Research Activities, May 2011, No. 369
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(2), pp. 167-173. Reprints (AHRQ Publication No. 11-R033) are available from the AHRQ Publications Clearinghouse.
Identifying where racial and ethnic health care disparities occur is important for targeting interventions to eliminate disparities. To do this, State and local public health officials and community health planners need data on population health and health care services for each racial and ethnic group. The author examined the extent of race-ethnicity coding in statewide hospital discharge data systems, compared it with national standards, and assessed the completeness and accuracy of race-ethnicity data collected in these systems. Information from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project State Inpatient Databases was the primary source of data for the study. Results showed that race data collections increased from 14 to 43 States between 1991 and 2008. In 2008, 20 States conformed to the 1997 Office of Management and Budget (OMB) standard, 4 did not collect Hispanic ethnicity, 19 used the 1997 OMB standard, 10 collected multiracial data, and 3 collected detailed racial-ethnic data.
Brown, J. S., Holmes, J. H., Shah, K., and others (2010, June). "Distributed health data networks. A practical and preferred approach to multi-institutional evaluations of comparative effectiveness, safety, and quality of care." (AHRQ Contract No. 290-05-0033). Medical Care 48(6 Suppl. 1), pp. S45-S51.
To address the need to evaluate the processes and outcomes of care of large populations, some propose creation of large, centralized, multipayer claims databases. An alternative is one or more distributed research networks that permit comparative effectiveness and other evaluations across multiple databases without creation of a central data warehouse. The researchers describe the design and pilot implementation of a distributed research network infrastructure intended to meet the broad needs of all parties for comparative effectiveness evaluation and other uses. The pilot successfully evaluated temporal trends in medication use and diagnoses at five separate sites, demonstrating some of the possibilities of using a distributed research network.
Chien, A. T., Kirchhoff, A. C., Schaefer, C. T., and others (2010, December). "Positive and negative spillovers of the health disparities collaboratives in federally qualified health centers." (AHRQ grants HS13625, HS10479, HS17146). Medical Care 48(12), pp. 1050-1056.
Since 1998, federally qualified health centers (FQHC) have participated in the Health Disparities Collaboratives (HDC), a large-scale quality improvement intervention sponsored by the Health Resources and Services Administration. Although HDCs have been evaluated for their intended effects on conditions such as asthma and diabetes, little is known about whether they engender positive or negative spillover effects in non-HDC clinical care or organizational function. The researchers surveyed team leaders at 135 FQHCs. Nearly half (45 percent) of respondents indicated that the HDC increased quality of care delivered to patients with chronic conditions not emphasized by the HDC. Only 5 percent responded that the HDC had diminished the quality of care. Large majorities of respondents signified that the HDC increased the ability of FQHCs to manage patients with multiple chronic conditions during a routine office visit (76 percent) and acute care visit (67 percent).
Chung, M., Balk, E. M., Ip, S., and others (2010). "Systematic review to support the development of nutrient reference intake values: Challenges and solutions." (AHRQ Contract No. 290-2007-10055). American Journal of Clinical Nutrition 92, pp. 273-276.
Dietary Reference Intake values are the nutrient reference values issued by the Institute of Medicine (IOM) of the National Academy of Sciences. The IOM and others have proposed that systematic reviews of the evidence should be used when revising the DRIs. The authors describe the basic process used in the first example of including a systematic review in the process of updating nutrient reference values, the major issues and challenges encountered summarizing large bodies of evidence for two nutrients with multiple health outcomes, and the solutions used to best support the IOM panel. They resolved the challenges by working with a technical expert panel to prioritize and select outcomes of interest, developing methods to use existing systematic reviews, translating results from studies not designed to address issues of interest by using a transparent process, and establishing tailored quality assessment tools to assist in decisionmaking.
Clancy, C. M. (2010, October). "Patient safety and medical liability reform: Putting the patient first." Patient Safety and Quality Healthcare, pp. 6-7. Reprints (AHRQ Publication No. 11-R035) are available from the AHRQ Publications Clearinghouse.
The goal of the Patient Safety and Medical Liability Reform Initiative is improving the overall quality of care by making patient safety the primary goal. Among the 20 grants under this program, some support the development of State-endorsed, evidence-based care guidelines, the promotion of transparency and enhanced communication between providers and patients, and early disclosure and offers of prompt compensation. In addition, the Agency for Healthcare Research and Quality (AHRQ) has produced and disseminated tools and resources to support safe practices. Working with the Department of Defense, AHRQ has developed an evidence-based curriculum and training support for teamwork improvement called TeamSTEPPS. AHRQ Director Carolyn M. Clancy, M.D., is optimistic that these and other AHRQ-funded projects will produce measurable improvements in safety for patients and help bring rationality and fairness to our medical liability system.
