Research Activities, November 2011
Carson, A.P., DaJuanicia, N.H., and Howard, D.L. (2010). "Weight change and functional limitations among older adults in North Carolina." (AHRQ grant HS13353). Journal of Community Health 35, pp. 586-591.
This study of adults age 65 and older in North Carolina finds that changes in weight are associated with a number of functional limitations that affect activities of daily living. Both weight gain (>8 percent increase in weight from age 50) and loss (>8 percent decrease) were associated with severe (4 or more) functional limitations compared with weight maintainers (<8 percent change).
Chetty, V.K., Culpepper, L., and Phillips, R.L. (2011, May). "FPs lower hospital readmission rates and costs." Graham Center Policy One-Pager. American Family Physician 83(9), pp. 1053A.
A new study finds that 30-day readmission rates for pneumonia, heart attack, and heart failure decrease as the number of family physicians increase. The study is based on data from the Medicare Compare Hospital Database that includes readmission rates for 4,459 hospitals and on data from the Area Resource File that shows the number of physicians per population at the county level.
Chin, M.H., and Goldmann, D. (2011, January)."Meaningful disparities reduction through research and translation programs." (AHRQ grant T32 HS00063). Journal of the American Medical Association 305(4), pp. 404-405.
The authors describe an approach for making equity an integral component and explicit requirement of funding announcements aimed at improving quality of care and outcomes. The approach makes disparities a key goal in the development and rollout of a grant initiative and requires applicants to provide a detailed description of how they will address the equity in their conceptual, intervention, and analytical models.
Clancy, C.M. (2011). "Kidney-related diseases and quality improvement: AHRQ's role." Clinical Journal of the American Society of Nephrology 6, pp. 1-3. Reprints (AHRQ Publication No. 11-R077) are available from the AHRQ Publications Clearinghouse.
The author, director of the Agency for Healthcare Research and Quality (AHRQ), stresses that AHRQ has done work relevant to the broad area of clinical nephrology by pinpointing where quality problems lie, advancing the evidence base to do something about them, and promoting patient-centered outcomes research to give patients and clinicians tools to make decisions about their care. A number of specific programs, tools, and products are described.
Cresswell, K.M., Bates, D.W., Phansalkar, S., and Sheikh, A. (2011). "Opportunities and challenges in creating an international centralized knowledge base for clinical decision support systems in ePrescribing." (AHRQ grant HS16970). BMJ Quality and Safety 20, pp. 625-630.
Given the redundancies in local and national developments related to clinical decision support systems (CDSSs) for ePrescribing, the authors consider some of the opportunities and challenges in moving towards a more concerted collaborative international effort in developing and maintaining the knowledge base for these systems. They hope that their ideas will stimulate debate, since a centrally shared resource could potentially result in significant cost savings facilitating increased adoption and penetration of CDSS internationally.
Curtis, J.R., and Levy, M.M. (2011). "Improving the science and politics of quality improvement." (AHRQ grant HS17715). Journal of the American Medical Association 305(4), pp. 406-407.
The authors discuss the results of an important study designed to evaluate the effectiveness of quality improvement efforts in community-based critical care units in Ontario. The goal of the multifaceted knowledge-transfer intervention was to increase adherence to six quality measures that have been documented to improve patient outcomes. Improvement was relatively modest, with improvements seen in only two of six measures.
Edmonds, B.T., Fager, C., Srinivas, S., and Lorch, S. (2011). "Predictors of cesarean delivery for periviable neonates." (AHRQ grant HS05696). Obstetrics and Gynecology 118(1), pp. 49-56.
A study testing for racial or ethnic disparities in periviable cesarean delivery has found that women of African American, Hispanic, and other racial or ethnic groups were somewhat less likely to undergo cesarean delivery. However, the odds were not statistically different from those of white women. Ultimately, maternal coexisting medical conditions and pregnancy complications were found to be the strongest predictors of cesarean delivery.
Gonzales, A.A., Ton, T.G.N., Garroutte, E.M., and others. (2010, Autumn). "Perceived cancer risk among American Indians: Implications for intervention research." (AHRQ grant HS108534). Ethnicity and Disease 20, pp. 458-462.
The researchers conducted a random survey of 182 American Indians to assess whether knowledge of cancer risk factors, attitudes about cancer prevention, and family history of cancer were associated with perception of risk. They found that neither knowledge of cancer risk factors nor attitudes toward cancer prevention were associated with risk perception. Perceived cancer risk was significantly associated with self-reported family history of cancer.
Haywood, C., Beach, M.C., Bediako, S., and others. (2011). "Examining the characteristics and beliefs of hydroxyurea users and nonusers among adults with sickle cell disease." (AHRQ grant HS 13903). American Journal of Hematology, pp. 85-87.
