Research Activities, September 2011
Arora, S., Kalishman, S., Dion, D., and others (2011, June). "Partnering urban academic medical centers and rural primary care clinicians to provide complex chronic disease care." (AHRQ grants HS15135, HS16510, and HS18171). Health Affairs 30(6), pp. 1176-1184.
In New Mexico, an innovative new model of health care education and delivery known as Project ECHO (Extension for Community Healthcare Outcomes) provides high-quality primary and specialty care to an underserved population with many unmet needs due to various chronic illnesses. New Mexico's severe hepatitis C problem led to the idea for Project ECHO. The project concept involves a team of University of New Mexico specialists conducting weekly teleconferences to review and discuss cases with primary care providers. This allows a cadre of health professionals trained in hepatitis C care to deliver specialty-level care to thousands of patients across the State. To date, Project ECHO has provided more than 10,000 specialty consultations to patients throughout the State.
Bertakis, K.D., and Azari, R. (2011). "Patient-centered care is associated with decreased health care utilization." (AHRQ grant HS06167). Journal of the American Board of Family Medicine 24, pp. 229-239.
This study correlated the amount of patient-centered care given to primary care patients during 1 year with their use of medical services and subsequent charges in five categories: primary care clinic visits, specialty care visits, emergency department visits, hospitalizations, and diagnostic services. Patient-centered care was measured through the use of the Davis Observation Code which the researchers used to classify each of 20 clinically significant behaviors observed during videotaped office visits of 509 patients. Patients who received a higher average amount of patient-centered care had significantly fewer annual visits for specialty care, less frequent hospitalizations, and fewer diagnostic tests. The total median annual charges for patients who had less patient-centered care was $1,435 compared with $948 for those who received patient-centered care.
Clancy, C.M. (2011). "Commentary: Precision science and patient-centered care." Academic Medicine 86(6), pp. 667-670. Reprints (AHRQ Publication No. 11-R059) are available from the AHRQ Publications Clearinghouse.
This article provides a commentary on a collection of comparative effectiveness research studies appearing in the same issue of this journal. Patient-centered outcomes research (PCOR), also known as comparative effectiveness research, examines which precise medications, treatments, devices, or delivery systems work best for which patients under which circumstances. Several of the articles describe the opportunities for academic health centers to engage in PCOR, and some detail the important challenges that PCOR entails. The author describes how PCOR differs from biomedical and clinical research. The author advocates that researchers engaged in PCOR explore innovative means to accelerate the translation of their research findings into practice.
Clancy, C.M., and Berwick, D.M. (2011). "The science of safety improvement: Learning while doing." Annals of Internal Medicine 154(10), pp. 699-701. Reprints (AHRQ Publication No. 11-R060) are available from the AHRQ Publications Clearinghouse.
The authors discuss how to design and analyze studies on patient safety improvement to facilitate their implementation on the front lines of care. They comment on an article in the same issue of this journal in which Shekelle and colleagues provide a framework for enhancing research in patient safety improvement by proposing criteria for the design and reporting of studies to facilitate the translation of the studies into practice. The article emphasizes how important it is that researchers clarify why they believe the intervention to improve patient safety should work. It also emphasizes the need to adequately describe the nature of the interventions as well as the need to document the characteristics of the setting and external environments in which an intervention took place. The goal is to guide potential implementation in similar and alternate settings.
Davis, R.L., Eastman, D., McPhillips, H., and others (2011). "Risks of congenital malformations and perinatal events among infants exposed to calcium channel and beta-blockers during pregnancy." (AHRQ grant HS10391). Pharmacoepidemiology and Drug Safety 20, pp. 138-145.
Calcium channel blockers (CCBs) and beta-blockers (BBs) are effective for the treatment of hypertension during pregnancy. The researchers studied more than 100,000 births from 1996 to 2000 in 5 large health maintenance organizations to discover the risks for perinatal complications and congenital defects among infants exposed in-utero to BBs and CCBs. They identified a total of 584 full-term infants exposed to BBs and 804 full-term infants exposed to CCBs at any time during pregnancy. They found an apparent increase in risk for seizures among infants whose mothers were taking CCBs during pregnancy and an increased risk for hypoglycemia among infants whose mothers were taking BBs during pregnancy. No increase in congenital anomalies among infants exposed to either CCBs or BBs was detected.
Dy, S.M., Taylor, S.L., Carr, L.H., and others (2011). "A framework for classifying patient safety practices: Results from an expert consensus process." (Contract No. 290-2009-1001). British Medical Journal of Quality and Safety 20, pp. 618-624.
