, S., and others (2011). "GRADE guidelines: 9. Rating up the quality of evidence." Journal of Clinical Epidemiology 64, pp. 1311-1316. Reprints (AHRQ Publication No. 12-R027) are available from the
AHRQ Publications Online Store
The authors examine the criteria for rating up the quality of evidence. The three primary reasons are: (1) when a large magnitude of effect exists, (2) when there is a dose-response gradient, and (3) when all plausible confounder or other biases increase confidence in the estimate effect. Rarely, other considerations that do not easily fit into the above categories may constitute reasons for rating up quality of evidence.
Halpern, S.D. (2011, October). "Financial incentives for research participation: Empirical questions, available answers, and the burden of further proof." (AHRQ grant HS18406). American Journal of the Medical Sciences 342(4), pp. 290-293.
Although paying patients and healthy volunteers for research participation is both effective and common, the practice remains controversial. The author considers the legitimate concerns about this practice, reviews the data that substantiate or repudiate these concerns, and considers the potential ethical merits of financial incentives. He concludes that the available data call into question each of the legitimate concerns and finds that restrictions on financial practices carry ethical problems of their own.
Han, H.-R., Chan, K., Song, H., and others (2011, October). "Development and evaluation of a hypertension knowledge test for Korean hypertensive patients." (AHRQ grant HS13160). Journal of Clinical Hypertension 13(10), pp. 750-757.
The researchers developed the High Blood Pressure Knowledge Test (HKT) and assessed its utility, reliability, and validity in a population of Korean Americans. Item difficulty and item discrimination were evaluated for each of the HKT's 24 items. The researchers found that the HKT is sensitive to differences in blood pressure control status and should provide a valid, reliable, and standardized measure of high blood pressure with wide relevance.
Hernandez, A.F. and Granger, C.B. (2012, January). "Prediction is very hard. Especially about the future." (AHRQ grant HS16964). Archives of Internal Medicine 172(2), pp.117-119.
Health systems have devoted increased resources to reducing readmissions following specific conditions, such as heart failure, acute myocardial infarction, and pneumonia. There is an urgent need to understand reasons for readmission and to define preventable readmissions. The authors comment on an article in the same issue that describes factors associated with 30-day readmission rates for percutaneous coronary intervention.
Hollenbeck, B.K. and Nallamothu, B.K. (2011). "Financial incentives and the art of payment reform." (AHRQ grant HS18726). Journal of the American Medical Association 306(18), pp. 2028-2030.
The authors discuss an article in the same issue that finds that physicians who provide and bill for a service (in this case, cardiac stress imaging) tend to do more of it. At issue here is the oft-debated controversy surrounding physician self-referral and its associated financial incentives, which are governed by the Stark laws. The authors argue that regulation is imperfect and that in the current era of health care reform, the focus should be less about eliminating incentives and more about getting the price right.
Huybrechts, K.F., Brookhart, M.A., Rothman, K.J., and others (2011). "Comparison of different approaches to confounding adjustment in a study on the association of antipsychotic medication with mortality in older nursing home patients." (AHRQ grants HS17918, HS16097). American Journal of Epidemiology 174(9), pp. 1089-1099.
Selective prescribing of conventional antipsychotic medication to frailer patients is thought to have led to overestimation of the association with mortality in pharmacoepidemiologic studies relying on claims data. The authors assessed the validity of different analytic techniques to address such confounding. Their results suggest that residual confounding has a relatively small impact on the effect estimate.
Jean-Jacques, M., Persell, S.D., Hasnain-Wynia, R., and others (2011). "The implications of using adjusted versus unadjusted methods to measure health care disparities at the practice level." (AHRQ grant HS17163). American Journal of Medical Quality 26(6), pp. 491-501.