Crystal, S., Gaboda, D., Lucas, J., and others (2010, June). "Assessing medication exposures and outcomes in the frail elderly. Assessing research challenges in nursing home pharmacotherapy." (AHRQ grants HS16097, HS11825). Medical Care 48(6 Suppl. 1), pp. S23-S31.
Within the nursing home population, a standardized electronic health record, the Minimum Data Set (MDS), provides unique opportunities for comparative effectiveness research. The MDS includes measures of patients' physical, psychological, and psychosocial functioning and active clinical diagnoses. When these data are merged with diagnosis, treatment, and outcome information from Medicare/Medicaid claims, they create great potential for examining patterns of medication use and select outcomes. The authors describe these datasets, present the strengths and challenges of using merged data about the nursing home population to study prescription drug exposures and outcomes in the frail elderly, and suggest strategies to address methodological difficulties. They conclude that merged data from nursing home sources can support unique study designs in comparative effectiveness research and provide great power. However, such studies pose many challenging design and analytic issues.
Glickman, S. W., Delgado, M. K., Hirshon, J. M., and others (2010). "Defining and measuring successful emergency care networks: A research agenda." Academic Emergency Medicine 17(12), pp. 1297-1305. Reprints (AHRQ Publication No. 11-R034) are available from the AHRQ Publications Clearinghouse.
In June 2010, the journal Academic Emergency Medicine convened a consensus conference on emergency care titled "Beyond Regionalization: Integrated Networks of Emergency Care." Its goal was to create a research agenda to support the development of the Institute of Medicine's vision of regionalized, coordinated, and accountable emergency care systems. This article explores the concept of integrated emergency care delivery and prioritizes a research agenda for how to best define and measure successful networks of emergency care. It focuses on the following five key areas: (1) the fundamental metrics that measure networks across time-sensitive and non-time-sensitive conditions, (2) how a network can be scalable and nimble and creative in terms of best practices, (3) the potential unintended consequences of networks of emergency care, (4) the development of large-scale, yet feasible, network data systems, and (5) the promotion of linkage of data systems across the disease course.
Howell, E. A., Holzman, I., Kleinman, L. C., and others (2010, September). "Surfactant use for premature infants with respiratory distress syndrome in three New York City hospitals: Discordance of practice from a community clinician consensus standard." (AHRQ grant HS10859). Journal of Perinatology 30(9), pp. 590-595.
Surfactant therapy prevents the development of respiratory distress syndrome (RDS) in many premature infants and shortens the course of RDS in others. A research team from Mt. Sinai Hospital in New York City sought to assess concordance with a locally developed standard of care for premature infants with RDS. The standard recommends treatment within 2 hours of birth. The subjects of the retrospective study were 773 infants weighing <1750 grams born in 3 New York City hospitals between 1999 and 2002. Of the 227 infants with signs of RDS at 2 hours of age, 37 percent received surfactant. At the 4-hour time point, 70 percent of the low-birth-weight babies who had shown signs of RDS had received surfactant. Eighty-five percent of white infants with RDS had received surfactant compared with 67 percent of Latino and 61 percent of black infants. If these findings are generalizable, the researchers believe there is a large opportunity to reduce infant morbidity from RDS and also to reduce racial/ethnic disparities in birth outcomes.
Lohr, K. N. (2010, June). "Comparative effectiveness research methods. Symposium overview and summary." (AHRQ Contract No. 290-05-0036). Medical Care 48(6 Suppl.1), pp. S3-S6.
The author offers an overview and summary of a symposium on research methods for comparative effectiveness studies sponsored by AHRQ in June 2009. The conference emphasized three thematic areas: study design and data collection, statistics and analytic methods, and policy issues and applications. The conference papers discussed these major areas of comparative effectiveness research (CER). Both primary data collection and analyses of databases (including electronic health records and distributed networks) are crucial for the comparative effectiveness agenda. Advances in research methods enable investigators to pay greater attention to important population subgroups, including persons of low literacy, non-English speaking patients, or the frail elderly. Both established and newer statistical techniques—e.g., propensity scoring and various types of modeling, including Bayesian approaches—offer analysts improved ways to address issues such as confounding and measurement bias. Finally, some papers provided guidance for and examples of extending CER into newer realms, such as evaluations of medical devices or surgical procedures.
