Research Activities, November 2010, No. 363
Aragon, S.J., McGuinn, L., Bavin, S.A., and Gesell, S.B. (2010). "Does pediatric patient-centeredness affect family trust?" (AHRQ grant T32 HS00032). Journal of Healthcare Quality 32(3), pp. 23-31.
According to Primary Provider Theory, physicians with higher magnitudes of patient-centeredness are concerned first and foremost with their patients' best interests; careful to understand their patients' feelings, perspectives and needs; and approachable, tactful, and skilled in relationships. The researchers measured whether patient-centeredness is an underlying ability of pediatricians that increases family trust. Data used in this study were from the Press Ganey Medical Practice Survey, which captures patients' ratings of physician care performance. The study found that pediatric patient-centeredness influenced family trust and explained 89 percent of its variability. Indirectly, through family trust, it also influenced family's confidence and likelihood to recommend the pediatrician. Patient-centeredness also significantly affected family ratings of their pediatrician's care behavior performance.
Carle, A.C., and Simpson, L. (2010, May/June). "Identifying child health priorities for comparative effectiveness research from the IOM's report." (AHRQ grant HS16957). Academic Pediatrics 10, pp. 155-158.
The Institute of Medicine's report on "Initial National Priorities for Comparative Effectiveness Research" developed a list of 100 research priorities, and identified 10 recommendations to develop and maintain a national comparative effectiveness research (CER) program. The authors describe the report and discuss its implications for pediatric research, teaching, and practice. The list of priority topics emphasizes population diversity and disparities; however, only 20 of the topics are specific to children. There are substantial hurdles to overcome in creating a robust CER workforce to research these various topics. For example, it is unclear where future pediatric CER investigators will go to acquire training. The authors conclude by making several recommendations, one of which is for the Academic Pediatric Association to develop specific strategies to engage parents and families and other stakeholders throughout the process of priority setting for CER research.
Clancy, C.M. (2010, March). "Comparative effectiveness research for pharmacists." Pharmacy Today. Reprints (AHRQ Publication No. 10-R076) are available from the AHRQ Publications Clearinghouse.
The author, Director of the Agency for Healthcare Research and Quality (AHRQ), discusses AHRQ's Effective Health Care Program and emphasizes its relevance to pharmacists. The Program oversees the Federal government's largest ongoing work in comparative effectiveness research (CER). Recent CER products of interest to pharmacists are on topics such as lipid-modifying agents, catheter-based radiofrequency ablation compared with anti-arrhythmic drugs used for atrial fibrillation, medications to reduce risk of primary breast cancer, and insulin analogues in premixed formulations for adults with type 2 diabetes. These reports focus on providing clinicians with the best evidence-based information on treatment options, but are not prescriptive in terms of making recommendations. The reports on lipid-modifying agents and insulin analogues are each supplemented by summary guides for the consumer and the clinician.
Clancy, C.M. (2010). "Getting to zero: New resources aim to reduce health care-associated infections." American Journal of Medical Quality 25(4), pp. 319-321. Reprints (AHRQ Publication No. 10-R079) are available from the AHRQ Publications Clearinghouse.
Health care-associated infections (HAIs) have an unacceptable effect on patient safety, in addition to imposing a heavy cost burden on patients and payers. Building on the federally funded Keystone Project, which helped hospital intensive care units in Michigan to sharply reduce the rate of bloodstream infections from intravenous lines, the Comprehensive Unit-Based Safety Program provides organizations with a structured strategic framework for safety improvement. It improves care practices by incorporating a number of key elements, including staff education in the science of safety training and assessment of each unit's patient safety culture. This expansion of the Keystone Project is part of a broader Federal effort by the Department of Health and Human Resources to significantly reduce HAIs within 5 years.
Cook, A.J., Elmore, J.G., Miglioretti, D.L., and others (2010, April). "Decreased accuracy in interpretation of community-based screening mammography for women with multiple clinical risk factors." (AHRQ grant HS10591). Journal of Clinical Epidemiology 63(4), pp. 441-451.
The researchers assessed the impact of clinical risk factors for breast cancer (use of hormone therapy, family history of breast cancer, previous breast biopsy) on radiologists' interpretations of mammograms and whether the influence of these risk factors varies according to radiologists' characteristics. They found that women with clinical risk factors for breast cancer were more often asked to return for additional mammograms and biopsies than women who had no risk factors. The study included 638,947 screening mammograms performed by 134 radiologists in 101 facilities. Increased recall rates for women with risk factors did not lead to a higher probability of detecting cancer. Recall rates were higher when the radiologist was younger, had interpreted more mammograms per year, and was affiliated primarily with a teaching institution.