Simple stratified data do not allow one to assess how much of the observed differences between groups are directly related to the characteristic of interest (e.g., race) or to other confounding variables such as racial differences in health insurance or burden of illness. The authors suggest that health care organizations should consider the routine use of adjusted methods to measure disparities in order to better inform disparity-reduction initiatives.
Kozhimannil, K.B., Adams, A.S., Soumerai, S.B., and others (2011). "New Jersey's efforts to improve postpartum depression care did not change treatment patterns for women on Medicaid." (AHRQ grant HS10391). Health Affairs 30(2), pp. 293-301.
Low-income women enrolled in State Medicaid programs may be at increased risk for developing postpartum depression. New Jersey was the first State to mandate screening for postpartum depression and also have an outreach and education campaign. This study looks at the effects of New Jersey's mandate and campaign on postdelivery use of mental health services in Medicaid enrollees.
Li, Q., Glynn, R.J., and Dreyer, N.A. (2011). "Validity of claims-based definitions of left ventricular systolic dysfunction in Medicare patients." (AHRQ Contract No. 290-05-0016, grant HS17731). Pharmacoepidemiology and Drug Safety 20, pp. 700-708.
This study evaluated the validity of claims-based definitions for systolic dysfunction (SD) and assessed misclassification bias from the claims-based definitions in two hypothetical comparative/clinical effectiveness studies. It found that claims-based definitions for SD had excellent specificity and good positive predictive value (PPV) but low sensitivity. Relatively small misclassification bias would result if definitions with good PPV could be used for cohort identification or confounding adjustment by restriction.
Ma, Y. and Mazumdar, M. (2011). "Multivariate meta-analysis: A robust approach based on the theory of U-statistic." (AHRQ grant HS16075). Statistics in Medicine 30, pp. 2911-2929.
The researchers propose a new nonparametric and non-iterative method for multivariate meta-analysis on the basis of the theory of U-statistic and compare the properties of three procedures under both normal and skewed data through simulation studies. They show a marginal effect on estimates from restricted maximum likelihood because of non-normal data distribution, and that the estimates from a multivariate method of moments and U-statistic-based approaches are very similar.
McCullough, E., Sullivan, C., Banning, P., and others (2011). "Challenges and benefits of adding laboratory data to a mortality risk adjustment method." (AHRQ grant HS10042). Quality Managed Health Care 20(40), pp. 253-262.
This study assessed the feasibility of linking separate electronic feeds of laboratory data and claims-based information and, if successful, to identify laboratory data elements that significantly improved mortality rate predictions. It found that the addition of 11 clinical laboratory test results increased the C statistic by 0.574 percent and R2 by 4.53 percent. The researchers concluded that this linkage resulted in a modest improvement in a commonly used risk of mortality tool.
McHugh, M.D., Kutney-Lee, A., Cimiotti, J.P., and others (2011). "Nurses' widespread dissatisfaction, burnout, and frustration with health benefits signals problems for patient care." (AHRQ grants HS17550, HS18534). Health Affairs 30(2), pp. 202-210.
In order to understand burnout and job satisfaction among nurses in both patient care and non-patient care roles, the researchers analyzed a survey of over 95,000 nurses. They found that nurses in direct patient care roles in hospitals and nursing homes had much higher job dissatisfaction and burnout than nurses in other roles. Nurses were particularly dissatisfied with their health benefits. Patient satisfaction levels were lower in hospitals where more nurses were dissatisfied or burned out.
Morgan, D.J., Okeke, I.N., Laxminarayan, R., and others (2011, September). "Non-prescription antimicrobial use worldwide: A systematic review." (AHRQ grant HS18111). The Lancet 11, pp. 692-711.
This systematic review was undertaken to quantify the global frequency and effect of non-prescription antimicrobial use. The authors identified 117 relevant articles published between 1970 and 2009, including 35 community surveys from five continents showing that non-prescription drug use accounted for 19 to 100 percent of antimicrobial use outside of northern Europe and North America. Other specific issues discussed include safety, drug resistance, and anti-tuberculosis drugs.