The researchers surveyed the attitudes and beliefs of 94 adults with sickle cell disease to compare current and previous users of hydroxyurea (HU) therapy with those who had never used it. They found that half of the never-users had received no information about HU from any source and 85 percent of never-users thought that HU would provide no improvement in their condition.
Hodge, J.G., Anderson, E.D., Kirsch, T.D., and Kelen, G.D. (2011). "Facilitating hospital emergency preparedness: Introduction of a model memorandum of understanding." (AHRQ grant HS14533). Disaster Medicine and Public Health Preparedness 5, pp. 54-61.
The authors discuss a model memorandum of understanding (MOU) that seeks to align regional hospitals through advance agreements on procedures of mutual aid that reflect modern principles of emergency preparedness and changing legal norms in declared emergencies. The MOU outlines essential principles on how to allocate scarce resources among providers across regions. The model MOU, which can be modified by hospitals depending on their needs and preferences, creates options for collaboration without significant legal obligations.
Krumholz, H.M., Lin, Z., Drye, E.E., and others. (2011). "An administrative claims measure suitable for profiling hospital performance based on 30-day all-cause readmission rates among patients with acute myocardial infarction." (AHRQ grant HS16929). Circulation: Cardiovascular Quality and Outcomes 34, pp. 243-252.
The researchers present a model to produce hospital-specific risk-standardized estimates of 30-day readmission rates after discharge for an acute myocardial infarction. The hierarchical logistic regression claims-based model produces estimates that are excellent surrogates for those produced from a medical record model. This model is being used to publicly report the variation in readmission rates among U.S. hospitals.
Kuna, S.T., Badr, S., Kimoff, J., and others. (2011). "An Official ATS/AASM/ACCP/ERS workshop report: Research priorities in ambulatory management of adults with obstructive sleep apnea." (AHRQ grant HS17402). Proceedings of the American Thoracic Society 8, pp. 1-16.
This workshop identified barriers preventing incorporation of portable monitor testing into clinical management pathways and determined the research and development needed to address these barriers. Recommendations were developed concerning research study design and methodology that include the need to standardize technology, identify the patients most appropriate for ambulatory management, ensure patient safety, and identify sources of research funding.
Manfredi, C., Cho, Y.I., Warnecke, R., and others. (2011). "Dissemination strategies to improve implementation of the PHS smoking cessation guideline in MCH public health clinics: Experimental evaluation results and contextual factors." (AHRQ grant HS10544). Health Education Research 26(2), pp. 348-360.
Using three dissemination strategies, researchers tested the effectiveness of dissemination interventions to improve implementation of smoking cessation guidelines in 12 Illinois maternal and child health clinics. The three strategies were: core dissemination (a tested smoking cessation program), core dissemination plus telephone counseling, and core dissemination with both telephone counseling and outreach visits to clinics. The seven clinics showing experimental effectiveness were distinguished by clinic type and absence of disruptive events from the other clinics.
Meissner, H.I., Klabunde, C.N., Han, P.K., and others. (2011, July). "Breast cancer screening beliefs, recommendations, and practices." (AHRQ interagency agreement with the National Institutes of Health). Cancer 117, pp. 3101-3111.
This study represents the first national assessment of primary care physicians' (PCPs) breast cancer screening beliefs, recommendations, and practices since 1989. It found that virtually all 1,212 PCPs surveyed reported routinely recommending mammography, clinical breast examinations, and breast self-examinations to their patients age 40 and over. Eighty percent of the PCPs reported that mammography for average-risk women age 50 and over was very effective in reducing cancer mortality.
Ovretveit, J.C., Shekelle, P.G., Dy, S.M., and others. (2011). "How does context affect interventions to improve patient safety? An assessment of evidence from studies of five patient safety practices and proposals." (AHRQ Contract No. 290-2009-10001). BMJ Quality and Safety 20, pp. 604-610.
Experience suggests that context is important for understanding why some patient safety practices are implemented successfully and are more effective in some organizations and regions and not in others. In a review of the literature on five patient safety interventions, researchers found little strong evidence of the influence of different context factors. However, the research reviewed was not specifically designed to investigate context influence.
Polivka, B.J., Casavant, M., and Baker, S.D. (2010). "Factors associated with healthcare visits by young children for nontoxic poisoning exposures." (AHRQ grant HS15713). Journal of Community Health 35(6), pp. 572-578.