Evaluations of patient safety practices (PSPs) are frequently undermined by the lack of a commonly accepted and theoretically informed framework within which to describe salient characteristics such as settings, participants, targeted clinical behaviors, and interventions. The authors develop and evaluate a framework for describing and classifying PSPs. Their final framework includes 11 classification dimensions such as setting, feasibility, and sensitivity to context. This framework may also serve as a foundation for further understanding of the role of context in evaluating effectiveness, uptake, and dissemination for diverse types of PSPs.
Eichenwald, E.C., Zupancic, J.A.F., Mao, W.Y., and others (2011). "Variations in diagnosis of apnea in moderately preterm infants predicts length of stay." (AHRQ grant HS10131). Pediatrics 127(1), pp. e53-e58.
Apnea of prematurity is expected to be uncommon in moderately preterm infants. The researchers studied infants born between 33 and 35 weeks, in whom the diagnosis of recurrent apnea is expected to be rare, and therefore more likely to reveal effects of hospital practice on discharge timing. The results for a cohort of 264 moderately preterm infants born in ten different facilities showed significant inter-neonatal intensive care unit variation as well as regional variation in the diagnosis of apnea. These differences accounted for almost one-third of the variation between hospitals in discharge timing in this group of infants. The results suggest the need for better definitions of clinically significant apnea events to promote national guidelines for the safe and timely discharge of moderately preterm infants.
Foy, R., Ovretveit, J., Shekelle, P.G., and others (2011). "The role of theory in research to develop and evaluate the implementation of patient safety practices." (AHRQ Contract No. 290-09-1000). British Medical Journal of Quality and Safety 20, pp. 453-459.
The authors of this paper highlight the value and uses of theory in research aiming to develop and evaluate patient safety practices (PSPs). They draw upon work undertaken for the Agency for Healthcare Research and Quality to improve the design, evaluation, and reporting of research on PSPs. Theory can be applied at different stages of developing and evaluating complex interventions to explain clinical and organizational behavior, inform PSP selection and development, and understand PSP effects, thereby developing a generalizable body of knowledge. The authors illustrate the value of theory in PSP development and evaluation by showing how the Theory of Planned Behavior applies to the example of hand washing.
Glance, L.G., Neuman, M., Martinez, E.A., and others (2011). "Performance measurement at a "tipping point." (AHRQ grant HS13904). Anesthesia & Analgesia 112(4), pp. 958-966.
The authors' goal is to provide anesthesiologists with the background they need to actively participate in the development of performance measures for anesthesiologists. In discussing outcome measures, stress is placed on the use of risk adjustment to avoid penalizing hospitals and physicians who treat high-risk patients. Administrative data is criticized for often failing to distinguish between pre-existing conditions and complications that develop after hospital admission. One source of bias in quality reporting is hospital differences in diagnostic practices. The authors point out that care process measures do not typically require risk adjustment as long as the appropriate target population is correctly specified.
Goode, A.P., Cook, C., Gill, J.B., and others (2011). "The risk of risk-adjustment measures for perioperative spine infection after spinal surgery." (AHRQ grant HS19479). SPINE 36(9), pp. 752-758.
The authors of this study developed a comorbidity index specific for perioperative spine infection and compared the results of this condition-specific comorbidity index with the Deyo Comorbidity Index, a well-established index, by using a nationally representative sample. Included was any spine surgical procedure associated with compression, disc repair, fusion, laminectomy, or disc repair of a prior spine surgery. Data were collected by using the Nationwide Inpatient Sample, part of the Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality. Twenty-three diagnoses found to be significantly associated with perioperative spinal infection made up the new condition-specific index. The new index was found to be significantly better than the Deyo Index at adjusting for total charges and length of stay at nonteaching hospitals, as well as death, length of stay, and total charges at teaching hospitals.
Lu, C.Y., and Johantgen, M. (2011). "Factors associated with treatment restriction orders and hospice in older nursing home residents." (AHRQ grant HS11990). Journal of Clinical Nursing 20, pp. 377-387.
Although hospice care is viewed as the "gold standard," geographic availability and financial reimbursement limits its use. Treatment-restriction orders may represent alternative approaches to defining wishes for end-of-life care. This study examined factors associated with do-not-resuscitate (DNR), do-not-hospitalize (DNH) orders, and hospice care in older nursing home residents. The researchers analyzed data from 10,023 admission records from 77 Maryland nursing homes. They found that the prevalence of DNR and DNH orders at admission was 28 and 3.4 percent, respectively. Only a small percentage (1.7 percent) of residents received hospice care on admission. White race increased the likelihood of having a DNR or DNH order. Treatment-restriction orders were associated with an increased likelihood of hospice use.