Mutter, R.L., Rosko, M.D., Grene, W.H., and Wilson, P.W. (2011). "Translating frontiers into practice: Taking the next steps toward improving hospital efficiency." (AHRQ Contract No. 233-08-00267P). Medical Care Research and Review 68, Suppl. 1, pp. 3S-19S. Reprints (AHRQ Publication No. 12-R028) are available from the
AHRQ Publications Online Store
This article is the introduction to a special issue of this journal sponsored by the Agency for Healthcare Research and Quality. It provides an overview of the issue, the aim of which is to assess the state of the science of using frontier techniques to measure provider efficiency and to identify steps that can be taken to increase accessibility to end users. Individual articles review the contributions made using these techniques, identify where gaps remain, and offer examples of the use of frontier approaches that hold promise for the future.
Norris, S.L., Holmer, H.K., Ogden, L.A., and Burda, B.U. (2011, October). "Conflict of interest in clinical practice guideline development: A systematic review." (AHRQ grant HS18550). PLoS ONE 6(10), p. e25153.
Conflict of interest (COI) is one important source of bias in the development of clinical practice guidelines (CPGs). This systematic review identified 12 studies reporting on this issue. All of the studies reported financial relationships between guideline authors and the pharmaceutical industry. However, no empirical data on the effect of COI on recommendations in CPGs was identified.
Norris, S.L., Atkins, D., Bruening, W., and others (2011). "Observational studies in systemic review of comparative effectiveness: AHRQ and the Effective Health Care Program." Journal of Clinical Epidemiology 64, pp. 1178-1186. Reprints (AHRQ Publication No. 12-R023) are available from the
AHRQ Publications Online Store
The Agency for Healthcare Research and Quality convened a workgroup to address the role of observational studies in comparative effectiveness reviews (CERs). It is unusual to find sufficient evidence from randomized controlled trials to answer all key questions about benefits or the balance of benefits and harms for certain medical interventions. Thus, the group concluded that the default approach for CERs should be to consider observational studies for questions of benefit or intended effects of interventions.
Rattanaumpawan, P., Tolomeo, P., Bilker, W.B., and Lautenbach, E. (2011). "A clinical prediction rule for fluoroquinolone resistance in healthcare-acquired gram-negative urinary tract infection." (AHRQ grant HS10399). Infection Control and Hospital Epidemiology 32(11), pp. 1125-1126.
Development of a clinical prediction score to identify those patients who are most likely to be infected with a fluoroquinolone-resistant gram negative urinary tract infection would be useful for optimizing empirical antibiotic therapy. The researchers developed a clinical prediction rule which they believe is a promising tool and provides the opportunity to optimize therapy for this condition.
Robinson, K.A., Saldanha, I.J., and Mckoy, N.A. (2011). "Development of a framework to identify research gaps from systematic reviews." (AHRQ Contract No. 290-07-10061). Journal of Clinical Epidemiology 64, pp. 1325-1330.
The authors developed a framework to facilitate the identification and characterization of research gaps from systematic reviews. The framework provides for the classification of where, how, and why the current evidence falls short. It characterizes a gap using PICOS (population, intervention, comparison, outcomes, settings) elements. The framework then identifies the reasons why the gap exists as insufficient or imprecise information, biased information, inconsistency or unknown consistency, or not the right information.
Sawchuk, C.N., Russo, J.E., Charles, S., and others (2011). "Does pedometer goal setting improve physical activity among native elders? Results from a randomized pilot study." (AHRQ grant HS10854). American Indian and Alaska Native Mental Health Research 18(1), pp. 23-41.
The researchers conducted a pilot study using pedometers to increase walking, physical activity, and fitness levels over 6 weeks among American Indian and Alaska Native primary care patients. Outcomes included step counts, self-reported physical activity and well-being, and performance on the 6-minute walk test. Elders significantly improved on the majority of outcomes.