Over a 4-year period, 2,494 children up to 5 years old in Columbus, Ohio, and its surrounding area made visits to local emergency departments or urgent care centers to treat poisonings. Poisoning exposures in the study were primarily to medication (77 percent), which a poison control center can generally help parents handle by telephone.
Pronovost, P.J., and Goeschel, C.A. (2011, July). "Time to take health delivery research seriously." (AHRQ Contract No. 290-06-0221 and AHRQ grant HS19934). Journal of the American Medical Association 306(3), pp. 310-311.
The authors argue for increased emphasis on research to improve the delivery of health care, in addition to research to create new treatments. Such changes would mean bringing human factors and systems engineers, sociologists, psychologists, and health services researchers into academic medical centers to use their skills in implementing basic biomedical research in clinical settings. The authors suggest that health care funders and researchers should supplement hypothesis-testing research with outcome-optimizing research.
Quest, T.E., Asplin, B.R., Cairns, C.B., and others. (2011). "Research priorities for palliative and end-of-life care in the emergency setting." (AHRQ grant HS18114). Academic Emergency Medicine 18, pp. e70-e76.
This article proposes a research agenda for studying the integration of palliative care in the emergency department setting. The agenda was developed by the Palliative Care Workgroup, part of a conference convened by the American College of Emergency Physicians. The group concluded that the integration of palliative care into routine emergency practice will require a paradigm shift in care delivery.
Rattanaumpawan, P., Tolomeo, P., Bilker, W.B., and others. (2011). "Risk factors for fluoroquinolone resistance in Enterococcus urinary tract infections in hospitalized patients." (AHRQ grant 10399). Epidemiology of Infection 139, pp. 955-961.
This study is the first study specifically designed to identify risk factors for fluoroquinolone (FQ) resistance in healthcare-acquired urinary tract infections. It found that independent risk factors for FQ resistance included cardiovascular diseases; hospitalization within the past 2 weeks; hospitalization on a medicine service; and recent exposure to beta-lactamase inhibitors, extended spectrum cephalosporins, FQs, and clindamycin.
Rivera-Soto,W.T., Rodriguez-Figueroa, L., and Calderon, G. (2010, December). "Prevalence of childhood obesity in a representative sample of elementary school children in Puerto Rico by socio-demographic characteristics, 2008." (AHRQ grant HS14060). Puerto Rico Health Science Journal 29(4); pp. 357-363.
Elementary school children in Puerto Rico have higher rates of overweight and obesity than is observed among Hispanic children in the United States, according to a new study. Overall, 27 percent of the students fit the criteria for obesity compared with 19 percent for non-Hispanic whites or blacks in the U.S., and 25 percent for all Hispanic children in the U.S. Another 11 percent of Puerto Rican elementary school children were overweight.
Sarkar, I.N., Butte, A.J., Lussier, Y.A., and others. (2011). "Translational bioinformatics: Linking knowledge across biological and clinical realms." (AHRQ grant HS19913). Journal of the American Medical Informatics Association 18, pp. 354-357.
The authors present translational bioinformatics (TBI) as a discipline that builds on the successes of bioinformatics and health informatics for the study of complex diseases. A major goal of TBI is to develop informatics approaches for linking across traditionally disparate data and knowledge sources, enabling both the generation and testing of new hypotheses. Projects involving TBI approaches to integrating biological and clinical data are already underway.
Schiff, G.D., Galanter, W.L., Duhig, J., and others. (2011, September). "Principles of conservative prescribing." (AHRQ grant HS16973). Archives of Internal Medicine 171, pp. 1433-1440.
The authors, who are physicians, pharmacists, and educators, have identified principles for safer and more evidence-based prescribing. These principles urge clinicians to think beyond drugs; practice more strategic prescribing; maintain heightened vigilance regarding adverse effects; and exercise caution and skepticism regarding new drugs. Taken together, these principles represent a shift in the prescribing paradigm from "newer and more is better" to "fewer and more time-tested" is better.
Schuur, J.D., Baugh, C.W., Hess, E.P., and others. (2011). "Critical pathways for post-emergency outpatient diagnosis and treatment: Tools to improve the value of emergency care." (AHRQ grant HS181134). Academic Emergency Medicine 18, pp. e52-e63.
This article reports the results of a working group charged to address methods to improve value in post-emergency department (ED) transitions. The working group was part of a conference convened by the American College of Emergency Physicians. The authors describe a model of post-ED pathways, describe the role of pathways in emergency care, list common diagnoses that are amenable to critical pathways in the outpatient setting, and propose a research agenda.
Seidling, H.M., Phansalkar, S., Seger, D.L., and others. (2011). "Factors influencing alert acceptance: A novel approach for predicting the success of clinical decision support." (AHRQ grant HS11169). Journal of the American Medical Informatics Association 18, pp. 479-484.