Maeda, J.L.K. (2011). "Evidence-based heart failure performance measures and clinical outcomes: A systematic review." (AHRQ grant HS17944). Journal of Cardiac Failure 16(5), pp. 411-418.
The author conducted a systematic review of studies that assessed the relationship between the evidence-based heart failure performance measures in the inpatient setting and the clinical outcomes of patients. Eleven original studies and one literature review met the study inclusion criteria. Improved patient outcomes were most strongly associated with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and beta-blocker use at discharge. In general, an increase in compliance with the heart failure performance measures led to a consistent improvement in patient outcomes. However, the strength, magnitude, and statistical significance of the positive effect was variable across the individual performance indicators.
Moy, E., Barrett, M., and Ho, K. (2011, January). "Potentially preventable hospitalizations United States, 2004-2007." Morbidity and Mortality Weekly Report 60 (Suppl.), pp. 80-83. Reprints (AHRQ Publication No. 11-R057) are available from the AHRQ Publications Clearinghouse.
To identify trends in a composite measure of potentially preventable hospitalizations among persons in the United States aged 18 and over, the Agency for Healthcare Research and Quality (AHRQ) analyzed data for 2004-2007 from AHRQ's Healthcare Cost and Utilization Project. During this period, the AHRQ Patient Quality Indicator composite rate of hospitalization declined from 1,617 to 1,510 per 100,000 adults. This decline perhaps reflected greater attention to care coordination by hospital and primary care providers. The rate of preventable hospitalization was higher among residents of two lower-income quartile neighborhoods than residents of the highest-income quartile neighborhood. Significant declines in preventable hospitalization were observed among non-Hispanic whites, Asian and Pacific Islanders, and Hispanics. During all years, the adjusted rate of preventable hospitalizations was higher among blacks and Hispanics than whites.
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. 290-09-1001). British Medical Journal of Quality and Safety 20, pp. 604-610.
This paper considers the research evidence about whether, or how, the implementation of five patient safety practices (PSPs) is influenced by context factors, such as an electronic medical record or the size of a health care organization. The study found little evidence reported in studies of five diverse PSPs that context factors influences implementation or effectiveness. For example, there was no strong evidence either for or against context factors either helping or hindering implementation of falls intervention in institutions. Also, no studies of different types of medication reconciliation interventions were found that rigorously assessed the influence of different context factors in implementation or in relation to outcomes of PSPs.
Peek, M.E., Tang, H., Cargill, A., and Chin, M.H. (2011, June). "Are there racial differences in patients' shared decisionmaking preferences and behaviors among patients with diabetes?" (AHRQ grant HS10479). Medical Decision Making 31, pp. 422-431.
The researchers surveyed 924 diabetes patients treated at 34 community health centers to determine any racial differences in patient preferences for shared decisionmaking (SDM) well as patient behaviors that may facilitate SDM. With regard to patient preferences, race was not associated with any of the three SDM domains (agenda setting, information sharing, or decisionmaking). With regard to patient behaviors, blacks were more likely to report initiating discussions with their physicians about four of six areas of diabetes care.
Peterson, E.D., Roe, M.T., Chen, A.Y., and others (2010). "The NCDR ACTION Registry—GWTG: Transforming contemporary acute myocardial infarction clinical care." (AHRQ grant HS16964). Heart 96, pp. 1798-1802.
The NCDR ACTION Registry—GWTG collects detailed in-hospital clinical, process of care, and outcomes data for patients admitted with acute myocardial infarction (AMI) in the United States. This paper briefly describes the methodology of the ACTION Registry—GWTG and summarizes the results of this registry's data to date. The registry is designed to assist hospitals in their quality improvement efforts. A hospital's aggregate composite performance score includes five acute guideline metrics and six discharge guideline metrics. As of September 2009, 383 sites had submitted 147,165 records into the database. The database includes information on patient demographics, processes of care, and in-hospital outcomes that can be used to provide important insights into the safety and effectiveness of AMI treatments when used in the real world.'
Pincus, H.A. (2011, June) "Academic health centers and comparative effectiveness research: Baggage, buckets, basics, and bottles." (AHRQ grant HS16092). Academic Medicine 86(6), pp. 659-660.