Gibbons, R.D., Amatya, A.K., Brown, C.H., and others (2010, April). "Post-approval drug safety surveillance." (AHRQ grant HS 16973). Annual Review of Public Health 31, pp. 419-437.
Once new drugs are approved and introduced into the marketplace, concerns remain regarding their safety. Rare adverse events cannot be determined during the approval process due to the short duration of the study and the relatively small size of the test population. The authors reviewed various methods for determining the possibility of adverse drug reactions, once the drugs are in the marketplace. These include spontaneous reports, meta-analysis of randomized controlled clinical trials, ecological studies, and analysis of medical claims data. Following their review of experimental and statistical methods for the analysis of postmarketing drug surveillance, they conclude that: shifting from spontaneous reports to longitudinal medical claims/records data is needed; more advance design and statistical methods are required to make better use of large observational databases; and coherence of results across many different databases, experimental design strategies, and statistical methodologies is key.
Krishnan, J.A., and Mularski, R.A. (2010, June). "Acting on comparative effectiveness research in COPD." (AHRQ grant HS17894). Journal of the American Medical Association 303(23), pp. 2409-2410.
Current guidelines for treatment of exacerbations from chronic obstructive pulmonary disease (COPD) recommend low doses of oral corticosteroids. The authors offer comments on a newly published comparative effectiveness study which found that although clinicians were much more likely to administer high-dose intravenous systemic corticosteroids than low-dose oral corticosteroids, there was no evidence that high doses were better. The authors suggest two alternatives for moving forward: either conduct a large-scale, pragmatic clinical trial to provide further evidence or advocate for translating these research findings into clinical practice now. The latter option could be combined with conducting further comparative effectiveness research (CER) within linked registries, potentially enabling ongoing surveillance of care quality and patient outcomes.
Lakshminarayab, K., Borbos, C., McLaughlin, B., and others (2010, 18 May). "A cluster-randomized trial to improve stroke care in hospitals." (AHRQ grant HS11073). Neurology 74(20), pp. 1634-1642.
The researchers studied the effect of a quality-improvement (QI) intervention that used clinical opinion leaders and management leaders as agents of change on the care of patients with acute ischemic stroke in 17 hospitals with a neurologist on staff. All of the hospitals underwent a baseline evaluation of adherence to the quality measures for 1,211 patients treated for stroke before the intervention (discharged during July�December 2000) and 1,094 patients treated after the intervention (discharged July�December 2003). The study found no significant difference in 10 quality measures between the 7 reporting hospitals out of 9 randomly assigned to the QI intervention and the 10 non-intervention hospitals. In addition, the researchers found evidence of increased quality of care over time, regardless of whether the hospital received the intervention or not. Based on the findings, the researchers concluded that it is problematic to use historical controls in quality-improvement studies.
Lien, H.-M., Lu, M., Ma, C.-T.A., and others (2010, March). "Progress and compliance in alcohol abuse treatment." (AHRQ grant HS10803) Journal of Health Economics 29(2), pp. 213-225.
Using data from alcohol abuse outpatient treatment programs in Maine, the researchers used a set of statistical models (basic, random-effect, fixed-effect, and finite-mixture) to examine the relationship between treatment progress and patient compliance with treatment recommendations. Unlike other studies, patient compliance and progress were looked at on a visit-by-visit basis, defined as attending a scheduled treatment visit and noted as progressing in the clinician's treatment notes. Patient records rarely indicated progress when a patient relapsed between visits. Patients who were making progress were less likely to drop out of treatment. However, the observation that a patient was progressing at a particular visit did not increase the likelihood of the patient attending the next scheduled visit.
Meissner, H.J., Tiro, J.A., Yabroff, K.R., and others (2010, March). "Too much of a good thing? Physician and patient willingness for less frequent Pap test screening intervals." (Interagency agreement between AHRQ and the Centers for Disease Control and Prevention). Medical Care 48(3), pp. 249-259.
Increased understanding of cervical cancer and the human papillomavirus has led professional organizations to revise clinical guidelines to allow for Pap test intervals of 2 to 3 years after the age of 30 if the woman has had 3 consecutive normal Pap tests. Recent reports suggest that physicians and patients may not be adopting these recommendations and continue to screen annually. The researchers used national surveys to identify physician and practice characteristics associated with recommending a less frequent interval and patient characteristics associated with a willingness to accept longer Pap intervals. They found that 32 percent of physicians had adopted a 3-year Pap test interval. Characteristics associated with using the longer test interval were: serving a higher proportion of Medicaid patients; white, non-Hispanic race; fewer years since graduation from medical school; and the U.S. Preventive Services Task Force being very influential in physician clinical practice. Women over 65 were more willing to follow a 3-year interval.