The researchers attempted to quantify the impact of some of the major human factors issues that may affect computer alert acceptance by specification of three variables—the display of the alert, the textual information, and the prioritization of the alerts. The alert display most strongly correlated with alert acceptance. The textual information did not influence the frequency of alert acceptance. Only drug-drug interaction alerts were included in the study.
Sloane, P.D., Wroth, T., Halladay, J., and others. (2011, July/August). "How eight primary care practices initiated and maintained quality monitoring and reporting." (AHRQ Contract No. 209-07-10014). Journal of the American Board of Family Medicine 24(4), pp. 360-369.
To better understand the process by which practices initiate, support, and maintain performance data reporting, the researchers conducted a study of 8 diverse practices, each of which was participating successfully in one or more of 34 performance-data-reporting programs. They found that implementing and sustaining quality reporting requires a complex set of motivators, facilitators, and strategies to overcome inherent barriers that can present themselves to practices seeking to implement change.
Tarnutzer, A.A., Berkowitz, A.L., Robinson, K.A., and others. (2011, June). "Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome." (AHRQ grant HS17755). Canadian Medical Association Journal 183(9), pp. E571-E592).
The most common causes of acute vestibular syndrome are vestibular neuritis and ischemic stroke in the brainstem or cerebellum, according to a review of 10 studies describing 392 patients. These studies focused largely on bedside test of vestibular and oculomotor function, as assessed through care examination of eye movements. Expert opinion suggests a combination of focused history and physical examination as the initial approach to determining if there is a stroke.
Taylor, S.L., Dy, S., Foy, R., and others. (2011). "What context features might be important determinants of the effectiveness of patient safety practice interventions?" (AHRQ Contract No. 290-09-1001). BMJ Quality and Safety 20, pp. 611-617.
In order to identify which contextual factors are likely to have the most relevance to and impact on a diverse range of patient safety practices, the authors used an iterative process of formal group discussions with a 22-member technical expert panel. The panel identified four broad domains of contextual features important to patient safety practice implementations: safety culture, teamwork and leadership involvement, structural organizational characteristics, external factors, and availability of implementation and management tools.
Tschampi, C., Bernardo, J., Garvey, T., and Garnick, D. (2011, July). "The need for performance measures on testing for latent tuberculosis infection in primary care." (AHRQ grant T32 HS00062). The Joint Commission Journal on Quality and Patient Safety 37(7), pp. 309-316.
Using a National Quality Forum-endorsed measure that calculates the rate of tuberculosis (TB) screening in persons with HIV as a model, the authors propose a set of performance measures focused on the rate of persons at high risk of TB who are tested for latent tuberculosis infection and have the test read. The proposed performance measures will address a neglected secondary prevention opportunity and will be consistent with national priorities and health reform.
Webb, J.R., Feinglass, J., Makoul, G., and others. (2010). "Can electronic health records help improve patients' understanding of medications?" (AHRQ grant HS17220). The American Journal of Managed Care 16(12), pp. 919-922.
Researchers have come up with a novel approach that incorporates the benefits of electronic health records with direct patient communication. Patients receive a computer-generated list of their medications to review in the waiting room before the physician visit. After their visit, patients were asked if they were still taking each medication in the manner prescribed and if they had any problems or concerns with it. Nearly half of patients expressed problems, concerns, or questions about their current medications. Use of the list was an opportunity to educate them.
Welsh, C.A., Flanagan, M.E., Hoke, S.C., and others. (2011). "Reducing health care-associated infections (HAIs): Lessons learned from a national collaborative of regional HAI programs." (AHRQ Contract No. 290-06-0001). American Journal of Infection Control, pp. 1-8.
In 2007, the Agency for Healthcare Research and Quality (AHRQ) created the AHRQ Healthcare-Associated Infections (HAI) initiative, which funded five regional collaboratives. These collaboratives consisted of 33 hospitals with a range of hospital types and geographic locations. This article summarizes the successes, challenges, and lessons learned that were common to these collaboratives.
Werner, R.M., Konezka, R.T., Stuart, E.A., and others. (2011, April). "Changes in patient sorting to nursing homes under public reporting: Improved patient matching or provider gaming?" (AHRQ grant HS16478). Health Services Research 46(2), pp. 555-571.
Public reporting of nursing home quality does appear to influence the type of patient going to a skilled nursing facility, the researchers found although they could not rule out that some providers are gaming the system by reducing the degree of pain or delirium reported at patient admission. The study compared the percentages of short-stay patients at an SNF without moderate to severe pain, without delirium, and whose walking remained independent or improved.