This editorial introduces a group of articles on comparative effectiveness research (CER) and its growing effect on academic health centers (AHCs). These articles illustrate diverse approaches that AHCs can apply to get involved in CER based on seven categories. These categories include workforce development, research infrastructure, evidence creation, analysis and synthesis, clinical and systems implementation, priority setting, and policymaking. The author concludes by stressing the need for AHCs to develop formalized institutional policy expertise in order to participate in the policy debates over rulemaking; coverage decisions; determination of quality, safety, and efficiency; and measures and expectations in evidence-based purchasing.
Pressler, S.J., Eckert, G.J., Morrison, G.C., and others (2011). "Evaluation of the health utilities index Mark-3 in heart failure." (AHRQ grant HS09822). Journal of Cardiac Failure 17(2), pp. 143-150.
Part of measuring cost-effectiveness in health care is measuring changes in the quantity and quality of life. In order to measure the health-related quality of life component of quality-adjusted life years, these researchers used the Health Utilities Index Mark-3 (HUI-3), an instrument designed to measure health status and produce utility scores of health-related quality of life. They evaluated the reliability, validity, and responsiveness of the HUI-3 in 211 patients with heart failure and compared the HUI-3 results with those of the Medical Outcomes Study Short-Form 12, the Living with Heart Failure Questionnaire, and the Chronic Heart Failure Questionnaire. The HUI-3 demonstrated satisfactory reliability and validity in this sample, supporting its use in cost-effectiveness studies.
Shamliyan, T.A., Kane, R.L., Ansari, M.T., and others (2011). "Development of quality criteria to evaluate nontherapeutic studies of incidence, prevalence, or risk factors of chronic diseases: Pilot study of new checklists." (AHRQ Contract No. 290-02-2009). Journal of Clinical Epidemiology 64, pp. 637-657.
The prevalence and incidence of chronic conditions have implications for policy and health care utilization. The authors of this paper develop valid and reliable quality criteria for observational studies that examine the incidence or prevalence of chronic conditions and risk factors for diseases. They also propose criteria for the design, reporting standards, and assessment of nontherapeutic observational studies in systematic reviews and evidence-based reports. They developed two checklists, one for studies of incidence or prevalence and another for risk factors. Poor reliability in evaluating studies from different research areas precludes recommending the checklists for widespread use.
Shekelle, P.G., Pronovost, P.J., Rachter, R.M., and others (2011, May). "Advancing the science of patient safety." (AHRQ Contract No. 290-09-1000). Annals of Internal Medicine 154(10), pp. 693-696.
The Agency for Healthcare Research and Quality (AHRQ) convened a panel of international experts in patient safety, who reviewed the literature and discussed how to improve the conduct and reporting of patient safety interventions. The group focused on why and how we evaluate safety interventions and make causal inferences about their effectiveness. Key evaluation issues that merit measurement and reporting include an explanation of the theory or logic model, a description of the patient safety practice in sufficient detail for others to replicate it, a detailing of the implementation process, and an assessment of the outcomes that include possible unintended effects. The authors propose that high-priority contexts of patient safety practices be grouped into: external factors, organizational structural characteristics, teamwork, leadership, patient safety culture, and management tools.
Shelton, J., and Jackson, G.P. (2011). "Palliative care and pediatric surgery." (AHRQ grant HS13833). Surgical Clinics of North America 91, pp. 419-428).
Between 53,000 and 55,000 children die each year, with half dying of chronic, life-long disorders. Many of these children's goals for symptom control at the end of life are not met. Pediatric surgeons can play an important role in offering procedures that may improve the quality of life for terminally ill children. This article provides a palliative care primer for the pediatric care surgeon. The interventions discussed include gastrostomy, pain control, thoracostomy and pleurodesis, and tracheostomy. The delivery of palliative surgical interventions requires ongoing evaluation of treatment goals and weighing the risk and benefits of procedures in the context of a shortened life span. There is limited published evidence about the efficacy of these procedures, and further research is needed to enable informed discussions of the risks and benefits of interventions in this population.
Smith, H.A., Matthews, A., Markovic, N., and others (2010). "A comparative study of complementary and alternative medicine use among heterosexually and lesbian identified women: Data from the ESTHER project (Pittsburgh, PA, 2003-2006)." (AHRQ grant HS17587). The Journal of Alternative and Complementary Medicine 16(11), pp. 1161-1170.
Lesbians are more likely to use complementary and alternative medicine (CAM) than heterosexual women, according to data from the Epidemiologic Study of Health Risk in Women project. Of the 479 lesbians who participated in the survey, 57.3 percent reported ever using CAM compared with 40.8 percent of heterosexual women. However, the type of CAM the women used varied little by their sexual orientation. Other predictors of CAM use included being white, having more years of education, experiencing discrimination in a health care setting, living in a large city, being very spiritual, and having a history of a mental health disorder.