Lorch, S. A., Myers, S., and Carr, B. (2010, December). "The regionalization of pediatric health care." (AHRQ grants HS15696, HS17960). Pediatrics 126(6), pp. 1182-1190.
Regionalization improves patient outcomes through two primary mechanisms: improved outcomes at high-volume, high-specialty centers and improved coordination of care within a given geographic area, assert the authors of this paper. They present a conceptual framework for the development of regionalized health care systems, describe types of evidence for regionalized systems, describe the overall deficiencies in the current literature, and outline a plan for future research. The authors use neonatal intensive care and pediatric trauma care as examples for other pediatric conditions that, in the future, may be amenable to a more regionalized approach to care.
Mukherjee, B., Ou, H-T., Wang, F., and Erickson, S. R. (2011). "A new comorbidity index: The health-related quality of life comorbidity index." (AHRQ grant HS17461). Journal of Clinical Epidemiology 64, pp. 309-319.
Comorbidity is the existence or occurrence of any distinct additional disease or diseases during the clinical course of a patient who has an index disease under study. A comorbidity index (CI) is a weighted measure that, when conducting statistical analyses, will control for the potential influence of those illnesses on an outcome of interest. The purpose of this study was to derive and validate a CI using diseases that have the greatest association with health-related quality of life (HRQL). A secondary goal was to use the Medical Expenditure Panel Survey database to compare the results of explanatory models that use the new index derived with a CI originally derived to predict mortality and health care resources use, the Charlson-CI. The study used a rigorous statistical approach to construct and validate a new HRQL-CI that outperformed the Charlson-CI.
Freedman, A. N., Sansbury, L. B., Figg, W. D., and others (2011). "Cancer pharmacogenomics and pharmacoepidemiology: Setting a research agenda to accelerate translation." Journal of the National Cancer Institute 102(22), pp. 1698-1705. Reprints (AHRQ Publication No. 11-R036) are available from the AHRQ Publications Clearinghouse.
Recent advances in genetic technology, combined with new discoveries in pharmacogenomics, have shed light on the substantial role of genomic factors to predict drug response and the clinical potential of genomic testing. To identify research priorities as well as the resources and infrastructure needed to advance these fields, the National Cancer Institute sponsored a workshop titled "Cancer Pharmacogenomics: Setting a Research Agenda to Accelerate Translation," in 2009. This article discusses five science-based recommendations and four infrastructure-based recommendations emanating from the workshop. These included ways to rapidly translate the results of bench research into medical practice and ways to test hypotheses generated from epidemiological and clinical investigations in the laboratory. Together, these complementary and interacting approaches will help to realize the benefits of a personalized approach to cancer treatment and prevention.
Halpern, S. D., Barnes, B., Hasz, R. D., and Abt, P. L. (2010, December). "Estimated supply of organ donors after circulatory determination of death: A population-based cohort study." (AHRQ grant HS18406). Journal of the American Medical Association 304(23), pp. 2592-2594.
Increased use of donors after circulatory determination of death (DCDD) has been advocated as the most viable method for increasing the supply of transplantable organs. The researchers conducted a prospective, population-based cohort study to estimate the potential increase in the supply of deceased donors that might accrue from optimal use of controlled DCDD, donors in whom life-sustaining therapies are withdrawn and organs are recovered following the loss of spontaneous circulation. After analyzing 21,082 deaths occurring at the 50 study hospitals and categorizing organs as optimal, suboptimal, and ineligible for transplantation, the researchers identified and referred 108 (49 optimal and 59 suboptimal) DCDD to the organ procurement organization before withdrawal of life-sustaining therapy. Their findings suggest that optimal identification and management of potential controlled DCDD could increase the supply of deceased organ donors, but by no more than 25 percent.
Platt, R., Takvorian, S. U., Septimus, E., and others (2010, June). "Cluster randomized trials in comparative effectiveness research. Randomizing hospitals to test methods for prevention of healthcare-associated infections." (AHRQ Contract No. 290-05-0033). Medical Care 48(6 Suppl. 1), pp. S52-S57.