Rosko, M.D., and Mutter, R.L. (2010, June). "What have we learned from the application of stochastic frontier analysis to U.S. hospitals?" Medical Research and Review. Reprints (AHRQ Publication No. 10-R073) are available from the AHRQ Publications Clearinghouse.
This article focuses on lessons learned from stochastic frontier analysis studies of U.S. hospitals on correlates of hospital inefficiency. They found that consensus has begun to emerge about the efficiency impact of a number of environmental forces, including Medicaid and Medicare share of discharges, HMO penetration, and the unemployment rate. Conflicting findings continue to be reported about the efficiency impact of other factors, such as hospital ownership and competition. Disparate results could occur because of the use of different data sources and methodological approaches or because of changes in the underlying impacts of these disparate approaches.
Saraiya, M., Berkowitz, Z., Yabroff, R., and others (2010, June). "Cervical cancer screening with both human papillomavirus and Papanicolaou testing vs. Papanicolaou testing alone." (Interagency agreement between AHRQ, the Centers for Disease Control and Prevention, and the National Cancer Institute). Archives of Internal Medicine 170(11), pp. 977-986.
Increased understanding of cervical cancer and the human papillomavirus (HPV) infection has led to the addition of the HPV DNA test along with the Pap test (known as HPV cotesting). To assess current cervical cancer screening practices, the researchers conducted a national survey of 1,212 primary care physicians (PCPs). They used three clinical vignettes to discover the physicians' recommendations for extending screening intervals with Pap test-based screening only or with the addition of HPV cotesting. Among Pap test providers who recommended HPV testing, 31.8 percent reported that they would conduct the next Pap test in 3 years for a 35-year-old woman with 3 normal Pap test results. Most PCPs did not recommend a second HPV test nor did they recommend the next HPV test at the same frequency as the Pap test.
Schmittdiel, J.A., Grumbach, K., and Selby, J.V. (2010, May/June). "System-based participatory research in health care: An approach for sustainable translational research and quality improvement." (AHRQ grant HS17031). Annals of Family Medicine 8(3), pp. 256-259.
The term "translational research" describes the translation of promising results from clinical studies into day-to-day medical practice. This type of research is still developing, and if it fails to adequately engage patients, clinicians, and other key stakeholders within health care systems through over-reliance on a traditional investigator-driven approach, it may lead to interventions that are not sustainable, note the authors. They are convinced that this pitfall may be avoided by applying the conceptual model and methods of community-based participatory research (CBPR) to translational research. They discuss the four key principles used by CBPR in engaging the community: (1) engage in collaboration and equitable partnerships in all phases of research; (2) build on the resources and goals already present in the community; (3) create and invest in long-term and robust partnerships; and (4) engage in research as a cyclical, iterative process.
Singh, H., Graber M. (2010). "Reducing diagnostic error through medical home based primary care reform." (AHRQ grant HS17820). Journal of the American Medical Association 304(4), pp. 463-464.
If implemented correctly, the patient-centered medical home (PCMH) can potentially address many current safety concerns in primary care. One underemphasized safety concern is diagnostic error, possibly the leading type of error in primary care. Among the leading causes of diagnostic error are breakdowns in information management, including communication and coordination of care. If information management problems are not addressed, they are likely to worsen in an era placing increased demands on the PCMH. Reducing diagnostic error will require performance-monitoring strategies that use refined metrics of processes and outcomes to address key indicators of diagnostic performance. Electronic surveillance and monitoring techniques using the "trigger" approach, followed by feedback to clinicians, could help local emergency departments and inpatient clinicians to promote mutual reporting of errors.
Snyder, R. and Fields, W. (2010, June). "A model for medication safety event detection." (AHRQ grant HS13131). International Journal for Quality in Health Care 22(3), pp. 179-186.
The researchers outline a system-focused model for detecting medication safety events that uses standardized measurement and data collection methodologies to collect preventable and nonpreventable adverse drug events (ADEs) as well as potential ADEs—whether or not they were intercepted by hospital staff. Traditional event detection relies on voluntary self-report, while the system-focused detection model also included data from computerized monitoring triggers, chart review, and diagnositc medical record codes. The researchers conclude from a 20-day preliminary trial at two community hospitals that patient safety event-reporting methods that take advantage of routine data collection (for example, retrospective reviews of 5 percent of patient charts, pharmacist surveillance, Pyxis® dispensing station trigger reports, laboratory value trigger reports) are much more effective in detecting MSEs than voluntary self-report methods.