Taylor, S.L., Dy, S., Foy, R., and others (2011). "What context features might be important determinants of the effectiveness of patient safety interventions?" (AHRQ Contract No. 290-09-1001). British Medical Journal of Quality and Safety 20, pp. 611-617.
Many practices have been implemented to improve the safety of patients, such as use of a checklist to prevent bloodstream infections. The effectiveness of these patient safety practices (PSPs) can vary markedly between different settings. Such variations in effectiveness are likely to be attributable to variations in a range of contextual factors affecting the implementation of PSPs, such as policies, regulations, or organizational characteristics. This paper reports on formal discussions with a 22-member technical expert panel to determine what contexts are likely to have major influences on PSP implementation and which should be described in PSP evaluations. The panel agreed on four context domains considered important: safety culture; teamwork and leadership involvement; structural organizational characteristics (e.g., financial or performance incentives or PSP regulations); and availability of implementation and management tools (e.g., training organizational incentives).
VanLare, J.M., Conway, P.H., and Rowe, J.W. (2011). "Building academic health centers' capacity to shape and respond to comparative effectiveness research policy." (AHRQ grant HS19682). Academic Medicine 86(6), pp. 689-694.
Comparative effectiveness research (CER) has implications for the research, education, and clinical care components of the missions of academic health centers (AHCs). The authors of this paper discuss specific opportunities for AHCs to shape and respond to CER policy—both Federal and that set by the new Patient-Centered Outcomes Research Institute—across the domains of research, human and scientific capital, data infrastructure, and translation and dissemination. They propose that AHCs develop a cross-functional role that integrates research and patient-outcome improvement responsibilities to inform CER policy and adopt CER findings at the local level. The organizational structure that best addresses this role will typically be a cross-cutting center or division that focuses on CER issues and opportunities in the AHC's clinical, research, and educational components.
Vashi, A., and Rhodes, K.V. (2011, April). "Sign right here and you're good to go": A content analysis of audiotaped emergency department discharge instructions." (AHRQ grant HS11096). Annals of Emergency Medicine 57(4), pp. 315-322.
The researchers analyzed audio recordings of 477 patient-provider conversations about discharge instructions recorded at two emergency departments (EDs): an urban academic tertiary medical center ED and a suburban community hospital ED. They found that verbal discharge instructions were often incomplete and patients' understanding of the instructions was seldom assessed. For example, although the majority of patients (73 percent) were instructed to seek primary care follow-up, less than half were give a specific time for followup. Patient-provider communication during the discharge process lasted less than an average of 4 minutes. The authors concluded that communication and content delivery during the ED discharge process needed improvement.
Xiao, Z., Li, X., and Stanton, B. (2011, January). "Perceptions of parent-adolescent communication within families: It is a matter of perspective." (AHRQ grant HS07392). Psychology, Health, & Medicine 16(1), pp. 53-65.
The researchers examined the concordance between parental and youth's perceptions of open communication in their families and its association with youth's psychosexual adjustment. Participants were 336 inner-city black parent-youth dyads participating in a community-based violence effectiveness trial in an eastern city. Psychosexual adjustment was measured with 13 existing scales, ten of which were derived from the Child Health and Illness Profile-Adolescent Edition. Twenty-eight percent of parent-youth dyads reported consistent high (high-high) and 26 percent reported consistent low (low-low) levels of perceived open family communication. By comparison, 45 percent reported inconsistent perceptions of open family communication (either high-low or low-high). Youth who perceived higher levels of open communication had higher indices of adjustment than youth who perceived low levels of open communication.
Zerzan, J.T., Gibson, M., and Libby, A.M. (2011). "Improving State Medicaid policies with comparative effectiveness research: A key role for academic health centers." (AHRQ grant HS19464). Academic Medicine 86(6), pp. 695-700.
The authors discuss how State Medicaid programs are already using comparative effectiveness research (CER) to inform policy, and they outline ways that academic researchers can support States by developing and communicating targeted CER. Several State Medicaid programs have used CER since 2003 to make benefit-coverage decisions under the auspices of two particular programs, the Drug Effectiveness Review Project (DERP) and the Medicaid Evidence-based Decisions project (MED). As of 2011, DERP has 11 States as members and has produced systematic reviews of 35 classes of drugs as well as numerous updates of reviews. DERP reviews the clinical literature comparing the safety, effectiveness, and effect on subpopulations of drugs within classes. MED, with 11 States participating, reviews clinical literature on various procedures and treatments and has, as of 2011, completed 170 reports.