Cluster randomized trials are randomized controlled trials that randomize groups (clusters) rather than individuals. They are the only feasible method for randomization when an intervention must be applied to an entire group, such as a community-based, health-promotion initiative. The researchers illustrate some of the potential of cluster randomization in comparative effectiveness research through a current trial that compares strategies to prevent methicillin-resistant Staphylococcus aureus (MRSA) infections in hospital intensive care units. This example demonstrates several of the design strengths of cluster randomized trials that make them likely to generate comparative effectiveness evidence in an efficient and timely manner, thus enabling swift policy action. The trial used patients admitted to 45 hospital ICUs to test three MRSA infection prevention strategies: active screening and isolation, active screening and decolonization of MRSA carriers, and universal decolonization without regard to MRSA status.
Rassen, J. A., Solomon, D. H., Curtis, J. R., and others (2010, June). "Privacy-maintaining propensity score-based pooling of multiple databases applied to a study of biologics." (AHRQ grant HS17919). Medical Care 48(6 Suppl. 1), pp. S83-S89.
A multicenter study of the safety of biologic medicines for the treatment of autoimmune diseases necessitates pooling data from multiple administrative data sources to attain sufficient statistical power to study certain rare safety outcomes. The researchers address the multiple methods considered in the design and planning of the project, and detail their chosen methods. The methods assessed were: full covariate sharing, cell-aggregated sharing, meta-analysis, and the propensity score (PS) based method. The PS-based pooling method offered strong protection of patient privacy and a reasonable balance between analytic integrity and flexibility of study execution. The researchers recommend its use in other studies that require both pooling of databases and multivariate adjustment, each in a manner that protects the privacy of the patients involved.
Smith, S. R. (2010, June). "Advancing methods for comparative effectiveness research." Medical Care 48(6 Suppl. 1), pp. S1-S2. Reprints (AHRQ Publication No. 10-R075) are available from the AHRQ Publications Clearinghouse.
Since the Effective Health Care program was established in 2005 through the Medicare Modernization Act, the Agency for Healthcare Research and Quality (AHRQ) has regularly convened researchers from different disciplines to propose, discuss, and deliberate new scientific approaches for conducting studies on comparative effectiveness and safety. In June 2009, AHRQ sponsored a symposium on research methods for comparative effectiveness studies and this supplement to Medical Care represents the proceedings as revised by the authors and independently reviewed by peers and the journal. The symposium had two main emphases: (1) examination of ways to enhance the inclusion of clinically heterogeneous populations in comparative and clinical effectiveness studies, and (2) ways to implement longitudinal investigations that capture longer-term health outcomes, including patient-reported outcomes.
Varadhan, R., Weiss, C. O., Segal, J. B., and others (2010, June). "Evaluating health outcomes in the presence of competing risks. A review of statistical methods and clinical applications." (AHRQ Contract No. 290-05-0034). Medical Care 48(6 Suppl. 1), pp. S96-S105.
The competing risks problem is determining the likelihood of benefit from an intervention for a specific outcome, in the presence of competing outcomes. The authors demonstrate the importance of considering this problem in the evaluation of treatment effectiveness, review appropriate statistical methods, and recommend how they might be applied. Their review offers a definition of the competing risks problem with illustrations. They then describe three methods for analyzing competing risks: cause-specific hazards (CSH), cumulative incidence function (CIF), and event-free survival (EFS) modeling. A simulation study is conducted to demonstrate that a treatment can have a varying impact on CSH, CIF, and EFS. They make recommendations for appropriate methods according to study objective.
Weiss, J. W., Thorp, M. L., and O'Hare, A. M. (2010). "Renin-angiotensin system blockade in older adults with chronic kidney disease: A review of the literature." (AHRQ grant T32 HS17582). Current Opinion in Nephrology and Hypertension 19, pp. 413-419.
Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are renin-angiotensin system (RAS) inhibitors. They have been shown to be effective in hypertension management, in reducing proteinuria, in slowing progression of renal disease, and in reducing cardiovascular risk among patients with chronic kidney disease (CKD). The researchers reviewed early and more recent literature on RAS blockade in general and in CKD populations, specifically looking at older age groups, to help delineate the risk-benefit profile of RAS inhibition in older adults with CKD and identify areas of uncertainty. They concluded that because few trials of ACE inhibitors and ARBs have enrolled a representative sample of older adults with CKD, the benefits and harms of these agents for slowing progression of kidney disease and other important outcomes in older adults are either uncertain or unknown.